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DRVA2019-0011
M.. L.4 See below for Finance Revenue Code: P /2\ fl 0\ L/-' U GLM of t/ DESERT - - DRIVEWAY APPROACH MAY 022019 PUBLIC WORKS CONSTRUCTION For the construct &AUINThrivate rbs, driveways, pavements, sidewalks, parking lots, sewers, water mains and other like public work 'IMPROVEMENTS and APPROVED SUBDIVISIONS. DATE: 5/2/2019 LOCATION OF CONSTRUCTION(Street address or Description): 54720 AVENIDA CARRANZA PURPOSE OF CONSTRUCTION: DRIVEWAY APPROACH DESCRIPTION OF CONSTRUCTION: ROSINI / DRIVEWAY APPROACH DIMENSION OF INSTALLATION OR REMOVAL: 20 APPROXIMATE TIME WHEN WORK WILL BEGIN: 5/3/2019 TIME OF COMPLETION: 5/17/2019 ESTIMATED CONSTRUCTION COST: Si.zoo.00 (Including removal of all obstruction, materials, and debris, backfilling, compaction and placing permanent resurfacing and/or replacing improvements) COMMENTS: In consideration of the granting of this permit, the applicant hereby agrees to: Indemnify, defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all penalties, liabilities or loss resulting from claims or court action and arising out of any accident, loss or damage to persons or property happening or occurring as a proximate result of any work undertaken under the permit granted pursuant to this application. Notify the Administrative Authority at least twenty-four (24) hours in advance of the time when work will be started at (760) 777-7097. To submit an inspection request, leave a message on the Inspection Request Hotline at (760) 777-7097 prior to 1:30 P.M. at least twenty-four (24) hours prior to the anticipated inspection. Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulations of the City of and to pay for any additional replacement necessary as the result of this work. HEY DUDE CONSTRUCTION INC P0 BOX 1018 THOUSAND PALMS, CA 92276 Name of Applicant (please print) Business Address HEY DUDE CONSTRUCTION INC P 0 BOX 1018 THOUSAND PALMS, CA 92276 Name of Contractor and Job Foreman Business Address 845115 LIC-0100746 Contractor's License No. City Business License No. CONTRACTORS SHIELD INSURANCE CO DSI-1256863-02 Applicant's Insurance Company Policy Number pIicant or Agent (760)343-5272 Telephone No. (760)343-5272 Telephone No. Finance Revenue Code PERMIT INSPECTION DRIVEWAY RESIDENTIAL $160.00 TECHNOLOGY ENHANCEMENT FEE $5.00 TOTAL: $0.00 PERMIT NO: DRVA2019-0011 DATE ISSUED: 5/2/2019 EXPIRATION DATE: 10/29/2019 BY: AARON HICKSON WORK INSPECTED BY: PERMIT COMPLETION DATE*: 1f the work is covered by a Subdivision Improvement Agreement, Subdivider shall request final acceptance of improvements from the Council. DRIVEWAY APPROACH PERMIT APPLICATION Applicant Information: Applicant/Owner (p/ease print name here,k (//i(./ Applicant Ad v' v 6,(4 ~, q __ Number Street City State Zip Code Address or Parcel No. of work locati n, if different from applica t's address ab ye: 54f-72c .4Ve 714/zA Z04 2,41F 4f %=C3 Number Street 4pp.., City State Zip Code Date:'9'/'ppiicant's Phone No: (40) ..6Z- atw x' Applicant's Signature: Approximate Start Date: 1 411JApproximate Completion Date: Contractor Information: Address: //8 Sd.MMtP .iiY5 f 97fl44 D,. #,3&!/+' i~47?éb J2AL ;qV &i=w Phone Number:7 ) 34352-72 Contractors License Number: Zi.c9/67 City Business License Number: 0ø79 / General Liability Insurance Company: 44609,4, iiVAwI SO Policy Request for Inspection - Please call (760) 777-7097 before 1.30pm to request an inspection at/east 24 hours prior to your requested inspection date. The Hub Counter (760) 777-7125. Please Note: Inspections are normally performed Monday through Friday between 8am and 4pm Permit Fee $160 + $5 Technology Enhancement Fee = $165 Total Fee Permit No. Date _iJJ4.... Permit Issued by: ______ Signature of Administrative Authority Work Inspected by: Inspector's Signature Comments: Date Issued Permit Completion Date: Note: Driveway approach must be constructed per City of La Quinta Standard #221 REV: 11/27/2018 ACOORLY CERTIFICATE OF LIABILITY INSURANCE DATE(MM!DOIYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the pollcy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME Randy