HomeMy WebLinkAboutContract 60690Date Received: 1/3/24
Time Received: 4:15PM
Record Number: PND-00173
City Secretary No.: 6_0_6_90 ___ _
PUBLIC PROPERTY EASEMENT ENCROACHMENT LICENSE AGREEMENT
TIER fl
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 by and through its duly authorized City Manager, Assistant City Manager, or Director of the Development Services Department, and. Southside City Church of Fort Worth, a(n) a Texas non-profit corporation ("Licensee")� acting by and through its duly
authorized signatory.
RECITALS
WHEREAS, Licensee is the owner of the. real property located at 2606 Hemphill Street;. Fort Worth, Texas 76110 ("Property''), being more particular described as, Lot 6 and 7, Block 2, Lot 6R, Block 2, Blanchard Addition, as recorded in Deed Records, by Instrument Number D219161498., in.Tarrant County, T� and;
WHEREAS, the City owns a sewer easement (the "Public Propertyt') adjacent
to the Property, in. the plat records of Tarrant County as plat number FS-23-035; and
WHEREAS, Licensee desires to construct, place, and maintain certain improvements which will encroach in, on, abov(\, or below the Public Property; and
WHEREAS, to accommodate the needs of the Licensee, the City will allow the
encroachment under the terms and conditions as .set forth in this Agreement.
NOW, THEREFORE, the City and Licensee agree as follows:
AGREEMENT
1.
The 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 in, on, above, or below andoccupy a portion of the City's Public Property as described in and at the location shown
on Exhibit "A," but only to the extent shown thereon, for the purpose of constructing, installing, and maintaining a private water line (the "Encroachment''). Upon completion
of the Encroachment, Licensee agrees to be responsible for maintaining the
Encroachment within the Public Property. Licensee shall not expand or otherwise cause
Tier UEasement Encroachment Agreement Pt1go I of 12 Revised 12/2022
the Encroachment to further infringe in or on the Public Property beyond what is
specifically described in Eghibit "A."
2.
All construction, installation, naai.ntenance, and operation of the Encroachment
axzd tbe use or occupancy of the Public Property shall comply with and be performed in
strict compliance with this Agreement and with the charter, ordinances, codes, and
policies of the City. Prior to the cot►struction or installation of the Encroachment,
Licensee shall submit all plans and spec�cations to tbe Director of the Development
Services Departn�ent or duly authorized representative. Licensee shall not commence
constructian or installation of the Encroachment nor make any use of the Public Property
until after the execution of this Agreement.
3.
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 ar�d the use and occupancy of the Public Property, zucluding the securing
the approval and consent of the appropriate utility compan.ies and agencies of the State of
Texas and its political subdivisions. In the event that any installation, reinstallatioq
relocation, or repair of any existing or future utility or improvements owned by or
constructed by or on behalf of the public or at public expense is made more costly by
viriue of the constz-uction, maintenance, or existence of the Encroachment and use of
Public k'roperty, Licensee s�all pay to City an additional amount equal to such additional
cost as determined by the Director of Transportation and Public Works, the Director of
the Water Department, the Director of the Developrnent Services Department, or their
duly authorized representative.
4.
Licensee agrees that City may enter and utilize the Public Property at any time for
any public purpose, including anstalling, repairing, replacing, ar mai�,taiuning
improvements to its public fac�lities or utilities necessary for the health, safety, and
welfare of the public. The City shall have no responsibility or liability for any damages
related to t�ae Encroachment resulting from the City's use of the Public Property;
however, the City slaa�l make reasonable efforts to minimize such damage.
5.
Upon termination of this Agreezx�ent, Licensee shall, at the option of and at no
expense to the City, remove the Encroachment and restore the Public Property to a
condition acceptable to tl�e Director of Transportation and Public Works, the Director of
the Water Department, the Director o� the Development Services Department or their
Tier ii Easement Encroachment Agreement Page 2 of 12
Revised 12/2022
duly authorized representative. Any such removal of the Encroachment shall be in
accordance witl� then-ex�sting City regulations and palicies. It is understooa and agreed
to by Licensee that if this Agreement terminates and Licensee fails to retnove the
Encroaclunent and restore the Public Property, Licensee hereby gives City permission to
remove the Encroachment and auy supporting structures from the Public Propezty, to
restore the Public Property, and to assess a laen on the Property for the costs expended by
the City in taking such actions.
6.
In order to defray all costs of inspection and supervision which the City has
incurred or will incur as a result of the constx-uction, maintenance, inspection or
management of the Eneroachxnent and use of Public Property as provided for by this
Agreement, Licensee agrees to pay to City at the time this Agreement is requested an
application fee in the sum of Nine Hundred Dollars ($900.00).
7.
Tl�e terrn of this Agreement shall be for thirty (30) years, commencing on the
date this Agreernent is executed by City. However, the City may terminate this
Agreement upon Licensee's noncompliance with any of the tem�s of this Agreerr�ent.
City shall notify Licensee in writing of any such noncompliance and if Licensee does not
cure the noncompliance within thirty (30) days of notice from City, the City may
tei-minate this Agreement. However, the City may, at its sole option, allow the Agreement
to remain in effect so long as Lice�see has talcen reasonable measures to cure the
noncompliance or is continuing to diligently attempt to remedy the noncompliance.
8.
It is further understood and agreed between the parties hereto that the Public
Property to be used and encroached upon is held by City as trustee for the public; that
City exercises such powers over the Public Property as laave been delegated to it by the
Constitution of the State of Texas or by the Texas Legislature; and that City cannot
cantract away its duty and its legislative power to control the Public Property for the use
and benefit of the public. It is accordin.gly agreed that if the governing body of City may
at any time during the term. hereof detez�ine i�o its sole discretion to use or caus� or
permit the Publie Property to be used for any ather publitc putpose, including but not
being limited to underground, surface, or overhead communication, drainage, sanitary
sewerage, transmission of natural gas or electrzcity, or any other pubiic purpose, whether
presently contemplated or nat, that the parties agree to negotiate in good faith in order to
accommodate both the Encroachment and the pubLic purpose.
Tier II Easement Encroachment Agreement I'age 3 of 12
Revised l2l2022
9.
LICENSEE COVENANTS AND AGREES TO INDEMNIFY, AND DOES
HEREBY INDEIVINIFY, HOLD HARMLESS, AND DEFEND CIT'Y, 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 WHA,TSOEVER KIND OR CHARACTER,
WHETHER REAL OR ASSERTED, ARISING OUT OF OR IN CONNECTION
WITH, DIRECTLY OR INDIRECTLY, THE CONSTRUCTION,
MAINTENANCE, OCCUPANCY, USE, EXISTENCE, OR LOCATION OF THE
ENCROACHMENT AND USES GRANTED HEREUNDER, WHETHER OR NOT
CAUSED, IN WHOLE OR IN PART, BY THE 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
ENCROACHMENTS AND ANY AND ALL ACTS OR OMISSIONS OF
LICENSEE, TTS OFFICERS, AGENTS, SERVANTS, EMPLOYEES,
CONTRACTORS, SUBCONTRACTORS, LICENSEES, OR INVITEES.
10.
While this Agreement is in effect, Licensee agrees to furnish City with a
Certificate of Insurance naming City as certificate holder as proof that is 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 located and described in Eghibit "A."
The amounts of such insurance shall be not less than
$1,000,000
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
immediately following notice to Licensee of such requirement. Such insurance policy
shall not be canceled or amended without at least thirty (30) days prior written notice to
the Building O�cial of the City. A copy of such Certificate of Insurance is attached as
Exhibit "B" and incorporated herein for all purposes. Licensee agrees, binds, and
obligates itself and 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
the Encroachment and restoration of the Public Property. All insurance coverage
required herein shall include coverage of all Licensee's contractors and subcontractors.
Tier I1 Eascment Encroachment Ageement Page 4 of 12
Rcviscd 12/2022
l �.
Licensee agrees to deposit with the City when this Agreennent is executed a
sufficient sum of money to be used to pay necessary fees to record this Agreement in the
real property records of ihe county in which tke Encroachment is located. After being
recorded, the original shall be returned to the City Secretary of the City of Fort Worth.
12.
Licensee agxees to comply fully with all applicable federal, state, and local laws,
statutes, ordinances, codes, and regulations in cnnnection with the construction,
operation, and maintenance of the Encroachment aud use of the Public Property.
13.
Licensee agrees to pay promptly when due all fees, t�es, or rentals provided for
by this Ag�reemezzt or by any federal, state, or local statute, law, or regulation.
14.
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 Ciiy, and Lxcensee 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 foz the acts and o�.issiozis of its ofFicers, agents, servants,
eznployees, contractors, subcontractors, licensees, and invitees. The doctrine oi
respondeat superior shall not apply as between City and Licensee, its officers, agents,
servants, employees, cantractors, and subcontractors, and nothing herein shall be
construed as creating a partnership or joint enterprise between City and Licensee.
15.
Licensee agreas and acknowledges that this Agreement is solely for the purpose
of permitting Licensee to construct, maintain, and locate the Eneroachment over or within
the Public Property and is not a conveyance of any right, title, or interest in or Co the
Public Property, nor is it meant to convey any right to use or occupy property in which a
third-party may have an interest. Licensee agrees that it will obtain all necessary
permissions before occupyin� such property.
Ticr fI �asement Cncroacliment Agreement Page 5 of 12
Revised l2/2022
16.
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 attorneys' fees.
17.
The parties agree that the duties and obligations contained in Section 5 sball
survive the termination of this Agreement.
18.
Licensee covenants and agrees that it will not assign all or any of its rights,
privileges, or duties under this Agreement without the 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 sigty (60) days of such foreclosure or
assignment and assumes all of Licensee's 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.
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.
20.
This Agreement shall be binding upon the parties hereto and their successors and
assigns.
21.
This Agreement may be executed in multiple counterparts, each of which shall be
considered an original, but all of which shall constitute one instrument
Tier II Easement �ncroachment Agreement Page 6 of 12
Rcviscd 12/2022
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[SIGNATURES APPEAR ON FOLLOWING PAGE]
Tier II Easement Encroachment Agreement
Page 7 of 12
Revised 12/2022
City:
CITY OF FORT WORTH
• �' ..:::::>�By: OJ Harrell (Jan 3, 2024 08:33 CST)
Licensee:
Southside City Church of Fort Worth
a Texas non-profit corporation
D.J. Harrell, Director of the
Development Services Department
Name: Darrel Auvenshine
Title: Authorized Signatory
Date: Jan 3, 2024
ATTEST:
Jannette Goodall,
City Secretary
Date: Jan 3, 2024
Tier II Easement Encroachment Agreement
Date: \ } / 3:-o / 2-o ;)--� • I
Approved As To Form and Legality
Jeremy Anato Mensah
Assistant City Attorney
Date: Jan 2, 2024
Contract Compliance Manager:
By signing I acknowledge that I am the person
responsible for the monitoring and administration
of this contract, including ensuring all perfo rmance
and reporting requirements.
J2Wffj/W ttottats on behalf of Dwayne Ho 7rs on behalf of. (Jan 2, 2024 09:22 CST)
Rebecca Owen
Development Services
Date: Jan 2, 2024
Page 8 of 12
Revised 12/2022
'''*"'THIS PAGE FOR CITY OF FORT WORTH OFFICE USE O�LY''dd,
STATE OF TEXAS § COUNTY OFT ARRANT §
BEFORE ME, the undersigned authority, a Notary Public in and for the State of
Texas, on this day personally appeared D.J. Harrell, known to me to be the person
whose name is subscribed to the foregoing instrument, and acknowledged to me that he
executed the same for the purposes and consideration therein expressed, as the act and
deed of the City of Fort Worth, and in the capacity therein stated.
GIVEN UNDER MY HAND AND SEAL OF OFFICE this 3rd day of
_Ja_n_u_a_ry ___ , 20�.
Wendy L.
Beardslee
Digitally signed by Wendy L.
Beardslee
Date: 2024.01 .03 1 4:52:41
-06'00'
Notary Public in and for the State of Texas
After recording return to:
Development Services Department
Development Coordination Office
200 Texas Street
Fort Worth, Texas 76102
Tier II Easement Encroachment Agreement
WENDY L BEARDSLEE Notary Public STATE OF TEXAS Nota ry I.D. 13323719-3 My Comm. Exp. July 28, 2025
Page 9 of 12
Revised 12/2022
STATE OF TEXAS §
COUNTY OF TARRANT §
BEFORE M�, the undersigned authority, a Notary Public in and for the State of
E �, on this day personally appeared Darrel Auvenshine, Authorized Signatory
(Title) known to me to be the person whose name is subscribed to the foregoing
instrument, and acknowledged to me that he or she executed the same for the purposes
and consideration therein expressed, as the act and deed of Southside City Church of Fort
Worth, a Texas non-profit corporation (entity type), and in the capacity therein stated.
GIVEN iJNDER MY HAND AND SEAL OF OFFICE this Zv� aay of DrcF�i�Ea�
20 23 .
�
Notary Public in and for the
State of%S
;�:���'st�;.,; DAVIDAVOORHEES
=•:'�:*= My Notary ID # 131399903
�'�:•;� �'' � Expires January 5, 2026
Tier II Easement Encroachmcnt Ageement
Page 10 of 12
Revised 12/2022
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EI�IT A .
Depiction and description o� the Encroachment
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Tier II Easement Encroachment Agreement Page 11 of 12
Revised 12/2022
N.T.S.
OWNED/DEVELOPED BY:
SOUTHSIDE CITY CHURCH
2606 HEMPHIL� STREET
FORT WORTH, TEXAS 76110
DARREL AWENSHINE
EMAIL: DAUVENSHINE@AOL.COM
PREPARED BY:
MJ THpMAS ENGINEERIPIG
4700 BRYANT IRVIN CT, STE: 204
FORT WORTH, TEXAS 76107
PH: (817) 732-9839
F/�X: (817)732-9841
REGISTRATION NO. F-9435
CONTACT: MICHAEL THOMAS, P.E.
MAPSCO NO. 76V
COUNCIL DISTRICT NUMBER: 1 �
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LOCATION MAP
FOR
2606 HEMPHIL STREET
(LOT 6R-1, BLOCK 2)
BLANCHARD ADDITION
CITY OF FORT WORTH, TEXAS
EXHIBIT "A"
LEGAL DESCRIPTIQN
ENCROACHMEiVT AGREEMENT
BEING a 10 foot wide strip of land situated in Lot 6R-1, Block 2, Blanchard Addition, to the City
of Fort Worth, Tarrant County, Texas, according to the plat recorded in County Clerk's File No.
D223096599, of the Official Public Records of Tarrant County, Texas. Said 10 foot wide strip of
land being more particu{arky described by metes and bounds, as follows:
S�GINNING at a point lying in the West line of an existing 12 foot wide sanitary sewer
easement, recorded in Volume 6512, Page 801, of the Deed Records of Tarrant County, Texas,
and said POINT OF BEGINNING a]so lying N 00° 21' 13" W 29.21 feet, from a'/2' iron rod
marked "Brittain & Crawford" set at the Northeast corner of Lot 5RB, Block 1, of Garret's Second
Addition, to the City of Fort Worth, Tarrant County, Texas, according to the plat recorded in
County Clerk's File No. D203185040, of the Official Public Recorcfs of Tarrant County, Texas,
and an ELL corner of aforesaid Lot 6R-1, Block 2, Blanchard Addition;
TH�NCE N 00° 21' 13" W 10.00 feet, continuing along the West line of said existing
12 foot wide sanitary sewer easement, to a point;
THENCE EAST at 12.00 feet crossing the East line of said existing 12 foot wide
sanitary sewer easement and the West line of an exis#ing 3 foot wide sanitary sewer
easement, recorded in County Clerk's File No. D203014925, of the Official Public Records
of Tarrant County, 7exas, and con#inuing in alf 15.00 feet, to a point lying in the East line of
said existing 3 foot wide sanitary sewer easement;
THENCE S 00� 21' 13" E 10.00 feet, along the East iine of said existing 3 foot wide
sanitary sewer easement, to a point;
THENCE WEST again severing said existing 3 foot wide sanitary sewer easement
and the existing 12 foot wide sanitary sewer easement, to the POINT OF BEGINNING
containing 0.003 acre (150 square feet) of land.
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L2 N 00°21'13° W 10.00'
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NOVEMBER 21, 2023
EXHIBIT MAP
OF
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BLOCK 2 BL��'�C�D��DDITION
CITY OI���F�WbR�hQ�4f�ANT
COUNT�'��I�E'_�X�D ADDITION
CI�1'Y OF FORT WORTH�
TARRANT COUNTY� TEXAS
SCALE 1"=20'
SOUTHSIDE CITY CHURCH\SOUTHSIDE CITY CHURCH-ENGROACHMENT-EXHIBIT.
OWNED/DEVELOPED BY:
SOUTHSIDE CIN CHURCH
2606 HEMPHILL STREET
FOF2T WORTH, TEXAS 76110
DARF2EL AUVEIVSHINE
�MAIL: DAUVENSHINE@AOLCOA
PREPARED BY:
MJ THOMAS ENGINEERING
4700 BRYANT IRVIN C7, STE: 20�1
FORT WORTH, TEXAS 761 Q7
PH: (817) 732-9839
FAX: (817)732-9841
REGISTRATION NO. F-9435
C�NTACT: MICHAEL 7MOMAS, P.E.
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EXISTING SEWER LINE
PROPOSED WATER LINE
PRQPOSED ENCRQACHA�ENT
EXH�BIT C1-
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2606 HEINPHiL STREET
(LOT 6R-1, BLOCK 2y
BLANCHARD ADDITION
CITY OF FORT WORTH, TEXAS
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OWNED/DEVELOPED BY:
SOUTHSIDE C17Y CHURCH
2606 HEMPHILL STREET
FQRT WpRTH, TEXAS 76110
DARR�L AUVENSHWE
EMAIL: DAUVENSHINE a�OL.GOM
PREPARED 8Y:
MJ THOMAS ENGINEERIiVG
4700 BRYANT IRVIN CT, STE: 204
FORT Wp3�TH, TEXAS 76107
PFf: (817) 732-9839
FAX: (817)732-98�4i
REGISTRATION NO. F-9435
CONTACT: MfCHAEL THOMAS, P.E.
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PROFILE SCALE
HORIZONTAL SCALE: 1 "=20'
VERTICAL SCALE: 1" =4'
EXHIBITc2-
PROFILE
�OR
2606 HEMPHIL STREET
(LOT 6R-1, g�OCK 2�
BLANCHARD ADDITION
CfTY OF FOR7 WORTH, TEXAS
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Tier II Easement Encroa.chment Agreement Page 12 of 12
, Revised 12/2022
�►c'a � CERTIFICATE OF LIABILITY INSURANCE
�nre �MMr�ormv�
'12I1312023
THIS CERTIFlCATE IS ISSUED AS A MATTER OF 1NFORMATION ONLY AND CONFERS NO RIGHTS UPON TH� CERTIFICATE HOLDER. TFflS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, IXTENd OR ALTER 7HE CpVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICA7'E OF INSURANCE i�OES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
Ii41PORTANT: If the certifi�ate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provlsions or be endorsed.
If SUBROGATION 15 WAIVED, subject to the terms and condltfons ot the poilcy, certafn pollcles may require an endorsement. A statement on
this certtficate does noE confer r[qhts to the certificate holder In Eleu of such endorsemenf(s).
rRooucEa Ross Insurance Agency
213 Old Hewitt Road
Waco TX 76712
INSURED gpUTHSIflE CITY CHURCH OF FORT WOR7H
2794 NW 20TH STREET
FORT WORTH TX 76'S06
INSUREA A !+
INSUREit B :
INSURER C :
INSUREFi D :
INSURE3i E :
,TY INSURANCE CO
NdIG N
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS �S TO CERTIFY THAT TNE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLiCY PERIOD
INDICATED. NOTWITHSTANDING ANY RE�UIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TWIS
CERTiFICATE MAY BE 1SSUED OR MAY PERTAIN, THE INSURANCE ,4FFORDED BY THE POLICIES �ESCRIBED HEREIN IS SUBJECT 70 ALL THE TERMS,
EXGLUSIONS AND CONDITIQNS OF SUCH POLICIES. �IMITS SHOWN MAY HAVE BEEN REDUCED BY PA1D CLAiMS.
INSR 7ypE OF INSl1RANCE �OL B POL]CY EFF POLICY E7(P U1MR5
LTR POLICY NUM6ER MMID� MMlI]U
/4 �/ COMMERCIALGENERALIJABILITY �/ 1CPKP20{1910180 1/15/2023 1I15l2624 �CHOCCURRENCE s14Q0000
✓ cv�,in�s-r.+noe � occuR °�ais�s �oca,�e� s100000
MEO EJ� (Any one persa�) E S��Q
PERSOP7AL&ADVINJURY S�QODOOO
GEMLAGGREGATEL�MITAPPLIESPER GENERALAG6REGATE S2QOOOOO
POLICY � jE a ❑ LOC PRODUCTS - COMPlOP AGG s2U4D000
OTHER: s
AUTOMOBILELL4BILITY COMBINED SfNGLE LIMIT s
Ea acadent
� ANY AUTO BODILY INJURY (Per person) S
OWNED SCHEDULED BODILY INJURY (Per accident) ;
AUTOS ONLY — AUTOS
HIRED NON-OWNED PROPERTYDAMAGE s
AUTOS ONLV AUTOS ONLY Per acdtlenl
S
U�NBRELLA WB OCCUR EACH OGGURRENCE 5
�G�� � CLAIMS-MAD� AGGREGATE S
DED RETEN1lON S s
WORKERS COMPENSA"f10N PER OiH-
AHDEMPLOYERS't1ABILITY y�N STATUT@ ER
ANYPkOPRIETOFt/PARTNER/D�CUTIVE ❑ NIA � E.LFACHACCIDENT S
OFFICERlMEMBER IXCLUDED7
(Hland�tory la NHj EL DISEASE - EA EMPLOYEE S
N yes, tlesdibe under
DESCRIPIION OF pPERA710N5 below EL DiSEASE - POLICY LIMfT S
��
DESGR1PT10N OF OPERATONS I LOCATiONS I VEHICLES (ACORD 107, Addi8onal Ramarks Schedula, may be attached H mom apace Is �equ'nad)
roject name-Sauthside City Ch�rch Tiny Homes Village Froject #PN23-00'i73
CERTIFICATE HOLDEi2
:ITY OF FORT W�i2TH
!00 TEXAS STREET
�ORT WORTH TX 76102
�N23-001i3
ACORD 25 (2016103)
GAN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFQRE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN
ACCORDANCE WITH TH� Pp41CY PROVYSIOkS.
AUTtiORIZED REPRESEHTATIVE
OB WEATHERLY
�O 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD natne and logo are registered marks oi ACORD
ProCuud oalnp Form� Bo�s Web softwero. www.Forms6aaa.com; y Impreeslve Publishlnfl 600-206-1877