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ENC2024-0034CALIFORNIA ENCROACHMENT PERMIT 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/or APPROVED SUBDIVISIONS. DATE: 03/28/2024 LOCATION OF CONSTRUCTION: Fronting APN 773-078-016 and 773-078-017; Avenida Bermudas South of Calle Tampico PURPOSE OF CONSTRUCTION: Place DG in public right-of-way by sidewalk DESCRIPTION OF CONSTRUCTION: Place DG next to sidewalk APPROXIMATE TIME WHEN WORK WILL BEGIN: 03/28/2024 DATE OF COMPLETION: 03/28/2024 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 regulations of the City of La Quinta and to pay for any additional replacement necessary as the result of this work. 78 BERMUDA LLC BRYAN NEWMAN Name of Applicant BRYAN NEWMAN Name of Contractor Contractor's License No. 78075 MAIN ST STE 104, LA QUINTA, CA 92253 (760) 275-2052 Business Address 50625 CALLE GUAYMAS, LA QUINTA, CA 92253 Business Address TBD City Business License No. Nautilus Insurance Compan NN1593345 Applicant's Insurance Company Policy Number FEES Credit Card Convenience Fee Technology Enhancement Fee Public Works Staff Time TOTAL: $4.78 $8.00 $183.00 $195.78 Telephone No. (760) 275-2052 Telephone No. PERMIT NO: ENC2024-0034 DATE ISSUED: 04/11/2024 EXPIRATION DATE: 04/11/2025 BY: Amy Yu If the work is covered by a Subdivision Improvement Agreement, Subdivider shall request final acceptance of improvements from the City Council. SITE � 105.8 7' PROPERTY LINE TEMPORARY 10 POWER POLE EXISTING 1 - 6"x 6"x 16' POLE IID POWER LOT 5 / APN 773-078-016 POLE 1 - METERMAIN 100 AMP SURFACE MOUNT PANEL LOT 6 / APN 773-078-017 UNIT NO.14 SANTA CARMELITA 3 - #2 THHN WIRE FOR RISER AT VALE LA QUINTA 1 - 10' PVC SCHEDULE 80 DG GROUND MB 18/82-83 -� 2 - GROUND RODS COVER I w 1 - 16' ARMORED #6 WIRE 0 0 1 - BELL BOX WITH 50 AMP PLUG WITH BUBBLE COVER o 48 m OWNER BRYAN NEWMAN °p o 1 - 50 AMP TWO POLE BREAKER :73 (760) 275-2052 Ln 2 - 20 AMP 120V BREAKER FOR (2) GFI PLUGS FOR SERVICE z W J O cn Q N 8 0 z LOT 5 �x Q BLOCK 122 ES�0° C O = C 105.78' PROPERTY LINE 0 o o w 0 0 o LOT 6 DG GROUND o O c� z o COVER o `n BLOCK 122 `o w 0 5 10 20 w z -' GRAPHIC SCALE: 1 "= 10' W 0 25.0' AHEITEC C E3 N 5 U L T I N G 105.68' PROPERTY LINE.. 777 East Tahquitz Canyon Way, Suite 309 Palm SPrings.0alifornia 92262 Phone:760.340.9060 I City of La Quinta The following General and Special Provisions are attached to and made a part of Permit Number ENC2024-0034 The followina shall always avvly: ENCROACHMENT ON PRIVATE PROPERTY: This permit authorizes work to be accomplished within the City of La Quinta's right of way ONLY. Whenever construction extends within private property, it is the responsibility of the permittee for his contractors to secure permission from abutting property owners. Such authorization must be secured by the permittee prior to starting work. TRACK -LAYING CONSTRUCTION EQUIPMENT: Cleated track -laying construction equipment shall not be permitted to operate on any paved surface unless fitted with smoother -faced street pads. All mechanical outriggers shall be fitted with rubber street shoes to protect the paving during excavations. Rubber -tired equipment only shall be used in backfill operation in paved areas. If the existing pavement is scarred, spalled, or broken during the term of this contract or if the pavement is marred, City of La Quinta shall request that these portions of road be resurfaced over their entire width. Resurfacing shall consist of one coat of two inches (2") of A.C. surfacing plus appropriate seal coat as specified above. PROTECTION OF TRAFFIC: All excavations and work areas shall be properly lighted and barricaded as deemed necessary by the City Engineer or City of La Quinta Public Works Inspectors. Suitable detours and detour signs shall be placed and maintained for the duration of the project. The City shall be notified twenty-four hours (24) in advance of any traffic detours or delineation. CARE OF DRAINAGE STRUCTURES: Any drainage structure to include corrugated metal pipe, concrete pipe, steel culvert and concrete structures encountered during excavation which necessitate removal shall be replaced in kind. In the event it becomes necessary to remove or cut existing drainage structures, City of La Quinta shall be notified prior to commencement of this work. Drainage structures and open drains