HomeMy WebLinkAbout6TH AVE FIRE DEPARTMENT � a
CITY OF ZEPHYRHILLS-BUILDING DEPARTMENT
DATE:02-12-2019 RIGHT-OF-WAY USE PERMIT PERMIT#
No construction under ground or above ground of any facility shall be accomplished on any City Rights of Way withoat written approval from the
City Building Department Any application for approval of construction operations on any City owned Rights of Way shall furnish a detailed drawing
1 showing the complete scope of the proposed work in triplicate to the office of the Building Official for approval prior to the commencement of any work.A
A t� copy of this permit is to be kept readily available at the site of the work at all times.
�v I
PARCEL I.D.8 26110010134000010 CITY ROAD 6th Avenue DATE 03-18-2019
LOCATION(Legal Description):North ROW of 6th Avenue adjacent to southwest boundary of City Hall property. See attached figure for exact location.
Permission is hereby granted to The Site Investigation Section of The Florida Department of Environmental Protection for the construction and maintenance of-
Three monitor wells(shallow,intermediate and deep).Monitor wells will be installed in a flush mounted 2'x 2'concrete pad with a 6 inch bolted on manhole cover.
Prior to construction underground utilities will be located by Florida One Call and a private utility locating service.Monitor wells will be sited at to prevent any
obstructions to traffic or pedestrians.Traffic control will be implemented during monitor well installation to protect pedestrians and traffic.
subject to the following conditions:
1. The construction and maintenance of such utility shall not interfere with the property and rights of a prior occupant
2. All work shall be done in keeping with the standards of the City Streets Department and under the supervision of the City Building Official,who
will be notified at least one day prior to commencement of construction.
3. Ali materials and equipment shall be subject to inspection by the City Building Official.
4. During construction all safety regulations of the Department of Transportation shall be observed and the City shall be relieved of of
responsibility from damage of any nature arising from this permit Subject to the same terms and conditions,the permit holder may take such safety
measures,including placing and display of caution signs,as it may deem necessary in conduct of construction and maintenance work hereunder.It is the
responsibility of the permittee to????
5. All private and all City properly shall be restored to its original condition as far as practical in the opinion of the City Building Official.
6. All underground crossing installations shall be laid at such depth as may be specified by the City Building Official.
7. The sketch covering the details of this installation shall be made apart of this permit This permit is granted with the understanding that the
applicant has notified of other utility users in the area covered by the permit and takes full responsibility for any damage incurred by prior installations as a
result of his operations in order that they may safe guard their interests.
8. It is expressly stipulated that this permit is a license for permissive use only and that the placing of facilities upon public property pursuant to
this permit shall not operate to create or to vest any property right in said holder.
9. Whenever the City decides to further exploit the City Rights of Way,any or of said poles,wires,pipes,cables,or other facilities and
appurtenances authorized hereunder,shall be Immediately removed from said Rights of Way,or reset or relocated thereon as required by the City Building
Official at the expense of the holder of this permit
10.The holder shall save and keep the City harmless from any and all damages,claims,or injuries that may occur by reason of the construction,
maintenance,and operation of said facility.
11.The holder shall complete the requested work within 90 days or this permit shall become null and void.In the event the work
requested Is not completed upon the expiration date of this permit,the City shall have the right to complete such work and to charge the holder of the permit
for all costs incurred in completing said work.
12.The holder shall post a cash or surety bond with the City Manager in the sum of$ dollars to guarantee performance of the
obligations herein,and to guarantee maintenance of the right-of-way described herein for a period of one(1)year following completion of the requested
installation.In the event a surety bond is posted,the surety bond shall be made payable to the City and shall obligate the surety to hold the City harmless in
the event the holder of this permit should fail to meet any of its obligations hereund�r.The bond shall also indemnify the City for an court costs and"
reasonable attorneys fees in the event legal action is required to collect on said bond.\
SUBMITTED BY:
(Permittee)FDEP y�Signature&Title CJ� Y�i""� P.G.
Address 2600 Blair-stone d,Tall rassee,FL 32399
Phone 850 245 8955
APPROVED BY:
CITY OF ZEPHYRHILLS
Building Olffiri ell
Date: /
Utilities Supe rsor L
Date: !` I
Public Works
Date:
i
City Manager
Date:
Page 1 of 1
Flush Mount Concrete Pad
Wei Cover : ; , Thicknoss:>4.0 in.
J Plug '• ",�.
(LockingI PVC Rpe
Plug �:. - I 2.04n.Sch 40
Plastic Plug - I`. �',:../I 24-In2 IengVi
_ PVC Riser
1.0-in.Sch.40
5A lengths
High Solids Bentonite Slurry �-
or Neat Cement Grout
_ Bentonito Well Seal
Thickness:a 2 feet
Grout Barrier
(20140 Sand or Collapsed
Natural Formation) e
Thickness:>2 foot above top
of screens t 1.0-In.x 2.5-In.OD
e Prepack Well Screen
PVC Bottom Plug
Expendable Paint. _.
