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PFI2020-00333
CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT i III _ COMMUNITY DEVELOPMENT Permit#: PFI2020-00333 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 09/24/2020 Parcel: 2S103DA05401 Jurisdiction: Tigard Site address: 13405 SW 107TH AVE Subdivision: None Lot: None Project: 107th Ave Sewer Connection Project Description: Disconnect from on-site septic and connect to public sewer Class of Work: FEES Type 2-Sidewalk/Driveway Approach Description Date Amount PFI Permit Fee 09/24/2020 $300.00 Owner: Total $300.00 REQUIRED INSPECTIONS Call 503-639-4175 for the IVR inspection request line or visit the City of PHONE: Tigard website at www.tiqard-or.qov to schedule inspections online. Contractor: PHONE: Applicant: JOE BELL PHONE: 5033578892 Please sign below to indicate acceptance of conditions and return a copy with the proposed work schedule along with names and contact information of responsible parties before beginning work. PermitteelApplicant Signature: See ap ^✓'`"l^v application off ' Issued By: ArrIA o Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY r Conditions for PF12020-00333 Type: Condition Name: Status: Severity: PFI_Sidewalk/[ 01 -WORK SITE REQUIREMENTS Applied Notice Applicant must comply with all applicable provisions of federal and state law,the Tigard Municipal Code, and the terms of any agreement with the City of Tigard regarding work to be done pursuant to this permit. PFI_Sidewalk/[ 02-WORK SITE AREA Applied Notice The work area and approach roads shall be maintained in a clean condition,free from obstructions and hazards. The spreading of mud or debris or storage of materials or equipment of any kind upon any public roadway is strictly prohibited and violation shall be cause for immediate cancellation of the permit. The City may at any time order immediate clean-up and suspension of work to accomplish clean-up. PFI_Sidewalk/[ 03-WORK SITE EROSION CONTROL Applied Notice Prior to starting work, effective and approved erosion control devices must be installed and maintained meeting the Clean Water Services and DEQ requirements. The City may at any time order corrective action and suspension of work to accomplish effective erosion control. PFI_Sidewalk![ 04-WORK SITE REPAIRS Applied Notice Disturbed landscaped areas shall be restored or replaced. Existing signs, pavement markings, mailboxes,etc. shall be reinstalled or replaced, with like kind of material. Obtain City approval of restoration work. PFI_Sidewalk/[ 05-TRAFFIC CONTROL SPECIFICATIONS Applied Notice Applicant shall provide traffic control according to the current edition of the"Manual on Uniform Traffic Control Devices [MUTCD]for Streets and Highways", U.S. Dept. of Transportation, FHWA, current edition,American Traffic Safety Services Association[ATSSA], and Oregon Temporary Traffic Control Handbook[OTTCH]. PFI_Sidewalk/[ 06-TRAFFIC CONTROL PLAN Applied Notice Submit a job specific traffic control plan. A copy of the approved traffic control plan shall be readily available at the work area. Traffic control devices,flag persons, etc.,shall be in place prior to initiation of construction work and shall be effectively maintained. PFI_Sidewalk/[ 07-TRAFFIC CONTROL ROAD CLOSURE Applied Notice Public roadway shall not be closed to traffic, at any time,without obtaining written approval from the City Engineer. The applicant is responsible to provide 48 hour advance notice of traffic flow disruptions to affected businesses, residents and area wide Emergency Services: 503-629-0111 (Tigard Police Dept., Tualatin Fire& Rescue)and to 503-962-8140(Tri-Met) and 503-431-2345(Tigard School District)and other service providers impacted by such closure. PFI_Sidewalkl[ 08-TRAFFIC CONTROL ADVANCE WARNING Applied Notice Advance warning of traffic disruption shall be provided to the public by placement of an approved advance notification sign at each end of the construction area 72 hours(min.) before initiation of construction work. PFI_Sidewalk/[ 09-TRAFFIC CONTROL PROPERTY ACCESS Applied Notice Access to existing properties shall be maintained at all times, including normal delivery service and mail service. Obtain City approval of any access closures. PFI_Sidewalk/[ 10-TRAFFIC CONTROL WORK HOURS Applied Notice Work is permitted in daylight between the hours of 7:00 a.m.to 7:00 p.m. Mon-Fri unless otherwise authorized by the City. PFI_Sidewalk/[ 11 -TRAFFIC CONTROL LIMITED WORK HOURS Applied Notice Hours of construction work on collector and arterial roads will be limited to 9:00 a.m.to 3:00 p.m. unless authorized by the City Engineer. Work will not be permitted on collector and arterial roads between 3:00 p.m.to 9:00 a.m. unless authorized by the City Engineer. PFI_Sidewalk/[ 12-TRAFFIC CONTROL MODIFICATION Applied Notice The City reserves the right to add to or modify traffic control requirements as necessary to effectively control traffic and to assure public safety. PFI_Sidewalk/[ 