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ExteNet Systems-CS200219T H E C I T Y O F COFFELL F x .A s 1. a PUBLIC RIGHTS-OF-WAY MANAGEMENT ORDINANCE REGISTRATION FORINT Submit completed. form to .the Engineering Dept., .Town. Center, .265 Parkway Blvd., .Coppell, TX, 754.19 This registration ford is required by Sec. .6-14-3 of the City of Cappell Code of Municipal Ordinances. -"t is to he renewed every other year by March 1. This document does not take the place of obtaining a Right -Of Way Use Permit prior to performing any work. in the public right-of-way. 171. 27 2020 1. Date of Submittal. 1 1 2. Narne.and Address of Service Provider (Include all names.used within the last 5year;s): E tenet. Systems 3. Is Provider certifiedby the Texas. Public. Utility Commission? () NO (X) YES if YES,. Certificate Number 60769 4. Does. Provider have a Valid License or Francitise.Agreement'with the City of Coppell? Not required under Chapter 284 of Texas Local (} NQ (. } YES if YES, Ordinance Number cloy_�rnment Code_ Date Approved 1 1 S. Provide Two Business. Contacts (ane -must. be within. the Dallas/Fort Worth area): Dia Kuykendall Dmiel Alverado Nanne Waste Regiarial. Manages., External Relations. Title 33`30.Keller.Springs, 203, Carrollton, Tx 75046 Address 214-727-9676 Construction .Manager Title 3330 Keller Springs, 203, Carrollton, TX 7506 Arldresx 214-682-7057 Telephone Telepl:ame 6. Provide Two Emergency Contacts (Must he available A TALL TIMES): :Matt Simpson Name Executive: Director, Network. Operations Titte 3.036 Warrenville Road., Lisle, i€160532 Adilrus 866492-5327 7'elephoire (No .Cliarge to. the City) Dia Kuykendall Natne Regianal .Manager, Extemal Relatia.ns rifle .3030 Keller .Springs .R..aad, 203, .Carrollton, TX 75006 Address 866-892-5327 telephone (No Charge to the Qj j 7. Have the names, addresses, and contact in#'ormation for all known contractors: or subcontractors that will be working in the public right-of-way on behalf of the Provider been furnished to the city? (x) YES ( ) NO if NO, Reason:. 8. Has proof of insurance meeting the requirements of Sec. 6-14 3 BA(ii)..of the Public Rights -OP Way Management Ordinance been furnished to the City (the City gust he named as an additional insured on the policy by using endorsement CG 20 26 or broarder)? (X) YES (' } NO if NO, Reason: A" l ' Dia KuykendallJail. 27,. 020 { Signature of Applicant Printed Name Elate FOR CITY USE ONLY (;0 REGISTRATION ACCEPTED ( )REGISTRATION DENIED Comments-. r 3.401 Sipiature of City .Representative Printed Name Date. Provider shall indenuiffy and forever halt harmless against tiro City of Coppe[.l each and.every claim, del►►a►1tf, .or cause of action that may he made or coine against it lay reason of or if any wayarising out of the closure, blocking, excavating, cutting, funneling, or otherwork by the proWder under. perrnit f mn the Cion,. if such per►nft is granted. Construction Contractors for ExteNet Systems. Verticom 7901 Ambassador Row Dallas, Texas 75247 Off ice`. 214.741.6898 Contact No. 1: Doug Wittrock Mobile: 214.681.9091 Contac No. 2: Chad Sigler M ob i le: 2 1 4,683..99.30 r ® CERTIFICATE OF LIABILITY INSURANCE [MM16DfYYYY) DATE�aRD CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 12/12/2019 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 iN$URER(S}; AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is anADDITIONAL INSURED,. the policy(les) must have ADDITIONAL INSURED provisions or be endorsed: If SUBROGATION IS WAIVED,.s.uhject.to the termsi 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), PRODUCER IMA, Inc. -:tiallas Division ONTA NAME; Meagan Richenberer PHONE 972-458-8700 972-,458-8755 6200. LBJ Freeway �u,. No. Exti .__... _.. _ ...W_.-._ --_ iA c, Ho] . . .. suite 20t} E-MAIL ADDRES•5,'_.m�82,i1.rlCllent7er�L l:r ImaCorp.00I11 ..mm...y.....- -....._.�- _..�....,... ..__.._..-_........ Dallas T.x.75240 - INS1fRER�Sj AFFORDING COVERAGE u — NAICp INSURERA: Valles Forge Insurance.Co. 20508 EXTESYS —.l-.--..---,---.,-.-------------.--- __- -- —INSURED INSURER a National Fire Ins. GOm 9[m _ Qf hlarifard 20478 P Y ExteNet Systems Inc; ExteNet Systems (California), _. .._...-.._.. . . _----€ ... _ w LLC', EXteNet Sj steals. New York Inc, ExteNet Systems INSURER c _Continental Insurance Company ......... 35289 (Virginia.) - 3030 Warrenville Rd;, 3rd IFL INSURER o_ American.Casualty Co of eadin�g, PA 20427 Lisle IL.60532 — _INSURER E; Underwriters aftLoygs LCndQn---------� S 1,.0OD,ODo....^^,T, INSURER F; Berkley insurance GoT2any 3266 COVERAGES CERTIFICATE. NUMBEW.21071132345 RSVISION A IJMRFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN: ISSUED TO THE INSURED NAMED ABOVE FOR THE: POLICYPERIOD INDICATED. NOTWITHSTANDINGANY REQUIREMENT,, TERM :OR cow.IT[ON 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.ANt3 CONDITIONS. br:SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY.PAID MIMS. INSR ADPL SUER; - _.._.-.-__.._...__...._____—______....,_.....-.w___.....,,.�.._......__.w LTR TYPECFIN$URANOE i POLICYNUMBER MMIDDYNYYYiIfMMIDr]YIYYYY LIMITS A XCOMMERCIg.-GEN ERAGLIABILITY .. Y I Y € 4013130714 02 112126 9/2/2021 EACH OCCURRENCE S 1,00{1,000 -_._...I --1 CLAIMS-MADEx i i r DAMAGE To.RrKTEti-_��.__..- - -----------._-.. OCCUR [ f PREMISES [Ea accurreilce�_ S 1,.0OD,ODo....^^,T, MED EXP (Anyone person) µ $ 15,006 PERSONAL 8 ADV [NJU_RY S1,000,000 I GEN'L AGGREGATE LIMIT APPLIES PER;-� 3 GENERAL AGGREGATE 0o $ 2,D,o00 1 3 POLICY rx )E x] I _ ;— •, T LOC j S PRODUCTS-CdMPIOPAGG S_2,000,0000W-�•VV�•Vf - __ .� ..._._. w.._._... .OTHER: E I i-5 B AUTOMOBILE LIABILITY -..-.- ..; Y 'Y '4013130681 I 1/2/2020 3 '11212021 ; COMBINED.SINGLELIMIT � 51,000,000. ._..._--- ANY AUTO l I BODILY INJURY (Per person) 5 OWNED SCHEDULED - - AUTOSONLY ._ AUTOS I BODILYlhIJi1RY[Peraccldenl] 5-- ' •• �.,•_-'-M �- - HIRED NON�OWNED X X' I s I ;; _-_ —' 5 AUTOS ONLY � UTOS ONLY I 'A Per accitlen[ l i 5 C X i[ OMBitELLALF49 X ' OCCUR �� Y Y 6056871852 1/212020 112/2021 EACH OCCURRENCE ------------_._._.-...._.....�.:.�_....._..__....__....—.._...--- 525,000,000 kCESS LEAH CLA€MS MADE! i AGGREGATE i DED RETENTIONSS j a not _5.25,000,600. b D WOfRKERSCO.... SATfON SAND EMPLOYERS'LIAUILITY I Y fi056871821. 1/212020 1121202'1. JX LPErR U OTH- A 7E ER Y.1 N ANYPROP01E7dFt PARTNEFOEHECUT€VE ; 605667.1848 1/212020 €1212021. t—� - OFFICER)MEMEFREXCLURER7 N NIA E -L. EACH ACCIDENT -- € 5 1,000,000Y �.--...--— -- (MandatoryinNH) Ir.yes;:describe Under E,L.OISEASE -EA EMPLOYEE ----------•----•••• 51,000,600 w �S DESCRIPTION.CF OPERATIONS below i E.L. DISEASE- POLICY LIMIT 1,D0o,0o0 E PROF ESSiONALfCYBERLIABILITY I MPL186.833720. .. 1/2/2020 1/2/2021 iLIMIT $10,OUoxo F POLLLICION€fAHILETY € j PCAOB50106170120 11212024 11212.021 LIMIT $10,000,060 DESCRIPTION OF OPERATIONS 1 LOCATIONS t VEHICLES (AC ORD:101, Addi lonDI Remarks Schedule; may he attached if more space Is roqu[red} Certificate Holders are included as Additional Insured on the General. Automobile and Umbrella Liability Policies if required by written contractor agreement. subject to the policy terms and conditions. A Waiver of Subrogation.is provided in -favor Of "Additi a n a I Insured" on the General, Automobile, Umbre11a.Liability and Workers Compensation Policies if required by written contract or agreement subject to policy terns and conditions. This Insurance is Primary and Non -Contributory on the General, Automobile and Umbrella Liability Policies subject to policy terms and conditions. See Attached— CERTIFICATE HOLDER rAAIrI=€ F ATInm d 1988-2015 ACORD CORPORATION. Ail rights reserved.. ACORD 25 (2016103) The ACORD name and logo are registered marks.of ACORD SHOULD ANY OF THE ABOVE.DESCRIBED POLICIES 13E CANCELLED. BEFORE THE EXPIRATION DATE. THEREOF, NOTICE WILL HE DELIVERED IN City Of Coppell ACCORDANCE WITH THE POLICY PROVISIONS. 255.E, Parkway Blvd. AUTHORIZED REPRESENTATIVE. Coppell TX 75019 USA d 1988-2015 ACORD CORPORATION. Ail rights reserved.. ACORD 25 (2016103) The ACORD name and logo are registered marks.of ACORD AC 0® AGENCY CUSTOMER ID: EXTESYS LOC.#: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAM EU INSUREb IMA, Inc, - Dallas.Division ExteNet Systems.lnc, ExteNet Systems (California),. LLC; ExteNet Systems New York Inc; ExteNet Systerns (Virginia) - 3030 WarrenVHle Rd.; 3rd FL POLICY NUMBER Lisle I L 60537 CARRIER AlAIG.aflO£ EFFECTIVE RATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,. FORM NUMBER: 25 FORM TITLE: CERTIFICATE dF LIABILITY MuRMCE Any Exclusion for Liability within .50 feet of railroad. tracks:has been deleted. 3.0. Day Notice of Cancellation with respects to the General, Autofnobile, Urnbrella Liability and Warners Campensation Policies if required by written contract or agreement subject to the policy. terms. and conditions.. Certificate Holder(s); City of. oppell, its .afflcers, employees, board members and elected representatives. ACORD 101 © 2008 ACORD CORPORATION. All riahts reserved. The. ACORD name and logo are registered marks:of ACORD