HomeMy WebLinkAbout100 W OLIVE ST - Filed P-PERMITS -Planning. Development & TransportationEngineering Depamncint P08ox580 281 NColegeAveFort Collins, CO 80524 970•221-8605 P 970.224--6134 F
Revocable Encroachment Permit for
Portable Sign in the Right-of-Way (minimum of 5 bulfn888 days iequlred for approval)
Applicant Name: t--1o..w-Qf" �ho0n
Company: Arno:w.. f-.1,,.):Wj, J},..,,0::11 o.m\ h),\\M\
AddreaaofSlgnLocatlon: )Do w. 0\�v, S-\..
City, State, Zip: 'Fo-<� Co\\;¥\'\, Co, 4\0S"i"\
Phone: 9, 1 Q -4 'i ':\ , l v,:'.rl
Company Addresa If different than Sign Address:-------------------
City, State, Zip:_-__________________________ _
Contact Name: __________ _ Contact Emall:_-__________ _
AppUcant agl'HS to submit with this pannlt appllcatlon a minimum 8 112• x 11• dlmenslonal drawing that UluatretN the location of the ptopOHd portable si gn. obstruction(•) or other alnlctun, or amenltln In the publlo right-of-way. Applicant muat also eubmlt the Indemnity AgNement and a c:o py of the Certfflcate oflnaurance with the City of Fon Collln• Engineering Dept • Additional lnslfflld.
Thie pennlt le non-transferable, la per90nal to the Applicant and la non-8881gnable. Applicant agrees that any transfer of ownership of the business holding the permit wlll terminate this permit and require a new appllcatlon to be flied by the new owner.
Applicant has ..ct this permit and agrees to abide by the current City of Foo Collins Municipal Codes, Standard Specfflcatlons and any such speclal conditions, restrictions and regulations that may be Im posed by the Cfty En gineer.
Appllcanls Signature: 2/7�.{4
Engineering Approval: _..;ai;::;::;;..."""'""'......,-t:=,......:.;;; ....... �:a.._-
Appllcetlon Fee: $_.1__.0-=-.Q=Q-=---------
oate:_l..._1/;_,_f /4""""""-f __ _
Date: _--''.L.4i...,;;;:;l=-----
Total Due: $._.1..a::0a.:...Q=-0=------
Condltlons: ____________________________ _
•Yleed 04116/2011 Permit Number: __________ _ 23-15013
Paid $10.00 CC0623 01.23.2023
. -
Cl�ofOf"t�OlllnS
INDEMNITY AGREEMENT FOR PORTABLE SIGN PERMRS
The Pcrmittcc hereby convenants that it will indemnify and hold the Lessor harmless from all claims. demands, judgments, costs and expenses, including attomey•s fees arising out of any accident or occurrence causing injury to any person or property whosoever or whatsoever due directly or indirectly to the issuance of the portable sip pennit and the placement and use of the permitted portable sign by the Pcrmittee and its agents and employees. unless such accident or occurrence results ftom any tortuous misconduct or negligent act or omission on the part of the City, its agents and employees.
Dated this __ c,_+_h __ day of J�"'\.0-f'!!,
Pennittee Name: MMIM> [o..\oo,;;r.
By: �Y!-� :::t"ha.re,¥1 a b)�\\J\i4k
Title: As,"!.;A:.½: � '1�\'\.cn-e,.l �.
,20 23
Address of Portable Sign: \ 00 ',.,). Qhvc. S>\:. I ro,� Ui\\M, Co, $051,
______, ACORD® CERTIFICATE OF LIABILITY INSURANCE r DATE IMM/DD/VYYYI 12/15/2022
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 INSURERISJ, AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is en ADDITIONAL INSURED. the policyliesl must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms end conditions of the policy. certain policies may require an endorsement. A statement on
this certificate does not confer righta to the certificate holder in lieu of such endorsement(s).
PRODUCER s��i�cT IMA SELECT LLC PHONE I FAX IA/C, No. Ex1I: 18881 881-3938 fA/C. Nol: (8771872-7604 1705 17TH ST STE 100 �-�n��ct.C!: • Nrvlce.cen1•rtlttravel•r•.eom DENVER, CO 80202 18881 661-3938 INSURERCSI AFFORDING COVERAGE NAIC II
INSURER A: TRAVELERS CASUALTY INSURANCE COMPANY OF AMERICA
INSURED INSURER B : THE PHOENIX INSURANCE COMPANY AMARA MASSAGE THERAPY & WELLNE 100 W OLIVE ST INSURER C: FORT COLLINS, CO 80524 INSURER 0:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER· 614662915510053 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 SUBJECT TO ALL THE TERMS, EXCLUSIONS ANO CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDI SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMM/DD/VYYYI IMM/DD/YYYYI LIMITS
A .__ X 680-6K219116-23 02/07/2023 02/07/2024 EACH OC(llJRRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY "'"M""c I U nc" , c"' = □CLAIMS-MADE IX] OCCUR pc,cuoccc ,�. $300,000 MED EXP (Anv one cerson) $5 000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000.000 � POLICY □ ��gT □LDC ----,--�. l'"nuo,no .. ,.,. $2 000,000 OTHER:
AUTOMOBILE LIABILITY COMBINED SING�E UMIT IEa a,;<;identl $
I--ANY AUTO BODILY INJURY !Per personl $ OWNED §"'"""' .__ AUTOS ONLY AUTOS BODILY INJURY IPer ecc,denll HIRED NON-OWNED PROPERTY DAMAGE.__ AUTOS ONLY AUTOS ONLY IPer accidentl $
.__ UMBRELLA UAB HOCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE .__ DEDLJ RETENTION $ AGGREGATE $
$
B WORKERS COMPENSATION N/A UB-6K268516-23 02/07/2023 02/07/2024 X jPER I IOTH•
AND EMPLOYERS' LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE □E.L. EACH ACCIDENT $100 000 OFFICER/MEMBER EXCLUDED? $100,000 (Mandatory In NHI e:,L, DISEASE • EA EMPLOYEE �,:�n1:ri&� OFndOPERATIONS below E .. L. DISEASE -POLICY LIMIT $500,000
DESCRIP TION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101. Additional Remuko Schedule, may be eneched If more apace lo required) j,:,-:�CE!VF"l1 AS RESPECTS TO GENERAL LIABILITY. CERTIFICATE HOLDER IS ADDITIONAL INSURED -STATE OR POLITICAL SUBDIVISIONS -PERMITS RELATING PREMISES, CG 20 13, FOR: DEC ') 2022 100 W OLIVE ST, FORT COLLINS, CO 80524 ·�
BY: ...................... , .. ,1 .
CERTIFICATE HOLDER CANCELLATION CITY OF FORT COLLINS ATTN: ENGINEERING D SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 281 N COLLEGE AVE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO BOX 580 ACCORDANCE WITH THE POLICY PROVISIONS. FORT COLLINS. CO 80522 AUTHORIZED REPRESENTATIVE 1..(.d� .. ,/&;-
I
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