13-DRAINAGE CONTROL Applied Notice Drainage shall be controlled within the work site and shall not adversely affect adjacent private property, public property and the receiving system. The City may at any time order corrective action and suspension of work to accomplish effective drainage control. PFI_Sidewalk/[ 14- UTILITY NOTIFICATION Applied Notice Oregon law requires following the rules adopted by the Oregon Utility Notification Center. Said rules are set forth in OAR 952-001-0100 through OAR 952-001-0080. Copies of said rules may be obtained from the Center by calling 503-246-1987. If you have any question about the rules, contact the Center. NOTE: Damage to utilities shall be corrected at the permit holder's expense PFI_Sidewalk/[ 15- UTILITY LOCATION CONFLICT Applied Notice Applicant must verify all existing utilities for both vertical elevation and horizontal location prior to start of work(pothole before digging if necessary). Should conflicts arise and redesign or relocation of facilities be necessary, it shall be done at the applicant's expense. Changes must be approved by the City in advance of work.Applicant shall coordinate the work with affected utility agencies. PFI_Sidewalk/[ 16-TEMPORARY PATCH Applied Notice A temporary hard-surface patch shall be placed on trenches within roadways at the end of each work shift. Obtain advance approval of patching method. No trench shall be left at any time in an un-safe condition. Applicant is responsible for and is liable for hazards or damage resulting from the prosecution of the work. PFI_Sidewalk/[ 17-REPAIR OF EXISTING FACILITIES Applied Notice Work under this permit shall include repair of existing facilities (roads, ditches, etc.) as may be necessary,as determined by the Inspector, to overcome deterioration or damage which occurred in conjunction with the work authorized by the permit. Corrective work shall be done at the applicant's expense. PFI_Sidewalk/[ 18-SEWER SYSTEM TEST Applied Notice A sewer system air-test and/or DVD T.V.test report and one set of"As-Builts"shall be provided for review and approval. PFI_Sidewalk/[ 19 -PRECONSTRUCTION MEETING Applied Notice Before initiating any construction activity, the applicant shall coordinate with the City's inspector,Trent Brickey at 971-228-9269,to establish a preconstruction meeting. Please call 503-639-4175 to schedule inspection. use code 711 PFI_Sidewalk/[ 20-NOTICE TO COMMENCE WORK Applied Notice The applicant shall notify the City's Inspector twenty-four(24) hours prior to commencing work, prior to any staged inspection, and after completing work covered by the permit. PFI_Sidewalk/[ 21 -PERMIT/PLAN ON SITE Applied Notice A copy of the permit including a Certificate of Insurance, and all attachments, and a copy of the approved construction plan and all amendments shall be readily available at the work area. All work shall conform to the permit terms, conditions and provisions and to the City approved permit plans, and approved plan amendments and to the City's standards and specifications and to these General Conditions. Changes to any of these must be approved by the City, in advance of work performance. PFI_Sidewalk/[ 22-DAILY INSPECTION REPORTS Applied Notice Applicant shall submit daily inspection reports, on a weekly basis,to the City's Inspector. PFI_Sidewalk/[ 23-MONUMENT PROTECTION Applied Notice Existing monuments, property corners, and survey markers shall be protected. Replacement shall be at the permit holder's expense. PFI_Sidewalk/[ 24-VALIDATION OF MATERIAL/CONSTRUCTION Applied Notice The City's Inspector may, at his discretion, require tests and or reports from the applicant to validate claims of material or construction adequacy/compliance. Such tests/reports shall be provided at the applicant's expense. PFI_Sidewalk/[ 25- EMERGENCY CONTACTS Applied Notice Provide to the City inspector, in writing,the names and 24 hour emergency telephone number of two(2) persons who have authority to resolve problems, take corrective action and, in general,will be responsible in case of any emergency. The applicant shall notify the City Inspector, in writing,of any/all assignment changes. PFI_Sidewalk/[ 26-RIGHT OF ENTRY/EASEMENTS Applied Notice Applicant to obtain proper right-of-entry and/or easements prior to starting work. Proof of right-of-entry or properly executed easements, shall be provided to the City. The City shall in no way be construed to be liable for the applicant's failure to obtain or provide for proof of right-of-entry or easements. PFI_Sidewalk/[ 27-PRIVATE PROPERTY AGREEMENTS Applied Notice Provide the City a copy of an executed agreement[s]from the owner for each private property disturbed by construction activity. PFI_Sidewalk/[ 28-AS-BUILT DRAWING Applied Notice One as-built drawing showing all new public improvements, including any revision made to the previously approved construction plans and, also,any improvement which may impact an existing public system or facility, shall