HomeMy WebLinkAbout18-Development Services
ORiGiNAL
CITY OF SAN BERNARDINO - REQUEST FOR COUNCIL ACTION
From: JAMES FUNK,
Director
Subject: Resolution authorizing and directing
execution of a License and Agreement with
Lockheed Martin Corporation (LMC) for
encroachment of a groundwater monitoring well in
the public right-of-way way of South Amos Street
approximately 170 feet north of East Dumas Street.
File No.15.02-1473
MCC Date: September 6, 2005
Dept: Development Services
Date: August 29, 2005
Synopsis of Previous Council Action:
12-20-04 Adopted resolution approving License and Agreement with Lockheed Martin
Corporation (LMC) for encroachment of a groundwater monitoring well in the public
right-of-way of San Jacinto Street, east of Gifford Avenue, south of Mill Street.
Recommended Motion:
Adopt Resolution
-h~~
Contact person: Mike Grubbs
Phone: 5179
Supporting data attached: Staff Report, Letter, Map Ward:
& Resolution
FUNDING REQUIREMENTS: Amount: N/A
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Source: (AeeL No.)
(Aect nl'>c:cription)
Finance:
Council Notes: t)P-1 j, ()(j) S- - ;A '10
Agenda Item No. J g
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CITY OF SAN BERNARDINO - REQUEST FOR COUNCIL ACTION
Staff Report
SUBJECT:
Resolution authorizing and directing execution of a License and Agreement with Lockheed
Martin Corporation (LMC) for encroachment of a groundwater monitoring well in the public
right-of-way way of South Amos Street approximately 170 feet north of East Dumas Street.
BACKGROUND:
On August 11, 2005, a request was received from Lockheed Martin Corporation (LMC), for an
encroachment permit to install a permanent groundwater monitoring well in the public right-of-
way of South Amos Street approximately 170 feet north of East Dumas Street. The purpose of
this monitoring well is to characterize water quality in the Bunker Hill groundwater basin. The
well design will consist of one 12-inch boring that will be advanced to a depth of approximately
900 feet below ground surface. The well will discretely monitor five grollndwater zones with
this system.
LMC is proposing to install this monitoring well at the location shown on the attached plat map
(Attachment 1 to the Agreement). This monitoring well will consist of a traffic-rated, below-
grade access vault atop the 900-foot deep well. Pavement over the vault will be restored flush
with the adjacent roadway surface.
A separate construction permit from the Public Works Division will be required prior to start of
work in South Amos Street. Tetra Tech, Inc., on behalf of Lockheed Martin, is in the process of
coordinating a Work Plan for the installation of this and other monitoring wells in the City. A
similar well was completed in San Jacinto Street, east of Gifford Avenue, south of Mill Street in
January 2005.
LMC will be responsible for obtaining all necessary permits from other agencies necessary to
complete this work. Prior to start of drilling, LMC, or its representative, will contact
Underground Service Alert (USA) and arrange for the marking of all subsurface utilities. During
drilling, all waste material (soil, drilling fluid, water, etc.) will be temporarily contained on site
and disposed of away from the site in accordance \vith state and federal regulations.
After completion of installation of the monitoring well, sampling will occur on a monthly basis
for an indefinite period of time.
Staff has field reviewed the site and determined that the installation of the groundwater
monitoring well in South Amos Street and the subsequent periodic monitoring will have minimal
impacts on the adjacent properties. Access to adjacent properties will be maintained at all times.
The applicant has paid the prescribed fee of $500.00 to cover adnlinistrative processing costs of
this License and Agreement.
Staff is recommending that an annual fee of $150.00 be payable under terms' of this License and
Agreement to cover continuous administrative costs of the License and Agreement.
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08/29/2005 10:20 AM
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CITY OF SAN BERNARDINO - REQUEST FOR COUNCIL ACTION
Staff Report · Continued
FINANCIAL IMPACT:
None.
RECOMMENDATION:
Adopt resolution.
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08/29/2005 10:20 AM
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3 RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING AND
DIRECTING EXECUTION OF A LICENSE AND AGREEMENT WITH LOCKHEED
4 MARTIN CORPORATION (LMC) FOR ENCROACHMENT OF A GROUNDWATER
5 MONITORING WELL IN THE PUBLIC RIGHT-OF-WAY OF SOUTH AMOS STREET
APPROXIMATELY 170 FEET NORTH OF EAST DUMAS STREET.
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RESOLUTION NO.
BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE CITY OF
SAN BERNARDINO AS FOLLOWS:
SECTION 1. That the Mayor and Common Council of the City of San Bernardino is
hereby authorized and directed to execute, on behalf of said City, a license and agreement with
Lockheed Martin Corporation (LMC) for encroachment of a groundwater monitoring well in the
public right-of-way of South Amos Street approximately 170 feet north of East Dumas Street, a
copy of which is attached hereto and incorporated herein as Exhibit "A".
SECTION 2. The authorization to execute the above referenced license and agreement
is rescinded if the parties fail to execute it within sixty (60) days of the passage of this
Resolution.
/ / /
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AUQust 29. 200)
/JOJ /!
qj&jos-
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RESOLUTION .... AUTHORIZING AND DIRECTING EXECUTION OF A LICENSE
AND AGREEMENT WITH LOCKHEED MARTIN CORPORATION (LMC) FOR
1 ENCROACHMENT OF A GROUNDWATER MONITORING WELL IN THE PUBLIC
2 RIGHT-OF-WAY OF SOUTH AMOS STREET APPROXIMATELY 170 FEET NORTH
OF EAST DUMAS STREET.
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I HEREBY CERTIFY that the foregoing resolution was duly adopted by the Mayor and
Common Council of the City of San Bernardino at a
meeting thereof
held on the
day of
, 2005, by the following vote, to wit:
Council Members:
AYES
NA YES
ABST AIN
ABSENT
ESTRADA
LONGVILLE
MCGINNIS
DERRY
KELLEY
JOHNSON
MCCAMMACK
City Clerk
The foregoing resolution is hereby approved this
day of
, 2005.
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24 Approved as to form
and legal content:
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WDITH VALLES., Mayor
City of San Bernardino
JAMES F. PENMAN
City Attorney
~y:.
A UQust 2<). 200';
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EXHIBIT "A"
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LICENSE AND AGREEMENT
THIS LICENSE AND AGREEMENT is made and entered into this
day of
, 2005, by and between
LOCKHEED MARTIN CORPORATION (LMC)
hereinafter referred to as "Licensee," and the CITY OF SAN BERNARDINO, a
municipal corporation hereafter referred to as "City."
WITNESSETH:
For and in consideration of the mutual promises and covenants herein
contained, the parties hereto do hereby agree as follows:
1. City hereby gives permission, removable and terminable as hereinafter
provided, to Licensee to install, use and maintain in conformance with existing laws on a
. certain portion of the City's public right-of-way for South Amos Street, approximately
170 feet north of East Dumas Street, a gr~.undwater monitoring well at such location
"
indicated in Attachment "1 It, and in accordance with that letter dated August 11, 2005,
from Licensee (Attachment "2"), both attached and made a part hereof, and subject to any
requirements or conditions as may be imposed by the Director of Development Services
of City.
2. This permission is. given to Licensee as an accommodation to Licensee
and shall be subject to an annual fee of $150.00, payable in advance to the Development
Services Department Real Property Section for each year that this License and
Agreement remains in effect.
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EXHIBIT "A"
3. Licensee hereby acknowledges the title and paramount interest of City to
the public right-of-way and agrees never to assail or resist said title or interest and to
observe present or future set-back requirements relating thereto.
4. City reserves the right to terminate the permission hereby given at any
time by giving Licensee at least thirty (30) days written notice of such termination,
except that City may, at its election, terminate said permission forthwith at any time if
Licensee shall fail to comply with or abide by each and all of the provisions hereof or
keep each and all of the Licensee's promises herein. Waiver by City of any breach of any
term or provision hereof shall not be deemed a waiver of any subsequent breach of the
same or any other term or provision hereof.
5. Licensee agrees to install, use and maintain said groundwater monitoring
well as required by this Agreement. Said groundwater monitoring well shall be
maintained at all times in a safe, neat, sightly and good physical condition. City shall be
~he sole judge of the quality of maintenance~- and upon written notice by City, through its
Director of Development Services, stating in general terms how and in what manner the
maintenance is required, Licensee shall be required to perform such required
maintenance. If Licensee fails to do so, then City shall have the right to perform this
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maintenance, the cost of which shall be borne by Licensee. Licensee further agrees to
install, use and maintain said groundwater monitoring well in conformity with applicable
Federal, State, and local laws, rules and regulations. Licensee shall at its own
responsibility and expense obtain and keep in effect all licenses, bonds and permits
necessary for the installation and existence of said groundwater monitoring well.
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EXHIBIT "A" .
