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LD24-3885
Permit Number: LD24-3885 LD - Utilities/ Excavation - Parallel Issued: 11/06/2024 Expired: 05/05/2025 Job Address: Margarita Rd E/S 280' S/O N General Kearny Rd Legal Description: City of Temecula - Land Development Division 41000 Main Street - Temecula, CA 92590 Mailing Address: P.O. Box 9033 Temecula, CA 92589-9033 Phone: (951) 308-6395 Fax: (951) 694-6475 Stephen Wade 7337 Central Ave Riverside, CA 92504 Applicant: Inland Engineering Services, Inc. 1373 Old Temescal Rd Corona, CA 92881 (951) 277-0800 ext 235 Contractor: Utility Work Order Number: PID 5549698 Description: Charter PID 5549698 WORK HOURS SHALL BE SUNDAY – THURSDAY, NO HOLIDAYS, 9:00pm – 5:00am Location: Margarita Rd E/S 280' S/O N General Kearny Rd Proposed work: Install one (1) new 24"x36" CATV vault as shown on Charter Spectrum "EXCAVATION PLAN 40573 MARGARITA RD, LD24-3885" All facilities shall be installed in accordance with City Standard Drawing 117. Traffic Control shall be in accordance with approved Traffic Control Plan LD24-3885 Permittee shall comply with all applicable Traffic Control General Notes. Safe pedestrian/bicycle traffic and driveway access shall be maintained at all times. Concrete repair shall be in accordance with City Standards and the Greenbook. Trench repair shall be in accordance with City Standard Drawing 407. Final compaction test results shall be provided by a soils engineer. Concrete curbs, walks, gutters, cross gutters and driveway approaches damaged during construction shall be removed from joint to joint and reconstructed in accordance with City Standards and the Greenbook. All disturbed landscaping and other improvements shall be removed/repaired and replaced to the satisfaction of the City Engineer or their designated assignee. Permittee shall contact LDInspections@temeculaca.gov a minimum of two (2) business days prior to any work. Page 1 of 3*****See Page 2 of this Permit for Permittee Responsibilities***** Permit Number: LD24-3885 LD - Utilities/ Excavation - Parallel Permittee must also request a final inspection to verify completion of project. Permittee Responsibilities This Permittee agrees to indemnify, defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all penalties, liabilities or loss resulting from claims or court action and arising out of any accident, loss or damage to persons or property happening or occurring as a proximate result of any work undertaken under the permit granted pursuant to this application. Trench repair shall be pursuant to City of Temecula Standard Drawing No. 407. 3.Traffic control devices shall be utilized to protect and control pedestrian and vehicular traffic in the construction area in accordance with the latest revision of the “Manual of Uniform Traffic Control Devices for Streets and Highways” (MUTCD). The contractor shall submit a specific traffic control plan for review and approval by the City in accordance with City “Traffic Control Plan Guidelines” for all work within Major Circulation Element streets. 2.BEFORE YOU DIG - CALL (TOLL FREE) 800-422-4133 A pre-construction meeting is required two (2) business days prior to any scheduled work. Permittee shall contact LDInspections@TemeculaCA.gov to schedule a meeting. 1. 4. Water Quality: Contractor shall remain in compliance with the City Water Pollution Control Ordinance. Contractor is required to provide protection of the City storm drain system. 5. Work hours shall be limited between 7:30 AM and 4:30 PM, Monday through Friday, unless otherwise noted. No work shall be allowed during City-recognized holidays." 6. THIS PERMIT IS ISSUED AND ACCEPTED SUBJECT TO THE FOLLOWING CONDITIONS AND ANY ATTACHED PROVISIONS: All U.S.A. mark outs shall be removed prior to completion of project.7. 8.All contractors and subcontractors shall have a valid City of Temecula business license and valid Certificate of Liability prior to start of work. 9.Should there be any claim against the City and the property owner with the encroachment being the proximate cause, the property owner shall be notified in writing to remove the encroachment within 30 days or the City will remove and bill the owner. 10.Permission is hereby requested to encroach into public right of way to perform work as set forth above. It is understood that this permit is limited to the work described herein and that all work is to be done in compliance with the provisions attached to this permit and with all other applicable rules. Permittee shall be responsible for said compliance, for acceptability of the work, for repair or replacement thereof if defective, and for repair or replacement of any existing improvement damaged by the doing of the work I hereby certify and agree on behalf of the Permittee that all laws, regulations and ordinances of the City of Temecula and the State of California and the terms and conditions of the Permit shall be complied with whether herein stated or not. 11. 