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Encroachment Application ENG20190286.pdf6/19/2019 Mail - Joel Patience - Outlook Re: Web Inquiry Joel Patience Thu 5/16/2019 10:03 AM To: Chave, Rob <Rob.Chave@ednnondswa.gov> Hi Rob: My wife and I own the property at 956 Maple Way. Her grand parents had it built and they lived there for decades. Her grandfather by the way was the steel engineer for the Battery Street tunnel and floating bridge. The stub of loth is just off of our garage and the portion farthest from us along the cliff has been the site of commercial and neighborhood dumping of yard debris for some sixty years. In urban archeology that means consecutive layers of flammable materials. As that portion became unstable for pedestrians, the dumping has migrated towards our property and it is now a major fire hazard. Thanks to the COE a chevron was constructed that stopped trucks but did not slow down local dumping traffic. I had put a small length of power pole down but it has been moved for access. As we have enjoyed working with the City on several local fronts and on this one for decades, we believe there to be only one solution remaining. Thanks, Joel > On May 16, 2019, at 8:23 AM, Chave, Rob <Rob.Chave@edmondswa.gov> wrote: > Hello: > You'll need to explain the problem more. I may not be the appropriate person to meet with, but I'll be happy to point you in the right direction. > Rob Chave I Planning Manager > Development Services Dept > -----Original Message----- • From: Joel Patience <joelpatience@hotmail.com> > Sent: Thursday, May 16, 2019 12:26 AM > To: Chave, Rob <Rob.Chave@edmondswa.gov> > Subject: Web Inquiry > Hi Mr. Chave: https://outlook. live. com/mail/sentitems/id/AQMkADAwATE4MTUxLWl1Nj ItOWFmOS0wMAltMDAKAEYAAAOHiAM04F8%2FRpq%2FAaeiE6HIBwDtW .. 1/2 6/ 19/2019 Mail - Joel Patience - Outlook > Would your schedule permit a short meeting over the next few business days? I have what might seem a complicated property problem and always gravitate to the planning department on account of my background. > Thanks very much. > Joel Patience https:Houtlook.live.com/mail/sentitems/id/AQMkADAwATE4MTUxLWIl NjitOWFmOSOwMAltMDAKAEYAAAOHiAM04F8%2FRpq°/a2FAaeiE6HIBwDtW.. 2/2 6/19/2019 Mail - Joel Patience - Outlook _ + New message Inbox 100 Junk Email is ,i� Drafts 8 1- Sent Items of Deleted Items J.= Archive 3322 1 CAI hike Conversation Hist... Dell Festa H oyt HP 11 .Junk NG Register New folder P Search (_ r '�) Reply iiil Delete b Archive & Junk Sweep J Move to <b Categorize 956 Maple - fence encroachment G) You replied on Wed 6/5/2019 5A5 PM McConnell, Jeanie <Jeanie.McConnell@edmondswa.go �� ••• v> Wod 65/201910:21AM You; Edmonds Engineering Permits =: Hi Joel, The City's storm maintenance division would be open to a fence encroaching into the loth Ave 5 right-of-way, so long as access to the storm line is maintained. If you choose to move forward with this approach, please submit an encroachment permit application and agreement for review and approval. Please refer toffy handout E2-_6 for Encroachment Permit Submittal Requirements. You can either submit the application and documents via email to engineeringpermits@edmondswa.gov or by visiting the permit center on the 2nd floor