The URL can be used to link to this page

DRVA2019-0019sRj Io ncev u ode ta Qa~t& —GL%4oftheDESERT— - OCT 0 2 2019 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 work improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS. DATE: 10/3/2019 LOCATION OF CONSTRUCTION(Street address or Description): 52245 AVENIDA DIAZ PURPOSE OF CONSTRUCTION: DRIVEWAY APPROACH DESCRIPTION OF CONSTRUCTION: LQ4 PROJECTS /_DRIVEWAY APPROACH DIMENSION OF INSTALLATION OR REMOVAL: APPROXIMATE TIME WHEN WORK WILL BEGIN: 10/7/2019 TIME OF COMPLETION: 10/31/2019 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 'lnspection 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 a regulnsofCity of and to payfor any additional replacement necessary as the result of this work. Si nature of Applicant or Agent NICOL CONSTRUCTION INC DBA° NICOL CLIMATE 41950 MARYN CT PALM DESERT, CA 92211 (760)567-2811 Name of Applicant (please print) Business Address Telephone No. NICOL CONSTRUCTION INC DBA NICOL CLIMATE 41950 MARYN CT PALM DESERT, CA 92211 (760)567-2811 Name of Contractor and Job Foreman Business Address Telephone No. 878070 LIC-0109262 Contractor's License No. City Business License No. Applicant's Insurance Company Finance Revenue Code PERMIT INSPECTION DRIVEWAY RESIDENTIAL $175.00 TECHNOLOGY ENHANCEMENT FEE $5.00 TOTAL: $0.00 Policy Number PERMIT NO: DRVA2019-0019 DATE ISSUED: (gf3f/q EXPIRATION DATE: BY: 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 City Council. I p Code Address: Phone Number: () 5 Z II Contractos License Number ta Qa 4q r GEM oJrhe DESERT - DRIVEWAY APPROACH PERMIT APPLICATION Applicant Information: ñ Applicant/Owner (p/ease print name here): I d"( Applicant Address: 3 AwvV si & Pg \rw5) Number Street City State Zip Code Address or ParcehNo. of work I ation, if different om applicant's addre s above: zg q72_5,) Number Street City State Zip Code Date: f1/3J4 APyfiant's P one . (7(0 O) -ZTh I Applicant's Signature: - Approximate Start Date: JJ_J.ft Approximate Completion Date: 4ç5j3jjj Contractor Information: City Business License Number: General Liability Insurance Company:... L Policy No. (see back for required insurance documents) 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 No. j)f4.,j g - Expiration pate 00 lei 4 Permit Issued by: ____________________________ Date Issued jçj31jj ,i9nature P Administrative Authority Work Inspected by: Permit Completion Date: 1/ 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: General Liability - $1M per occurrence I $2M general aggregate 11 General Liability - Additional Insured Endorsement (for ongoing and completed operations) I1 General Liability -Primary I Non-contributory Endorsement I1 Automobile Liability - $1M combined single limit O Workers' Compensation - Statutory Limits I Employer's Liability $1M per accident or disease 0 Workers' Compensation - Waiver of Subrogation Endorsement ri ACGRE( CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDOIYYYY) I 10/0212019 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(les) 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 Dean Mofidi Insurance Services, LLC CONTACT NAME: Virginia F Mulhleman PHONE IFAX (AIC. No. ExTh (760)318.4099 I (760)318.4311 4633 East Ramon Road ADDRESS: E.MAIL vlrginia@pslnsureme.com Palm Springs, CA 92264 License #: 0H05039 INSURER(S) AFFORDING COVERAGE NAIC p INSURER A: Security National Insurance Company INSURED Dana Nicol INSURER B: Infinity Commercial Auto 20260 INSURER C_:_ DBA Nicol Construction Inc. INSURER 0: 72163 Northshore Ste B INSURER E: Thousand Palms, CA 92276 NSURERF: CUVtKA(iE5 CERTIFICATE NUMBER: 0000LI000-959993 RFVISIflM Iii IMPED- '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 SHOMI MAY HAVE BEEN REDUCED BY PAID CLAIMS. - TYPE OF INSURANCE , JIRi I POLICY NUMBER POLICY EFF (MMIDDIYYYr POUCY EXP iuwvyyy LIMITS A xl COMMERCIAL GENERAL LIABILITY CLAIMS-MADE [] OCCUR V NA110958604 05/1112019 05/1112020 EACH OCCURRENCE S 11000,000 -111gua To PREMnES(EeocaI $ 100,000 MED EXP (Any one person) S 5,000 PERSONAL & ADV INJURY S 1,000.000 GEWL AGGREGATE LIMIT APPLIES PER: POLICYJECT LOC OTHER: GENERAL AGGREGATE s 2,000,000 PRODUCTS - COMPOP AGG 5 1,000.000 S B AUTOMOBILE UABILiTY