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HomeMy WebLinkAboutT-MOBILE WEST LLC (LA33000C) INSURANCE ON FILE A-2023-187C WORK MAY PROCEED UNTIL INSURANCE EXPIRES CITY CLE R DATE: N V 0 6 2021 SUPPLEMENT AGREEMENT o CNN GS This Supplement("Supplement"),is approved by Licensor this i r3 day of 04 , 20 d (the date executed by all parties, referred herein as "Supplement Effective Date"). 1. Supplement. Licensee has submitted an application for approval to use a Municipal Facility pursuant to that certain Municipal Facility License Agreement between Licensor and Licensee dated November 30, 2023 ("Agreement"). Licensor has reviewed the application and grants approval subject to the terms of this Supplement. All of the terms and conditions of the Agreement are incorporated hereby by reference and made a part hereof without the necessity of repeating or attaching the Agreement.In the event of a contradiction,modification or inconsistency between the terms of the Agreement and this Supplement, the terms of this Supplement shall govern. Capitalized terms used in this Supplement shall have the same meaning described for them in the Agreement unless otherwise indicated herein. IF THE SUPPLEMENT IS NOT COUNTER-SIGNED BY LICENSEE AND RETURNED TO LICENSOR WITHIN 30 DAYS AFTER LICENSOR HAS GRANTED APPROVAL, THE SUPPLEMENT SHALL BE VOID AND OF NO LEGAL EFFECT. IF LICENSEE STILL WANTS TO USE THE MUNICIPAL FACILITY, LICENSEE WILL BE REQUIRED TO SUBMIT A NEW APPLICATION AND ASSOCIATED FEES. 2. Licensed Area Description and Location. Licensee shall have the right to use the space on the specific Municipal Facility(the "Licensed Area") depicted in Attachment 1 attached hereto to install Equipment as further listed in Attachment 2 attached hereto. 3. Equipment. The Equipment to be installed at the Licensed Area is described and depicted in Attachment 1. 4. Term. The term of this Supplement shall commence on the Supplement Effective Date and continue for the life of the Agreement, as described in Paragraph 2 of the Agreement. 5. License Fee/Alternate License Fee. The initial fee for this Supplement shall be as follows per year: $270.00. This fee is subject to annual increase as provided in the Agreement, and is payable in accordance with the Agreement. 6. Performance Bond. The Performance Bond [circle one] is / is no covered by existing performance bond. If not covered by existing performance bond, a bons is required pursuant to Section 8 of the Agreement. 7. Miscellaneous. [Signature page follows] A-1 IN WITNESS THEREOF, the parties hereto have caused this Supplement to be legally executed in duplicate, effective upon execution by both parties. Licensor: CITY OF SANTA ANA, CA By: orlp j°*`- Name:Nabil Saba,P.E. Title: Executive Director Public Works Agency Date: c l /2 S) 20 Zy Licensee: Accepted: --MO!A L (4 1 LC By: Name: Title: DI ce 'ur- Date: IU f/1• jD.t4 Attachments: Attachment 1 —Licensed Area (LA33000C) Attachment 2—Equipment List and Description A-2 Attachment 1 Licensed Area [Map showing licensed area of applicable Municipal Facility and showing proposed Equipment installation.] A-3 ® x.. o N b a)n cn cu ) ro U ¢' .. c yy c t 1- •, U a OT o '� y Y -0 O L : N L O1 O J E w 1 o L' ImF2i o 2 u N y 1J r = 1- Q ao .,, v % -. O O L. • • • • 0 • 1S NOSY.a • • • • • d • 0.3 • • • O: • • • • • • • • 0 0 ,--1 o • • ® • • • • to. o • •cD • • • • • • 4 'c.,cc 0♦ • 0 0 0. 0 • to • • o 0 0 0 0 0 0 o o • • • • 0 o • • • Q • • • 0 • • • d 0 o • C. Is • • 4:1 • N ® • • ce o U I • • • • • 1,.. al _:af m E • .js`�> o r i o i s • • • C u Q n • 0 g o •: : A.] 1 owl o NO Q • O �j o pi • • o •• • • • 0 i • • 0 • 0 0 0 • 111 + 1 Attachment 1 LA33000C - KENT SCE LIGHT STANDARD 3820 3/4 KENT AVE - SANTA ANA, CA 92704 • • (N)T-MOBILE PANEL — ' x ; ANTENNAS BEHIND(E)FRP RADOME.NOT VISIBLE • '5;' f=ate t fir, I' ) _ _� _� ► A-5 LA33000C - KENT SCE LIGHT STANDARD 3820 3/4 KENT AVE - SANTA ANA, CA 92704 , , fl . (.0, ti:1 .. .*,. s, . -. ir 1 ,. I 2.7 .. ! 