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HomeMy WebLinkAboutContract 51094 CONTRACT 140. RIGHT OF WAY ENCROACHMENT AGREEMENT (COMMERCIAL) THIS AGREEMENT is made and entered into by and between the City of Fort Worth, a home rule municipal corporation of Tarrant County, Texas ("City"), acting herein by and through its duly authorized City Manager, its duly authorized Assistant City Manager or Planning and Development Department Director, and 12 6',L / � E:!�!4 Asitx4AL if _[full legal name], a(n) L I L1 [type of entity] "Licensee", acting herein by and through its duly authorized n a A 4/1- [title], the owner of the real property located at �3 (0 2 17 la 10 Fort Worth, Texas 76 t) ("Property"). RECITALS WHEREAS, Licensee is the owner of certain real property situated in the City of Fort Worth, Tarrant County, Texas, more particularly described in the attached Legal Description of the Property; and WHEREAS, the City has a street, alley, sidewalk, and/or other public right-of- way(individually or collectively, the "Public Right-of-Way") adjacent to the Property as shown on the map attached to this Agreement as Exhibit"A" and incorporated herein for all purposes; and WHEREAS, Licensee desires to construct/place and maintain certain improvements which will encroach onto the Public Right-of-Way; and WHEREAS, City will allow the encroachment under the terms and conditions as set forth in this Agreement to accommodate the needs of the Licensee, NOW,THEREFORE, the City and Licensee agree as follows: AGREEMENT 1. City, in consideration of the payment by Licensee of the fee set out below and covenants and agreements hereinafter contained, to be kept and performed by Licensee, hereby grants permission to Licensee to encroach upon, use and/or occupy portions of the space under, on, and/or above the City's Public Right-of-Way to construct/install and/or allow to remain, certain improvements for the purpose of C 42 M it (whether one or more, the "Improvemen s") as escribed in and at the location shown on Exhibit "A" but only to ROW Encroachment Agreement-Commercial OFFICIALINCO CITY etcl the extent shown thereon. Upon completion of the Improvements, Licensee agrees to be responsible for maintaining the Improvements. Licensee shall not expand or otherwise cause the Improvements to further infringe in or on City's Public Right-of-Way beyond what is specifically described in the Exhibit(s) attached hereto. 2. All construction, maintenance and operation in connection with such Improvements, use and occupancy shall be performed in strict compliance with this Agreement and the City's Charter, Ordinances and Codes, and in accordance with the directions of the City's Director of Transportation and Public Works, or his or her duly authorized representative. Licensee shall submit all plans and specifications to the applicable Director or his or her duly authorized representative prior to the construction of the Improvements. Licensee shall not commence construction of the Improvements until receiving written approval by the Director, but such approval shall not relieve Licensee of responsibility and liability for concept, design and computation in the preparation of such plans and specifications. 3. Upon completion of the construction and installation of the Improvements, there shall be no other encroachments in, under, on or above the surface area of the Public Right-of-Way, except as described herein and depicted on Exhibit "A". 4. Licensee, at no expense to the City, shall make proper provisions for the relocation and installation of any existing or future utilities affected by such encroachment, use and occupancy, including the securing of approval and consent from any affected utility companies and the appropriate agencies of the State of Texas and its political subdivisions. In the event that any installation, reinstallation, relocation or repair of any existing or future utility or improvements owned by, constructed by or on behalf of the public or at public expense is made more costly by virtue of the construction, maintenance or existence of such encroachment and use, Licensee shall pay to City an additional amount equal to such additional cost as determined in the reasonable discretion of the Director of Transportation and Public Works, or his or her duly authorized representative. 5. Upon prior written notice to Licensee, except in the case of an emergency, Licensee agrees that City may enter and utilize the referenced areas at any time for the purpose of installing, repairing, replacing, or maintaining improvements to its public facilities or utilities necessary for the health, safety and welfare of the public or for any other public purpose. City shall bear no responsibility or liability for any damage or disruption or other adverse consequences resulting from the Improvements installed by Licensee, but City will make reasonable efforts to minimize such damage. In the event ROW Encroachment Agreement-Commercial Page 2 of 12 Revised 10/2017 that any installation, reinstallation, relocation or repair of any existing or future utility or improvements owned by, constructed by or on behalf of the public or at public expense is made more costly by virtue of the construction, maintenance or existence of the Improvements and use, Licensee shall pay to City an additional amount equal to such additional cost as reasonably determined by the Director of Transportation and Public Works or the Director of the Water Department, or said Director's duly authorized representative. 6. Licensee agrees to pay to City at the time this Agreement is requested an application fee of$325.00 in order to defray all costs of inspection and supervision which City has incurred or will incur as a result of the construction, maintenance, inspection or management of the encroachments and uses provided for by this Agreement. Licensee agrees to pay a fee in the amount of$.56 per square/linear foot of the encroachment area upon execution of this Agreement and annually thereafter. 7. The term of this Agreement shall be for 30 years commencing on the date this Agreement is executed by City. However, this Agreement shall terminate upon Licensee's non-compliance with any of the terms of this Agreement. City shall notify Licensee in writing of the non-compliance, and if not cured within 30 days, this Agreement shall be deemed terminated unless such non-compliance is not susceptible to cure within 30 days, in which case this Agreement shall be deemed terminated in the event that Licensee fails to commence and take such steps as are necessary to remedy the non-compliance within 30 days after written notice specifying the same, or having so commenced, thereafter fails to proceed diligently and with continuity to remedy same. 8. Upon termination of this Agreement, Licensee shall at no expense to City remove the Improvements encroaching into the Public Right-of-Way, and restore the Public Right-of-Way to a condition acceptable to the Director of Transportation and Public Works, or his or her duly authorized representative, in accordance with then-existing City specifications. It is understood and agreed by Licensee that if this Agreement terminates and Licensee fails to remove the Improvements and restore the Public Right-of-Way, Owner hereby gives City permission to remove the Improvements along with any supporting structures, restore the Public Right-of-Way, and assess a lien on the Property for the costs expended by the City in taking such actions. 9. It is further understood and agreed between the parties hereto that the Public Right-of-Way to be used and encroached upon as described herein, is held by City as trustee for the public; that City exercises such powers over the public right-of way as have been delegated to it by the Constitution of the State of Texas or by the Texas ROW Encroachment Agreement-Commercial Page 3 of 12 Revised 10/2017 Legislature; and that City cannot contract away its duty and its legislative power to control the Public Right-of-Way for the use and benefit of the public. It is accordingly agreed that if the governing body of City may at any time during the term hereof determine in its sole discretion to use or cause or permit the Public Right-of-Way to be used for any other public purpose, including but not limited to, underground, surface or overhead communication, drainage, sanitary sewerage, transmission of natural gas or electricity, or any other public purpose, whether presently contemplated or not, that this Agreement shall terminate upon 60 days' written notice to Licensee. In the event this Agreement is terminated under this Section 9, Licensee shall perform the obligations regarding removing the Improvements and restoring the Public Right-of-Way described in Section 8. 10. Licensee agrees and acknowledges that this Agreement is solely for the purpose of permitting Licensee to construct, maintain and locate the Improvements over or within the described Public Right-of-Way and is not a conveyance of any right, title or interest in or to the Public Right-of-Way nor is it meant to convey any right to use or occupy any property in which a third party may have an interest. Licensee agrees that it will obtain all necessary permissions before occupying such property. 11. Licensee agrees to comply fully with all applicable federal, state and local laws, statutes, ordinances, codes or regulations in connection with the construction, operation and maintenance of the Improvements, encroachment and uses. 12. Licensee agrees to pay promptly when due all fees, taxes or rentals provided for by this Agreement or by any federal, state or local statute, law or regulation. 13. Licensee covenants and agrees that it shall operate hereunder as an independent contractor as to all rights and privileges granted hereunder and not as an officer, agent, servant or employee of City, and Licensee shall have exclusive control of and the exclusive right to control the details of its operations, and all persons performing same, and shall be solely responsible for the acts and omissions of its officers, agents, servants, employees, contractors, subcontractors, licensees and invitees. The doctrine of respondeat superior shall not apply as between City and Licensee, its officers, agents, servants, employees, contractors and subcontractors, and nothing herein shall be construed as creating a partnership or joint enterprise between City and Licensee. 14. ROW Encroachment Agreement-Commercial Page 4 of 12 Revised 10/2017 LICENSEE COVENANTS AND AGREES TO INDEMNIFY, AND DOES HEREBY INDEMNIFY, HOLD HARMLESS AND DEFEND CITY, ITS OFFICERS, AGENTS, SERVANTS, EMPLOYEES, AND ELECTED OFFICIALS FROM AND AGAINST ANY AND ALL CLAIMS OR SUITS FOR PROPERTY DAMAGE OR LOSS AND/OR PERSONAL INJURY, INCLUDING DEATH, TO ANY AND ALL PERSONS, OF WHATSOEVER KIND OR CHARACTER, ARISING OUT OF OR IN CONNECTION WITH, THE CONSTRUCTION, MAINTENANCE, OCCUPANCY, USE, EXISTENCE OR LOCATION OF THE IMPROVEMENTS AND ENCROACHMENT AND USES GRANTED HEREUNDER, WHETHER OR NOT CAUSED, IN WHOLE OR IN PART, BY ALLEGED NEGLIGENCE OF OFFICERS, AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS, SUBCONTRACTORS, LICENSEES, ELECTED OFFICIALS, OR INVITEES OF THE CITY; AND LICENSEE HEREBY ASSUMES ALL LIABILITY AND RESPONSIBILITY FOR SUCH CLAIMS OR SUITS. LICENSEE SHALL LIKEWISE ASSUME ALL LIABILITY AND RESPONSIBILITY AND SHALL INDEMNIFY CITY FOR ANY AND ALL INJURY OR DAMAGE TO CITY PROPERTY ARISING OUT OF OR IN CONNECTION WITH THE IMPROVEMENTS AND ANY AND ALL ACTS OR OMISSIONS OF LICENSEE, ITS OFFICERS, AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS, SUBCONTRACTORS, LICENSEES, INVITEES, OR TRESPASSERS. 15. While this Agreement is in effect, Licensee agrees to furnish City with a Certificate of Insurance naming City as certificate holder, as proof that it has secured and paid for a policy of public liability insurance covering all public risks related to the proposed use and occupancy of public property as described or depicted in Exhibit "A". The amounts of such insurance shall be not less than $1,000,000 Commercial General Liability With the understanding and agreement by Licensee that such insurance amounts may be revised upward at City's option and that Licensee shall so revise such amounts promptly following notice to Licensee of such requirement. Such insurance policy shall not be canceled or amended without at least 30 days prior written notice to the Building Official of the City of Fort Worth. A copy of such Certificate of Insurance is attached as Exhibit "B" and incorporated herein for all purposes. Licensee agrees to submit a similar Certificate of Insurance annually to City on the anniversary date of the execution of this Agreement. Licensee agrees, binds and obligates itself, its successors and assigns, to maintain and keep in force such public liability insurance at all times during the term of this Agreement and until the removal of all encroachments and the cleaning and restoration of the Public Right-of-Way. All insurance coverage required herein shall include coverage of all Licensees' contractors and subcontractors. ROW Encroachment Agreement-Commercial Page 5 of 12 Revised 10/2017 16. Licensee agrees to deposit with the City when this Agreement is executed a sufficient sum of money to be used to pay the fees to record this Agreement in the Real Property Records of Tarrant County, Texas. After being recorded, the original shall be returned to the City Secretary of the City of Fort Worth. 17. In any action brought by the City for the enforcement of the obligations of the Licensee, City shall be entitled to recover interest and reasonable attorney's fees. 18. Licensee covenants and agrees that it will not assign all or any of its rights, privileges or duties under this Agreement without the prior written approval of the City, and any attempted assignment without such written approval shall be void. In the event Licensee conveys the Property, Licensee may assign all of its rights and obligations under this Agreement to the new owner of the Property, and Licensee shall be deemed released from its duties and obligations hereunder upon City's approval in writing of such assignment, which approval shall not be unreasonably conditioned or withheld. Foreclosure by a secured lender of Licensee or assignment to a secured lender by Licensee in the event of default or otherwise shall not require City approval provided that said lender notifies City in writing within 60 days of such foreclosure or assignment and assumes all of Licensees' rights and obligations hereunder. However, no change of ownership due to foreclosure or assignment to any secured lender of Licensee shall be effective as to City unless and until written notice of such foreclosure or assignment is provided to City. 19. THE PARTIES AGREE THAT THE DUTIES AND OBLIGATIONS CONTAINED IN PARAGRAPH 8 SHALL SURVIVE THE TERMINATION OF THIS AGREEMENT. 20. Any cause of action for breach of this Agreement shall be brought in Tarrant County, Texas. This Agreement shall be governed by the laws of the State of Texas. 21. This Agreement shall be binding upon the parties hereto, their successors and assigns. ROW Encroachment Agreement-Commercial Page 6 of 12 Revised 10/2017 [SIGNATURES APPEAR ON FOLLOWING PAGE] ROW Encroachment Agreement-Commercial Page 7 of 12 Revised 10/2017 THIS AGREEMENT may be executed in multiple counterparts, each of which shall be considered an original, but all of which shall constitute one instrument. City: Licensee: City of o ort By: wa- - By: C_C,C Randle Harwood Name: LA4 Nor Director Title: -621Wf V-'e — Planning and Develop ent Department Date: , 20 (02J Date:��� , 20 f ?� 4 ATT ST: 011 'may roved As To Form and Legality itys' ec Assistant City Attorney 7 Contract Compliance Manager By signing I acknowledge that I am the person Responsible for the monitoring and Administration Of this contract, including ensuring all performance And reporting requirements. 2 W 014A Janie S. Morales Development Manager OFFICIAL RECORD CITY IIi6GRETARY FT.WORTH,TX ROW Encroachment Agreement-Commercial Revised 10/2017 "THIS PAGE FOR CITY OF FORT1 ' OFFICE USE 1 STATE OF TEXAS § COUNTY OF TARRANT § This instrument was acknowledged before me ar>z:-_Aje , 201 by Randle Harwood, Director of the Planning and Development Department of the City of Fort Worth, on behalf the City of FortW f N Publi , Sate of ex 5 'A"vnfli JENNIFER LOUISE EZERNACK -,Notary Public,State of Texas Comm. Expires 03-01-2020 fill',��.� Notary ID 130561630 ROW Encroachment Agreement-Commercial Page 9 of 12 Revised 10/2017 STATE OF TEXAS § COUNTY OF TARRANT § BEFORE ME, the undersigned authority, a Notary Public in and for the State of Texas] _ o thi day personally appeared Pb ��' TA m✓)0 w f Ef— (title), known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me th he�lhe executed the same for the purposes and consideration therein expressed, as the act and deed of a , and in the capacity therein stated. GIVEN UNDER MY HAND AND SEAL OF OFFICE this`'d'` ay of ,P 20 PVe`�?���� - Co gym: OF Notary Pu n and or %7.4ES 04-Za State of After Recording Return to: City of Fort Worth Planning and Development Department CFA Office 200 Texas Street Fort Worth TX, 76102 ROW Encroachment Agreement-Commercial Page 10 of 12 Revised 10/2017 METES AND BOUNDS OF THE PROPERTY ROW Encroachment Agreement-Commercial Page 11 of 12 Revised 10/2017 .;v` 164 :L 090 OWE P 11i, AVE. o 10S.7" N&9oi81 a ,V Q qo �, ;� I• �i 15 191 Imo, ,Strrc'-, �, w _. 89°08 4 150.13 Q 14 "000 K �. g2ZA0 I k:e�.iu 4.Ot � p CLOSE in OR w of piMICATEO Oft PRAINAafi RO,W. 4,-R r ses�a7� Llry. I ws'y�; Tr_ t. Q A I` R=pp FAS B t .t b ./r RAE 31 0, n �. app LzQa*,49i N (h •}1Q/�+4(y ~ -•.J T:127�W , Vxly p V C /V fAS�MNT 'Y ! EXIST.SAN. ._ F SEWER .. i+ '`RYAN .SOUT`HEAS`T ''ADDIT.IONr �+f'• 6 , ` • k Ar'yr,,.il'Rn. t.� - W. -�i.h ..t .f ,iTjQ,t ixt "Vin, Ll C? ICTION t ''Yti7�RUctUQ¢tG64EIio.= � `tltaYTPR" cCeeama'=�� j'DO HEREBY CERTIFY THIS 4 INI►EIOHT, 95iN9'f00ro4op N a � AUT'NOTLIMITE01 PfjAT TO 9E TRUE AND . .aIFtI�Ia e ►Y+yLU3 lbFr +c� sl+ Ias utast;R t _ jt' E jr�g[ (O'4;I:Atd0NSfFINCT9O4& C6RREC7 AS`SURVEYED ON TH[; GROUND, • '' b PE, 8 f A• rAD NOWN?CN TNIS PLAT • � �<. q � �dl' .N���� xj�CITYIC�IC�O Tt4,.c� ,� .. K�. ctTY;�LAKt41M1�sIDNr hk PLAT OF .s'g ox ttiyy #r �+,*, TrA . Pt r�fsrrwtT,Is':j+aLla'© t i�coaaEa WITS yLa O T S 4-R, 5- R, rel 9- R f ►�� six-Ia s P>{eaiaA t ij�+AL� '+ y RAih�r s.sWi .l BLOCK 14 t...»i............... PLAT`tP�AOVEa } 9 23998 MONT ADDIT.IOU" r' _'NO I` - s "K2{•t;1, `i+i4`�{, 'i A REVISION OF » etJb'BUII'ANYDINO P£AMif NA1 Li4 IB�Ufr " a i T HR U .5 5 6- TH U. 13 R er 7 MADE FDR THE CbNS7RU 11 {AQfhI 14 IF Misr WATER;'SEWER 8TdRM`D1YA) 7R ON A PORTION OF TRACTS UT F A ' 4 -ytAND PAVINOIMI'ROVEMEN71A r,. Htt ety '1 THE D. DULANEY SURVEY #igBTAiNt0'fAmE°UYf?0[sfOR;r31!dt�� r :, s`"•.,.xLl4 ti +rp,:.? ..��,.JS'}.',:�= 7n+j s. . r 1'O,t� WORTH TARRANT COUNTY 7�E•S�AS . ,.•. r-,..;E.at1. .:.3,i }..,.o-,+�"1x.sw J r'�e .