12.I hereby warrant and represent to the City that I am authorized to execute this Permit Application on behalf of the Permittee and bind the Permittee to the agreements contained herein and any conditions of the Permit. ******Contractor and all subcontractors shall be present at the pre-construction meeting; otherwise, the meeting will be rescheduled to a later date****** Any work commencing within the City right-of-way before permit issuance or a pre-construction meeting shall be subject to a 72-Hour suspension of said work and an assessment of double permit fees.13. Permitee Date Page 2 of 3 Permit Number: LD24-3885 LD - Utilities/ Excavation - Parallel City Engineer or Authorized Representative Date 11/06/2024 Page 3 of 3 W5-1 ROAD NARROWS W5-1 12 ' M I N . 100'**TO BE DETERMINED BY THE CITY OF TEMECULA** RE V ' D 0 4 / 0 3 / 23 MARGARITA RD (40 MPH) PID# 5549698 LD24-3885 N WORK HOURS SUNDAY - THURSDAY NO HOLIDAYS 9:00 PM- 5:00AM 250'250'250' 110' SHOULDER TAPER 50' BUFFER 250' 34 ft 11 3/8 in 393' 121 ft 210' WORK AREA VE R D E S L N (M P H N O T P O S T E D P V SHEET 01 OF 02 PROJECT: PID# 5549698 CITY OF TEMECULA WORK LOCATION: MARGARITA RD N/O N GENERAL KEARNY RDINLAND ENGINEERING SERVICES, INC. TARGET/SERVICE ADDRESS: 40573 MARGARITA RD, TEMECULA, CA 925911373 OLD TEMESCAL RD, CORONA, CA 92881 TEL: 951.277.0800 FAX: 951.277.5300 DESIGNER OWNER 1-800-422-4133 AT LEAST TWO DAYS BEFORE YOU DIG UNDERGROUND SERVICE ALERT OF SOUTHERN CALIFORNIA TICKET# DIGALERT COMPASS EXCAVATION PLAN DESIGNED BY:INLAND ENGINEERING SERVICES DRAFTED BY:INLAND ENGINEERING SERVICES TEL. NUMBER:(951) 277-0800 x257 PERMIT COORDINATOR: EMAIL: DATE: 08/23/2024 THOMAS GUIDE PG GRID #XXXXXXXXXX SUBSTRUCTURE MAP #XXXXXXXXXX CADASTRAL MAP #XXXXXXXXXX PLANS & PROFILES #XXXXXXXXXX SEWER INDEX #XXXXXXXXXX DRAINAGE MAP #XXXXXXXXXX REFERENCES VICINITY MAP N.T.S. NORTH TOTAL WORK DURATION: 2 DAYS CONSTRUCTION NOTES: 1.BORE UNDER ALL CURBS & GUTTERS. 2.EXISTING TV VAULTS ARE TO REMAIN IN PLACE. 3.USE 1 SACK SLURRY IN STREETS. USE NATIVE SOIL IN PKWY. 4.ALL CONDUITS SHALL BE SCH-40 UNLESS OTHERWISE SPECIFIED, ALL SWEEPS TO POLES SHALL BE SCH-80. 5.CONTRACTOR TO POT HOLE FOR EXISTING DEPTH OF UTILITIES CONDUIT PRIOR TO START OF CONSTRUCTION. 6.CONTRACTOR TO REMOVE & REPLACE DAMAGED CONCRETE MATCH EXISTING LANDSCAPE TO THE SATISFACTION OF THE SATISFACTION OF THE CITY RESIDENT ENGINEER. PRIVATE ENGINEER'S NOTICE TO CONTRACTORS: THE EXISTENCE AND LOCATION OF ANY UNDERGROUND UTILITIES OR STRUCTURES SHOWN ON THESE PLANS ARE OBTAINED BY A SEARCH OF AVAILABLE RECORDS DONE BY THE CONTRACTOR ON USA, AND TO THE BEST OF OUR KNOWLEDGE. THERE ARE NO EXISTING UTILITIES EXCEPT THOSE SHOWN ON THESE PLANS. THE CONTRACTOR IS REQUIRED TO TAKE ALL PRECAUTIONARY MEASURES TO PROTECT THE UTILITIES SHOWN AND ANY OTHER LINES OR STRUCTURES NOT SHOWN ON THESE PLANS. THE CONTRACTOR IS REQUIRED TO POT HOLE THE EXISTING UTILITIES AND VISUALLY LOCATE THE LINE OR STRUCTURE WHILE PERFORMING THE JACK AND BORE OPERATION AND IS RESPONSIBLE FOR THE PROTECTION AND ANY DAMAGED TO THE THESE LINES OR STRUCTURES. CONSTRUCTION CONTRACTOR AGREES THAT IN ACCORDANCE WITH GENERALLY ACCEPTED CONSTRUCTION PRACTICES, CONSTRUCTION CONTRACTOR WILL BE REQUIRED TO ASSUME SOLE AND COMPLETE RESPONSIBILITY FOR THE JOB SITE CONDITION DURING THE COURSE OF CONSTRUCTION OF THE PROJECT, INCLUDING SAFETY OF ALL PERSONS AND PROPERTY; THAT THIS REQUIREMENT SHALL BE MADE TO APPLY CONTINUOUSLY AND NOT BE LIMITED TO NORMAL WORK HOURS, AND CONSTRUCTION CONTRACTOR FURTHER AGREES TO DEFEND, INDEMNIFY, AND HOLD HARMLESS THE PRIVATE ENGINEER FORM ANY AND ALL LIABILITY, REAL OR ALLEGED, IN CONNECTION WITH THE PERFORMANCE OF WORK ON THIS PROJECT. THE CONTRACTOR SHALL BE RESPONSIBLE TO REPORT DISCREPANCIES IN PLANS AND/OR FIELD CONDITIONS IMMEDIATELY TO THE DESIGN ENGINEER FOR RESOLUTION PRIOR TO CONSTRUCTION, AND SHALL BE RESPONSIBLE FOR DISCREPANCIES NOT SO REPORTED AND RESOLVED GENERAL NOTES: 1.ALL WORK SHALL CONFORM TO LATEST EDITION OF THE "STANDARD SPECIFICATION FOR PUBLIC WORKS CONSTRUCTION, ADOPTED BY THE CITY AS MODIFIED BY STANDARD PLANS. 2.THE EXISTENCE AND LOCATION OF UTILITY LINES SHOWN HEREON ARE OBTAINED BY SEARCH OF AVAILABLE RECORDS. OTHER UTILITY LINES MAY EXIST; CONTRACTOR SHALL VERIFY PRIOR TO START OF CONSTRUCTION AND SHALL USE EXTREME CARE AND PROTECTIVE MEASURES TO PREVENT DAMAGE TO THE SAME. HE IS RESPONSIBLE FOR THE PROTECTION OF ALL UTILITY LINES, VALVES, METERS, TRAFFIC SIGNAL CONDUIT,& DETECTOR LOOPS, ETC.; WITHIN LIMITS OF WORK WHETHER THEY ARE SHOWN OR NOT. 3.AT LEAST TWO WORKING DAY PRIOR TO STARTING WORK NOTIFY UNDERGROUND SERVICE ALERT (1-800-422-4133). 4.INDEMNIFICATION CLAUSE-CONTRACTOR AGREES THAT HE SHALL ASSUME SOLE AND COMPLETE RESPONSIBILITY FOR JOB SITE CONDITIONS DURING THE COURSE OF CONSTRUCTION OF THE PROJECT, INCLUDING SAFETY OF ALL PERSONS AND PROPERTY, THAT THIS REQUIREMENT SHALL APPLY CONTINUOUSLY AND NOT BE LIMITED TO NORMAL WORKING HOURS; AND THAT THE CONTRACTOR SHALL DEFEND, INDEMNIFY AND HOLD THE OWNER AND THE ENGINEER HARMLESS FROM ANY AND ALL LIABILITY, REAL OR ALLEGED, IN CONNECTION WITH THE PERFORMANCE OF WORK ON THIS PROJECT EXCEPTING FOR LIABILITY ARISING FROM THE SOLE NEGLIGENCE OF THE OWNER OR THE ENGINEER. 5.ALL WORK AREA AND STREET TRAFFIC CONTROL SHALL BE PER LATEST EDITION CA MUTCD: (CALIFORNIA MANUAL ON UNIFORM TRAFFIC CONTROL DEVICES) UNLESS OTHERWISE SPECIFIED. 6.ALL PAVEMENTS, CURBS , GUTTERS, SIDEWALKS, DRIVEWAYS AND OTHER EXISTING IMPROVEMENTS TO BE RECONSTRUCTED SHALL BE RECONSTRUCTED PER CITY IMPROVEMENT STANDARDS. 7.PRIOR TO THE BEGINNING OF ANY EXCAVATION AND THROUGHOUT THE COURSE OF CONSTRUCTION WORK THE CONTRACTOR SHALL COMPLY WITH THE CALIFORNIA OCCUPATIONAL SAFETY AND HEALTH OF 1973 INCLUDING ALL REVISIONS AND AMENDMENTS THERETO. 