HomeMy WebLinkAboutDirectional Drilling Services of WI 2018 •
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FEE: $20.00 2 J
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: 'b it ec-1'io�ct / �r, i I icy ((J/c es of - d Type of organization:
individual partnership
Qcorporation
ADDRESS: 367 / BJ arSk,
/ State of Incorporation
&-"C z-es4 72--- 7/
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: 0 2 f J q)
EXPIRATION:
BOND TERM: it I j Y>
INSURANCE TERM: 3t II 11
DATE: 3- - 0
Applicant's Signature
_ FZO - 66a - 7332—
Telephone Number
Annual Work in the Right-of-Way License 4/19/05 REC {DIVE
EMAR
0 S 2018
CITY CL1E:tC�'S�TiC1�
ANNUAL EXCAVATION/WORK IN RIGHT-OF-WAY BOND
PRINCIPAL(S) (Legal name(s) and business address(es)) Type of organization:
Directional Drilling Services of WI NE Inc individual partnership
3671 Buyarski Rd ✓ corporation
Green Bay,WI 54311-9453
State of Incorporation WI
Surety(ies)(Names(s) and business address(es))
West Bend Mutual Insurance Company
PO Box 620976
Middleton,WI 53562
Penal Sum of Bond: $5000.00
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 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 employ-
ment 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 December31,2017 (Date of Issuance)to December 31, 20 18
(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: West Bend Insurance Company
`7 A" C WW
Name Name
S J1 Attorney-in-fact
Title Title
PO Box 620976 Middleton, WI 53562
Address
Any person signing in a representative capacity (e.g., an attorney-in-fact) must furnish evidence of authority if that repre-
sentative is not a member of the firm or partnership or an officer of the corporation involved.
Annual Excavation/Work in the Right-of-Way
04/15/05
INSURANCE REQUIREMENTS
FOR CITY OF OSHKOSH
STREET/SIDEWALK OBSTRUCTION /
SIDEWALK LAYERS / CURB CUT CONTRACTORS /
EXCAVATION/WORK IN RIGHT-OF-WAY LICENSES
It is hereby agreed and understood that the insurance required by the City of Oshkosh is primary coverage and
that any insurance or self insurance maintained by the City of Oshkosh, its officers, council members, agents,
employees or authorized volunteers will not contribute to a loss. All insurance shall be in full force prior to
commencing work and remain in force for the license year.
1. GENERAL LIABILITY COVERAGE
A. Commercial General Liability
(a) $500,000 general aggregate
(b) $500,000 products —completed operations aggregate
(c) $500,000 personal injury and advertising injury
(d) $500,000 each occurrence limit
B. Claims made form of coverage is not acceptable.
C. Insurance must include:
(a) Premises and Operations Liability
(b) Blanket Contractual Liability
(c) Personal Injury
(d) Explosion, collapse and underground coverage
(e) Products/Completed Operations
(f) The general aggregate must apply separately to each project/location
2. BUSINESS AUTOMOBILE COVERAGE
A. Limits - $250,000 each person/$500,000 each accident for Bodily Injury and $100,000
for Property Damage
OR
$500,000 Combined Single Limit for Bodily Injury and Property Damage each accident
B. Must cover liability for"Any Auto" — including Owned, Non-Owned and Hired
Automobile Liability
3. WORKERS COMPENSATION AND EMPLOYERS LIABILITY— If required by Wisconsin
State Statute or any Workers Compensation Statutes of a different state.
A. Must carry coverage for Statutory Workers Compensation and Employers Liability
limit of:
$100,000 Each Accident
$500,000 Disease Policy Limit
$100,000 Disease — Each Employee
4. BUILDER'S RISK/INSTALLATION FLOATER
A. City of Oshkosh will not assume responsibility for loss, including loss of use, for
damage to property, materials, tools, equipment, and items of a similar nature which
are being either used in the work being performed by the contractor or are to be
installed or erected by the contractor.
, If the contractor is responsible for loss and coverage is desired for this exposure, the
contractor may, at his own cost, procure Insurance to cover same.
5. ADDITIONAL PROVISIONS
*Additional Insured — On the General Liability Coverage and Business Automobile Coverage. City
of Oshkosh, and its officers, council members, agents, employees, and authorized volunteers shall
be Additional Insureds.
