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DRVA2019-0014venue Codes r;Et LII See below for Finance Re JUL 082019 - GEM efx DESERT - DRIVEWAY APPROACH CITYOFLAQUINTA PUBLIC WORKS CONSTRUCTION DESIGN & DEVELOPMENT DEPARTMENT For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS. DATE: 7/8/2019 LOCATION OF CONSTRUCTION(Street address or Description): 52435 AVENIDA BERMUDAS PURPOSE OF CONSTRUCTION: DRIVEWAY APPROACH DESCRIPTION OF CONSTRUCTION: VAN /_DRIVEWAY APPROACH DIMENSION OF INSTALLATION OR REMOVAL: MATE TIME WHEN WORK WILL BEGIN: 7/9/2019 TIME OF COMPLETION: 7/11/2019 ESTIMATED CONSTRUCTION COST: (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 regulltipsgef the,, —.00 and to pay for any additional replacement necessary as the result of this work. ignaiuof Applicant or Agent ACOSTA CONSTRUCTION 47750 ADAMS STREET #423 LA QUINTA, CA 92253 (760)619-9630 Name of Applicant (please print) Business Address Telephone No. ACOSTA CONSTRUCTION 47750 ADAMS STREET #423 LA QUINTA, CA 92253 (760)619-9630 Name of Contractor and Job Foreman Business Address Telephone No. 955217 License No. Applicant's Insurance Company Finance Revenue Code PERMIT INSPECTION DRIVEWAY RESIDENTIAL $160.00 TECHNOLOGY ENHANCEMENT FEE $5.00 TOTAL: $165.00 LIC-764088 City Business License No. 4i 10 765Z3O1 Policy Number PERMIT NO: DRVA2019-0014 DATE ISSUED: Agr/hj EXPIRATION DATE: BY: WORK INSPECTED BY*: PERMIT COMPLETION DATES: if the work is covered by a Subdivision Improvement Agreement, Subdivider shall request final acceptance of improvements from the City Council. 4thaa - (E.I '/:. fESERT DRIVEWAY APPROACH PERMIT APPLICATION Applicant Information: Applicant/Owner (p/ease print name here,k 2o. t , L 1\ co&-\—c Applicant Aress: 7 O 4423 L -\ C A - Number Street City State Zip Code Address or Parcel No. oLwork location, if different from applicant's address above: .71 01 9 L C ,-cx C q" Lic 3 Number S3S Street J(J /3E4A.5 City State Zip Code Date: 7_j!..1j..1 Applicant's Phone No: V6 C ) é i q 4" 6 . p Applicant's Signature:. Approximate Start Date: Li /j-1 Approximate Completion Date: Contractor Information: Address: L(7750 tçVvç s- J- 44- L4 LA Q C, VA- Number Street City State Zip CodL Phone Number: (760) L7_'- _7(.b Contractors License Number: ~TS_2t1 City Business License Number: GeneralLiabilityInsuranceCompany: _PolicyNo.X .W10IS2.30L 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 PermitFee$160 +$5TechnologyEnhancementFee =$165TotalFee Permit No.tj,,tS_ fExpi ration Date 7_i_7_ij Permit Issued by: Signature of Administrative Authority Work Inspected by: Inspector's Signature Comments: Date Issued 7_iIi1L,2 Permit Completion Date: __/....._I. Note: Driveway approach must be constructed per City of La Quinta Standard#221 REV: 11/27/2018 ACORb° CERTIFICATE OF LIABILITY INSURANCE 1 DATE(MMIDDIYYYY) 07/08/2019 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 policy(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 Andrew Miller Pacific United Insurance Services PHONE Eat): (619) 274-8144 I NO): (619) 274-8143 SS: admin@paciflcunitedins.com LAIC. 7851 Mission Center Court INSURER(S) AFFORDING COVERAGE NAIC I Suite 322 PISLIRERA: AmTrust International Underwriters Ltd San Diego CA 92108 INSURED INSURER B: Infinity Select Insurance Company Raul Acosta, DBA: Acosta Construction INSURER C: INSURER D: 47750 Adams Street #423 INSURERE: INSURER F: La Quinta CA 92253 COVERAGES CERTIFICATE NUMBER: CL1883012027 REVISION NUMBER: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. lFJR LIR TYPE OF INSURANCE - s'IBBL INSO USTt V1IV0 POLICY NUMBER POLICY EFF 'MMIDDIYYYY) POLICY EXP (MMIOONYYY) UNITS______________ >4 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE 19 OCCUR DAMAGETORENTED PREMISES (Ea occurrence) S 100,000 MED EXP (Any one poison) S 5,000 - PERSONAL& ADV INJURY s 1.000.000 A V XN107652301 09/07/2018 09/07/2019 GENtAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY [] T LOC PRODUCTS - COMPIOP AGO S 2,000,000 IOThER: - AUTOMOBILE LIABILITY - - COMBINED SINGLE LIMIT (Ea accident s 1,000,000 BODILY INJURY (Per Person) S ANYAUTO B SCHEDULED - A OWNED UTOS ONLY AUTOS 504-5956-21717-001 09/07/2018 09/07/2019 BODILY INJURY (Per adonI) S PROPERTY DAMAGE (Par, - HIRED NON-OMIED - AUTOS ONLY AUTOS ONLY I . S - UMBRELLA UAB OCCUR EACH OCCURRENCE S AGGREGATE S EXCESS UAB H CLAIMS-MADE , . OED I I RETENTION S S - WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N - - PER 0TH, STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE E.L. EACH ACCIDENT S OFFICERIMEMBER EXCLUDED? NIA (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE S - If yes, describe under DESCRIPTION OF OPERATIONS below - - E.L. DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Romance Schedule, may be attached If more spice Is required) Certificate Holder is named as additional Insured per the attached endorsement (.MlI1IUAIL MULLJtN City of La Quinta 78495 CalIe Tampico SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE La QUinta CA 92253 @1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: XN107652301 COMMERCIAL GENERAL LIABILITY NX GL 189 05 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSUREDS - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Policy Number: XN107652301 Endorsement Effective: 9/7/2018 12:01 a.m. Named Insured: Counter Signed By: - RAUL ACOSTA, DBA ACOSTA CONSTRUCTION (.. • SCHEDULE Name of Person or Organization: Any person or organization that the named insured is obligated by virtue of a written contract or agreement to provide insurance such as is afforded by this policy. Location: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II -Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to "bodily injury" or "property damage" occurring after All work, including materials, parts or equipment furnished in connection with such work, on the project (other than services, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed: or That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. The words "you" and "your" refer to the Named Insured shown in the Declarations. POLICY NUMBER: COMMERCIAL GENERAL LIABILITY NX GL 189 05 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. D. The following are added to SECTION V - DEFINITIONS: "Your work" means work or operations performed by you or on your behalf; and materials, parts or equipment furnished in connection with such work or operations. E: The following additional provisions apply to any entity that is an insured by the terms of this endorsement: Primary Wording With respect to the Third Party shown above, this insurance is primary and non-contributing. Any and all other valid and collectable insurance available to such Third Party in respect of work performed by you under written contractual agreements with said Third Party for loss covered by this policy, shall in no instance be considered as primary, co-insurance, or contributing insurance. Rather, any such other insurance shall be considered excess over and above the insurance provided by this policy. 2. Waiver of Subrogation If required by written contract or agreement: We waive any right of recovery we may have against an entity that is an additional insured per the terms of this endorsement because of payments we make for injury or damage arising out of "you work" done under a contract with that person or organization.