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Page 1 of 4
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Rev, 05/07
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RIGHT-Of-WAY USE PERMIT APPLICATION
Permit validfor 90 calendar daysfrom date of approval
Submit permit application to the Engineering Dept., Town Center, 255 Parkway Blvd.
Date of Submittal: Applicant's Job # / Work Order #
PERMIT FEE: $100.00
(No charge to Utility Companies with approved Franchise/ROW Use Agreement)
License Agreement Approved (date) / / Certificated Telecom Provider? Y N
D Plans provided and approved
(Erosion Control/safety fences must be installed prior to beginning work)
Project Name / Location:
General Contractor: 'ku.JSCf".. C(..OP"",,,\S t c~ \
Contact #
Permit issued to Company / Representative:
Address:
Telephone #:
Emergency Telephone #:
Utility Company Represented:
D Oncor Electric Delivery
D Time Warner Cable
D Atmos Energy
D CoServ Electric/Gas
D Verizon
D Other*
DSBC/ AT&T
* If "Other" is checked, please note that franchise or right-of-way use agreements will be required.
General Description of Work (provide four [4J sets of plans):
S\os("'('ic.. \e~~k.Jd
Completion requires submittal of Completioff Verification
~ Was contact made with City and/or utility companies to locate existing utilities?
if NO, Reason: No..*" nee~J!..c. YES D
~ Is removal of existing streets, alleys, or sidewalks necessary? YES D
if YES, must have City inspection prior to concrete replacement
NOG-
NO~B-
Right-of-Way Use Permit Application Page 2 of 4
Revised 06/03
Representative(s) of the Contractor must adhere to all construction standards approved by the City of Coppell, which
includes but is not limited to: Erosion Control Ordinance, compaction requirements (density tests may be required at
the applicants expense) and barricading according to the Texas Manual on Uniform Traffic Control Devices.
~ Any excavation requiring closing of a street/alley must be reported prior to closing to the following:
Police Department @ 972-304-3600
Fire Department @ 972-304-3500
Street Department @ 972-462-5150
Engineering Department @ 972-304-3679
~ Attach barricade plan / trench safety plan if a lane or street closure is required.
NOTE: Street closures are allowed from 9:00 a.m. until 3:00 p.m. ONLY unless otherwise approved by City
Engineer.
~ Attach Work Order (franchise only) and/or 4 sets of prints showing proposed work.
(Application with original signatures should be submitted to the Engineering Department before approval.)
Printed Name
Date
~.Y 44'-/
Printed Name
Date
Ke"" G~ I PP-IN
prfnted Name
~,30 # g
Date
~ Comments: re,t'M.i"," p ~,.~i~~ \-0 ">~I"'H.\- a.1~",+ ,,/r w-.y 0/1'\\'f' C.t.,,,,hAt"" } ~"l,y J ~..,t.v"~J
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~ NOTE: Notify City Inspector at 972-304-3679 prior to beJ{inninJ{ work and prior to
backfill for concrete, trench, ditch and open pit inspections. (Backfill must
meet all construction standards approved by the City of Coppell.)
Applicant shall indemnify and forever hold harmless against the City of Coppel! each and every claim,
demand or cause of action that may be made or come against it by reason of or if any way arising out of the
closure, blocking, excavating, cutting, tunneling, or other work by the applicant under permit from the City,
if such permit is granted.
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Geophysical Company
PERMIT TO CONDUCT GEOPHYSICAL OPERATIONS
PROSPECT: LewisvilIe Phase II 3D
JOB: #19907
PERMIT COPOl
9/20/2008
City ofCoppell Right of Way
Coppell TX
Dawson Geophysical Company, or other Agents, Contractors, Sub-Contractors, Assigns, Successors, etc., hereby requests your permission to conduct
a seismographic survey, including the right of ingress and egress, across your land in Tarrant and Dallas County, Texas, and more fully described below:
Tract ID 55555-05: 0.54 acres (100.00% Surface Int in 0.54 ac), part of North point Dr, Right of Way Survey, Road Abstract, Tarrant County.
Tract ID 55555-07: 0.18 acres (100.00% Surface Int in 0.18 ac), part of Gateview, Right of Way Survey, Road Abstract, Dallas County.
Tract ID 55555-13.3: 3.53 acres (100.00% Surface Int in 3.53 ac), Northpoint Dr., Right of Way Survey, Road Abstract, Dallas County.
Tract ID 55555-13.4: 3.08 acres (100.00% Surface Int in 3.08 ac), part of Creek view Dr., Right of Way Survey, Road Abstract, Dallas
Tract ID 55555-13.7: 35.28 acres (100.00% Surface Int in 35.28 ac), part of Northpoint Dr, part of Royal Ln, part of Gateview, part of
Creekview Dr, part of BethaI Rd, Right of Way Survey, Road Abstract, Tarrant County.
Tract ID 55555-13.8: 10.05 acres (100.00% Surface Int in 10.05 ac), part of Royal Ln, Right of Way Survey, Road Abstract, Dallas County.
Tract ID 55555-24: 21.16 acres (100.00% Surface Int in 21.16 ac), Coppell Rd, Sandy Lake Rd, Canyon Dr, part of Royal Ln, Freeport Pkwy,
Right of Way Survey, Road Abstract, Dallas County.
Tract ID 55555-24.1: 1.30 acres (100.00% Surface Int in 1.30 ac), part of Freeport Pkwy, Right of Way Survey, Road Abstract, Dallas
Tract ID 55555-24.2: 8.78 acres (100.00% Surface Int in 8.78 ac), Freeport PkwylRuby Rd., Right of Way Survey, Road Abstract, Dallas
Tract ID 55555-24.3: 0.44 acres (100.00% Surface Int in 0.44 ac), part of Freeport Pkwy, Right of Way Survey, Road Abstract, Dallas
Tract ID 55555-24.5: 1.67 acres (100.00% Surface Int in 1.67 ac), Part of Canyon Dr, Right of Way Survey, Road Abstract, Dallas County.
Tract ID 55555-25: 7.14 acres (100.00% Surface Int in 7.14 ac), part of Patriot Dr and part of Trade Center Dr, Right of Way Survey, Road
Abstract, Dallas County.
Tract ID 55555-250: 0.58 acres (100.00% Surface Int in 0.58 ac), part of Freeport Pkwy, Right of Way Survey, Road Abstract, Dallas County.
Our operations will be conducted in accordance with standard industry practices and in a prudent and careful manner, and we agree to indemnify and hold
you harmless from all liability and claims, if any, that may result from the operations conducted under this permit. In the unlikely event this survey is
cancelled or moved, or this property is not crossed, we will notifY you and this permit shall become null and void. For this seismic survey it is our
intention to include under this permit any mineral interests (where your interest is in the minerals only) owned by you that we may not be aware of at
this time, lying within the boundaries of this survey.
Unless otherwise voided by conditions stated herein, this agreement shall survive any lease, sale, trade or conveyance of property interests described
above and made after execution date of this agreement and will be binding on successors or assigns, but in no event will this agreement extend beyond one
year from the date herein.
If your permission is granted, please so indicate by signing this permit form in the space provided below and retain the other copy for your records.
Please fill in your phone number ifit is not already indicated below. It is very important that you include your SSN or Tax J.D. for payment and let us
know about any tenant/renter information affecting the lands covered by this permit.
This form should be returned to:
Dawson Geophysical Company 1 Cajun Exploration, L.P.
PO BOX 8723, Fort Worth, TX 76124
Mindy Hurst, Permit Agent
as agent for Dawson Geophysical Company
If you have any questions, please call me:
Cell 979-332-2001 1 Office 817-921-33441 Fax 817-921-
3451
Permission Granted By:
City ofCoppell Right of Way
SSN or Tax J.D.:
Date:
Your current telephone number:
Your e-mail address, if any:
Please provide the names and phone numbers of any tenants or renters of your property:
Tenant Owner(s):
TRAFFIC CONTROL PLAN
1. Contractor's Name and contact Information: Dawson Geophysical,
508 W. Wall Street #800, Midland, Texas 79701.
Phone# 817-332-5511 Fax: 817-332-5516
2. Type of Work to be Done: 3 D Seismic Survey done with RSR
receivers and vibroseis trucks.
3. Map showing City Limits within the job attached, showing all roads
that we will travel.
4. Work Hours will be: 9am - 4pm.
5. Police escort, provided by off duty officers, will be arranged to escort
equipment thru the city, if required.
6. This is a moving operation but we will use flaggers if needed.
7. Hazard crew will scout area for any potential problems before job
begins.
Summary of How Seismic Operations Work:
First, our permit agents permit the area that we will be working in. Once an
area is permitted we then have our survey crew arrive to mark access and
points with pin flags, flagging and wooden stakes. The Hazard Crew will
survey the area at that time to be aware of any Hazards that we may incur. If
there is heavy brush in an area our brush crew will endeavor to clear a path,
when not denied by the permit. The recording crew will then layout the
monitoring devices (geophones) and cables, much like a continuous
extension cord. This equipment can be on the ground up to 21 days. Last,
our vibroseis trucks will drive to the area to send out the sound waves
(referred to as thumping). We usually move thru an area rather quickly in
most cases. Once the job is finished the crews will pick up the equipment
and most people will be unaware that we were ever there.
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THE.CITY'OF
COPPELL
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Planning Department
255 Parkway Blvd
Cappell, Texas 75019
Phone: 972-304-3678
Fax: 972-304-7092
PLANNING DEPARTMENT CONTACT:
DIRECT DIAL:
Marcie Diamond
972-304-3676
FAX COVER SHEET
DATE: April 22, 2008 PAGES: 11 (including cover sheet)
TO: Mindy Hurst FAX: 817-921-3451
Dawson Geophysical
Items Transmitted:
Executed copiesof Right of Entry permits for city owned property.
- -- - - .)
Remarks:
As we discussed,. a-pproximateiy 4-weeK's prior to-any activity~ we.will ne~t~t;~l
addendum to assure no interference with park activities or fOnsJruction of th!;l
memorial park due to the seismic tesJing. - -
If you have any questions or would like additional information, please contact me at
972-304-3676 or e-mail atmdiamond@ci.coppell.tx.us.
STATE OF TEXAS
~
~
~
KNOW ALL MEN BY THESE PRESENTS:
COUNTY OF DALLAS
RIGHT OF ENTRY
That the City of Coppell, Texas, ("City"), a Texas municipality under the laws of the State
of Texas, by and through its authorized representative does hereby grant and extend to the Dawson
Geophysical Company / Cajun Exploration, L.P. ("Company") and its contractors, the Right of
Entry under, over, through and across the property described and depicted in Exhibit "A" attached
hereto and made a part hereof (the "Property"), to proceed with the seismographic survey, subject
to the City and the Company entering into an agreement which shall be attached and incorporated
herein, as an Addendum to this Right of Entry, which specifies the time, location and operation of
the seismographic survey activities within the park as not to interfere with the enjoyment and use
of Wagon Wheel Park and any of its facilities or to interfere with construction activities on or
around Rolling Oaks Memorial Center. The property will be restored as near as possible to the
original condition as it existed prior to the seismographic survey.
It is expressly understood that this Right of Entry and possession in no way waives or
affects the City's right to receive any damages to City's remaining property occasioned by said
rights being hereby especially reserved unto City and its successors and assigns.
This Right of Entry and consent to proceed with the project shall expire upon completion of
the seismographic survey.
Company's operations shall be conducted in accordance with standard industry practices
and in a prudent and careful manner, and Company agrees to indemnify and hold City harmless
from all liability and claims, if any, that may result from the operations conducted under Permit
COP02, dated December 15, 2007 (hereinafter "Permit"). In the unlikely event this survey is
cancelled or moved, or this property is not crossed, Company shall notify City and said Permit shall
become null and void. For this seismic survey it is Company's intention to include under said
Permit any mineral interests (where City's interest is in the minerals only) owned by City that
Company may not be aware of at this time, lying within the boundaries of this survey.
Unless otherWise voided by conditions stated in said Permit, this Agreement shall survive
any lease, sale, trade or conveyance of property interests described in said Permit and made after
the execution date of this Agreement and will be binding on successors or assigns, but in no event
will this Agreement extend beyond one year.
In consideration for the right to enter and conduct the tests, Company shall pay to City the
sum of two thousand thirty-four dollars and twenty-one cents ($2,234.21).
The undersigned is the authorized representative of the City, which is the owner of the
Property, described in Exhibit "A" and executes this Right of Entry for the purposes stated herein.
The rights reserved herein to the City may be assigned to a subsequ~nt purchaser of the property.
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Executed on the ~. d~y of /-
,2008.
CITY:
COMPANY:
----
By:
Itt, City Manager
'f Coppell, Texas
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By: );1 fNrt. /1" /IILIt5V-
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Its: rUhllr A-./.t?/l"/-
Dawson GeophysIcal Company /
Cajun Exploration, L.P.
TM 25337.2.000
CITY'S ACKNOWLEDGEMENT
STATE OF TEXAS ~
~
COUNTY OF DALLAS ~
This instrument was acknowledged before me on the .2L Jfday of ~ '
2008, by Jim Witt, the City Manager of the City of Coppell, Texas, which the owner of the
property depicted in Exhibit "A".
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COMPANY'S ACKNOWLEDGEMENT
STATE OF TEXAS ~
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COUNTY OF DALLAS ~
This instrument was acknowledged before me on the ~ day ofJ.-.c/<, /1 ,
2008, by . ./Jt,,:'''!tl/kto-f, of Dawson Geophysical Company/Cajun
Exploration, L.P., 0 behalf of said limited partnership.
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SCOTT S~BAS'IAN
Nota'y Puolic, State. of Texas
fvl\ ';"mmission Expires
October 21, 2009
TM 25337.2.000
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ACORD CERTIFICATE OF LIABILITY INSURANCE I DATE (MMlDDIYYYY)
TN 03/03/2008
PRODUCER (432)571-4900 FAX (432)682-3863 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Stoltz and Company, Ltd. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
3300 North A Street, Ste 1100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
-Midland, TX 79705
INSURERS AFFORDING COVERAGE NAIC#
INSURED Dawson Geophyslcal Company INSURER A St. Paul Fire & Marine Ins Co
508 West Wall, Suite 800 INSURER B Travelers Indemnity Company
Midland, TX 79701-5010 INSURER c:
INSURER D
INSlFER 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
POLlCIES_ AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_
II,~ ~~} TYPE OF INSURANCE POliCY NUMBER POLICY EFFEC11VE POLICY EXPIRATION LIMITS
GENERAL LIABILITY VK04204074 01/01/2008 01/01/2009 EACH OCCURRENCE $ 1,000,00e
~ COMMERCIAl GENERAl LIABILITY DAMAGE TO REWED $ 300, OO(
f-- tJ CLAIMS MADE [KI OCCUR 5,00(
MED EX? (Anyone person) $
I---
A PERSONAl & mv INJURY $ 1,000,001
f--
GEf'.ERAl AGGREGATE $ 2,000,001
i--
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $ 2.000,00(
!Xl n PRO- nLOC
X POLICY JECT
ALlTOMOBILE LIABILITY VK04204074 01/01/2008 01/01/2009 COMBINED SiNGlE LIMIT
f-- (Ea aCCident) $ 1, 000, OO(
X ANY AUTO
f---
AlL OWNED AUTOS BODIL Y INJURY
f-- $
SCHEDUlED AUTOS (Per person)
A -
HIRED AUTOS BOOIL Y INJURY
- $
NON-OWNED AUTOS (Per accident)
-
- PROPERTY DAMAGE $
(Per aCCident)
GARAGE LIABILITY AUTO ONL Y - EA ACCIDENT $
=l ANY AUTO OTHER THAN EA ACe $
AUTO ONL Y AGG $
EXCESSIUMBRElLA LIABILITY VK04204074 01/01/2008 01/01/2009 EACH OCCURRENCE $ 25,000,00e
IJ OCCUR o CLAIMS MADE AGGREGATE $ 25,000,00(
A $
~ DEDUCTIBLE $
X RETENTION $ 10, ooe $
WORKERS COMPENSATION AND HHUB216IC3610~ 01/01/2008 01/01/2009 xl T~&Y~~~~Y<: I IO~
EMPLOYERS' LIABILITY 1,000,00e
B ANY PROPRIETORIPARTNERiEXECUTIVE E L EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? E L DISEASE - EA EMPLOYEE $ 1, 000, ooe
If yes, descnbe under 1.000 OO(
SPECiAl PROVISIONS below E L DISEASE - POLICY LIMIT $
OTHER
IfIESCRlPTlON OF OPIiRATlQNS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAl PROVISIONS
E Job: Lewlsvllle Phase 1
3lanket waiver of subrogation on General Liability, Auto L iabil ity, and Work Comp policies as required
lY written contract with respects to work performed by the named insured (s). Blanket additional
. nsured on General Liability and Auto Liability as required by written contract with respects to work
lerformed by the named insured (s) .
City of Coppell
255 Parkway Blvd
Coppell, TX 75019
SHOULD Am OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAlL
-.JJ!.... DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BLIT FAILURE TO MAlL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF Am KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES_
AUTHORIZED REPRESENTATIVE
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Mark A Stoltz/JRB
ACORD 25 (2001/08)
@ACORD CORPORATION 1988
STATE OF TEXAS
~
~
~
KNOW ALL MEN BY THESE PRESENTS:
COUNTY OF DALLAS
RIGHT OF ENTRY
That the City of Coppell, Texas, ("City"), a Texas municipality under the laws of the State
of Texas, by and through its authorized representative does hereby grant and extend to the Dawson
Geophysical Company I Cajun Exploration, L.P. ("Company") and its contractors, the Right of
Entry under, over, through and across the property described and depicted in Exhibit "A" attached
hereto and made a part hereof (the "Property"), to proceed with the seismographic survey. The
property will be restored as near as possible to the original condition as it existed prior to the
seismographic survey.
It is expressly understood that this Right of Entry and possession in no way waives or
affects the City's right to receive any damages to City's remaining property occasioned by said
rights being hereby especially reserved unto City and its successors and assigns.
This Right of Entry and consent to proceed with the project shall expire upon completion of
the seismographic survey.
Company's operations shall be conducted in accordance with standard industry practices
and in a prudent and careful manner, and Company agrees to indemnify and hold City ham1less
from all liability and claims, if any, that may result from the operations conducted under Permit
COPO I, dated December 14, 2007 (hereinafter "Permit"). In the unlikely event this survey is
cancelled or moved, or this property is not crossed, Company shall notify City and said Permit shall
become null and void. For this seismic survey it is Company's intention to include under said
Permit any mineral interests (where City's interest is in the minerals only) owned by City that
Company may not be aware of at this time, lying within the boundaries of this survey.
Unless otherwise voided by conditions stated in said Permit, this Agreement shall survive.
any lease, sale, trade or conveyance of property interests described in said Permit and made after
the execution date of this Agreement and will be binding on successors or assigns, but in no event
will this Agreement extend beyond one year.
In consideration for the right to enter and conduct the tests, Company shall pay to City the
sum of twenty-five dollars ($25.00).
The undersigned is the authorized representative of the City, which is the owner of the
Property, described in Exhibit "A" and executes this Right of Entry for the purposes stated herein.
The rights reserved herein to the City may be assigned to a subsequent purchaser of the property.
Executed on the.;7 / day of f ;:./ , 2008.
CITY:
COMPANY:
By:
~tt, City Manager
I
9f Coppell, Texas
.
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By: /!/ti ;V(>,V' lilt Ie 051-
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Its: I~;lr/nlr /I-:} 1'./1-1--
Dawson Geophysical Company I
Cajun Exploration, L.P.
TM 25337.2.000
CITY'S ACKNOWLEDGEMENT
STATE OF TEXAS ~
~
COUNTY OF DALLAS ~
This instrument was acknowledged before me on the ,2/ #day of
2008, by Jim Witt, the City Manager of the City of Coppell, Texas, whic
property depicted in Exhibit "A".
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COMPANY'S ACKNOWLEDGEMENT
STATE OF TEXAS ~
~
COUNTY OF DALLAS ~
This instrument was acknowledged before me on the JELday of AI'~I,/ ,
2008, by 4.7" IJ~A.ut/r- , of Dawson Geophysical Company/Cajun
Exploration, L.P., on behalf of said limited partnership.
(Seal)
(::;'\!~)
SCOTT SEBASTIAN
, ),' ,'. " .Dlle. Slaleof Texas
'. '. (j'llmission Expires
.'C':.rer 21, 2009
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-............-...---
TM 25337.2.000
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Lewisville 3D Phase I
Permit 10
04-20-08
CJ Job Outline
... Sources
. Receivers
D Surface Tracts
D COP01
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DA SON
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ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (w.tIDDIYYYY)
111 03/03/2008
PRODUCER (432)571-4900 FAX (432)682-3863 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Stoltz and Company, Ltd. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
3300 North A St reet, Ste 1100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Midland, n: 79705
INSURERS AFFORDING COVERAGE NAIC#
INSURED Dawson Geophysical Company INSLflER A St. Paul Fire & Marine Ins Co
508 West Wall, Suite 800 INSl..RER B Travelers Indemnity Company
Midland, TX 79701-5010 INSlRER C
INSlRER D
INSlRER E
,.."', ,r:-... AGES
THE POLICIES OF INSURANCE LISTED BELOW HtlVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TIiE POLICY PERIOD INDICATED. NOTWITHSTANDING
mY REQUIREMEP\'T, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMEP\'TWITH RESPECT TO WrlICHTHlS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY TIiE POLICIES DESCRIBED HEREIN IS SUBJECT TO AlL THE TERMS, EXCLUSIONS AND CONomONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HtlVE BEEN REDUCED BY PAID CLAIMS.
~R ~~ 1YPE OF INSURANCE POlICY NLUBER POLICY EfFECT1VE PClUCY EXPIRATION LIMITS
GENERAL LIABIUTY VK04204074 01/01/2008 01/01/2009 EAOi OCCURRENCE $ 1,000,OO(
- 300, OO(
X COMMERCIAL GENERAl LIABILITY OAIW\GE TO RENTED ., $
^
I CLAIMS tMl:E [!] OCCill MED EXP (MY one per.;on) $ S,OO(
A PERSONAL & ADV IN..U?Y $ 1,000,00(
G8\ERAl AGGREGATE $ 2,000,00(
I-- 2, 000, OO(
GENt. AGGREGATE LIMIT APPLIES PER: PRODUCTS. COIoP/OP AGG $
Xl PCUCY n '1& nLOC
ALTTOMOBLE UABUTY VK04204074 01/01/2008 01/01/2009 CCM3INED SINGLE LIMIT
X- l Ea accident) $ 1,000,OO(
ANY AUTO
-
ALL O'vV1'€) AUTOS BOOIL Y IN.ulY
- $
SCI-EDUEO AUTOS (Per per.;on)
A I--
HIRED AUTOS BOOIL Y IN..tRY
- $
NON.{)Wtfl) AUTOS (Per accidert)
-
- PROPERTY DAA'AGE $
(Per accident)
R:~ AUTO ON!.. Y . EA ACCIDENT $
OTHER THAN EA ACC $
AUTO OM. Y: AGG $
EXCESSIUMBREU.A LIABIUTY VK04204074 01/01/2008 01/01/2009 EAOi OCCURRENCE $ 2S, 000, 00c
~ 0CClJl 0 CLAIMS MADE AGGREGATE $ 25,OOO,00(
A $
~~aE $
X RETENrION $ 10, 00< $
WORKERs COMPENsATION AKJ HHUB2161C3610J! 01/01/2008 01/01/2009 X I TVjfiyW~ I IO~
EMPLOYERS" UABUTY 1,000,00<
B N,Y PROPRIETORIPARThlER/EXECUTIVE E.L EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED? E.L DISEASE - EA EWLOYEE $ 1,000,00<
It yes. descnbe LIlder 1, 000 :roc
SPECIAl. PROVISIONS below. E.L. DISEASE - POLICY LIMIT $
OTHER
IESCRJPnON OF OPERATIONS I LOCATlONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAl PROVISIONS
E Job: Lewisville Phase 1
lanket waiver of subrogation on General L iabil ity, Auto Liability, and Work Camp policies as required
V written contract with respects to work perfonned by the named insured (5). Blanket additional
lsured on General Liability and Auto liability as required by written contract with respects to work
~rformed by the named insured (s).
City of Cappell
255 Parkway Blvd
Coppell, TX 75019
SHOULD AHY OF THE ABOVE DESCRIBED POLIClES BE CANCELLED BEFORE THE
EXPIRATlON DATE /HEREOF, THE ISSUING INSURER WILL ENOEA VOR m IAAIL
~ DAYS WRIT1EN NOTICE m THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATlON OR LIABlUTY
OF ANY KIND uPON THE INSURER, ITS AGENTS OR REPRESENTAllVES.
ALTTHORfZED REPRESENTA11VE
?tf<- ' .ttfr-
:ORD 25 (2001108)
Mark A Stoltz/JRB
@ACORD CORPORATION 1988