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HomeMy WebLinkAboutFive Star Snow Trails Assoc., Inc.-Trail Permit-08.08.2008 • ►2--� . oc� - 2c FIVE STAR SNOW TRAILS j ASSOCIATION, INC 1314 Washington St, Cedar Falls, IA 50613-4153 Phone/Fax:319-266-0445 ♦Cell:319-231-0819 ♦email:damelick@cfu.net August 27, 2008 City of Waterloo Attn: City Clerk 715 Mulberry Street Waterloo, IA 50703 Enclosed for your consideration is the Application to the Iowa Department of Transportation(IDOT) for renewal of the permit to establish and sign a snowmobile trail within the right of way of state highways. A portion of that trail resides within the city limits of Waterloo. The IDOT requires that each affected city approve the application before being processed by the Department. Page 3B of the application has a block for the signature of the responsible individual representing Waterloo. PLEASE USE THIS PAGE FOR THE CITY SIGNATURE. DO NOT COMPLETE THE SIMILAR SECTION SHOWN ON PAGE 1 OF THE APPLICATION. Permits are issued for one season only and must be renewed each year. This application is the same as the one which was approved last year for the city of Waterloo. Items 1, 2, 8, 9 on page 4 and items#17, 18, 19, 20, 21, and 22 on page 5 are the only items which affect Waterloo. If you have any questions concerning the application and related paperwork,you may contact me at: 319-266-0445(Home) or 319-231-0819(Cel1) or e-mail to: damelick@cfu.net I would appreciate it very much if city action could be taken at the next Council meeting,if Council action is required. The IDOT is short on staff and it could take them some time to take their action, so it is imperative that we get the application in their hands as soon as possible, so as to beat the freezing temperatures and first snowfall with signing of the trail. Please return to me in the enclosed, "postage applied" envelope as soon as possible after action has been taken by city officials. Thank you for your assistance with this matter. Sincerely, esy Dick Melick Q`" Five Star Snow Trails, Inc Administrative Advisor ���Iowa DForm 810028 epartment of Transportation Application to Perform Work Within State Highway Highway Division I1Ames,IA 50010 Right-of-Way FOR DEPARTMENT USE ONLY Permit Number ' Highway Number County (SEE ATTACHED LISTING) Black Hawk DOT Project Number Expiration/Completion Date N/A 4/15/2009 APPLICANT(INDIVIDUA},OR COMPANY) (ASSISTANCE FROM DEPARTMENT AVAILABLE UPON REQUEST) First Name Middle Initial Last Name Phone Number Richard C Melick Company Name (319) 266-0`I l5 Phone Number Five Star Snow Trails Association Street Address (319) 266-0445 City/Town State Zip Code 1314 Washington St Cedar Falls IA 50613-4153 WORK TO BE ACCOJNPLISHED 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: Snowmobile Trail and Trail Crossing locations as indicated on the attached listing. Trail is located partially within the cite limits of Dunkerton. Janesville and Waterloo. All crossings shad go into effect after all signs along the highway have been installed by DOT Forces. WORK SITE LOCATION (SEE ATTACHED LISTING) The proposed work as described above is located in Section , Twp. 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 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,Nf.l., Last--Print or Type) Ant Signature(Handwriitte�n)� Date Richard C. Melick Appli �Z i''t"""�—e:, 8/28/2008 CITY ACTION(IF PROPOSED WORK IS WITHIN AN INCORPORATED CITY,CITY ACTION 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". I I Recommend Approval I Do Not Recommend Approval I I None Required Auth.City Officlal Signature (Handwritten) Title Date I _ Name of Authorized pity Official(Print or Type) Authorized City Official for the City of (SEE ATTAC -IEP CITY ACTION SHEETS) FEDERAL HIGHWAY ADMINISTRATION ACTION (DEPARTMENT REPRESENTATIVES WILL REVIEW THE REQUEST AND OBTAIN FHWA ACTION,WHEN NECESSARY) Recommend Approval I I Do Not Recommend Approval f ] None Required Authorized FHWA Representative Signature Date (DOT Final Action&Agreements on next page) Page 1 of 2 bEPARTMENT OF TRANSPORTATION FINAL ACTION Application Approved I I Application Denied Permit Number Authorized Highway District Representative Signature Date (Type or Print): IRENE ERR, E.O.T. Notice of intention to commence activities on the highway rights-of-way shall be submitted by the applicant a minimum of 48 hours prior to actually commencing the activities as herein granted by this approved application. Notice is to be given to the following Iowa Department of Transportation representative: Local DOT Contact Person(Type or Print Name) Phone Number DOUG LICRTEIG (319)233-3055 Street Address City/Town State ZIP Code 1875 WEST RIDGEWAY AVE. PO BOX 1888 WATERLOO IA 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: PLEASE NOTE: The sponsor agrees to hold harmless the State of Iowa and the Iowa Department of Transportation and to indemnify them from any claim, demand or action by or on behalf of any person or entity arising out of or in connection with anything having to do with the snowmobile route. including, but not limited to. its establishment. construction. use. maintenance. signing. configuration or existence. 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 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 Auth. City Official Signature Title Date (Handwritfen) May D ( g4-6) r ame of Authorized City ial (Print or type) Authorized City Official for the City of / T1-h-cr)-e WATERLOO 3B 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) 13. Crossing of 1-380/US 20 at intersection with County V49. Club will install signs to direct Groomer and snowmobiles to cross over I-380&US 20 on the overpass bridge and not cross at grade. "No Snowmobiling" signs will be placed along the on and off ramps on both sides of the freeway. Trail marker signs will be installed along the bridge deck. Milepost 66.52 14. Crossing of IA 281 at the alley between Main St and Sycamore St in Dunkerton. Milepost 13.75 15. Crossing of IA 281 at the Kwik Star Convenience Store at the south edge of Dunkerton. Milepost 13.27 16. Crossing of IA 281 at County C57. 17. Marked, "ungroomed" trail along both ditches of US 63 from Hudson city limits north to milepost 158.04, south of US 20 interchange. 18. Crossing of US 63 south of interchange with US 20 at milepost 158.04. 19. Marked, "ungroomed"trail along west ditch only of US 63 in Waterloo from milepost 158.04, crossing under US 20, and proceeding north to Ridgeway Ave. 20. Crossing of US 63 at Ridgeway Ave in Waterloo, milepost 159.58. 21. Marked, "ungroomed" trail along the east ditch only of US 63 from Ridgeway Ave in Waterloo, milepost 159.58, south approx 500 feet to the parking lot of Heartland Inn Motel. Trail will end at that point. 22. Crossing of US 63 at Airline Highway in Waterloo, milepost 166.71. 23. *Crossing ofUS 63 approx.25 miles north of West Bennington Rd and approx 170 feet north of the small green highway milemarker 171. This location in a highway"turn-around) with farm field driveways coming directly from both the east and west farm fields. (This item completely revised for this application.) Black Hawk County-2008 5 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 23 has been completely rewritten with this application. All other locations shown on this application are the same as listed on the 2007 application. Note:Marked,"groomed"trail indicates that a track driven motorized trail 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 