3,0-In.OD
Typical Monitor Well Cross Section
Is-
Typical Monitor Well Pad
Construction•
• 1
DEPARTMENT OF FINANCIAL SERVICES
Division of Risk Management
STATE RISK MANAGEMENT
TRUST FUND
Policy Number: WC-2000 State Employee Workers' Compensation
and Employer's Liability
Certificate of Coverage
Name Insured: Department of Environmental Protection
Coverage Limits:
Coverage A-Compensation coverage is provided to comply with the applicable State Workers'
Compensation, Occupational Disease Laws and any rule promulgated thereunder.
Coverage B $200,000.00 each person
$300,000.00 each occurrence
Inception Date: • July 1, 2018
Expiration Date: July 1, 2019
DFS-DO-867
(REV.7/17)
DEPARTMENT OF FINANCIAL SERVICES
Division of Risk Management
STATE RISK MANAGEMENT TRUST FUND
STATE EMPLOYEE WORKERS' COMPENSATION AND
EMPLOYER'S LIABILITY
CERTIFICATE OF COVERAGE
In consideration of the provisions and stipulations contained herein or added hereto and for the premium charged, the State Risk Management Trust
Fund, hereinafter referred to as the "Fund", certifies that the State department or agency named in this certificate is hereby entitled to workers'
compensation coverage as set forth in the Workers' Compensation Laws and to employer's legal liability coverage as established herein. Coverage
shall be effective on the inception date at 12:01 a.m.,standard time.
This certificate is comprised of the foregoing provisions and stipulations,together with such other provisions and stipulations as may be added hereto by
the Fund in the future:
I. Coverages directly from a bodily injury by accident is included within
A. Coverage A-Workers'Compensation the term"bodily injury by accident". The term"bodily injury
To pay promptly when due all compensation and other by disease"includes only such disease as is not included
benefits required of the insured by the Workers' within the term"bodily injury by accident".
Compensation Laws. (d) Assault and Battery - Under Coverage B, Assault and
Battery shall be deemed an accident unless committed by
B. Coverage B-Employer's Liability or at the direction of the insured.
To pay on behalf of the insured all sums which the insured
shall become liable to pay as damages because of bodily IV. Applications of Coverage
injury by accident or disease, including death,at any time This certificate applies only to (1) injury by accident occurring
resulting therefrom, which are sustained by an employee during the coverage period,or(2)occupational injury by disease
of the insured and which arise out of and in the course of as such is defined by law which occurs during the coverage
his employment with the insured in the United States of period.
America,its territories or possessions,or while temporarily
employed outside the United States of America, its V. Exclusions
territories or possessions. This certificate does not apply under Coverage B:
(a) to any claim or judgment for punitive damages;
II. Defense,Settlement,Supplementary Payments (b) to any claim for interest for the period prior to judgment;
As respects the insurance afforded by the other terms of this (c) to that portion of a claim or judgment which is in excess of
certificate,the Fund shall: the statutory limits of liability;
(a) defend any proceeding against the insured seeking such (d) to liability assumed by the insured or any third party
benefits and any suit against the insured alleging such pursuant to any contract or agreement in writing;
injury and seeking damages on account thereof, even if (e) to any obligation for which the named insured or any
such proceeding or suit is groundless,false,or fraudulent. carrier
The Fund will investigate all claims filed against the as his insurer may be held liable under any workers'
insured in order to determine the legal liability of the compensation, unemployment compensation or disability
insured and to determine damages sustained by the benefits laws,or under any similar law;
claimant. The Fund will negotiate,settle,or deny the claim (f) to any action by officers,employees,agents,or volunteers
based on these findings and appropriate Florida law. as defined in Chapter 110, Part V, Florida Statutes,
(b) pay all expenses incurred by the Fund, all costs taxed committed in bad faith, or with malicious purpose or in a
against the insured in any such proceeding or suit,and all manner exhibiting wanton and willful disregard of human
interest accruing after entry of judgment until the Fund has rights,safety,or property.
paid, tendered, or deposited in court such part of such
judgment as does not exceed the limit of the Fund's liability VI. Conditions:
thereon; A. Premium
(c) pay amounts incurred under this insuring certificate, Premium charges shall be assessed in accordance with
except settlements of claims and suits, in addition to the the provisions of Chapter 284, Part II, Florida Statutes,
amounts payable under Coverage A,or the applicable limit and any rules promulgated thereunder utilizing a
of liability under Coverage B. retrospective rating arrangement premium calculation
method whereby 80%of the premium is based on losses
III. Definitions actually incurred by the insured and 20% is based on the
(a) Workers'Compensation Law-The workers'compensation changes in risk exposures(employees,volunteers,etc.)of
law and any occupational disease law of a state an insured. The premium must be paid promptly by an
designated in this certificate, but does not include those insured agency from its operating budget upon receiving
provisions of any such law which provide non-occupational the premium bill or invoice.
disability benefits.