6. Upon termination of this Agreement, Licensee agrees to immediately
remove said groundwater monitoring well from the public right-of-way and to restore the
public right-of-way to the satisfaction of the Director of Development Services. If
Licensee fails to exercise its duties under this paragraph, City shall have the right to
remove said groundwater monitoring well and to restore the premises at no cost or
liability to the City. Licensee covenants and agrees to reimburse City for such removal
and/or restoration.
7. City shall in no way be responsible for loss ot or damage to said
groundwater monitoring well or for any property belonging to or leased by Licensee, its
officers, servants, agents or employees, that may be stolen, destroyed or in any way
damaged during the installation, use or maintenance of said groundwater monitoring
well.
8. Licensee shall exercise its privileges under this license at its own risk.
,Licensee shall indemnify, defend and hold harmless City, its elective and appointive
boards, commissions, officers, agents and employees from any costs, claims, damages,
injuries, and liability resulting from, arising out of, or in any way connected with, the
construction, installation, use and maintenance of said groundwater monitoring well, the
occupation or use of the public areas of such structure, both during and after the
installation thereof, and including but not limited to any costs, claims, damages, injuries,
and liability resulting from the conduct of Licensee or the employees, invitees, guests or
ag'ents of Licensee, or Licensee's failure to perform its promises in connection herewith.
9. The Licensee's attention is directed to Section 7-3, "Liability Insurance",
of the Standard Specifications for Public Works Construction, 2003 Edition, providing
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EXHIBIT" A"
that the Licensee shall furnish the City with policies or certificates of liability insurance
prior to execution of the contract. All of the Insurance Policies shall name the City of
San Bernardino as an additionally insured. The endorsement shall be provided by the
agent of the insurance company and shall be notarized to that affect. ACCORD Forms
are not acceptable nor forms signed by the broker, unless they have Power of Attorney to
bind the insurance provider. (See attached Attachment "3") Licensee shall maintain
minimum limits of insurance no less than:
A) General Liability: $1,000,000.00 per occurrence and $2,000,000
aggregate for bodily injury, personal injury and property damage. Commercial
General Liability Insurance or other form with a general aggregate limit shall
apply separately to this project/location.
B) Products/Completed Operations: $1,000,000.00 per occurrence and
$2,000,000.00 aggregate.
C) Automobile Liability: $1,000,000.00 per accident for bodily injury and
property damage.
D) Employer's Liability: $1,000,000.00 per accident for bodily Injury or
illness.
E) The Licensee's attention IS directed to Section 7-4, "Worker's
Compensation Insurance", of Standard Specifications for Public Works
4 of7
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EXHIBIT "A"
Construction, 2003 Edition, providing that the Licensee shall file a signed
certification Certificate of Worker's Compensation Insurance before start of work
under terms oftrus Agreement.
10. This license is personal to Licensee. It is nonassignable and any attempt
to assign this license will terminate the license privileges granted to Licensee under this
Agreement.
11. Licensee agrees that should any action, whether real or asserted, at law or
in equity, arise out of the terms of this Agreement, or by Licensee's operations on the
premises, venue for that action shall lie in San Bernardino County, California.
12. Licensee hereby certifies that it will not discriminate against any employee
or applicant for employment because of race, color, religion, sex, marital status, national
origin or disability. Licensee's hiring practices and employee policies shall comply with
applicable Federal, State and local laws. Such action shall include, but not be limited to,
_ the following: Recruitment and recruitment advertising, employment, upgrading and
promotion.
13. The prevailing party in any legal action to enforce or interpret any
provision(s) of this Agreement shall be entitled to recover from the losing party all
attorney's fees, court costs .and necessary disbursements in connection with that action.
The costs, salary and expenses - of the City Attorney and members of his office in
connection with that action, shall be considered as attorney's fees for the purposes of this
Agreement.
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EXHIBIT" A"
14. All official notices relative to this Agreement shall be in writing and
addressed to the following representatives of Licensee and City:
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Licensee
Mr. Chris Ingalls
Lockheed Martin Corp. (LMC)
Shared Services, Energy,
Environment, Safety and Health
Remediation
2950 N. Hollywood Way, Ste. 125
Burbank, CA 91505
Ph: (818) 847-0272
Fax: (818) 847-0256
City
Mr. James Funk, Director
Development Services Department
City of San Bernardino
300 North "D" Street
San Bernardino, CA 92418
Ph: (909) 384-5357
Fax: (909) 384-5155
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EXHIBIT "A"
LICENSE AND AGREEMENT: INST ALLA TION, MAINTENANCE AND
MONITORING OF A GROUNDWATER MONITORING WELL IN THE PUBLIC
RIGHT-OF-WAY OF SOUTH AMOS STREET APPROXWA TEL Y 170 FEET
NORTH OF EAST DUMAS STREET.