ANY AUTO =OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON-OWNED - AUTOS ONLY AUTOS ONLY - - ________ 504610029598001 0511112019 11/11/2019 (Es yogiftnt) COMBINEOSINGLE UNIT $ 1.000,000 BODILY INJURY (Per person) S BODILY INJURY (Per accident) S I PROPERTY DAMAGE (Per enddenit S 1,000,000 - - UMBRELLA UAB xc t.toe L_J IILCLAJMS-MAOE OCCUR - EACH OCCURRENCE S AGGREGATE $ DED I I RETENTIONS $ - - WORNERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERJEXECunvE OFFICERIMEAIBER EXCLUDED? (Mandatory In NH) lives, describe under DESCRIPTION Of OPERATIONS below NIA - ________ __________________ I PER 0TH. STATUTE E EACH ACCIDENT S E.L DISEASE - EA EMPLOYEE S ILL. DISEASE - POLICY UNIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarte Schedule, may be attached If more apace is required) 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 8.201 ' W4.I/Jni2df.- (VFM) ACORD CORPORATION. All rinhfs rmmrvmrI stored 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 SCHEDULE Policy Number NAI 10958604 Endorsement Effective: 5/11/2019. 12:01 a.m. Named insured Countersigned NICOL CONSTRUCTION INC, DBA: NICOL CLIMATE CONTROL Name of Poison 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 same project. C. The words "you" 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 Wordino 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 Subroaation 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. 49-010807 11 May Include Copyrighted Material of Insurance Services Offices, Inc. Page 1 of I Used with permission ACCORtIr CERTIFICATE OF LIABILITY INSURANCE J DATE(MWDDNYYY) 10102/2019 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(les) 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 Customer Service Department Target Insurance Services lPHONE A/C No E.,(800) 450-8013 I . No): (866) 227-3052 6630 Flanders Drive EWJL Certnicates@premieragencyservices.com INSURER(S) AFFORDING COVERAGE NA/CS San Diego CA 92121 INSURERA: Security National Ins Co 19879 INSURED - INSURER B: Nicol Construction Inc., DBA Nicol Climate Control INSURER C: 67851 OcotlIlo Trail INSURER 0: INSURERE: Desert Hot Springs CA 92241 - - lJU F: Lar-K I WIGAIft NUMMK VV'-. IOlO DUiQIrflI IlIIUDD. 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 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. LTR __ - TYPE OF INSURANCE . . POUCY NUMBER POLICY EFF jDIyyyy POUCY EXP (Mp5yyyy) UNITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED PREP.ESES (Ea occurrence) S I CLAiMS-MADE [] OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY S GENt AGGREGATE LIMIT APPLIES PER POLICY fl LOC GENERAL AGGREGATE $ PRODUCTS- COMP/OP AGO $ _______ $ - _1OTHER. _______ AUTOMOBILE LIABILITY - COMBINED SINGLE UNIT (Eaaccldent) ANYAUTO BODILY INJURY (Per peacn) $ - OWNED 11 SCHEDULED - AUTOS ONLY ____ AUTOS HIRED I I NONOWNED - AUTOS ONLY AUTOS ONLY BODILY INJURY (Per adanI) ___________________ $ PROPERTY DAMAGE (Per $ - UMBRELLA IlAO Ld OCCUR EACH OCCURRENCE S AGGREGATE $ EXCESS UAB CLAIMS-MADE DED I I RETENTION S S - A MO,iI(ERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORPARTNERJEXECUTIVE ••• OFFICER/MEMBER EXCLUDED? L_J N/A V . SWC1217913 12/01/2018 _STATUTE I_I _ER 12101/2019 A PER I I 0Th- N ELEACHACCIDENT 1,000•000 E.L. DISEASE - EA EMPLOYEE S 1.000,000 (M.ndato.y In NH) If yes, desabe under DESCRIPTION OF OPERATIONS below - E.L. DISEASE- POLICY LIMIT 5 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached If mare space Is required) * Workers Compensation Waiver of Subrogation applies to the extent provided in the attached forms. Certificate holder RE: LAQuinta Project 52160 Avenida Herrera 'Subject to all policy terms. excl usions and conditions' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of La Qulnta ACCORDANCE WITH THE POLICY PROVISIONS. 78495 Calle Tampico AUTHORIZED REPRESENTATIVE La Quinta CA 92253 ii. I) / (5)1955-2015 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. 04.84) 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 1211/2018 Policy No. SWC1217913 Endorsement No. 6 Insured Nicol Construction, Inc. Premium $ 20,343 Insurance Company Security National Insurance Company Countersigned by WC 04 03 06 (Ed. 04-84)