HomeMy WebLinkAboutContract 35142���Y �����������1 �
CONTR,4�T N(� .
CONSENT AGREEl�iENT
FOR
TEIvii'ORARY USE OF PUBLIC PROPERTY
STf1TE OF TEXAS
COi1TiTY OF TARRANT
THIS AGRF,F1bIF,NT is made and entered into hy and hetween the City of Foi•t �Vordl, a
municipal corporation of Tairant County, Texas, acting herein by and tlirough its duly attthorized
Building Official, hereinafter referred to as lhe "Ci[y" and
�a¢r W 6 2'r4-1 H PFa �il�lt.►2S
Acting by and tl�rough its duly aut(iorized agent, 1�2i1�N p���
Hereinafter referred to as "Grantee".
W ITImTES�ET�:
For and in consideration of tlie payment by Grantee of cl�arges set out below and the true and
faithfi�i per•fiormance of the mutual covenants herein contained, City iiereby grants tn Grantee
permission to tempoi•arily encrolch upon, uses a�id occupy portion of the space l�nder, on and/or
above the streets, alleys, sidetivalks or other public rights-of-way as follo�vs:
5T" S�rzr�r 1 i�anlE� (9�" 5�2c� or�i�. t��vt �u��,�:
(�1U CcamY�Rc.� 5i .
The locatinn and ciescription of said enecoachment is more particularly described in EYliibit "B"
attachec! hereto, incorporated hei�ein and made a pat-t hereof for all purposes.
2.
All iise and occup�ncy of p�iblic strcet, alleys, sidewalks or othej• public rights-of-�vay under
this aareement shall be in strict compliance with the Charter, Ordi�lances and Codes of the City
and in accordance with the directions of the Building OEficia( and the Director of Transportation
and Public Woi•ks of City.
.� �,,� ^. L,i
�� ,,�j�',��j �� ` � �
1y '�. 2 �rI1 �,,I•�� j ,`�U\,1 A.
CONSENT ACRE�dAENTforTemFnrary us� nf pubGc prope.�yt dq�j i J � e.
1�I
a j'J11`I 1����>S �`,i!?pu;
P '`.. L `y c�1f�L^��( �
� ;�:i:'�"��'11.;n�i �;�,�:�
��� �f�o ..: `J�+�• �
� . � ���„ _ -. -. . . . . . ._-
3.
ITpon expiration nf this a�•eement and the privileges granted hereunder, there shall he vo
ena•oachment by Grantee in, tmder, on or above the surface of the public rights-of-�vay invol��ed.
�.
Grantee agrees to pay in advance an encroachment fee foc the temporaiy privilege of
encroaching upon a portion of the public rights-of-�vay as descrit�ed in Exhibit "B". Said fee is
calculateci in the manner And amoimts prescribed by tl�e Bui(ding Cocie of the City of Fort Worth
tor temporary use or occupancy of public property. The estimated total amouni of said fee is:
5�"' , �o' x �oo'� �ro �YS x�� _� 1��2 I o���
(�TM ; 1 O � 7c I OC7 � +r �_I�F��� x� �9� =_g �1'6�.� —3 ( a �9 ----
,03 ta$g� �'��(�o
g.
Grantee, at no expense to City, shall make proper provision for the relocation and/or
installation of any existing or future t�•af�c cont�•ol devises or other imp�•ovements affected by
suclt encroachmenf, use and occupaucy, including the secttring of approval and consent from the
appropriate agei�cies of the St1fe 1nd its political stibdivisions. In the evelit that auy iiist111ation,
reinstallation, relocation or repair of any e:cisting or firture traffic control device or improvement
owned or constructed by oi• on behalf of the pub(ic or at public eYpense is ma<le more costly by
virtue of the eYistence of siicll eiicroachment and use, Grantee shall pay to City 1nd additional
auio�mt equaf to such aciditional cost as determined by City.
b. � ���
�tt� Jr>�>�/
The term of this agceement shatl be for �}� days, from _�flN �_ to _ Mlil� �,�
Provided, however, should the need for the encroachments granted heretinder at any time cease,
Grantea lgrees to immediately notify City of such condition; and, upon receipt of such notice by
the Building OfCicial oC the Ci�y of Fort ��ortli, tl�is agreement sl�all tecmiiiate. ,
i.
It is expi•essly understood and agreed tltat tllis Consent A�reement is for a temporary
enc�•oacllment in, ui�dec•, over and upon the public propec•ty as located and described in Exhibit
2
CONSFNT AGRFFPAFNT*or Tempoiary use of public propertyt .dec
"B". This agi•eement shall not be construed as the granting of a permanent easement,
enccoachment or license upon City's public streets, al(eys, sidewalks, oi• othei• riglrts-of-�,vay.
�.
City, throiigh its duly authorized representatives, sliall have the full and tuu•estricted right to
enter upon all public rights-of-tivay for the purpose of making inspections to determine
Compliance with Yhe terms, covenants and conditions herein. In the event that any inspection
should reveal a Ureach of any terms, covenants or conditians hei•ein, City shall gi��e Grantee
noCice of such breach. Shoald such breach nol be correc[eci by Grantee within twenty-four (24)
l�ours of receipt of the notice, or within sucl� shocter period of time as deemed necessa�y by the
�3uilding Ofiicial for the protection of public health or safety, City may terminate and cancel this
agreement.
9.
Upon eYpiration or termination of this agreement for any reason �vl�afsoever, Grantee shall, at
no espeuse to City, restore the public rigt�ts-of-�v,ay and adjaceut supporting struchu�es to a
conclition acceptable to the DirecCor of Trans�o��tatio❑ and Public Works or his dnly authorized
representative and in lccordance �vith then existing City specifications, and Grantee shall remove
all barricades, equipmeirt, supplies, materials or other property from said location. Urantee
further covenants and agrees that for a perioct of one (1) year after the termination of this Conserrt
Agreement, Grantee will repair all conditions or damages to the sti•eets and siciewall<s or otiier•
rights-of-way that have resulted from Gt•antee's use or occupancy of the st��eets and sidewall<s or
other rights-of-way, 1s determiued by the Directo�• of T�•ansportation and Public Works or his
designee. Gra��tee agrees to begiu such repairs within tkiirty (30) days of receipt oF uotice fi�om
the l�irector of '1'ranspot�tatiou and Public Works or his designee. A(t repairs shall be performed
in an espeditious and worl:manlike manner and sliall comply with 2ll �pplicable laws, codes,
ordinances and City specifications.
C�i the event tliat Grintee fails to compl}� 4vith the covenants herein containeci wifh respect to
such rertioval or restoration, the City shall have the riglit to reit�ove or dispose of any barricades,
equipnient, supplies, materials or other property and repair any conditions �vhich in tlie opinion of
ti�e City are necessary to 0ring the public rights-of-�vay to the condition pi•escribed herein, and
City shall not be responsible for trespass or any other damage or liahility ii� connection with such
removal or restoration. Gratrtee shall reimburse City for the cost and expense of such cemoval
anc!/or replirs iinmediately followiiig billiiig for sa}ne by City.
3 CCNSE�ffr�GREElAENTfarlemrorary�.ise�tpub!icproperiyl'oc '-:� ; ,l pi � J.��',�
'��_,r���,�:�,.�,.�5�����,,
,, ,, r �, �� ; 't� '� S`�
t,' �,'; ��� �iV�i_.!l;�!.
�;� � � ���,� ,�.
2q~`�U �',���r
Ir ;'.;' ;�' iJ; � I�; i �.2 G�� �
� •...
���—
Nothing herein shall be construed as a waiver by City to enforce penal sanctions prescribed
by the Code of tl�e Ciry of Fort Worth and the laws of the SYate nf '�exas for Grantee's continued
encroachment npon the public rights-of-�vay following termination of this Consent Agreement.
10.
It is furthei• tmderstood and ag��eed beriveen the par-ties liereto that City holds tlie city streets,
alleys, sidewalks and other public rights-of-way, including the portions of such streets ��sed and
eiicroaclied upon as described l�erein, as trustee for ihe publie; that City esercises such nowers
over tlie streets as I�ave been delegated to it by the Constitution of the State of Texas or by the
LegislaCure; and the City cannot contract away its dnty and its legislative power to conti•ol tlle
streets for the use and beneiit of the public. It is accordingly agreed that if the governing body of
City, to wit, its City Council, shall at any time during the term lieceof determine in its sole
discretiou to use or cause or permit to be used For any public pm�pose the said encroached portion
of the streets, then this agreemenl shall be autorrialicllly canceled and terminated.
11.
Grantee agrees to comply ft�Uy with all applicable federal, state and locai laws, ;tatutes,
ordinances, codes or regulations in connection with the consh•uction, operation and maintenance
c�Psaiel ei�croachments and uses.
12.
Grantee agrees ta pay promptly �vhen due all fees, taxes or rentals pi�ovided f�r by this
agreement or by any fedei-al, state oc locai statue, law or regulation.
13.
Crantee covenants and agrees that it shall execcise all rigl�ts and privileges granted hereunder
as an iildependent cont�'actor, and not as an officer, agent, se�vant or employee of City; that
Grailtee shall h�ve exchisive control of �nd the exclusive right to control the cietails of its
operations ana activities on sai<l described public property and all persons performing sanie, and
shall be solely responsible for the zcts and o�nissions of its officers, agents, servants, employees,
contrlctors, subcontractors, licensees and invitees; thlt the doctrine of res}�ondeat superior sha(1
not apply as between City and Grantee, its ofiicets, agents, seivants, empioyees; contractors and
subcontractors, and nothin� herein shall be covsYrued as creating a partnership or joint enterprise
bet�veen City and Grantee.
4
CONSENT AGREEMENTfc; Temporery use cf public prooerb/t.doc
i �d.
GRAl�TEi �aVEi�IAio'i'S AND AGIiEE� TO 1�IDE�i�i%'�', at�ID D�ES HEREB'Y
�i�1I>EMIP'3C, �O�,D �iARMi�ESS A�1� DEFENI9 CITY, I'i'S O�FI��R�, �GE1�1T�,
�E1�i�AtaITS riit`ID ��L1PL�i'EE�, FROM :�"dI� ti�GAI�atST APd� E1IoIi) ALi, CLAI�t� �I�
�UITS FOR PROP�RTY DAi�IAGE OR LOSS A�1Ii/OR PERSt)I+1AL I�JU32�,
�1°1CLUDING DEATH, TO APd-'I AND AI,L PERSOIv�, OF 1�HAT�OEV�1� K_IN� (�R
C�ARACT�12, �V�I�T��ER REAL 0�2 A�SERT�lj, ARI�Yi�iG OUT OF OR �t
�OI°t��CTIOAi WITH, DIFBECTLY OR Ii`VDIRECTLY, TH� IYIA1PdTEI�A�ii��,
OCCUPAI�l�Y, �JSE, EXIST�l�tCE 012 LOCATIO� C)I' 5AID EI�ICROACHIVIENi Ai�
USE� GR:��TTE�D HERiU1�IDER, WH�THER OR �OT �AUS�, i�T �VHOL� OR PAat`I',
�3'Y ALLEGEii �IEG�IG�I�tCE OF OI'I'IC�RS, A��i�I'TS, S�iZVAiiITS, ��'IPLOY���,
�CO�1Tl�C'�ORS, �iJBCONTRACTORS, I�I(:F,iV�EF� OR Ii+IIV1TEES OF' CIT�'; AI�TI�
GRAN'I'E� H�12�BY A��Ui�IE� ALL LIl�L'1LITY AI�ID R�SPOt��IBiLITY fl� CI�'�',
IT5 O�'FIC�TdS9 AG�I�JTS, SERVArtTS AIVD Ei�/IPLOY�]C5, I'OR SUCH CLAIP✓I5 flIZ
�UIT�. GRAI�ITEE �HALL LIKEbVi�E A��UIb1E EiLi, Ll:'�BiLi'I"Y Ala1ll
i27CSP�N�I�3ILI'I'3t AP+i]D SHALL INDEIYiPIIFY C�Ti' FOR A�Y AI'dD �LL g1itJ�JRY OR
�A;y�A�E 'T'O CITi� PR�PERT�', ARI�II�U OUT OT OR Ii�] COAIIV�CTIOI�i �s1ITH
AAdY Ai�1D ALL A�T� OR OI1'IISSIOIiTS OF GR.4�I'd'L'E, iTS OFFiC�R�, AG�I+IT�,
��ItVANTS, E1�ZPI,�Y�ES, COIVTRAC'TOR�, SUBCO�TI2ACTORS, LICESI�IE��,
INVITE�S OR TR�SPASSERS.
I 5.
Grantee agrees to furnish City with a Certific2te Of IriSLICAt1CO3 n;tming City :Zs cet•tificate
holder, as proof that it has secured attd paid for a policy of public (iability insurance covering all
public risks related to the proposed use and occupancy of public property as loc<lted and
described in Exhibit "B". The amounts of such insura�ice shall be not less that the follo�ving:
Property damage, per occtu•rence $100,000.00
Boclily inj�n�y, per persou 5250,000.00
Boclily injury or death, pee occurrence �500,000.00
WiYh the understanding of and agreement by Grantee that such insurancc amounts sh211 be; revised
upward at City's option and that Grantee shall so revise such atnount immediately following
notice to Grantee of such requirement. Such insurance policy shall provide that it cannot be
canceled or amended without at least thirty (30) days' prior written notice to tlle Bui(di}ig O�cial
5 CONSEYT AGREE?AEMTfar Temporary uee r,f puF.lir. pmperi�/1 dnc
of the City of Fort Worth. A copy of such Certificate of Insurance is artacl�ed as Exhibit "A".
Grantee agrees to submit a similar Certificate of Instu•ance ai�nually tn City nn the anmver•saiy
dltc of the execution of tl�is agreement.
Grantee, agrees, binds and obligates itself, it successors and assigns, to maintain anc3 keep iu
force such public liability insurance at all times duri�lg the te�1n ot this agreement and until the
removal of all encroachments and the cleaning and restoration of the city streets. All iusurance
coverage required herein shall include coverage of all Grantee's contracto�;s.
16.
Grantee covenants and agrees that it will not assign all oc any of its rights, privileges or duties
�uider this contract without prior written approval oPCity, and any attempted assignmenl without
sucll prior written approval shall he void.
17.
This agreemeut shall be binding upon tl�e parties hereto, their successors and assigns.
1 S.
5hould any lction, whether real or asserted, at la�v or in equity, arise out oP the terms and
conditions of this a6reement or out of the use and occupaucy of City property as permitted
hereunder, venue for said actiot� sh111 be in Tarrant Counly, Texas.
]9.
In any actio�� brougl�t by City for tlie enforcement of the obligations of G�antee, City shall be
entitled to recover interest and reasonable attorneys' fees.
E�CECUTED this ay day of JiA►J__ __-------° 200 �
GRANT�R: GRA
CITY OF FORT WORTH
,�iG�i/ ✓ �
s�"fj( ' B«ildi g Official
;
(�2i� P��2
P�����
-rit�e
� � � , 1 � , � `.
CONSENT AGREEPdENTfor Temocrar/ use ot Fublic prcpertyl de� �';' r ��� ��,: i, t� IS J��i J;) �,
�; �1�,� ;,�'��'�;'��,!��,C,.
L:; '� ��, � V 1•. ��: �:'u`
.:�,:��'ijJ �'R9
��� '��.i:'.'.�;1:C1� �LG�:a
i
APPRO O �1 AND i.FC'sALTTY:
As � tant C Attorney
City Secretary
�� ��C� �ia�'������
Date
�
! 1, � _ . ��
COMSENTAGREEMENTforTempm�ryuseoiFu6ifcpropenyt�od,-'•,� ](� p�ri�"�'^�f ''�
''t��'J'v�E''�� 1i�v�J�,J
fJ .
,' .1p .,�I .��1 �'I(_�il 1.�!•1 f�,�,,1�
`� J d,�'' c' �'ts ..: � u;-:'�.. ��
� -r,::l�_r,�U n� p:,
1�0 `:`!`�' ';l� u155'�,�
i_ ._._�---�:..:......
STATE OF TEXAS
COUNTY OF TAR1tANT
BEFORE ME, the undersigned nuthority, a Notary�Public in nnd
For tf�e State of Texas, on this �lay personaldy appearerl �'-1ci.�� %
� 1 ���� � � ,known to me to be the person whose
name is subscribed o tlae foregoang instrument, and acknowledged to me
thnt he/she execute�l the same for th�p u�rposes�!gnd cansideration therein
expPessed, as the act and tleed of f�fii •/� L✓'����l�!!� ,
and in the capacity therein stated
GIVF.IV ER MY HAND AND SEAL OF OFFICE thic �— rlay
of , 20� . �
� ��f
/ �, �,
Af�t�nt � ,
�1 � ,c�,
T�rle '
�-� � �
��
.� Natary Public in, and for
The State of Texas
rj = ,,;;;�;r��,,,, =�—T.=—It G. NAREZ �
; � =!'. . c� ,;. •
'� ; =,F �'i •;�' = Notary Public, State of Texas �
- , f;`6,`�,.�; My Commission Expires
�''%��nF���•'' Sepf�rrlbe� 10, 2009
�,,,���„
;9
�'�'ATE t��' �'EX,4�'
�:'��Il��'�' ��' TAR�A1�1'7'
E�'FORE I�IE, tfte ccndef�sig�te�l ructhot�ity, a 1Voi«fy I'ciblic iya anrl
�'of' i{ae Strcie of 7'exrrs, ott this �Ircy peysotaally tippet�rerl
�iZf�� PA"�EL ,letaoivn to tne Po be Phe person �vlzose
ntenie i�s szsb.scriberl 10 �`lte foregoitag insircranenP, an�l recktaotivderlgerl to »ze
th«t he/s6ie e�ecuied Plte same fot� ihe purposes rrnd co`asidef•rr2ion 2laeYein
expt�esserl, as tlae uct nnrl �Ceed o� FoQT WoR� W P►a'�TN�S y
�ry�d rn ilte ct��acity t6rerein stated.
�YYI
GIITF'TiT ZI1�JD�R NlY hTAND �1.ND ,iEAL ()F �F'FICE tlti.� 2`� -��«y
of SAYll1�U�Y , 20�..
A ttfzt
�� � l� i li
7'itle
,'t_
�..
�Uunq� F
�,��a� rue�,� NENAL PRAFULL SHAH
�_,• '�"= Notary Public, State of Texas
My Commission Expires
:�;tFn��E:�`�� SAptefTlbef 20, 2009
nuw�"
Y�
1Vatnty Prtblzc fn «�z�Cfof�
Tlze ,State of �'ex�s
0
" "f �d"' �'s`,t I��;Sf�'r'l,;�f;;
v �J��`. . V`:%
� �"'�-,i'1 nli 0��?
kr'�� \% '`;I�2P ;�lL �!?!.'��:
�:JJ� G c :�'
n
`�R �;:;,J'n"��.. i fifi i \
c �
�I i
Y Ua .'':J'i.U'il�� 15G5;o
��� � ��-- �
������, �����
,� , ;,_, �, :� � �,� ,
� t`dIV��1i���.' i i � � ��
�
iv�CJRE rNAN 3 DA�"�
SiD�WALKFFE �E� �,c� � �
�iRFF�c �FF __ - — -- - _ �;_,� ;
�,
�
5TM S-�ne.�.'t-
�!— 1 � 1-10�
d0�) ��.:.f�-�_
�� � I
iaa �
�� �
�����'����� � �«�
Contractors Name: (�
Point of Contact: � �i
Phone Number: — '-� " - ci
Building Peimit Number:_ � � -`� . �
Purpose for Clos e: >�' G�� ��'�-
Begin Date: / e���_ End Date: %� (l ��
Type of Taper according to posted speed limit:
Tapers @ 30 MPH 10ft Offset 30ft minimum
Tapers @ 35 MPH lOft Offset 35ft m;n;mum
Tapers @ 40 MPH lOft Offset 40ft minimum
� .��SS
+ >;�Y�: -
i.>'YS ----- _ -
,�f' `���� �' ' �. � �
_ - ��
(�_:'. �' ' 9 ' n`_ 4� sy� �j �YL� . . . '_ — � f}/4f��( ��
; �' � i y � '� t�' � 1�:� �' k � � = � `� � Ar � �,., ��, �,. •
r} �; � r; �� � El � r�.�r r r� +�RRI�,RS OR �RCT��Tc ��,
,��,, ` P� t',.
- --- SYNEPRO-01 JOVI
' p0.TE (MMIDDlYYYY�
412412006
�_��r� CERTIFICATE �F t—��B��-��Y�sNSURAN'�UEDASAPONTHE�ERTI�ICATEI��
(916) 231-1741 p�,(LY AND CONFERS NO RIGHTS U
pRODUCER HOLdER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Acordia of California lnsurance SeNices, (nc. qLTER THE COVERAGE AFFORDED BY THE POLICIES BEL.OW.
CA DOI LIC #0352275 NA1C #
11017 Cobbterock Drive, Suite 100 _ —
�Rancho Cordova, CA 95670 i INSURERS AFFORDING COVERAGE i --
American Zurich Insurance Company _k4��42
INSURED PRL Investments, Inc.
P.O. Box 94265
Lubbock, TX 79493
INSURER A
iNsuReRe American Intemational Specialty Lines
INSURER C --"
INSURER 0. _--
inlSURER E�.