listed as"THE STATE OF IOWA AND ALL OF ITS POLITICAL SUBDIVISIONS". Note: A copy of the Insurance for the Sno Hawks Snowmobile Club for the current year is enclosed. Insurance renewal for year 12-1-2008 to 12-1-2009 is in process. Policy has not yet been issued. A copy of the approved policy will be provided to each entity involved upon receipt of the policy, which is expected to be sometime during the month of December 2008. Black Hawk County-2008 6 ACORN CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDYYYY) i2/Q3/2007 PRODUCER (563) 547-2161 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION V & V Insurance Agency, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR PO Box 159 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. . 103 8th St E Cresco IA 52136- INSURERS AFFORDING COVERAGE I NAIC# INSURED INSURER A.Dakota Fire Insurance Co • SNO HAWKS INC. I INSURER B: 1314 WASHINGTON ST INSURER C: INSURER D: CEDAR FALLS IA 50613- INSURER E. COVERAGES 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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'Lt °POLICY EFFECTIVE POLICY EXPIRATION LTR INSRDI TYPE OF INSURANCE POLICY NUMBER ! DATE(MM/DD/YY) DATE(MM/DD/YY) LIMITS ' GENERAL LIABILITY ' / / / / EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occurrence) $ X ' CLAIMS MADE OCCUR 3D31117 12/01/2007 12/01/2008 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ / / / / GENERAL AGGREGATE $ 1,000,000 GE'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ - �� POLICY)(^ Ter I{ I LOC / / / / AUTOMOBILE LIABILITY I / / / / COMBINED SINGLE LIMIT ANY AUTO (Ea accident) S ■ ALL OWNED AUTOS / / / / BODILY INJURY IIIAUTOS (Per person) $ HIRED AUTOS / / / / BODILY INJURY (Per accident) $ NON-OWNED AUTOS • / / / / PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / / / OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY / / / / EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE / / / / $ RETENTION $ $ WORKERS COMPENSATION AND / / / / TORY LIMITS R EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? / / / / E.L.DISEASE-FA EMPLOYEE $ If yes,describe under _____ SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT S OTHER / / / / / / / / / / / / DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Snowmobile Club and Trail liability insurance, including liability coverage for (1) Groomer. Additional insured: See (5) attached sheets. Premise liability coverage is Excluded on this policy. This policy has a $250 deductible per claim. CERTIFICATE HOLDER CANCELLATION ( ) - ( - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION LI BILITY OF ANY K UPON THE _ UTH INSURER,ITSEPRESE T REPRESENTATIVES. II`� 4 AUTHORIZED REPRESENTATIVE i 25(2001/08) ©ACORD CORPO4-,---- ACORD8 fee,-INS025(0108).05 ELECTRONIC LASER FORMS,INC.-(800)327-0545 7 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001/08) { INS025(woe)os Page 2 of 2 �U_v_ MASTER POLICY NAME: IOWA STATE SNOWMOBILE POLICY# 3D31117--08 ASSOCIATION * SNOWMOBILE CLUB ENDORSEMENT * CARRIER: DAKOTA FIRE INSURANCE COMPANY EFFECTIVE DATE: 12-01-07 TO: 12-01-08 RETROACTIVE DATE: 11-30-04 CLUB#: 039 CLUB NAME: SNO HAWKS INC ENDORSEMENT#: 01 ADDRESS: 1314 WASHINGTON STREET CEDAR FALLS, IA 50613 COVERAGE : SNOWMOBILE CLUB ONLY /f SNOWMOBILE/ATV CLUB ❑ TRAIL LIABILITY EXPOSURE: ®YES ❑NO CLUB PREM $1000.00 MP ENDST FILING FEE +❑APPLIES PREMISES LIABILITY EXPOSURE ❑ YES ®NO SURPLUS LINES TAX +EAPPLIES PREMISES LOCATED AT: STAMPING FEE TAX +❑APPLIES SL SERVICE CHARGE +❑APPLIES #GROOMERS: 1 #/USE OTHER EQUIPMENT: 0 #EMERGENCY SLEDS: 0 (EMERGENCY SLED)IS A SPECIFIC SLED ATTACHED TO A SNOWMOBILE TO CARRY INJURED PEOPLE TO AN EMERGENCY VEHICLE WHEN DUE TO WEATHER THE EMERGENCY VEHICLE CANNOT GET TO THE INJURED PARTY.