shall be kept free of debris at all times for proper drainage. RIGHT-OF-WAY CLEANUP: Any surplus material resulting from excavation and backfill operations shall be removed from the right of way. All paved surfaces shall be broomed clean of earth and other objectionable materials immediately after backfill and compaction. Existing gutter line and drainage ditches shall be replaced to their original standard or better. All excess material shall be removed prior to paving. Water tanker shall be used, as required, to sprinkle the job site to keep down dust conditions and shall be used immediately after backfill. DE -WATER OPERTATIONS: If de -watering operations are required and pumps are forcing water on City of La Quinta roads, it shall be the responsibility of the permittee (contractor) to control this water and to provide off-street barricades when necessary. CLOSING STREETS: No street shall be closed. A minimum of one lane of traffic shall be maintained at all times to provide limited access for the adjoining property owners and emergency vehicles. In the event it is felt by the permittee that he must close a street for any length of time, permittee shall contact this office to obtain the necessary permission. SPECIAL PROVISIONS The following shall apply when indicated: ® R1 NOTIFICATION: Permittee shall notify the City at (760) 777 - 7097 at least forty-eight hours (48) in advance of starting construction. ❑ R2 UTILITY CLEARANCE: (Substructures) Prior to making any excavations within the City of La Quinta right-of-way authorized by permit, the permittee shall contact all concerned utility companies relative to the location of existing substructures. Damage to existing substructures resulting from operations conducted under this permit shall be the sole responsibility of the permittee. ® R3 UTILITY CLEARANCE (Surface Structures) No work shall be done under this permit until all utilities are clear of the proposed work site. The permittee shall notify all concerned utility companies of the proposed work. ❑ R4 PAVEMENT WIDENING: Area between the proposed concrete gutter line and the existing road pavement shall be surfaced with ( ** N/A ** ) inches of A.C. paving placed on ( ** N/A ** ) inches of ( ** N/A ** ) aggregate sub -base course having an "R" value of not less than ( ** N/A ") and in conformance with the City of La Quinta Road Improvement Standards and Specifications, Ordinance #461. ❑ R5 PARKWAY GRADING: Area between the property line and top of the proposed concrete curb shall be graded to a slope of one-fourth inch ('/4") to one foot (1'). ❑ R6 GRADE CHECKING: City of La Quinta shall check grades upon receipt of plan and profile and/or grades as established by a licensed engineer. ❑ R7 CURB REMOVAL FOR DRIVEWAYS: A portion of the existing concrete curb and/or curb and gutter (** N/A **) feet shall be removed. Curb and/or curb and gutter shall be saw cut prior to removal. Depressed curb, matching concrete gutter and concrete driveway approach shall be constructed in conformance with City of La Quinta Standard #207. ❑ R8 DRIVEWAYS: A.C. driveways shall be constructed as not to alter existing drainage pattern. Surfacing between the property line and the existing road paving shall be two and a half inches (2 '/2") of A.C. paving on (" N/A ") of class (" N/A ** ) aggregate base. ® R9 SIGHT CLEARANCE: Sight Clearance of six -hundred feet (600') in all directions shall be assured and maintained at all times. ❑ R10 SOIL STERILIZER: The area to be surfaced shall be treated with soil strerilizer. Rate of application shall comply with the manufacturer's specifications. City of La Quinta ® R11 COORDINATE WORK: The proposed work shall be subordinated to any operation, which the State of California or City of La Quinta may conduct in this area during the period of this permit. Work shall be coordinated with the State or City of La Quinta forces to preclude delay or interference with State or City of La Quinta projects. ❑ R12 SURVEY MONUMENTS: Prior to excavation or beginning of construction, all survey monuments which exist on the centerline of all streets or property lines when included shall be completely tied out so they may be readily and correctly, replaced by a licensed civil engineer or surveyor at the expense of the permittee. A complete set of notes showing the ties