HomeMy WebLinkAboutIowa Department of Transportation-10/7/2013Iowa Department of Transportation
Form 810028 (02-11)
APPLICATION TO PERFORM WORK
WITHIN STATE HIGHWAY RIGHT-OF-WAY
FOR DEPARTMENT USE ONLY
Permit Number
7A —loki— OZ.C.
Highway Number
218
County
Black Hawk
DOT Project Number
200(5)
Expiration/Completion Date
January 1, 2014
APPLICANT (INDIVIDUAL OR COMPANY) (ASSISTANCE FROM DCPARFMENT AVAILABLE UPON REQUEST)
First Name
Lynn
Middle
C
Last Name
Kloberdanz
Phone Number
319-833-3008
Ext.
Company Name
Black Hawk Co. Engineer
Phone Number
319-833-3008
Ext.
Street Address
316 E 5th St. Ste. 211
City/Town
Waterloo
State
IA
ZIP Code
50703
WORK TO -BE ACCOMPLISHED
Approval is hereby requested to enter within the state right-of-way and to complete the proposed work as detailed on the attachments
and further described as follows:
Use of US Hwy 218 from Eagle Rd. (D46) in Black Hawk Co. to Orange Rd. in Waterloo
for a detour route while culvert replacement is taking place on Dysart Rd. (V37).
This project will take place between October 9, 2013 and November 15, 2013.
and shall be located as shown on the detailed plan attached hereto. (See current Iowa Department of Transportation Utility
Accommodation Policy for submittal of detailed plan requirements.)
WORK SITE LOCATION
The proposed work as described above is located in Section , Twp.
Range on Highway No. 218
(direction) from Waterloo Corp. Limit
generally located 6
(miles) south
(city, county line, or other land line). Work proposed is more
specifically located as being from (Milepost #) and (Highway Station)
to (Milep.ost #) and (Highway Station) on the side of highway.
Applicant Signature and Agreement
The undersigned have read the stipulations of this permit agreement as stated as well as attachments which may be included and by
signing this application agree to abide by all stipulations and to complete the work as proposed in compliance with the stipulations and
attachments within one year from the date Department approval is received for said request. Failure on the part of the applicant to
abide by the stipulations or to construct the work desired as stipulated and within the time frame stated shall render this agreement and
request null and void. The undersigned also agrees to save harmless the State of Iowa and the Iowa Department of Transportation
from any damage or losses that may be sustained by any person or persons on account of the conditions and requirements of this
agreement.
Applicant Name (First, Mi., Last - Print or Type)
Applic-n Signatu a (Han. • 'tte)
Date
Lynn C. Kloberdanz
/�`
k2 //5//0
%�'�t�'
C1TYACTION.'(IPRROPOSED WORK IS' WITHIN:AN.�VCORPORATED CITY,.CITY.TIO
IS.REQUIRE.D) -
"The undersigned city joins in the grants embodied in the above permit executed by the Iowa Department of Transportation on
condition that all of the covenants and undertakings therein running to the Iowa Department of Transportation shall inure to the benefit
of the undersigned city and recommends action on said permit application as noted below by the delegated city official".
Recommend Approval
0 Do Not Recommend Approval
0 None Required
Hand ' en.Sign u --
Title
nrY E/6/Ak
Date
Type or Print Name Authorrized Official for the City of
/Qf't�iRaQ IIATE/C...00
FEDERAL HIG.HWAYADMINI5TRATIO.N ACTION .
(DEPARTMENT REPRESENTATIVE*WILLL-:REVlEW=THE,REQUEST AND: OBTAIN',FHWA ACTION, WHEN NECESSARY).
Recommend Approval 0 Do Not Recommend Approval 0 None Required
Authorized FHWA Representative Signature
Date
(DOT Final Action and Agreements on next page)
Page 1 of 2
DEPARTMENT OFTRANSPORTATION`FJNAC ACTION
® Application Approved D Application Dented
Permit Number:
Authorized Highway District Representative Si ture Date /
Dave Ramirez �� ! / l l /3
Nbtice otintention to coni mertce:ectivitied on" the highway rights-of-way'shali be submitted' by the applica a minimum bf`4'8 hours prior to actually commencing the activities
as herein granted by thlsi'approved application: Notice la to be given to the following Iowa Oepartrnent • ransportation representative:
Local DOT Contact Person (Type or Print Name)
Doug Lickteig
Phone Number
319-233-3055
Street Address
1875 W Ridgeway Ave
City/Town
Waterloo
State
IA
ZIP Code
50704
AGREEMENTS
The applicant agrees that if granted a permit to do said work the following stipulations shall govern.