be provided to the City by a registered civil engineer along with an engineer's certification of installation compliance(Certificate of Compliance). PFI_Sidewalk/[ 31 -OTHER Applied Notice Other City of Tigard PFI#: 2020-00333 _ ENGINEERING DEPARTMENT I i,, N It l Public Facilities Improvement (PFI) Permit PROJECT INFORMATION TYPE OF WORK Project name: 107th Ave ❑ TYPE 1—Franchise Utility Work Brief description of project: Disconnect from onsight septic and performed by NWN,PGE, or utility agency reconnect to public sewer. ❑ TYPE 2—ROWSidewalk/Driveway/Sewer Work performed for the purpose of: • Sidewalk installation or repair • Driveway approach installation and repair SITE INFORMATION • Sanitary sewer lateral installation and Location (address if available): 13405 SW 107th AVE main line tap ❑ TYPE 3—Full Scale Development Work Tigard, OR 97223 performed with land use approval which includes any of the following: • Subdivisions or Partitions APPLICANT INFORMATION • Street widening Name: Bell Construction, INC. /Joe Bell • Mainline installation for salutary sewer, storm sewer, Tigard water, and Tigard Mailing address: 47333 SW Carpenter Creek RD water service area City/State: Forest Grove, OR Zip: 97116 ❑ TYPE 4—Small Cell Technology Phone: 503 357-8892 CI TYPE 5—Tigard Triangle Email: joebellconstruction@gmail.com Phone: 503-357-8892 NOTE: Type 1 and 2 applications may be Contact name: Joe Bell emailed to rowpermits@tigard-or.gov. Phone: 503-357-8892 Email: joebellconstruction@gmail.com CONTRACTOR INFORMATION ® Same as applicant Name: Bell Construction, INC. CCB Number: 113011 Mailing address: 47333 SW Carpenter Creek RD City/State: Forest Grove, OR Zip: 97116 Phone: 503-357-8892 Email: joebellconstruction@gmail.com ENGINEER INFORMATION Name: Bell Construction, INC. Mailing address: 47333 SW Carpenter Creek RD City/State: Forest Grove, OR Zip: 97116 Phone: 503-357-8892 Email: joebellconstruction@gmail.com ADDITIONAL INFORMATION Estimated value of work is required(if over$5,000):$ $25,000 (within the public right-of-way) Is work related to a LAND USE DECISION? 0 Yes RI No Case number: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 1 of 4 APPLICANTS NOTE: Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for work,if required by the city pursuant to TMC 15.04.140. * With the exception of a utility operating pursuant to a valid franchise or license with the City of Tigard,when the owner and the applicant are different people,the applicant must be the purchaser of record or a lessee in possession with written authorization from the owner or an agent of the owner. The owner must sign this application in the space provided or submit a written authorization with this application. Franchised or Licensed Utilities are not required to obtain the owner's signature on the application. I the applicant, certify fy that: • To the best of my knowledge,all the information provided within this application package is complete and accurate. • The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject property. • If the application is granted,I will exercise the rights granted in accordance with the terms and subject to all the conditions and limitations of the approval. rQ` �a.C� Joe Bell 9/9/2020 Applicant's authorized agent's signature Print name Date Property owner's signature (if required) Print name Date STAFF USE ONLY Case No: PFI2020-00333 Permit fee: 360-00 Received by: LS Date: 9/23/20 Approved by: /r-,ci7f Date: 7JZ/bUw Notified by: kt— Date: QI*2-D City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 2 of 4 DEVELOPMENT ENGINEERING FEES Public Facility Improvement(PFI)Permit: INITIAL PFI PERMIT FEE Part 1: Required submittal fee is 10%of the Net PH Permit Fee.See below for calculations.Minimum of$300. NET PFI PERMIT FEE Part 2: All non-water system improvements engineer's estimate X 7%(less the initial PH Permit Fee). WATER LINE CONSTRUCTION FEE Part 3: All public water system improvements engineer's estimate X 12%. FOR STAFF USE ONLY FOR STAFF USE ONLY TYPE 4: SMALL WIRELESS FACILITY TYPE 1—3: DETAILED SUBMITTAL CHECKLIST REQUIREMENTS Does applicant have a right-of-way license? 0 Yes 0 No TYPE 1 AND TYPE 2-Must include a sketch showing: Under the wireless facilities standards,is the proposal ❑ Dimensions considered?