to these monuments shall be furnished to the City Engineer prior to the removal of any monuments. This office shall be notified upon completion or replacement of all survey monuments for proper clearance. ❑ R13 PAVEMENT CUTTING: Pavement will be mechanically saw cut to a straight edge prior to excavation. Method of pavement cutting shall be approved through the office of the City Engineer. (Under no circumstances shall excavating equipment be used to excavate prior to cutting or pavement.) Excavation material shall be placed in such a position as to best facilitate the general flow traffic. Prior to final paving operations, any damage to pavement straight edges shall be corrected. ❑ R14 LIMIT OF EXCAVATIONS: Excavations shall be limited to one -thousand feet (1000') of open trench before backfill operations must begin. All excavations shall be properly barricaded with lights overnight, on weekends and holidays for the protection of the traveling public. The Public Works Inspector shall determine the suitability of excavation barricading in each case. No excavation shall remain open for a period exceeding five (5) days. No excavation shall be made unless the construction material is actually on the work site. ❑ R15 BACKFILL MATERIAL: Backfill shall be free of brush, roots or other organic substance detrimental to its use for purposes of producing and adequately consolidated backfill. Ant material which the City of La Quinta deems unsuitable (spongy or saturated material) which is encountered during excavation shall not be used for backfill, but shall be supplemented or replaced by an approved sand or gravel. ❑ R16 BACKFILL SAND: Backfill shall be approved transit -mix sand or equivalent and shall be placed on lifts not greater than three feet (3') and vibrated using vibrostamper or equivalent equipment. Alternate methods may be substituted, but in any case, a relative compaction of ninety-five percent (95%) shall be maintained with the structural section of the roadway. ❑ R17 BACKFILL PLACEMENT: Backfill shall be applied in layers of not more than fifty percent (50%) of the total depth of the trench before flooding or a maximum of five feet (6) lifts where trenches are of excessive depths. Care is to be exercised that the backfill material is not subjected to extreme swell by flooding operations. Backfill material shall be placed so that the resulting compaction shall not be less than ninety percent (90%) or equivalent to the surrounding ground, whichever is the greater compaction. Where ponding or flooding is used for a maximum settlement, adequate dikes will be constructed to retain the water. Where jetting is used, the jets shall be of sufficient length to reach the bottom of each layer and the water supply shall be continuos. ❑ R18 COMPACTION TESTS: If so required by the inspector, compaction test shall be made at intervals of not more than one - thousand (1000') feet and a maximum of one (1) test on each road. One (1) copy of each test shall be forwarded tot the City Engineer for approval and filed prior to making permanent repairs. Compaction tests shall be made as outlined in Section 6.3.01 of the Standard Specifications, Division of Highways, State of California, dated January 1973. ❑ R19 COMPACTION TESTS: If so required by the Inspector, compaction tests shall be made for each crossing or service line. One (1) copy of each test shall be forwarded to the City Engineer for approval and filed prior to making permanent repairs. Compaction tests shall be made as outlined in Sections 6.3.001 of the Standard Specifications, Division of Highways, State of California, dated January 1973. ❑ R20 TEMPORARY PAVEMENT REPAIRS: After completion of backfill and compaction operations, a temporary patch consisting of two inches (2") of SC-800 shall be placed on a prepared sub -grade. The SC-800 temporary paving shall be placed after a maximum of three -thousand linear feet (3000') or trench has been excavated and backfill operations completed, but in no case shall the placement of the temporary pavement exceed a five (5) day limit. ❑ R21 PERMANENT PAVEMENT REPAIR: After backfill and compaction have been completed, a temporary patch consisting of three inches (Y) of SC-800 shall be placed immediately. A permanent patch of Asphalt Concrete surfacing per City of La Quinta Standard 