1. The applicant shall carry on the construction, repair, and maintenance with serious regard to the safety of the traveling public and
adjacent property owners and shall save the State and the Iowa Department of Transportation harmless of any damage or losses that
may be sustained by the traveling public on account of such construction, repair, or maintenance operations.
2. The applicant shall indemnify and save harmless the State of Iowa, its agencies, and employees, from any and all causes or
actions, suits at law or in equity, for losses, damages, claims, or demands, and from any and all liability and expense of whatsoever
nature, arising out of or in connection with the applicant's use or occupancy of the public highway.
3. The applicant shall hold the State and the Iowa Department of Transportation harmless of any damage that may result to said
highway because of the construction or maintenance of the facility, and shall reimburse the State or the Iowa Department of
Transportation for any expenditures that the State of Iowa or the Iowa Department of Transportation may have to make on said
highway rights-of-way on account of said applicant's construction or maintenance activity or lack thereof.
4. Traffic protection shall be in accordance with Part VI of the current Manual on Uniform Traffic Control Devices for Streets and
Highways. The applicant shall be responsible for correctly using signs as needed while work is in progress. Flagging operations are
the responsibility of the applicant.
5. Before beginning any work within the highway rights-of-way, it is the responsibility of the applicant to contact utility companies
whose installations may be affected or encountered. Contact should be made at 1-800-292-8989, a minimum of 48 hours in advance
of starting construction. If the work requested in this application should cause a need to relocate or modify an existing utility, any cost
associated shall be as negotiated between the applicant and the utility owner.
6. A copy of the approved application shall be available on the job site at all times for examination by Department of Transportation
officials.
7. The applicant shall seed and mulch all disturbed areas within the highway right-of-way and shall be responsible for the vegetative
cover until it becomes well established. Any surfaced areas such as driveways or shoulders and sodded waterways and plantings
which are disturbed shall be restored to their original condition.
8. If the proposed work results in a pool of water on the applicant's property, this pool of water will be exclusively owned, controlled,
and maintained by the applicant. That part of the modification located on highway right-of-way will be maintained by the Iowa
Department of Transportation for road purposes only.
9. The applicant shall maintain any drainage structure built within the right-of-way that is built for the benefit of the applicant and not
necessary for highway use.
10. This permit is subject to any laws now in effect as well as any new laws which may be hereafter enacted and all applicable rules
and regulations of local, state, and federal agencies.
11. This permit is subject to all the rules and regulations of the Iowa Department of Transportation, and to revocation by the Iowa
Department of Transportation at any time and at no cost to the Department, when in the judgment of the Department it is necessary in
the improvement or maintenance of the highway or for other reasonable cause.
12. The applicant agrees to give the Iowa Department of Transportation 48 hours notice of intention to start construction or perform
maintenance on the highway right-of-way. Any modification to the proposed work shall be approved by the Department prior to making
the change.
13. Unless specifically noted in item #15, all work performed within the right-of-way shall be restricted to a time frame of 30 minutes
after sunrise to 30 minutes before sunset.
14. After November 24, 2008, all personnel in the highway right-of-way shall wear ANSI 107 Class 2 apparel at all times when
exposed to traffic or construction equipment.
15. All proposed work covered by this permit shall be at the applicant's expense. The applicant shall reimburse the Iowa
Department of Transportation for any materials removed from the highway right-of-way described as follows:
16. The following special requirements shall apply to this permit:
Disclosure Statement: The Information furnished on this form will be used by the Department of Transportation to determine approval or denial of the
application. Failure to provide all Information will result in denial of the application. Information furnished Is public information and copies may be
provided to the public upon request.
Page 2 of 2
10A Iowa Department of Transportation
1875 W. Ridgeway Ave. P.O. Box 1888
Waterloo, Iowa 50704-1888
Office 319-235-1832
david.ramirez@dot.iowa.gov
October 21, 2013
Five Star Snow Trails
Attn: Dick Melick
1314 Washington Street
Cedar Falls, Iowa 50613
RE: Permit # 7A-2013-027, Black Hawk County, Ref. # 604.2
Dear Mr. Melick,
Please find the approved Application to Perform Work Within State
Highway Right of Way for the trail grooming and sign placement in
Black Hawk County and surrounding communities.
The work is to be accomplished in accordance with the agreements
on page 2 of the permit to include the special requirements and
attachments. Please review the agreement section of the permit.
Please provide a copy of this to your client for their project
files. If you have any questions please call me at 319-235-1832.
Sincerely,
Dave Ramirez E.O.T.
District 2
c.c. Dave Little, Assistant District Engineer, District 2
Jeff McCollough, Design Tech Specialist, Traffic and Safety
Doug Lickteig, Waterloo Area Supervisor
Michael Schares, Mayor, City of Dunkerton
Ernest Clark, Mayor, City of Waterloo
Iowa Department of Transportation
Form 810028 (02-11)
APPLICATION TO PERFORM WORK
WITHIN STATE HIGHWAY RIGHT-OF-WAY
WORK TO BE ACCOMPLISHED
Approval is hereby requested to enter within the state right-of-way and to complete the proposed work as detailed on the attachments
and further described as follows:
Snow mobile Trail and Trail Crossing locations as indicated on the attached listing.
Trail is located partially within the city limits of thmkertonodilleftat and Waterloo.
All crossings shall go into effect after all signs along the highway have been installed by IDOT forces.
All signs placed on the ROW by the applicant shall be removed by the applicant
and shall be located as shown on the detailed plan attached hereto. (See current Iowa Department of Transportation Utility
Accommodation Policy for submittal of detailed plan requirements.)
WORK SITE LOCATION
The proposed work as described above is located in Section , Twp. (SEE ATTACHED LISTING)
Range on Highway No. generally located (miles)
(direction) from (city, county line, or other land line). Work proposed is more
specifically located as being from (Milepost #) and (Highway Station)
to (Milepost #) and (Highway Station) on the side of highway.
Applicant Signature and Agreement
The undersigned have read the stipulations of this permit agreement as stated as well as attachments which may be included and by
signing this application agree to abide by all stipulations and to complete the work as proposed in compliance with the stipulations and
attachments within one year from the date Department approval is received for said request Failure on the part of the applicant to
abide by the stipulations or to construct the work desired as stipulated and within the time frame stated shall render this agreement and
request null and void. The undersigned also agrees to save harmless the State of Iowa and the lowa Department of Transportation
from any damage or losses that may be sustained by any person or persons on account of the conditions and requirements of this
agreement
Applicant Name (First, M1., Last- Print or Type)
Richard C. Melick
App' nt Signa regHendwnft
Date
09/25/2013
Ci'TY AC 1 ION W P PO I INCL PQ , ' A t I I E? 04
"The undersigned city joins in the grants embodied in the above permit executed by the Iowa Department of Transportation on
condition that all of the covenants and undertakings therein running to the Iowa Department of Transportation shall inure to the benefit
of the undersigned city and recommends action on said permit application as noted below by the delegated city official".
Ei Recommend Approval Ei Do Not Recommend Approval I I None Required
Handwritten Signature
Title
Date
Type or Print Name
(SEE ATTACHED CITY ACTION SHEETS)
FEDERAI tIGl t Y AI MI IS TIO it I
(DEPARTMENT. . 5 T
Ei Recommend Approval
Authorized Official for the City of
(SEE ATTACHED CITY ACTION SHEETS)
Do Not Recommend Approval
NEQEssAR
El None Required
Authorized FHWA Representative Signature
Data
(DOT Final Action and Agreements on next page)
Page 1 of 2
Highway Number
(SNS ATTACHED LISTING)
County
Black Hawk
Permit Number
74 — 2d /3 — o 2.-7
DOT Project Number
N/A
Expiration/Completion Date
04/15/2014
APPLICANT (INDIVIDUAL OR COMPANY) _ (ASSISTANCE FROM DEPARTMENT
AVAILABLE
UPON REQUEST)
Phone Number
319-231-0819
First Name
Richard
Middle Initial
C
Last Name
Melick
Company Name
Five Star Snow Trails
Phone Number
319-231-0819
Street Address
1314 Washington Street
City/Town
Cedar Falls
State
Ia
ZIP Code
50613-4153
WORK TO BE ACCOMPLISHED
Approval is hereby requested to enter within the state right-of-way and to complete the proposed work as detailed on the attachments
and further described as follows:
Snow mobile Trail and Trail Crossing locations as indicated on the attached listing.