of City Hall. If you submit via email, we will follow-up with you via email to let you know when the permit has been set-up and payment can be accepted. Please let me know if you have any additional questions. Thank you, Jeanie Jeanie McConnell - Engineering Program Manager lea nie.mcconnell oedmondswa.gov 425-771-0220, ext 1338 Web Map: www.ma sp edmondwa.gov Permit Center Hours: M, T, Th, F - 8:OOam - 4:30pm Wednesdays-8:30am - noon https://outlook.live.com/mail/inbox/id/AQMkADAwATE4MTUxLWIl NjItOWFmOSOwMAItMDAKAEYAAAOHiAM04F8%2FRpq%2FAaeiE6HIBwDtWNE7. 1 /1 OF EDP O A . O U� cn Si— . I g9\) ENCROACHMENT PERMIT APPLICATION ADDRESS OF PROPOSED PUBLIC USE: PROPERTY OWNER NAME: �+y� I.���J PHONE:'���i� PROPERTY OWNER MAILING CONTACT NAME: - A PH0NE: CONT ACr U�1 EMAIL ��1-.1- `��/�1/rt,�- J �` �'�-}����L,L�i,���*� • p� �i��(' �( Describe the portion of public space, City right-of-way or easement area to be utilized (i.e., overhead space of sidewalk, 10 foot City utility easement along north property line, etc): Describe the type of encroachment or use desired (i.e., fence 6 feet by 150 feet, awning 3 feet wide by 7 feet long, etc.): 1��° _�'�1 - <. C (" -:x -1 c;,• : : �V ------------------DEPARTMENT APPROVALS ---FOR CITY USE ONLY------- PlanningDivision Approved By ADB# Date Public Works Approved By Date Remarks or Comments: .� Engineering Division Approved By Date Certificate of Insurance Verified By Date Encroachment Agreement sent to City Clerk for recording Date ENCROACHMENT PERMIT# ISSUANCE DATE BUILDING PERMIT # RECORDING # When recorded mail to: City Clerk City of Edmonds 121 Fifth Avenue North Edmonds, WA 98020 SPACE ABOVE THE LINE FOR ItECORDERS USE Assessor's Parcel No.: Applicant: ENCROACHMENT AGREEMENT This ENCROACHMENT AGREEMENT ("Agreement") is entered into between the CITY OF EDMONDS ("City") and/✓�f(fK JIJ ("Owner[s]"), in accordance with Chapter 18.70 of the Edmonds Community Development Code. 1. The Property. Owner is the owner of that certain real property located at ,-zty, YWC-7-57 within the City of Edmonds, Washington, Assessor's Parcel Number and more particularly described as follows-- F.int 1- &MV LQ' `ILd- dab fl i1 12!. t?A&j2 t , or as described in Exhibit "A" attached hereto and incorporated herein by reference. 2. The Easement. The City right-of-way adjacent to owner's property or an existing easement used for (strike those that don't apply) [sPef,.paidIa�y(1'ysiddwalk, bi �tth, pedestrian-eggement, s ewer, water storm, other t�C f► �i JJ6 �' t' Orr 3. The Encroachment. The Owner desires to encroach upon the public easement and the City hereby covenants and agrees and grants its permission to Owner to allow �Jy Iyf�w , k- L 1 s. I o, ib , i ii-'a portion of the City right-of-way/easement. A partial site plan, scaled 1"=20', showing the location of the encroachment is attached as Exhibit.'V' and incorporated by reference. Thits Agreement is subject to the following terms and conditions: 41 E26-EncroachAgreement 2.13.13.fmal.doc be necessary to prevent damage to the City's utility system, or any other public facility which may be impacted by the Owners' failure to properly use the easement. 8. Successors and Assigns. This Agreement shall be binding and inure to the benefit of the parties hereto and their respective legal representatives, successors, and assigns. Owner agrees to incorporate this agreement by reference in any subsequent deeds to the property, but any failure to do so does not invalidate this provision. 9. Capacity. Each party represents that the person(s) executing this Agreement on behalf of such party has the authority to execute this Agreement and by,;such signature(s) thereby bind such party. IN WITNESS WHEREOF, the parties hereto have executed this Agreement on this ij— day of —A J ?soft. Ems`( , 20 OWNER(Sj : STATWOFWA,SHINGTON OF SNOHOMISH This day, personally appeared before me, 1(1 �A4ienr.E - �ti�� v�nn , to me known to be the person(s) who executed the within and foregoing document and that (he/she/the Au signed the same as (his/her/their 46,1r free and voluntary act and deed for the aes and purposes therein mentioned. ' ROBERT P JORGENSEN (VOTARY PUBLIC STATE OF WASHINGTON COMMISSION EXPIRES AUGUST 9, 2021 CITY OF EDMONDS ENGINEERING DIVISION Notary Public ?1064 Jr Typed or Printe ame My Commission expires: 16 /-? .21 E26-EncroachAgreement 2.13.13.fmal.doc SW 114, SE 1 4, SEC. 24, T. 27N. , E. 3E. , W.M. - raRo uchutnrrtuf (MARCH 1999) J•0RAS51MSC M/k a SNOHOh1.,SFI COUNTY, WASHINCTON ! /awtnuuclNr _ MAIN 5T - - � o , 1" 6RASS DISC W/ 'X' 1 IN 25" I P. DDVN 0.2 IIELO POSITION (MARCH 1999) 1 .- fA5-. E60.Q7(PJ(C) 0 75.,30 60 , MERIDIAN: PLAT OF CITY OF EDMONDS • I /'� DA YTON 5 T. ' BASIS OF'FJEARING: CENTERLINE OF 9th St. S. I MEET; OR EXCEEDS SURVEY STANDARD AS PER: 1 -- -- -- 9a%0�� moo — WAC 332-130I - t J0' I WAC 332-130-090 13 14 15 xr io 17 18 19 ZD ( WAC 332-IJO-100 1 "ff/1ff/Jf.7 s I INSTRUMENT USED: WILD TC-IOXX SURVEY PERFORMED BY FIELD TRAVERSE . , 2' t HOUSE < a a I LEGEND ; i,j1 ,�,ry/n,T)„p l,ry/�p - 1 • Z O SET 518-x 24" REBAR/CAP WSI 15916 (MARCH 1999) ❑ SET 2", 2" STAKE IN LINE , • , • HOUSE t 'A W.A ' 0° P0=Z ' - t 3 I IB FOUND REBAR AS N07ED , A ! ti SM CORAWAroW ' L �5M rl O FOUND MONUMENT/CASE • SO n;� ao�19 IQ T 1 Vi .`./ i I •�� O' I • (C) CALCULATED MPII"LC WAY I I CONC. IS 1.4' WEST OF CDR w.., 30 •,•,(W ... j"� ,:.,. M'. ,. :. ... ..__ 4� __—�___1___—___ V) _ _ EAST 660.00(P)(C)_^_ .... 13f1aaP%iCi -' d — MEASURED ' PROPERTY LINE O\ raw pH+A N% fitP 1VARor l9mJ a � T � • I d y+•� SEr w9 amw cAv Al 28 27 26 25 24 23 22 21 LEGAL DESCRIPTION • • � ^ a 1 LOT, 16, 17, 18, 19, 20, BLOCK 69, PLAT OF CIPY OF EDIe0Nn5 • I VOLUME 2 OF PLATS, AT PAGE JJ , SNOHOMISH COUNTY, Wit AUG 12 ---.--A--------J• 1 ---------------------L NOTES • M1 '�( _ I.) MID SURVEY HAS BEEN PREPARED FOR OW 1fJ�C'U C!•iAR J� WHOSE NAMES APPEAR HEREON ONLY, AND %%M I ftK� !O 4Nv ljl �r UNNAMED THIRD PARTIES WITHOUT EXPRESS AECOf ArVo-:Y K- tA= - SURVEYOR. - • 1NT � y- N "I", "NUMEN T/CASE 1 2" BRASS DISC W/ "X' aJ A OF CAL INT. & . 2.) BOUNDARY LINES SHOWN AND CORNERS SET REPRESE GLEN LOCATIOIJS; OWNERSHIP LINES MAY VARY, NO GUARANTEE OF OWNERSHIP IS INPRESSED OR I 1 . . 'A! Ir OF INT. IMPLIED THIS RPERFORMED) WITHOUT ME BENEFIT OF A TITLE REPORT AND EAST660.00(P)(C) (4m01 1999) 99J DOES' NOT PURPOORTT T TO SHOW ALL ENCUMBER MILE RESTRICTIONS �!IlfS PA110N5, AND OCCLIPA lIINJ 'A911CII MAY fPIG'VMHER MILE 10 OR USE OF !1�IIS PI'tOPERI Y. IiqqGP, 125C 05 i A.F:- N0. A.UDITOR'5 CERTIFICATE ��/z 3UI�YEYOR'S CERTIFICATE+' P,L ORD OF dJdZ7JEY F0_n,: usl- � FII F""I) FOR RECORD THIS 7 -1 , _ UAv OF f,�1uy 7999, _ I': 'Cx G • THIS MAP CORRECTLY REPRESENTS A SURVEY MADE BY ME OR UNDER MY +� — �e • '�•m (ZS) _i56-2700 d�.4 ,�`' "� u���, �>� ����'4���_�o�, /� AT 3_J_O _�. I,l., IN BOOK --- OF SOR'JEYS, Al PAGE DIRECTION IN CONF01IMIANC'E WITH THE REQUIREMENT'S OF THE SURVF_) ;' b��• 4• n�' � �y SW 1/4. SE 1/4, SEC.24, T.27N., R.3L'„ W.W. AT 711E REOUCST 0! VIESTERN SURVEYORS, INC. RECORDING ACT AT THE REQUEST OF JOEL PATIENCE IN MARCH, % .� �c, �•i L4ND USE CONSULTANTS A,- Or %ATE REv: frY vrc aNACCT .1;1c T; ;clr q E1013 7Efi WILLIGER, I ;('� IAA 199.9 KENNETH L. LONG, PLS C)1/(L ENGINEERS 0 LAND SURVEYORS AS J/99/99 A�1'JIa n,.E):EA/� 3 DJR 7.02.99 �1fX Or F U. NU D.J. KIDDIE A NO. i-. 30' %1, Nc _ __.___ COION,Y AUDITOR i)EI''J,7 COON n' '! II)ITOR REGISTRATION N0. 18911 Tmaz �''S' !:fWG rf1YY 99 SOUTH EJERETf ' WA 48 A 59:JdROS.DN/G GRP 219 Of 4, mob"'•^ - HELD POSITION (MARCH 1999) — : I I L I I 1 , _-------- 1 13 14 15 5.1 1 T —77/777 , 1 , I , 1 1 ' 1 I 1 � 1 1 1 1 ;I � 1 1 110 USE / 1 ' 1 / 1 I 1 i I 1.2-- I ' I 1 1 1 1 , I 1 � : 1 : 1 I CONC. IS 1.4' WEST OF COR. u — EAST 660.00(P)(C) — ®— EAST P 660.00(P)(C)— W YTON S% • o I n --_ 150.00(P)(C) - - 80.00 -__ -- 70.00 -- 16 17 18 : 19 20 1 1 I I 1 I I 1 n 1 I 1 1 ♦0.2" 1 1 1 1 1 1 I a i Lo ^ I 1 1 1 1r •1 I 1 1 HOUSE / O 2.4' 1 j 1 AREA OF POSSIBLE CONTAMINATION 1 536 S0. FT. (PER CLIENT) 1 12.8" JUNE 15, 1999 I I 150.00(P)(C)� - i FOUND REBAR NO CAP (MARCH 1999){ r 0,2 N. tt 0.3 E. OF CALC. COR. 1? 'Grw 30" SET WSI REBAR CAP AT CORNER 1 I ' 1 1 1 7 � 28 27 26 25 24 23 22 21 Ic 1 1 , o 30' WALNUTST EAST 660.00(P)(C) tj7, ilp `o M 956 0111- A MAPLE WAY =n Ln 55 kn V- Q � L n M 1 W o o ON ON > o 0 0 0 MAPLE ST 1: 1,128 O 0 47.02 94.0 Feet This map is a user generated static output from an Internet mapping site and is for reference only. Data layers that appear on this map may or may not be accurate, WGS_1984_Web Mercator_ Auxiliary_Sphere current, or otherwise reliable. © City of Edmonds THIS MAP IS NOT TO BE USED FOR DESIGN OR CONSTRUCTION Legend = Creeks ® Seismic Hazard Areas Earth Subsidence and Landslide) r, L _ Minimum Buffer Adjacent to Ha: Wetlands Wetlands Boundary _ Wetland Boundaries Not Completel Wetland Known Extents Floodplains Q Landslide Hazard Area 40% Severe Erosion Hazard 15%-40% ❑ Erosion Hazard Areas 15%-40% Notes POLICY NUMBER: COMMERCIAL GENERAL LIABILITY NX GL 189 05 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. D. The following are added to SECTION V — DEFINITIONS: "Your work" means work or operations performed by you or on your behalf; and materials, parts or equipment furnished in connection with such work or operations. E. The following additional provisions apply to any entity that is an insured by the terms of this endorsement: Primary Wording With respect to the Third Party shown above, this insurance is primary and non-contributing. Any and all other valid and collectable insurance available to such Third Party in respect of work performed by you under written contractual agreements with said Third Party for loss covered by this policy, shall in no instance be considered as primary, co-insurance, or contributing insurance. Rather, any such other insurance shall be considered excess over and above the insurance provided by this policy. 2. Waiver of Subrogation If required by written contract or agreement: We waive any right of recovery we may have against an entity that is an additional insured per the terms of this endorsement because of payments we make for injury or damage arising out of "you work" done under a contract with that person or organization. oR CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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 have ADDITIONAL INSURED provisions or 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 CNTACT NOME: CERTIFICATES Contractors Insurance NW tAc"c°.IN 206 219-5392 A N : 866 214-8634 PO BOX 13033 E 2AR,tss: certs@a cinwinc.com Olympia, WA 98508 INSURERS AFFORDING COVERAGE NAIC # INSURER A: AM Trust International Underwriters LTD. INSURED INSURER B : DB Home Service LLC INSURER C : PO Box 726 INSURER D : Edmonds, WA98020 INSURERE: INSURER F n llvC�w/+CQ !`COTICI!`ATC \11111A000. nnnnnnnn n RFVICIAN NIIMRFR• 1 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 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. tNSR L U�fi POLICYEFF POLICY LIMITS T TYPE OF INSURANCE POLICY NUMBER YYY MI A X COMMERCIAL GENERAL LIABILITY Y EN115831000 07/15/2018 07/15/2019 EACH OCCURRENCE $ 1,000,000 n• n CLAIMS -MADE rk OCCUR $ 100,000 MED EXP (Any one person) $ 5,000 _ PERSONAL &ADV INJURY $ _1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG X POLICY DC LOC _ $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED PROPERTY DAMAGE (Per eccww) $ AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YINANY PROPRIETOR/PARTNER/EXECUTIVE ER STATUTE J ER _ E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N I A $ E.L. DISEASE -POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) It is understood and agreed that the City of Edmonds is named as an additional insured for the City right-of-way. CERTIFICATE HOLUER t AIVI.CLLAI IUIV City of Edmonds Engineering Division 121 5th Avenue North Edmonds, WA 98020 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. EO REPRESENTATIVE © 1988-2015 ACORD CORPORATION. All rlgnts reservea. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Printed by CER on June 17, 2019 at 10:55AM AmTrust International Underwriters DAC P.O. Box 318004 LM= Cleveland, OH 44131-0880 877-528-7878 GENERAL LIABILITY DECLARATIONS Policy Number EN115831000 Policy Period From 07-15-2018 To 07-15-2019 12:01A.M. Standard Time at the Named Insured's Address Transaction NEW BUSINESS Named Insured and Address Producer CONTRACTORS INSURANCE NW INC DB HOME SERVICE LLC PO BOX 13033 PO BOX 726 OLYMPIA, WA 98508 EDMONDS, WA 98020 Telephone: (503) 922-1458 Business Description Type of Business Audit Period RESIDENTIAL REMODELING Limited Liability Corporation IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. LIMITS OF INSURANCE General Aggregate Limit (Other than Products -Completed Operations) $ 2,000, 000 Products — Completed Operations Aggregate Limit $ 2,000,000 Each Occurrence Limit $ 1,000, 000 Personal and Advertising Injury Limit $ 1, 000, 000 Medical Expense Limit, any