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Encroach application & insurance cert.pdf..J t ) k' I-, D A"I f-3 , RE(".0RDJ[N(1'F' #: ENCROAC"JIME'N'r P"li,R,M'1'1-'A.'13P]'.,ICA"flON �Nc, ). S91) Check box for Encroacbment Including Artwor,li in the Pub is Ilight-of-Way. Phone r PROPERTY OWNERNAI"E: 0'� ...... . . . ..... ....... . ....... . . ....................... . . ........... 1`110PEIV11Y OWNER. MAILINGADDRE"s's: _........m ... . . ........... . . . .................................. . . ............ . ........... . ........ . .. . ........... ---- -- ........................................................................ . BUSINESS NAME (for Coinruercial apr)hcatioos)� ...... . . .. ... . . ............... . ........... . .. . . . Phone BUSINESS OWNER NAM'E,: ADDRE'SS OF PUBLIC ENCROACHMENT: . ............................ Permanent structures encroaching upon arty portion of public space, City right --():["-way or easement area shall meet all Code Requirements as set forth in the following chapter of the EdnlOnds Coin.n.junity Development Code, 18,70 STREET USE AND ENCROACHMENT PERMITS PERMIT ISSUANCE X n- E- 'n' —cr o"a-c-1, r n-e-n—t Fe—rrriit may be issued, at the discretion of the, Developrnent, Services Director, City Engineer or their respective, designee, for perinanent structures encroaching upon any portion of public space, City right-of-way or easentent area, if the structures are placed in compliance with the above referenced Code Section and the IbIlowing criteria are met: 1. It has been concluded that the proposal will not adversely ixripact public space open to vehicular or pedestrian travel; 2, Architectural Design Board approval basbeen. granted or the process has- been administratively approved; 1 The proposal will not unreasonably interfere with the rights of the public; and 4. The, proposal either benefits the public interest, safety or convenience (e.g., supports or protects the City street) or is an accessory structure such as a fence normally associated with residential use of the property as fully complies with the requirements of Criteria 3 above. 5. Edmonds Arts Colm-nission has reviewed the required materials and made a favorable reconu-nondation, DESCRIPTIOF PROPOSED ENCROACHMENT.' (hiclude total square footage of encroacbment and give, specific location such as, a' west of face of curb and 10'south of c/l of driveway entrance) See attached. ".)':V "Iq 1UAEucrow,,,W nf,',d Applicationdoc Ruvised 10/9/200'7 NOTE: The issuance of this permit is understood by the applicant to be of a temporary nature, revocable by the City per ECDC 18.70.040 and that no vested right is granted. Applicant is responsible to provide a copy of lite insurance certificate to the City at the beginning o, Peach calendar year, no later than the 21" day of J"anuaty. IrVDE KITY, The applicant understands and l )) his/her signature to this application, agrees to hold the City of Edmonds harnyiless front any injuries, damages or claims of any kind or description whatsoever, foreseen or unforeseen, that may be made against the applicant or the City of Edmonds, or any of its departments or employees, including but not limited to the defense of any legal proceedings including defense costs, court costs, and attorneyfees by reason ofgranting thispermit. In addition, the applicant understands that helshe shall provide and continually maintain during the term of the permit a certificate of insurance naming the city as an additional insured, with respect to liability, and providing that it shall be primary as to any other policy of insurance. CODE APPLICATION: By signing the application below the applicant warrants that s/he has read or had the opportunity to read Chapter 18.70 of the Edmonds Community Development Code and s/he understands that all terms of the adopted ordinance are incorporated Herein as if set forth in full and this application and permits t refore awe/u t_ta,tlze terms of those Chapters. SIGNATURE Ah� � � _._. � DATE D-�: o +. ******* DEPARTMENT **** FOR CITY USE ONLY ******* Date Rev'd: _ by: Cert. of Insurance verified by: Date Public ►forks Approved by: -Remarks: . Planning Division Approved Remarks: B# Date, . Ldatonds Arts Comm " sion Approved By: Date Remarks: _. OEngineering Division Approved bjQt Date Remarks: . 6.- H � �a� f `91�i 1 O �i � S�G1�9! �� h�s -7 YOd BUdDIN S:kBngr\Forrns\Encroachment Appl.i.ca€ion,doc Revised 10/9/2007 1. 313 SF steel & glass canopy from south end to 2/3 of west side of building going north. 2. 36 SF steel & wood trellis at west side of building level 3 midpoint. 3. 33 SF precast concrete cornice at west side of building level 3 midpoint. 4. Flagpole at west side of building adjacent to curb, 46' from south end of building. S. Landscape irrigation west and north sides of building. As -built plan will be filed with the city upon completion of the project. EDMON-4 Ole IO: CS CERTIFICATE OF LIABILiTY INSURANCE DATE (MMIDDIYYYY) 47141114 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 T14E POLICIES BEI THIS CERTIFICATE OV INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: l: the ce€lificate holder is an ADDITIONAL_ INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject io the terms and conditions of the policy, certain policies may regUiC0 ars endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorser'nent(s). PRODUCER 206�2�3 X76 Lovsted-Worthington tori LLC c� P.O. Box 607 Bothell WA 93041 206 234 34G7 424 Third Ave W Seattle, WA 98119 CONTACT _NAME: aHONN Ext:_—_... ---- E-MAIL APABEss: _ INSURER(S) AFFORDING COVERAGE NAIC S Dean R. Young INSURERA:CGEOnY Insurance Company -_...._ ____..------------ -------- ................__...-...._ INSURED Edmonds 2020, LLC 307 Bell Street INSURER B: ------.-_. EACH OCCURRENCE $ 5,001 Edmonds, WA 93020 INSURER C: INSURER D, INSURER E : 06/12/14 INSURER F: ° mA C r E 100,000 PREMISES Ea occurrence $ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER - THIS IS TO CERTIFY THAT 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 SUKECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR LTR TYPE OF INSURANCE DD I WVD POLICY NUMBER POLICY EFF MMID�IIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 5,001 A X ComMERCIALGENERAL LIABILITY. X 103GL000463700 06/12/14 06112/16 ° mA C r E 100,000 PREMISES Ea occurrence $ CLAIMS -MADE OCCUR _ MED EXP (Any one person) S 6,400 PERSONAL &ADV INJURY $ 5,000,000 X stop gap GENERAL $ 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: _A_GGREGATE PRODUCTS -COMPIOPAGG $ 5,000,000 POLICYPRO- LOC EmpBen. ._.. $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED- SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NONOWNED--PROPERTY HIREDAUTOS AUTOS DAMAGE $— Peraomdenl)_„__ $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE OED I I RETENTIONS S WORKERS COMPENSATION AND EMPLOYERS' LIABILD"Y YIN WC STATU- OTH- TO RY LIMITS ER��-� E.L. EACH ACCIDENT $ -- ANY PROPRIETORIPARTNFRIEXECUTIVE OFFICERIMEMBER EXCLUDED? ❑ N 1 A --- E. L. DISEASE - EA EMPLOYEE $ - (Mandatory In NH) If yes, descriUe under DESCRIPTION OF OPERATIONS below "-_-- E -L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) E-26 Encroachment Permit #ENG20140287(for architectural features) and ENG20140300 (for shoring) Encroachment Address: 130 2nd Ave N ** Its is understood and agreed that the City of Edmonds is an additoinal insured per CG20120509 attached. City of Edmonds Engineering Division 121 Sth Avenue Nortlf I~_dts'donds, WA 980"- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, [NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 9'198L* 2G10ACC rD C0RPORATtOa-4. n,}I riclhis rc.—scrvs;cf. o�C'JR 96 (24'1014!5) ;ITt? A� (il'Zi €�cl G zlrac4 logo &t' ,�fl!�.OiCC( ffrnrL CI f C!{?ID