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DRVA2019-0018p V s 1 w 2AT five ii de: OCT 022019 U PUBLIC WORKS CONSTRUCTION CITY OF LA QUINTA DESIGN & DEVELOPMENT DEPARTMENT For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains and other like public work improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS. DATE: 10/3/2019 LOCATION OF CONSTRUCTION(Street address or Description): 52160 AVENIDA HERRERA PURPOSE OF CONSTRUCTION: DRIVEWAY APPROACH DESCRIPTION OF CONSTRUCTION: LQ 4 PROJECTS /_DRIVEWAY APPROACH DIMENSION OF INSTALLATION OR REMOVAL: APPROXIMATE TIME WHEN WORK WILL BEGIN: 10/7/2019 TIME OF COMPLETION: 10/31/2019 p 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 an regulations of the City of and to pay for any additional replacement necessary as the result of this work. Sign ture of Applicant or Agent NICOL CONSTRUCTION INC DBA NICOL CLIMATE . 41950 MARYN CT PALM DESERT, CA 92211 (760)567-2811 ta Qabtra GEM .JCIRDESERT - - DRIVEWAY APPROACH Name of Applicant (please print) NICOL CONSTRUCTION INC DBA NICOL CLIMATE Business Address 41950 MARYN CT PALM DESERT, CA 92211 Telephone No. (760)567-2811 Telephone No. Name of Contractor and Job Foreman Business Address 878070 LIC-0109262 Contractor's License No. City Business License No. Applicant's Insurance Company - Policy Number Finance Revenue Code PERMIT INSPECTION DRIVEWAY RESIDENTIAL $175.00 TECHNOLOGY ENHANCEMENT FEE $5.00 TOTAL: $0.00 PERMIT NO: DRVA2019-0018 DATE ISSUED: ____ EXPIRATION DATE: W/2D BY:40(4 WORK INSPECTED BY*: PERMIT COMPLETION DATE: *If the work is covered by a Subdivision Improvement Agreement, Subdivider shall request final acceptance of improvements from the Council. a ca ow (V GEM of the DESERT - DRIVEWAY APPROACH PERMIT APPLICATION Applicant Information: Applicant/Owner (please print name here): Applicant Address: Number Address or Parcel No. of wo r.i. -% .. 'I I Street Street location, if different from applicant's address above: /. , a /1 State Zip Code Date: JO /, APrrnt's Phone Applicant's Signature: - Approximate Start Date: Approximate Completion Date: Jj3jJ... Contractor Information: Address: D Code Phone Number: (?(0 ) 5t,--7'I I Contractors License Number: O7-o City Business License Number: General* Liability Insurance Company: Policy No. (see back for required insurance documents) Request for Inspection - Please call (760) 777-7097 before 1:30pm to request an inspection at least 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 No. Expiratio Date /O/lti 0018A I//Il Permit Issued by: ,4 t/*(i&._ Date Issued /OljIj Signature of ministrative Authority Work Inspected by: Permit Completion Date: Inspector's Signature Comments: Note: Driveway approach must be constructed per City of La Quinta Standard #221 REV: 8/19/2019 RE: Driveway I Encroachment Permits - Compliance with Insurance Requirements Per Engineering Bulletin #97-04 please provide proof of the insurance items and endorsement certificates below: D General Liability - $1M per occurrence / $2M general aggregate IJ General Liability - Additional Insured Endorsement (for ongoing and completed operations) General Liability - Primary I Non-contributory Endorsement 0 Automobile Liability - $1M combined single limit 0 Workers' Compensation - Statutory Limits / Employer's Liability $1M per accident or disease 0 Workers' Compensation - Waiver of Subrogation Endorsement n ACGRD CERTIFICATE OF LIABILITY INSURANCE DA1MMICOffYYfl 1010212019 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 ACONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the poilcy(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). A PRODUCER cO NAM NTE:CT Virginia F Mulhleman Dean Mofidi Insurance Services, LLC PHONE I FAX EAC.NOEXII. (760)318.4099 I (760)318.4311 4633 East Ramon Road E-MAL AOORESS: virginia@pslnsureme.com Palm Springs, CA 92264 License #: 0H05039 INSIJRER(S)AFFORDINOCOVERAGE CC - NAI - INSURED Dana Nicol INSURER S: Infinity Commercial Auto 120260 INSURER C: DBA Nicol Construction Inc. I I 72163 Northshore Ste B INSURER 0: I Thousand Palms, CA 92276 INSURER E: I INSURER F: flUM rFRTIflrATF NIIMRFR nnnrvmnnAsERei RVISICThI NIIMRFP. I 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. IL7R - INSR A TYPE OF INSURANCE UBR WV131 POLICY NUMBER POLICY EFF MMIOO(VYYYI POLICY EXP IMMIDOIYYYYJ UNITS A X COMIMEFtCIALGENERAL LIABILITY Y CLAIMS-MADE OCCUR I I 51 NA110958604 0511112019 0511112020 EACH OCCURRENCE S 1.000,000 DAMAGE TO RENTED PREMISES (S. aonrysnc.) 