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HomeMy WebLinkAboutT-MOBILE WEST LLC (LA33845C) INSURANCE ON FILE WORK MAY PROCEED A-2023-187A UNTIL INSURANCE EXPIRES 5 I l 202—S CITY CLEgv O 6 2024 DATE: ��uu SUPPLEMENT AGREEMENT „xsole,�)barn" m� This Supplement("Supplement"),is approved by Licensor this \ j day of .2t , 20,aq (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 bon. 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: Q Nam : _ abil Saba, P.E. Title: Executive Director Public Works Agency Date: j 7.5--/ 2029 Licensee: Accepted: I - Nlibi West Lt.C. By: ► Name: r` Title: j t'h� Date: �(c�� Attachments: Attachment 1 —Licensed Area(LA33845C) 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.] Al 0 • . , § p 2 ± / \ 2 % ° ® 3 2 k , ) \ ® ) \ \ - \ - - - . } / \ . \ \ wu � | 4 ! f e 0 0 0 o e o Co 0 0 0 0 0 0 0 0 0 0 , o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 L. 0 0 0 0 k , 0 ` G 0 u 0 0 : 0 0 0 0 0 0 0 , o ~ J \ ^ a f0 o 00 0 0 0 0 0 0 0 A- 0 0 0 0 0 0 • 0 0 d 0 0 0 0 0 0 0 a. 0. 0 0 / e o 0 7 0 o o a o 0 U \ E ° \cn o \ \ , 0 0 0 o o 0 0 0 0 0 0 0 0 0 ° \ 0 0 , o 2 \ iti ° ° ° 0 % 0 0 0 \ ƒ / 1P 0 \ U 0 0 on 0 0 0 0 < Attachment 1 LA33845C - MACARTHUR RAITT STREET LIGHT 1850 3/4 W. MACARTHUR BLVD - SANTA ANA, CA 92704 , ,,,,,, ' '-.11t'''s i , - . dr 1 ..,.. ‘..:,...„...1 4 11. • j�1 ! l ‘•-• it , k 1 f i '1,.. . i _ .5, [ . ._ . . i.,,- , _ __ I,, sTr_' •fir .`--- '{ % .._ ' % N. i ✓ 4 vr rr-_ . acArthur Blvd. �' -- • 1r..,, W_MacArthur Blvd, •, ,..)tic, •. • — -\— 4. . • . -•: 42 •.. ,iN ''.:. 4.4., . , Y •-• .. r .� , .. . _ . ...td. 41in f, a`` i , 44, W;MacArthur Blvd , •5 t s. t 1N�N�ac Ivd t J I. 41, , tglike 4 i WA:40.0;..r1114:, 1 . . .. 1 • .. . -,... i,41M*N. • 2)(4* . ., A-5 LA33845C - MACARTHUR RAITT STREET LIGHT 1850 3/4 W. MACARTHUR BLVD - SANTA ANA. CA 92704 % (N)T-MOBILE PANEL ANTENNAS BEHIND(E)FRP • RADOME,NOT VISIBLE • 4�F•k !, v• • , , ,z-i ', } leg,' 41 111, a 11.1111 IMF A-6 G� Pl- c — W? �" .g8 ^4 I H ae a 98(c42 • ! 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L (El ` `=•�• ). � � \ K 2 ! ! ƒ ƒ > Q , z g°4t = ) \ ` . ` . 58 \ / / •? : : { I \ LUCI CI \ ^ | ;; }! — ƒ2§! ; _. 1 \ P § ^ ! to { z i \ 2 , ! g Id • — ., ) Illi | • , , $ I� N tg ° e t C. , , Po ! / / a \ ) { ) / g \ • A� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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(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 Lockton Companies,LLC NCONTACT AME: Three City Place Drive,Suite 900 HOO.E EXI): FAX P No): St.Louis MO 63141-7081 E-MAIL (314)432-0500 ADDRESS: midwestcertificates@lockton.com INSURER(S)AFFORDING COVERAGE NAIC f! ___ 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: 20183932 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. TNSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSO WVD I l POLICY NUMBER (MMfDDlYYYY) IMMIDDlYYYY) LIMITS A x COMMERCIAL GENERAL LIABILITY Y Y 7012343900 5/1/2024 5/I/2025 EACH OCCURRENCE S 10,000,000 DAMAGE rb RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) _ S 1 0,000,000 MED EXP(Any one person) S 25,000 PERSONAL&ADV INJURY $ 10,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 20,000,000 1 POLICY !In X LOC PRODUCTS-COMP/OP AGG S 20,000,000 OTHER: $ A AUTOMOBILE LIABILITY y y 7012343878 5/1/2024 5/1/2025 COMBINED NGLE LIMIT s(Ea accident)SI 5,000,000 x ANY AUTO BODILY INJURY(Per person) S XXXXXXX OWNED SCHEDULED — AUTOS ONLY AUTOS BODILY INJURY(Per accident) S XXXXXXX HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) SXXXXXXX SXXXXXXX B }( UMBRELLA LIAR X OCCUR N N 7014886953 5/1/2024 5/1/2025 EACH OCCURRENCE S 5,000,000 13 EXCESS LIAB CLAIMS-MADE SIR applies per policy ` AGGREGATE S 5,000,000 DED X RETENTIONS 10,000 S XXXXXXX WORKERS COMPENSATION _ — B AND EMPLOYERS'LIABILITY N 7012343895(AOS) 5/1/2024 5/1/2025 X 1 STATUTE I ERH B ANY PROPRIETOR/PARTNER/EXECUTIVE Y!N 7012343881(CA) 5/1/2024 5/1/2025 C OFFICERJMEMBEREXCLUDED? N N/A 7012447142 AZ,MA,OR,W1) 5/1/2024 5/1/2025 E.L.EACH ACCIDENT $ 2�00,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 2,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 2,000,000 DESCRIPTION OF OPERATIONS!LOCATIONS!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.**Sec Attached Endorsements** LA33845C-1850 3/4 MacArthur Blvd. Santa Ana,CA CERTIFICATE HOLDER CANCELLATION See Attachments SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 201 20183932 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS. CityRisk Management Division 20 Civic Center Plaza, 4th Floor AUTHORIZED REPRESENTA Santa Ana CA 92701op 1 ©1988-2 CORDC�ORPORATI N. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD7 /D/346/ Attachment Code:D59064I Master ID: 1358772,Certificate ID: 20183932 v��I Loacrou 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 20183932 •Email:stl-edelivery@lockton.corn •Phone: 314-812-3888 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. Lockton Companies tea_ 67- gird"q-solzy Locicton Companies Three C:ityPlace Dr.Suite 900/St. Louis, MO 63 14 1-7 088 314--432-0500 i lockton_corn Attachm 5 278 Master ID: 1358772,Certificate ID:20183932 POLICY HOLDER NOTICE—COUNTRYWIDE 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. A 41c 16[34231 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:20183932 CNA ' NOTICE OF CANCELLATION TO CERTIFICATE,HOLDERS 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. '.o `4 11/41 . Gel 31914 Form No: CNA68021XX(02-2013) Policy No:7 12343878 Endorsement Effective Date: 5/1/2024 Policy Effective Date:5/1/2024 Endorsement No: Policy Page: Underwriting Company: Continental Casualty Company ©Copyright CNA All Rights Reserved.