(check all that apply): 0 Small Cell ❑Macro ❑ Street Name How many install sites are proposed as part of this permit ❑ Site Address application? TYPE 3- Must provide 4 sets of plans (sized 24 x 36 or 22 x 34) and an electronic version of all submittal The proposed equipment is located on which of the following. items. The plans must that include: ❑Public Right-of-Way 0 Private Property ❑ Cover—Site,Vicinity,Abbreviation,Legend If equipment is to be located on private property,describe the ❑ General Notes(City,Water,Sewer,etc.) type&use: ❑ Street(Plan,Profile) ❑ Water,Storm and Sanitary(Plan Profile) ❑ Water Quality Facilities ❑ Grading ❑ Landscaping/Tree Plan ❑ Composite Utility Plan(Electrical,Phone,Gas, Storm, Sanitary,Water,Signage,Street Lights,etc.) ❑ Details ❑ Traffic Sight Distance ❑ Signing and Striping ❑ Street Light Plan and Photometric ❑ Engineers seal/signature ❑ Sheet label(project land use name,revision and plan log block,dates and sheet numbers.) ❑ Engineer's Construction Estimate Additional Submittals (per land use conditions,if applicable) ❑ Traffic Report ❑ Storm water Drainage Calculations ❑ Geotechnical Report ❑ Preliminary Access Report(Sight Distance) ❑ Proposed Plat ❑ Pathway Design ❑ Water Provider Approval City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 3 of 4 i' c \\ ) � t Edge of Pavement �� Duch �► 1 J , 'dal'Drai3 = "• r • o ' ' T— iohr.ZeI Sl erTi'nr I I I•r uI : . _ Existing House I / 1/4"! ie I ;2.1 ".I i 8i02 1 I i Existing Shop I Pcvepcei I — I � 6 I �_I o p h — — — 95 —.—.—.1.—. i I i'I i I Fve Hydrant(CH) I I scale r'==i' I 1 I i I I TYPE 1 AND TYPE 2: MINIUM SKETCH REQUIREMENTS (Put N/A if not applicable) North arrow Property lines&dimensions Existing utilities locations (sewer,storm,water) Street&street names All existing structures Proposed work Existing curb or edge of pavement Utility&street light poles Existing S/W or D/W apron Slope of property Trees City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 4 of 4 ��Q4 Q�o�LS O.FbR itP 4 �S�SS�C�inn w.„,\- 1rs.55 'A1.4 r WA, NO\ nn .41 WIN 0,4c 3Lios 10n4, a1/4K.- y� 1 % � � �, - ,aco® CERTIFICATE OF LIABILITY INSURANCE DATE(MNICONYYY) ‘.....--", 09/09/2020 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(les)must 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 Michael Benda NAME: AOA West.Inc. PHONE 503-245-1960 FAX 503-245-2049 (A/C,No,Eat): (A/C,No): PO Box 23485 E-MAIL ADDRESS: michael@aoawest.com INSURER(S)AFFORDING COVERAGE NAIC# Tigard OR 97281 INSURER A: Ohio Security Insurance Company INSURED INSURER B: The Ohio Casualty Insurance Company Bell Construction Inc.dba Aloha Sanitary Service INSURER C: 47333 SW Carpenter Creek Rd. INSURER D: INSURER E: Forest Grove OR 97116 INSURER F: 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 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS TYPE OF INSURANCE AUULODUH POLICY EFF POLICY EXP INSR WVD POLICY NUMBER (MMDD/YYYY) (MM/DD/YYYY) LIMITS GENERAL UABILITY EACH OCCURRENCE $ 1,000.000 uAMAAEIUHtNItu Nit I COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 1,000,000 CLAIMS-MADE J OCCUR MED EXP(Any one person) $ 15,000 A X BKS 56817720 09/01/2020 09/01/2021 PERSONAL$ADVINJURY $ 1,000.000 GENERAL AGGREGATE $ 2,000.000 GEN'L AGGREGATE UMITAPP�LIES�PER: PRODUCTS-COMP/OPAGG $ 2,000,000 - POLICY PE- II I LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMI I 1,000,000 (Ea accident) $ ANYAUTO BODILY INJURY(Per person) $ A AUT OWNED �- SCHEDULEDAU BAS 56817720 09/01/2020 09/01/2021 BODILY INJURY(Per accident) $ HIRED AUTOS NU A e WNED (Pr aER�iDAMAGE $ ) — $ Not UMBRELLA LIAB ✓ OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE USO 56817720 09/01/2020 09/01/2021 AGGREGATE $ 1,000,000 DED ` if RETENTION$ 10,000 W C STATU- O7H- $ WORKERS COMPENSATIONIN ✓ I 1,000,000 AND EMPLOYERS'LIABILITY TORY LIMBS l ER A ANY OF ICER/MEMBER EXCLUDED?XECUTIVE YI�I N/A XWS 56817720 02/04/2020 02/04/2021 E.L.EACH ACCIDENT $ 1,000,000 (Mandalory In NH) I I EL.DISEASE-EA EMPLOYEE $ 1,000,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,II more space is required) re: Right-of-Way Permit:13405 SW 107th Ave.,Tigard,OR 97223. The City of Tigard,its elected and appointed officials,officers,agents,employees,and volunteers ar named as additional insured per the attached CG8810 04/13 endorsement. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Tigard THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 13125 SW Ha!!BWd ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Tigard OR 97223 / 1. /' /J I 9/14141444 tTV�1/ lll�xll�"/MA ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG88100413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY EXTENSION This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE PART INDEX SUBJECT PAGE NON-OWNED AIRCRAFT 2 NON-OWNED WATERCRAFT 2 PROPERTY DAMAGE LIABILITY — ELEVATORS 2 EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) 2 MEDICAL PAYMENTS EXTENSION 3 EXTENSION OF SUPPLEMENTARY PAYMENTS—COVERAGES A AND B 3 ADDITIONAL INSUREDS— BY CONTRACT, AGREEMENT OR PERMIT 3 PRIMARY AND NON-CONTRIBUTORY —ADDITIONAL INSURED EXTENSION 5 ADDITIONAL INSUREDS— EXTENDED PROTECTION OF YOUR "LIMITS OF INSURANCE" 6 WHO IS AN INSURED—INCIDENTAL MEDICAL ERRORS/MALPRACTICE AND WHO IS AN INSURED - 6 FELLOW EMPLOYEE EXTENSION —MANAGEMENT EMPLOYEES NEWLY FORMED OR ADDITIONALLY ACQUIRED ENTITIES 7 FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES 7 KNOWLEDGE OF OCCURRENCE, OFFENSE, CLAIM OR SUIT 7 LIBERALIZATION CLAUSE 7 BODILY INJURY REDEFINED 7 EXTENDED PROPERTY DAMAGE 8 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US — 8 WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU U 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office.Inc. with