Loading...
ENG2021-0259 APPROVED ROW PERMITOF WAY MINOR PERMIT PERMITNUMBER, City of Edmonds EdmondsRIGHT 98020 1 1 ' www.cityofedmonds.gov Description: PAVEMENT CORES FOR CITY'S ELM WAY PROJECT ISSUED: 07/28/2021 Address: 121 5TH AVE N EDMONDS WA 98020 EXPIRES: 01/24/2022 rmit Type: RIGHT OF WAY MINOR Permit Subtype: CITY Parcel Number: 00434400100300 i NAME TYPE NAME ADDRESS PHONE APPLICANT HWA Geosciences 21312 30th Dr SE, Bothell WA 98021 (425)774-0106 CONTRACTOR HWA Geosciences 21312 30th Dr SE, Bothell WA 98021 (425)774-0106 OWNER EDMONDS CITY OF 250 5TH AVENUE N, EDMONDS WA 98020 FEE INFORMATION DESCRIPTION AMOUNT PAID CITY TECHNOLOGY FEE CHARGED PER PERMIT $40.00 $0.00 RIGHT OF WAY MINOR PERMIT FEE $110.00 $0.00 REQUIREMENTS REQUIREMENT TYPE NOTES TRAFFIC CONTROL Traffic control and public safety shall be in accordance with City regulations as required by the City Engineer. Every flagger must be trained as required by WAC 296-155-305 and must have certification verifying completion of the required training in their posession. RESTORATION Restoration is to be in accordance with City codes. All street -cut trench work shall be patched with asphalt or City approved material prior to the end of the workday - No Exceptions WARRANTY The contractor is responsible for workmanship and materials for a period of one year following the final inspection and acceptance of the work. INSPECTION SCHEDULING: WWW.MYBUILDING PERMIT.COM 24 HR NOTICE REQUIRED INDEMNITY The Applicant has signed an application which states he/she holds the City of Edmonds harmless from injuries, damages or claims of any kind or description whatsoever, foreseen or unforeseen, that may be made against 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 and attorney fees by reason of granting this permit. THIS DOCUMENT IS NOT VALID UNTIL FEES ARE PAID AND THE CITY ENGINEER OR HIS/HER DEPUTY HAS SIGNED BELOW aW 07/28/2021 RELEASED BY DATE Printed: Wednesday, July 28, 2021 1:04:33 PM 1 of 2 WAY MINOR .UM PERMIT City of • • • Edmonds•:• • ENG2021-0259 www.cityofedmonds. ov/425.771.0220 CONDITIONS CONDITION TYPE Easement and/or permission from adjacent property owner is required prior to entry or work within ADJACENT PROPERTY an adjacent property. It is the owner's responsibility to repair/replace all damage of utilities or frontage improvements in DAMAGE TO FRONTAGE City right of Ways or Easements to City Standards caused by or occurring during the permitted IMPROVEMENTS project. ESC REQ Maintain erosion and sedimentation control per City and SWMMW standard requirements. Sound/Noise originating from temporary construction sites as a result of construction activity are exempt from the noise limits of ECC Chapter 5.30 only during the hours of 7:00am to 6:00pm on SOUND OR NOISE weekdays and 10:00am and 6:00pm on Saturdays, excluding Sundays and Federal Holidays. At all other times the noise originating from construction sites/activities must comply with the noise limits of Chapter 5.30, unless a variance has been granted pursuant to ECC 5.30.120. TRAFFIC CONTROL Traffic Control per approved plan and MUTCD. All Flaggers shall be certified. All utilities shall be located prior to any excavation. New locates shall be called for if at time of UTILITY LOCATES excavation, original locates are no longer identifiable. INSPECTIONS INSPECTION TYPE DATE RESULT COMPLETE Printed: Wednesday, July 28, 2021 1:04:33 PM 2 of 2 ENG2021-0259 of ECIM°tios RECEIVED RIGHT OF WAY CONSTRUCTION PERMIT APPLICATION J U L 23 2021 Complete and submit this Application in accordance with the Submitta:I CITY OF EDMONDS /Ivc. is') Requirements outlined in Right -of -Way permit Handout E6�. DEVELOPMENT SERVICES DEPARTMENT If any field is not applicable to your project, write "N/A' instead of leaving blank. All fields required. Incomplete Applications will be denied. SECTION A General • Project Name Elm Way Walkway Project- City of Edmonds Site Address or if no site address use Property Address at NW corner of project area: City ROW -Various locations, see attachments Associated Permits: BLD PLN ENG Owner and Entity Holding Franchise (if applicable) Name of Company e0 CienceS inc. Franchise Ordinance No: NA Point of Contact Ahmed Mahmoud,a em e Title Geotechnical Engineer Address 31312 30th Dr. SE, Suite 110 city Bothell State WA zip 98021 Phone - - Email AMAHMOUD@HWAGEO.COM Contractor and Authorized Agent of Owner Name of Company Same as above (see note below) Contractor Contacts During Construction Primary Name Same as above Agent Name Title Title Mobile Address Email City State Zip Secondary Name Phone Title Email Mobile City of Edmonds Business License No: 026378 Email State License No: Contractor verifies it is currently bonded Contractor verifies it currently has general liability insurance NOTE: ECDC 18.6o. o2o requires that the Application be signed by a licensed and bonded contractor unless otherwise approved by the city engineer. ❑ Multifamily residential ❑ Commercial ❑ City project ❑ Single family residential subdivision ❑ Single family -other ❑ Industrial ❑ Demo and rebuild or from vacant land? 9 Other, please specify: Traffic control and 2 pavement cares . ❑ Utility Franchise Work associated with development (check one of the above boxes as welt ❑ Traffic Control Only (no associated development) ❑ Utility Franchise Work (no associated development) City of Edmonds ROW construction permit Application --Page 1 of 3 Updated 3/25/2021 Include an overall narrative description of the proposed work. Be specific and detailed: Describe infrastructure to be impacted, such as, poles, wires, conduit, utility mains, etc. Include whether this is construction, maintenance, or repair. Include description of proposed construction methods, (e.g., bores, trenches, overhead wires proposed, depth for underground utilities, etc.) 2 6-inch diameter pavement cores to determine pavement thickness Utility locates will be called prior to drilling to avoid impacting utilities. Upon completion the holes will be backfilled and the ground restored to pre -drilled condition. Pavement will be restored with compacted Aquaphalt or concrete whichever is prefered. Traffic control to consist of flaggers/traffic cones and signs. Traffic control supervisor from TCS will be on site during lane closures and will manage the traffic control signs and cones as drilling moves from one location to the other. All HWA explorations will need a lane closure and flaggers to control the traffic. Please see attachments for boring locations and TCP. RIGHT-OF-WAY CLOSURE AREA TOTAL DURATION (Number of Months) Sidewalk 72 hours + LF x LF SF Alley 72 hours + LF x LF SF Parking 72 hours + LF x LF SF SECTION B - If you are not a utility company performing work in the City ROW, skin to SECTIONC. •e of 1. The work in the right of way is on or for the following type of facilities: ❑ telecommunications ❑ cable ❑ water ❑ sewer ❑ power ❑ storm ❑ gas • • •. • •• 1. Details Does the utility owner have existing overhead infrastructure in the area of work? • 2. 1 Will any equipment be added underground or above ground (e.. pedestals, vaults, etc.)? If yes, describe: 3. Does the proposed work connect a lot or commercial development with utilities that serve more than one lot or commercial development? 4. Does the work involve rebuilding or relocating an existing aboveground utility system which connects a lot or commercial development to an existing underground common utility stem? 5. Does the work involve proposed additions to an aboveground utility system? If es: Are the additions for the purpose of serving new commercial development? Are the additions for the purpose of serving a single-family residential subdivision? Does your project involve rebuilding or replacing utility equipment which currently serves more than one lot or commercial development? If yes, answer the following questions related to project area, i.e. the actual area in which the 6a. I Does your project involve wires/cables/lines? If yes: I How many are existinz? I I How many are to be added? I I I I City of Edmonds ROW construction permit Application --Page 2 of 3 Updated 3/25/2021 6b. Does your project involve poles? If yes: How many poles are existing in the project area? What is the height of the existing poles? How many poles are to be removed? Are additional poles to be laced? How many? I I What is the height of the additionalpoles? 6c. Are any poles to be modified/rebuilt/replaced? If yes: How many? I I What is the height of the poles after? Describe the modification rebuild: SECTION C Traffic Control and Public Safety. Traffic control and public safety shall be in accordance with City regulations as required by the City Engineer. Every flagger must be trained as required by WAC 296-155-305 and must have certification verifying completion of the required training in their possession. Restoration. Restoration shall be in accordance with City codes and Standards. All street cut trench work shall be patched with asphalt or City approved material prior to the end of the workday -NO EXCEPTIONS. Insurance. The City may require the owner or contractor to provide proof of insurance acceptable to the City prior to any permit approval. Indemnification. The Applicant agrees to defend, indemnify, and hold harmless the City of Edmonds, its officials, officers, employees, and agents against any injuries, damages, or claims of any kind or description whatsoever, foreseen or unforeseen, including defense costs and attorney fees, resulting directly or indirectly from any act or omission of the Applicant, its subcontractors, anyone directly or indirectly employed by them, and anyone for whose acts or omissions they may be liable, arising out of, related to, or by reason of the granting of this permit; and specifically including but not limited to all loss by the failure of the Applicant to fully or adequately perform, in any respect, all authorizations or obligations under the permit. These indemnification requirements shall survive the expiration, revocation, or termination of any resulting permit approval. Acceptance of terms, conditions, and requirements. Applicant accepts the terms, conditions, and requirements set forth in this Application and agrees they apply to any resulting permit and shall comply with them to