Trail is located partially within the city limits of thmkertonodilleftat and Waterloo.
All crossings shall go into effect after all signs along the highway have been installed by IDOT forces.
All signs placed on the ROW by the applicant shall be removed by the applicant
and shall be located as shown on the detailed plan attached hereto. (See current Iowa Department of Transportation Utility
Accommodation Policy for submittal of detailed plan requirements.)
WORK SITE LOCATION
The proposed work as described above is located in Section , Twp. (SEE ATTACHED LISTING)
Range on Highway No. generally located (miles)
(direction) from (city, county line, or other land line). Work proposed is more
specifically located as being from (Milepost #) and (Highway Station)
to (Milepost #) and (Highway Station) on the side of highway.
Applicant Signature and Agreement
The undersigned have read the stipulations of this permit agreement as stated as well as attachments which may be included and by
signing this application agree to abide by all stipulations and to complete the work as proposed in compliance with the stipulations and
attachments within one year from the date Department approval is received for said request Failure on the part of the applicant to
abide by the stipulations or to construct the work desired as stipulated and within the time frame stated shall render this agreement and
request null and void. The undersigned also agrees to save harmless the State of Iowa and the lowa Department of Transportation
from any damage or losses that may be sustained by any person or persons on account of the conditions and requirements of this
agreement
Applicant Name (First, M1., Last- Print or Type)
Richard C. Melick
App' nt Signa regHendwnft
Date
09/25/2013
Ci'TY AC 1 ION W P PO I INCL PQ , ' A t I I E? 04
"The undersigned city joins in the grants embodied in the above permit executed by the Iowa Department of Transportation on
condition that all of the covenants and undertakings therein running to the Iowa Department of Transportation shall inure to the benefit
of the undersigned city and recommends action on said permit application as noted below by the delegated city official".
Ei Recommend Approval Ei Do Not Recommend Approval I I None Required
Handwritten Signature
Title
Date
Type or Print Name
(SEE ATTACHED CITY ACTION SHEETS)
FEDERAI tIGl t Y AI MI IS TIO it I
(DEPARTMENT. . 5 T
Ei Recommend Approval
Authorized Official for the City of
(SEE ATTACHED CITY ACTION SHEETS)
Do Not Recommend Approval
NEQEssAR
El None Required
Authorized FHWA Representative Signature
Data
(DOT Final Action and Agreements on next page)
Page 1 of 2
Five Star Snow Trails
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RAW 1.1.4
CITY ACTION (IF PROPOSED WORK IS WITHIN' AN INCORPORATED CITY, CITY ACTION IS REQUIRED)
"The undersigned city joins in the grants embodied in the above permit executed by the Iowa Department of Transportation
on condition that all of the covenants and undertakings therein running to the Iowa Department of Transportation shall inure
to the benefit of the undersigned city and recommends action on said permit application as noted below by the delegated city
official".
Recommend Approval
❑ Do Not Recommend Approval
0 None Required
Official Signature
Auth. City
Title
Date
(Handwri en}
5\Jbjor-10/I
41 2013
Va a of Aut 0 "zed City Official (Print or type)
Authorized City Official for the City of
iChdl J. Scho es
DUNKERTON
3
CITY ACTION (IF PROPOSED 1NORK IS WITHIN AN INCORPORATED CITY, CITY ACTION IS REQUIRED)
"The undersigned city joins in the grants embodied in the above permit executed by the Iowa Department of Transportation
on condition that all of the covenants and undertalangs therein running to the Iowa Department of Transportation shall inure
to the benefit of the undersigned city and recommends action on said permit application as noted below by the delegated city
official".
Recommend Approval
0 Do Not Recommend Approval 0 None Required
Auan th. en} Official Si n ure
(H
—.44J%
Title
ate
/0/77 / 3
game of Authorized City Official (Print or type
Authorized City Official fo the C of
-Eki $' f (9_ Q,krk
WATERLOO
3A
IOWA DEPARTMENT OF TRANSPORTATION
Application to perform work within State Highway Right -of -Way
FIVE STAR SNOW TRAILS ASSOCIATION
Snowmobile Trail and Crossing Locations -Black Hawk County
1. Crossing of US 218 in Waterloo at Marigold Dr, milepost 176.84.
2. Marked, "ungroomed" trail along both ditches of US 218 from Marigold Dr in Waterloo,
milepost 176.84, to bridge at the north Washburn city limits.
