MCI-CS041012T H E C 1 T Y O F
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) MCIm6tro ACCESS TRANSMISSION SERVICES, LLC
PUC Certificate Number (for certificated telecommunications providers) fiQ o (j I
City of Coppell License Ordinance No
41L"C..ySArm;jv 972 -7153 43/3/ 7 /NY6C9 --4464
Contact Names/Numbers Jason Carr Phone# 972-753-4367/Cell-214-869-0715
2477 Gateway Dr.
Irving, TX 75063
Contractor(s) Name A t -t,;
c ti
Contact Information
Emergency Contact
Liability Insurance Carrier- Ac
(Sec. 6 -14 -3 (h))
proof of coverage
Plans of Record provided to Engineering Dept. for existing facilities Y N
For proposed facilities Y N
Forward registration form and fee to Engineering Dept., City of Coppell,
255 Parkway Blvd., Coppell TX 75019
For office use only
Registration Fee of $250.00 paid / / Receipt No.
MCI's list of contractor:
Future Telecom, Inc.
1170 Bruton Rd
Balch Spring, TX 75180
Office: 972 - 3329 -6400
Fax: 972 - 329 -6401
Contact: Don Riggs
Mobile: 214 - 908 -0901
2 °a Contact: David "Jocko" Helmers
John Burns Construction Company of Texas, Inc.
655 E. Main St.
P.O. BOX 1117
Lewisville, TX 75067
Office: 972 - 434 -6789
Fax: 972 -221 -8301
Contact: Tom Nelson
Mobile: 214 - 226 -9676
MasTec North America, Inc.
4747 Irving Blvd.
Suite 221
Dallas, TX 75247
Office: 214 -571 -2542
Fax: 214 -571 -2555
Contact: Glenn W. Travis
Mobile: 214 -535 -7235
The Fishel Company
1661 N. Highway 377
Roanoke, TX 76262
Office: 817- 430 -8747
Contact: Bryan Dunlevy
Mobile: 817- 925 -3179
n
PRODUCER
Aon Risk services ,Inc. of Washington, D.C./ Hunti
1120 20th Street NW
Washington DC 20036
PHONE - (866) 266 -7475 FAX- (866) 467 -7847
INSURED
MCImetro Access Transmission SVCS, LLC
1133 19th Street, NW
Washington DC 20036 USA
DATE(MM /DD /YY)
10/12/04
THIS CERTIFICATE 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.
COMPANIES AFFORDING COVERAGE
COMPANY Zurich American Ins Co
A
COMPANY
B
COMPANY
C
COMPANY
4
a�
w
IN.
b
~c.
v
.b
O
x
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.
CO POLICY EFFECTIVE POLICY EXPIRATION
LTR TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YY) DATE (MM/DD/YY) LIMITS
tD
A GENERAL LIABILITY GL0287142706 07/01/04 07/01/05 GENERAL AGGREGATE $2 000 000 n
04 -05 COMM GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE Z OCCUR
OWNER'S & CONTRACTOR'S PROT
A AUTOMOBILE LIABILITY
X ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
GARAGE LIABILITY
7 ANY AUTO
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION AND
EMPLOYERS' LIABILITY
THE PROPRIETOR/ rj INCL
PARTNERS/EXECUTIVE H
OFFICERS ARE: EXCL
BAP287142806
04 -05 BUSINESS AUTO COVERAGE
TAP 2871429 -06
04 -05 BUSINESS AUTO COVERAGE
DAMAGE
ONLY - EA ACCIDENT
i THAN AUTO ONLY:
EACH ACCIDENT
AGGREGAT
OCCURRENCE
EL EACH ACCIDENT
EL DISEASE- POLICY LIMIT
EL DISEASE -EA EMPLOYEE
DESCRIPTION.OF OP I L CAI NS/VEHIC S/SPECIAL ITEMS
Re: Project`$�fY �uij�ing A�, Depository Trust & Clearing Corp. 1333 Crestside, Coppell, TX 75019.
City of Coppell, Texas is included as Additional Insured.
