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TC2016-00784 See below for Finance Revenue Codes ENCROACHMENT PERMIT Of PUBLIC WORKS CONSTRUCTION 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: 10/25/2016 LOCATION OF CONSTRUCTION(5treet address or Description): FRED WARING- JEFF/DUNE PALMS PURPOSE OF CONSTRUCTION: STRIPING OF BIKE LANE DESCRIPTION OF.CONSTRUCTION: ONE DAY; FRED WARING; STRIPING MODIFICATIONS DIMENSION OF INSTALLATION OR REMOVAL: 2165 IF OF BIKE LANE MATE TIME WHEN WORK WILL BEGIN: 10/25/2016 TIME OF COMPLETION: 10/25/2016 ESTIMATED CONSTRUCTION COST: S3.373.00 (Including removal of all obstruction, materials, and debris, backfilling, compaction and placing permanent resurfacing and/or replacing improvements) COMMENTS: SEE PROJECT CONTRACT AND SPECIFICATIONS FOR WORK ORDER 2016-0013 FOR PERMIT CONDITIONS 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. Signature of Applicant or Agent SUPERIOR PAVEMENT MARKINGS INC 5312 CYPRESS ST CYPRESS, CA 90630 (714)995-9100 Name of Applicant (please print) Business Address Telephone No. SUPERIOR PAVEMENT MARKINGS INC 5312 CYPRESS ST CYPRESS, CA 90630 (714)995-9100 Name of Contractor and Job Foreman Business Address Telephone No. 776306 : 111794 CoOtractor's License No. City Business License No. IRONSHORE SPECIALITY INSURANCE COMPANY AGS0078000 Applicant's Insurance Company Policy Number Finance Revenue Code TOTAL: $0.00 PERMIT NO: TC2016-0078 DATE ISSUED: EL!. c/, EXPIRATJPN DATE: W6RK INSPECTED BY*: PERMIT COMPLETION DATE*: 1f the work is covered by a Subdivision Improvement Agreement, Subdivider shall request final acceptance of improvements from the City Council. California MUTCD Page 66-9 (FHWA's MUTCD 2003 including Revisions 1 and 2, as amended for use in California) Figure 6C-71i. Component Parts of a Temporary Traffic Control Zone Legend I Direction of- travel ..: . •.:':: : .• I . I. . . . .. ... Downstream Taper Termination Area 21e1s traffic resume normal operations Suitor Space (longItudinal) . . ..,... .. .. Tridlic Space . . . . • : . .. aiuic Work 1 the activity area IS $01 aside (or r.. wor liars. equipment . . . . . L . and material storage I . .. . . . . . 4 . . . ....... Activity Area .... lsWhere work Butter Space 1 4 lakes place provides . .. . BUOSO •• . .. . protecUon . .2 (longitudinal) • ...... for Irotf I provides pmtactton for and workers. tmtfc and workers TMnSl ...................................... ......................................... L.,. . . . . ... .. .: ..... .. . lIoNea movos traffic but -r,1r'1 • ci Its normal path ..t . . . . . . . . . .. .• • a — '.. •' ShoulderTapar . . . . . . . . .... 0 Advance Warning Area ' tells traffic what to I ' expect ahead : . ..• . . . .: . . r- z' i-_'' $ . . . . . . . • •.: :. . . . ( .4 . .X.. . & ••L4s• • ':4 .' . ..• .. .:i. . .. .• • . ... •• .•• .. . . . ••. .•. Chapter 6C — Temporary Traffic Control Clements January 21,2010 Par' 6- Temporasy Traffic Control il o 4 aM1L 100 PUBLIC WORKS DEPARTMENT APPLICATION FOR PERMIT Date 1000e1'24 2016 act No: Project Name: gg €! cinity'etween Dune PIms R efferonAve - Purpose of Construction (i.e.: Rough.Gradiñg, Offsite Street, etc.) - Description of Construction (i.e.: See Plan Set No. 01234) Dimension of Installation or Removal: L Approximate Construction Start Date: Qtqhe 2Qt6;: : Approximate Construction Completion Date I0ctóbë25 2016 Estimated Construction Cost Estimated Construction Cost shall include the removal of all obstructions, materials, and debris, back-filling, compaction and placing permanent resurfacing and or replacing improvements Contact Name mith L hone Number 09/844-7518 Name of Applicant/Owner Applicant Address 0'E Applicant Telephone Number 951-845-2799 1' ' Applicant E-mail Address:[ Name of Contractor: Contractor Address: I65Ô E.Firs t!Bèaüinnt 'Ca. 9 TT[... Contractor Telephone Number: Contractor State License Number: 776306 :. 4 . ' ;•- .1 Contractor City Business License Number: 10111794 - 1"14*4V1*`V1 Contractor E-mail Address:nnu rveetitmarkij"corn . fl A COPY OF THE CURRENT INSURANCE CERTIFICATE MUST BE PROVIDED-4 Applicant or Contractor General Liability Insurance Company:.. dian Harbor irVsu?ar'Ee Compan Applicant or Contractor General Liability Insurance Policy Number: SG0.048259 Office Use Only: . Office Use Only: Inspection Fee: Assigned Permit Number: 7.'( -Z_ ,c - C) O 78' Permit Fee: Approval Date: As-Built Expiration Deposit: - Date:___________________________________________________ Dust Control issue Deposit: . . Date: Credit Amount: . - Administrative Authority: TOTAL FEEDUE: i JritIIc :nrkIlee — Frirrna X £&r,r,IIr'?I,,r1I. .nriIi,-tirn 0i.arvyit n,et,I ARt? CERTIFICATE OF LIABILITY INSURANCE I DATE (MMIDDIYYYY) 10/11/2016 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 Patriot Risk & Insurance Services 100 Spectrum Center Drive, Suite #400 Irvine, CA 92618 CONTACT NAME: PHONE I FAX INC, No. Ett: (949) 486-7900 I (Nc. No): (949)486-7950 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC H INSURER A: Indian Harbor Insurance Company 36940 www.pathsk.com 0K07568 INSURED Superior Pavement Markings, Inc. INSURER B: Ohio Casualty Insurance Company 24074 INSURER C: Scottsdale Insurance Company 41297 5312 Cypress St. Cypress CA 90630 INSURER D: Security National Insurance Company 33120 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 32323185 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. INSR LTR - TYPE OF INSURANCE L. • ii • POUCY NUMBER POLICY EFF lilliMpoInnryl POLICY EXP iMMioirnryn UNITS____________ A - / COMMERCIALGENERALUABILITY CLAIMS-MADE OCCUR / - - ESG0048259 9/18/2016 9/18/2017 EACH OCCURRENCE $ 1,000.000 DAMAGE To RENTED PREMISES (Es ocrsirrsncu) $ 300,000 MED EXP (My one person) $ 5. 000 PERSONAL SADVINJURY $ 1,000, 000 GENt AGGREGATE LIMIT APPLIES PER: PoucyJECT LOC _IOTHER: GENERAL AGGREGATE $ 2,000,ODO PRODUCTS - COMP/OP AGG $ 2,000,ODO $ B AUTOMOBILE LIABILITY L ANY AUTO OWNED - AUTOS ONLY fl SCHEDULED AUTOS HIRED NON-OWNED - AUTOS ONLY AUTOS ONLY BA057466224 8/1/2016 8/1/2017 1!ISINGLE LIMIT $i,aoo.00n BODILY INJURY (Per person) S BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per ecdent) $ C L UMBRELLAUAB EXCESS UAB LJ OCCUR I CLAIMS-MAOE - - - - XLS0100567 9/18/2016 9/18/2017 EACH OCCURRENCE $ 5.000.000 - AGGREGATE $ 5,000,000 - DIED I I RETENTIONS $ - D - WORKERS COMPENSATION AND EMPLOYERS' LIABIUTY YIN ANYPROPRIETORIPARThERIEXECUTIVE OFPICERIMEMBEREXCLUDED? '( (Mandatory In NH) If yes, describe under DESCRIPTiON OF OPERATIONS below NIA - / - SWC1111690 6/1/2016 6/1/2017 / PER v STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE- EA EMPLOYEE S 1,000.00 E.L. DISEASE -POLICY LIMIT I S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more Space Is required) Re: SPM Job #4771 / Fred Warning Drive Striping Modifications- La Quints City of La Quinta is named as Additional Insured as respects to General Liability per endorsement attached where required by written contract. Waiver of Subrogation applies In favor of Workers Compensation per attached endorsements. 30-day notice of cancellation / 10-days for non-payment of premium. CERTIFICATE HOLDER CANCELLATION City of La Quinta SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 78495 Calle Tampico THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. La Quinta CA 92247 AUTHORIZED REPRESENTATIVE .. I Leonard E. Ziminsky © 1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 32323185 I 16,17 OL/AU/tMB/WC I Annette Romero I 10/11/2016 113023 AM (par) I Page 1 of 5 This certificate cancels and supersedes ALL previously issued certificates. Superior Pavement Markings, Inc. POLICY NUMBER: ESG0048259 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED — OWNERS, LESSEES OR CONTRACTORS — SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations As required by written contract signed by both All Locations parties prior to loss Information required to complete this Schedule, If not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: Your acts or omissions; or The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However The insurance afforded to such additional insured only applies to the extent permitted by law; and If coverage provided to the additional insured is required by a contract or agreement, the Insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: 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- location 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. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 32323185 I 16/17 GL/AU/UP/WC I Annette Romero I 10/11/2016 113023 AI (PDT) I Page 2 of 5 This certificate cancels and supersedes ALL previously issued certificates. C. With respect to the insurance afforded to these additional insureds, the following is added to Section In - LImits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured Is the amount of insurance: 1. Required by the contract or agreement or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 ©insurance Services Office, Inc., 2012 CG 20 10 04 13 32323105 I 16/17 GL/AU/UMB/WC Annette Romero I 10/11/2016 11,30,23 AN (P01') I Page 3 of 5 This certificate cancels and supersedes ALL previously issued certificates. Superior Pavement Markings, Inc. POLICY NUMBER: ESG0048259 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED — OWNERS, LESSEES OR CONTRACTORS — COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations As required by written contract signed by both parties prior to loss All Locations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section Ii — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". However The insurance afforded to such additional insured only applies to the extent permitted by law; and If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional Insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: Required by the contract or agreement; or Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 37 04 13 © Insurance Services Office, Inc., 2012 Page 1 of I 32323185 I 16/17 GL/AU/r.848/WC I Annette Romero I 10/11/2016 113023 A14 (POT) I Page 4 of 5 This certificate cancel. and .upexuedee ALL previously issued certificates. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY I WC 0403 od (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA 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 2.00% 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. Endorsement EffectIve 6/1/2016 PolIcy No. SWC111169O Endorsement No. Insured Superior Pavement Markings, Inc. .. •• Insurance Company Security National Insurance Company Countereigned by t~ 32323165 I 16/17 GL/AU/W48/WC I Annette Romero I 10/11/2016 113023 M (POT) I Page 5 of S This certificate cancel, and supersedes ALL previously issued certificate,. California MUTCD Page 6C-9 (FHWA's MUTCD 2003 including Revisions I and 2, as amended for use in California) Figure 6C-1. Component Parts of a Temporary Traffic Control Zone 1J— Legend I Direction of travel I' •t1 : Downstream Taper Termination Area lets traffic resume normal operations Suffer Space (lorigiludinal) Traffic Space allows traffic to pass through the activity area Work Space Is Sot aside for workers, equipment. and material storage Butler Space (lateral) provides protection for ItalIc and workers Buffer Space (longitudinal) provides protection for traffic and workers Activity Area Is where wcdc takes place Transition Area moves traffic out of Its normal path a a I L i U 0 J. I Chapter 6C— Temporaiy Italic Control Elements Part 6 - Temporary Traffic Control Shoulder Taper Advance Warning Area tells traffic what to expect ahead January 2 I, 2010