the satisfaction of the City Engineer. Applicant further agrees to comply with the conditions listed on the Submittal Requirements; with all applicable city ordinances, including but not limited to ECDC Title 18; and with all applicable requirements of state and federal law. Statement of Applicant. I declare under penalty of perjury under the laws of the State of Washington that: I am a licensed and bonded contractor; the information provided herein is correct and complete; and I am authorized by owner to act on its behalf and have authority to bind the owner to this application. Fees. The Applicant is responsible for all permit fees. APPLICANT SIGNATURE: oflem.dolahmoud DATE:07/06/2021 APPLICANT PRINTED NAME: AHMED MAHMOUD APPLICANT TITLE: Geotechnical engineer /r �=, �, . _ ri ri i NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE City of Edmonds ROW construction permit Application --Page 3 of 3 Updated 3/25/2021 BUFFER DATA LONGITUDINAL BUFFER SPACE = B SPEED (MPH) 25 30 1 35 1 40 1 45 1 50 1 55 1 60 65 70 LENGTH (feet) 155 200 1 250 1 305 1 360 1 425 1 495 1 570 645 730 TABLE ATTENUATOR ROLL AHEAD DISTANC — HOST VEHICLE 9,900 TO 22,000 lbs. HOST EIGHT > 22,000 lbs. < 45 5-55 MPH > 55 MPH < 45 MPH 45-55 MPH 1 123' 172' 74' 100' PROTECTIVE VEHICLE (WORK VEHICLE) = R NO SPECIFIED DISTANCE REQUIRED ONE LANE . ROAD AHEAD 48" 48" 48" W20-4 48x W20-7A ROAD WORK ARED AHEAD TO STOP 48" 48" LEGEND I� FLAGGING STATION b TEMPORARY SIGN LOCATION D CHANNELIZING DEVICES PROTECTIVE VEHICLE 300' W20-7B W20.7B (OPTIONAL IF 40 MPH OR LESS) RECEIVED Jul 28 2021 CITY OF EDMONDS DEVELOPMENT SERVICES DEPARTMENT SIGN SPACING = X (1) RURAL HIGHWAYS 60 165 MPH 800't RURAL ROADS 45/55 MPH 500't RURAL ROADS & URBAN ARTERIALS 35/40 MPH 350't RURAL ROADS, URBAN ARTERIALS, 25 / 30 MPH RESIDENTIAL & BUSINESS DISTRICTS 200't (2) URBAN STREETS 25 MPH OR LESS 100't 2 (1) ALL SPACING MAY BE ADJUSTED TO ACCOMMODATE INTERSECTIONS AND DRIVEWAYS. (2) THIS SPACING MAY BE REDUCED IN URBAN AREAS TO FIT ROADWAY CONDITIONS. 50' TO 100' 59TO 100' 6 DEVICE 6 DEVICE MINR B MIN. AREA O C 13 W20.7B (OPTIONAL IF 40 MPH OR LESS) 48' B ROAD ED WORK TO STOP AHEAD 48" 48" 48' 48' . W20.7B ONE LANE W20.1 ROAD AHEAD 48" 48" W20-7A W20-4 615RED W20-7B (OPTIONAL IF 0 MPH OR LESS) TO STOP 48' W20-7B \\ 48' ONE -LANE, TWO-WAY TRAFFIC CONTROL WITH FLAGGERS NOT TO SCALE D BY +oe xuxeeN BY 1 BY CON—T NO. —0. N0. GR. T. L ADM. REVISION DATE I BY CHANNELIZATION DEVICE SPACING (FEET) MPH TAPER TANGENT 50/65 10 TO 20 80 35/45 10 TO 20 60 25130 1 10 TO 20 40 NOTES //48 1. ALL SIGNS ARE BLACK ON ORANGE. 2. EXTENDING THE CHANNELIZING DEVICE TAPER ACROSS SHOULDER IS RECOMMENDED. 3. NIGHT WORK REQUIRES ADDITIONAL ROADWAY LIGHTING AT FLAGGING STATIONS. SEE THE STANDARD SPECIFICATIONS FOR ADDITIONAL DETAILS. 4. SEE SPECIAL PROVISIONS FOR WORK HOUR RESTRICTIONS. Amokplot I MAP uffd�o�ds Ne�Er�6"�a TC1� Washington State V Department of Transportation TRAFFIC CONTROL PLAN "N r" r" N It O O N O N W r N o z N W V W M o N LL 0 J ° T en E Ew w i U Z w U Z w U O w NOW A� " CERTIFICATE OF LIABILITY INSURANCE DATE //2021 Y) 07/0707021 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 CONTACT Orion Insurance / Ralph Taylor NAME: Orion Insurance Group (425) 771-5197 FAX(425) 673-4427 A/CONNo Ext : No : 10634 E. Riverside Dr. E-MAIL rtaylor@orioninsgroup.com ADDRESS: INSURERS) AFFORDING COVERAGE NAIL # Suite #300 INSURERA: Travelers Insurance Company 36137 Bothell WA 98011 INSURED INSURER B: CRC -Admiral Insurance Company 24856 IHWA GeoSclences Inc. INSURER C 21312 30th Drive SE, Suite 110 INSURER D INSURER E Bothell WA 98021-7010 INSURER F: COVERAGES CERTIFICATE NUMBER: CL19112604262 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 INSR LTR TYPE OF INSURANCEAUUl INSD WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES Ea occurrence 1,000,000 $ MED EXP (Any one person) $ 10,000 PERSONAL& ADV INJURY $ 1,000,000 A Y Y 680-009N931138-1947 12/01/2020 12/01/2021 AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 OLICY PRO ❑ LOC JECT: RTHER PRODUCTS-COMP/OPAGG $ 2,OOQ000 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 X BODILY INJURY (Per person) $ ANY AUTO A OWNED SCHEDULED AUTOS ONLY AUTOS Y Y BA-3P900632-19-GRP 12/01/2020 12/01/2021 BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ HIRED �/ NON -OWNED AUTOS ONLY /� AUTOS ONLY X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 A EXCESS LIAB CLAIMS -MADE Y Y CUP-003P901597-19-47 12/01/2020 12/01/2021 DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N /A Y 680-009N931138 STOP GAP 12/01/2020 12/01/2021 SPER TATUTE EORH X1 E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1,000,000 $ $3,000,000 Each Claim $75,000 Professional Liability Claims Made B Including Pollution Liability E000003589305 12/01/2020 12/01/2021 $3,000,000Aggregate Deductible DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) R E C E I V E Full Prior Acts for 2m/2m limits and 03/07/2018 for 3m/3m limits. Excess Professional Liability limits of 2m/2m limits over primary professional liability policy-retro date 12/1/2020 through Navigators, Policy# CE20MPLZO71641C. Project Name: Elm Way Walkway J U L 23 2021 David and Evans and Associates, Inc. and City of Edmonds are listed as additional insureds with primary non-contributory wording except with I to professional liability and worker's compensation. 30-days notice of cancellation modification applies to certificate holder. A blanket waiver of subrogation applies in favor of additional insureds for all policies including the worker's compensation and professional liability. CITY OF EDMONDS DEVI PI CERTIFICATE HOLDER CANCELLATION SERVICES DEPARTMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN David Evans and Associates, Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 2100 SW River Parkway AUTHORIZED REPRESENTATIVE Portland OR 97201 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. XTEND ENDORSEMENT FOR ARCHITECTS, ENGINEERS AND SURVEYORS This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE PART GENERAL DESCRIPTION OF COVERAGE — This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to this Coverage Part and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing is a general coverage description only. Read all the provisions of this endorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered A. Non -Owned Watercraft — 75 Feet Long Or Less B. Who Is An Insured — Unnamed Subsidiaries C. Who Is An Insured — Retired Partners, Members, Directors And Employees D. Who Is An Insured — Employees And Volunteer Workers — Bodily Injury To Co -Employees, Co - Volunteer Workers And Retired Partners, Members, Directors And Employees E. Who Is An Insured — Newly Acquired Or Formed Limited Liability Companies F. Blanket Additional Insured — Controlling Interest G. Blanket Additional Insured — Mortgagees, Assignees, Successors Or Receivers PROVISIONS A. NON -OWNED WATERCRAFT — 75 FEET LONG OR LESS 1. The following replaces Paragraph (2) of Exclusion g., Aircraft, Auto Or Watercraft, in Paragraph 2. of SECTION I — COVERAGES — COVERAGE A — BODILY INJURY AND PROPERTY DAMAGE LIABILITY: (2) A watercraft you do not own that is: (a) 75 feet long or less; and (b) Not being used to carry any person or property for a charge: 2. The following replaces Paragraph 2.e. of SECTION II — WHO IS AN INSURED: e. Any person or organization that, with your express or implied consent, either H. Blanket Additional Insured — Governmental Entities — Permits Or Authorizations Relating To Premises I. Blanket Additional Insured — Governmental Entities — Permits Or Authorizations Relating To Operations J. Incidental Medical Malpractice K. Medical Payments — Increased Limit L. Amendment Of Excess Insurance Condition — Professional Liability M. Blanket Waiver Of Subrogation — When Required By Written Contract Or Agreement N. Contractual Liability —Railroads uses or is responsible for the use of a watercraft that you do not own that is (1) 75 feet long or less; and (2) Not being used to carry any person or property for a charge, B. WHO IS AN INSURED — UNNAMED SUBSIDIARIES The following is added to SECTION II — WHO IS AN INSURED: Any of your subsidiaries, other than a partnership or joint venture, that is not shown as a Named Insured in the Declarations is a Named Insured if: a. You are the sole owner of, or maintain an ownership interest of more than 50% in such subsidiary on the first day of the policy period; and CG D3 79 02 19 C 20.7 The Travelers Indemnity Company All rights reserved Page 1 of 6 Includes copyrighted materia, of Insurance Services Office, Inc with its permission COMMERCIAL GENERAL LIABILITY b. Such subsidiary is not an insured under similar other insurance. No such subsidiary is an insured for "bodily injury" or "property damage" that occurred, or "personal and advertising injury" caused by an offense committed: a. Before you maintained an ownership interest of more than 50% in such subsidiary; or b. After the date, if any, during the policy period that you no longer maintain an ownership interest of more than 50% in such subsidiary. For purposes of Paragraph 1. of Section II — Who Is An insured, each such subsidiary will be deemed to be designated in the Declarations as - a. A limited liability company; b. An organization other than a partnership, joint venture or limited liability company, or c. A trust; as indicated in its name or the documents that govern its structure. C. WHO IS AN INSURED — RETIRED PARTNERS, MEMBERS, DIRECTORS AND EMPLOYEES The following is added to Paragraph 2. of SECTION II —WHO IS AN INSURED: Any person who is your retired partner, member. director or "employee" that is performing services for you under your direct supervision, but only for acts within the scope of their employment by you or while performing duties related to the conduct of your business. However, no such retired partner. member, director or "employee" is an insured for. (1) "Bodily injury -.- (a) To you, to your current partners or members (if you are a partnership or joint venture), to your current members (if you are a limited liability company) or to your current directors; (b) To the spouse, child. parent, brother or sister of that current partner, member or director as a consequence of Paragraph (1)(a) above; (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraph (1)(a) or (b) above; or (d) Arising out of his or her providing or failing to provide professional health care services. Unless you are in the business or occupation of providing professional health care services, Paragraphs (1)(a), (b), (c) and (d) above do not apply to "bodily injury" arising out of providing or failing to provide first aid or "Good Samaritan services" by any of your retired partners, members, directors or "employees", other than a doctor. Any such retired partners, members, directors or "employees" providing or failing to provide first aid or "Good Samaritan services" during their work hours for you will be deemed to be acting within the scope of their employment by you or performing duties related to the conduct of your business. (2) "Personal injury": (a) To you, to your current or retired partners or members (if you are a partnership or joint venture), to your current or retired members (if you are a limited liability company), to your other current or retired directors or "employees" while in the course of his or her employment or performing duties related to the conduct of your business, or to your other "volunteer workers" while performing duties related to the conduct of your business; (b) To the spouse, child, parent, brother or sister of that current or retired partner, member, director, "employee" or "volunteer worker" as a consequence of Paragraph (2)(a) above; (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraph (2)(a) or (b) above; or (d) Arising out of his or her providing or failing to provide professional health care services. (3) "Property damage" to property: (a) Owned, occupied or used by; or (b) Rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by; you, any of your retired partners, members or directors, your current or retired "employees" or "volunteer workers", any current partner or member (if you are a partnership or joint venture), or any current member (if you are a limited liability company) or current director. Page 2 of 6 © 2017 The Travelers Indemnity Company All rights reserved CG D3 79 02 19 Includes copyrighted matenat of Insurance Services Otfxe inc with its permission D. WHO IS AN INSURED — EMPLOYEES AND VOLUNTEER WORKERS — BODILY INJURY TO CO -EMPLOYEES, CO -VOLUNTEER WORKERS AND RETIRED PARTNERS, MEMBERS, DIRECTORS AND EMPLOYEES The following is added to Paragraph 2.a.(1) of SECTION II —WHO IS AN INSURED: Paragraphs (1)(a), (b) and (c) above do not apply to "bodily injury" to a current or retired co - "employee" while in the course of the co - "employee's" employment by you or performing duties related to the conduct of your business, or to "bodily injury" to your other "volunteer workers" or retired partners, members or directors while performing duties related to the conduct of your business. E. WHO IS AN INSURED — NEWLY ACQUIRED OR FORMED LIMITED LIABILITY COMPANIES The following replaces Paragraph 3, of SECTION II —WHO IS AN INSURED: 3. Any organization you newly acquire or form, other than a partnership or joint venture, and of which you are the sole owner or in which you maintain an ownership interest of more than 50%, will qualify as a Named Insured if there is no other similar insurance available to that organization. However: a. Coverage under this provision is afforded only (1) Until the 180th day after you acquire or form the organization or the end of the policy period whichever is earlier, if you do not report such organization in writing to us within 180 days after you acquire or form it; or (2) Until the end of the policy period, when that date is later than 180 days after you acquire or form such organization, if you report such organization in writing to us within 180 days after you acquire or form it; b. Coverage A does not apply 10 "bodily injury" or "property damage" that occurred before you acquired or formed the organization; and c. Coverage B does not apply to "personal and advertising injury" arising out of an offense committed before you acquired or formed the organization For the purposes of Paragraph 1. of Section II — Who Is An Insured, each such COMMERCIAL GENERAL LIABILITY organization will be deemed to be designated in the Declarations as: a. A limited liability company; b. An organization other than a partnership. joint venture or limited liability company; or c. A trust; as indicated in its name or the documents that govern its structure. F. BLANKET ADDITIONAL INSURED — CONTROLLiNG INTEREST 1. The following is added to SECTION i1 — WHO IS AN INSURED: Any person or organization that has financial control of you is an insured with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" that arises out of: a. Such financial control; or b. Such person's or organization's ownership, maintenance or use of premises leased to or occupied by you. The insurance provided to such person or organization does not apply to structural alterations, new construction or demolition operations performed by or on behalf of such person or organization. 2. The following is added to Paragraph 4. of SECTION II —WHO IS AN INSURED - This paragraph does not apply to any premises owner, manager or lessor that has financial control of you. G. BLANKET ADDITIONAL INSURED — MORTGAGEES, ASSIGNEES, SUCCESSORS OR RECEWERS The following is added to SECTION II — WHO IS ANINSURED Any person or organization that is a mortgagee, assignee, successor or receiver and that you have agreed in a written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only with respect to its liability as mortgagee, assignee, successor or receiver for "bodily injury", "property damage" or "personal and advertising injury" that: a. Is "bodily injury" or "property damage" that occurs, or is "personal and advertising injury" caused by an offense that is committed, CG D3 79 02 19 m 2017 The Travelers ndemni y Company All rights reserved. Page 3 of 6 includes copyrighted material of Insurance Services Office, Inc with its permission. COMMERCIAL GENERAL LIABILITY subsequent to the signing of that contract or agreement; and b. Arises out of the ownership, maintenance or use of the premises for which that mortgagee, assignee, successor or receiver is required under that contract or agreement to be included as an additional insured on this Coverage Part The insurance provided to such mortgagee. assignee, successor or receiver is subject to the following provisions a. The limits of insurance provided to such mortgagee, assignee successor or receiver will be the minimum limits that you agreed to provide in the written contract or agreement or the limits shown in the Declarations whichever are less. b. The insurance provided to such person or organization does not apply to (1) Any "bodily injury" or "properly damage" that occurs, or any "personal and advertising injury" caused by an offense that is committed after such contract or agreement is no longer in effect, or (2) Any "bodily injury", "property damage" or "personal and advertising injury" arising out of any structural alterations. new construction or demolition operations performed by or on behalf of such mortgagee assignee, successor or receiver H. BLANKET ADDITIONAL INSURED — GOVERNMENTAL ENTITIES — PERMITS OR AUTHORIZATIONS RELATING TO PREMISES The following is added to SECTION 11 -- WHO IS AN INSURED Any governmental entity that has issued a permit or authorization with respect to premises owned or occupied by, or rented or loaned to. you and that you are required by any ordinance law, building code or written contract or agreement to include as an additional insured on this Coverage Part is an insured but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" arising out of the existence ownership, use, maintenance, repair, construction, erection or removal of any of the following for which that governmental entity has issued such permit or authorization, advertising signs. awnings, canopies, cellar entrances, coal holes driveways, manholes. marquees, hoist away openings, sidewalk vaults, elevators, street banners or decorations, I. BLANKET ADDITIONAL INSURED — GOVERNMENTAL ENTITIES — PERMITS OR AUTHORIZATIONS RELATING TO OPERATIONS The following is added to SECTION II — WHO 1S AN INSURED Any governmental entity that has issued a permit or authorization with respect to operations performed by you or on your behalf and that you are required by any ordinance, law, building code or written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only with respect to liability for "bodily injury" "property damage" or "personal and advertising injury" arising out of such operations The insurance provided to such govemmental entity does not apply to: a. Any "bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the governmental entity; or b. Any "bodily injury" or "property damage" included in the "prod ucts•completed operations hazard". J. INCIDENTAL MEDICAL MALPRACTICE 1. The following replaces Paragraph b. of the definition of "occurrence in the DEFINITIONS Section b. An act or omission committed in providing or failing to provide "incidental medical services", first aid or "Good Samaritan services" to a person, unless you are in the business or occupation of providing professional health care services. 2. The following replaces the last paragraph of Paragraph 2.a.(1) of SECTION II —WHO IS AN INSURED: Unless you are in the business or occupation of providing professional health care services, Paragraphs (1)(a), (b), (c) and (d) above do not apply to "bodily injury' arising out of providing or failing to provide (a) "Incidental medical services" by any of your "employees" who is a nurse. nurse assistant, emergency medical technician, paramedic, athletic trainer, audiologist, dietician. nutritionist, Page 4 of 6 . ZOt? The Travelers Indemnity Company All rights reserved CG D3 79 02 19 ncludes copyrighted material of Insurance Services Office Inc with its permission occupational therapist or occupational therapy assistant, physical therapist or speech -language pathologist; or (b) First aid or "Good Samaritan services" by any of your "employees" or "volunteer workers", other than an employed or volunteer doctor. Any such "employees" or "volunteer workers" providing or failing to provide first aid or "Good Samaritan services" during their work hours for you will be deemed 10 be acting within the scope of their employment by you or performing duties related to the conduct of your business. 3. The following replaces the last sentence of Paragraph 5. of SECTION III — LIMITS OF INSURANCE For the purposes of determining the applicable Each Occurrence Limit, all related acts or omissions committed in providing or failing to provide "incidental medical services", first aid or "Good Samaritan services" to any one person will be deemed to be one "occurrence". 4. The following exclusion is added to Paragraph 2., Exclusions, of SECTION I — COVERAGES — COVERAGE A — BODILY INJURY AND PROPERTY DAMAGE LIABILITY: Safe Of Pharmaceuticals "Bodily injury" or "property damage" arising out of the violation of a penal statute or ordinance relating to the sale of pharmaceuticals committed by, or with the knowledge or consent of the insured. 5. The following is added to the DEFINITIONS Section: "Incidental medical services" means: a. Medical, surgical, dental, laboratory, x- ray or nursing service or treatment, advice or instruction, or the related furnishing of food or beverages; or b. The furnishing or dispensing of drugs or medical, dental, or surgical supplies or appliances. COMMERCIAL GENERAL LIABILITY that is available to any of your "employees" for "bodily injury" that arises out of providing or failing to provide "incidental medical services" to any person to the extent not subject to Paragraph 2.a.(1) of Section II — Who Is An insured. K. MEDICAL PAYMENTS — INCREASED LIMIT The following replaces Paragraph 7. of SECTION III — LIMITS OF INSURANCE: 7. Subject to Paragraph 5. above, the Medical Expense Limit is the most we will pay under Coverage C for all medical expenses because of "bodily injury" sustained by any one person, and will be the higher of: a. $10,000; or b. The amount shown in the Declarations of this Coverage Part for Medical Expense Limit L. AMENDMENT OF EXCESS INSURANCE CONDITION — PROFESSIONAL LIABILITY The following is added to Paragraph 4.b., Excess Insurance, of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS This insurance is excess over any of the other insurance, whether primary, excess, contingent or on any other basis. that is Professional Liability or similar coverage, to the extent the loss is not subject to the professional services exclusion of Coverage A or Coverage B M. BLANKET WAIVER OF SUBROGATION — WHEN REQUIRED BY WRITTEN CONTRACT OR AGREEMENT The following is added to Paragraph 8., Transfer Of Rights Of Recovery Against Others To Us. of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS If the insured has agreed in a written contract or agreement to waive that insured's right of recovery against any person or organization, we waive our right of recovery against such person or organization, but only for payments we make because of: 6. The following is added to Paragraph 4.b., a. "Bodily injury" or "property damage that Excess Insurance, of SECTION IV — occurs; or COMMERCIAL GENERAL LIABILITY CONDITIONS: b. "Personal and advertising injury" caused by This insurance is excess over any valid and an offense that is committed. collectible other insurance, whether primary, subsequent to the signing of that contract or excess, contingent or on any other basis, agreement CG D3 79 02 19 m 2017 The Travelers Indemnity Company All rights reserved Page 5 of 6 Includes copyrighted material of Insurance Services Office, Inc with its permission COMMERCIAL GENERAL LIABILITY N. CONTRACTUAL LIABILITY— RAILROADS 1. The following replaces Paragraph c. of the definition of "insured contract" in the DEFINITIONS Section: c. Any easement or license agreement; 2. Paragraph f.(1) of the definition of "insured contract" in the DEFINITIONS Section is deleted. Page 6 of 6 Q 2017 The Travelers Indemnity Company All rights reserved CG D3 79 02 19 Includes copyrighted matena of .nsurance Services Office Inc with its permission POLICY NUMBER: 680-9N931138-20-47 EFFECTIVE DATE: 12/01/2020 ISSUE DATE: 11/23/2020 LISTING OF FORMS, ENDORSEMENTS AND SCHEDULE NUMBERS THIS LISTING SHOWS THE NUMBER OF FORMS, SCHEDULES AND ENDORSEMENTS BY LINE OF BUSINESS IL TO 19 02 05 COMMON POLICY DECLARATIONS * IL TO 25 08 01 RENEWAL CERTIFICATE * MP TO 01 02 05 BUSINESSOWNERS COVERAGE PART DECLARATIONS * IL T8 01 01 01 FORMS ENDORSEMENTS AND SCHEDULE NUMBERS IL T3 16 05 12 COMMON POLICY CONDITIONS - WASHINGTON * MP TO 33 04 09 MASTER PAC ACCOUNT EXPOSURE ENDORSEMENT BUSINESSOWNERS MP T1 30 02 05 TABLE OF CONTENTS - BUSINESSOWNERS COVERAGE PART - DELUXE PLAN MP PO 06 09 15 ARCHITECTS, ENGINEERS AND SURVEYORS PROPERTY ENHANCEMENT MP T1 02 02 05 BUSINESSOWNERS PROPERTY COVERAGE SPECIAL FORM MP Tl 05 02 05 AMENDATORY PROVISIONS - OFFICES * MP T3 07 03 97 PROTECTIVE SAFEGUARDS ENDORSEMENT FOR SPRINKLERED LOCATIONS AND RESTAURANTS MP T3 25 01 15 FEDERAL TERRORISM RISK INSURANCE ACT DISCLOSURE MP T3 50 11 06 EQUIPMENT BREAKDOWN - SERVICE INTERRUPTION LIMITATION MP T3 56 02 08 AMENDATORY PROVISIONS - GREEN BUILDING AND BUSINESS PERSONAL PROP COV ENHANCEMENTS CP 01 60 12 98 WASHINGTON CHANGES - DOMESTIC ABUSE MP T4 31 07 16 WASHINGTON