3. Crossing under US 218 by way of bridge at north Washburn city limits, milepost 175.58
(NO SIGNING REQUIRED ON ROADWAY)
4. * * * This item is completely removed and the number retained to avoid renumbering balance
of items.
5. Marked, "groomed" trail along east ditch only, of US 218 from the convenience store at 7112
LaPorte Road in Washburn to East Schrock Road, southeast of Washburn.
6. Crossing of US 218 at East Schrock Road, milepost 173.74.
7. Marked, "groomed" trail along both ditches of US 218 from East Schrock Road, milepost
173.74 to LaPorte City north city limits.
8. *This item is completely removed and the number retained to avoid renumbering balance of
items.
9. *This item is completely removed and the number retained to avoid renumbering balance of
items.
10. Crossing of US 218 at County C57 north of Cedar Falls. Stop signs will be placed along the
trail on both sides ofthe highway requiring snowmobiles to stop prior to crossing the first two
lanes and also in the median to require snowmobiles to stop before crossing the next two
lanes. milepost 192.88.
11. **Crossing US 218 at West Gresham Road north of Cedar Falls. Stop signs will be placed
along the trail on both sides of the highway requiring snowmobiles to stop prior to crossing
the first two lanes and also in the median to require snowmobiles to stop before crossing the
next two lanes.
12. This item number is listed to avoid re -numbering the balance of items .
Black Hawk County-2013.wpd 4
IOWA DEPARTMENT OF TRANSPORTATION
Application to perform work within State Highway Right -of -Way
FIVE STAR SNOW TRAILS ASSOCIATION (Cont'd)
Snowmobile Trail and Crossing Locations -Black Hawk County (Cont'd)
* Item 8 and 9 are removed due to temporary suspension ofthe trail leaving George Wyth State Park
due to development in the area. The trail will be re -opened when an alternative route is developed.
* *Item 11 is reinstated as a permanent change on the application. It was approved as an amendment
to the 2012 application.
***Item 4 is removed as the trail now proceeds northward on private property after crossing under
the bridge mentioned in item 3.
* * * *Items number 17, 18, 19, 20, & 21 as shown on the 2012 application have been removed as
that portion of the trail system has been temporarily suspended. Item 22 & 23 have been
renumbered as items 17 & 18 respectively.
#Item 14 is changed to reflect the current crossing location.
Item 15 is removed due to no longer being able access the Kwik Star station..
All other locations shown on this application are the same as listed on the 2012 application.
Note: Marked, "groomed" trail indicates that a track driven motorized tl ail grooming tractor pulling
a snow drag will be operating to prepare the trail for snowmobile use and special signs applicable to
snowmobile trails will be installed.
Note: Liability insurance for the Five Star Snow Trails Association is covered on page 4 of the
"Land Owners as Additional Insureds" page on the enclosed Certificate of Insurance for the Sno
Hawks Snowmobile Club. All towns involved and the Iowa Department of Transportation are
covered by the additional insured that is listed as "THE STATE, OF IOWA AND ALL OF ITS
POLITICAL SUBDIVISIONS".
Black Hawk County-2013.wpd
6
RSA DCERTIFICATE OF LIABILITY INSURANCE
�D `'og�223
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 SUBROGAI1ON 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
V & V Insurance Agency ,PHONE
Inc
PO Bax 159
103 $ th St E
Cresco IA 52136-
CONTACT
NAME:
(AIC. No. Extl: (563) 547-2161
FAX (5x31 547-2046
(A1C. Not:
AADD"REEss: insurance@vandvins . com
INSURER(S) AFFORDING COVERAGE
NAIC #
Hamm A:Dakota Fire Insurance Company
INSURED SNO HAWKS INC .
