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HomeMy WebLinkAboutHousworth, Jeramiah 2019 FEE: $20.00 SINGLE-SITE RIGHT-OF-WAY EXCAVATION LICENSE Application is made for a license to work within the Right-of-Way: NAME: V E A M,A ll 1VOG(S iAla Crti Type of organization: X individual _partnership pc� n/ 4679 ./f.Qom corporation E-MAIL: S ouSor ADDRESS: /721 000 ST. State of in�nrnnratinn OSR OS li a1L- 531902_ Right-of-Way Permit#: 201904835 (To Be Completed by City Staff) I(We)further agree to provide the City of Oshkosh 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 (b) $500,000 personal liability and advertising injury (c) $500,000 general aggregate (d) $500,000 products-completed operations aggregate and shall name the City of Oshkosh,its officers,council members, agents,employees, and authorized volunteers as an additional insured thereon. Proof of said coverage in the form of an insurance certificate shall be submitted to the City of Oshkosh 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 City of Oshkosh Public Works Department-Engineering Division. DATE ISSUED: ¶ V!I 1zc19 EXPIRATION: a 131 (7019 BOND TERM: 9• l• ,°l -ID tt•?,l•`j01I INSURANCE TERM: C(•i. t%-gyp Ct•°I•Ze DATE: `G'2°1• lit "„ : -.A I / W 'licants Signatur-r 910-20.3 -2/r/ Telephone Number 1:\Engineering\ROW Permits\Single-Site ROW Excavation Bond&License_]-5-19.doc SINGLE-SITE RIGHT-OF-WAY EXCAVATION BOND Bond Number: W150355778 PRINCIPAL(S)(Legal name(s)and business address(es)) Type of organization: Jeramiah Housworth X individual _partnership 1721 Ohio St Oshkosh, WI 54902 _corporation Surety(ies)(Name(s)and business address(es)) State of Incorporation Wisconsin Old Republic Surety Company 445 S Moorland Rd, Suite 200 Brookfield, WI 53005 Penal Sum of Bond: ,5,00(1.O(1 Right-of-Way Permit#: ZO(90`B'30 (To Be Completed by City Staff) 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 pursuant to the right-of-way permit specified above. 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 street, sidewalk, terrace, or other public right-of-way, vacated right-of-way, or City easement areas in accordance with the current edition of the Standard Specifications for City of Oshkosh, Wisconsin; and pay to the City of Oshkosh any amounts due for services or materials furnished in connection therewith within one(1)month 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 thirty(30)days of written demand for payment;however,the penal sum of this bond shall not exceed$5,000. 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 in accordance with the approved right-of-way permit from 09/01/2019 (Date of Issuance) to December 31, 20 19 (Date of Expiration) for the specified right-of-way permit number listed on this form. This bond shall cover claims made for work performed under the license and corresponding right-of-way permit and for an additional two(2) year maintenance period beyond the above expiration date. The principal agrees to correct all maintenance issues brought to the attention of the Principal(s)upon receiving notice from the City of Oshkosh within the two(2)year maintenance period. SIGNATURES/SEALS: r Princip For the Surety: afore Als•vos/4_,--// SignatureeuflFygig t/YliAY r� f Elise Faust "� � °�' ` SEAI, Name Name %��.. PRoPE Qlt/iVE Attorney-in-Fact y 4, Title ( Title 445 S Moorland Rd,Suite 200 Brookfield,VN 53005 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. 1:\Engineering\ROW Permits\Single-Site ROW Excavation Bond&Licensc_1-8-19.doc **** * OLD REPUBLIC SURETY COMPANY POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS:That OLD REPUBLIC SURETY COMPANY, a Wisconsin stock insurance corporation.does make,constitute and appoint: Elise Faust of Brookfield,WI its true and lawful Attorney(s)-in-Fact, with full power and authority, not exceeding $10,000,000, for and on behalf of the company as surety, to execute and deliver and affix the seal of the company thereto (if a seal is required). bonds, undertakings, recognizances or other written obligations in the nature thereof, (other than bail bonds, bank depository bonds, mortgage deficiency bonds, mortgage guaranty bonds, guarantees of installment paper and note guaranty