HomeMy WebLinkAboutNak Concrete LLC 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: IA \L.. Co}\ur(?)1I \CJ Type of organization:
, 'r ^� _individual _partnership
E-MAIL: 1)Q 1 M'�1,o Vi U A k(J W q v CO I. C,A rn Zcorporation
53�ADDRESS: M fkrt,(1 1 (� r1 Y t 1���() State of incnmoration
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CO (001 \ 4 '0 GG4 W f 3 Right-of-Way Permit#: Zplgo'1C,L
(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) $500,000 products-completed operations aggregate
and shall name the City of Oshkosh,its officers,council members,agents,employees,and authorized volunteers as an
additional insured thereon. Proof of said coverage in the form of an insurance certificate shall be submitted to the City of
Oshkosh prior to issuance of any permit to perform work within the right-of-way.
Each individual project/address at which work will be performed requires a separate permit which may be obtained from
the City of Oshkosh Public Works Department-Engineering Division.
DATE ISSUED: 131.2 (°\
EXPIRATION: rZ•Ai-7SNCI
BOND TERM: 7'30.1:28 m r z.. 31.7dg
INSURANCE TERM: S•l$•2019 -ro S• 'Slo )
DATE: -4•S(•20(1
Ap icant's Signature
')‘d) � to - 1103'\
Telephone Number
!:\Engineering\ROW Permits\Single-Site ROW Excavation Bond&License_1$19.doc
SINGLE-SITE RIGHT-OF-WAY EXCAVATION BOND
PRINCIPAL(S)(Legal name(s)and business address(es)) Type of organization:
NAK Concrete LLC
57 Marcella Avenue _individual _partnership
_corporation
Combined Locks,WI 54113
WI
Surety(ies)(Name(s)and business address(es)) State of Incorporation
West Bend Mutual Insurance Company
PO Box 620976
Middleton,WI 53562-0976
Penal Sum of Bond: $5,000.00 Right-of-Way Permit#: Zo19 l(07
(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 07/30/2019 (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 rece' . g notice from the City of Oshkosh within the two(2)year maintenance period.
SIGNATURES/ LS•
For the P ' al: a LLC For e S ety: West Ben ut al Ins an ompany
Si ature / Signs
�lcii 44-ft %� -SE
Name ,l/ Name
(IW 4 zr (' f/ -'i
Attorney-In-Fact
Title Title
PO Box 620976,Middleton,WI 53562-0976
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.
I:\Engineering\ROW Permits\Single-Site ROW Excavation Bond&License_1-8-19.doc
WEST BEND THE SILVER LINING®
A MUTUAL INSURANCE COMPANY'
Bond No. 2417564
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:
Cynthia Casey
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 and Zero Cents 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 seal to be hereto duly attested by its secretary this 22nd day of Se tember, 2017.
Attest ii ..
Christopher C. Z gart _ c'°RP°R"6-, Kevin A. Steiner
Secretary '" SQL, Chief Executive Officer/President
State of Wisconsin ..._..
County of Washington
On the 22nd day of September, 2017, 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. .•••BEy•.,
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NOTAAy';
—_, Juli A nedum
PUBLIC =?; Senior orporate Attorney
:°TF .•s..o.`'• Notary Public,Washington Co.,WI
•.••of................
wa
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 30th day of July , 2019 .
co�otive• k�..g:,
SEALS, Heather Dunn
cP ;' Vice President-Chief Financial Officer
Notice: Any questions concerning this Power of Attorney may be directed to the Bond Manager at NSI, a division of West Bend
Mutual Insurance Company.
1900 S. 18th Ave. West Bend,WI 53095 I ph(262) 334-6430 I 1-800-236-5004 I fax (262) 338-5058 I www.thesilverlining.com