its permission. Page 1 01 8 With respecl to coverage afforded by this endorsement, the provisions of the policy apply unless modified by the endorsement A. NON-OWNED AIRCRAFT Under Paragraph 2. Exclusions of Section I -Coverage A-Bodily Injury And Property Damage Liability, exclusion g. Aircraft,Auto Or Watercraft does not apply to an aircraft provided' 1. It is not owned by any insured 2. It is hired. chartered or loaned with a trained paid crew; 3. The pilot in command holds a currently effective certificate issued by the duly constituted authority of the United States of America or Canada. designating her or him a commercial or airline pilot; and 4. It is not being used to carry persons or property for a charge. However, the insurance afforded by this provision does not apply if there is available to the insured other valid and collectible insurance, whether primary, excess (other than insurance written to apply specifically in excess of this policy) contingent or on any other basis. that would also apply to the loss covered under this provision B. NON-OWNED WATERCRAFT Under Paragraph 2. Exclusions of Section I-Coverage A- Bodily Injury And Property Damage Liability, Subparagraph (2)of exclusion g.Aircraft, Auto Or Watercraft is replaced by the following. This exclusion does not apply to. (2) A watercraft you do not own that is' (a) Less than 52 feet long: and (b) Not being used to carry persons or property for a charge C. PROPERTY DAMAGE LIABILITY-ELEVATORS 1. Under Paragraph 2. Exclusions of Section I-Coverage A-Bodily Injury And Property Damage Liability, Subparagraphs (3), (4)and(6)of exclusion j. Damage To Property do not apply if such "pipperty damage` results from the use of elevators. For the purpose of this provision elevators do not include vehicle lifts. Vehicle lifts are lifts or hoists used in automobile service or repair operations. 2. The following is added to Section IV-Commercial General Liability Conditions,Condition 4. Other Insurance, Paragraph b. Excess Insurance; The insurance afforded by this provision of this endorsement is excess over any property insurance, whether primary, excess, contingent or on any other basis. D. EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) If Damage To Premises Rented To You is not otherwise excluded from this Coverage Part' 1. Under Paragraph 2. Exclusions of Section I -Coverage A- Bodily Injury and Property Damage Liability: a. The fourth from the last paragraph of exclusion j. Damage To Property is replaced by the following. Paragraphs(1), (3)and(4)of this exclusion do not apply to "property damage' (other than damage by fire, lightning, explosion, smoke or leakage from an automatic fire protection system) to (i) Premises rented to you for a period of 7 or fewer consecutive days: or (If) Contents that you rent or lease as part of a premises rental or lease agreement for a period of more than 7 days Paragraphs(1), (3)and(4)of this exclusion do not apply to"property damage"to contents of premises rented to you for a period of 7 or fewer consecutive days A separate limit of insurance applies to this coverage as described in Section III-Limits of Insurance. 'i 2013 Liberty Mutual Insurance CG 88 10 0413 Includes copyrighted material of Insurance Services Office.Inc.with its permission Page 2 of 6 b. The last paragraph of subsection 2. Exclusions is replaced by the following: Exclusions c. through n. do not apply to damage by fire, lightning,explosion. smoke or leakage from automatic fire protection systems to premises while rented to you or temporarily occupied by you with permission of the owner. A separate limit of insurance applies to Damage To Premises Rented To You as described in Section III—Limits Of Insurance. 2. Paragraph 6. under Section III—Limits Of Insurance is replaced by the following: 6. Subject to Paragraph 5.above,the Damage To Premises Rented To You Limit is the most we will pay under Coverage A for damages because of"properly damage"to. a. Any one premise: (1) While rented to you, or (2) While rented to you or temporarily occupied by you with permission of the owner for damage by fire, lightning, explosion, smoke or leakage from automatic protection systems; or b. Contents that you rent or lease as part of a premises rental or lease agreement. 3. As regards coverage provided by this provision D. EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) - Paragraph 9.a. of Definitions is replaced with the following: 9.a. A contract for a lease of premises However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire, lightning, explosion, smoke,or leakage from automatic fire protection systems to premises while rented to you or temporarily occupied by you with the permission of the owner, or for damage to contents of such premises that are included in your premises rental or lease agreement, is not an"insured contract". E. MEDICAL PAYMENTS EXTENSION If Coverage C Medical Payments is not otherwise excluded,the Medical Payments provided by this policy are amended as follows: Under Paragraph 1. Insuring Agreement of Section I—Coverage C—Medical Payments, SLbparagraph(b)of Paragraph a.is replaced by the following: (b) The expenses are incurred and reported within three years of the date of the accident; and F. EXTENSION OF SUPPLEMENTARY PAYMENTS—COVERAGES A AND B 1. Under Supplementary Payments—Coverages A and B, Paragraph 1.b. is replaced by the following: b. Up to$3,000 for cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. 2. Paragraph 1.d. is replaced by the following: d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or"suit", including actual loss of earnings up to$500 a day because of time off from work. G. ADDITIONAL INSUREDS-BY CONTRACT,AGREEMENT OR PERMIT 1. Paragraph 2. under Section II—Who Is An Insured is amended to include as an insured any person or organization whom you have agreed to add as an additional insured in a written contract,written agreement or permit. Such person or organization is an additional insured but only with respect to liability for"bodily injury","property damage"or"personal and advertising injury" caused in whole or in part by: a. Your acts or omissions, or the acts or omissions of those acting on your behalf, in the performance of your on going operations for the additional insured that are the subject of the written contract or written agreement provided that the"bodily injury"or"property damage"occurs, or the"personal and advertising injury"is committed, subsequent to the signing of such written contract or written agreement;or ©2013 I iberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office, Inc with its permission Page 3 of 8 b. Premises or facilities rented by you or used by you; or c. The maintenance, operation or use by you of equipment rented or leased to you by such person or organization; or d. Operations performed by you or on your behalf for which the state or political subdivision has issued a permit subject to the following additional provisions' (1) This insurance does not apply to"bodily injury", 'property damage" or"personal and advertising injury arising out of the operations performed for the state or political subdivision; (2) This insurance does not apply to"bodily injury"or"property damage" included within the "completed operations hazard". (3) Insurance applies to premises you own. rent or control but only with respect to the following hazards' a) The existence. maintenance. repair. construction, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees. hoist away openings, sidewalk vaults, street banners, or decorations and similar exposures, or (b) The construction, erection, or removal of elevators, or (c) The ownership, maintenance, or use of any elevators covered by this insurance However 1. The insurance afforded to such additional insured only applies to the extent permitted by law and 2. it coverage provided to the additional insured is required by a contract or agreement. the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. With respect to Paragraph 1.a. above, a person's or organization's status as an additional insured under this endorsement ends when. (1) All work, including materials, parts or equipment furnished in connection with such work on the project(other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) al the location 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. With respect to Paragraph 1.b. above, a person's or organization's status as an additional insured under this endorsement ends when their written contract or written agreement with you for such premises or facilities ends With respects to Paragraph 1.c.above this insurance does not apply to any"occurrence"which takes place after the equipment rental or lease agreement has expired or you have returned such equipment to the lessor. The insurance provided by this endorsement applies only if the written contract or written agreement is signed prior to the"bodily injury'or"property damage". We have no duty to defend an additional insured under this endorsement until we receive written notice of a"suit" by the additional insured as required in Paragraph b.of Condition 2. Duties In the Event Of Occurrence, Offense, Claim Or Suit under Section IV—Commercial General Liability Conditions. n 2013 Liberty Mutual Insurance Pa e 4 of 8 CG 88 10 04 13 Includes copyrighted material of Insurance Services Office.Inc_with its permission. 9 2. With respect to the insurance provided by this endorsement, the following are added to Paragraph 2. Exclusions under Section I -Coverage A- Bodily Injury And Property Damage Liability: This insurance does not apply to. a. "Bodily injury or property damage' arising from the sole negligence of the additional insured. b. Bodily injury" or'property damage" that occurs prior to you commencing operations at the location where such"bodily injury"or"property damage occurs. c. "Bodily injury', "property damage"or"personal and advertising injury"arising out of the rendering of or the failure to render. any professional architectural, engineering or surveying services, including' (1) The preparing, approving, or tailing to prepare or approve. maps. shop drawings, opinions. reports, surveys, field orders, change orders or drawings and specifications, or (2) Supervisory. inspection architectural or engineering activities This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision. hiring, employment, training or monitoring of others by that insured, if the"occurrence"which caused the 'bodily injury" or"properly damage", or the offense which caused the"personal and advertising injury", involved the rendering of, or the failure to render, any professional architectural, engineering or surveying services d. "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 service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location 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 eJ Any person or organization specifically designated as an additional insured for ongoing operations by a separate ADDITIONAL INSURED-OWNERS, LESSEES OR CONTRACTORS endorsement issued by us and made a part of this policy. 3. With respect to the insurance afforded to these additional insureds. the following is added to Section III- Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: a. Required by the contract or agreement: or b. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations H. PRIMARY AND NON-CONTRIBUTORY ADDITIONAL INSURED EXTENSION This provision applies to arty person or organization who qualifies as an additional insured under any form or endorsement under this policy Condition 4. Other Insurance of SECTION IV-COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows: a. The following is added to Paragraph a. Primary Insurance: If an additional insured's policy has an Other Insurance provision making its policy excess, and you have agreed in a written contract or written agreement to provide the additional insured coverage on a primary and noncontributory basis, this policy shall be primary and we will not seek contribution from the additional insured's policy for damages we cover i 2013 liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material or Insurance Services Office.Inc..with its permission Page 5 of 8 b. The following is added to Paragraph b. Excess Insurance: When a written contract or written agreement, other than a premises lease, facilities rental contract or agreement, an equipment rental or lease contract or agreement. or permit issued by a state or political subdivision between you and an additional insured does not require this insurance to be primary or primary and non-contributory, this insurance is excess over any other insurance for which the additional insured is designated as a Named Insured Regardless of the written agreement between you and an additional insured, this insurance is excess over any other insurance whether primary, excess. contingent or on any other basis for which the additional insured has been added as an additional insured on other policies ADDITIONAL INSUREDS - EXTENDED PROTECTION OF YOUR "LIMITS OF INSURANCE" This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this policy 1. The following is added to Condition 2. Duties In The Event Of Occurrence, Offense, Claim or Suit: An additional insured under this endorsement will as soon as practicable. a. Give written notice of an"occurrence"or an offense that may result in a claim or"suit under this insurance to us. b. Tender the defense and indemnity of any claim or'suit"to all insurers whom also have insurance available to the additional insured; and c. Agree to make available any other insurance which the additional insured has for a loss we cover under this Coverage Part. d. We have no duty to defend or indemnify an additional insured under this endorsement until we receive written notice of a "suit"by the additional insured 2. The limits of insurance applicable to the additional insured are those specified in a written contract or written agreement or the limits of insurance as stated in the Declarations of this policy and defined in Section III-Limits of Insurance of this policy whichever are less These limits are inclusive of and not in addition to the limits of insurance available under this policy. J. WHO IS AN INSURED - INCIDENTAL MEDICAL ERRORS/MALPRACTICE WHO IS AN INSURED-FELLOW EMPLOYEE EXTENSION -MANAGEMENT EMPLOYEES Paragraph 2.a.