HomeMy WebLinkAboutAmerican Engineering Testing Inc 2018 FEE: $20.00
ACCOUNT# 100-0050-4972-00000
ANNUAL EXCAVATION/WORK IN THE RIGHT-OF-WAY LICENSE
Application is made for a license to work within the Right-of-Way:
NAME: -fl vier, C �3 ►tom¢-t-vw+o) ) csils, q , Type of organization:
U �J individual partnership
!! )C corporation
SU (-ADDRESS: J -- `'1e'' r-Q A . State of Incorporation Yi4N
I (We) further agree to provide the City 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 for Bodily Injury and Property Damage Liability
(b) $500,000 personal injury
(c) $500,000 general aggregate
(d) $500,000 products/completed operation aggregate
and shall name the City of Oshkosh, its employees and officers, as an additional insured thereon. Proof of
said coverage in the form of an insurance certificate shall be submitted to the City 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 Public Works Department.
DATE ISSUED: I I J I
EXPIRATION: 1 21.3I I
BOND TERM: 1111611 $ 12-/31 11. ?
INSURANCE TERM: Iitlt I/ I t
DATE: I 1/1 clI,
App 'cant's Signature
6 /— 'g�-- ys—/
Telephone Number 13�
Annual Work in the Right-of-Way License
4/19/05
EWE
DEC 0 $ 2018
ANNUAL EXCAVATION/WORK IN RIGHT-OF-WAY BOND
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PRINCIPAL(S)(Legal name(s) and business address(es)) Type of organization:
American Engineering Testing Inc. individual partnership
✓ corporation
550 Cleveland Ave N St. Paul, MN 55114
Surety(ies) (Name(s) and business address(es)) State of Incorporation New Jersey
Selective Insurance Company of America
40 Wantage Ave, Branchville, NJ 07890
Penal Sum of Bond: $5000.00 Bond No. B 1208705
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.
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 area within the right-of-way to as good a condition as it was in prior
to Principal's activities; and pay to the City of Oshkosh any amounts due for services or materials furnished in connection
therewith within one week 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 30 days of written demand for payment, however the penal sum of this bond shall not exceed $5000.
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 November 19, 2018 (Date of Issuance) to December 31, 2018 (The annual
license period). This bond shall cover claims made for work performed during this annual license period and for an additional two-year
maintenance period beyond the expiration of this annual license period.
SIGNATURES/SEALS:
For the Principal : For the Surety:
A rican Engineer e ing Inc. Sele e Insyrance Company of America
'At
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1 di (1X-616)( el/A'0
ame N-me
£/7/Q/.3k r(d,'" Attorney-In-Fact
Title Title
245 Roselawn Ave E Ste 31 Saint Paul, MN 551 1 7-1 943
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.
Annual Excavation/Work in the Right-of-Way
4/15/05
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Selective Insurance Company of America
SELECTIVE ® 40 Wantage Avenue
Branchville,New Jersey 07890 BondNo.B 1208705
973-948-3000
POWER OF ATTORNEY Right-of-Way Permit
SELECTIVE INSURANCE COMPANY OF AMERICA, a New Jersey corporation having its principal office at 40
Wantage Avenue, in Branchville, State of New Jersey("SICA"), pursuant to Article VII, Section 1 of its By-Laws, which
state in pertinent part:
The Chairman of the Board, President, Chief Executive Officer, any Executive Vice President,
any Senior Vice President or any Corporate Secretary may, from time to time, appoint attorneys
in fact, and agents to act for and on behalf of the Corporation and they may give such appointee
such authority, as his/her certificate of authority may prescribe, to sign with the Corporation's
name and seal with the Corporation's seal, bonds, recognizances, contracts of indemnity and
other writings obligatory in the nature of a bond, recognizance or conditional undertaking, and
any of said Officers may, at any time, remove any such appointee and revoke the power and
authority given him/her.
does hereby appoint Barbara Louise Olson
, its true and lawful attorney(s)-in-fact, full authority to execute on SICA's behalf fidelity and surety bonds or undertakings
and other documents of a similar character issued by SICA in the course of its business,and to bind SICA thereby as fully
as if such instruments had been duly executed by SICA's regularly elected officers at its principal office, in amounts or
penalties not exceeding the sum of: Five Thousand Dollars($5,000.00)
Signed this 19, day of November, 2018
SELECTIVE INSURANCE COMPANY OF AM :. i " C04p
U SEAL '
Q By: .1.(k, 1928
W Brian C.Sarisky sct
Its SVP,Strategic Business Units,Commer• . `-__EK*
• STATE OF NEW JERSEY :
W :ss. Branchville
U COUNTY OF SUSSEX .
On this 19, day of November,2018 before me,the undersigned officer,personally appears4,Brian,c. Sarisky,who
acknowledged himself to be the Sr.Vice President of SICA,and that he,as such Sr.Vice President,bei74e4445)
do,executed the foregoing instrument for the purposes therein contained,by signing the name of the cation by hiniPtelf
as Sr. Vice President and that the same was his free act and deed the free act and deed of SICA. U= OTA •t�„
Charlene KGmble =BandN B,12 'ion; _
Notery Public of New Jersey , 'O�at�°
My Commission Expires 612/2021 Notary Public
The power of attorney is signed and sealed by facsimile under and by the authority of the following Resoluti6ti'adbpthd by
the Board of Directors of SICA at a meeting duly called and held on the 6th of February 1987,to wit:
"RESOLVED,the Board of Directors of Selective Insurance Company of America authorizes and approves the use of a
facsimile corporate seal,facsimile signatures of corporate officers and notarial acknowledgements thereof on powers of
attorney for the execution of bonds,recognizances,contracts of indemnity and other writing obligatory in the nature of a
bond,recognizance or conditional undertaking."
CERTIFICATION .Oa GQkp
I do hereby certify as SICA's Corporate Secretary that the foregoing extract of SICA's By-Laws and Reso �-: = 'i1T�.�Q,
force and effect and this Power of Attorney issued pursuant to and in accordance with the By-Laws is val� a SEAL
Signed this 19, day of November , 2018 I
f wp y 926 .63
�// � ! airill
II
chael H. Lanza, SICA Corporat= ecretary *
IImportant Notice: If the bond number embedded within the Notary Seal does not match the number in the upper B91(4-14)
right-hand corner of this Power of Attorney-contact us at 973-94R-3000.
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