*Notice
NOTE: City of Oshkosh requires 30 day written notice of cancellation, non-renewal or material
change in the insurance coverage.
*The insurance coverage required must be provided by an insurance carrier with the "Best" rating
of"A"—VII" or better. All carriers shall be admitted carriers in the State of Wisconsin.
*Certificates of Insurance
A copy of the Certificate of Insurance must be on file with the City Clerk and show that it meets
these specifications including the "Additional Provisions."
INSURANCE REQUIREMENTS
STREET/SIDEWALK OBSTRUCTION PERMITS/
WORK IN RIGHT-OF-WAY PERMITS
11-27-02
f
N ✓ 2021489
WEST BEND
A MUTUAL INSURANCE COMPANY
Power of Attorney
Know all men by these Presents, That West Bend Mutual Insurance Company, a corporation having its principal office in
the City of West Bend, Wisconsin does make, constitute and appoint:
TRACEY KOLTZ
lawful Attorney(s)-in-fact, to make, execute, seal and deliver for and on its behalf as surety and as its act and deed any
and all bonds, undertakings and contracts of suretyship, provided that no bond or undertaking or contract of suretyship
executed under this authority shall exceed in amount the sum of: Five Thousand Dollars($5,000.00)
This Power of Attorney is granted and is signed and sealed by facsimile under and by the authority of the following
Resolution adopted by the Board of Directors of West Bend Mutual Insurance Company at a meeting duly called and held
on the 21st day of December, 1999.
Appointment of Attorney-In-Fact. The president or any vice president, or any other officer of West Bend Mutual Insurance
Company may appoint by written certificate Attorneys-in-Fact to act on behalf of the company in the execution of and
attesting of bonds and undertakings and other written obligatory instruments of like nature. The signature of any officer
authorized hereby and the corporate seal may be affixed by facsimile to any such power of attorney or to any certificate
relating therefore and any such power of attorney or certificate bearing such facsimile signatures or facsimile seal shall
be valid and binding upon the company, and any such power so executed and certified by facsimile signatures and
facsimile seal shall be valid and binding upon the company in the future with respect to any bond or undertaking or other
writing obligatory in nature to which it is attached. Any such appointment may be revoked, for cause, or without cause,
by any said officer at any time.
In witness whereof, the West Bend Mutual Insurance Company has caused these presents to be signed by its president
undersigned and its corporate -al to be hereto duly attested by its secretary th• 1st day arch, 2009.
Attest 00 i 1/ �
1�PORAr
Ja , J. Pa '� F',' \ Kevin A. Steiner
Se •tary :►-4 SEAL{tj Chief Executive Officer/President
State of Wisconsin `.•e`•
County of Washington .......
On the 1st day of March, 2009 before me personally came Kevin A. Steiner, to me known being by duly sworn, did
depose and say that he resides in the County of Washington, State of Wisconsin; that he is the President of West Bend
Mutual Insurance Company, the corporation described in and which executed the above instrument; that he knows the
seal of the said corporation; that the seal affixed to said instrument is such corporate seal; that is was so affixed by order
of the board of directors of said corporation and that he signed,his name thereto by like order. , h d 1.. �uw G f 11!vv- �J
*/ NOTARY 1* : John weII
a''. PUBLIC f Z? Executive Vice President- Chief Legal Officer
,`9)' '?q Notary Public,Washington Co.WI
',PP.wy SG•••'' My Commission is Permanent
The undersigned, duly elected to the office stated below, now the incumbent in West Bend Mutual Insurance Company, a
Wisconsin corporation authorized to make this certificate, Do Hereby Certify that the foregoing attached Power of
Attorney remains in full force effect and has not been revoked and that the Resolution of the Board of Directors, set forth
in the Power of Attorney is now in force.
Signed and sealed at West Bend, Wisconsin this day of ,
•••:0A*....... —
ooRPORArF, —f—�T,� Z.,—I
1 SEAT.oi Dale J. Kent
' Executive Vice President-
Chief Financial Officer
Notice: Any questions concerning this Power of Attorney maybe directed to the Bond Manager at NSI, a division of
West Bend Mutual Insurance Company.
8401 Grecnway Blvd. Suite 1100 I P.U. Box 620976 I Middleton,WI 53562 I ph (608) 410-3410 I www.thesilverlining.com