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FEE: $20.00
ACCOUNT#100-0050-4972-00000
ANNUAL STREET/SIDEWALK OBSTRUCTION LICENSE
Application is made for a license tomaintain treet/sidewalk obstruction:
NAME: C } DN\Q__,
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ADDRESS: 332l 36 � A6\1 a
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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 for street or sidewalk obstruction.
Each individual project/address at which an obstruction will be placed requires a separate permit which may be
obtained from the office of the City Clerk.
DATE ISSUED: I— (i
I RECE1�
EXPIRATION: 1 n:2)l I l —�
JUN 20w18
BOND TERM: `1b' -3)' \�
CITY CLERIC'SS p
INSURANCE TERM: `— --� \
prine
DATE: Q' ! I
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v Applicant's Signature
CaT- ( -4:7/ 70 73
Telephone Number
Street/Sidewalk Annual Obstruction License
11-27-02
Power of Attorney
KNOW ALL MEN BY THESE PRESENTS THAT:
Nationwide Mutual Insurance Company,an Ohio corporation AMCO Insurance Company,an Iowa corporation
National Casualty Company.an Ohio corporation Allied Property and Casualty Insurance Company,an Iowa corporation
hereinafter referred to severally as the"Company"and collectively as"the Companies'does hereby make,constitute and appoint:
Anita R.Calderon,Dana R.Clark,Mike Kuper,Michael Paez,Matthew Gilmer,Joshua Severson,Andrew Roby,Jeff Thielen,Cristopher Hansen,Robert N.Johnston,Elizabeth
Moore,Ashlee Schuling,Paulette M.Dyson,Ben Lewis,Morgan Collins,Becky Nichols,Jeff Cose.Richelle Smith,Aaron J Jamison,Kim Wells,Carmon R.Wilson.Sandra Alrtz,
Spencer Paris,Larry D.Slegh,Richard E.Harman IV,Logan Dorpinghaus,Corey Days,Patrick Johnson, Jill DeRobertis.Regina Wicks,Dominic Amoroso.Kyle Huntrod,Jenne
Weiland,Twanisha Siejkowski,Heidi Cornelison.Michael Mailer,Stephen G Sanker,Diana Kelly,Brian Pflum,Stevie Voigt,Cale Rizer,Guy Tenold,Cassie McKittnck,Ashley
Leavell,Michael Kix,Rob Lentz
each in their individual capacity,its true and lawful attorney-in-fact,with full power and authority to sign,seal,and execute on its behalf any and all bonds and
undertakings,and other obligatory instruments of similar nature,in penalties not exceeding the sum of
FIVE MILLION AND NO/100 DOLLARS ($5,000,000.00)
and to bind the Company thereby,as fully and to the same extent as if such instruments were signed by the duly authorized officers of the Company;and all acts
of said Attorney pursuant to the authority given are hereby ratified and confirmed.
This power of attorney is made and executed pursuant to and by authority of the following resolution duly adopted by the board of directors of the Company:
"RESOLVED,that the president.or any vice president be.and each hereby is,authorized and empowered to appoint attorneys-in-fact of the Company,
and to authorize them to execute and deliver on behalf of the Company any and all bonds.forms,applications.memorandums,undertakings,
recognizances,transfers,contracts of indemnity,policies,contracts guaranteeing the fidelity of persons holding positions of public or private trust,and other
wntings obligatory in nature that the business of the Company may require;and to modify or revoke,with or without cause,any such appointment or
authority;provided,however,that the authority granted hereby shall in no way limit the authority of other duly authorized agents to sign and countersign any
of said documents on behalf of the Company."
"RESOLVED FURTHER,that such attorneys-in-fact shall have full power and authority to execute and deliver any and all such documents and to bind the
Company subject to the terms and limitations of the power of attorney issued to them,and to affix the seal of the Company thereto;provided,however,that
said seal shall not be necessary for the validity of any such documents."
This power of attorney is signed and sealed under and by the following bylaws duly adopted by the board of directors of the Company.
Execution of Instruments.Any vice president.any assistant secretary or any assistant treasurer shall have the power and authority to sign or attest all
approved documents,instruments,contracts,or other papers in connection with the operation of the business of the company in addition to the chairman of
the board,the chief executive officer,president,treasurer or secretary;provided,however,the signature of any of them may be printed,engraved,or
stamped on any approved document,contract,instrument,or other papers of the Company.
IN WITNESS WHEREOF,the Company has caused this instrument o be ealed an my attested by the signature of its officer the 1st day of
May 2017 .
111\ 1�\ Antonio Albanese, Vice President of Nationwide Mutual Insurance Company, National
m �uu•Mse,, 1�w., ( Casualtyom an AMCO Insurance Company,Allied Property and Casualty Insurance Company�. zf, ot+., P Y• P Y Y P y
/r72•SEAL S
, • 0 ACKNOWLEDGMENT
SEAL •
$ ,/ / STATE OF NEW YORK,COUNTY OF NEW YORK:ss
arD�(tiris�♦ , rii,+ 'I On this 1st day of May 2017 ,before me came the above-named officer for the
��1 ,\11 Company aforesaid,to me personally known to be the officer described in and who executed the
41V11111
preceding instrument.and he acknowledged the execution of the same,and being by me duly
Ir sworn,deposes and says,that he is the officer of the Company aforesaid,that the seal affixed
Gasuajr I�ycWu!.. P Y • p Y
y . valour hereto is the corporate seal of said Company,and the said corporate seal and his signature were
o c$ _�' duly affixed and subscribed to said instrument by the authority and direction of said Company.
•
• 1904 ��;SEAL s� BARRY T BASSIS
c0 /
2 t r Notary Public.State of New York
SEAL is, .
v•• No.026A4656400 r
• Ohio %OiMF\_.� Qualified in New York County
Notary Public
Commission Expires April 30,2019 My Commission Expires
CERTIFICATE April 30,2019
I,Laura B.Guy,Assistant Secretary of the Company,do hereby certify that the foregoing is a full,true and correct copy of the original power of attorney issued
by the Company,that the resolution included therein is a true and correct transcript from the minutes of the meetings of the boards of directors and the same has
not been revoked or amended in any manner;that said Antonio C.Albanese was on the date of the execution of the foregoing power of attorney the duly elected
officer of the Company.and the corporate seal and his signature as officer were duly affixed and subscribed to the said instrument by the authority of said board
of directors;and the foregoing power of attorney is still in full force and effect.
IN WITNESS WHEREOF,I have hereunto subscribed my name as Assistant Secretary,and affixed the corporate�id Company this 21st day of
June 2018
I his power of attorney expires:_ April 30,2019 a
Assistant Secretary
BDJ 1(05 17)00