Loading...
HomeMy WebLinkAboutMidwest Engineering Services-Monitoring Well Hight AVe ii AUG 1 8 2010 H CITY ri r V,c awr: City Attorneys Office Phone: (920) 236-5115 Fax: (920) 236-5106 http;//www.ci.oshkosh.wi.us August 18, 2010 Mr. Paul Winter Midwest Engineering Services 5042 Washington St. 608 N. Stanton Street PO Box 435 Ripon, WI 54971 Butte Des Morts, WI 54927 Re: Privilege in Street/ City of Oshkosh Sec. 66.045, Wis. Stats. Installation of Monitoring Well - 135 High Avenue Gentlemen: On August 10, 2010, by resolution#10-237, the City of Oshkosh Common Council approved your request for a privilege in street permit subject to certain conditions that are made a part of the approval resolution. In order for the permit (which much be obtained at the Public Works Department) to be valid, each one of these conditions must be satisfied. To that end,please find enclosed for your signature an Agreement releasing, and holding the City harmless, from all liability arising from your use of the permit. This, along with the insurance filing requirements ($200,000/$500,000 limits)are part of state law that enables the City to allow you this use. Kindly return to this office the signed Agreement along with your proof of insurance, either a separate policy, or naming the City as an additional insured on your policy. If you include the City as an additional insured, please use the following language: "City of Oshkosh, and its officers, council members, agent, employees and authorized volunteers as additional insured." These conditions of approval must be met before you exercise the privilege in street. Direct any questions about insurance and liability releases to this office. Any other questions concerning the remaining conditions should be directed to the Public Works Department at 236-5065. Thank you for your cooperation. Sincerely, CITY OF OSHKOSH Lynn A. Lorenson City Attc,ey cc: amela R. Ubrig - City Clerk Steve Gohde, Engineering Darryn Burich, Corn. Dev. Clerk. AGREEMENT WHEREAS, the City of Oshkosh has granted to the undersigned a privilege to place an obstruction within the sidewalk right -of -way as follows: Installation of a monitoring well within the right -of -way of High Avenue, adjacent to 135 High Avenue, per attached Exhibit A. WHEREAS, State law provides that by its acceptance of this privilege the undersigned shall become primarily responsible for damages to person or property by reason of the granting of the privilege; NOW, THEREFORE, in consideration of the City of Oshkosh, a Municipal Corporation granting permission to the undersigned to place an obstruction within the sidewalk right -of -way, the undersigned agrees that he is solely responsible for his activities under this agreement. The undersigned hereby releases the City of Oshkosh from all debt, claims, demands, damages, actions and causes of action whatsoever which may result from the placement of an obstruction in the sidewalk right -of -way by the undersigned. Further, the undersigned agrees to protect and hold the City of Oshkosh harmless against all actions, claims and demands of any kind or character whatsoever which may in any way be caused by the activities under this privilege by the undersigned or agents or employees. Further, the undersigned agrees to indemnify and refund to the City all such sums which the City may be obligated or adjudged to pay, including the City's attorney fees and costs, on such actions, claims or demands within 30 days after written request for such indemnification. The undersigned agrees that this paragraph is to be liberally construed in favor of the City of Oshkosh, in consideration of the privilege granted by the City under this agreement. This agreement and the privilege cannot be assigned without the written consent