***WARRANTED THAT AN EMT OR PARAMEDIC MUST ACCOMPANY OUR SNOWMOBILE CLUB DRIVER. (NO PROFESSIONAL LIABILITY COVERAGE IS PROVIDED) COVERED CLUB ACTIVITES: SEE ATTACHED SCHEDULE OF SPECIFICALLY COVERED ACTIVITIES ****************************************************************************** THIS CLUB IS MADE UP OF OTHER INDIVIDUAL CLUBS WHO EACH CARRY THEIR OWN CLUB LIABILITY POLICY FOR THEIR ACTIVITIES. ❑ YES ® NO IF YES,THE FOLLOWING EXCLUSION APPLIES TO THE COVERAGE PROVIDED FOR THE CLUB LISTED ABOVE. EXCLUSION: IT IS HEREBY AGREED AND UNDERSTOOD THAT"NO COVERAGE"EXISTS FOR ANY ACTIVITIES OF THE INDIVIDUAL CLUBS WHICH MAKE UP THE CLUB: ****************************************************************************** ADDITIONAL INSURED'S ONO EYES SEE ATTACHED ENDORSEMENT **OTHER THAN CLUB CG7501 (1-06) CONTRACTED LANDOWNERS FOR USE OF TRAILS ONLY LIMITS: $1,000,000 OCCURRENCE $1,000,000 GENERAL AGGREGATE **COVERAGE IS FOR SPECTATOR LIABILITY ONLY. COVERAGE FORMS APPLICABLE ARE THE SAME AS SCHEDULED ON THE MASTER ASSOCIATION POLICY. IF YOU HAVE ANY QUESTIONS YOU SHOULD REFER TO THE ASSOCIATION FOR POLICY INFORMATION. DATE ISSUED: 1/3/08 HB 'eU INSURANCE PeENCY ,DALE COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION - VICARIOUS LIABILITY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE* Name of Person or Organization: SEE ATTACHED * If no entry appears above,information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement. A. SECTION II—WHO IS AN INSURED is amended to include as an additional insured the person or organization shown in the Schedule,but only with respect to liability for"bodily injury","property damage"or"personal and advertising injury"caused,in whole,by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations;or 2. In connection with your premises owned by or rented to you. B. This insurance does not apply to any "bodily injury", "property damage" or "personal and advertising injury" resulting from any act or omission by, or willful misconduct of the additional insured shown in the Schedule, whether the sole or a contributing cause of the loss. The coverage afforded to the additional insured is limited solely to the additional insured's"vicarious liability"that is a specific and direct result of your conduct. "Vicarious liability"as used in this endorsement means liability that is imposed on the additional insured solely by virtue of its relationship with you,and not due to any act or omission of the additional insured. Includes copyrighted material of ISO Properties,Inc.with its permission. CG7501 (1-06) Page 1 of 1 ciuBx _ SNO HAWKS, INC LANDOWNERS AS ADDITIONAL INSURED FOR CLUB CONTA.CF. ll TRAIL TIM.GE ONLY **COMTLE'l NAME AND ADDRESS REQUIRED NAME AND ADDRESS NAME AND ADDRMS 55. Ronald Steege 63. The State of Iowa and all of its political 9321 Logan Ave sub-divisions Waterloo, IA 50703 Wallace State Office Bldg Des Moines, IA 50319 56. Gene Stokes 6225 Ford Road 64. Five Star Snow Trails Association Cedar Falls, IA 50613 5912 Aster Lane . Waterloo, IA 50701 57. Michael & Kathy Tellingbuisen 7611 N. Union Rd 65. City of Janesville, IA Janesville, IA 50647 227 Main Street • Janesville, IA 50647 58. Clifford & Marcie Trent 8339 Leversee Rd. 66. Dave Jacob Cedar Falls, IA 50613 8808 Burton Ave Cedar Falls, IA 50613 59. Alan Walker 1303 E Bennington Rd 67. Washburn BP Store Waterloo, IA 50703 7305 LaPorte Road Washburn. IA 50702 59. Charles Wilmot 2596 Joplin Ave Denver, IA 50622. 60. Raymond & Pauline Youngblut 6732 LaPorte Road Waterloo, IA 50706 61. Tim Youngblut 6905 LaPorte Road Washburn, IA 50706 • 62. David Zeien 4622 West Cedar Wapsi Road Cedar Falls, IA 50613 Page 4 of 4 If additional space as needed, please copy this form. S . • . , r