Rosten ZJO Fytl: (760) 7768849 I 1401: (760) 776-5189 Rosten Insurance Agency 73413 Terraza Dr. MESS: Ieeanne@rosteninsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: SCOTTSDALE INS. 41297 Palm Desert CA 92260 INSURED INSURER B: AM TRUST NORTH AMERICA INSURER C: ACE AMERICAN INS, CO. 22667 Hey Dude Construction INC. INSURERO: PO Box 1018 INSURER B: INSURER F: THOUSAND PALMS CA 92276- COVERAGES CERTIFICATE NUMBER: RFVISIflN NtJMRFR: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iSk LTR TYPE OF INSURANCE IADOL SUBR im POLICY NUMBER POLICY EFF IMMIDO1YYYYI POLICY EXP 114M10D1YYYY) LIMITS_______________ A - )( F COMMERCIAL GENERAL LIABIUTY I CLAIMS-MADE [j] OCCUR Y - RB50020472 04/21/2019 04/21/2020 EACH OCCURRENCE S 1,000,000 D AMAGE TO RENTED PREMISES (Ea occurrence) $ 50'000 MEDEXP (AM one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: POLICY ] LOC _ OTHER: GENERAL AGGREGATE S 2,000,000 PRODUCTS - COMPIOP AGG $ 1,000,000 AUTOMOBILE LIABILITY - ANY AUTO - OWNED SCHEDULED AUTOS ONLY 1 AUTOS HIRED NON-OWNED - AUTOS ONLY AUTOS ONLY - WPP156009400 06/06/2018 06/06/2019 COMBINED SINGLE LIMIT Me adent) $ 1,000,000 BODILY INJURY (Per person) S BODILY INJURY (Per accident) S PROPERTY DAMAGE accident) - UMBRELLA (JAB XCESS LIAB RED L.J OCCUR CLAIMS-MADE - - EACH OCCURRENCE $ AGGREGATE S - I I RETENTIONS S C - WORKERS COMPENSATION AND EMPLOYERS LIABILITY Y I N ANY PROPRIETORIPARTNERIEXECIJT1VE r—' OFFICERIMEMBER EXCLUDED? LNJ (Mandatory In NH) IfM descflbe under DRIPTION OF OPERATIONS below NIA - Y - RWCC-4880830A 06/01/2018 06/01/2019 I PER I 0TH- I_STATUTE_I_I_ER E.L. EACH ACCIDENT $ 2,000,000 E.L. DISEASE - EA EMPLOYEE 5 2,000,000 E.L. DISEASE - POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more apace Is required) The City of La Quinta is hereby named as additionally Insured with respects to the policy of the above-named insured. IiL'I('JRil SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of La Quints ACCORDANCE WITH THE POLICY PROVISIONS. 78495 CaIle Tampico AUTHORIZED REPRESENTATIVE La Quinta Ca 92253 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Any contractual indemnity payments made on behalf of any additional insured under an "insured contract" shall reduce the applicable limits of insurance on a dollar for dollar basis. Any contractual indemnity payments are subject to the terms, conditions and limitations of the policy. This endorsement does not create a duty on our part to defend the additional insured or to participate in, contribute to, or reimburse any person, organization or entity for any fees or expenses incurred in the defense of the additional insured. SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS, and SECTION IV—PRODUCTS! COMPLETED OPERATIONS LIABILITY CONDITIONS, Condition 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit of the policy is amended to include: An additional insured under this endorsement shall in addition to complying with all provisions of the policy: Give written notice to us of an occurrence or an offense which may result in a claim or "suit" within thirty (30) days of notice to the additional insured. Give written notice to us of a claim or "suit" brought against the additional insured within thirty (30) days of the additional insured being served with the claim or "suit." Give written notice to any other insurer who has or may have coverage under its policy or policies for a claim, "suit" or demand for defense or indemnity within thirty (30) days of the additional insured being served with the claim, "suit" or demand for defense or indemnity. Such notice must demand the full coverage available under the policy. The additional insured will not take any action to waive or limit such other coverage available to it. Obtain and provide to us copies of each and every policy from each and every insurer identified pursuant to the preceding paragraph. This endorsement is subject to all terms, conditions and exclusions of the policy, which remain unchanged. SOS-38 (1.I8) Page 2of2 8. This endorsement does not create a duty on our part to defend the additional insured or to participate in, contribute to, or