111, lc-ft-0,- ... ,.. , 11; ''''N IG•r:: ',OE :::::7 :4 4.. VV.' tlir • ,ST,.1 -,i3::: . : .r. t 1 /J l ' fir '. . 1 W Kent Ave are to W,X nt A,e. w W Kent Ave IY Kent Ave 4.[ 1`14 i ; no —--14101 `111 '' -:-.Z" - • I il 1 ! .....1 .. fi: r I I. ,...... , y RPM ,.. �FS, r, i I I i . .- k '". ' '.' ' Ate. , %..»7 �, m S ' �a ' �poi. � I 1ff A-6 Attachment 2 Equipment NEM 19 A• II WINS 9460 MCMAHON% �11 1. USE SWIUFtCNAEA SUPPLIED 4ANUFALIunq:ERICSsox 1�WE MNIUFACNPER SUPPLIED 1 WOUNDNO IASSUPIIE. NONMINfi WNOXGIE NFG: CUN115LGP0 MODEL RFUS 460 025+P68 HEIGHT: 19.0 IN Ih%fL TMT191158-2I-43 WIDTH: 1S1 IN at KGNR 0E IN _ DFPIN: IR.I IN /' NUR AO IN (P)SCREWS(1 PER REMOTE R)Ei0 WFMI@ 109 WS �• y _ DFMH: 4.2 IN MOUNT).FRONDED - UNR(flIN) wEGNI: 118.1 LLd W/MWN6 �� VIJIUFACNREF' '\ \ WFIONI: 15)E16 / 5%H DE BY \ ki 1]]EU w PPOYIDEO BY �4'� MOUNTING HARimmE �AL-E PER NMI)-\.. / �' 1. USE 1IFA N T,YC HAHDNARE FUR RHOS 1Z ti 2• PI007 NUTS WHH e%. AIFACHMGT. SPPIN0,,M REOLMED * • 1 MI' ,, ON EOUPNENE y� O MNlUFACTLWE'S J,i:, , ,- SPECIFICATIONS Cy" '�9.CA U 4 al t -M IL P1040 UNISIRN,OR ! up APFHWEU EQUAL M1.----- EE SE flANT SEE RRU MOUNTING DETAIL �r°E 1 RRUS 4460 B25+1366 SPECIFICATIONS $,°s. 2 TMA SPECIFICATIONS xiSE 3 ([)ANTENNA SCHEME M WXttT IM.11 FAO CMG,nw.WOE u..Au MIL 1MMO. w,wca(1 N Sill nw MM.. a Min% l Er-ii aim rvvra,nrn 01 Mc a,M nI FM iFiE UN, l0r/ema-N IN,Mro w�E„-:1 ..a Ai Van?, in il-r rims mn-ln6n iMME x,W1 11 a:n uw afro, Pi amnia'it,_iP .srtxc . tiro,WE fro ,F-r n.f. 5 051-5, (01.5Exf WA 0)Memo alloy, 01.A. rimmur,-:a a in LIEN FIXTURECI III FM rE -;q Um POI[ Q I (C-11 .-\cl.) i . _ ,i Q)T-NmIE 84101E TEST-WCIE 0801 war- --(II 118081C DM,TIE Mill{ M.are(5)SEEM 0P14-01 .bet,.1y 1< (E)r-,to�84 IE50 4) �6 tci41�'"""a (qT-Imm[PANEL atom 10 Rmµ M.(1)IIe s[cma(roru-)) NEW ANTENNA PLAN s_j,_b._, , , ArA3 A-7 ACGP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD2WY) 5/1/2025 10/23/2024 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 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 Lockton Companies,LLC NAME: Three City Place Drive,Suite 900 PHONE FAX St.Louis MO 63141-7081 IA/C.No.Extl: (A/C,No): E-MAIL (314)432-0500 ADDRESS: midwestcertificates@lockton.com INSURER(S)AFFORDING COVERAGE NAIC!I _ INSURER A:Continental Casualty Company 20443 _ INSURED T Mobile US,Inc. INSURER B:The Continental Insurance Company 35289 1358772 Its Subsidiaries and Affiliates INSURER c Transportation Insurance Company 20494 _ 12920 SE 38th Street INSURER D: Bellevue WA 98006 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 18576359 REVISION NUMBER: XXXXXXX 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INS) WVD, POLICY NUMBER (MM/DD/YYYY) I MM/DD/YYYY} LIMITS A X COMMERCIAL GENERAL LIABILITY y y 7012343900 5/1/2024 5/1/2025 EACH OCCURRENCE $ 10,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $ 10,000,000 MED EXP(Any one person) $ 25,000 PERSONAL 8.ADV INJURY $ 10,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 20,000,000 POLICY I JEC X LOC PRODUCTS-COMP/OP AGO S 20,000,000 OTHER: $ A AUTOMOBILE LIABILITY y y 7012343878 5/1/2024 5/1/2025 COMBINED SINGLE LIMIT (Ea eceldenll $ 5,000,000 x ANY AUTO BODILY INJURY(Per person) S XXX30Ca OWNED SCHEDULED _ AUTOS ONLY _AUTOS BODILY INJURY(Per accident) $ XXXXXXX HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) S XXXXXXX S XXXXXXX B X UMBRELLA LIAR X OCCUR N N 7014886953 5/1/2024 5/1/2025 EACH OCCURRENCE $ 5,000,000 B EXCESS LIAR SIR appliesper policy B CLAIMS-MADE pp p y AGGREGATE E 5,000,000 terms&conditions DED X RETENTIONS 10,000 $ XXXXXXX B WORKERS COMPENSATION X PERTUTE ER AND EMPLOYERS'LIABILITY Y/N N 7012343895 AOS) 5/1/2024 5/1/2025 B ANY PROPRIETOR/PARTNER/EXECUTIVE 7012343881 CA) 5/1/2024 5/1/2025 E.L.EACH ACCIDENT $ 2,000,000 _ C OFFICER/MEMBEREXCLUDED? n N/A 7012447142 AZ,MA,OR,WI) 5/1/2024 5/1/2025 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE_$ 2,000,000 Ryes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) THIS CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER.APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TERM(S)REFERENCED. The