HomeMy WebLinkAboutWinnebago County 2019 FEE: $20.00
ANNUAL RIGHT-OF-WAY OBSTRUCTION LICENSE
Application is made for a license to maintain street/sidewalk obstruction:
Type of organization:
NAME: ��n�lJ fl CO1� W 1 S(�`(�g�� YP S
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_individual _partnership
E-MAIL: A.peArtkauxkk.Ca.virn 4ebafp.w -u s ' —corporation ?C &Al/
I I State of Incorporation
ADDRESS: 1I7 044eC— J�P,
ed� ,� d fl.a�snv���.t�T�tIS
0S1nIGGS�1 �1� 1 �yci, Dl
I (We) further agree to provide the City of Oshkosh with a surety bond issued by a company licensed in the State of
Wisconsin in the amount of Five Thousand Dollars($5,000.00).
I(we)further agree to secure a Commercial General Liability Policy with limits of:
(a) $500,000 each occurrence
(b) $500,000 personal liability and advertising injury
(c) $500,000 general aggregate
(d) $500,000 products-completed operations aggregate
and shall name the City of Oshkosh, its officers, council members, agents, employees, and authorized volunteers as an
additional insured thereon. Proof of said coverage in the form of an insurance certificate shall be submitted to the City of
Oshkosh prior to issuance of any permit for street or sidewalk obstruction.
Each individual project/address at which an obstruction will be placed requires a separate permit which may be obtained
from the City of Oshkosh Departmentof Public Works-Engineering Division.
DATE ISSUED: ' /214/1 1
EXPIRATION: (Zf 31 / I QI
BOND TERM: 11 l 2/(/ l(4— 124 I / I c
INSURANCE TERM: I f t/ I"[ —. / /f /7i 0
DATE: Llf 211/ I 6)
Applicant' Signature
gr9Q -a ? =?-3Ll'-t ac20 -a 30-3 t
Telephone Number
1:\Engineering\ROW Permits\Annual ROW Obstruction Bond&License_1-8-19.doc
Bond#08663743
ANNUAL RiCII F-OF-WAY OBSTRUCTION BONI)
PRINCIPAL(S)(legal name(s)and business address(rti it Type of organization:
Winnebago County.Wisconsin �Individual Partnership
112 Otter Avenue _Corporation
X Governmental Entity
Oshkosh,WI 54901
Surety(ies)(Name(s)and business a,ldress(cs)) Stale of bncurpuraticm
. Fidelity and Deposit Company of Maryland
3910 Keswick Road
Baltimore,MD 21211
Penal Sum of Bond: $5,000.00
OBLIGATION:
We,the Principal(s)and Surety(ies),are firmly bound to the City of Oshkosh in the above penal sum. For payment of the penal sum,
we bind ourselves,our heirs,executors,administrators,and successors,jointly and severally.
CON Dfl IONS:
'Iiu Principal contemplates placing an obstruction within right-of-way an•a(a)within thy City of Oshkosh trout Lime In time during the
calendar year shown below. The Principal desires that all of those projects be covered by a single bond rather than a separate bond for
each contract.
The Principal shall faithfully perform all work done in the City of Oshkosh with proper care and skill;obey all laws of the Mate of
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Wisconsin and ordinances of the City of Oshkosh in connection with such work performed and with the employment of labor;properly
replace and restore any street, sidewalk, terrace, or other public right-of-way, vacated right-of-way, or City easement areas in
accordance with Use current edition of the Standard Specifications for City of Osirknslr, Wiscmuin;and pay to the City of Oshkosh any
amounts due for services or materials furnished in connection therewith within one(1)month of invoice.
The Principal shall for a period beginning on the date of issuance of this bond through a two(2)year period from the expiration date of
.the annual license save, defend, and hold harmless the City of Oshkosh from and against any and all claims,damages, costs,and
expenses of any kind or eharacter arising out of or resulting,however remotely,from the work performed by the Principal under the
attached license,including but not limited to,all accidents and damages caused by any failure to erect and maintain sufficient barriers
or lights at the place where licensee has placed obstruction ur performed work,or by failure to guard against injury to persons passing
upon the street or sidewalk,or by failure to promptly remove all tools,implements,refuse,and unused materials from said right of-
way. The Principal shall indemnify and refund to the City of Oshkosh all sums which it may become obligated en pay,including
damages,punitive damages,attorney fees,and court costs,within thirty(30)days of written demand for payment;however,the penal
sum of this bond shall not exceed$5,0011.
It is understood and agreed by the Principal(s)and Surcty(ics)that this bond supplements,but doss not take the place of,any liability
insurance required to he carried by said Principal(s)herein by the City of Oshkosh policies nr ordinances
TERM OF BOND:
This bond shall cover work performed from April24,2019 (Date of Issuance)to December 31,211 19 (the annual license
period). This bond shalt cover claims made for work performed during this annual license periud and for an additional two(2)year
maintenance period beyond the expiration of this annual license period The principal agrees to correct all maintenance issues brought
to the attention of the Principal(s)upon receiving notice from the City of Oshkosh within the two(2)year maintenance period.
SIGNATURES/SEALS:
'or the Principal For the Surety.
_. _.. . kiVihin ••44.1orry.,..„....
hn3twe Signature
beJ Ls 19eitYo-Sz,it.k Karen M.Flynn —
Name ( Name
is't'+ram{- ifs... . •4 re.4-'t" r Vice President-Underwriting
title Title
18550 West Capitol Drive
.Iitookfield,WI 53045 •
Address
Any persons signing in a representative capacity(e.g.,an attorney-in-fact)most furnish evidence of authority if that representative is not
a membet of the firm or partnership ur an officer of the corporation involved.
I:r hi a,nrr,IAsN ISM r'n,m.1 Annml ROW tibuun,r1bn no„d I,I,lens,I-M.Iv(IOC
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WISCONSIN COUNTY MUTUAL INSURANCE CORPORATION
ADDITIONAL INSURED ENDORSEMENT
Use of Property
Named Insured Winnebago County
Date this endorsement takes effect 1/1/2019
Endorsement Number 11
Policy Number 17119
Policy Period 1/1/2019 to 1/1/2020
(We win not fill in the above unless we issue this endorsement after we issue your policy.)
IN CONSIDERATION OF AN ADDITIONAL PREMIUM CHARGED OF $25.00, THE
FOLLOWING IS HEREBY ADDED AS AN ADDITIONAL INSURED WITH REGARD TO
THE USE OF THE PROPERTY LISTED BELOW:
PROPERTY: Winnebago County project involving sidewalk closure, date &
location of project to be determined annually by Winnebago County.
ADDITIONAL INSURED: City of Oshkosh
PO Box 1130
Oshkosh, WI 54903
2/14/2019y,..
Date Authorized Agent
WCMIC-END 7711 (4/05)