IN WITNESS, the parties have executed this Agreement on the
day of
, 2005.
Judith Valles, Mayor
CITY OF SAN BERNARDINO
ATTEST:
LOCKHEED MARTIN CORP. (LMC)
Rachel Clark, City Clerk
~-~~
Licensee
Approved as to form
And legal content:
C~f .$\~~'~r TI'\~h. S~.ar ~C\~~("""
PrInted Name and it)e
James F. Penman
City Attorney
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Monitoring Well LMW-13 Location
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lOCATION
San Bernardino, California
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0507.097.01
08/25/05
FIGURE
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A IT ACHMENT "2"
TETRA TECH, INC.
17770 Cartwright Road, Suite 500
Irvine, CA 92614
Telephone (949) 253-2958
FAX (949) 250-6776
August 11, 2005
City of San Bernardino
Development Services Engineering Division
"0" Street, 3rd Floor
San Bernardino, California 92418
Attention:
Mr. Michael Grubbs
Application for Excavation, Encroachment and Lane Closure Permit for
Groundwater Monitoring Well Installation
. Dear Mr. Grubbs:
.
Subject:
Tetra Tech, Inc, on behalf of our client, Lockheed Martin Corporation (LMC), is requesting
excavation, encroachment and lane closure permits for the purpose of drilling, installing, and
sampling a groundwater monitoring well (Lrv1W-13). Attachment A contains information
pertinent to this application for wells LMW-13. The groundwater monitoring wells will be
installed and sampled in response to Clean-up and Abatement Order 97-58 Issued by the
California Regional Water Quality Control Board (RWQCB), Santa Ana Region. Installation
and sampling of this monitoring well will provide groundwater quality data over an extended
period of time.
Well Location Siting
The proposed location for monitoring well LMW-13 is along the west side of South Amos
Street, 170 feet north of East Dumas Street. The geographic coordinates (UTM in meters,
NAD 83) for this location are 3,770,860.95 North and 474,007.13 West.
The proposed monitoring well location is shown on the map, aerial photograph and plat map in
Attachment A (Figures 1 through 3).
P:\lOCKHEE0\2005\2005-2006 New Westbay Wefls\Permt Applications\City of San Bemardino\lMW-13 Revised Location\EncrQachmentPermitApp Rev 1.doc
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Mr. Michael Grubbs
August 11, 2005
Page 2
ATTACHMENT "2"
Regulatory Oversight
A Work Plan is being developed for the installation of these and other monitoring wells in the
area. The Work Plan will be submitted to the Santa Ana Regional Water Quality Control Board
(RWQCB) prior to the commencement of drilling.
Well Design
The design will consist of one 12-inch boring that will be advanced to a depth of approximately
900 feet below ground surface (bgs) using conventional mud-rotary drilling techniques. A
schematic of the mud rotary system is included in Attachment A as Figure 4. Upon reaching
total depth, geophysical logs will be run at the well location to refine lithologic information that
will be gathered during drilling. Geophysical and lithologic data from the well location will be
analyzed and used to refine and finalize the design of the multi-port monitoring well. The well
will discretely monitor five groundwater zones within the aquifer system. A typical multi-port
well design is provided in Attachment A on Figure 5. The surface completion of the multi-port
well will be within a traffic-rated, below-grade well vault that is in compliance with City of San
Bernardino specifications and has been approved for use by the city at a previous (San Jacinto
Street) well location. A drawing of the surface completion is provided in Attachment A on
Figure 6.
Prior to commencement of invasive work, Tetra Tech will obtain a well permit from San
Bernardino County Department of Health Services and will contact Underground Services Alert
(USA) to obtain utility clearance for the prof)O.sed well. The first 1 0 feet of the well will be
drilled using an air knife to ensure that any subsurface utility that was not identified by USA will
not be damaged. \^Jastes generated during drilling (Le., water, drilling fluids, and soil cuttings)
will be temporarily stored in appropriate vessels adjacent to the drill site pending sampling and
receipt of analytical results. Following receipt of analytical results, the wastes will be
transported from the drill site and disposed of in accordance with state and federal
requirements.