8.THE CONTRACTOR SHALL HAVE COPIES OF THE PLANS ON THE PROJECT SITE AND BE FAMILIAR WITH ALL APPLICABLE STANDARDS. 9.THE CONTRACTOR SHALL BE RESPONSIBLE FOR DAMAGE TO EXISTING ABOVE OR BELOW GROUND IMPROVEMENT, AS A RESULT OF HIS REPLACEMENT OF SAME TO THE SATISFACTION OF THE CITY. 10.ALL BACKHOE EXCAVATION SHALL BE SAW CUT TO FACILITATE REMOVAL BY THE USE OF A POWER DRIVEN SAW. THE CUT SHALL BE STRAIGHT, CLEAN, AND TO THE FULL DEPTH OF THE SECTION OF MATERIAL TO BE REMOVED. 11.EXISTING PORTLAND CEMENT CONCRETE SHALL BE SAW CUT TO FACILITATE REMOVAL BY THE USE OF A POWER DRIVEN SAW. THE DEPTH OF THE CUT SHALL BE DEEP ENOUGH TO PRODUCE A CLEAN, STRAIGHT BREAK WITHOUT CRACKING, CHIPPING LOOSENING ADJOINING PCC. THE EXISTING PCC SHALL BE CUT BEYOND THE CONFIGURATION OF THE TRENCH OR EXCAVATION AREA AS MAY BE REQUIRED BY THE PUBLIC WORKS INSPECTOR TO ELIMINATE SMALL "FLOATING" PIECES OF CONCRETE. CONCRETE PANELS SHALL BE REMOVED OR REPLACED FROM SCORE LINE TO SCORE LINE(ENTIRE PANEL) WHERE PCC IS DAMAGED OR CRACKED. THE SAW CUT LIMITS SHALL BE LOCATED NO CLOSER THAN 3 FEET FROM A SCORE LINE OR COLD JOINT. MIN. PCC REMOVAL IS 25 SQUARE FEET, SCORE LINE TO SCORE LINE. 12.UNLESS OTHERWISE NOTED: 3" CONDUIT BENDS SHALL HAVE A RADIUS OF 3'. 2" CONDUIT BENDS SHALL HAVE A RADIUS OF 2'. PLACE 1 SACK SLURRY MIX AROUND ALL CONDUIT BENDS HAVING A RADIUS OF LESS THAN 50'. 13.ALL CONDUIT SHALL BE SCH-40 UNLESS OTHERWISE SPECIFIED. ALL SWEEPS TO POLES SHALL BE SCH-80. 14.REMOVE AND REPLACE CURB AND GUTTER ABOVE SWEEPS TO VAULTS IN THE SIDEWALK, OR BORE UNDER CURB AND GUTTER. JETTING IS NOT ALLOWED. 15.THE CONTRACTOR SHALL NOTIFY THE APPLICABLE DEPARTMENTS OF THE CITY AT LEAST TWO DAYS BEFORE START OF THE WORK. DURING THE COURSE OF WORK. THE CONTRACTOR SHALL CALL FOR INSPECTION OF ALL APPLICABLE WORK. 16.ALL SHRUBS, PLANTS, OR TREES THAT HAVE BEEN DAMAGED OR DISTURBED DURING THE COURSE OF THE WORK SHALL BE REPLANTED OR REPLACED PER CITY ENGINEER'S DIRECTION. 17.DURING THE COURSE OF THE WORK, PEDESTRIANS AND VEHICULAR ACCESS MUST BE MAINTAINED AT ALL TIMES. 18.NON-SKID CALTRANS APPROVED STEEL PLATES SHALL BE RECESSED IN TRENCH CROSSING MAJOR STREETS (AREA DESIGNATED BY THE CITY ENGINEER) AND INSTALLED PER CALTRANS SPECS. PAVEMENT SHALL BE COLD PLANED TO A DEPTH EQUAL TO THE THICKNESS OF THE PLATE AND TO THE WIDTH AND LENGTH EQUAL TO THE DIMENSIONS OF THE PLATES. 19.STEEL PLATES USED FOR BRIDGING MUST EXTEND A MINIMUM OF 12" BEYOND EDGES OF TRENCH. 20.TEMPORARY PAVING WITH COLD MIX SHALL BE USED TO FEATHER THE EDGES OF THE PLATES TO MINIMIZE WHEEL IMPACT. CONTRACTOR MAY BE REQUIRED TO WELD PLATES TOGETHER TO MINIMIZE RATTLING. CONTRACTOR MAY BE REQUIRED TO SWEEP UP LOOSE GRAVEL SEVERAL TIMES PER DAY AS DEEMED NECESSARY BY CITY ENGINEER. 21.BRIDGING SHALL BE SECURED AGAINST DISPLACEMENT USING ADJUSTABLE CLEATS, SHIMS OR OTHER DEVICES. 22.RESTORE ALL LANDSCAPING, INCLUDING IRRIGATION SYSTEM AROUND VAULTS. 23.INSTALL VAULTS NEXT TO CURB WHERE POSSIBLE. 24.NEW PAVEMENT SHALL BE PER CITY STANDARD 25.TACK COAT SHALL BE APPLIED OVER ROADWAY SURFACE PRIOR TO PAVEMENT INSTALLATION. TACK COAT SHALL BE PG 64-10 PAVING ASPHALT OR SS-1H EMULSIFIED ASPHALT PER "GREEN BOOK" REQUIREMENTS. 26.ONE SACK SLURRY MIX SHALL BE USED FOR BACKFILL. ALL SLURRY BACKFILLS WILL REQUIRE 72 HOURS OF CURE TIME. ALL EXCAVATION. TRAFFIC CONTROL NOTE: CONTRACTOR SHALL SET UP TEMPORARY TRAFFIC CONTROL SHOWN ON ACCOMPANYING TRAFFIC CONTROL PLAN PER MUTCD AND/ OR WATCH MANUAL (LATEST EDITIONS). PREFERENCE AT THE DISCRETION OF THE GOVERNING MUNICIPALITY. SCALE:1"=20' EXCAVATION LEGEND - GENERAL PROP. VAULTV PROP. BORE PROP. TRENCH EX. PEDESTALP PROP. BORE PIT PROP. POTHOLE CONCRETE TO BE REMOVE & REPLACE EX. HANDHOLE / SCE VENT EX. UTILITY HOLE EX. LIGHT POLE EX. TREE EX. VAULT / PEDESTAL / CABINET EX. TELEPHONE POLE EX. FIRE HYDRANT C/L CENTER LINE C&G CURB & GUTTER R/W RIGHT OF WAY CITY BOUNDARY EX. VAULTV EX. ANCHOR EX. PEDESTALP ARMORCAST VAULT 24"x36" POLYMER SPLICE BOX MODEL # A6001974APCX18 (LID TO BE MARKED WITH COMPANY LOGO) agrim@inland-engineering.com AMBER GRIM WHERE PLAN NOTES CONFLICT THE CITY OF TEMECULA NOTES SHALL GOVERN. MA R G A R I T A R D M A R G A R I T A R D N GENER A L K E A R N Y R D N GENER A L K E A R N Y R D CONSTRUCTION NOTES: 1.OPEN TRENCH TO PLACE PVC (SCH-40) CONDUIT. COUNT AND SIZE PER CONDUIT DATA BLOCK ..................................... 4 L.F. 2.BORE TO PLACE PVC (SCH-40) CONDUIT. COUNT AND SIZE PER CONDUIT DATA BLOCK ................................... 240 L.F. 3.TIE INTO EXISTING CATV PEDESTAL ........................................................ 1 EA. 4.PLACE 24"x36" CATV VAULT (HAND DIG ONLY) ....................................... 1 EA. 5.PLACE 3'x5' BORE/RECEIVING PIT ............................................................. 2 EA. 6.PLACE 3'x5' POTHOLES TO LOCATE UTILITIES ........................................ 1 EA. 7.PLACE PVC (SCH-40) CONDUIT STUB OUT. COUNT AND SIZE PER CONDUIT DATA BLOCK ....................................... 1 EA. EX. WATER EX. STORM DRAIN EXCAVATION LEGEND - UTILITIES W SD LD24-3885 CLEARED BY CITY OF TEMECULA PUBLIC WORKS Tricia.ortega 10/01/2024 10/01/2024 10/01/2024 10/01/20 SHEET 02 OF 02 PROJECT: PID# 5549698 CITY OF TEMECULA WORK LOCATION: MARGARITA RD N/O N GENERAL KEARNY RDINLAND ENGINEERING SERVICES, INC. TARGET/SERVICE ADDRESS: 40573 MARGARITA RD, TEMECULA, CA 925911373 OLD TEMESCAL RD, CORONA, CA 92881 TEL: 951.277.0800 FAX: 951.277.5300 DESIGNER OWNEREXCAVATION PLAN DESIGNED BY:INLAND ENGINEERING SERVICES DRAFTED BY:INLAND ENGINEERING SERVICES TEL. NUMBER:(951) 277-0800 x257 PERMIT COORDINATOR: EMAIL: DATE: 08/23/2024 TOTAL WORK DURATION: 2 DAYS agrim@inland-engineering.com AMBER GRIM LD24-3885 04/09/2024 Acrisure 2655 Camino Del Rio North #200 San Diego CA 92108 Hope Perry (Zamichieli) (619) 683-9990 (619) 683-9999 hperry@acrisure.com Inland Engineering Services Inc. 1373 Old Temescal Rd. Corona CA 92881 Middlesex Insurance Co 23434 Florists' Mutual Insurance Company 13978 Certain Underwriters at Lloyds 15642 At-Bay Specialty Insurance Company 19607 Mt. Hawley Insurance Company 37974 24-25 All Lines A Y Y A0248653004 04/15/2024 05/01/2025 1,000,000 500,000 5,000 1,000,000 3,000,000 2,000,000 PROJ. AGGREGATE 10,000,000 A Y Y A0248653001 04/15/2024 05/01/2025 1,000,000 COMP/COLL DED 100/250 A 0 A0248653006 04/15/2024 05/01/2025 5,000,000 5,000,000 B Y Y A0248653005 05/01/2024 05/01/2025 1,000,000 1,000,000 1,000,000 C Professional Liability ANE5429827.24 04/15/2024 05/01/2025 Policy Aggregate Limit $2,000,000 Each Claim Limit $2,000,000 City of Temecula is afforded Additional Insured, Primary Non-contributory and Waiver of Subrogation where required by written contract per attached Endorsements. City of Temecula 41000 Main St. Temecula CA 92590 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY Inland Engineering Services Inc.Acrisure 25 Certificate of Liability Insurance: Notes INSURER D: At-Bay Specialty Insurance Company NAIC# 19607 Cyber Liability Policy #AB-6653839-03 Policy Period: 5/1/2024 - 5/1/2025 POLICY AGGREGATE LIMIT: $1,000,000 INSURER E: Mt. Hawley Insurance Company NAIC# 37974 Pollution Liability Policy #EGL0011705 Policy Period: 4/29/2024 - 5/1/2025 POLICY AGGREGATE LIMIT: $5,000,000 EACH POLLUTION INCIDENT: $5,000,000 ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD © 2008 ACORD CORPORATION. All rights reserved. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER:FORM TITLE: ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE Page of AGENCY CUSTOMER ID: LOC #: AGENCY CARRIER NAIC CODE POLICY NUMBER NAMED INSURED EFFECTIVE DATE: POLICY NUMBER: A0248653004 © Insurance Services Office, Inc., 2018 COMMERCIAL GENERAL LIABILITY CG 20 37 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s)Location And Description Of Completed Operations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A.Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". However: 1.The insurance afforded to such additional insured only applies to the extent permitted by law; and 2.If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B.With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1.Required by the contract or agreement; or 2.Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. Page 1 of 1CG 20 37 12 19 04/08/2024A0248653 Middlesex Insurance Company 00001 0000000000 24099 0 N1 49a51b0d-df71-471d-8ad6-786ec2926a3449a51b0d-df71-471d-8ad6-786ec2926a34 Any person or organization you are required to add as an additional insured under a written contract or agreement in effect prior to any accident, injury, or damage All locations and jobs performed that have a written contract, agreement or permit. Page 1 of 2CG 20 10 12 19 04/08/2024A0248653 Middlesex Insurance Company © Insurance Services Office, Inc., 2018 POLICY NUMBER: A0248653004 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE CG 20 10 12 19 Name Of Additional Insured Person(s) Or Organization(s)Location(s) Of Covered Operations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A.Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1.Your acts or omissions; or 2.The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1.The insurance afforded to such additional insured only applies to the extent permitted by law; and 2.If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B.With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1.All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2.That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. 00001 0000000000 24099 0 N1 3d9d26e6-1a1c-4191-9943-6029a2cb9c673d9d26e6-1a1c-4191-9943-6029a2cb9c67 All locations and jobs performed that have a written contract, agreement or permit Any person or organization you are required to add as an additional insured under a written contract or agreement in effect prior to any accident, injury, or damage C.With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1.Required by the contract or agreement; or 2.Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. © Insurance Services Office, Inc., 2018 CG 20 10 12 19Page 2 of 2 04/08/2024A0248653 Middlesex Insurance Company COMMERCIAL GENERAL LIABILITY CG 71 25 06 22 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONTRACTORS BLANKET ADDITIONAL INSUREDS, PRIMARY & NONCONTRIBUTORY, WAIVER OF SUBROGATION This endorsement modifies the coverage provided under the following Coverage Form(s): COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 1.Additional Insureds - Automatic Status for 13 Additional Insured Types Section II - Who Is An Insured is amended to include the following as additional insureds when you have agreed to add that person or organization as an Additional Insured on your policy in a written contract or written agreement with that person or organization, or because of a permit issued by a state or political subdivision; provided the injury or damage occurs subsequent to the execution of the contract or agreement or issuance of the permit and while the contract, agreement or permit remains in effect. A.Owners, Lessees Or Contractors - Automatic Status When Required In A Written Construction Agreement With You 1)A person or organization with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: a.Your acts or omissions; or b.The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured. With respect to the coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. Coverage enhancements are listed below. For details of each coverage, please read the corresponding policy provisions in the body of this endorsement. 1.Additional Insureds - Automatic Status for 13 Additional Insured Types A.Owners, Lessees Or Contractors - Automatic Status When Required In A Written Construction Agreement With You B.Owners, Lessees Or Contractors - Automatic Status When Required In Written Construction Agreement With You (Completed Operations) C.State or Governmental Agency or Subdivision or Political Subdivision - Permits or Authorizations D.Lessor of Leased Equipment E.Owners or Other Interests From Whom Land Has Been Leased F.Manager or Lessor of Premise G.Mortgagee, Assignee, or Receiver H.Controlling Interest I.Co-owner Of Insured Premises J.Executors, Administrators, Trustees Or Beneficiaries K.State Or Governmental Agency Or Subdivision Or Political Subdivision - Permits Or Authorizations Relating To Premises L.Vendors M.Grantor of Franchise 2.Primary and Noncontributory - Other Insurance Condition 3.Waiver Of Transfer Of Rights Of Recovery Against Others To Us (Waiver Of Subrogation) - Automatic Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 5CG 71 25 06 22 04/08/2024A0248653 Middlesex Insurance Company 00003 0000000000 24099 0 N1 3e095d27-f0df-4c74-acc1-f5f0bd75c2ce3e095d27-f0df-4c74-acc1-f5f0bd75c2ce POLICY NUMBER: A0248653004 A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. 2)With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: a."Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: 1.The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or 2.Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, engineering or surveying services. b."Bodily injury" or "property damage" occurring after: 1.All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2.That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. B.Owners, Lessees Or Contractors - Automatic Status When Required In Written Construction Agreement With You (Completed Operations) 1)Any person(s) or organization(s) with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" performed for that additional insured and included in the "products-completed operations hazard", but only when that portion of the “products-completed operations hazard” is not excluded by endorsement. 2)With respect to the insurance afforded to these additional insureds, the following additional exclusion applies: This insurance does not apply to: "Bodily injury" or "property damage" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a.The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b.Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage" involved the rendering of or the failure to render any professional architectural, engineering or surveying services. C.State or Governmental Agency or Subdivision or Political Subdivision - Permits or Authorizations Any state or governmental agency or subdivision or political subdivision, subject to the following provisions: 1)This insurance applies only with respect to operations performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit or authorization. 2)This insurance does not apply to: Includes copyrighted material of Insurance Services Office, Inc., with its permission. CG 71 25 06 22Page 2 of 5 04/08/2024A0248653 Middlesex Insurance Company a."Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or b."Bodily injury" or "property damage" included within the "products-completed operations hazard". D.Lessor of Leased Equipment 1)Any person(s) or organization(s) with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your maintenance, operation or use of equipment leased to you by such person(s) or organization(s). 2)With respect to the insurance afforded to these additional insureds, this insurance does not apply to any "occurrence" which takes place after the equipment lease expires. E.Owners or Other Interests From Whom Land Has Been Leased 1)Any person(s) or organization(s) with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by you or those acting on your behalf in connection with the ownership, maintenance or use of that part of the land leased to you by the additional insured person(s) or organization(s). 2)With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: a.Any "occurrence" which takes place after you cease to lease that land; b.Structural alterations, new construction or demolition operations performed by or on behalf of the additional insured person(s) or organization(s). F.Manager or Lessor of Premise Any person(s) or organization(s) with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by you or those acting on your behalf in connection with the ownership, maintenance or use of that part of the premises leased to you by the additional insured person(s) or organization(s), subject to the following additional exclusions: This insurance does not apply to: 1)Any "occurrence" which takes place after you cease to be a tenant in that premises. 