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Home My WebLink About03-30000030 ENCROACHMENT PERMIT CITY OF BAKERSFIELD PUBLIC WORKS DEPARTMENT 1501 TRUXTUN A VB BAKERSFIELD CA 93301 (661) 326-3724 TO THE CITY ENGINEER OF THE CITY OF BAKERSFIELD CALIFORNIA: Pursuant to the provisions of Chapter 12.20 of the Bakersfield Municipal Code, the undersigned applies for a permit to place, erect, use and maintain an encroachment on public property or right of way as therein defined. Application Number pin number . . . . . . Property Address parcel/APN: Application description 03-30000030 Date 7/21/03 4667 730 POTOMAC AVE 172-122-04-00-5 PW - ENCROACHMENT PERMIT Owner Contractor UNION CEMETERY ASSN POBOX 3066 BAKERSFIELD CA 93385 OWNER/BUILDER BAKERSFIELD CA 93301 --------------------------------------------- Permit . . . . . Additional desc . Phone Access Code Permit Fee Issue Date . . . ENCROACHMENT PERMIT 109561 145.00 7/21/03 valuation o Qty Unit Charge Per 1.00 145.0000 EA PW ENCROACHMENT Extension 145.00 -------------------------------------------------- Special Notes and Comments , irrigation pipe line under S. King st - consisting of 14" steel conductor with 8" CL 160 water line. Ins. ok per. Risk Mgmt Location is Union Cemetery, King and Potomac Fee sununary Charged Paid Credited Due ----------------- ---------- ---------- ---------- ---------- Permit Fee Total 145.00 145.00 .00 .00 Grand Total 145.00 145.00 .00 .00 Applicant acknowledges the right of the City Engineer, pursuant to the Bakersfield Municipal Code Chapter 12.20 to revoke the pe' time. t ~~=- ~\'SC~ 'nt Name ' I HEREBY CERTIFY THAT I HAVE MADE AN INVESTIGATION OF THE FACTS STATED IN THE FOREGOING APPLICATION AND FIND THAT THE MAINTENANCE OF SAID ENCROACHMENT (1) WnL (NOT) SUBSTANTIALLY INTERFERE WITH THE USE OF THE PLACE WHERE THE SAME IS TO BE LOCATED AND (2) WnL (NOT) CONSTITUTE A HAZARD TO PERSONS USING SAID PUBLIC PLACE; SAID APPLICATION IS THEREFORE (GRANTED) (DENIED), Said permit shall expire on date stated above. , ,. U Signature of City Engineer ~ - Additional Terms on the Back Applicant agrees that if this application is granted. applicant shaU indemnify, defend, and hold harmless CITY, its officers, agents and employees against any and alI liability, claims, actions, causes of action or demands whatsoever against them, or any of them, before administrative or judicial tribunals of any kind whatsoever, arising out of, connected with, or caused by applicant, or in any way arising from, the terms and provisions of this permit or the placement, use (by applicant or any other person or entity) or maintenance of said encroachment. whether or not caused in part by a party indemnified hereunder, except for CITY's sole active negligence or willful misconduct. The applicant further agrees to maintain the aforesaid encroachment during the life of the said encroachment or until such time that this permit is revoked. Applicant further agrees that upon the expiration of the permit for which this application is made, if granted. or upon revocation thereof by the City Engineer, applicant will at his own cost and expense remove the same from the public property or right of way where the same is located, and restore said public property or right of way to the condition as nearly as that in which it was before the placing, erection, maintenance or existence of said encroachment. Applicant further agrees to obtain and keep all liability insurance required by the City Engineer in fulI force and effect for however long the encroachment remains. Applicant shall furnish the City Risk Manager with a certificate of issuance evidencing sufficient coverage for bodily injury or property damage liability of both and required endorsements evidencing the insurance required. I have read and acknowledge the above. ~ ~licant's Initials 3~ v' !) q/Jg 1fI' 4 . - BAKERSFIELD PUBLIC WORKS DEPARTMENT MEMORANDUM TO: Raul M. Rojas, Public Works Director FROM: Marian P. Shaw, Civil Engineer IV, Subdivisions DATE: July 29,2003 SUBJECT: Encroachment Permit Application for 8" cl. 160 private irrigation line across S. King St. north o/Virginia Ave. Union Cemetery Association 730 Potomac Ave. Engineering and Traffic staff has reviewed the attached encroachment permit to allow the installation of 8" cl. 160 private irrigation line across South King Street north of Virginia A venue. The site is located at 730 Potomac Avenue. The applicant has provided proof of appropriate insurance coverage to Risk Management, and has provided signatures of all immediate neighbors stating that they have no objection to the proposed construction. Based on their review, staff recommends approval of the permit. S:\PERMITS\ENCROACH\03-04 Pennits\730 Potomac Ave.doc 03 ~ 3 0 \ IE ,0: \: I, ~ en UNION CEMETERY WEST SIDE OF' KING ST. UNION CEMETERY EAST SIDE OF' KING ST. , f'ROI'OS[D ROAD BORE LOCATION ________________J : _ V;;~~~~~~:~.~t-- jth ...sIBErt 1- ----r- r----------------- I I I ~ ----------------. I I I I I I I I I BORE LOCATION DETAIL HYDRA TEe IRRIGA flON FOR A GROWING WORLD ~ NORTH 1'. STEEl PIPE CASING WILD STEEl PIPE 1/'. WALL OR APPROVED EQUAL s" CL 1 eo IPS PVC GASKETED PIPE s.s~. OD. X 7.11" ID. (SOH 26) z.x,. WOOD SKIDS CONTINUOUS CROSS SECTION BORE NOTES 1. ~ BORE WILL BE ON A 90 DEGREE ANGLE ACROSS THE eo' CITY RIGHT Of WAY AS SHOWN ON THIS IW'. 2. ROAD BORE LOCATION WILL HAVE DISTANCE WEASURED IN FEET FROM THE CENTER or VIRGINIA AVE, AS DESCRIBED ON THE ATTACHED APPUCAOON rORW. 3. ~ BORE WILL WEET THE CURRENT CITY STANDARDS. UNION CEMETERY S. KING ST. & VIRGINIA AVE. ROAD BORE DETAIL SHEET DA1I MY_ ICM.I ... 10 ICM.I IPIC. NO. 1111. II1II1' 110. _:-(;tI;a.'l;l..~t: l'I.lr"J:III"~a.'fiI:l" ~"'liF.l.I.l.-.-a.'.l~l".:f SENT BY: CITY O~ BAKEAS~IELDj 661 3:24 74B3j JUL-7-03 4::29PMj PAGE 7!7 APPLICATION FOR ENCROACHMENT PERMIT TO THE CITY ENGINEER OF TilE CITY OF BAKERSFIELD, CALIFORNIA: Pursuant to the provisi~ ofChaptcr 12.20 of the Bak~sfield Municipal Code,'the undt:rsi~ed applies fOf a permit to place, en:ct, use and mamtam an encroacmnent on pubhc property or right-of-way as therem defined, 1, Full name of applicam and complete address including phone number: UNI ON ~1?Me' i1:JIZf( Ass;'; , k.f."'~ PO't7JM Ae. {p. p, f?(J~ i O~fP, 'i1A~F7BL1~ COA q ~ 3 8S- 2, Nature or description of the cncroachment (or which this application is made: ,720M Irrl 'ndN 0 ~C)L.<Ill~ ~'M ftAut. CC/N1~S'tl.v CuI'JOlA. C'n,(..., WIT,., fj · ~ c... 'hDCS"~ ,,) WATl:?fZ. LtN IT 3, Location of the proposed encroachment: Pea..p~ O/CIA " All... "t-tJ C~"'ff:,fl.. 4JG" 0' .1U<'th ~(^t 43 W: /l)(/,..~ ()I ~~IL L<I\JE' 0+ Vr I f(lr rtJrut 4, Period of time for wbich the ene cot is to be maintained: Fo~ pe-e Pe'T"unfj ...... flJQI1F W 1"1)4 p~c 411 ~ Applicant agrees tha.t if this application is granted, applicant shall indemnjfy, defend and 110Jd harmless City, its otlicers, agents and c;mpJoyees against.~y an~ allliabil.ity, ~~lS, a~Ol~s, cau~es oi action or deJ~'1.a.1ldsl wllatsoevc::r ~~I1St them, or any of them, before adnUrtlstratlvc, quasl-JudlcJal, or Judicial tnbunals of any kind wnatsoever, arising out 0(, conncetod with, or caused by applicant's placement, erection, use (by applicant or any other pCf$on or entity) or maintenance of said encroachment. The applicant furthcr agrees to maintain the aforcsaid clleroachrncnt during the life of said encroachment or until such time iliat this permit is revoked. Applicant further agrees to obtain and keel> allliabiIity insurance required by the City Engineer in full foree and cffect for however long the encroachment remauts. Applicant shall furmsh the City Risk Manager with a Certificate of Insurance evidencing sufficient coverage f()r bodily anjury or property damage liability or both and required endorsements evidencing the insurance required. The iype(s) and amount(s) of insurance cover3Sc is: _" LOO(;, 000 ~OlJ.p~~t~ 6e.v~f.., LIIV31L-f~ Applicant acknowledges the right of the City Engineer, pursuant to Bakersfield Municipal Code Chapter 12,20 to revoke the permit sf an~c. ./"- Dare: 7 / / ~ ()() 3---.,. . 19IJature 0 PERMIT I HEREBY CERTIFY THAT I HAVE MADE AN INVESTIGATION OF THE FACTS STATED IN THE FOREGOING APPLICATION AND FIND THAT THE MAINTENANCE OF SAID ENCROACHME.NT (1) WILL (NOT) SUBSTANTIALLY IN'l'ERFERE WlTn THE USE OF THE PUBLIC PLACE WHERE THE SAME IS TO BE LOCATED AND (2) WILL (NOl) CONStITUTE A HAZARD TO PERSONS USING SAID PUBLIC PLACE; SAID APPLICATiON IS THEREFORE (GRANTED) (DENIED). SAID PERMIT SHAL,L EXPIRE Date: Slgnat\lre of City Engineer No. <.1:" 'R()\ J~I )1\'J\"'('lIll'~\";n.DlT'IrlaoChmC:l\fPt: l'TJ'IitA 9p. wpi CERTIFICATE OF LIABILITY INSURANC~~g~AH I DA~Lt:;;~,l3 THIS CERTIFICATE IS ISSUED AS A MATTER OF 1NF~~TlON ONL,( AND CONFERS NO RIGHTS UPON tHE CERTIFtCATE HOLDER. THIS CERTIfiCATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, 1" JUL 24 2003 8:59AM 6617217683 HYDRATEC A.qQJU).. PRODUCeR .. Hay ,%n.urance Agency Inc.!UVIS 2001. po Street '. BAKERSi'IELD CA 93301 Pbon81661-324-!l614 Fax:LIC #0308408 INSURED INSURERS AFFORDING COVERAGE INSURER A: INSUReR B: INSURER c: INSURER D: INSURER E: PIREMAN'S FUND INS. CO. , Onion Cemetery Association Ruth.. West . P..O~Box 3[)66 Bakersfield CA 93385 I ,,:,: COVERAGES ", TH5POUCIlSoto,INSURANCE LI$TCO BELOW HAVe BeeN ISSUED TO TKE INSURED NAMED ABOVE FOI'l THE POUCY PERIOO INDICATED, NOlWtTHSTAHDlNG ,,' I'Hf IleQUlRfMI!NT;T&RM OR CONDITION OF AN'( CONTRAcT OR OTHER OOCUNENT WITH RESPECT TO WHICH "THIS CERTlFlCA TE MAY BE ISSUED OR .. M.IIV I'eRTAIN. TtiE,INSURANCE AFFORDS) BY THE POUCIES DeSCRIBED HEFll"1N I$SUIlJECTTO ALL THE TERlAS, EXClUSIONS AND CONDITIONS ~ SUCH POUcIES.AGGREGATE UNITS SHOWN MAY HAVE. BEEN RBlUCED BY PAID CLAIMS, . .m TYPIEOF INllURANCE '. POLICY NUMBER &~t~iw., DATE r.M~ ~ENEAAL WASILin' A X ~e-RCIAi.. GENERAl. LWlILrfYMZX8 0802402 , I cui....s MADE W OCCUR 07/02/03 07/02/04 EACH' OCCU~RE~E fiRE DAMAGE /IiJl~ aile Ire) UEO EXJI CAPI)!, an!I peraon) PERSONAL &NN INJURY GENERAL AGGREGATiO PRODUCTS.~PAGG BJD1:) Ben. :L:tili: :..;; i~~~~~.~~$~APPUES PER: ~:;ilJ ,"oucVJ<~H'JECT n LOG \[ ":. "~81LEuAaIUTY F ANYAUTO ,. r- All OWNED AUTOS ,~ :~.CHEPU~j;I;l~UTOS .: ~~~D.~r, ;:~~~~E9:'r08 ' PROPERTY DAMAGE (Per DCcldenll COMBINED SINGLe LMT lea a_nl) BOOR. Y INJURY l"- persan) 1)i~ "~.' ('-~f;t ~I &oDlL Y INJURY (per accIdentl 0" .~ \~.~. ',':: ,'.:. :..,~>{. AUTO ONLY - EA ACCIIlENT ' EA M:C AGG ~GAAAGa..' '_......:.(.il81UrV::. -'j;NyAUTO" . ' ' OTtiERTHAN AUTO OMLV: EXCESS LIABILITY ~~OCCUR '. ' D ClAIMS MACE EACH occURReice AGGREGATE ,i;i~ ~',~~,~,2;;. ~1~'.~1\ ;::::::TK)N ANIl '\'1 i~ms:;~ .1 TORV LIMri~ E.L. EACH ACCIOEHT ' , E,t. DISEASE, EA EMPLOYEE , E.L OISEASE. POLICY UMlT $ . . .:. ~~~: ',:; };;~,..',},<.:t> ' " ~Vl ~1;I~~~_~;~TlONSII.OCATION~CLESll!XCLU510HS ADDED BY I!NIlOMEMENT/8'ECIAL PROVISIONS :<;'~:cert:.::rf!~c:.tef~',bQld.r is 1ncluded as addi.tional insured a8 resp.cts to work , perfo~dby the named insured. Project t.ocatlons Insureds freaises. lO aotic. of caD~ellaeion applies for nonpayment of premium. day ,-,'U' \:l;<cERnFICATEHOLDER I y I ACDITIONAL INSURED: INSURER LETTER: A . CANCaLATION p.2 , . LNTS $ 1., 000, DOG '10a,ooo $5,000 $1. 000,000 $2,000,000 "'2 000,'000, I"., ....1/2 00000 o~i':'. r\;~. ......, ,.;,; ... . I . ,. 'i:~ .' ~.l~; '. ?i;;i .,. , l' ,'. ',.'. ' $ . $ $ I " 'If':" 10=';,.< . :, '. -' . ". it ~;: ;.,',:., . ,..,....'. '.; i; ;~:'~ .~ . . City of :Bakersfield. its Mayor Council, Agents, Employees & Volunteers, 1505 Truxtun Ave Bakersfield, CA 93301 SHOULD ANY Of THE ABOVE DESCRIBED POLICES 81 CIlNCl!LUll> WORE THE EXPIRATION DAn: THeREOF. THe ISSUINGIN8URER WILL ENDEJWOR TO Il'\o\l1. ..J.Jl- DAV$ WRlnEH :aonc TO THE' C!!RTIRCATE HOLDER N.AMI!D TO THE LEFT. BUT FAILURE TO DO SO SIWJ. I E! No OBUGATlON OR UAIlIUTY OF ANY KIND UPON THEIN8URER,1TS AGENTS OR All ESE ITAlIV s. ' .. I' iN ES~ATIVE 4nnrA ~ v ./ _____ '" '" CI'l'Y013 I ACORD. 25.& (7197) OACORDCORPDRAnoN 1988 ., '. .- - . ~:tz::~~..:::~~~~. i -.-:-,- ;~:,,/_:,\;',: ....;::.l~(- ,~,~<~',:.~'.;.~",';:.::-: :~~~ JUL 24 2003 8:59AM .., . -.. . . .".. '." ".:;-'=:,,:..!~,,<-; J;~<;;k/;~:, ': . ~;R,~~l~XNO.. ,.(~f($\iS;~EO: HVDRATEC 6617217683 , THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS FORM B p.3 '. ':~ ~t, - '-;~',11 .;:,:1. ..:-.:>?:~~ ..t~~ . :,':~~ Mzxa0802402 Union Cemetery AssocIation COMMERCIAL GENERAL LIA~i~i~ This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE PERSON OR ORGANIZATION: ',' ~;', ':'" -- '~" ." . . ".': ..-.'.;.... '>':.CiW,..~~9f Bakersfield, it mayor, council, agents. employees, and volunteers . ," :,' . (lfnR,entry appears above, information required to complete this endorsement wnl be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (SECTION II) is amended to include as an insured the person or organization shown in the Schedule, but only with respects to liability arising out of your ongoing operations perfonned for that insured. CG2010 1093 Copyright, Insurance Services Office. Inc. 1992 ~ . - Bj\.KERSFIELD PUBLIC WORKS DEPARTMENT MEMORANDUM TO: Pat Flaherty, Risk Manager FROM: Marian P. Shaw, Civil Engineer IV, Subdivisions DATE: July 23,2003 SUBJECT: Encroachment Permit Application for 730 Potomac Ave. Union Cemetery Assn. Private 8" irrigation line w/14" steel casing under S. King Street approx. 43' north of centerline of Virginia Ave. Please review the insurance certificate with the attached encroachment permit and return to me at your earliest convenience. f~ S:\PERMITS\ENCROACH\INSURANC\730 Potomac Ave.doc " ...~~ ~ . - BAKERSFIELD PUBLIC WORKS DEPARTMENT MEMORANDUM TO: Ryan Starbuck, Civil Engineer III FROM: Marian P. Shaw, Civil Engineer IV, Subdivisions DATE: July 23,2003 SUBJECT: Encroachment Permit Application for 730 Potomac Ave. Union Cemetery Assn. Private 8" irrigation line w/14" steel casing under S. King Street approx. 43' north of centerline of Virginia Ave. Please review the attached encroachment permit and return to me at your earliest convenience. ok -O"'lt.- L4",t. of "t-""c<-'::P,'c.. t", -Iu.."L, Plfrc..e-.r,'.,,,,,, 1-0 vev-..A./..... ,,~{-. ltt:r- all T/V"'"I-#~, % 7/ 2("/() J S:\PERMITS\ENCROACH\TRAFFIC\702 Potomac Ave.doc l' A CORDTOf CERTIFICATE OF LIABILITY INSURANCE \ bAn: INMIllDIYYY'O 7/11/2003 PROOUCER (661) 322-9993 THIS CERTIFICATE IS ISSUED AS A MAnER OF INFORMATION DIBuduo & DeFendls Insurance Agency, Inc. . Bakersfield ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR License # 0707137 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 9548 Bakersfield, CA 93389-9548 INSURERS AFFORDING COVERAGE NAIC# ---'.--." ,..._.~".- F. HarnIsch, Ir\(;. DBA: Hy-dra'tec IN SUR""" A; Allied Group 1~:lUl\ED P.O. Box 276 INSURER 9; State Compensation Insurance Fun_~......._.,. . -...... Delano, CA 93215.0000 IN8Ul\E~ C: ,. --.. ...-, -', .-.. .~~UR~~_Q;..__,.. . ..._ . _._..._ __........ ...._.. INSURER E: HYDRA TE-01 TULO COVERAGES THE POLICIES OF INSURANCE LISTED aElOW HAVE eeeN ISSUED TO THE INSURED NAMED A60VE FOR THE POLICY PE~IOD INDICATED. NOTWITHStANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 6E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDEO BY tHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THt TERMS, EXCLUSIONS AND CONOITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ....r".--. POLICY EFFECTIVE POLICY EXPIRATION POLICY NUMBER LIMit!! ~NEML LIABILITY EACH oeCUR~ENeE $ 1,OOO,ooe ACP78100992089 9/112002 9/1/2003 ClJI'Wl:Gncr~~T!O" .. 200,001 A X X COMMERCI.6,L GENERAL L1A1llLlTY .~R.E.~!~.~S '... occu....ne~\ $ I~~] CLAIMs MAbE 0 OCCUR 10 DAY NOTICE FOR NON. A YMENT OF P ~EMIUM. MEO EXP (Any ona porson) $ Ii,OOI PERSONAL & AOV INJURY S 1,000,001 - _0"" ..............--- 2,000,001 GEN"~LAGGREGATE s .._.,.'.-~.- ---2JOO,OOC ~'L AGGREnE LIMIT ^P~iS PER: PROOUCTS . COMP/OP AG~, $ PO\.ICY ~~~.; LOC AUtOMOBILE UABILITY COMBINED SINGLE LIMIT 1,000,00 A :!.... ANY AUTO ACP78100992089 9/1/2002 9/1/2003 (Ea .<<Gonl) S ~'. f..- ALL OWNEO AUTOS 900lL YINJURY $ SCHEOULED AUTOS \P,r p,"on) ~ ...---..-. .'.'-- HIReD AUTOS BODILY INJURY X (Pa' aocldm') S NON-OWNED AUTOS ~- :,omp & C~.~~_~.!.~ .~_!1 ~~_~. .. ..,,_..~'-- X PROl'eRry bAMACE --' (Por _ldll1') $ ~RAGE LIABILITY AUTO ONLY. EJ\ ACCIO"NT S \ ....-.-...-..-- ANY AUrO OTHER THAN .~_~.~CC $ AUTO ONLY: AGG ~ EXCII:SG/UMBRELlA LIABILITY EACH OCCURRENCE S 4,OOO,OOC A 1]' occu~ 0 CLAIMS MADE ACP78100992089 9/112002 9/112003 AGGREOATE $ 4,OOO;OOC --....... ~ ... ==l OF.OUCTllIlE S -"..- ~ErENTIO'" . ,. $ WORKERS COMPENsAll0N AND I T~$ tfJI~" I X I O~W' B II:MPlOVII:R~' UAlIllITY ~O2117503 1/1/2003 1/112004 E.l. t;AC~ ACCIOENT . 1.000.001 .6,NY PROPRIETOR/PARTNERlEXECVTIVI; O~~leEM"EM9Ef\ EXCLuoe07 E.~. OlSEA6E . EA EMPLI:!.!~~ $ --1",000,001 ~ml~L~pA~cl'v~~tcrNS bolo.. E,~. Ol9EASE . ,"OUCY LIMIT $ 1,000,001 OTHER A Equipment Coverage ~CP78100992089 9/112002 9/1/2003 Les,ed/A,entod $50,000 Llml tlE9CRIPTION OF Ol'EAATlON$' LOCloTlONS I VII:HIClU' EXCLUSIONS ADDED BY ENDORSEMENT ISPII:CIAL PIl,OVlSION8 The City of Bakersfield, Its mayor, council, officers, agenbJ, employees & volunteers are named 8!1 additional insureds with respects to th& g&neralliablllty policy CERTIFICA TE HOLDER CANCELLATION City or Bakersfield Department of Public Works 1501 Truxtun Avenue Bakersfield. CA 93301- SHOULD ANY OF THIl ABOVII: DUCRlBED POLlelES liE CANCELLED BEFORII: THE EXPIAATlO DA TE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3..2..- DAve W~ITTEN None., TO nil_ CERTlI'ICATE l10LbER NAMED TO nlE LEFT, BUT 'A'LU~E TO bO SO SHALL IMI'O!!E NO Ol!llCAllON OR LIABILITY OF ANY t<IND UPON THE INSURER, ITS AGENTII OR REPRE~II:Nr"T1Vn. AUTHOI\~"D l\epl\"ENT""W~ ".;.".-' ;;.- ~::::---) ..... ,./ , ..~~._--- ---'-" f> ACOf{D CORPORATION 1988 ACORD 26 (2001108) 90/Z0 'd I09ZlEv699 'ON X~~ SlON3j30 ~ OnOnSIO Wd 09:EO l~j EOOZ-Il-1nr Ij:Uil:II'.I: 'In_1.::I!)..-'-:C:.l! ~r:r"iJllIIlIlllr"'_11I :t:.l!.tl:Jl'R:)lr:}~_ HYDRATE.01 TULO IMPORTANT If the certificate holder i$ an ADDITIONAL INSURED, the policy(les) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED. subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate doe$ not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing Insurer(s). authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend. extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08) 90/to 'd 109Z18V699 'ON X~j SIGN3j3G ~ OOGOSIG Wd 09:80 I~j 800e-II-10r 111,lm1.1: n...l:I:l....:t2 ~r:[~i.II_x'ur.._111 .~..r:J!,-=JI.r:):_ ;<:, POLICY NUMBER: ACP781 00992089 COMMERCTAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CG20 1011 8S AOOmONAL INSURED-OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided Wlder the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: CITY OF BAKERSFIELD, ITS MAYO~ COUNCIL, AGENTS, EMPLOYEES AND VOLUNTEERS 1505 TRUXTUN AVENUE BAKERSFIELD, CA 93301 RE: ALL CALIFORNIA OPERATIONS rROJECf LOCATION: UNION CEMETERY, KING & POTOMAC AVE., BAKERSFIELD, CA (If no entry appea(s above) intonnation required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) f WHO IS AN INSURED (Section 11) is amended to include as an insured the person or organization shown in the Schedule.. but only with respect to liability arising out of "your work" for that insured by or for you. The insurIlnce ulTorded to said Additional Insured by thEse policies aPI>lIes as primary insurance Bod any other insurance mailJtail'led by said Additional Insured will be excess only, and will not c:ontrib~te with the polities listed in this certificate, Copyright Insurance Services. Inc. 1984 90/VO 'd I09ZI€v699 'ON X~j SIGN3j3G ~ OnGnSIG Wd 09:€O I~j €OOZ-ll-lnr KJ';I;[t,~.:--n".J.;I~"':4~ ~r.r~;.a_XII'T"._111 _:t~.":n'R:]IIr:).:_ . POLICYHOLDER'S COpy _._~,___,_ -_-t....-~~._,--.:--,_..~-"'--:.;...- __,,_ _.o_._,~.'-----~_.;'_______' .1..-;;->1"r _,II>; ,..... .. '''~~'' "'b, ~ ,,"J>, "'.',}J ;i ./ / ./ Dear Policyholder RE: INFORMATION WHICH EFFECTS YOUR WORKERS' COMPENSATION PAYROLL AUDIT Enclosed is your copy of State Fund' s Workers' Compensation certificate of insurance your company recently requested. The Certificate Holder, who has requested the certificate of insurance, has also requested a "Waiver of Subrogation" endorsement to your policy. The endorsement, by law, requires a provision for additional premium charge. The Waiver of Subrogation Surcharge is 3%. The 3% surcharge shall be applied onlv to the premium developed on the payroll of your employees while engaged in work for the party named on this endorsement. In order to properly apply the Waiver of Subrogation, you must maintain accurate segregated payroll records for these employees engaged in work for the party named on this endorsement. If you should have any questions, please feel free to give our office a call at (661) 664-4156. W A VR-LTR.DOC - - -----------,.-- ------ - -- _.,- -'- ---... ~3m . cJ.<7j :ll ~ I '>- ~ . - BAKERSFIELD PUBLIC WORKS DEPARTMENT MEMORANDUM TO: Raul M. Rojas, Public Works Director FROM: Marian P. Shaw, Civil Engineer IV, Subdivisions DATE: July 29,2003 SUBJECT: Encroachment Permit Application for Groundwater monitoring well. Stuart's Petroleum 4456 California Ave. Engineering and Traffic staff has reviewed the attached encroachment permit to allow the installation of groundwater monitoring well. The site is located at 4456 California A venue. The applicant has provided proof of appropriate insurance coverage to Risk Management, and has provided signatures of all iq:tmediate neighbors stating that they have no objection to the proposed construction. ( Based on their review, staff recommends approval of the permit. S:\PERMITS\ENCROACH\03-04 Permils\4456 California Ave.doc L03~~9