5 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENt AGGREGATE LIMIT APPLIES PER: POUCY EACT 0 LOC [OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS. COMPE)P AGG S 1.000,000 $ B AUTOMOBILEUAEJUTY ANY AUTO OWNED = AUTOS ONLY [i] HIRED NON-OWNED - AUTOS ONLY AUTOS ONLY - 504610029598001 0511112019 1111112019 1 NGLEUMIT s 1,000,000 BODILY INJURY (Per Person) $ BODILY INJURY (Per accident) S PROPERTY GAMAGE (Per aeddentl 1.000.000 $ - UMBRELLA UAB EXCESS I.IAB HCLAIMS-MADE OCCUR - EACH OCCURRENCE $ AGGREGATE $ - DED I I RETENTIONS $ - - WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARThERIEXECUTWE OFFICERIMEMBER EXCLUDED? (Mandatory In NH) descrilm under DSCRIPTI0N OF OPERATIONS below N IA - - PER 0Th- STATUTE ER EL EACH ACCIDENT $ E.L. DISEASE- EA EMPLOYEE S EL DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Renisot. Schedule, mey be ettached if mere space Is ,equlred) Certificate Holder listed as Additional Insured. City of La Quinta 78495 Calle 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. AUTHORIZED REPRESENTATIVE FM) 4489-2015 I ACORD CORPORATION. All riahts reserved. registered marks of ACORD ACORD 25 (2016103) The ACORD name and logo Printed by VFM on October 02, 2019 at 03:25PM 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 Sti4FflhJlF Policy Number NA1 10958604 Endorsement Effective: 5/11/2019 12:01 am. Named insured Countersigned NICOL CONSTRUCTION INC. DBA: NICOL CLIMATE CONTROL 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. (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 service, 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 some project. C. The words "yf and "your" refer to the Named Insured shown In the Declarations. D. "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. Primary WordIng If required by written contract or agreement: Such insurance as is afforded by this policy shall be primary insurance, and any insurance or self-insurance maintained by the above additional insured(s) shall be excess of the insurance afforded to the named insured and shall not contribute to it Waiver of Subro-gation 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 "your work" done under a contract with that person or organization. 49-010307 11 May Include Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 1 Used with permission 43RD® CERTIFICATE OF LIABILITY INSURANCE DAMIDDIYYYY) 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 poHcy(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 CON'rAcT Customer Service Department Target Insurance Services :1ro. xtI: (800) 450-8013 I No): (866) 227-3052 6630 Flanders Drive 1. ADD R35: Certiflcates@prsn1ieragencyservices.com INSURER(S) AFFORDING COVERAGE NAJC$ INSURER A: Security National Ins Co 19879 San Diego CA 92121 INSURED INSURER B: Nicol Construction Inc., DBA Nicol Climate Control INSURER C: 67851 ocotillo Trail INSURER D: INSURER E: INSURER F: Desert Hot Springs CA 92241 COVERAGES CERTIFICATE NUMBER: WC 18-19 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 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. LTR - TYPE OF INSURANCE ' uer R POLICY NUMBER POLICY EFF POLICY EXP (MMIDDIYYYY) UMITS_______________ - COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S DAMAGE TO RENTED J I CLAIMS-MADE 1:1 OCCUR PREMISES (Es occurrence) S MED EXP (Any one person) S = PERSONAL &ADV INJURY S GENt. AGGREGATE UNIT API'UES PER: GENERAL AGGREGATE $ - PRO- E LOC POI. [] .IECT PRODUCTS- CONP/OPAGG $ ___ $ - 1OTHER: AUTOMOBILE LIABILITY - COMBINED SINGLE DO — (Eaaccidenl) I- BODILY INJURY (Per person) $ ANVAUTO - OWNED SCHEDULED - AUTOS ONLY L_J AUTOS BODILY INJURY (Per accident) S PROPERTY DAMAGE HIRED I I NON-OWNED - AUTOS ONLY AUTOS ONLY UMBRELLA UAB OCCUR EACH OCCURRENCE S FH AGGREGATE $ EXCESS UAB CLAIMS-MADE - OEO I I RETENTION $ - - A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY TY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory In NH) NIA V SWC1217913 12101/2018 12101/2019 %A PER I OT STATUTE I _ER W ILLEACHACCIDENT ___________________ i,000,000 ________________ _______________ E.L. DISEASE -EA EMPLOYEE 1,000,000 - If yes. describe under DESCRIPTION OF OPERATIONS below - - E.L. DISEASE - POLICY UNIT $ 1,000,000 DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached If more space Is required) Workers Compensation Waiver of Subrogation applies to the extent provided in the attached forms. Certificate holder RE: LA Quinta Project 52160 Avenida Herrera Subject to all policy terms, exclusions and conditions* City of La Quints 78495 Calls Tamplco SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 86 CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE La Quints CA 92253 CD 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 0444) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CAUFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2% of the California workers compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Any person or organization as required by written contract. This endorsement changes the policy to which It is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement Is Issued subsequent to preparation of the policy.) Endorsement Effective 121112018 Policy No. SWC1217913 Endorsement No. 6 Insured Nicol Construction, Inc. Premium $ 20,343 Insurance Company Security National Insurance Company Countersigned by WC 040308 (Ed. 04-84)