bonds, self-insurance workers compensation bonds guaranteeing payment of benefits, asbestos abatement contract bonds, waste management bonds,hazardous waste remediation bonds or black lung bonds),as follows: Effective Date: 9/1/2019 12:00:00 AM Bond Number:W150355778 Bond Amount: Five Thousand Dollars $5,000.00 Principal Name:Jeramiah Housworth Obligee Name: City of Oshkosh of Oshkosh,WI and to bind OLD REPUBLIC SURETY COMPANY thereby, and all of the acts of said Attorneys-in-Fact, pursuant to these presents, are ratified and confirmed. This appointment is made under and by authority of the board of directors at a special meeting held on February 18, 1982. This Power of Attorney is signed and sealed by facsimile under and by the authority of the following resolutions adopted by the board of directors of the OLD REPUBLIC SURETY COMPANY on February 18,1982. RESOLVED that the president, any vice president or assistant vice president, in conjunction with the secretary or any assistant secretary, may appoint attorneys-in-fact or agents with authority as defined or limited in the instrument evidencing the appointment in each case,for and on behalf of the company to execute and deliver and affix the seal of the company to bonds, undertakings, recognizances, and suretyship obligations of all kinds,and said officers may remove any such attorney-in-fact or agent and revoke any Power of Attorney previously granted to such person. RESOLVED FURTHER that any bond, undertaking, recognizance,or suretyship obligation shall be valid and binding upon the Company (i) when signed by the president. any vice president or assistant vice president, and attested and sealed(if a seal be required)by any secretary or assistant secretary;or jii) when signed by the president. any vice president or assistant vice president,secretary or assistant secretary,and countersigned and sealed(if a seal be required)by a duly authorized attorney-in-fact or agent;or (in) when duly executed and sealed (if a seal be required) by one or more attorneys-in-fact or agents pursuant to and within the limits of the authority evidenced by the Power of Attorney issued by the company to such person or persons. RESOLVED FURTHER that the signature of any authorized officer and the seal of the company may be affixed by facsimile to any Power of Attorney or certification thereof authorizing the execution and delivery of any bond, undertaking,recognizance,or other suretyship obligations of the company, and such signature and seal when so used shall have the same force and effect as though manually affixed. IN WITNESS WHEREOF. OLD REPUBLIC SURETY COMPANY has caused these presents to be signed by its proper officer,and its corporate seal to be affixed this 26th day of August 2019 0` 'S gfT` OLD REPUBLIC SURETY COMPANY WJ coeroe.rr, p' p SEAL ;; At 14. o rae Assistant Secre ary President STATE OF WISCONSIN,COUNTY OF WAUKESHA-SS On this 26th day of August 2019 ,personally came before me. Alan Pavlic and Kevin Abitz ,to me known to be the individuals and officers of the OLD REPUBLIC SURETY COMPANY who executed the above instrument. and they each acknowledged the execution of the same, and being by me duly sworn, did severally depose and say: that they are the said officers of the corporation aforesaid, and that the seal affixed to the above instrument is the seal of the corporation. and that said corporate seal and their signatures as such officers were duly affixed and subscribed to the said instrument by the authority of the board of directors of said corporation. **AA • Al<A411 -K.• go s.,,t Notary Public My Commission Expires: 09/28/2022 CERTIFICATE (Expiration of notary's commission does not invalidate this instrument) I. the undersigned, assistant secretary of the OLD REPUBLIC SURETY COMPANY, a Wisconsin corporation, CERTIFY that the foregoing and attached Power of Attorney remains in full force and has not been revoked; and furthermore, that the Resolutions of the board of directors set forth in the Power of Attorney.are now in force. 0243967 0 CJ. �o�row�re 3 9 SEAL = Signed and sealed at the City of Brookfield,WI this 26th day of August 2019 o roe. � V ORSC 22262(3-06) Assistant Secretary STATEWIDE SERVICES, INC.