Loading...
HomeMy WebLinkAboutPolka, Pheasant Creek Farm & Oshkosh 5 _ DATE(MM/DD/YYYY) AC"RL> CERTIFICATE OF LIABILITY INSURANCE 12/07/2016 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS 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 L ndee Lewis NAME: y t'c teFa m PHONE 920.231.9710 A/c No Lyndee Lewis Agency LLC ADDRIL 1050 Witzel Ave INSURERS AFFORDING COVERAGE NAIC# Oshkosh WI 54902 INSURER A: State Farm Fire and Casualty Company 25143 INSURED INSURER B: Michael&Jean Polka INSURER C: 1195 Heidi Haven Dr INSURER D: Oshkosh WI 54904 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 ADDLTYPE OF INSURANCE IVSD WVD SUER POLICY NUMBER POLICY EFF POLICY M DD/YYYY LIMITS LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 300,000 DAMAGE TRENTED O CLAIMS-MADE El OCCUR PREMISES Ea occurrence) ccurrence $ MED EXP(Any one person) $ Homeowners 49-BV-X695-3 04/11/2016 04/11/2017 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY F] JECT F__] LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident r $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE 49-BY-G588-2 10/01/2016 10/01/2017 AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER I OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I JER _ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L,EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A — (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLESACORD 101,Additional Remarks Schedule,may be attached If more space is required) µ ( Y Combined Total of 1.3 million liability CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, ;NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVI5 ONS. CARIZE EPRESE ATIVE i ©19 -201ACO D CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.12 03-16-2016 ii .. - - _ _ iv.ii'1R11!1 l ENCROACHMENT AGREEMENT This Agreement is between the City of Oshkosh (City) and Michael L. Polka and Jean M. Polka (Collectively, Owner). The parties enter into this agreement for$1.00 and other good and valuable consideration as described in this Agreement, the receipt of which is acknowledged. The Owner is the fee owner of the Property identified with Parcel Number 91342953500 and commonly known as 1195 Heidi Haven Drive, Oshkosh (Property). The City holds a Drainage Easement(Easement)over and through the westerly twenty(20)feet of the Property as identified on the Second Addition to Pheasant Creek Farm Plat, which was recorded with the Winnebago County Register's Office on February 23, 2005 with document number 1345731, which is attached and incorporated into this Agreement as Exhibit A, and with the Property more particularly described as: Lot One Hundred Nineteen (119) in SECOND ADDITION .TO PHEASANT CREEK FARM in the Thirteenth Ward, City of Oshkosh, Winnebago County, Wisconsin, The Owner desires to install fencing within and across the City's Drainage Easement. The Owner proposes a chain link fence along the northern Property boundary, and twenty-five (25) feet north of the southern Property boundary, both of which will be within the City's Drainage Easement (Encroachment). The fencing will be installed in a manner substantially conforming to the location and description as identified in Exhibit B, which is attached to this Agreement. The City has reviewed the Owner's request and Will allow the placement of the requested Encroachment. The approval of the Encroachment is premised on fence construction and maintenance in a.manner that will allow the continued proper drainage, including maintenance, as designed for the Drainage Easement. Both parties agree that all of the City's terms and conditions in this Agreement are considered material Specific terms and conditions of this agreement between City and Owner follow. 1. The City grants permission to the Owner to construct a chain link fence which will encroach into the City's Drainage Easement, provided that the Encroachment is materially similar to the location and description submitted for the City's review and approval. Changes and/or alterations to the Encroachment must be approved in writing in addition to any written permits, licenses, and similar approvals. The location and other information about the fencing allowed are found on the drawing attached and incorporated into this Agreement as Exhibit B. 2. The City's permission for this Encroachment is contingent upon the initial, and continuing, compliance with all applicable local,'state, and federal statutes, codes, rules, and Ordinances. December 4, 2015 2