CHANGES COMMERCIAL GENERAL LIABILITY * CG D4 69 02 19 TOT AGG LIMIT OTHER THAN PROJECTS CG TO 34 02 19 TABLE OF CONTENTS - COMMERCIAL GENERAL LIABILITY COVERAGE FORM CG Tl 00 02 19 CG Tl 00 02 19 COMMERCIAL GENERAL LIABILITY COVERAGE FORM * CG D2 69 04 16 ADDL INS -STATE OR POL SUBDIV-PERMITS CG D3 09 02 19 AMENDATORY ENDORSEMENT - PRODUCTS -COMPLETED OPERATIONS HAZARD CG D3 81 09 15 BLANKET ADDITIONAL INSURED (ARCHITECTS, ENGINEERS AND SURVEYORS) CG D6 75 02 19 AMEND -WHO IS INS-ARCHIT/ENG/SURVEY ACTIV CG D2 03 12 97 AMEND - NON CUMULATION OF EACH OCC * CG T8 01 12 20 GENERAL, PURPOSE ENDORSEMENT CG D3 79 02 19 XTEND ENDORSEMENT FOR ARCHITECTS, ENGINEERS AND SURVEYORS CG D3 80 10 11 EXCLUSION - ENGINEERS, ARCHITECTS OR SURVEYORS PROFESSIONAL LIABILITY CG D4 21 07 08 AMEND CONTRAL LIAB EXCL - EXC TO NAMED INS "TEXT IN THIS FORM HAS CHANGED, OR THE FORM WAS NOT ON POLICY BEFORE. IL T8 01 01 01 PAGE: 1 OF 2 POLICY NUMBER: 680-9N931138-20-47 EFFECTIVE DATE: 12/01/2020 ISSUE DATE: 11/23/2020 COMMERCIAL GENERAL LIABILITY (CONTINUED) CG D6 18 10 11 EXCLUSION - VIOLATION OF CONSUMER FINANCIAL PROTECTION LAWS CG DO 76 06 93 EXCLUSION - LEAD CG D1 42 02 19 EXCLUSION - DISCRIMINATION CG F2 58 01 08 WASHINGTON CHANGES CG F2 66 02 19 WASHINGTON CHANGES - EMPLOYMENT -RELATED PRACTICES EXCLUSION EMPLOYMENT PRACTICES LIABILITY + PR TO 07 02 15 EMPLOYMENT PRACTICES LIAB COVG PART DEC PR T1 10 04 09 EMPLOYMENT PRACTICES LIABILITY COVERAGE FORM PR T5 23 03 15 COVG FOR FINANCIAL INTEREST IN FOREIGN ORGANIZATIONS -EMPLOYMENT PRACTICES LIABILITY PR F1 55 04 09 WASHINGTON MANDATORY ENDORSEMENT MULTIPLE SUBLINE ENDORSEMENTS CG T3 33 11 03 LIMITATION WHEN TWO OR MORE POLICIES APPLY INTERLINE ENDORSEMENTS IL T3 68 01 15 FEDERAL TERRORISM RISK INSURANCE ACT DISCLOSURE IL T4 12 03 15 AMNDT COMMON POLICY COND-PROHIBITED COVG IL T4 14 01 15 CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM IL T3 82 05 13 EXCLUSION OF LOSS DUE TO VIRUS OR BACTERIA IL 01 23 11 13 WASHINGTON CHANGES - DEFENSE COSTS IL 01 57 07 02 WASHINGTON CHANGES - ACTUAL CASH VALUE IL 01 73 07 02 WASHINGTON CHANGES - EXCLUDED CAUSES OF LOSS IL 01 98 09 08 NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT (BROAD FORM) POLICY HOLDER NOTICES * PN T4 54 01 08 IMPORTANT NOTICE REGARDING INDEPENDENT AGENT AND BROKER COMPENSATION * PN T5 86 04 09 EPL+ - RISK MANAGEMENT LETTER * PN MP 57 04 17 IMP NOT PROT SAFEGUARDS SPRK AND REST * PN T7 72 07 11 IMPORTANT NOTICE - EMPLOYMENT PRACTICES LIABILITY HOTLINE PN MP 38 01 11 IMPORTANT NOTICE - JURISDICTIONAL INSPECTIONS * TEXT IN THIS FORM HAS CHANGED, OR THE FORM WAS NOT ON POLICY BEFORE. IL T8 01 01 01 PAGE: 2 OF 2 POLICY NUMBER: BA-2R034194-20-47-G EFFECTIVE DATE: 12/01/2020 ISSUE DATE: 10/21/2020 LISTING OF FORMS, ENDORSEMENTS AND SCHEDULE NUMBERS THIS LISTING SHOWS THE NUMBER OF FORMS, SCHEDULES AND ENDORSEMENTS BY LINE OF BUSINESS IL TO 02 11 89 IL TB O1 01 01 IL TO 05 06 10 COMMERCIAL AUTO CA TO 01 02 15 CA TO 02 02 15 CA TO 03 02 15 CA TO 30 02 16 CA TO 31 02 15 CA 00 01 10 13 CA 01 35 10 13 CA 21 34 10 13 CA 99 03 10 13 CA T4 59 02 15 CA T3 53 02 15 INTERLINE ENDORSEMENTS COMMON POLICY DECLARATIONS FORMS ENDORSEMENTS AND SCHEDULE NUMBERS COMMON POLICY CONDITIONS - WASHINGTON BA- COVERAGE PART DECS (ITEMS 1 & 2) BUSINESS AUTO COVERAGE PART DECLARATIONS (ITEM 3) BUS AUTO COV PART DECLARATIONS-4&5 BUSINESS AUTO/MC COV PART -UM SUPPL SCHD TABLE OF CONTENTS -BUSINESS AUTO COV FORM BUSINESS AUTO COVERAGE FORM WASHINGTON CHNG WASHINGTON UNDERINSURED MOTORISTS COVERAGE AUTO MEDICAL PAYMENTS COVERAGE AMENDMENT OF EMPLOYEE DEFINITION BUSINESS AUTO EXTENSION ENDORSEMENT IL T4 12 03 15 AMNDT COMMON POLICY COND-PROHIBITED COVG IL O1 23 11 13 WASHINGTON CHANGES - DEFENSE COSTS IL 01 98 09 OB NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT (BROAD FORM) IL T8 0101 01 PAGE: 1 OF 1 POLICY NUMBER: CUP-3P901597-20-47 EFFECTIVE DATE: 12/01/2020 ISSUE DATE: 11/23/2020 LISTING OF FORMS, ENDORSEMENTS AND SCHEDULE NUMBERS THIS LISTING SHOWS THE NUMBER OF FORMS, SCHEDULES AND ENDORSEMENTS BY LINE OF BUSINESS IL T8 01 01 01 FORMS ENDORSEMENTS AND SCHEDULE NUMBERS UMBRELLA / EXCESS EU 00 02 09 20 POLICY DECLARATIONS EXCESS FOLLOW -FORM AND UMBRELLA LIABILITY INSURANCE POLICY EU 00 03 08 18 SCHEDULE OF UNDERLYING INSURANCE EU 00 01 07 16 EXCESS FOLLOW -FORM AND UMBRELLA LIABILITY INSURANCE EU 02 34 07 16 AMENDMENT OF COVERAGE - DEFINITIONS EU 03 46 08 18 NON CUMULATION OF OCCURRENCE LIMIT EU 01 44 07 16 COVERAGE FOR FINANCIAL INTEREST IN FOREIGN INSURED ORGANIZATIONS EU 03 15 08 18 AMENDMENT OF UNDERLYING INSURANCE DEFINITION EU 00 07 07 16 CAP LOSSES - CERT ACTS TERRORSM AND EXCL EU 01 30 08 1B ARCHITECT, ENGINEER OR SURVEYOR PROFESSIONAL SERVICES EXCLUSION - COVERAGE B EU 01 48 08 18 DAMAGE TO PROPERTY EXCLUSION - COVERAGE A EU 02 09 08 18 NUCLEAR ENERGY LIABILITY EXCLUSION (BROAD FORM) - COVERAGES A AND B EU 02 90 07 16 WATERCRAFT LIABILITY EXCLUSION - COVERAGE B EU 03 31 08 18 DISCRIMINATION EXCLUSION - COVERAGE B EU 03 44 08 18 LEAD EXCLUSION - COVERAGE B EU 00 74 07 16 WASHINGTON CHANGES INTERLINE ENDORSEMENTS IL T3 68 01 15 FEDERAL TERRORISM RISK INSURANCE ACT DISCLOSURE IL T8 01 0101 PAGE: 1 OF 1