Certificate Holder and other entities defined by written contract,statute,permit application or written agreement are additional insureds on a primary and non-contributory basis under general liability and are additional insured under automobile liability as required by written contract.Waiver of Subrogation applies under general liability and automobile liability as required by written contract**See Attached Endorsements** LA33000C-3820 3/4 Kent Ave.Santa Ana,CA 92704 CERTIFICATE HOLDER CANCELLATION See Attachments SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 18576359 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS. Risk Management Division 20 Civic Center Plaza,4th Floor AUTHORIZED REPRESENTATI Santa Ana CA 92701op 1 ©1988.2 CORD CORPORATI N. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 4, i0/ /Zif Attachment Code: D590641 Master ID: 1358772,Certificate ID: 18576359 lall1 LOCKTON City of Santa Ana Risk Management Division 20 Civic Center Plaza,4th Floor Santa Ana CA 92701 IMPORTANT NOTICE Dear Certificate Holder for T-Mobile and its subsidiaries (including Sprint): In our continued effort to provide timely certificate delivery, Lockton Companies is transitioning to paperless delivery of Certificates of Insurance going forward. To ensure future renewals of this certificate,we need your email address. Please contact us via one of the methods below, referencing Certificate ID 18576359 •Email:stl-edelivery©lockton.corn 'Phone: 314-872-3888 If we do not receive your email address via one of the above methods prior to the client's next renewal,we will assume you no longer need the certificate. If you received this certificate through an internet link where the current certificate is viewable,we have your email and no further action is needed. The above inbox is for collecting email addresses for renewal electronic certificate delivery ONLY. You will not receive a response from this inbox. Thank you for your cooperation. Locicton Companies n#71-* Lockton Companies /P 3Q 2q Three C'ityl'lac:e Dr. 'i l. `00 St. Louis. j,10 63 141-708 314-432-0500/ lockton.com Attach e• 278 Master ID: 1358772,Certificate ID: 18576359 A . . . _ POLICY HOLDER NOTICE—COUNTRYWIDE l .. It is understood and agreed that: If the Named Insured has agreed under written contract to provide notice of cancellation to a party to whom the Agent of Record has issued a Certificate of Insurance,and if the Insurer cancels a policy term described on that Certificate of Insurance for any reason other than nonpayment of premium,then notice of cancellation will be provided to such Certificate holders at least 30 days in advance of the date cancellation is effective. If notice is mailed,then proof of mailing to the last known mailing address of the Certificate holder on file with the Agent of Record will be sufficient to prove notice. Any failure by the Insurer to notify such persons or organizations will not extend or invalidate such cancellation,or impose any liability or obligation upon the Insurer or the Agent of Record. All other terms and conditions of the policy remain unchanged. This endorsement,which forms a part of and is for attachment to the policy issued by the designated Insurers, takes effect on the Policy Effective date of said policy at the hour stated in said policy,unless another effective date(the Endorsement Effective Date)is shown below,and expires concurrently with said policy. .4,,,,,,A 4.,_ ottotAr <0/30)vi Form No: CNA75014XX(01-2015) Policy No: 7012343900 Endorsement Effective Date: 5/1/2024 Policy Effective Date: 5/1/2024 Endorsement No: Page: 1 of 1 Underwriting Company: Continental Casualty Company ©Copyright CNA All Rights Reserved. Attachment Code: D559289 Master ID: 1358772,Certificate ID: 18576359 CNA ,ii .,. _,_..__ . ,..._ .____ , ,,,, ,..„,,..„,..