HomeMy WebLinkAboutTom Van Handel 2019 FEE: $20.00
?!a;\ chcdle. -
SINGLE-SITE RIGHT-OF-WAY EXCAVATION LICENSE
Application is made for a license to work within the Right-of-Way:
NAME: 7(NII 014 it o '/,/f Type of organization:
individual _partnership
E-MAIL: /Pt e 7`-vh ei corporation
�j � w
�lGf4�f State of inrornnration
ADDRESS: `�3DF
//44-4 � 5jJ
7/3 Right-of-Way Permit#:
(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: Mil IZb1°"
EXPIRATION: 1113112611
BOND TERM: 12 I s 1269 To 1Z.I311?bt'1
INSURANCE TERM: z./1 I2d9 'ro Z I t 12020
DATE: IZ4 !Wick
Applicant's Signature
920 :33.--i2,2l
Telephone Number
1:\Engineering\ROW Permits\Single-Site ROW Excavation Bond&License_1-8-19.doc
oni
SINGLE-SITE RIGHT-OF-WAY EXCAVATION BOND Bond No. 354224271
PRINCIPAL(S)(Legal name(s)and business address(es)) Type of organization:
TOM VAN HANDEL CORP. _individual _partnership
y corporation
1830 E. Edgewood Dr.,Appleton,WI, 54913 State of Incorporation M A
Surety(ies)(Name(s)and business address(es))
LIBERTY MUTUAL INSURANCE COMPANY
175 Berkeley Street, Boston, MA,02116
Penal Sum of Bond: $5,000.00 Right-of-Way Permit#:
(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 12/5/2019 (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:
For the Prci al: TOM VAN HANDEL CORP. For the Surety: IB MUTUAL INSURANCE COMPANY
Signature Signa e
/I& 1 /�/_-o / Kelly Cody
Name v'' ` �' Name
A..Si / T✓J/- Attorney-in-Fact
Title Title
P.O. Box 23004, Gren Bay,WI 54305-3004
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&License_t-8-19.doc
This Power of Attorney limits the acts of those named herein,and they have no authority to
n bind the Company except in the manner and to the extent herein stated.
c - Libei`y Liberty Mutual Insurance Company
, lThe Ohio Casualty Insurance Company Certificate No:8201176-354019
� ��� West American Insurance Company
SURETY
POWER OF ATTORNEY
KNOWN ALL PERSONS BY THESE PRESENTS:That The Ohio Casualty Insurance Company is a corporation duly organized under the laws of the State of New Hampshire,that
Liberty Mutual Insurance Company is a corporation duly organized under the laws of the State of Massachusetts,and West American Insurance Company is a corporation duly organized
under the laws of the State of Indiana(herein collectively called the"Companies"),pursuant to and by authority herein set forth,does hereby name,constitute and appoint, Kelly Cody,
Christopher Hoyden,Roxanne Jensen,Brian L.Krause,Trudy A.Szalewski
all of the city of Green Bay state of Wisconsin each individually if there be more than one named,its true and lawful attorney-in-fact to make,
execute,seal,acknowledge and deliver,for and on its behalf as surety and as its act and deed,any and all undertakings,bonds,recognizances and other surety obligations,in pursuance
of these presents and shall be as binding upon the Companies as if they have been duly signed by the president and attested by the secretary of the Companies in their own proper
persons.
IN WITNESS WHEREOF,this Power of Attorney has been subscribed by an authorized officer or official of the Companies and the corporate seals of the Companies have been affixed
thereto this 1st day of May , 2019 .
Liberty Mutual Insurance Company
tNsuR cp rnrso.�p , tNs4 The Ohio Casualty Insurance Company
!OeLQ°R.,, 4.. ""eyoe,;?-7y� 2uoaP°Ra,oYc,� West American Insurance Company
1912 ra
0l. 1919 ra
1991 cn
N d�sS,1clius da 0 �NAMPS�,dL� �s ��'°IANP ,aLe4/1,pf:,1,/ 4.- 4-//
ei7 * t� .y1 } 10 H,1,r * 1,� By• /- v�
c David M.Carey,Assistant Secretary =
ro
State of PENNSYLVANIA
=
a�i County of MONTGOMERY ss cu
m C
0 a) On this 1st day of May , 2019 before me personally appeared David M.Carey,who acknowledged himself to be the Assistant Secretary of Liberty Mutual Insurance 0
`O 2 Company,The Ohio Casualty Company,and West American Insurance Company,and that he,as such,being authorized so to do,execute the foregoing instrument for the purposes=l-
as
a`� > therein contained by signing on behalf of the corporations by himself as a duly authorized officer. o Lii
�_ >-
N 2 IN WITNESS WHEREOF,I have hereunto subscribed my name and affixed my notarial seal at King of Prussia,Pennsylvania,on the day and year first above written. c eL
o
O a) _,c, ---- COMMONWEALTH OF PENNSYLVANIA Q 4/t
L - Notarial NotaryS• eal B �, ,�/G% , I e 0 c
Qj O Teresa Pastella, Public ��[ q�(//{��
O N - Upper Merlon Two..Montgomery County y:
C N My Commission Expires March 28.2027 Teresa Notary Public o E
• _ ti•:,^ cam ;` Member.Pennsylvania Association of Notaries CL O
rIS cl)a) This Power of Attorney is made and executed pursuant to and by authority of the following By-laws and Authorizations of The Ohio Casualty Insurance Company, Liberty Mutual E a'
o.a Insurance Company,and West American Insurance Company which resolutions are now in full force and effect reading as follows: o aa)
E}i ARTICLE N-OFFICERS:Section 12.Power of Attorney. '".
o Any officer or other official of the Corporation authorized for that purpose in writing by the Chairman or the President,and subject to such limitation as the Chairman or the 2,
2 >, President may prescribe,shall appoint such attorneys-in-fact,as may be necessary to act in behalf of the Corporation to make,execute,seal,acknowledge and deliver as surety >o
• as any and all undertakings,bonds,recognizances and other surety obligations.Such attorneys-in-fact,subject to the limitations set forth in their respective powers of attorney,shall 2 N
have full power to bind the Corporation by their signature and execution of any such instruments and to attach thereto the seal of the Corporation.When so executed, such '"C°
instruments shall be as binding as if signed by the President and attested to by the Secretary.Any power or authority granted to any representative or attorney-in-fact under the �co
provisions of this article may be revoked at any time by the Board,the Chairman,the President or by the officer or officers granting such power or authority. o,
ARTICLE XIII-Execution of Contracts:Section 5.Surety Bonds and Undertakings. 0 o cfl
Any officer of the Company authorized for that purpose in writing by the chairman or the president,and subject to such limitations as the chairman or the president may prescribe, I---
shall appoint such attorneys-in-fact,as may be necessary to act in behalf of the Company to make,execute,seal,acknowledge and deliver as surety any and all undertakings,
bonds,recognizances and other surety obligations.Such attorneys-in-fact subject to the limitations set forth in their respective powers of attorney,shall have full power to bind the
Company by their signature and execution of any such instruments and to attach thereto the seal of the Company.When so executed such instruments shall be as binding as if
signed by the president and attested by the secretary.
Certificate of Designation-The President of the Company,acting pursuant to the Bylaws of the Company,authorizes David M.Carey,Assistant Secretary to appoint such attorneys-in-
fact as may be necessary to act on behalf of the Company to make,execute,seal,acknowledge and deliver as surety any and all undertakings,bonds,recognizances and other surety
obligations.
Authorization-By unanimous consent of the Company's Board of Directors,the Company consents that facsimile or mechanically reproduced signature of any assistant secretary of the
Company,wherever appearing upon a certified copy of any power of attorney issued by the Company in connection with surety bonds,shall be valid and binding upon the Company with
the same force and effect as though manually affixed.
I,Renee C.Llewellyn,the undersigned,Assistant Secretary,The Ohio Casualty Insurance Company,Liberty Mutual Insurance Company,and West American Insurance Company do
hereby certify that the original power of attorney of which the foregoing is a full,true and correct copy of the Power of Attorney executed by said Companies,is in full force and effect and
has not been revoked. ,1
IN TESTIMONY WHEREOF,I have hereunto set my hand and affixed the seals of said Companies this+ day of i.XQ-P f (90/9
4 otsr/,p 0.1 INs` this
"oRPog4j,4740 yOQ'4onvoR„A. \Pcpspok,9yn
r FaF Q3 Fcn e CI, to
L�
1912 0 - 19191991 0jo �s �yDIANP as Renee C.Llewellyn,Assistant Secretary
H,,) 1,4 H1 * 1.� ''yM * h