600 shall be placed no later than ( " N/A ** ) days after completion of temporary road repair. ❑ R22 FOG SEAL: A fog seal coat consisting of an application of asphaltic emulsion shall be applied over all patch areas as determined by the City Engineer. ❑ R23 STREET RESTRIPING: Where street striping is still visible on street to be excavated, such striping shall be replaced upon completion of permanent repairs. ❑ R24 TREE RELOCATION OR REMOVAL: Tree relocation within the City of La Quinta road right-of-way shall be accomplished by a licensed, bonded and insured tree service, and handled safely without interference or hazard to the traveling public. It shall be the responsibility of the permitte to maintain the tree in a vigorous growing condition at its new location. Trees to be removed shall be in sections, which can be handled safely without interference or hazard to highway traffic. The entire width of the tree stump, shall be removed and disposed of so that no debris remains in view of the highway. The stump hole shall be backfilled and thoroughly compacted as specified in the following paragraph. Where it becomes necessary to restrict traffic, the work shall be restricted to a maximum of five -hundred feet (500') at any one time. Adequate signs, flagmen and or barricades shall be provided to protect the traveling public at all times. Large holes resulting from tree removal shall be backfilled and compacted to not less than ninety percent (90%) or equivalent tot the surrounding ground, whichever is the greater compaction as determined by the impact or field method. Compaction tests shall comply with Section 6.3.01 of the Standard Specifications, Division of Highways, State of California, dated January 1973. PERMIT NO. ENC2024-0034 Place DG by Sidewalk / Fronting APN 773-078-016 and 773-078-017; Avenida Bermudas South of Calle Tampico In addition to the standard permit conditions, the following shall apply: 1. Pursuant to Section 14.16.320 of the La Quinta Municipal Code (Ordinance 10 § 1 (part), 1982), all work shall be performed in accordance with the latest edition of the Standard Specifications For Public Works Construction (SSPWC) and as directed by and to the satisfaction of the City Engineer. 2. 78 Bermuda LLC (Bryan Newman), hereinafter referred to as "Permittee", shall be responsible for providing continuous dust and erosion control. This permit or copy of it shall be on the work site for inspection during the actual work performed. 4. Streets shall be kept clean. They shall be completely cleaned at the end of each working day and more frequently, if required. 5. Pursuant to Section 6.08.050 of the La Quinta Municipal Code (Ordinance 18 § 1, 1982), throughout the work site, the Permittee shall comply with City regulated work hours. Operation and maintenance of equipment within one-half mile of human occupancy shall be performed only during the following time periods: October 1st to April 30: Monday -Friday 7:00 a.m. to 5:30 p.m. Saturday 8:00 a.m. to 5:00 p.m. May 1st to September 30: Monday -Friday 6:00 a.m. to 7:00 p.m. Saturday 8:00 a.m. to 5:00 p.m. Work shall be prohibited on legal holidays and Sundays. Note: Construction work (including setting up traffic control devices) is not permitted on any Arterial street (ie any 4 lane street) before 8:30 a.m. and after 4:30 p.m. 6. Work within 500 feet of a signalized intersection shall be performed between the hours of 9 a.m. - 3 p.m. Traffic control shall be set up after 9 a.m. and removed before 3 p.m. The Permittee shall contact the City Traffic Maintenance Technician at (760) 777-7070 if signal operation at the intersection is to be altered in any way. 7. The permittee shall submit inspection requests by calling the City Inspection Hotline at (760) 777-7097 before 1:30 p.m. and at least twenty-four (24) hours prior to the anticipated inspection. 8. Pursuant to Section 14.16.110 of the La Quinta Municipal Code (Ordinance 10 § 1 (part), 1982), Permittee shall assume responsibility for repair of any pavement damage to any public or private street and for any damage to other City streets or facilities as a result of work performed under this permit. 9. The Applicant or Contractor shall furnish the City satisfactory evidence of insurance in the amounts provided in Engineering Bulletin for Indemnification & Insurance Requirements. This insurance shall be kept in full force and effect at all times by Applicant or Contractor during the prosecution of the permitted work and updated Certificate of Liability Insurance shall be submitted to the City. Each policy shall name the City as an additional insured. Special Conditions Page 1 of 3 PERMIT NO. ENC2024-0034 Place DG by Sidewalk / Fronting APN 773-078-016 and 773-078-017; Avenida Bermudas South of Calle Tampico 10. Pursuant to Section 14.16.250 of the La Quinta Municipal Code (Ordinance 10 § 1 (part), 1982), at residential streets, advance warning signs and traffic control shall be installed and maintained in accordance the latest edition of the California Manual of Uniform Traffic Control Devices (CA MUTCD) or the latest edition of the Work Area Traffic Control Handbook (WATCH). On Collectors to Arterial Streets, the permittee must submit a traffic control plan which shall be from or prepared under the guidance of the latest edition of the California Manual of Uniform Traffic Control Devices (CA MUTCD) or the latest edition of the Work Area Traffic Control Handbook (WATCH). Traffic Control plans not from the CA MUTCD or the WATCH shall be signed and stamped by a civil or traffic engineer registered in the State of California. It shall be the Permittee's responsibility to appropriately detour and barricade all construction sites. Pursuant to Section 14.16.290 of the La Quinta Municipal Code (Ordinance 10 § 1 (part), 1982), street closures shall not be permitted. A minimum of two (2) travel lanes of paved surface shall be maintained at all times. 11. Prior to excavating, if required, the Permittee shall contact Underground Service Alert at 1-800-422- 4133. It shall be the Permittee's responsibility to notify the Public Works Department of anticipated excavation which impact City facilities, including but not limited to traffic signal conduits and loops, irrigation lines, electrical conduits, and storm drain facilities. 12. Should additional work, materials, or modifications of the work be required in order to meet City standards, safety requirements, signage requirements, or to fit actual field conditions, the work shall be performed by the Permittee as directed by and to the satisfaction of the City Engineer at no cost to the City of La Quinta. 13. Pursuant to Section 14.16.370 of the La Quinta Municipal Code (Ordinance 10 § 1 (part), 1982), backfill compaction within street rights -of -way shall conform with Section 306-1.3 of the latest edition of the Standard Specifications For Public Works Construction (SSPWC), except as otherwise specified herein. No excavation is anticipated in the Scope of Work or within this permit. 14. All excavations within City of La Quinta right-of-way shall be backfilled, and temporarily paved if within the existing travel way, at the end of every workday as directed by and to the satisfaction of the City Engineer for the protection of the public. Lengths of open trench shall not greatly exceed that which can not be backfilled in the same day. Excavated trenches shall not be allowed open overnight, however, Permittee may leave a length of excavated trench, not to exceed twenty (20) feet in length, open overnight at a point where construction will begin the next day, provided that this length of trench is completely covered by steel plating. No excavation is anticipated in the Scope of Work or within this permit Special Conditions Page 2 of 3 PERMIT NO. ENC2024-0034 Place DG by Sidewalk / Fronting APN 773-078-016 and 773-078-017; Avenida Bermudas South of Calle Tampico 15. All landscaping, irrigation, decorative rock, decorative concrete, sidewalk, lighting, etc., shall be replaced to its original condition. 16. Any damage to public hardscape caused by work under this permit shall be repaired as directed by the City Engineer. This includes but is not limited to sidewalks, curb and gutter, landscaping, and pavement especially within the surrounding public streets. 17. Access and egress to all local properties shall be maintained at all times. 18. Pursuant to Section 14.16.375 of the La Quinta Municipal Code (Ordinance 10 § 1 (part), 1982), permanent pavement replacement shall be completed no later than seven (7) days after the completion of the work. Permanent pavement replacement shall conform to the following conditions: No asphalt work is anticipated within the scope of work or this permit. 19. Permittee shall permanently stabilize any and all soil that was disturbed as a result of work performed under this permit with an approved dust control treatment. Soil stabilization shall be done immediately after completing the operation. 20. The City of La Quinta reserves the right to require modifications of the work be made at permittee's sole cost for proper sight distance requirements per guidelines in the AASHTO "A Policy on Geometric Design of Highways and Streets, 5th Edition" or latest, in the installation of all appurtenances abutting and within the public street right-of-way. 21. Pursuant to Chapter 12.56 of the La Quinta Municipal Code (Ordinance 10 § 1 (part), 1982) the City has designated certain city streets as Truck Routes. The weight limit for restricted streets (i.e., streets not part of the Truck Route network) is three (3) tons; trucks exceeding the weight limit may use a restricted street if making a delivery or pickup on the subject street, or if this permit specifically grants permission to use the street to deliver street construction materials and/or equipment. 22. The City of La Quinta reserves the right to revoke, suspend or void this permit at any time. 23. The permittee shall indemnify, hold harmless and assume the defense of the City from all damages, delay costs, costs or expenses in law or equity that may arise out of work under this permit. Special Conditions Page 3 of 3 ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 04/11 /2024 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 Dean Mofidi Insurance Services, LLC 4633 East Ramon Road CONTACT NAME: Dean Mofidi AC,No,Ect: (760)318-4099 AID No: (760)318-4311 E-MAIL ADDRESS: dean@psinsureme.com Palm Springs, CA 92264 INSURERS AFFORDING COVERAGE NAIC # License #: OH05039 INSURER A: NAUTILUS INSURANCE COMPANY 17370 INSURED INSURER B INSURERC: 78 BERMUDA LLC 78075 MAIN ST STE 104 INSURER D : LA QUINTA, CA 92253 INSURERE: INSURER F : COVERAGES CERTIFICATE NUMBER: 00003141-263415 REVISION NUMBER: 5 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 SUER POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y NN1593345 08/29/2023 08/29/2024 EACH OCCURRENCE $ 1 000 000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JE� LOC PRODUCTS - COMP/OP AGG $ 1,000,000 $ OTHER: AUTOMOBILE LIABILITY CO MBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ HCLAIMS-MADE AGGREGATE $ EXCESS LIAB DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? N / A E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) LOCATIONS : APN# 773-078-016 & 773-078-017 City of La Quinta 78495 Calle Tampico La Quinta CA 92253 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATI�,XVEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH,,?rHE POLICY PROVISIONS. AUTHORIZED © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Printed by DDM on 04/11/2024 at 10:48AM POLICY NUMBER: NN1593345 COMMERCIAL GENERAL LIABILITY CG20121219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION - PERMITS OR AUTHORIZATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: City of La Quinta 78495 Calle Tampico La Quinta, CA 92253 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. I A. Section II — Who Is An Insured is amended to include as an additional insured any state or governmental agency or subdivision or political subdivision shown in the Schedule, subject to the following provisions: 1. This insurance applies only with respect to operations performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit or authorization. However: a. The insurance afforded to such additional insured only applies to the extent permitted by law; and b. 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. 2. This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or b. "Bodily injury" or "property damage" included within the "products -completed operations hazard". 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. This endorsement shall not increase the applicable limits of insurance. CG 20 12 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 COMMERCIAL GENERAL LIABILITY CG 20 01 12 19 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 LIQUOR 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 your 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 that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 NAUTILUS INSURANCE COMPANY CA POLICY NUMBER: NN1593345 Named Insured: 78 Bermuda LLC Endorsement Effective Date: 03/28/2024 Endorsement Type: other ENDORSEMENT # 1 Agency # 046600 BASS UNDERWRITERS, INC. 455 Universitv Ave Suite 330 Sacramento,CA 95825 GENERAL CHANGE ENDORSEMENT Amending class codes for locations 03 and #4 to 45539 in lieu of 49451 45539 - Land - occupied by person other than insured for business purposes - LRO - e) 12 rate 3.234 Adding the below AI to form CG2012 City of La Quinta 78495 Calle Tampico La Quinta, CA 92253 All other terms and conditions remain unchanged. Authorized Representative 0 4/ 11 / 2 0 2 4 Date Issued: S901 (06/22) Includes copyrighted material of Insurance Services Office, Inc., with its permission. Declaration Regarding California Workers` Compensation You are required to complete this form because you have not filed a certificate regarding workers' compensation insurance with City of La Quinta. California law requires all employers to carry workers' compensation insurance, even if they have only one employee. If you do not know whether you are required to carry workers' compensation insurance, find out by contacting the California Department of Industrial Relations ("DIR"). Information is also available on the DIR's website at http:JJwww.dir.ca.gov. You should also consult with your attorney, insurance agent or broker, or carrier regarding the specifics of your situation and your options. If you are subject to the Workers' Compensation Laws of California, you must promptly file a certificate of Workers' Compensation Insurance with City of La Quinta. If you have a certificate of self-insurance from the DIR, you must file that certificate with City of La Quinta. When completing this form, remember that the term "employee" includes clerical persons as well as any other persons employed by your company including drivers. ACKNOWLEDGMENT (initial) California Labor Code § 3700 requires employers to carry workers' compensation insurance or to obtain a certificate from the Director of Industrial Relations demonstrating that the employer is self -insured. California Labor Code § 3700.5 makes it a criminal offense for an employer to fail to secure compensation as required by the workers' compensation provisions of the Labor Code. Violation of Labor Code § 3700 is punishable by a fine of up to $10,000 and/or imprisonment for up to one year. (initial) California Labor Code § 3710.1 provides that where an employer fails to provide compensation required under § 3700, the Director of the Department of Industrial Relations shall issue a stop order, prohibiting the employer from using employee labor until such time as the employer complies with the provisions of § 3700. Labor Code § 3710.2 makes it a criminal offense to disregard such stop orders. W_ (initial) I acknowledge that if evidence is found that contradicts this declaration, City of La Quinta will promptly notify all relevant state agencies to ensure full insurance compliance required by Workers' Compensation Laws of California. �0_ (initial) I understand that California Labor Code § 3700 et seq. requires employers to provide workers' compensation insurance coverage for any employees of my business. I hereby warrant that this business is exempt from the California Labor Code provisions regarding workers' compensation insurance because it has no employees. 1.0 (initial) I agree to hold City of La Quinta and its officers, officials, employees, and agents harmless for loss or liability which may arise from the failure of my business to comply with the laws of the State of alifornia regarding workers' compensation insurance. (initial) If I hire employees in the future, I will immediately notify City of La Quinta and provide a certified Workers' Compensation certificate to the City. CERTIFICATION I (we) certify under penalty of perjury, under the laws of the State of California, that I (we) have read and understood the above stated requirements regarding Workers' Compensation and that I(we) am (are) in compliance. I(we) certify that the forgoing is true and correct. �7� �+ Executed thisyS day of vi # 20 A2 at 4—California Signat a eclarant Print Name of Declarant fmyd u Print Name of Company