„-", NOTICE OF CANCELLATION -10 CERTIFICATEHOLDERS ..._ . It is understood and agreed that: If you have agreed under written contract to provide notice of cancellation to a party to whom the Agent of Record has issued a Certificate of Insurance,and if we cancel a policy term described on that Certificate of Insurance for any reason other than nonpayment of premium,then notice of cancellation will be provided to such Certificateholders at least 30 days in advance of the date cancellation is effective. If notice is mailed,then proof of mailing to the last known mailing address of the Certificateholder on file with the Agent of Record will be sufficient to prove notice. Any failure by us to notify such persons or organizations will not extend or invalidate such cancellation,or impose any liability or obligation upon us or the Agent of Record. All other terms and conditions of the policy remain unchanged. This endorsement,which forms a part of and is for attachment to the policy issued by the designated Insurers, takes effect on the Policy Effective date of said policy at the hour stated in said policy,unless another effective date(the Endorsement Effective Date)is shown below,and expires concurrently with said policy. 4 w /9jVgerA /61/3D/ 4/ Form No: CNA68021XX(02-2013) Policy No:7012343878 Endorsement Effective Date: 5/1/2024 Policy Effective Date:5/1/2024 Endorsement No: Policy Page: Underwriting Company: Continental Casualty Company 0 Copyright CNA All Rights Reserved. Attac��87 Certificate ID: 18576359 DESIGNATED INSURED FOR COVERED A • O‘In, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement,the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s)or organization(s)who are"insureds"for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form.This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: T-MOBILE US, INC. Endorsement Effective Date:5/1/2024 SCHEDULE Name Of Person(s)Or Organization(s): Where required by written contract executed prior to loss. Information required to complete this Schedule,if not shown above,will be shown in the Declarations. Each person or organization shown in the Schedule is an" insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an"insured"under the Who Is An Insured provision contained in Paragraph A.1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Apti/ed /CT CAA.0'.4,-, I0/3O f 2 ' Form No: CA 20 48 10 13 Policy No: 7012343878 Endorsement Effective Date:5/1/2024 Policy Effective Date: 5/1/2024 Underwriting Company: Continental casualty Policy Page: © Copyright Insurance Services Office,Inc.,2011 Attachment Code: D559286 Certificate ID: 18576359 Waiver of Transfer of Rights of Recovery Against Others to the Insurer Endorsement This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Any person or organization where required by written contract provided that such contract was executed prior to the date of loss(as permissible by law). (Information required to complete this Schedule, if not shown above, will be shown in the Declarations.) Under COMMERCIAL GENERAL LIABILITY CONDITIONS, it is understood and agreed that the condition entitled Transfer Of Rights Of Recovery Against Others To Us is amended by the addition of the following: With respect to the person or organization shown in the Schedule above, the Insurer waives any right of recovery the Insurer may have against such person or organization because of payments the Insurer makes for injury or damage arising out of the Named Insured's ongoing operations or your work included in the products-completed operations hazard. All other terms and conditions of the Policy remain unchanged. This endorsement, which forms a part of and is for attachment to the Policy issued by the designated Insurers,takes effect on the effective date of said Policy at the hour stated in said Policy, unless another effective date is shown below, ApdG CNA75008XX(10-16) Policy No: 701 343 00 Page 1 of 1 Endorsement No: CONTINENTAL CASUALTY COMPANY Effective Date: 5/1/2024 Insured Name:T-MOBILE US, INC. Copyright CNA All Rights Reserved. Includes copyrighted material of Insurance Services Office,Inc.,with its permission.