reimburse any person, organization or entity for any fees or expenses incurred in the defense of the additional insured. SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS, Condition 2. Insured's Duties In The Event Of Occurrence, Offense, Claim Or Suit of the policy is amended to include: An additional insured under this endorsement shall in addition to complying with all provisions of the policy: Give written notice to us of an "occurrence" or an offense which may result in a claim or "suit" within thirty (30) days of notice to the additional insured. Give written notice to us of a claim or "suit" brought against the additional insured within thirty (30) days of the additional insured being served with the claim or "suit". Give written notice to any other insurer who has or may have coverage under its policy or policies for a claim, "suit" or demand for defense or indemnity within thirty (30) days of the additional insured being served with the claim, "suit" or demand for defense or indemnity. Such notice must demand the full coverage available under the policy. The additional insured will not take any action to waive or limit such other coverage available to it. Obtain and provide to us copies of each and every policy from each and every insurer identified pursuant to the preceding paragraph. The coverage provided by this endorsement is primary and non-contributory and no insurance held or owned by the additional insured shall be called upon to cover damages under this policy up to the limits of this policy, but only if the "bodily injury" or "property damage" under this policy is caused directly, in whole or in part, from your ongoing operations performed for the additional insured. This endorsement is subject to all terms, conditions and exclusions of the policy, which remain unchanged. 4/24/2019 ATIVE DATE S0S55(II8) Page 2of2 ACc)RIJ CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDTYYYY) 1 ___2528577 5/11/2019 This CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. This CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the pollcy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such_endorsement(s). PRODUCER CONTACT Willis of Greater Kansas City Inc. PHONE FAX 5700W 112th Street, Ste. 100 844 290-4908 iAtCJo,EstI: - (A/C, No): SS: BBSICeItSlIOCktonaffiflity.COfl1 Overland Park, KS 66211 INSURER(S) AFFORDING COVERAGE NAIC C INSURER A: ACE American Insurance Co. 22667 INSURED Barrett Business Services, Inc. INSURERB INSURER C: L/CIF HEY DUDE CONSTRUCTION, INC. . 8100 NE Parkway Drive, Ste. 200 Vancouver, WA 98662 INSURER D INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER- TH IS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WiTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE 'Nm' .0tI '' POLICY NUMBER POLICY EFF IMMIDDIYYYYI POLICY EXP (MMIODWYYY) LIMITS - - COMMERCIAL GENERAL LIABILITY CMSADE D OCCUR - EACH OCCURRENCE S DAMAGE TO RENTED PREMISES (Ea ounce) S MED EXP (Any one person) S PERSONAL & ADV INJURY S GENI. AGGREGATE LIMIT APPLIES PER: 1 POLICY 1:1 LOC _JOTHER: GENERAL AGGREGATE S PRODUCTS - COMP/OP AGG S S AUTOMOBILE LIABILITY - ANY AUTO - ALL OWNED r—i SCHEDULED AUTOS AUTOS - AUTOS AUTOS NON.OWNED PROPERTY DAMAGE HIRED (Per accidentl UMBRELLA COMBINED SINGLE LIMIT (Es aidenti BODILY INJURY (Per person) $ BODILY INJURY (Per S I - UAB EXCESS UAB I CI.AIMS.MADE _J OCCUR - - EACH OCCURRENCE S AGGREGATE S - DEC) I I RETENTIONS . S A - WORKERS COMPENSATION ANY PROPRIETORIPARTNER/EXECUTIVE r—i OFACERIMEMBER EXCLUDED? L_J (Mandatory in NH) descnbe under We be OF OPERATIONS below NIA - X - AND EMPLOYERS' LIABILITY YIN C65188041 6/1/2018 6/1/2019 I PER STATUTE I I ER I 0TH- X E.L. EACH ACCIDENT S 2,000,000 E.L. DISEASE - EA EMPLOYEd $ 2,000.000 E.L. DISEASE - POLICY LIMIT S 2.000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space I. required) Policy Slate r CA Blanket Waiver of Subrogation in favor of certificate holder when requred by written convect City Of La Quinta 78495 Calls Tampico La Quinta, CA 92253 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. All nahts reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD