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ENC2023-0006ta Qaigra -- GEM oftb<DESERT — ENCROACHMENT PERMIT PUBLIC WORKS CONSTRUCTION See below for Finance Revenue Codes For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains and other like public works improvements in connection wth MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS. DATE: 1/13/2023 LOCATION OF CONSTRUCTION(Street address or Description): JEFFERSON ST (INDIO BLVD TO AVE 50) PURPOSE OF CONSTRUCTION: REAS TYPE II SLURRY SEAL (JOINT PROJECT WITH INDIO AND LA QUINTA). DESCRIPTION OF CONSTRUCTION: JOINT SLURRY WITH INDIO DIMENSION OF INSTALLATION OR REMOVAL: FULL WIDTH OF ASPHALT GUTTER TO GUTTER FROM INDIO TO AVENUE 50 (4 MILES) APPROXIMATE TIME WHEN WORK WILL BEGIN: 1/8/2023 TIME OF COMPLETION: 6/30/2023 ESTIMATED CONSTRUCTION COST: (Including removal of all obstruction, materials, and debris, backfilling, compaction and placing permanent resurfacing and/or replacing improvements) COMMENTS: THIS ENCROACHMENT PERMIT IS FOR WORK WITHIN THE CITY OF LA QUINTA ONLY 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 ity of La Quinta and to pay for any additional replacement necessary as the result of this work. PETROCHEM MATERIALS INNOVATION LLC 6168 INNOVATION WAY CARLSBAD, CA 92009 Name of Applicant (please print) Business Address PETROCHEM MATERIALS INNOVATION LLC 6168 INNOVATION WAY CARLSBAD, CA92009 Name of Contractor and Job Foreman Business Address 991274 Contractor's License No. CRUM+ & FORSTER SPECIALTY INSURANCE COMPANY Applicant's Insurance Company inance Revenue Code TOTAL: $0.00 765507 City Business License No. GLO-091457 Policy Number PERMIT NO: ENC2023-0006 DATE ISSUED: 1/13/2023 EXPIRATION DATE: 7/12/2023 BY: UBALDO AYON WORK INSPECTED BY*: PERMIT COMPLETION DATF reirCpplicant o- (760)603-0961 Telephone No. (760)603-0961 Telephone No. *If the work is covered by a Subdivision Improvement Agreement, Subdivider shall request final acceptance of improvements from the City Council. T4hf 4 4 a" PUBLIC WORKS DEPARTMENT APPLICATION FOR PERMIT Date: r 1�'5 /�VT9 Tract No: I Project Name:. �_n �: 7 LJ10D_ Vicinity �•��_ �. ���� L • _ � Purpose of Construction (i.e.: Rough Grading, Offsite Street, etc.)A� "rymM Description of Construction (i.c.: See Plan Set No. 01234) '0WPL-kCAwL-> tM�� "P><CAS Q( SS y 'Tr- AS"A4LT-. Dimension of Installation or Removal:. L_)�T(k C`. - Approximate Construction Start Date: I j Zo_'� Approximate Construction Comp tion Date:, Estimated Construction Cost: $f t" C)Q�� Estimated Construction Cost shall include the removal of all obstructions, materials, and debris, back -filling, compaction and placing permanent resurfacing and or replacing improvements Name of Contractor: Contractor Address: r A,,A %? A Contractor Telephone Number: F&Aw4c Contractor State License Numbe�Z�+-f, Contractor City Business License Number: Contractor E-mail Address:, �{�,�,j.j (f T-[b2A_-pc,c)j2!?L< , Co", ►A COPY OF THE CURRENT INSURANCE CERTIFICATE MUST BE PROVIDED Applicant or Contractor General Liabil� Insurance Company: Z0V Ic A'~ 1 l t '� f i4-1'E C v. Applicant or Contractor General Liability Insurance Policy Number: Office Use Only: I I Office Use Only: Inspection Fee: Assigned Permit Number: Permit Fee: Approval Date: As -Built Expiration Deposit• Date: Dust Control Issue Deposit: Date: Credit Amount: Administrative Authority: TOTAL FEE DUE: PETRMAN-01 BFENG ,4coR0 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1 /18/2023 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 License # OC36861 San Diego-Alliant Insurance Services, Inc. 701 B St 6th FI San Diego, CA 92101 CONTACT Robin Hamilton NAME: PHONE FAX (A/C, No, Ext): (951) 225-2578 (A/C, No): ADDRESS: Robin.Hamilton@alliant.com INSURERS AFFORDING COVERAGE NAIC # INSURER A: Crum & Forster Specialty Insurance Company 44520 INSURED INSURER B: Zurich American Insurance Company 16535 INSURER C : Petrochem Materials Innovation, LLC INSURER D : 6168 Innovation Way Carlsbad, CA 92009 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 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 ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM DD YYY POLICY EXP MM DD YYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X X GLO-091457 10/1/2022 10/1/2023 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence 50,000 $ MED EXP (Any one e'son) $ X Ded - $5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X PECOT- ❑ LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY BAP106300404 10/1/2022 10/1/2023 COMBINED SINGLE LIMIT Ea accident 1,000,000 $ X BODILY INJURY Perperson) $ BODILY INJURY Per accident $ X PROPERTY DAMAGE Per accident $ A UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE SEO-120522 10/1/2022 10/1/2023 EACH OCCURRENCE $ 5,000,000 X AGGREGATE $ 5,000,000 DED RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A X WC106300304 10/1/2022 10/1/2023 X PER OTH- STATUTE ER E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Encroachment permit. City of La Quinta is named additional insured (GL) per attached. Coverage is Primary and non contributory. Waiver of subrogatio applies(GL/WC). CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of La Quinta Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 78-495 Calle Tampico La Quinta, CA 92253 AUTHORIZED REPRESENTATIVE i� ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 33 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN A WRITTEN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured. However, the insurance afforded to such additional insured: 1. Only applies to the extent permitted by law; and 2. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, engineering or surveying services. CG 20 33 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 2 2. "Bodily injury" or "property damage" occurring after: a. 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 b. 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. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement you have entered into with the additional insured; or 2. Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. CG 20 33 12 19 © Insurance Services Office, Inc., 2018 Page 2 of 2 COMMERCIAL GENERAL LIABILITY CG20371219 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 prior to the As required by written contract signed prior to the "bodily injury" or "property damage". "bodily injury" or "property damage" and if covered under this policy. 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: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 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: 1. Required by the contract or agreement; or 2. Available under the applicable limits of insurance; whichever is less. 2. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the applicable limits of insurance. 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. CG 20 37 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 Policy Number: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under this policy provided that: (1 ) The additional insured is a named insured under such other insurance; and (2) You have agreed in writing in a contract or agreement prior to the injury or damage that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured where the additional insured is a named insured. However, the insurance provided under this endorsement will not apply beyond the extent required by such contract or agreement. 1<111S431t:I4I Ilt4!4 E--7_1►IsX610121111 WalZR3eIiki:I&2201RLWA.442"1iTM111111101ilyVLei 41.1 CFSIC-GL-1002(0912020) Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Person or Organization: Any person or organization you have agreed in a written contract to waive any right of recovery against provided the written contract is signed prior to the injury or damage Effective Date: The later of the effective date of this policy, the date of this endorsement, or the date on which "your work" first started on the project to which this endorsement applies, but in no event later than the policy expiration date or applicable earlier termination date of this policy The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations. This endorsement applies only: 1. to ongoing operations performed by the Named Insured for the person or organization named above on or after the effective date of this endorsement; and 2. when you and such person or organization have agreed in writing in a contract or agreement entered into prior to the loss or occurrence that such right of recovery is waived; and 3. when the "suit" for damages against the person or organization in the Schedule is based on the Named Insured's sole negligence. Subrogation shall not be waived with respect to any liability arising directly or indirectly out of any of the following actions of persons or organizations named above: 1. "Professional services"; 2. Modifying or changing specifications without the express written consent of the Named Insured; or 3. Any activities beyond the scope of monitoring the progress of the Named Insured. For the purposes of this endorsement, "professional services" includes but is not limited to the following: 1. Preparing, approving, recommending, or failing to prepare, approve, or recommend maps, drawings, opinions, reports, surveys, change orders, designs, specifications, hazard assessment plans, response actions, abatement methods or products, air monitoring plans, or insurance requirements; 2. Supervisory, inspection, training, or engineering services; and/or 3. Monitoring, testing, analysis, legal, accounting, architectural, medical, processing, consulting, or advisory services. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. This endorsement forms a part of the Policy to which attached, effective on the inception date of the Policy unless otherwise stated herein. (The following information is required only when this endorsement is issued subsequent to preparation of the Policy.) Endorsement effective: Policy No.: Endorsement No. : Named Insured: Countersigned by CFSIC-GL-2490(10/2013) Page 1 of 1 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 04 03 06 (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 0 % of the California workers' compensation pre- mium otherwise due on such remuneration. Schedule Person or Organization Job Description ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY FOR WORK PERFORMED BY YOU FOR THAT PERSON AND/OR ORGANIZATION. WC 252 (4-84) WC 04 03 06 (Ed. 4-84) Page 1 of 1