Time Warner-CS040501T 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) ., e YZl✓eney' . L ► P.
PUC Certificate Number (for certificated telecommunications providers) -5'PZc` A7 6"/z 7
City of Coppell License Ordinance No.
Contact Names/Numbers r%a ���'f� 972 -zff y = 7�il'�2r%' -77� •%
4k ee c17-Z- u-kn-5--2VZ &/42,4/- ?7D- Ki60
Contractor(s) Name
Contact Information
Emergency Contact
�rrS.iswhih er-iY A-4r%/ 12e`C7Z-070f
Liability Insurance Carriers
(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 11 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.
7z �-
AefV 14
MARSH CERTIFICATE OF INSURANCE CERTIFICATE NUMBER
SEA-000806683 -01
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
MARSH USA, INC. NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE
122517TH STREET, SUITE 2100 POLICY. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE
DENVER, CO 80202 -5534 AFFORDED BY THE POLICIES DESCRIBED HEREIN.
Attn: Sarah Rector 303- 308 -4776 COMPANIES AFFORDING COVERAGE
COMPANY
01810 —CAS- A ST. PAUL FIRE AND MARINE INS
INSURED
COMPANY
TIME WARNER TELECOM INC.
B
TIME WARNER TELECOM OF TEXAS, L.P.
COMPANY
15303 DALLAS PARKWAY, SUITE 610
ADDISON, TX 75001
C
COMPANY
D
COVERAGES This certificate supersedes and replaces any previously issued certificate for the policy period noted below. 1
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CONDITIONS AND EXCLUSIONS OF SUCH POLICIES. AGGREGATE
LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MM /DD/YY)
POLICY EXPIRATION
DATE (MMIDD/YY)
LIMITS
GENERAL
LIABILITY
GENERAL AGGREGATE
$ 2,0,400
A
X
COMMERCIAL GENERAL LIABILITY
TE09407280 05/01/04
05/01/05
PRODUCTS - COMP /OP AGG
$ 2,000,000
CLAIMS MADE a OCCUR
PERSONAL & ADV INJURY
$ 1.000.000
EACH OCCURRENCE
$ 1,000.000
OWNER'S & CONTRACTOR'S PROT
FIRE DAMAGE (Any one fire )
$ 1.000,000
MED EXP (Anyone n
$ 10,000
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
$ 1,000,000
X
A
ANY AUTO
TEOM7280 05/01/04
05/01/05
BODILY INJURY
(Pw pin)
$
A
ALLOWNEDAUTOS
SCHEDULED AUTOS
TE09407280-01 (TX) 05/01/04
05/01/05
BODILY INJURY
(Per accident)
$
HIRED AUTOS
NON-OWNED AUTOS
PROPERTY DAMAGE
$
GARAGE LIABILITY
AUTO ONLY -EA ACCIDENT
$
OTHER THAN AUTO ONLY:
ANY AUTO
EACH ACCIDENT
$
AGGREGATE
$
EXCESS LIABILITY
EACH OCCURRENCE
$
AGGREGATE
$
UMBRELLA FORM
$
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
X TORY LIMITS ER
EL EACH ACCIDENT
$ 1,000,000
A
WVA9404407 05/01/04
05/01/05
THE PROPRIETOR/ X INCL
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL
EL DISEASE - POLICY LIMIT
$ 1,000,000
EL DISEASE -EACH EMPLOYEE
$ 1,000,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSTVEHICLES (SPECIAL ITEMS
CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED AS RESPECTS TO GENERAL LIABILITY.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE POLICES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,
THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAL _ 0 DAYS WRrf1EN NOTICE TO THE
CITY OF COPPELL CERTIFICATE HOLDER NAMED HEREIN. BUT FAILURE TO MAL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
255 PARKWAY BLVD
DALLAS, TX 75019 LIABLm OF ANY KIND UPON THE INSURER AFFORDING COVERAGE, ITS AGENTS OR REPRESENTATIVES. OR THE
ISSUER OF THIS CERTIFICATE.
MARSH USA INC.
sY: Rebecca J. Clark Ci t...► 4 d..a_
MM1(3102) VALID AS OF: 09/14/04