2)Structural alterations, new construction or demolition operations performed by or on behalf of the person(s) or organization(s) shown in the Schedule. G.Mortgagee, Assignee, or Receiver Any person(s) or organization(s) with respect to their liability as mortgagee, assignee or receiver and arising out of the ownership, maintenance or use of a premises by you. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for such additional insured person(s) or organization(s). H.Controlling Interest 1)Any person(s) or organization(s) with respect to their liability arising out of: a.Their financial control of you; or b.Premises they own, maintain or control while you lease or occupy these premises. 2)This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. I.Co-owner Of Insured Premises Any person(s) or organization(s) with respect to their liability as co-owner of a premises co-owned by you and covered under this insurance. J.Executors, Administrators, Trustees Or Beneficiaries Any executor, administrator, trustee or beneficiary of your estate or living trust while acting within the scope of their duties as such. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 3 of 5CG 71 25 06 22 04/08/2024A0248653 Middlesex Insurance Company 00003 0000000000 24099 0 N3 3e095d27-f0df-4c74-acc1-f5f0bd75c2ce3e095d27-f0df-4c74-acc1-f5f0bd75c2ce K.State Or Governmental Agency Or Subdivision Or Political Subdivision - Permits Or Authorizations Relating To Premises Any state or governmental agency or subdivision or political subdivision, subject to the following additional provision: This insurance applies only with respect to the following hazards for which the state or governmental agency or subdivision or political subdivision has issued a permit or authorization in connection with premises you own, rent or control and to which this insurance applies: 1)The existence, maintenance, repair, construction, erection or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, street banners or decorations and similar exposures; or 2)The construction, erection or removal of elevators; or 3)The ownership, maintenance or use of any elevators covered by this insurance. L.Vendors 1)Any person(s) or organization(s) (referred to throughout this endorsement as vendor), but only with respect to liability for "bodily injury" or "property damage" arising out of "your products" which are distributed or sold in the regular course of the vendor's business. However: a.The insurance afforded to such vendor only applies to the extent permitted by law; and b.If coverage provided to the vendor is required by a contract or agreement, the insurance afforded to such vendor will not be broader than that which you are required by the contract or agreement to provide for such vendor. 2)With respect to the insurance afforded to these vendors, the following additional exclusions apply: a.The insurance afforded the vendor does not apply to: 1)"Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; 2)Any express warranty unauthorized by you; 3)Any physical or chemical change in the product made intentionally by the vendor; 4)Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; 5)Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products; 6)Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; 7)Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor; or 8)"Bodily injury" or "property damage" arising out of the sole negligence of the vendor for its own acts or omissions or those of its employees or anyone else acting on its behalf. However, this exclusion does not apply to: (1)The exceptions contained in Subparagraphs d. or f.; or Includes copyrighted material of Insurance Services Office, Inc., with its permission. CG 71 25 06 22Page 4 of 5 04/08/2024A0248653 Middlesex Insurance Company (2)Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products. b.This insurance does not apply to any insured person or organization, from whom you have acquired such products, or any ingredient, part or container, entering into, accompanying or containing such products. M.Grantor of Franchise Any person(s) or organization(s) with respect to their liability as grantor of a franchise to you. However: 1.The insurance afforded to such additional insureds only applies to the extent permitted by law; and 2.If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1.Required by the contract or agreement; or 2.Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. If there is any difference in coverage afforded to an additional insured in this endorsement and that provided under another additional insured endorsement attached to this policy, the broader coverage will apply to that additional insured. 2.Primary And Noncontributory Insurance The following is added to the Other Insurance Condition and supersedes any provision to the contrary: This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1)The additional insured is a Named Insured under such other insurance; and (2)You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. 