(1) of Section II -Who Is An Insured is replaced with the following: (1) "Bodily injury"or"personal and advertising injury". (a) To you, to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability company), to a co-"employee" 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 co-"employee" or"volunteer worker"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 Paragraphs(1) (a)or(b)above: or (d) Arising out of his or her providing or failing to provide professional health care services. However, if you are not in the business of providing professional health care services or providing professional health care personnel to others, or if coverage for providing professional health care services is not otherwise excluded by separate endorsement. this provision (Paragraph (d)) does not apply ©2013 Liberty Mutual Insurance CG 88 10 04 13 includes copyrighted material of Insurance Services Office.Inc..with its permission. Page 6 of 8 Paragraphs(a)and(b) above do not apply to"bodily injury"or"personal and advertising injury"caused by an "employee"who is acting in a supervisory capacity for you. Supervisory capacity as used herein means the "employee's"job responsibilities assigned by you, includes the direct supervision of other"employees"of yours. However, none of these"employees"are insureds for"bodily injury"or"personal and advertising injury"arising out of their willful conduct,which is defined as the purposeful or willful intent to cause`bodily injury" or"personal and advertising injury", or caused in whole or in part by their intoxication by liquor or controlled substances. The coverage provided by provision J. is excess over any other valid and collectable insurance available to your "employee". K. NEWLY FORMED OR ADDITIONALLY ACQUIRED ENTITIES Paragraph 3.of Section II-Who Is An Insured is replaced by the following: 3. Any organization you newly acquire or form and over which you maintain ownership or majority interest. 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 until the expiration of the policy period in which the entity was acquired or formed by you: b. Coverage A does not apply to"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. d. Records and descriptions of operations must be maintained by the first Named Insured. No person or organization is an insured with respect to the conduct of any current or past partnership,joint venture or limited liability company that is not shown as a Named Insured in the Declarations or qualifies as an insured under this provision. L. FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES Under Section IV—Commercial General Liability Conditions,the following is added to Condition 6. Representations: Your failure to disclose all hazards or prior"occurrences"existing as of the inception date of the policy shall not prejudice the coverage afforded by this policy provided such failure to disclose all hazards or prior"occurrences"is not intentional. M. KNOWLEDGE OF OCCURRENCE, OFFENSE, CLAIM OR SUIT Under Section IV—Commercial General Liability Conditions,the following is added to Condition 2. Duties In The Event of Occurrence, Offense, Claim Or Suit: Knowledge of an`occurrence", offense,claim or"suit"by an agent, servant or"employee" of any insured shall not in itself constitute knowledge of the insured unless an insured listed under Paragraph 1. of Section II—Who Is An Insured or a person who has been designated by them to receive reports of "occurrences". offenses. claims or"suits" shall have received such notice from the agent. servant or "employee". N. LIBERALIZATION CLAUSE If we revise this Commercial General Liability Extension Endorsement to provide more coverage without additional premium charge, your policy will automatically provide the coverage as of the day the revision is effective in your state O. BODILY INJURY REDEFINED Under Section V-Definitions, Definition 3. is replaced by the following: 3. "Bodily Injury" means physical injury, sickness or disease sustained by a person. This includes mental anguish,mental injury, shock,fright or death that results from such physical injury, sickness or disease. ®2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office.Inc.with its permission. Page 7 of 8 P. EXTENDED PROPERTY DAMAGE Exclusion a. of COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY is replaced by the following' a. Expected Or Intended Injury "Bodily injury"or"property damage"expected or intended from the standpoint of the insured This exclusion does not apply to"bodily injury"or"property damage' resulting from the use of reasonable force to protect persons or property. Q. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US-WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU Under Section IV - Commercial General Liability Conditions, the following is added to Condition 8. Transfer Of Rights Of Recovery Against Others To Us: We waive any right of recovery we may have against a person or organization because of payments we make for injury or damage arising out of your ongoing operations or"your work"done under a contract with that person or organization and included in the"products-completed operations hazard"provided' 1. You and that person or organization have agreed in writing in a contract or agreement that you waive such rights against that person or organization: and 2. The injury or damage occurs subsequent to the execution of the written contract or written agreement 1 ©20131 itxerty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 8 of 8