Upon completion of drilling and well construction activities, groundwater- -samples will be
collected from the multi-port well on a regular sampling schedule. The periodic sampling will
be non-intrusive and requires minimaJ equipment or disruption to the neighborhood.
Schedule
Drilling is tentatively scheduled to commence as early as September 6, 2005, depending on
your approval of this application. The daily work schedule will be in compliance with City of
San Bernardino requirements. The estimated duration of drilling and well installation at this
site is approximately four weeks, with an additional four to six weeks required for well
development. Subsequent sampling will require less than one day to complete. Because of
our compressed schedule, your expedited review and processing of this request is greatly
appreciated.
P:\lOCKHEED\2005\2005-2006 New Westbay Wells\Pemit Apphcabons\Ctty of San Bemardino\lMW-13 Revised location\EncroachmentPemitApp.doc
Mr. Michael Grubbs
August 11, 2005
Page 3
. Permit Application
Completed City of San Bernardino Department of Development Services Encroachment and
Lane Closure Permits, and Public Works Division Application for Excavation Permit forms are
included in Attachment B. We will pay the required fees upon assessment by the city. A
completed, signed License and Agreement document for this location is included as
Attachment C.
ATTACHMENT "2"
We appreciate your timely review of this application. In the meantime, should you have any
questions or comments regarding this application for an encroachment permit, please call
either Mr. Scott Parsons or myself at (949) 253-2958.
Sincerely,
Tetra Tech, Inc.
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Brendan Shine, P.E.
Senior Engineer
. Attachments
cc: Mr. Bill Bath, Lockheed Martin Corporation-...
Mr. Christopher Ingalls, Lockheed Martin Corporation
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USING riPE II CEMENT AND 3/4.' ~1AX.
AGGREGATE.
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San Bernardino, California
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-a.. TETRA TECH INC. DRAFTED: 6
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tMne. C.lbnla 8:1104
DATE:
ACORD ~
CERTIFICAT~ OF INS~~NCI;
PRODUCER
THIS CERTIFICATE ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE
COMMERCIAL ASSOCIATES INS, INC
~26 EAST LA PALMA AVE
NAHEIM, CA 92807
(714) 524-4949 FAX: 524-4940
CO"f'ANY
A CNA-TRANSCONTINETAL
INSURED
COMPANY
B CNA-VALLEY FORGE
INLAND LANDSCAPING SERVICES
3000 CALIFORNIA STREET
SAN BERNARDINO, CA 92407
COMPANY
C CHUBB GR8UP-FEDERAL INSU~~NCE
COMPANY
D
COVERAGES
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 1$ SUBJECT TO ALL
THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAlO CLAIMS
CO TYPE OF "SURANCE POLICY NUMBER .-oucY IFFEC11VE POlICY EXPlRA T10N LIMrrS
L TR DATE (MIIIVYIDD) DATE (MMrNIDO)
GENERAL LIABILITY GENERAL AGGItEGA TE
PROOUC~1tfOII AGO
A X CO.MERCIAL GENERAL LIABILITY PERSONAL & AlN INJURY
CLAIMS MADE [!] OCCUR lC22875769 02/01/98 02/Gl/99 EACH OCCURENCE
X OWNER'S & CONTRACTOR'S 'ROT
FIRE DAMAGE (Anyone fin t
Med ..p (Anyone ......ont
AUTOIIOIIILE UABlLlTY
COMBINED SINGLE LIMIT
ANY AUTO
ALL OWNED AUTOS fJODIL Y INJUTY
(Per peROn)
SCHEDUlED AUTOS
tillED AUTOS 80DIL Y "JURY
NON-owNED AUTOS SAP 5197135 02/01/98 02/01/99 (Per Kddentt
llROf'ERTY ACCIDENT
GARAGE UABlllTY AUTO ONLY -€A ACCIOE.NT
ANY AUTO
EXCESS lIAS'Un
UMBRELLA FORM
O1lfER THAN U"8REL1.A FORM
~KEJlIS co II PEH SA T10H AHD
EII.....OYE.... UAIIIUTY
THE PROPRIETORI 02/01 /~8 EL DISEASE. ~ UMIT
PAATNEltSI'EXECUTNE INCL We. )('KX~ c>2/D ,/9g
OFFICERS ARE: DCL Et DISEASE. EA EMPLOYEE
OTHER
12, 000, 000
11,000,000
11,000,000
I 1, 000, 000
1 50, 000
s 5 , 000
. 1, 000, 000
.
.