one person $ 5,000 Fire Damage Limit, any one fire $ 100, 000 AMENDED LIMITS OF LIABILITY Refer to attached schedule, if any. LOCATIONS OF ALL PREMISES YOU OWN, RENT OR OCCUPY Refer to attached schedule. CLASSIFICATIONS Refer to attached schedule. TOTAL PREMIUM FOR THIS COVERAGE PART $ 5,369.00 OTHER CHARGES $ POLICY FEE (Fully Earned) $ 175.00 STATE TAX $ 110.88 STAMP FEE $ 5.54 TOTAL DUE $ 5,660.42 Forms and Endorsements Applicable to this Policy See attached These Declarations together with the common policy conditions, coverage part declarations, coverage part coverage form(s) and form(s) and endorsements, if any, issued, complete the above numbered policy. Issued Date: 07-11-18 Authorized Signature This contract is registered and delivered as a surplus line coverage under the insurance code of the state of Washington, Title 48 RCW. It is not protected by any Washington state guaranty association law. LICENSED SURPLUS LINES PRODUCER Builders & Tradesmens Insurance Services LICENSE NUMBER 720470 Page 1 of 2 -INSURED- GL330000 WA 0212 AmTrust International Underwriters, DAC P.O. Box 318004 Cleveland, OH 44131-0880 Policy Number: EN115831000 Named Insured: DB HOME SERVICE LLC COMMERCIAL GENERAL LIABILITY EXTENSION OF DECLARATIONS LOCATION OF PREMISES Location of All Premises You Own, Rent or Occupy: 1-1. 1002 DAYTON ST, EDMONDS, WA 98020 PREMIUM Rate Advance Premium Location Classification Code No. Exposure Basis Prem. Ops. Prod/Comp Prem.Ops. Prod/Comp Ops. 1- 1 RESIDENTIAL REMODELING 91340 250,000 (r) INCL 21.48 INCL 5,369 1- 1 ROOFING -RESIDENTIAL 98678 INCL (r) INCL INCL INCL INCL 1- 1 CONTRACTORS EXECUTIVE 91580 INCL (r) INCL INCL INCL INCL SUPERVISORS OR EXECUTIVE SUPERINTENDENTS 1- 1 CONTRACTORS -SUBCONTRACT 91585 INCL (r) INCL INCL INCL INCL WORK-IN CONNECTION WITH CONSTRUCTION, RECON- STRUCTION, REPAIR OR ERECTION OF BUILDINGS Extension of Declarations — Total Advance Annual Premium 5,369.00 Includes copyrighted material of Insurance Services Off ice, Inc., w it h it s permission. Copyright, Insurance Services Off ice, Inc. Issued Date: 07-11-18 GL33000B WA 0212 -INSURED- Page 2 of 2 POLICY NUMBER: EN115831000 COMMERCIAL GENERAL LIABILITY NX GL 189 05 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSUREDS - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Policy Number: EN115831000 Named Insured: Booth, Don, DBA: DB Home Service LLC Endorsement Effective: 7/15/2018 12:01 a.m. Counter Signed By: SCHEDULE Name of Person or Organization: Any person or organization that the named insured is obligated by virtue of a written contract or agreement to provide insurance such as is afforded by this policy. Location: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II — Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to "bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than services, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed: or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. The words "you" and "your" refer to the Named Insured shown in the Declarations. DB Home ServiceLLP II j. A r. Comm;,2-rcial Grpm-ral Labillk,";: A: 1: X� . . . ............. :--- 56 Vorifiad by POFfillor r-- 1 06/03/2019 ------------- 61312019 --- - IZ Contractors, Insurance NW Inc