HomeMy WebLinkAboutJacobson Contracting LLC 2018 FEE: $20.00
ACCOUNT# 100-0050-4972-00000 Sr\°\
ANNUAL EXCAVATION/WORK IN THE RIGHT-OF-WAY LICENSE
Application is made for a license to work within the Right-of-Way:
NAME: Type of organization:
individual partnership
� corporation
ADDRESS: AD 3 �j. f4orair) uW�
State of Incorporation
()Sr\VI)An W, SL qO 2—
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: l 1
EXPIRATION: J `. I
BOND TERM: \el; ' l9;1
•ECEIVED
INSURANCE TERM: ` ' l DEC 0 5 2017
CITY CLEF:v"53 OFFICE
DATE: \L' 51 '
Applicant's Signature
7?D 379 --/tP '
Telephone Number
Annual Work in the Right-of-Way License
4/19/05
ANNUAL EXCAVATION/WORK IN RIGHT-OF-WAY BOND
66260718
PRINCIPAL(S)(Legal name(s) and business address(es)) Type of organization:
JACOBSON CONTRACTING LLC individual partnership
_X corporation
6403 E DECORAH AVE, OSHKOSH, WI 54902-7632
Surety(ies) (Name(s) and business address(es)) State of Incorporation Wisconsin
Auto-Owners Insurance Company
6101 Anacapri Blvd, Lansing, MI 48917-3968
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 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 12/31/2017 (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:
JACOBSON CONTRACTING LLC Auto Owners Insurance Company
Name � pQ� m
* aul a.Oppenlander,Attorney-in- 3(`°"'°""`'fi
Title Title Fact SEAL:
6101 Anacapri Blvd,Lansing,MI 48917-3968
Address
Any person signing in a representative cap ct y . .,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 ExcavationNVork in the Right-of-Way
4/15/05
DATE AND ATTACH TO ORIGINAL BOND
• AUTO-OWNERS INSURANCE COMPANY
LANSING,MICHIGAN NO 66260718
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS: That the AUTO-OWNERS INSURANCE COMPANY AT LANSING,MICHIGAN,a Michigan Corporation,having its
principal office at Lansing,County of Eaton,State of Michigan,adopted the following Resolution by the directors of the Company on January 27, 1971,to wit:
"RESOLVED, That the President or any Vice President or Secretary or Assistant Secretary of the Company shall have the power and authority to appoint
Attorneys-in-fact,and to authorize them to execute on behalf of the Company,and attach the seal of the Company thereto,bonds and undertakings,recognizances,
contracts of indemnity, and other writings obligatory in the nature thereof. Signatures of officers and seal of Company imprinted on such powers of attorney by
facsimile shall have same force and effect as if manually affixed. Said officers may at any time remove and revoke the authority of any such appointee."
Does hereby constitute and appoint Paul D.Oppenlander
its true and lawful attorney(s)-in-fact,to execute,seal and deliver for and on its behalf as surety,any and all bonds and undertakings,recognizances,contracts
of indemnity and other writings obligatory in the nature thereof,and the execution of such instrument(s)shall be as binding upon the AUTO-OWNERS INSURANCE
COMPANY AT LANSING, MICHIGAN as fully and amply, to all intents and purposes, as if the same had been duly executed and acknowledged by its regularly
elected officers at its principal office.
IN WITNESS WHEREOF, the AUTO-OWNERS INSURANCE COMPANY AT LANSING, MICHIGAN, has caused this to be signed by its authorized officer
this 1st day of August,2016.
4 I`
Denise Williams Senior Vice President
STATE OF MICHIGAN} „.
COUNTY OF EATON ss E.
E. r• kF/r
J' vueiK: '}
On this 1st day of August,2016,before me personally came Denise Williams, to me known,who being duly sworn,did depose and ?`+'' couNrNowry a Ke+i
bn`7.7 FfVrro i
say that they are Denise Williams,Senior Vice President of AUTO-OWNERS INSURANCE COMPANY,the corporation described in and s M;anpcN io.soaz ,
which executed the above instrument,that they know the seal of said corporation,that the seal affixed to said instrument is such Corporate "c ryo"p .2
Seal,and that they received said instrument on behalf of the corporation by authority of their office pursuant to a Resolution of the Board of 4,'vr-..
Directors of said corporation. �''a;..rpp.`�Mycommission expires March 10,2022CC) C-7/41-1:42-1 )
Susan E.Theisen Notary Public
STATE OF MICHIGANss.
COUNTY OF EATON J
I, the undersigned First Vice President, Secretary and General Counsel of AUTO-OWNERS INSURANCE COMPANY, do hereby certify that the authority to
issue a power of attorney as outlined in the above board of directors resolution remains in full force and effect as written and has not been revoked and the
resolution as set forth is now in force.
g g 9 5thday December 2017 ................w
Signed and sealed at Lansing, Michigan.Dated this of `+ NERs,,ysG,,,
I CORPORATE':c$ I
.. SEAL )
William F.Woodbury, First Vice Prorrdent,Secretary and General Counsel
2940(10-17) Print Date:12/05/2017 Print Time:01:41:36 PM