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Fiberlight-CS0909147 K t C ! T Y O F CC)PPELL T ~ O E X A 8 , a 9 RIGHT-OF-WAY MAINTENANCE USE FEE Ordinance No. 2001-944, Sec. 6-14-3. Registration Form for Service Provider Registration expires March I of every other year after the calendar year in which the first registration occurs. If registration is not renewed by the expiration date, after written notice from the City, the facilities of the service provider will be deemed to have been legally abandoned. Service Provider (include any business name provider operates under or has operated under for past 5 years) ',~- ~,~ ~ ~.. ~.. ~ PUC Certlficate Numl3er (for certificated telecommunications providers) # 314 5 9 ; S POCA # 6 0 7 3 6 City of Coppell License Ordinance No. ContactNames/Numbers Russell Lytle, operations Manager 817-795-4000 (Direct); 817-795-6233 (Fax) 817-538-8532 (Cell) COntractor(S} Name Future Telecom Contact Information Don Riggs 972-329-6400 Emergency Contact Judd Carothers 817 - 613 -1825 Liability Insurance Carrier Marsh USA, Inc . (Sec. 6-14-3 (h}) Attach proof of coverage Plans of Record provided to Engineering Dept. for existing facilities Y N For proposed facilities ~. Y •N' N Forward registration form and fee to Engineering Dept., City of Coppell, 2SS Parkway Blvd., Coppell TX 75019 For office use only Registration Fee of $250.U0 paid 9 /~~! D,~_ Receipt No. ~~2 ~ 6~0 i PRODUCER Marsh USA Inc. 701 Market Street, Suite 1100 St. Louis, MO 63101 Attn: stlouis.certrequest@marsh.com 800679-STND-GAWU P-09/10 212-948-0811 INSURED FiberLight, LLC 3655 Brookside Parkway, Suite 550 Alpharetta, GA 30022 THIS CERTIFICATION IS 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 AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURER A: St. Paul Fire & Marine Ins Co 24767 INSURER B: N/A N/A INSURER C: INSURER D INSURER E: ', 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ~'R """ ~ TYPE OF INSURANCE LTR INSRD POLICY NUMBER ruuur errtcl Ivt DATE (MM/DD/YVYV) rULIGT tXYIHA I ION DATE (MMIDD/YYYY) LIMITS A '.,. X GENERAL LIABILITY TE01202096 05/09/2009 05/09/201 O EACH OCCURRENCE 1 00~ 0~0 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES1Ea occurrence $ 1000 ~~~ ~'i CLAIMS MADE ~ OCCUR MED EXP (Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1 000 000 GENERAL AGGREGATE $ 2,000,000 ' , GENERAL AGGREGAT PRIOMIT APPLIES PER ' PRODUCTS -COMP/OP AG $ Q~QQQ~QQQ ', POLICY JECT '~ X LOC - AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT ' $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) ~ PROPERTY DAMAGE , (Per accident) $ GAR AGE LIABILITY AUTO ONLY - EA ACCIDENT $ 'I ANY AUTO OTHER THAN EA ACC $ _ AUTO ONLY: $ AGG EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE __ $ RETENTION $ ' WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS' LIABILITY ~. ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N .L. EACH ACCIDENT - --~ ----- $ - OFFICER/MEMBER EXCLUDED? .L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under L DISEASE -POLICY LIMIT $ SPECIAL PROVISIONS below . . OTHER UESCKIY I IUN Uh UPEKA IIUNS/LUCA I IONS/VEFIIGLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS City of Coppell is included as additional insured on the above General Liability Policy only as required by written contract and as respects to building access license agreement. XCU is silent under the GL policy. CERTIFICATE HOLDER City of Coppell 255 Parkway Blvd Coppell, TX 75019 ACORD 25 (2009/01) CHI-002657774-01 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND IU{POZN pgE THE INSURER, ITS AGENTS OR REPRESENTATIVES. Of MaBhEUSA IneSENTATIVE Mary Radaszewski © 1998-2009 ACORD CORPORATION. All Rights Reserved The ACORD name and logo are registered marks of ACORD v > m a' ~ S ~ ~ c V T m 1~Q{ q -_-___ ___ .____ >~ I ,~ ~ ' ° - ~ a N aqn',". i. C. m AC Ci) i ~ j _,. ____. __ . ~,~, T ~z51 -. RFl v~l ~ ,. GFl~H 0 ~ r~iEO« _ _. i __ _ ~~~ ~ s;~. ~~ ~ ,.,~~~.~ p~~..,~ A~,~~ ~.~~...,.~.,~. 12005 wac~ovrla eaN~c, N.a ACH R/T 061000227 FIBERLIGHT, LLC sa-2vsio DATE 3655 BROOKSIDE PARKWAY Sep 9, 2009 SUITE 550 Check Number: 12005 ALPHARETTA, GA 30022 AMOUNT PH (678) 366-0027 c Memo: Registration Fee ~ 250.00 PAY Two Hundred Fifty and 00/100 Dollars TO THE ORDER OF: City of Coppell TWO SIGNATURES REQUIRED OVER lr5,000.00 ~~