1314 WASHINGTON ST
R
CEDAR FALLS IA 50613-
INSURER B :
/ /
10/01/2013
/ /
/ /
/ /
/ /
/ /
INSURER C :
EACH OCCURRENCE
INSURER D :
EMISES (TEaENTED
occurrence)
INSURER E :
MED EXP (My one person)
INSURER F:
•
THIS IS TO tliktIFY`THA'i''I E Fi110(ES 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
TYPE OF INSURANCE
ADDL
INSR
SUBR
WVD
POLICY NUMBER
POLICY EFF
(MMIDDJYYYYI
POLICY EXP
IY
JMMIDDMY�
LIMITSLTR
A
GENERAL
X
LIABILITY
COMMERCIAL GENERAL LIABILITY
4878753
/ /
10/01/2013
/ /
/ /
/ /
/ /
/ /
/ /
10/D1I2014RP
/ /
/ /
/ /
/ /
/ /
EACH OCCURRENCE
$ 1,000,000
EMISES (TEaENTED
occurrence)
$
MED EXP (My one person)
$
X
CLAIMS -MADE
OCCUR
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$ 1, 000, 000
PRODUCTS - COMP/OP AGG
$
GEM_ AGGREGATE LIMIT APPLIES
7 POLICY 1— JF O-
PER:
LOC
$
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OW NED
AUTOS
HIRED AUTOS
_
SCHEDULED
AUTOS
NON -OWNED
AUTOS
/ /
/ /
/ /
/ /
/ /
/ /(Ea
/ /
/ /
/ /
/ 1
ciCOMMINdenU SINGLE LIMIT
$
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
$
UMBRELLA LIAB_
EXCESS (JAB
OCCUR
CLAIMS -MADE
/ /
/ /
I /
/ /
/ /
/ /
EACH OCCURRENCE
$
AGGREGATE
$
$
DED
RETENTION $
WORKERS
AND
ANY
OFFICER/MEMBER
(Mandatory
If yes,
DESCRIPTION
COMPENSATION
EMPLOYERS' UABILITYTORY
PROPRIETOR/PARTNER/EXECUTIVE
EXCLUDED?
in NH)
describe under
OF OPERATIONS below
Y/ N
N 1 A
/ /
I /
/ /
/ /
/ /
/ /
/ /
/ /
WC STATU-
UMRS
OTH-
ER
E.L. EACH ACCIDENT
$
EL DISEASE - EA EMPLOYEE
$
EL DISEASE -POLICY LIMIT
$
/ /
/ /
/ /
1 /
DESCRIPTION
Snowmobile
Utility
sheets.
OF OPERATIONS 1 LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It more space Is required)
Club and Trail Liability Insurance, including Liability coverage for (1) Groomer and (1)
vehicle used for trail maintenance only. Additional insureds for Trail Usage: See (2) attached
Premise liability coverage is Excluded on this policy.
CERTIFICATE HOLDER
"^••"`-"-` `. "'
( ) -
(
) -
-
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POUCY PROVISIONS_
AUTHORIZED REPRESENTATIVE
at f //'
n An58_9MIn Annan cnRPORATl e - All riahts reserved.
1
ACORD 25 (2010/05)
INS025 (2010.01
The ACORD name and logo are registered marks of ACORD
CLUB NAME:, SNO HAWKS, INC.
LANDOWNERS AS ADDITIONAL INSURED FOR.
CLUB CONTRACTED TRAIL USAGE ONLY
61. Mary D. Shining Trust
5311 Hyacinth Drive Unit 64
Cedar Falls, LA 50613-6415
62. William A. Shining Trust
5311 Hyacinth Drive Unit 64
Cedar Falls, IA 50613-6415
71. Charles Wilmot
2596 Joplin Avenue
Denver, IA 50622
63. Ronald Steege
9321 Logan Avenue
Waterloo, IA 50703
72. Raymond & Pauline Youngblut
6732 LaPorte Road
Waterloo, IA 50706
73. The State of Iowa & All of its political
Subdivisions
Wallace State Office Building
Des Moines, IA 50319
64. Eugene E. & Jean M. Stokes
6225 Ford Road
Cedar Falls, IA 50613
65. Tall Pine Farms, Inc.
7411 North Raymond Road
Dunkerton, IA 50626
66. Michael & Kathy Tellinghnisen
7611 North Union Road
Janesville, IA 50647
67.* Clifford R. & L. Marcella Trent
8339 Leversee Road
Cedar Falls, IA 50613
68. Alan & Marilyn Walker
1303 East Bennington Road
Waterloo, IA 50703
74. Five Star Snow Trails Association
5912 Aster Lane
Waterloo, IA 50701
69. Washburn BP Store
7305 LaPorte Road
Washburn, a 50702
70. City of Janesville Iowa
227 Main Street
Janesville, IA 50647
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