XCU IS NOT EXCLUDED.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
City of Coppell. Texas EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
Attn : Engineering Department 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
255 Parkway Blvd. BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
Coppell, TX 75019 USA
OF ANY KIND UPON THE COMPANY. ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
PRODUCTS - COMP /OPAGG
$2,000,000
m
�
m
PERSONAL& ADV INJURY
$1,000,000
m
EACH OCCURRENCE
$1,000,000
FIRE DAMAGE(Anv one fire)
$1,000,000
C
Z
MED EXP (Any one person)
$25,000
07/01/04
07/01/05
cc
COMBINED SINGLE LIMIT
$2,000,000
w
07/01/04
07/01/05
t
BODILY INJURY
U
( Per person)
BODILY INJURY
(Per accident)
DAMAGE
ONLY - EA ACCIDENT
i THAN AUTO ONLY:
EACH ACCIDENT
AGGREGAT
OCCURRENCE
EL EACH ACCIDENT
EL DISEASE- POLICY LIMIT
EL DISEASE -EA EMPLOYEE
DESCRIPTION.OF OP I L CAI NS/VEHIC S/SPECIAL ITEMS
Re: Project`$�fY �uij�ing A�, Depository Trust & Clearing Corp. 1333 Crestside, Coppell, TX 75019.
City of Coppell, Texas is included as Additional Insured.
XCU IS NOT EXCLUDED.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
City of Coppell. Texas EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
Attn : Engineering Department 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
255 Parkway Blvd. BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
Coppell, TX 75019 USA
OF ANY KIND UPON THE COMPANY. ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Additional Insured — Automatic - Owners, Lessees Or
Contractors - Broad Form
X
Policy No.
Eff. Date of Pol.
Exp. Date of Pol.
Eff. Date of End.
Producer
AWL Pre.
Return Prem.
GLO 2871427 06
07/01/2004
07/01/2005
$
$
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the:
Commercial General Liability Coverage Part
A. WHO IS AN INSURED (Section II) is amended to include as an insured any person or organization whom you are required
to add as an additional insured on this policy under a written contract or written agreement.
B. The insurance provided to additional insureds applies only to "bodily injury", "property damage" or "personal and advertis-
ing injury" covered under Section I, Coverage A, BODILY INJURY AND PROPERTY DAMAGE LIABILITY and
Coverage B, PERSONAL AND ADVERTISING INJURY LIABILITY, but only if:
1. The "bodily injury" or "property damage" results from your negligence; and
2. The "bodily injury", "property damage" or "personal and advertising injury" results directly from:
a. Your ongoing operations; or
b. "Your work" completed as included in the "products- completed operations hazard ",
performed for the additional insured, which is the subject of the written contract or written agreement.
C. However, regardless of the provisions of paragraphs A. and B. above:
1. We will not extend any insurance coverage to any additional insured person or organization:
a. That is not provided to you in this policy; or
b. That is any broader coverage than you are required to provide to the additional insured person or organization in the
written contract or written agreement; and
2. We will not provide Limits of Insurance to any additional insured person or organization that exceed the lower of
a. The Limits of Insurance provided to you in this policy; or
b. The Limits of Insurance you are required to provide in the written contract or written agreement.
D. The insurance provided to the additional insured person or organization does not apply to:
1. "Bodily injury",
tional insured; or
"property damage" or "personal and advertising injury" that results solely from negligence of the addi-
U -GL- 1175 -A CW (9/03)
Includes copyrighted material of Insurance Services Office, Inc. with its permission. Page 1 of 2
2. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering or 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; and
b. Supervisory, inspection, architectural or engineering activities.
E. The additional insured must see to it that:
1. We are notified as soon as practicable of an "occurrence" or offense that may result in a claim:
2. We receive written notice of a claim or "suit' as soon as practicable; and
3. A request for defense and indemnity of the claim or "suit' will promptly be brought against any policy issued by an-
other insurer under which the additional insured also has rights as an insured or additional insured.
F. The insurance provided by this endorsement is primary insurance and we will not seek contribution from any other in-
surance available to any additional insured person or organization unless the other insurance is provided by a contractor
other than you for the same operations and job location. Then we will share with that other insurance by the method de-
scribed in paragraph 4.c. of SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS.
Any provisions in this Coverage Part not changed by the terns and conditions of this endorsement continue to apply as writ-
ten.
U- GL- ]175 -A CW (9/03)
Page 2 of 2