(b) State - Any state or territory of the United States of B. Inspection
America and the District of Columbia. The Fund shall be permitted, but not obligated,to inspect
(c) Bodily Injury by Accident-Bodily Injury by Disease-The at any reasonable time, the workplaces, operations,
contraction of disease is not an accident within the machinery, and equipment covered by this certificate.
meaning of the word"accident",as used in the term"bodily Neither the right to make inspections, nor the making
injury by accident", and only such disease as results thereof, nor any report thereon shall constitute an
DFS-DO-867
Revised 8/09 Page 1 of 2
undertaking on behalf of or for the benefit of the insured or The words "damages because of bodily injury by
others, to determine or warrant that such workplaces, accident or disease, including death at any time
operations,machinery,or equipment are safe. resulting therefrom"in Coverage B include damages
for care and loss of services and damages for which
C. Insured's Duties in the Event of Injury,Claim or Suit the insured is liable by reason of suits or claims
(1) Notice of Injury brought against the insured by others because of
When an injury occurs, notice shall be given such bodily injury sustained by employees of the
immediately, in accordance with current reporting insured arising out of and in the course of their
procedures by the insured to the Fund. Such notice employment. The limits of liability for Coverage B
shall contain particulars sufficient to identify the are those established by Section 768.28, Florida
insured along with reasonably obtainable information Statutes.
respecting the time, place, circumstances of the (6) Other Insurance
injury, the names and addresses of the injured and Coverage A - If the insured has other insurance
all known witnesses. Such notice is to be directed to against a loss covered by this certificate, the Fund
the Division of Risk Management,State Employees' shall not be liable to the insured hereunder for(1)a
Workers'Compensation Claims, greater proportion of such loss than the amount
P. O. Box 8020, Tallahassee, Florida 32314-8020, which would have been payable under this
or to contract service vendor in accordance with certificate had no such other insurance existed, and
current reporting procedures. (2) the amount which would have been payable
(2) Notice of Claim or Suit under each other policy applicable to such loss had
If claim is made or suit or other proceedings is each such policy been the only policy so applicable.
brought against the insured, the insured shall Coverage B-If there is a valid and collectible policy
immediately forward to the Fund every demand, of insurance applicable to any otherwise valid claim
notice,summons,or other process received by it or hereunder,the coverage extended by this certificate
its representative. shall not apply.
(3) Assistance and Cooperation of the Insured (7) Subrogation
The insured shall cooperate with the Fund,and at its In the event of any payment under this certificate,
request, shall attend hearings and trials, assist in the Fund shall be subrogated to all rights of recovery
effecting settlements, secure and give evidence, therefor of the insured and any person entitled to the
obtaining the attendance of witnesses. The insured benefits of this coverage against any person or
shall not except at its own cost,voluntarily make any organization, and the insured shall execute and
payment, assume any obligation, or incur any deliver instruments and papers and do whatever
expense other than for such immediate medical and else is necessary to secure such rights. The insured
other services at the time of injury as are required by shall do nothing after loss to prejudice such rights.
the Workers'Compensation Law. (8) Cancellation
(4) Statutory Provisions-Coverage A Failure of the Fund to receive the amount of
The Fund shall be directly and primarily liable to any premiums billed to the insured agency within the
person entitled to the benefits of the Workers' time frames allowed by law may result in
Compensation Law under this certificate. The cancellation of the certificate of coverage.
obligations of the Fund may be enforced by such Payments must be made promptly from the insured's
person, or for his benefit, by any agency authorized operating budget upon receipt of the premium bill as
by law, whether against the Fund alone or jointly specified in Section 284.36, Florida Statutes, and
with the insured. As between the employee and\the lack of prompt payment will result in a request from
Fund,notice or knowledge of the injury on the part of the Fund to the Comptroller to transfer premiums
the insured shall be notice or knowledge, as the from any available funds of the delinquent agency
case may be, on the part of the Fund. The Fund under the provisions of Section 284.44(7), Florida
shall, in all things, be bound by and subject to the Statutes.
findings, judgments, awards, decrees, orders or (9) Terms of Coverage Conformed to Statute
decisions rendered against the insured in the form Terms of this certificate which are in conflict with the
and manner provided by law and within the terms, provisions of the Workers' Compensation Law, or
limitations, and provisions of this certificate not Section 768.28, Florida Statutes, are hereby
inconsistent with existing law. amended to conform to such laws.
All of the provisions of the Workers' (10) Self-Insurance Coverage
Compensation Law shall be and remain a part of this Coverage for defending and paying claims under this
coverage as fully and completely as if written herein certificate is provided under the authority of Chapter
insofar as coverage applies to compensation and 284,Florida Statutes,wherein the state is authorized
other benefits provided by this certificate and in to administer a self-insurance program. Provision of
respect to special taxes, payments into security or this certificate does not constitute the issuance of
other special funds,and assessments required of or insurance other than on a self-insurance basis, and
levied against compensation insurance carriers payment of any covered claim obligations is
under the Workers'Compensation Law. contingent upon availability of legislative funding.
The insured shall reimburse the Fund for any
payments required of the Fund under the Workers'
Compensation Law, which are made in excess of
the benefits regularly provided by such law, solely
because of injury to (a)any employee by reason of
the serious and willful misconduct of the insured, or
(b) any employee employed by the insured in
violation of law with the knowledge or acquiescence
of the insured or any executive officer thereof.
(5) Limits of Liability-Coverage B
DFS-DO-467
Revised 8/09 Page 2 of 2