I
DESCRIPTION OF OPERA noN S/L OCA TIONSNEHICLESlSPECIAL ITEMS
JOB LOCATION: ALL CALIFORNIA OPERATIONS OF THE N~~ED INSURSD
RE: AD 2000, CONTRACT 9898
BELOW NAMES AS ADDITIONAL INSURED WITH RESPECTS TO GENEPA: LIABILITY
CERlJFJCATE HOLDER.. . - ,: CANCELLAnON
THE CITY or SAN BERNARDINO
DEPARTMENT OF DEVELOPMENT SERVICES
PUBLIC WORKS DIVISION
300 NORTH "0# STREET
SAN BERNARDINO, CA 92418-0001
SHOULD N4Y OF THE ABove DESCRIBED POLICIES BE CANCELLED BEFORE 1lE
EXPIRATION DATE THEREOF THE ISSUING COMPANY WILL (~rg,-~~.gA WMAIL
!!. DAYS WRrTTEN NOTICE TO THE CERTIFICATE HOLDER NAMES TO THE LEFT.
lilT F' AIUJRi TO ~IifJL. il 'Ct.-t ~fOTlCi tW\b~ IUPOt& ..0 OIl'{"&TJQ~J QR L!MIL.lyY
Ot A~fY I<ltlQ IIPQ~' T~' ~~HPA~JY rTt .C'..l'E QR R&PAitttf,1'''T~~1
~R~~~
ACORD 25-S (1/95) . ..
... >.,
..:. ." ..':' ....: ~-,
e ACORD CORPORA~..:.~~~~~
SP-16
.
.
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A TT ACHMENT "3"
COMMERCIAL GENERAL LIABILITY
NAMED INSURED;
POLICY NUMBER:
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
ADDITIONAL INSURED ------ OWNERS, LESSES OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART-OCCURRENCE
SCHEDULE
NAME OF PERSON OR ORGANIZATION:
CITY OF SAN BERNARDINO
DEVELOPMENT SERVICES/PUBLIC WORKS
300 NORTH "0" STREET
SAN BERNARDINO, CA 92418-0001
(If no entry appears above, information required to complete this endorsement will be shown in the
Declarations as applicable to this endorsement.)
WHO IS AN INSURED (Sect.ion II) is amended to include as an insured the person or organization shown
in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you.
NOTE: MUST BE SIGEND BY AUTHORIZED REPRESENTATIVE FOR PROVIDER.
ALSO SUPPLY POWER OF ATTORNEY GIVING AUTHORITY TO BIND
--
CG 20 10 11 85
Authorized Representative for
CNA Insurance Group
Golden Eagle Insurance Company
SP-11
** FOR OFFICE USE ONLY - NOT A PUBLIC DOCUMENT **
RESOLUTION AGENDA ITEM TRACKING FORM
Meeting Date (Date Adopted): q. Lt . t.51tem #
Vote: Ayes / _r] Nays
Change to motion to amend original documents 0
/R
Resolution #
,;<C'[)5- :l0 t:;;
Abstain
Absent
Companion Resolutions
Null/Void After: days /
Resolution # On Attachments: 0 Note on Resolution of attachment stored separately: 0
PUBLISH 0
POST 0
RECORD W/COUNTY 0
By:
Date Sent to Mayor: r; - 1 . DS- ./
D'te of M,yo<', Sig",""" :~? 0 'l,
Date of Clerk/CDC Signature: ,I ~( C ~
Reso, Log Updated: ~
Seal Impressed: ~
Reso. # on Staff Report IZJ
Date Memo/Letter Sent for Signature:
151 Reminder Letter Sent:
Date Returned:
2nd Reminder Letter Sent:
Not Returned: 0
Request for Council Action & Staff Report Attached:
Updated Prior Resolutions (Other Than Below):
Updated CITY Personnel Folders (6413, 6429, 6433,10584,10585,12634):
Updated CDC Personnel Folders (5557):
Updated Traffic Folders (3985, 8234, 655, 92-389):
V'
Yes No By_
Yes NoJ By_
Yes NoL By_
Yes No-L' By
Yes No/ By_
Copies Distributed to:
Animal Control 0 EDA
City Administrator 0 Facilities
City Attorney t;}/' Finance
Code Compliance 0 Fire Department
Development Services ~-0 Human Resources
Others:
D
D
D
o
D
Information Services D
Parks & Recreation 0
Police Department 0
Public Services D
Water Department D
Notes:
/
V
Ready to File: _
Date:~' l \{/ ~ ~
Revised 12/18/03