of the City of Oshkosh. The privilege is subject to all terms and conditions contained in any authorizing resolution adopted by the City of Oshkosh Common Council, which is incorporated by reference as if fully recited within this document. By executing this agreement and by using the privilege, the undersigned agrees to fully abide by such terms and conditions, including revocation upon written notice for noncompliance with the authorizing resolution and this agreement. Dated this 1 1 day of Flare h , . MIDWEST EN ERING SERVICES By: ; t�e�� And: o Name & Title: Name & Title: l A V L t ft jL OW AP an STATE OF WISCONSI 4 ) ► SS. WINNEBAGO COUNTY ) a 0 ll Personally came befor me this 1 1 day of Marc , 28iP6 the above -named Bran yOU»r War +h and 1av 1 W I Y' 4-t4 S of MIDWEST ENGINEERING SERVICES to me known to be s ch per•6n(s) and officers who executed the foregoing document and acknowledged that they executed the same as such officers by its authority, for the purpose therein contained. CAA CHELSEY N HOLM Notary Public, IN/tiny bap Co., Wisconsin Notary Public My Commission: w 1 y 41- 1 o1.O / 9 State of Wisconsin Attachment: Exhibit A - Resol. #10 -237 and attachments of Oshkosh Common Council Meeting 8/10/10. AUGUST 10, 2010 10 -237 RESOLUTION (CARRIED LOST LAID OVER WITHDRAWN PURPOSE: APPROVE GRANTING PRIVILEGE IN STREET TO MIDWEST ENGINEERING SERVICES & PAUL WINTER TO INSTALL A MONITORING WELL WITHIN THE RIGHT -OF -WAY OF HIGH AVENUE ADJACENT TO 135 HIGH AVENUE INITIATED BY: MIDWEST ENGINEERING SERVICES & PAUL WINTER PLAN COMMISSION RECOMMENDATION: Approved w /conditions WHEREAS, Midwest Engineering Services, petitioner, and Paul Winter, partner /owner of property at 135 High Avenue, requests the Common Council grant a privilege in street to Midwest Engineering Services, general contractor and other subcontractors as may be required to install a monitoring well within the right -of -way of High Avenue adjacent to 135 High Avenue, and WHEREAS, Section 66.0425, Wis. Stats., provides for the granting of a privilege in a right -of -way; and WHEREAS, the Plan Commission approved of this request with conditions. NOW, THEREFORE, BE IT RESOLVED by the Common Council of the City of Oshkosh that the proper City officials are hereby authorized and directed to grant Midwest Engineering Services, general contractor and other subcontractors as may be required to install a monitoring well within the right -of -way of High Avenue adjacent to 135 High Avenue, per the attached, and upon completion of said installation, Paul Winter, partner /owner, will assume liability for said monitoring well within the right -of- way, contingent upon the following: 1) Placement of the monitoring well shall be coordinated with the Department of Public Works to prevent conflicts with existing underground utilities. 2) The monitoring well shall be flush mounted to prevent interference with pedestrian traffic. 3) The monitoring well be installed in a manner that is approved by the Department of Public Works with no modifications or changes in construction procedure without prior approval by the Department of Public Works. 4) If no longer needed, the monitoring well be properly abandoned and removed in accordance with City standards and under the direction of the Department of Public Works. REVISED AUGUST 10, 2010 10 -237 RESOLUTION CONT'D 5) Any problem which may arise as a result of the placement of the monitoring well be the responsibility of the contractors and owner to correct in coordination with the Department of Public Works. 6) All appropriate permits be obtained prior to the start of placement of the monitoring well. 7) The monitoring well be modified or removed immediately upon the request of the City. 8) The monitoring well be part of and documented with Digger's Hotline system. 