�+ RA��*b ' '� Il:' T{�tHQi57' T.J, .1.: ��J;oC"'t :t a o� �� 4, z :F' WIF'T;.: �#�r'' ?�a�,krc� ,. _R t A Yf q"'X J 7t1 � • NCikEf A - 8EL" QN ,t igDD.1:TlON :Y�CbT IFFY .CENTER Rig` `, YfOR1N ` TEXAS" 16!02 Fll.f of t,. .�� a ,- r °� +• .. "'� y• rti..,.� r :vA-- i ry .,'I+, b rr _` ,+J t EXHIBIT "A" Location and Description of Encroachment and Improvements ROW Encroachment Agreement-Commercial Page 12 of 12 Revised 10/2017 M w a U Z Z LL M U 2 O �w U 4 U S w N W �J :max,• a Mr+.;k.,:t+,is�y+lp�Mr'Ml•x�ata+Hw¢x�r •� � m a U U IL T W 4 p CL aC a r -' rl u c Z Lj w N r U = cr U L7. -F K >. 4A w �. J W a ¢ p IL J - } W a U Z Z w O w U O p Z w N Q r z a U to a F'` Fw5 i w I a E t Z P S Z 11 �x •.Y �' id.• W C ly mj'oo BN. W � N O a wud„aB w 1 WJ Lw W w W W LL Q Park of yu",so LZI � O W LLJ Q O U J s = a & U W C� w a w a j a N w cr o s Z 1 w p y�. x aaylvu�A � Z W J W } z a z (H O Z LL LL �� H J W F— Q��ul O U Z� Q-- O w� n I SOUTH RIVERSIDE DRIVE 5 00' 53' 00" E 100.00' 5 00' 53' 00" E 50.01' I I u1 Q>OC ,Joh N < z� �sH 9 w o m�WJm o F a I I z er Y1p� W � � WYE Lu LuIL� a W L4 waW �-0 zaaCLm Lu u Nr L N — — u- L o �, W O �W� O -4WS g $(v La O �— O cv, — O O W N O O La 6 co N 190'091 3 „00 M, .00 N W 0 0 �n 0 N CERTIFICATE OF LIABILITY INSURANCE DATE/2512018 Yi c72io1 e 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. if SUBROGATION IS WAIVED,subject to the terms 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 NAME: r SUSAN HEDARY RAINBOW INSURANCE AGENCY P11oNE _. .. _.— FAx Nr•.s`�l 2929 CLEBURNE RD EMAIL A6DRESS;,..EAlNBDWNS QTMNLL-QQM�___.—.-._.—.__......._._.. FORT WORTH TX 76110 INSURERISi AFFORDING COVERAGE NAIC x ...._�._�..�..�_:_ ......._..._. ............_ .___... .._�..._._ INSURER A: MOUNT VERNON FIRE INSURANCE COMPANY _ INSURED ABDEREL-NAMED INS uReRe. __ _ DBA AYE&ASSOCIATES LLC. +NsuRER c 6001 MILLWOOD DR. tNSURERD: ARLINGTON TX 76015 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOIAJ HAVE BEEN ISSUED TO THE WSURED 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. tNSR'.�_....�..."...'—. ....POIiCY EFF POIiCY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER 041MfODfYYYYY NiM1DOtYYYY GENERAL LIABILITY ! EACH OCCURRENCE I OG �_. X COMMERCIAL GENERAL LIABILITY PRFMISEs(Fa cs u enceti 3 O 00 1 CLAIMS MADE X E OCCUR � IVED EXP;Arr,cane persor: 3 15,900.00 A ! IAGL018L94Y7 0712412018;07f24I2019 PERSONAL.s Acv INJURY ; 1,000,00Q.00 ,_ _..... ......�__�... __. �_._., .. .... GENERALAGGR GATE . 2.000:000.00 GEN L AGGREGATE UMiT APPLIES PER PRODUCTS•C IP CIP A,G 5 jNCLUrJED POLICY PR T I I LOC _ AUTOMOBILE LIABILITY I i A'ltel tN SINGLE L+6°iT ..._ 17 ANY.AUTO ! i BODILY INJURY Pe,pqrso S ALL OVANEO SCHEDULED ._;AUTOSi AUTOS I I BODILY M'URY(Per a=der) 1............ FRQPE'7DAMAGE DrrG`c .— ....._. -.�._... ._..._ ';. HIRED AUTOS AUTOS! NON-OWNED UMBRELLA LIAR OCCUR EACHOCCURRENCE 2 EXCESS LIAR ._. _ 'lAGGREGATE ( DED RETENTION$ 3 'WORKERS COMPENSATION ( I �'JC STinTU i AND EMPLOYERS'LIABILITYY t N `. CRY..IL1iTz EK ANY PROPHi--TCR,PARTNER1EXECUT7VE � E L EACH,ACCIDENT �OFFICJMENBER ExC UD'G7 ._........—.. ........._...... (Mandatary in NR) E.L.DISEASE F.A EM? OYES S ........__ . ..._ . .._...._. �_..... ' it yes,describe un:,er � I niz SCRIP nc OPERATION' gnu. ; E L PISEASE POLICY LIMIT 3 I I DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) PROPERTY LOCATION: 2368 S.RIVERSIDE DR, FORT WORTH TX 76104 PROPERTY LOCATION: 2374 S.RIVERSIDE DR, FORT WORTH TX 76104 CERTIFICATE HOLDER CANCELLATION CITY OF FORT WORTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PLANNING&DEVELOPMENT-CFA OFFICE ACCORDANCE WITH THE POLICY PROVISIONS. PN 1 S-00045 A IZ REPRESENTATIVE 200 TEXAS ST, FORT WORTH TX 76102 r —VTVEr201b*d'0ftbC0RPbRAN. All rights reserved, ACORD 25(2010/05) The ACORD name and logo are registered marks Of ACORD