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HomeMy WebLinkAbout210462 YETI ELECTRICAL SERVICESAdobe Scan Jun 06 2022 (2)A 41 � City Of " Wh6atjdg c COMMUNITY DEVELOPMENT 7500 W. 291' Avenue * Wheat Ridge, CO 80033 * O: (303)235-2855 * F: (303)235-2857 Contractor Waiver for Workers' Compensation Insurance I, (print your name), verify that I am the sole owner or partner of (company name): 4- C- i C 5 l ce ry i C.oS which has no employees and is not required by the State of Colorado to carry workers' compensation insurance. I further state that if I hire contractors/subcontractors, they are in compliance with the State of Colorado Workers' Compensation insurance requirements, have obtained the required contractor's license from the City of Wheat Ridge and will be listed on the permit. Signature: /�7— ��X� Date: D l 6 G l -0 -z- Z iurauu veparLment OT Keguiatory Agencies i Colorado Department of Regulatory Agencies Division of Professions and Occupations Division of Professions and Occupations Electrical Board I Electrical Board Yeti Electrical Services LLC Yeti Electrical Services LLC Electrical Contractor Electrical Contractor EC.0101071 10/01/2020 EC.0101071 10/01/2020 Number Issue Date Number Issue Date Active 09/30/2023 Active 09/30/2023 Credential Status Expire Date Credential Status Expire Date Verify this credential at: dpo.colorado.gov / Verify this credential at: dpo.colorado.gov nivicinn nirrsrtnn. Rnnno Winric rr#nHnntial HnIA-r Cionati irP Divkinn nirar-tnr-) Rnnna HinPc ri-PrlPntial Hnlrinr rionAh in: T © DATE (MMIDDIYYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE 06/03/2022 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 CONTACT NAME: American Family Insurance - Business Insurance Tom Walker Agency Inc PHONE FAX 3333 S Wadsworth Blvd Unit D300 (AIC, No, Ext): 866-908-0626 (AIC, No): Lakewood, CO 80227 E-MAIL (303) 604-9606 ADDRESS: service@amfambusinessinsurance.com twalker@amfam.com EACH OCCURRENCE INSURER(S) AFFORDING COVERAGE NAIC # A INSURER A: Midvale Indemnity Company 27138 N INSURED INSURER B: INSURER C: YETI ELECTRICAL SERVICES LLC INSURER D: 4365 S GRANT ST INSURER E: ENGLEWOOD CO 80113 INSURER F: COVERAGES CERTIFICATE NUMBER: 283378003169658 REVISION NUMBER: 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MMIDDIYYYY) POLICY EXP (MMIDDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A CLAIMS -MADE X OCCUR N N GLP1101920 01/14/2022 01/14/2023 DAMAGE TO RENTED PREMISES (Ea occurrence) $100,000 MED EXP (Any one person) $10,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY ❑ PRO ❑ LOC JECT PRODUCTS - COMP/OP AGG $2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) ANY AUTO OWNED SCHEDULED BODILY INJURY AUTOS ONLY AUTOS Per accident PROPERTY DAMAGE HIRED NON -OWNED AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LAB OCCUR EACH OCCURRENCE AGGREGATE EXCESS LAB CLAIMS -MADE DED RETENTION $ WORKERS COMPENSATION PER I OTH- I AND EMPLOYERS' LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECU -TIVEOFFICER/MEMBER EXCLUDED? N/A E.L. EACH ACCIDENT E.L. DISEASE- EA EMPLOYEE (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT PROFESSIONAL LIABILITY OCCURRENCE AGGREGATE DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Electrician CERTIFICATE HOLDER CANCELLATION Wheat Ridge Building Division SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 7500 W 29th Ave BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Wheat Ridge, CO 80033 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD