HomeMy WebLinkAbout04-30000042
ENCROACHMENT PERMIT
CITY OF BAKERSFIELD
PUBLIC WORKS DEPARTMENT
1501 TRUXTUN AVE
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 Municipalcode, tQ~ 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 . . 04-30000042 Date
Pin number . . . . . . .714752
Property Address 8100 STINE RD
Application description . . . PW - ENCROACHMENT PERMIT
7/13/04--------- ---
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Owner
Contractor
Gurdwara-Curu-Angad-Darbar lnc
8100 Stine Road
Bakersfield CA 93313 BAKERSFIELD CA 93301. A
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Permit . . . . .
Additional desc .
Phone Access Code
Permit Fee . . :
Issue Date . . .
OWNER/BUILDER
ENCROACHMENT PERMIT
200451
150.00
4/02/04 Valuation
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Qty Unit Charge Per Extension
1.00 150.0000 EA PW ENCROACHMENT 150.00
- - - u~~~~i~~ - ~~~~~ -~~ - ~~~~~~~ - uuu-ATrs-free-Cl:fgfits- ;-uYUrty-b-oxes, fire hydrants and
FRONT YARD BLOCK WALL water valves are to be oILtheToutside of the fence.
See details attached.
Fee sununary Charged:. Paid Credited Due
Permit Fee Total
Grand Total
150.00 150.00 .00 .00
150.00 150.00 .00 .00
Fence type:'~r.ought iron
Height: 6' max.
Applicant acknowledges the right of the City Engineer, pursuant to the Bakersfield Municipal Code Chapter 12.20 to revoke the
pet' at any 'ime.
~ ) <:;'1;2-. -'L-A \.--...A.-V" \<:V \ p \ '? ~ H NO H A \A.I 8
Signature of Applicant (Owner! Agent) - Print 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) WILL (NOT)
SUBSTANTIALLY INTERFERE WITH THE USE OF THE PLACE WHERE THE SAME IS TO BE LOCATED AND (2)
WILL (NOT) CONSTITUTE A HAZARD TO PERSONS USING SAID PUBLIC PLACE; SAID APPLICATION IS
THEREFO~ (DENIED). Said permit shall expire on date stated above.
~
Signature of City fngineer
..,
Additional Terms on the Back
-- - -------:;- -----
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Applicant agrees that if this application is granted, applicant shall indemnify, defend, and hold harmless CITY, its officers, agents and
employees against any and all 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 full 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 ~&bedge the abave.
_Applicant's Initials
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BAKERSFIELD
PUBLIC WORKS DEPARTMENT
MEMORANDUM
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TO: Raul M. Rojas, Public Works Director
FROM: Marian P. Shaw, Civil Engineer IV, Subdivisions
DATE: January 5,2005
SUBJECT: Encroachment Permit Application for 8100 Stine Road.
Gurdwara Guru Angad Oarbar Inc
6' wrought iron fence behind sidewalk along Stine Rd & Hosking Rd.
Engineering and Traffic staff have reviewed the attached encroachment permit to allow the
installation of 6' wrought iron fence behind sidewalk along Stine Rd & Hosking Rd. The site is
located at 8100 Stine Road.
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\8100 Stine Rd.doc
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BAKERSFIELD
PUBLIC WORKS DEPARTMENT
MEMORANDUM
TO: Ryan Starbuck, Civil Engineer III
FROM: Marian P. Shaw, Civil Engineer IV, Subdivisions
DATE: September 15, 2004
SUBJECT: Encroachment Permit Application for 8100 Stine Road.
Gurdwara Guru Angad Darbar Inc
6' Wrought iron fence at 6" min. at back of sidewalk.
Please review the attached encroachment permit and return to me at your earliest convenience.
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S:\PERMITS\ENCROACH\TRAFFIC\8100 Stine Rd,doc
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BAKERSFIELD
PUBLIC WORKS DEPARTMENT
MEMORANDUM
TO: Pat Flaherty, Risk Manager
FROM: Marian P. Shaw, Civil Engineer IV, Subdivisions
DATE: September 5,2004
SUBJECT: Encroachment Permit Application for 1701 Pacheco Road.
Secor International
2" diameter monitoring well in sidewalk.
Please review the insurance certificate with the attached encroachment permit and return to me
at your earliest convenience.
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S:\PERMITS\ENCROACH\INSURANC\1701 Pacheco Rd.doc
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CD INSTALL HANDICAP RAJ.lP PER CITY or BAK[R$fIEL DEfAlL $-41, V ~rL~UM~dr~&\::N~% ~'6:~g~D~I~o ~~~~1Jw.U
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PARCEL B OF LLA 393
IMPROVEMENT LEGEND
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INSTAll STANDARD 9500 LU~IN STREET LICHT ANCPULL BOX
PER CITY Of 8AKERSflEtODETAIL 5-31 V
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11+28.11 ~1.62' MT
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STRIPING 8AYTAPER DATA
OFFSET
FROM CL
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STATIONS
12+28.77
12+18.77
12+08.77
11+98.77
11 +88. 77
11+78.77
11+68.77
11+58.77
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IMPROVEMENT LEGEND
f<'j$'~U. SIC+> "CN H-I. I'UI Clll Of a.<KEFlSF,ElD 0('''''. 1_19
INSTALL STANDARD 9500 LUMIN STllEET UGH AND PULL 80~
PER CITY OF 8AKERSFIELD DETAil S-~l.
ORIVEWAY STAlIONING (0 CENTER OF DRIVE.vAY)
INSTALL HANDICAP RAMP PER CITY OF 8AK!::RSfIELD DErAlLS-41.
~~T"....'i~\:fE "e. CURB AfoD GUTTER PER Clll OF BMERSflELD
INSTAl~ ~.~. SjW PER CITY ~ BAKERSF1ElD DETAil S-3.
(E)SEI'tUfMANHOLE
INSTALL UNDER SlDEWALK
DRAIN PER COO DErAil S-l~
ALL "[6T REFERE~CES ARE INCICATED BY IiU.ldlilll. AND
APPLYTOThEPLANANDPROFlLEOFTHISSf<EET~
ThE f'oUIABER REFERENCED CORRESPONDS TO STATION.
LOCATION, OR OISPOSI\ION AND ELEVAT;QN OAf A SOlD\IiloI
IN ThE PROfiLE OF ThiS SHEET Qt1U. D!,,:PUCA1E NUYBERS
~ONOThERSI1EE'S,
LHIEf! REFERENCE
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ALL STATIONING IS CWTE~UNE STAnONI~G
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ACORDTM CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDIYY)
10-11-04
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
KHULLAR INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
301"H"STREET # A ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
BAKERSFIELD CA 93304
INSURERS AFFORDING COVERAGE
INSURED INSURER A: USF INSURANCE CO.
GURDWARA GURU ANGAD DARBAR INC. INSURER B:
INSURER c:
8100 STINE ROAD INSURER D:
BAKERSIFIELD CA 93313 INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOlWlTHSTANDING
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE POUCY NUMBER ~f1,iY,=8~ "%~~ ,~!:m~JJg,N UM\TS
LTR
GENERAL UABILITY LGBCP25154 02-01-04 02-01-05 EACH OCCURRENCE $1,000,000
A 7" COMMERCiAl GENERAl L1ABILllY FIRE DAMAGE (Anyone fire) $100,000
I CLAIMS MADE [l] OCCUR MED EXP (Anyone person) $5,000
PERSONAl & ADV INJURY $1,000,000
GENERAl AGGREGAlE $2,000,000
GEN'L AGGREGAlE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $2,000,000
I POliCY n P:Ri n LOC
AUTOMOBILE UABILITY COMBINED SINGLE LIMIT
,,- $
#lY AUTO (Ee accident)
f--
- AlL OWNED AUTOS BODILY INJURY
(Per person) $ I
SCHEDULED AUTOS
-
HIRED AUTOS BODILY INJURY
- $
NON-OWNED AUTOS (Per eccident)
-
- PROPERlY DAMAGE $
(Per accident)
GARAGE UABILITY AUTO ONLY - EA ACCIDENT $
R #lY AUTO OTHER TH#I EA ACe $
AUTO ONLY: AGG $
EXCESS UABILITY EACH OCCURRENCE $
tJ OCCUR D CLAIMS MADE AGGREGAlE $
$
R DEDUCTIBLE $
RETENTION $ $
., WC STATU- I IOTH-
WORKERS COMPENSATION AND TORY LIMIT" ER
EMPLOYERS' UABILITY E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT $
OTHER
A BUILDING LGBCP25154 450,000
DESCRIPTION OF OPERATlONSlLOCATlONSlVEHICLESlEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
ADD I TONAL INSURED; OWNER, LESSEES OR CONTRACTORS FORM B
CITY OF BAKERSFIELD ,ITS MAYOR COUNCIL, AGENTS, EMPLOYEES AND VOLUNTEERS
THE POLICY IS ENDORSED FOR COVERAGE.
CERTIFICATE HOLDER III ADDITIONAL INSURED; INSURER LETTER: X CANCELLATION
The City of Bakersfield, SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEfORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,. BUT FAILURE TO. DO so SHALL
1501 Truxtun Ave. l~~ OBUGATION OR UABILITY ~~~N~.e:~: OR
REPRES TAT1VES ~,,', WJI'. 'U){';ltl"',
. ,'."-"-" ,-,,- ',' :'>~'- - ".... ' ". :" '..
Bakersfield I~ REPRES:;:P: .-- ~,.....,..._.,^,,,c, ,~
CA 93301 .;c.,1/V 1 0 ~./
I ~I. '-;;:::r
, ..... -. -- - -----. _a. ...__
. ..:
6192944303 TO 16613257556
BURNS & WILCOX INSURANce SERVICES, INC.
S;.tn Diego Bral'lCft QtftCP. .26GO Camino dol RIo Narth. Suite 308, S:KI Diego. CiS 92108
pnOfle: 61!t/88S.1920 - Fa~: 619/294-4608
P.01
NOV ~3 2004 10:03 AM FR BURNS & WILCOX
MEMORANDUM
: ciakii: 11/23/2004
: 1'0-: KHUlLAR IN~ufU\NCF AGENCY
31) t H STREET #^
BAKERSFiElD. CA 0330'1
Di<lJ'Y; 11/2312004
Fax Number. 661/32b-7556
" nom;. MEUSSAA. Wf.(IGHT
Rfi
QURDvvARO GIIRU ANGAD DAAB#lING
LGBCP26154
fil~ Reference: ~$2007.~ARKO~-M.'>:.l5OO'MAW
~o~:plMl:Je fmd tha foUowlng:
: .:( .;) : Application for:
, () . ominDl POlicY, as ~rllinned above.
. f: ) . cer1ificate(~) of Insl.lI"a1nce.
... ~ ) . Addlllon;,d In5llred Endorsement(s) nLUllber(ed):
'. ~}. Endo~lllent(s) number(ad): 3
f ). The enr.\ooed endorsemcnt(s) must ~ signed and dated by the No'lmed Insured and returner1 tu our office no
later then:
tx}. Other: QR1CINAU:i WILL FOLLOW OY MAIL
':Thank you
,~~ /(A)M-IJ-
..: DWSO-MST -O2l04~)
NOIJ 2p 2004 10 :.03 AM FR BURNS 8< WILCOX 6192944303 TO
: '(1'hc ^tt3ChI1'l9 CI31.L'iH need be completed only wMO tnlS ellUUI:>\,;lllCII. ,., ,,,,,......... ...~~ -- -,' .1 66 1 3257556
P.02
ENDORSI!MENT
NO._3 _
1i1w~rnent, efff:!dive on iO[1512004 at 12:01 AM ~t.mdard time. torms aI part of
: r.Plicy~.:. LG6C1-'251~ 01 thE! U$F INSUR....NCE COMPANY
(NAME OF 1~IIRAN('1: l;OMPANY)
.. 1Ssl!lC(t,1O.. GUF/PWARO GURU AHCAD OARBAR INe
THIS ENDURSEMf:NT CHANGE:O THE POLICY. PlEASF READ IT CARE:I-ULL Y.
CHANGE ENDORSEMENT
.. '
~I oorjsideration ot me premIum ctl<'!ryed:
It ij; ur.<tefstood ::md :ilgreed that
. 1::R~le BasiS ................... ".. 0
..2;, Premium .........,................... 0
'. 3, Amount .............................,- 0
. ~; umlts of liallility .................. [l
, 5~ Inc?eptiol'l Date .... ,............. 0
.6; Expiration Dote .................... 0
f N:01rAe of Insured .........~.'....... 0
a. Loc3tlOn Of Proper1y ........... 0
9. ClasGific3tion Add@(!" ,,,.... D
10 Clas5ification Dclete<1 ........- 0
1'1. M<liling AddrC3:;1
of the In!!:Llfetl..................,. r:J
12. DescriptlOfl 01
Property C;Ol/erGCl........... 0
15 Covemge ........................... 0 17. Mortgagee: /\cldcd10eleted -...... 0
14. AdditJonallnsllrP.d
Endorsement ........ .un......"... W
15. endorsement .............",,,...... 0
16. Olher ........._.................n.........n 0
o IS Correclf:!d IX Changed to Read as rollows
00 Is Amended to RI>.::1d loll> Folklws
o The Following Form III madt! a part of the POliCY
o The Following Form is Deleted from the Pulicy
rr IS HEREBY AGREED I::.NDOAAEMENT #2 IS AMENDED N~ t-OL.LOWS'
. i=ORM CG2Q10 (07/04) IS AMENDEO PER THE: ATTACHEn,
:~~ 'NEREIH COttT.AlNED SHALL BE HI9.D TO VMY. ALT~, WANf=. OR EXl!ND Nfi or THE TERMS. CONDl11Ot\IS. OR
~~ OF nlE POLICY TO wtIl(;H THIS ENDOftSEMEt4T IS ATTACHiiD OTt4~K Ttl AI5OV~ S:ATED.
; "~ 11I2312004-MAW-SKN C L
.AT: SAN, OIFGO. CA BY. <- .R
AUTHORIZED
'mf-EMo-G (0H4)
r-
~~
APPLICATION FOR ENCROACHMENT PERl\1IT
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
toplace, erect, use and maintain an encroachment on public property or right-of-way as therein defined.
twr- ~
3. Location of the proposed encroachment: 9J I 0 0
.
OL..:1
I2d
4. Period of time for which the encroachment is to be maintained:
~LD If'
Applicant agrees that if this application is granted, ap'plicant shall indemnify, defend and hold harmless City, its
officers, agents and employees against any and all liabIlIty, claims, actions, causes of action or demands, whatsoever
against them, or any pfthem, before administrative, quasi-judicial, or judicial tribunals of any kind whatsoever, arising
out of, connected with, or caused by applicant's placement, erection, use (by applicant or any other person or entity)
~r maint~nce of said encroac~ent. TJ:1e applic~t further ~grees to maintain the aforesaid encroachment during the
hfe of saId encroachment or until'such tune that this pernut IS revoked. .
. '
Applicant further agrees that upon the expiration of the permit for which this application is made, if granted, or !mQ!!
the revocation thereofby the CIty eDlzineer, applicant will at his own cost and expense remove the same from the public
propert~ or right,of w~y ~her.e the same is loca!ed, and ~store s~d public prop~rty or right .of way to the condition
as near y as that In which It was before the placmg, erectIon, mamtenance or eXIstence 01 saId encroachment. .'
Applicant further agrees to obtain and keep all liabilitY insurance required by the City Engineer in full force and effect
for however long the encroachment remains. Applicant shall furnish the City Risk Manager with a Certificate of
Insurance evideI:1cing sufficient coverage for bodily injury or property damage liability or both and. required
endorsements evidencing the insurance required. The type(s) and amount(s) of insurance coverage is:
Applicant acknowledges the right of the City Engineer, pursuant to Bakersfield Municipal Code Chapter 12.20 to
revoke the permit at any time.
Date: 3- 3 I · 0 ,{
PERMIT
I HEREBY CERTIFY THAT I HAVE MADE AN INVESTIGA nON OF THE FACTS STATED IN THE
FOREGOING APPLICATION AND FIND THAT THE MAINTENANCE OF SAID ENCROACHMENT (1) WILL
(NOT) SUBST ANTIALL Y INTERFERE WITH THE USE OF THE PUBLIC PLACE WHERE THE SAME IS TO
BE LOCATED AND (2) WILL (NOT) CONSTITUTE A HAZARD TO PERSONS USING SAID PUBLIC PLACE;
SAID APPLICATION IS THEREFORE (GRANTED) (DENIED). SAID PERMIT SHALL EXPIRE
Date:
Signature of City Engmeer
No.
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; CITY O~. BAKERSFIELD
~ DEPARTMENT OF PUBLIC WORKS
TO WHOM IT MAY CONCERN:
We the undersigned, have no objection to the construction of a fence beside the
sidewalk within the public right of way.
4) Name:
Address: 8235 57/A /~
5)~:::s: . {!::/7~~:
'.'6)Name: ~~.
Address:'J92tJ f7J'Ju 'Ql;
of
SIGNED:
1) Name:
Address:
2) Name:
Address:
. 3) Name:
Address:
"$/"D SIt N~
(Street for puposed encroachment)
Bv: .If! AvJJ g It. ~.,S))J fJt
(Owners Name)
. ~l(JO .S7/N(
(Address of purposed encroachment)
Phone: h h I 3 'I 6 . ~ D ~
Date: L./ . ';).. . D Li
.
Date: if ( :l. I fJ i./
, .
Date: L.J. -';;, - tJ t...{
/1.
Date: </- Z - 0 (j
Date: J/f-:2 - 'Of
Date: f - 2. - (J' 2.f
"",
I, .'
NOU 23 2004 10:03 AM FR
. . .'. BUR N 5 8< W I Leo x
8192944303 TO 18813257558
P.03
. ~t.1CY NUMBER: LG8~'2'!l1~4
COMMERCIAL GEMERAL UABILnY
CG 20 10 01 04
tHIS ENDORSEMENT CHANGES THE POLICY. pU;:Ase READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
i'liis endorsement mQdir~~ in&uranc~ provIded under the followIng:
: CrJMMERCIAL Gt:NERN- LIABILITY COVERAG~ PART
SGHF-OULE
Name Of Add"dionallnsured pef!lOf1(s)
Or organl:z.ation(S):
: Cl'tV 01- E!AKF.RSFIElD.IT'S MAYOR, COUNCIL.
,A~NlS,EMI-'LOYEES AND VOLUN'I ~E~S
i '1~ TRUXTON ^V~lIIuE
, BPlKERSFIEI.O. CA. ~3201
LCM;ation($} Of Covered operations
8100 STINE ROAD
BAKER~FIELD. CA. Qa31~
. nftinm:ltiOfl reQUired to complete thiS SChe(tllltl. if not :shown above, will he shown in the Uec1ar<'ltiufl&.
,.. SoetiM 11 _ Who b An Insured is a~nded to
iridude ~ an addltior~1 insured the person(l;) or
organir;..tion{s) shown in the ~e<lule. but only
\Nith respect to liabilit)' for "bodily injUry'", "Ilroperty
~1amaoe" or "perso~1 and advertising injury"
~seO, itl whole or in part, Oy:
1. your acts Of (Imissiorts; or
2. . The act:> or omlssiol"lR of ttlQ3C ;1Cting on your
. behalf:
in thc. perf(lrmanc~ of your ongoing operations for
thR i!dditional insur~C1(i) ;;Il the Ioc8tion(8) CliSig.
'n3ted abOve.
8. With respect to tile insuralJ(;@. afforded to these
additiOnal 'n~urt:ldS. the following addilional ~xclu-
:sions apply:
ihls illsurance does not apply to "bodUy injUry" or
"property d~lTIage. occurring after:
1. All worl<, inclurling materials, parts or e1juip-
mellt furnished in connectiOl1 with such worK,
on the projec\ (other than service, mClintenanOe
or repairs) to be perfullned by or on benalf of
the arjdilional insurcd(s} at the Ir.!Cation of the
covered operations hRS been completed; or
2. That portion of .your work" out of which me
injUry or damage an!)e3 h36 been plll to its in-
tended uoe Dy any pt!l !'ion or orgQnization other
than ~noth~r contractor or !;\Jtx;untr~ctor Cn
gelled in performing operotions for a prim;ipal
i'lS a pari: of the 6ame projp.cl.
OG 20 1 D 07 04
~ 150 Properties, Inc;., 20()4
Page 1 of 1
o
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** TOTAL PAGE.03 **
/
Se~RAlfCE"'CO.MPANY.
.~;. "-':'-'~""y':,,: ,~;. 4'. ~'':''''~'/-~.i ,:---~-;-:~I""-',."... ~,;.".: ,,::-,,..' -':."
.' ~_~. , '~P.RIMARY FACILlTY,:nc~~"
_.COMMERCIAL:'GENERAL UABIUJ"Y COVERAGE PART
.< ftr;:~~.i~r ". SUPPLEMENTAL DECLARATIONS
~ ;;'~-:'(:''''':-'i~;'":':'.-:' ,~.~. . . .'
1"HeS'e"Supplemental Declarations form a part of policy number LGBCP25154
LIMITS OF INSURANCE ..
General Aggregate Limit (other than Products/Completed Operations) $ 2,000,000
:
Products/Completed Operations Aggregate.,Limit $ 2,000,000
", ,
Personal and Advertising Injury Limit -- $ 1,000,000
." ,
Each Occurrence Limit "- $ 1 ,000,000
Fire Damage Limit $ 100,000 anyone fire
Medical Expense Limit $ 5,000 anyone person
BUSINESS DESCRIPTION AND LOCATION OF PREMISES I
Form of business: !
o Individual o Joint Venture o Partnership 00 Organization (Other than Partnership or Joint Venture)
Business descrip!ion:
RELIGIOUS TEMPLE
Location of all premises you own, rent or occupy:
8100 STINE ROAD, BAKERSFIELD, CA 93313
PREMIUM
Rate Advance Premium
Classification Code No. *Premium Basis PRlCo All Other PrlCo All Other
CHURCHES OR OTHER HOUSES OF WORSHIP 41650+ 7,500 INCL 104.370 $ INCL $ 783.00
(PRODUCTS - COMPLETED OPERATIONS AREA
ARE SUBJECT TO THE GENERAL
AGGREGATE LIMIT)
..
\
\
/
.
FORMS AND ENDORSEMENTS (other than applicable forms and endorsements shown elsewhere in the policy)
Forms and endorsements applying to this Coverage Part and made part of this policy at time of issue:
PER SCHEDULE OF FORMS AND ENDORSEMENTS
,
I
,
DEDUCTIBLE: $ NJA Per Claimant
*(a) Area, (c) Total Cost, (m) Admission, (p)payroll, (s) Gross Sales, (u) Units, (0) Other
THIS SUPPLEMENTAL DECLARATIONS AND THE COMMERCIAL LIABILITY DECLARATIONS, TOGETHER WITH THE COMMON
POLICY CONDITIONS, COVERAGE FORM(S) AND ENDORSEMENTS COMPLETE THE ABOVE NUMBERED POLICY.
II"" DC ~n ... ,,, nl')'