HomeMy WebLinkAboutDorner 2019 FEE: $20.00
ANNUAL RIGHT-OF-WAY EXCAVATION LICENSE
Application is made for a license to work within the Right-of-Way:
•
Dorner Inc. Type of organization:
NAME:
individual _partnership
E-MAIL:
dorner.inc@dornerinc.com X corporation
ADDRESS: E506 Luxemburg Rd, PO Box 129
State of Incorporation Wisconsin
Luxemburg, WI 54217
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 Twenty Five Thousand Dollars($25,000.00).
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 to perform work within the right-of-way.
Each individual project/address at which work will be performed requires a separate permit which may be obtained from
the City of Oshkosh Public Works Department-Engineering Division.
DATE ISSUED: 1/24/19
EXPIRATION: 12/31/19
BOND TERM: 1 nit 19 -b 12.(Si.J 1.9
6/1/18 - 6/1/19
INSURANCE TERM:
DATE: 2/13/19
COCk0AAPJ/In..0-4/
Applicant's Signature
920-845-2442
Telephone Number
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ANNUAL RIGHT-OF-WAY EXCAVATION BOND Bond Number:49033
PRINCIPAL(S)(Legal name(s)and business address(es))
T e of organization
Dorner, Inc. individual Li partnership
E506 Luxemburg Road / corporation
Luxemburg,WI 54217
Surety(ies)(Name(s)and business address(es)) State of Incorporation Wisconsin
:t 1=CLf VED
Western National Mutual Insurance Company
4700 W 77th St FEB
Edina, MN 55435-4818 6 2019
Penal Sum of Bond: $25,000.00 DLPT OF PUBIC
OBLIGATION: OSHKOSII, WIS(,tW�RNS
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.
CONDITIONS:
The Principal contemplates performing work within the right-of-way area(s)within the City of Oshkosh from time to 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 State of
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 the current edition of the Standard Specifications for City of Oshkosh, Wisconsin; 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 character 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 or 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 to 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$25,000.
It is understood and agreed by the Principal(s)and Surety(ies)that this bond supplements,but does not take the place of,any liability
insurance required to be carried by said Principal(s)herein by the City of Oshkosh policies or ordinances.
TERM OF BOND:
This bond shall cover work performed from January 24, 2019 (Date of Issuance) to December 31, 20 19 (the annual license
period). This bond shall cover claims made for work performed during this annual license period 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:
For the P ' cipal: pFor the ty: _` ` 2 , /
CZL4"<
Signature Signature °`'�"o �\:
Daniel Dorner Connie Smith I fit SEAL!21
Name Name Iii
%:4� IF;'
President Attorney in Fact
Title Title
2920 ENLOE ST, HUDSON, WI 54016
Address
Any person signing in a representative capacity(e.g.,an attorney-in-fact)must furnish evidence of authority if that representative is not
a member of the firm or partnership or an officer of the corporation involved.
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W NATIONAL
The.rlolionahiy company
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS: That Western National Mutual Insurance Company, a Minnesota mutual insurance company, does
make, constitute and appoint: Connie Smith J RYAN BONDING INC
Its true and lawful Attorney(s)-in-Fact, with full power and authority for and on behalf of the Company as surety, to execute and deliver and affix
the seal of the Company thereto (if a seal is required) bond, undertakings recognizances or other written obligations in the nature thereof, (other
than bail bonds, bank depository bonds, mortgage deficiency bonds, mortgage guaranty bonds, guarantees of installment paper and
note guaranty bonds, self-insurance workers compensation bonds guaranteeing payment of benefits, hazardous waste remediation
bonds or black lung bonds), as follows:
All written instruments in an amount not to exceed an aggregate of Twenty-Five Thousand Dollars($25,000.00) for any
single obligation, regardless of the number of instruments issued for the obligation.
and to bind Western National Mutual Insurance Company thereby, and all of the acts of said Attorneys-in-Fact, pursuant to these presents, are
ratified and confirmed. This appointment is made under and by authority of the board of directors at a meeting held on September 28, 2010. This
Power of Attorney is signed and sealed by facsimile under and by the authority of the following resolutions adopted by the board of directors of
Western National Mutual Insurance Company on September 28, 2010:
RESOLVED that the president, any vice president, or assistant vice president in conjunction with the secretary or any assistant secretary,
may appoint attorneys-in-fact or agents with authority as defined or limited in the instrument evidencing the appointment in each case, for
and on behalf of the company to execute and deliver and affix the seal of the Company to bonds, undertakings, recognizances, and
suretyship obligations of all kinds, and said officers may remove any such attorney-in-fact or agent and revoke any Power of Attorney
previously granted to such person.
RESOLVED FURTHER that any bond, undertaking, recognizance, or suretyship obligation shall be valid and binding upon the Company
(i) when signed by the president, any vice president or assistant vice president, and attested and sealed (if a seal be required) by any
secretary or assistant secretary; or
(ii) when signed by the president, any vice president or assistant vice president, secretary or assistant secretary, and countersigned and
sealed(if a seal be required)by a duly authorized attorney-in-fact or agent; or
(iii) when duly executed and sealed (if a seal be required) by one or more attorneys-in-fact or agents pursuant to and within the limits of
the authority evidenced by the Power of Attorney issued by the Company to such person or persons.
RESOLVED FURTHER that the signature of any authorized officer and the seal of the company may be affixed by facsimile to any Power
of Attorney or certification thereof authorizing the execution and delivery of any bond, undertaking, recognizance, or other suretyship
obligations of the Company; and such signature and seal when so used shall have the same force and effect as though manually affixed.
IN WITNESS WHEREOF,Western National Mutual Insurance Company has caused these presents to be signed by its proper officer and
its corporate seal to be affixed this 16th day of December , 2015.
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( SEAL
Jon R. Hebeisen, Secretary Larry A. Byers, Sr. Vice President
STATE OF MINNESOTA,COUNTY OF DAKOTA
On this 16th day of December, 2015, personally came before me, Jon R. Hebeisen and Larry A. Byers and to me known to be the
individuals and officers of the Western National Mutual Insurance Company who executed the above instrument, and they each acknowledged the
execution of the same, and being by me duly sworn, did severally dispose and say; that they are the said officers of the corporation aforesaid, and
that the seal affixed to the above instrument is the seal of the corporation, and that said corporate seal and their signatures as such officers were
duly affixed and subscribed to the said instrument by the authority of the board of directors of said corporation
JENNIFERAYOUNG 9�
,.. '.4( W NOTARY PUBLIC-MMJESOTA 7
• k MY COMMISSiON EXPIRES 001/2021 Jennifer A. Young, Notary Public
My commission expires January 31,2021
CERTIFICATE -
I, the undersigned, assistant secretary of the Western National Mutual Insurance Company, a Minnesota corporation, CERTIFY that the foregoing
and attached Power of Attorney remains in full force and has not been revoked; and furthermore, that the Resolutions of the board of directors set
forth in the Power of Attorney, are now in force.
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Signed and sealed at the City of Edina, MN on 1/24/2019 Jennifer A. Young, Assistant Secretary