3.Waiver Of Transfer Of Rights Of Recovery Against Others To Us (Waiver Of Subrogation) - Automatic The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV - Conditions: We waive any right of recovery against any person or organization, because of any payment we make under this Coverage Part, to whom the insured has waived its right of recovery in a written contract or agreement. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person or organization prior to loss. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 5 of 5CG 71 25 06 22 04/08/2024A0248653 Middlesex Insurance Company 00003 0000000000 24099 0 N5 3e095d27-f0df-4c74-acc1-f5f0bd75c2ce3e095d27-f0df-4c74-acc1-f5f0bd75c2ce POLICY NUMBER: A0248653004 © Insurance Services Office, Inc., 2018 COMMERCIAL GENERAL LIABILITY CG 24 04 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s) Or Organization(s): Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV - Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. Page 1 of 1CG 24 04 12 19 04/08/2024A0248653 Middlesex Insurance Company 00001 0000000000 24099 0 N1 77171d79-070d-4055-b94f-04db6398c58b77171d79-070d-4055-b94f-04db6398c58b Any person or organization from whom you are required to waive your right to recover under a written contract or agreement in effect prior to any loss or damage POLICY NUMBER: A0248653001 SCHEDULE COMMERCIAL AUTO CA 76 01 06 15 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED - PRIMARY AND NONCONTRIBUTORY - COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM AUTO DEALERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated. Named Insured: Inland Engineering Services, Inc. Endorsement Effective Date: 04/15/2024 Name Of Person(s) Or Organization(s): Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A.Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in: (1)Paragraph A.1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms; or (2)Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. B.Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other auto insurance issued to the person or organization in the schedule under your policy provided that: (1)The person or organization is a Named Insured under such other insurance; and (2)Prior to the “accident” you have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the person or organization. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1CA 76 01 06 15 04/08/2024A0248653 Middlesex Insurance Company 00001 0000000000 24099 0 N1 e5148181-0760-412b-98e2-6ef9e68926a4e5148181-0760-412b-98e2-6ef9e68926a4 Any person or organization from whom you are required to waive your right to recover under a written contract or agreement in effect prior to any loss or damage. Named Insured: Inland Engineering Services, inc. Endorsement Effective Date: 04/15/2024 Name(s) Of Person(s) Or Organization(s): POLICY NUMBER: A0248653001 COMMERCIAL AUTO CA 04 44 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. SCHEDULE Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization. © Insurance Services Office, Inc., 2011 Page 1 of 1CA 04 44 10 13 04/08/2024A0248653 Middlesex Insurance Company 00001 0000000000 24099 0 N1 45800998-7eb6-4231-ab16-e6e0de6b84f445800998-7eb6-4231-ab16-e6e0de6b84f4 Any person or organization from whom you are required to waive your right to recover under a written contract or agreement in effect prior to any loss or damage (Ed. 4-84) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Name: Address: Description of Waiver: JobID: (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement No. Premium Countersigned by This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Page 1 of 1 03/29/2023 00002 0000000000 23088 0 N1 d817710f-8fba-466b-b831-82704acebcecd817710f-8fba-466b-b831-82704acebcec Any person or organization from whom you are required to waive your right to recover under a written contract or agreement in effect prior to any loss or damage Policy No. A0248653005Endorsement Effective 5/1//2024 Insured Inland Engineering Services, Inc. Florists' Mutual Insurance Company WC 00 03 13 (Ed. 4-84) © 1983 National Council on Compensation Insurance. A0192224005 Middlesex Insurance Company 1373 Old Temescal Rd Corona, CA 92881-3315 Blanket as Required by Written Contract or Written Agreement Executed Prior to Loss Land Development Encroachment Permit 41000 Main Street Temecula, Ca 92590 Phone: 951-694-6444 www.temeculaca.gov R:\LAND DEVELOPMENT DIVISION\Forms\Permit Applications\Word\Encroachment Permit App.docx Page 1 of 2 Revised: 08/29/2024 APPLICATION INFORMATION PERMIT NO.: Type of Encroachment: Excavation - Crossing Street/Storm Drain Sewer/Water Utility Trenching Excavation - Parallel Signing & Striping Traffic Signal Other The undersigned hereby applies to excavate, construct and otherwise encroach on City street right-of-way, as follows: Name(s) of street(s) and/or street address: Utility Work Order #: Start Date: End Date: In consideration of granting this application, all applicants including utility companies hereby agree to: 1. If applicable, submit a set of Construction Drawings, Traffic Control Plans, proof of City Business License for all parties working within the city right-of-way, proof of Contractor’s License along with this application at the time of submittal. See the Traffic Control Plan Checklist for details. 