9) The petitioner, contractors and owner of the monitoring well secure and submit to the City Clerk a separate insurance policy which names the City as an additional insured with a minimum coverage of $200,000 per person and $500,000 in general aggregate. 10) It is the responsibility of the petitioner to file in a timely manner a new insurance certificate with the City Clerk upon expiration of an existing certificate. Failure to do so will result in the revocation of the privilege in street upon 10 days notice • 11) The petitioner, contractors and owner of the monitoring well fiber optic stem execute hold harmless agreements with the City. • Indicates Revision @;) OJHKOJH ON THE WATER TO: Honorable Mayor and Members of the Common Council FROM: Darryn Burtch t Lj Director of Planning Services DATE: August 5, 2010 RE: Approve Granting Privilege in Street to Midwest Engineering Services and Paul Winter Adjacent to 135 High Avenue (Plan Commission Recommends Approval) BACKGROUND The subject properties are located in the City's downtown just west of North Main Street. The area can be characterized with a mix of commercial /residential, commercial, multiple family and public and private parking lot uses. Midwest Engineering Services requests an easement on City property to install a monitoring well as part of an environmental investigation associated with the facility at 135 High Avenue. The well is proposed to be located within the south sidewalk of High Avenue in front of 135 High Avenue. The Oshkosh Common Council has approved similar privilege and easement requests for the placement of numerous wells as part of investigations for 118 and 135 High Avenue. ANALYSIS The well is needed to collect water samples to determine the extent of soil and groundwater contamination with groundwater samples being collected quarterly from the wells until closure of the site is obtained from the Wisconsin Department of Natural Resources. The well will be abandoned per NR 141 regulations when the investigation is complete. The Department of Public Works has reviewed and recommends approval of the request with the final location of the well to be coordinated and approved by their office to avoid conflicts with existing underground utilities and to be flush mounted to avoid potential pedestrian traffic conflict. FISCAL IMPACT None anticipated. RECOMMENDATION The Plan Commission approved of this request at its August 3, 2010 meeting. Approved, City Manager ITEM: GRANT PRIVILEGE IN THE STREET AT 135 HIGH AVENUE Plan Commission meeting of August 3, 2010 GENERAL INFORMATION Petitioner Midwest Engineering Services Owner: City of Oshkosh Action Requested: Midwest Engineering Services requests an easement on City property to install a monitoring well as part of an environmental investigation associated with the facility at 135 High Avenue. The well is proposed to be located within the south sidewalk of High Avenue in front of 135 High Avenue. i The Oshkosh Common Council has approved similar privilege and easement requests for the placement of numerous wells as part of investigations for 118 and 135 High Avenue. Applicable Ordinance Provisions: N/A Property Location and Type: The subject properties are located in the City's downtown just west of North Main Street. The area can be characterized with a mix of commercial/residential, commercial, multiple family and public and private parking lot uses. ANALYSIS The well is needed to collect water samples to determine the extent of soil and groundwater contamination. Groundwater samples will be collected quarterly from the wells until closure of the site is obtained from the Wisconsin Department of Natural Resources. The well will be abandoned per NR 141 regulations, when the