HomeMy WebLinkAboutWisconsin Bell dba AT&T 2018IMP •
FEE: $20.00
ACCOUNT# 100-0050-4972-00000
ANNUAL EXCAVATION/WORK IN THE RIGHT-OF-WAY LICENSE
)35,51.\\
Application is made for a license to work within the Right-of-Way:
—_ I �( , Type of organization:
NAME: UU\s(on,s n
individual partnership
. 1. corporation
ADDRESS: 6. 0 t io s p n v� ,n,
�� OM � � ��`�� State of Incorporationl., \Nli
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:
EXPIRATION: l Z ✓H 16
BOND TERM: `2, memo
o
INSURANCE TERM: Lfr- `'— 15 JAN 0 8 2018
CITY CLERK'S OFFICE
DATE: -. 3- I 1 ----
Applicant's Signature
12-0 - .216-6( 61-01
Telephone Number
Annual Work in the Right-of-Way License
4/19/05
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• .
Bond Number 39S212204
ANNUAL EXCAVATION/WORK IN RIGHT-OF-WAY BOND
PRINCIPAL(S)(Legal name(s)and business address(es)) Type of organization:
Wisconsin Bell, Inc. dba AT&T Wisconsin
individual partnership
70 E. Division Street
Fond du Lac, WI 54935 X corporation
State of Incorporation
Surety(ies)(Name(s)and business address(es))
Liberty Mutual Insurance Company
175 Berkeley Street, Boston, Massachusetts 02116
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.
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 January 1,2018 (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 addition
two-year maintenance period beyond the expiration of this annual license period.
SIGNATURE/SEALS:
For-the P For the Surety:
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Wisconsin a Ii;inC:.dba AT&T Wisconsin Liberty Mutual Insurance Company
Name Name
•
\I(*(-61) �t /13/17
Title Title Heidi A. Notheisen, Attorney In Fact
Jennifer De La Torre �;; > R `'
Assistant Treasurer 175 Berkeley Street, E3tastofn, Massachusetts 02116
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. 1Nsu
Annual Excavation/Work in the Right-of Way j?4"°off+cc,
4/15/05 i 1912 n
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LMS-15706 04/10
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ACKNOWLEDGMENT BY SURETY
STATE
OF Missouri
City of St. Louis } "'
On this 13th day of November , 2017 ,before me personally
appeared Heidi A. Notheisen ,known to me to be the Attorney-in-Fact of
Liberty Mutual Insurance Company
,the corporation
that executed the within instrument,and acknowledged to me that such corporation executed the same.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal, at my office in the aforesaid
County,the day and year in this certificate first above written.
My Commission Expires: December 03,2019 K seyJones
— — — - - N tary Public in to of Missouri
(Seal) KELSEY JONES City of St. Louis
Notary Public, Notary Seal
State of Missouri Commission Number: 15973646
St. Louis City
Commission # 15973646
My Commission Expires December 03, 2019
S-0230/GEEF 2/98
This Power of Attorney limits the acts of those named herein,and they have no authority to bind the Company except in the manner and to the extent herein stated. Not
valid for mortgage,note,loan,letter of credit,bank deposit,currency rate,interest rate or residual value guarantees. To confirm the validity of this Power of Attorney call
610-832-8240 between 9:00 am and 4:30 pm EST on any business day.
Liberty Mutual Insurance Company
The Ohio Casualty Insurance Company
West American Insurance Company
POWER OF ATTORNEY
KNOWN ALL PERSONS BY THESE PRESENTS: That The Ohio Casualty Insurance Company is a corporation duly organized under the laws of the State of New Hampshire,that
Liberty Mutual Insurance Company is a corporation duly organized under the laws of the State of Massachusetts. and West American Insurance Company is a corporation duly
organized under the laws of the State of Indiana(herein collectively called the"Companies"),pursuant to and by authority herein set forth,does hereby name,constitute and appoint,
Heidi A.Notheisen
of the city of St.Louis ,state of Missouri its true and lawful attorney-in-fact,with full power and authority hereby conferred to sign,execute and
acknowledge the following surety bond:
Principal Name: Wisconsin Bell,Inc.dba AT&T Wisconsin
Obligee Name: City of Oshkosh
Surety Bond Number: 39S212204 Bond Amount: $5,000.00
IN WITNESS WHEREOF.this Power of Attorney has been subscribed by an authorized officer or official of the Companies and the corporate seals of the Companies have been affixed
thereto this 27th day of February.2017.
The Ohio Casualty Insurance Company
PL 1NSUgq J''' I0th C.," Liberty o R CO' Liberty Mutual Insurance Company y
�tiJ paPO�f�r� Les�co�o r4)2�n �,�e` " Rar``o Wes American Insurance Company
1912 i i 1919 i ,. 1991 e 9
�,+ ai ab 'a� 2 By: rY ,w �
m)9ssACH JS' p sr NAMe ' "hoiA$' ' David M.Carey,Assistant Secretary
* * a
STATE OF PENNSYLVANIA ss
COUNTY OF MONTGOMERY
On this 27m day of February.2017,before me personally appeared David M.Carey,who acknowledged himself to be the Assistant Secretary of,Liberty Mutual Insurance Company.
The Ohio Casualty Company,and West American Insurance Company,and that he,as such,being authorized so to do,execute the foregoing instrument for the purposes therein
contained by signing on behalf of the corporations by himself as a duly authorized officer.
IN WITNESS WHEREOF,I have hereunto subscribed my name and affixed my notarial seal at King of Prussia.Pennsylvania,on the day and year first above written.
0.yP PAs, COMMONWEALTH OF PENNSYLVANIA
�Q...040oNwE4,i%, Notarial Seal 1
,)
OF Teresa Pastelta,Notary Public By: 1/4-4.Z-d--d)
�a /L 4�4lUpper MerionTwp.,Montgomery County fff CCC
`rP� My Commission Expires March 28,2021 Teresa Pastella, otary Public
Member,Pennsylvania Association of Notaries
This Power of Attorney is made and executed pursuant to and by authority of the following By-laws and Authorizations of,The Ohio Casualty Insurance Company,Liberty Mutual
Insurance Company,and West American Insurance Company which resolutions are now in full force and effect reading as follows:
ARTICLE IV—OFFICERS—Section 12.Power of Attorney.Any officer or other official of the Corporation authorized for that purpose in writing by the Chairman or the President,and
subject to such limitation as the Chairman or the President may prescribe,shall appoint such attorneys-in-fact,as may be necessary to act in behalf of the Corporation to make,execute,
seal,acknowledge and deliver as surety any and all undertakings,bonds,recognizances and other surety obligations. Such attomeys-in-fact,subject to the limitations set forth in their
respective powers of attorney,shall have full power to bind the Corporation by their signature and execution of any such instruments and to attach thereto the seal of the Corporation.
When so executed,such instruments shall be as binding as if signed by the President and attested to by the Secretary.Any power or authority granted to any representative or attorney-
in-fact under the provisions of this article may be revoked at any time by the Board,the Chairman,the President or by the officer or officers granting such power or authority.
ARTICLE XIII—Execution of Contracts—SECTION 5. Surety Bonds and Undertakings.Any officer of the Company authorized for that purpose in writing by the chairman or the
president,and subject to such limitations as the chairman or the president may prescribe,shall appoint such attomeys-in-fact,as may be necessary to act in behalf of the Company to
make.execute.seal,acknowledge and deliver as surety any and all undertakings,bonds,recognizances and other surety obligations. Such attorneys-in-fact subject to the limitations set
forth in their respective powers of attorney,shall have full power to bind the Company by their signature and execution of any such instruments and to attach thereto the seal of the
Company. When so executed such instruments shall be as binding as if signed by the president and attested by the secretary.
Certificate of Designation—The President of the Company,acting pursuant to the Bylaws of the Company,authorizes David M.Carey,Assistant Secretary to appoint such attorneys-
in-fact as may be necessary to act on behalf of the Company to make,execute,seal.acknowledge and deliver as surety any and all undertakings.bonds.recognizances and other
surety obligations.
Authorization—By unanimous consent of the Company's Board of Directors,the Company consents that facsimile or mechanically reproduced signature of any assistant secretary of
the Company.wherever appearing upon a certified copy of any power of attorney issued by the Company in connection with surety bonds,shall be valid and binding upon the Company
with the same force and effect as though manually affixed.
I.Renee C. Llewellyn,the undersigned,Assistant Secretary,of The Ohio Casualty Insurance Company,Liberty Mutual Insurance Company.and West-American Insurance Company
do hereby certify that the original power of attorney of which the foregoing is a full,true and correct copy of the Power of Attorney executed by said Companies,,is in full force and effect
and has not been revoked. ,'•-\'.v' 6,�..
IN TESTIMONY WHEREOF,I have hereunto set my hand and affixed the seals of said Companies this 13th day of November- ' 2017
�1� oaP �r�r� (919 °
' 1912 2 1991 a By:a° i fieg1e C.Llewellyn,Assistant Secretary
�) 'ssACNUS" ,� yl CHAMP`"" !� �i %MOP' -