2. Indemnify, defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all penalties, liabilities or loss resulting from claims or court action and arising out of any accident, loss or damage to persons or property happening or occurring as a proximate result of any work undertaken under the permit granted pursuant to this application. (See below for specific liability insurance requirements.) 3. Remove/relocate any encroachment installed/maintained under this permit, upon written notice from the City Engineer. 4. Notify the Land Development Inspection Division via email at LDInspections@temeculaca.gov at least two (2) working days prior to commencing construction. Hold a pre-construction meeting prior to the start of construction. The developer/general contractor must be present for the timely request of inspections. 5. Comply with the Standard Specifications, most current Improvement Standard Drawings for Public Works Construction, City of Temecula Municipal Code Chapters 13.04 and 18.12, terms and conditions of the permit and all applicable rules and regulations for the City of Temecula and other public agencies having jurisdiction. LIABILITY INSURANCE REQUIREMENTS PROVIDE PROOF OF INSURANCE COVERAGE MEETING THE REQURIEMENTS STATED BELOW OR A CITY ATTORNEY APPROVED EQUIVALENT WITH THE CITY NAMED AS ADDITIONAL INSURED. IN THE EVENT THAT THE INSURANCE IS PROVIDED BY THE CONTRACTOR, THE CITY AND THE OWNER/DEVELOPER MUST BE NAMED AS ADDITIONAL INSURED. THIS REQUREMENT SHALL BE MET BY EITHER THE APPLICANT (DEVELOPER, OWNER, PUBLIC UTILITY AGENCY OR FRANCHISE) OR BY THE CONTRACTOR PERFORMING THE SUBJECT WORK, PRIOR TO BEGININNG ANY WORK PROPOSED UNDER THE SUBJECT ENCROACHMENT PERMIT. Proof of coverage shall be by certificate (Accord or equivalent) naming the City of Temecula as certificate holder and the minimum Open trench 4' and Bore 240' to place PVC (SCH-40) conduit for comm cable. Tie into (1) ex. Pedestal. Place (1) new 24"x36" CATV vault. Place (1) PVC conduit stub out. PID# 5549698 40573 Margarita Rd ( Margarita Rd N/o General Kearny Rd) 10/07/2024 10/10/2024 LD24-3885 CLEARED BY CITY OF TEMECULA PUBLIC WORKS Tricia.ortega 10/01/2024 10/01/2024 10/01/2024 10/01/20 Land Development Encroachment Permit 41000 Main Street Temecula, Ca 92590 Phone: 951-694-6444 www.temeculaca.gov R:\LAND DEVELOPMENT DIVISION\Forms\Permit Applications\Word\Encroachment Permit App.docx Page 2 of 2 Revised: 08/29/2024 limits of insurance coverage shall be as follows: a. General Liability: One million dollars ($1,000,000) per occurrence for bodily injury, personal injury and property damage. If Commercial General Liability Insurance or other form with a general aggregate limit is used, either the general aggregate lim it shall apply separately to this project/location or the general aggregate limit shall be twice the required occurrence limit. b. Automobile Liability: One million dollars ($1,000,000) per accident for bodily injury and property damage. c. Worker’s Compensation as required by the State of California; Employer’s Liability: One million dollars ($1,000,000) per accident for bodily injury or disease. d. Course of Construction: Completed value of the project. There is a limited exception to this requirement. Owners of single family homes doing work on the home’s driveway approach located in the public right-of-way, may use their homeowners insurance with public liability and property damage coverage in at least the following minimum limits and which will name the City of Temecula as an additional insured for the duration of the encroachment permit: BODILY INJURY $250,000.00 EACH PERSON $500,000.00 EACH OCCURANCE $500,000.00 AGGREGATE PRODUCTS AND COMPLETED OPERATIONS PROPERTY DAMAGE $100,000.00 EACH OCCURANCE $250,000.00 AGGREGATE PRODUCTS AND COMPLETED OPERATIONS A combined single limit homeowner’s policy with aggregate limits in the amount of $1,000,000.00 will be considered equivalent to the required minimum limits. Homeowners: a copy of the required homeowners insurance and a Certificate of Insurance showing the City named as an additional insured shall be attached to the application. The undersigned applicant and/or contractor states that they have read and agrees to meet all the conditions on this application, including provisions of required liability insurance or a City Attorney approved equivalent, and acknowledges that this application will be made a part of the encroachment permit. APPLICANT’S INFORMATION (THIS SECTION MUST BE COMPLETED) Company Name: Mailing Address: Contact: Phone #: E-mail: I hereby warrant and represent to the City that I am authorized to execute this permit application on behalf of the permittee and bind the permittee to the agreements contained herein and any conditions of the permit. Authorized Signature: Date Applied: CONTRACTOR’S INFORMATION Company Name: Mailing Address: Contact: Phone #: 24-HR Emergency #: State Contractor’s License #: Class: City Business License #: Charter Communications(Stephen/Owner) / Inland Engineering Services (Amber/Agent) 7337 Central Ave, Riverside, Ca 92504 / 1373 Old Temescal Rd, Corona, Ca 92881 Amber Grim 951.277.0800 x257 agrim@inland-engineering.com 08/30/2024 Inland Engineering Services 1373 Old Temescal Rd, Corona, Ca 92881 Alfred Mongello 951.277.0800 951.515.0233 931684 A 056867