investigation is complete. The Department of Public Works has reviewed and recommends approval of the privilege request, however, they are requesting the fmal location of the well be coordinated and approved by the Public Works office to avoid conflicts with existing underground utilities. An additional concern did arise during staff review that the proposed well is not indicated as being flush mounted with the sidewalk. Staff is recommending the well be flush mounted to avoid potential pedestrian traffic conflict. RECOMMENDATION /CONDITIONS Staff recommends approval of the easement to place a monitoring well on City property subject to the following conditions: 1. Placement of the well shall be coordinated with the Department of Public Works to prevent conflicts with existing underground utilities. 2. The monitoring well shall be flush mounted to prevent interference with pedestrian traffic. 3. The monitoring well(s) are installed in a manner that is approved by the Department of Public Works with no modification or changes in construction procedure without prior approval by the Department of Public Works. 4. If no longer needed, the well(s) be properly abandoned and removed in accordance with City standards and under the direction of the Department of Public Works. 5. Any problem that may arise as a result of placement of the well(s) be the responsibility of the petitioner /owner to correct in coordination with the Department of Public Works. 6. All appropriate permits be obtained prior to the start of placement of the well(s). 7. The well(s) be modified or removed immediately upon request of the City. 8. The petitioner /owner secures and submits to the City Clerk a separate insurance policy which names the City as an additional insured with a minimum coverage of $200,000 per person and $500,000 in general aggregate. 9. It is the responsibility of the petitioner /owner to file in a timely manner a new insurance certificate with the City Clerk upon expiration of an existing certificate. Failure to do so will result in the revocation of the easements within ten (10) days of notice. 10. The petitioner /owner execute a hold harmless agreement with the City. 11. The facility be part of and documented with Digger's Hotline system. The Plan Commission approved of the easement for the monitoring well as requested with conditions noted. The following is the Plan Commission's discussion on this item. Mr. Buck presented the item and stated that the well would be located in front of the former Oshkosh Tent and Awning building and reviewed the site, surrounding area and proposed site plan. He further stated that there were currently 12 to 18 existing wells in the general vicinity and that the conditions recommended for this request were the standard nine conditions with the addition of two more. He reviewed the conditions and noted that the additional two were to have the monitoring well be flush mounted to prevent interference with pedestrian traffic and to have the placement of the well be coordinated with the Department of Public Works to prevent conflicts with existing underground utilities. Ms. Lohry inquired about the history of the area that would explain the reason for the number of monitoring wells placed in this vicinity. Mr. Buck responded that there were previous establishments located in the area that were laundry and awning facilities which both used chemicals that possibly created contamination. Motion by Thoms to approve the easement to place a monitoring well on City property as requested with the following conditions: 1. Placement of the well shall be coordinated with the Department of Public Works to prevent conflicts with existing underground utilities. 2. The monitoring well shall be flush mounted to prevent interference with pedestrian traffic. 3. The monitoring well(s) are installed in a manner that is approved by the Department of Public Works with no modification or changes in construction procedure without prior approval by the Department of Public Works. 4. If no longer needed, the well(s) be properly abandoned and removed in accordance with City standards and under the direction of the Department of Public Works. ITEM -EASEMENT-HIGH AV 2 • 5. Any problem that may arise as a result of placement of the well(s) be the responsibility of the petitioner /owner to correct in coordination with the Department of Public Works. 6. All appropriate permits be obtained prior to the start of placement of the well(s). 7. The well(s) be modified or removed immediately upon request of the City. 8. The petitioner /owner secures and submits to the City Clerk a separate insurance policy which names the City as an additional insured with a minimum coverage of $200,000 per person and $500, 000 in general aggregate. 9. It is the responsibility of the petitioner /owner to file in a timely manner a new insurance certificate with the City Clerk upon expiration of an existing certificate. Failure to do so will result in the revocation of the easements within ten (10) days of notice. 10. The petitioner /owner execute a hold harmless agreement with the City. 11. The facility be part of and documented with Digger 's Hotline system. Seconded by Vajgrt. Motion carried 8 -0. ITEM - EASEMENT -HIGH AV 3 City of Oshkosh SUBMIT TO: General Application Dept. Church Ave., P.O. ox 1130 QN 215 Church Ave., .. Box 1130 ON THE WATER Oshkosh, WI 54901 PHONE: (920) 236 -5059 **PLEASE TYPE OR PRINT USING BLACK 1NK•` APPLICANT INFORMATION • Petitioner. t P 1 � PP,� Sell/ t GP GP.) Date: - I /t 4 l� CO A , � � . ^ ,mi l) r � Petitioner's Address: (O'i ! v . J fa�� v� S-( r P7 City: P ✓_ State: VI Zip: ✓ ' ` 7 ( J Telephone #: (`j)o 7 t • ")---DO Fax: (7)-1.0745 a)..)_)._ Other Contact # or Email: b )U J t W £&J i P3 L pr . c. Status of Petitioner (Please Check): Downer RRep�reesentative Tenant ['Prospective Buyer Petitioner's Signature (required): / I - � Date: 6/q J I u OWNER INFORMATION r � Owner(s): G,+�, W l �r Date: Owner(s) Address: 504 We•Ji1,i l� S,V� p� ivy City: ett POPS MIAs State: W. Zip: 6 Telephone #: ( -75 `t a a Fax: (-- ) — Other Contact # or Email: Q Alm Peat) 1. G a INN Ownership Status (Please Check):AIndividual ['Trust DPartnership ['Corporation Property Owner Consent: (required) By signature hereon, I/We acknowledge that City officials and/or employees may, in the performance of their functions, enter upon the property to inspect or gather other information necessary to process this application. I also understand that all meeting dates are tentative and may be postponed by the Planning S 6 ::pionlyzm i tl u e l te submissions or other administrative reasons. Property Owner's Signature: Date: fp /O TYPE OF RE 1 UEST: • Access Control Variance • • Easement /' /J /�^ l .� Privilege in Street (identify) N is.4 Tl 44%. P 14,/ ( `' 6) 4 - VJ � t.i rte J �� Slnt S �'t • Other (identify) U f 104, SITE INFORMATION • Address/Location of Proposed Project: 1 4 ,3 1 1 ✓`r OP fA 1- Proposed Project Type: Iris to it, tJ(0. /V1es .' r, � W t t r ^ -{1 Stcf P v L L, S'''gAL 4' iltt, . P, Current Use of Property: a . � r, . Zoning: Land Uses Surrounding Your Site: North: r t t AUP 41 .A.P South: ✓k1 �Qr p� / East C, 4 y 7"�,,r i ,.� / o West: S } PUP`S Iu D Application fees are due at time of submittal. Make check payable to City of Oshkosh. D Please refer to the fee schedule for appropriate fee. FEE IS NON - REFUNDABLE For more information please visit the City's website at www.ci.oshkosh.wi.us/Community Development/Planning.htm Staff Date Rec'd X 1'1° • • midi/vest engineering services, inc. IMES geotechnical • environmental • materials engineers BOB N. Stanton Street Ripon, WI 54971 -1182 RECEIVED 920- 745 -2200 FAX 920 - 745 -2222 www.midwesteng.com • JUL 012010 June 30, 2010 COMMUNITY DEVELOPMENT Department of Community Development City of Oshkosh 215 Church Avenue P.O. Box 1130 Oshkosh, Wisconsin 54901 SUBJECT: PROPOSED MONITORING WELL Right of Way located adjacent to the northeast of 135 High Avenue - MES Project # 12 -51010 WDNR BRRTS # Gillen LLC #02 -71- 519535 • To Whom It May Concern: - In accordance with the City of Oshkosh's request, MES has prepared the following letter requesting permission to install a soil boring converted to a groundwater monitoring well within the sidewalk of the city right of way located adjacent to the northeast of 135 High Avenue (Former Oshkosh Tent and Awning). The location of the proposed monitoring well is shown on the attached figure. The purpose of the soil boring and groundwater monitoring well is to define the extent of soil and groundwater contamination at the site, which is required for the site investigation by the Wisconsin Department of Natural Resources (WDNR). The WDNR is also requiring that the well be installed within the sanitary/groundwater utility trench that enters the northeast side of the building to evaluate potential migration of contaminants within the utility trenches along High Avenue. The well will be approximately 13 feet in depth. The well will be sampled quarterly and abandoned when the groundwater quality standards of the WDNR are met and the site is closed. The well location (Figure 2) has been selected by Ms. Kathy Sylvester of the WDNR. Also, enclosed with • • this letter please find the City of Oshkosh General Application, a map with the proposed monitoring well location, a certificate of insurance and a check from Mr. Paul Winter (owner) for the $100 review fee. If you have any questions, or wish to discuss any part of this plan, please contact MES at 920- 745 -2200. Sincerely, MIDWE T ENGINEERING SERVICES, INC. B nYoun- h Hydrogeo • ■ st c: Mr. Paul Winter (Letter and Figure) Ms. Kathy Sylvester (WDNR) (Letter and Figure) • CORPORATE OFFICE WAUKESHA. WI 262-970-0764 4 APPLETON. WI • CHIPPEWA FALLS, WI • GREEN BAY, WI . / , s , f / FL, r W / I . Aol .4.: 2 , \ , o • .. ' d • 0 • i V \ ■ i" N tea= ` \ 0 . \ \\ J W W i ' J ZO Z ■ J -0 x! p, fig Z a, Q = ` �� ',0 � y;�� i� W \ ej! 97. i �Si, O Oa \ W a. W / U IZ . -/ IZ N W d a 9 / . v . / 0 lell 0 1111 - ' / 1 . • . TS ii • ej i ��•/ . El / .•(41 s` 2 v g $ / F 7 • • \ . • , _.....,...„ - , ,** . - - Z ,,, .- in i ilm lig !g / II v o . 111-111 i P i t / • . • • • 5 ''..f.1:t,:f7.:.-.-4,7-...? ii. i e \,` .� ;+• -,3r / ►�- /roe ,`•\ N. t ..,..N. 4 '\ � ,\ i ]T \ • ,_ i ` i r ,% 4: ' i \ rT N. N. e. 4 .-,‘ '''7.;-';'%'' . " N. <Z47‘ • \ " ► M gr. - ti 4:)/ do i N. • SUBJECT 7 .` - •• SITE ` �' , \• _ • •\ '\ , , ` / \ ^ 111 111 /// S r r * 770 a� ��� }•f +,L- �«�� ", y ty a � ,o. c'...... \� t r 44.k."4‘7"... '-'%., - i r 0 ` T ' DISCLAIMER Thb map b nsltlpr a Ispaty re corded map nor MONITORING WELL AV �` " compilation It b Intandsd to be used data 135 HIGH N 01HKOlH ibis drawing b a comp orrs data and Infonnat on loeatsd In various ,._a,,,, county ON na reKra and skits olrloss and other :Duress a frsctlnp the arse shown and It b to bs used Tor reference C it y o f Oshkosh purposes onIy The City of Oshkosh b not nF �� _ D e p artment o sponslbla for any lna fou nd, pi sus n coi talns Scale. — 100 Comm unity Development if dasonpell city found, Oshkosh. contact the City of Oshkosh. Created by - dffi 07/22/10 6 - - , . , -- i 1 ., 1 .1Y I 5..)-- � -_�� L�J pi • j .. LI � A JOH ' '1'1 _ 0 °o ' � :. F- F- sir °0 11111 11111 i w i L I -,.. 4. i.. .- . . ii g 0 . im o u j ce i U A L � Pi "STON PL. E. E . ii E. ,p M i D , LE AVE. H ,.i, 41. AVE CO • o CO 1 ANION i E. ? ID A r ill _ �� • �� � W p O A 00 , a �' Ai �; — ' ILL ' • U • 3 ` i i +' [� g , HUDSON ' ,_. z ., ' • In • ' co _ 1 0- - 1 ev 01 1 41 , - 7% . 0 ,-iii 4 iiiw_,•-pr: -141.5,1. . , IP e. . ib7.1, , A.. tra i ' '''''', i !P j tiVfa:11414111P , - Q D a Ca II rirlr „,,,,,,,,k .,,„,,,,, iv .,, 7 , A 'ID Ai 1 . r III 1 1 A I 1 l e. I I C1:1 lial •■• 1 cc itt tit . I, CP . 4 ...*. 1 L ST L so . 4.1. i---■ fi 1"1"L 1- - - 11.11 1 F li in - – i ill.” " 6 TH A . , ,, � r -, 4•1.74 a._ _ . a mi . 1 8TH AV = ii 1 P P _ s 300 .. i � 400 300 �, , a 1 il It VE. • - --I � Egli �1t/C7� 0TH A A. aril . e IIMV AI MN • MIN a D _ I I !11ThA. __ I ME III St ,, , - , ,,i ,...-....,. Ir , rJ d I 2TH AV . Z �� Ii z 0 /� UTH • RK AV I fn E. a Aria ■■ DISCLAIMER This map Is neither a legally recorded map nor MONITORING WELL a d n not This Is drawirawi It Is s a compilation to be used as one. of records, data 1 HIGH AV N O.IHKOJH and Information located In various city, county °M TIE MAT°' 'nd state offices and other sources affecting City of Oshkosh area shown and It Is to be used for reference ;urposes only. The City of Oshkosh is not re- _ r Department Of a Ifdlsc ieforany Inaccuracies herein contained. Scale, 1 rr - 1000' Community Development If discrepencla are found, please contact the City of Oshkosh. 07/22/10 Created by - dff 7 Y , • , ' ' q � ' . * 4 f � r� �, '', , te ' � ...,:. �. s v� � y . - ,(+/, ••� J ` �A y -V� '�. �a . ` f . \''''*-,,,,,. '4 \ ` • � �- • W ' .a 4 : SUBJE;GT w SITE >R f �, . a . . z a , s T r � E � -oaf i l � 1 • - '- DISCLAIMER This map is ne ithe r a legally recorded map nor M O NITOR I NG WELL �T ( (� a survey and It is not Intended t be used as one. 1 35 HIGH AV lr OJ l l�Of fl This drawing is a comp of records, data and iniortnatl located la various city, county and state o ffices and other sourc affecting ~A the area shown and It Is to b used for re ference City of Oshkosh purposes only. The City o f Oshkosh is not re- spons for any Inaccura ho reln contained. Scale: 1 i — O�t Department of If discrepencies are fo please contact the Community Development City of Oshkosh. Created by - dff 07/22/1 0 8 CITY HALL 215 Church Avenue PO. Box 1130 Oshkosh, Wisconsin 54903 -1130 City of Oshkosh OfHKQfH City Attorney's Office Phone: (920) 236 -5115 Fax: (920) 236 -5106 http; / /www.ci.oshkosh.wi.us August 18, 2010 Mr. Paul Winter Midwest Engineering Services 5042 Washington St. 608 N. Stanton Street PO Box 435 Ripon, WI 54971 Butte Des Morts, WI 54927 Re: Privilege in Street/ City of Oshkosh Sec. 66.045, Wis. Stats. Installation of Monitoring Well - 135 High Avenue • Gentlemen: On August 10, 2010, by resolution #10 -237, the City of Oshkosh Common Council approved your request for a privilege in street permit subject to certain conditions that are made a part of the approval resolution. In order for the permit (which much be obtained at the Public Works Department) to be valid, each one of e conditions must be satisfied.------ To that end, please find enclosed for your signature an Agreement releasing, and holding the City harmless, from all liability arising from your use of the permit. This, along with the insurance filing requirements ($200,000/$500,000 limits) are part of state law that enables the City to allow you this use. Kindly return to this office the signed Agreement along with your proof of insurance, either a separate policy, or naming the City as an additional insured on your policy. If you include the City as an additional insured, please use the following language: "City of Oshkosh, and its officers, council members, agent, employees and authorized volunteers as additional insured." These conditions of approval must be met before you exercise the privilege in street. Direct any questions about insurance and liability releases to this office. Any other questions concerning the remaining conditions should be directed to the Public Works Department at 236 -5065. Thank you for your cooperation. Sincerely, CITY OF OSHKOSI :" Lry1111 A. Lorenson City Attorney cc: Pamela R. Ubrig - City Clerk Steve Gohde, Engineering Darryn Burich, Com. Dev. l ® DATE (MMIDD/YYYY) A ` ° ° CERTIFICATE OF LIABILITY INSURANCE 3/24/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION 15 WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Linda Jensen NAME: _ PHONE _ __- PHONE (262) 255 -5100 FAX (2621102-0941 R & R Insurance Services , Inc . 1A/c No.E ! (ac,No); E -MAIL lind. jensen@rrins . com N80 W14824 Appleton Ave ADDRESS: ___ ______._.___ PRODUCER 0 PO Box 1180 S _ Menomonee Falls WI 53052 -1180 INSURER(S) AFFORDING COVERAGE 1 NAICN INSURED INSURER A :Liberty Mutual INSURERS :United Wisconsin Ins Co Midwest Engineering Services Inc INSURERC:Architects & Engineers Ins Co 608 N. Stanton Street -- INSURER D - INSURER E Ripon WI 54971 1 INSURER F COVERAGES CERTIFICATE NUMBER:CL11 324 2 91 6 9 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR' TYPE OF INSURANCE INSR W UBR POLICY EFF POLICY EXP ! LTR INS I VD POLICY NUMBER (MM /DO/YYYY) I !MM /00/YYYY! LIMITS A 1 GENERAL LIABILITY I EACH OCCURRENCE IS 1,000,000 - DAMAGE TO RENTED 500,000 �,! X 1 COMMERCIAL GENERAL . LIABILITY JZ91456564021 1 PRHJIISES_(Ea occurrence) $ - -__, CLAIMS -MADE _ 1 OCCUR X 3/23/2011 ; 3/23/2012 _ MED EXP (Anone son 5, 000 `.� I • PERSONAL S. AOV INJURY $ 1,000,000 I _ - ! • i GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS - COMP /OP AGG $ 2,000,000 r P 1 POLICY f X ; JE I ._.. - LOC I , I$ A i AUTOMOBILE LIABILITY I I COMBINED SINGLE LIMIT 1 $ 1, 000 , 000 1 SJZ91456564011 3/23/2011 X3/23/2012 (Ea accident) - X i ANY AUTO I ~_ i BODILY INJURY (Per person) 1 I ALL OWNED AUTOS ! ;BODILY INJURY (Per aceitl enf 5 - SCHEDULED AUTOS PROPERTY DAMAGE $ ' X i HIRED AUTOS E I _(Per accident) — _- ! X ! NON - OWNED AUTOS ' I ' $ A i X I UMBRELLA LIAB X : OCCUR i 1 `EACH OCCURRENCE _ _ $ 3,000,000 i ! EXCESS LIAB i H791456564031 3/23/2011 13/23/2012 : TE ;$ 3,000,000 - CLAIMS -MADE I I Tz AGGREGATE _�. _- I DEDUCTIBLE i I $ X RETENTION S 10,000 I i $ 8 I WORKERS COMPENSATION I I ! ! ! - VVC S ; iOTH- I AND EMPLOYERS' LIABILITY 1 , / N i X .LTQRY LIMIT$ __03_ ANY PROPRIETOR/PARTNER /EXECUTIVE 1 L II-tt2/01/2010,12/01/2011 OFFICER/MEMBER EXCLUDED? N !N /A I E._ L. EACH ACCIDENT _i$ 1,000,000 (Mandatory in NH) 1 I E L. DISEASE -EA EMPLOYEg $ 1,000,000 If yes, descrit a under EL DISEASE - POLICY LIMIT I $ 1,000,000 DESCRIPTION OF OPERATIONS below ! 1 C Professional /Pollution i r ICPG11 3/23/2011 3/23/2014 ; Per Claim 1,000,000 - $50,000. deductible 1 3 : Aggregate 3,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule. if more space Is required) RE Project: Installation of Monitoring Well - 135 High Avenue - privilege in street /City of Oshkosh. City of Oshkosh, its officers, council members, agent, employees and authorized volunteers is an additional insured for general liability as required in a written contract or agreement but only as respects to actual or alleged negligence arising out of the acts or products of the named insured_ Form CERTIFICATE HOLDER CANCELLATION (920) 236 - 5106 lzamow@ ci . oshkosh. wi . us SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Oshkosh 215 Church Avenue Oshkosh, WI 54 903 AUTHORIZED REPRESENTATIVE !!1 E Clark Bowerman /LJ33 - - ��C ACORD 25 (2009/09) © 1988 -2009 ACORD CORPORATION. All rights reserved. INS025 (2oosog) The ACORD name and logo are registered marks of ACORD 1 ' d aaaa SirL 0 6 `]W 12133W I OW3 1S3Uf1 1 I W ez T :80 I T OE JeW