COVERAGES
UBJECT TO ALL THE TERMS, EXCLUSiONS AND CONDITIONS OF SUCH
DITION OF ANY CONTRACT OR OTHER DOCUMENS WITH RESPECT TO WHICN THIS CERTIFICATE MAY BE ISSUED OR
THE POLICIES OF INSURANCE US NED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTAND
ANY REQUIREMENT, TERIv1 OR CO
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREI uMirs
—_� _ I POLICY AFF�ECTIVE POLICY EXPIDD TION �,OOO,OI
POLICIES AGGRcGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLA��4
iucd�ADD'l� ___........,�.�r-c � _ POLICY NUMBER 5 —
i , EACN OCCURRENCE
cENew+� uasiurr
A I X I X'�, COMMERCIAL GENERAL LIAB�LITY
�— X occuR
. � CLAlIv1S MNGE I`J
�I-- — —
�I I—J — . 5 PER�
� GEN'L AGGREGATE LIM.IT APPUE
—�
�— i JECT I X j LOC
i I POLICY �
�I I �AU�TOMOBILF L�AB�LITY
/� �, ,' l� I ANY AUTC
�
'I �i �� ALL ONJNED AUTOS
r—
�SCHEDULED AUTOS
���
iI,I I%'� FiIRED AUTOS
i � � X I NON-OWNED AUTOS
I, —11
—J —
I
�I �I� GARAGE LIABILITY
, I �I ANY AUTO
P0378531201
�TAP591563101
EXCESSIUMBRELLA LIABILITY ig746421
B � �X � OCCUR I,� CLAIMS MADE �
�'I �
� OEDUCT18LE
i X' RETENT�oN s 10,000�
WORKERS COMPENSATION AND ��
� EMPIOYERS' LIABILITY
�! ANYPROPRIETDWPARTNER/EXFCUTNE
; OfFiCEWIJ�EMBER EXCLUDED7 'I
��,IfVes,descnbe unaer �
I 5I1/2006
�
5/1/2006
I
51112006
5/112007 pREMiSES Ea occurence��_
� MED EXP (!vry one per_ s°�1 `_i �
� PERSONAL & AGV INJURY ' S
� GENE�=FGGREGATE �
� PRODUCTS - COMPlOP AGG I S
L---- I
I �
�
OMBWED SINGLE LIId1T I `
5���2�p7 I ;Eaac;,ident) _�_
BODILY INJURY i 5
(Per person) I
----�I--
I
BODIIY INJURY I 5
(Per acddent) i _
PROPERT' DAIdAGE ,I g
(Per accider.t)
i�
AU70 ONLY - EA ACCIDENT
EA AC�
OTHER THAN
AUTO ON�Y AGG I �
IEACHOGCURRENCE
51112007 AGGREGFtiTE
� OTHER �, I �
I
DESCRIPTION OF OPERA7�ON5/ LOCA710NS I VEHICLES I EXCL11510NS A�DED BY ENDORSEMENT I SPECIAL PROVISIONS
1,OOO,QUt
— �o,00�
1,OOd,001
2,OOO,DOi
2���0���
�,�0����
$ 25,0OO,OD
$ 25,OOQ,00
$ — —
� —_
S
�� E L EACH ACGI�[NT i=
' E.L. DISEASE - EA EMPLOYEc 5
I EL. DISEASE - POLICY LIMIT ,£
arriers financia{ strength is AX-V
E: Clarion Hotel in Ft. WoD OT10193) foot s project and wa vert of subrogati on'is 'ncluded perCG2404(10193)e Su'bj ct to '10'day c�ancellation
dditional insured per CG2 (
�r non-payment of premium. THIS CERTIFICATE VOIDS AND SUPERCE CAN ELLATIONICATE ISSUED 4(24/0 .
CERTIFIGATE HOLDER SHOULD ANY OF THE ABOVE DESCRI6ED �OUCIES BE CANCELLED BEFORE THE EXPIRATION
Q WRITTEN
City of Fort Worth
Transportation &. Public Works St. Mgmt. Dept
311 W• 10th St.
Fort Worth, TX 76102-
ACORD 25 (2001108)
DATE THEREOF, THE ISSUING WSURER WILL EN�EAVOR TO MAIL
DAYS
NOT�CE TO THE CERTIFlCATE HOLDER NAME� TO THE LEFT, BUT FAILURE TO DO 50 SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
AVTNORIZE� REPRESENTATIVE
OO AGORD CORPORATION 1988
SYNEPRO-01 JOVI
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 (2001108)