CITY OF SARATOGA SPRINGS HOLD HARMLESS AGREEMENT

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1 CITY OF SARATOGA SPRINGS HOLD HARMLESS AGREEMENT The City of Saratoga Springs requires: A Certificate of Insurance naming the City of Saratoga Springs as an Additional Insured evidencing the following coverages: Commercial General Liability: $1,000,000 per occurrence/$2,000,000 aggregate including completed products and operations and personal injury liability insurance (City of Saratoga Springs is Additional Insured) Excess Insurance: $4,000,000 per occurrence aggregate (City of Saratoga Springs is Additional Insured) Statutory Workers Compensation and Employer s Liability Insurance for all employees: Evidence of New York State Statutory Workers Compensation and Employer s Liability Insurance for Contractor s employees from a NYS authorized insurance company: C or U-26.3 Forms. Evidence of New York State Statutory Disability Benefits Insurance per Workers Compensation Law 220(8) on a DB or DB- 155 Form. Certificates of Insurance should be addressed to the attention of: Building Department City of Saratoga Springs 474 Broadway Saratoga Springs, NY The Contractor acknowledges that failure to obtain such insurance on behalf of the municipality constitutes a material breach of contract and subjects it to liability for damages, indemnification and all other legal remedies available to the City. The Contractor is to provide the City with a Certificate of Insurance naming the City as Additional Insured on a primary and non-contributory basis prior to the commencement of any work or use of City facilities. The failure to object to the contents of the Certificate of Insurance or the absence of same shall not be deemed a waiver of any and all rights held by the municipality. In the event the Contractor utilizes a Subcontractor for any portion of the services outlined within the scope of its activities, the Subcontractor shall provide insurance of the same type or types and to the same extent of coverage as that provided by the Contractor. All insurance required of the Subcontractor shall name the City of Saratoga Springs as a Certificate Holder and Additional Insured for all those activities performed within its contracted activities for the contact as executed. In all cases, the following hold harmless agreement shall apply: The Contractor shall indemnify and save harmless the City of Saratoga Springs, its Agents and Employees (hereinafter referred to as City ), from and against all claims, damages, losses and expense (including, but not limited to, attorneys fees), arising out of or resulting from the performance of the work or purchase of the services, sustained by any person or persons, provided that any such claim, damage, loss or expense is attributable to bodily injury, sickness, disease, or death, or to injury to or destruction of property caused by the tortious act or negligent act or omission of Contractor or its employer, agents or subcontractors. Signature/Date: Company Address Authorized Representative/Title: Blasting Permit Application

2 City of Saratoga Springs Application for Blasting Permit Building Department, 474 Broadway, Saratoga Springs, NY Tel: (518) ext Fax: (518) Applicant Name: Applicant Address: Applicant Telephone Number: Cell Number: Job Site Address: Reason for Blasting: Section Block Lot GPS Coordinates Zoning District: Use of Building(s): Construction Type: First Floor Occupancy: Number of Stories: Is Job Site on Flood Plain? Is Job Site in Historic District? Architectural Approval Required From Planning Board? Job Site Owner: Job Site Owner Address: Contractor Name: Contractor Address: Contractor Telephone Number: Your application for a blasting permit must contain the following attachments including this original and four (4) copies: (Attached?) Evidence your firm is duly licensed pursuant to Section 458 of the Labor Law in the State of New York and the United States Bureau of Alcohol, Tobacco and Firearms. Precise location of the intended detonation of explosives, as well as the size charges intended to be detonated and the proposed schedule for detonation of explosives. Executed City of Saratoga Springs Hold Harmless Agreement Naming the City as an Additional Insured on Commercial General Liability including completed products and operations and personal injury liability insurance in the amount of One Million Dollars ($1,000,000) per occurrence and Two Million Dollars Aggregate ($2,000,000) AND Excess Liability Insurance in the amount of Four Million Dollars ($4,000,000) per occurrence aggregate. Applicant must also show evidence of Statutory Workers Compensation and Employers Liability Insurance or a waiver of same as permitted by law. Written evidence that the person intending to detonate has obtained permission to do so from all utilities within the blasting area including gas, electric, communications, cable and water and sewer. Description of all structures, including residential dwellings, located within 250 feet of the blast site and a list of the names and the addresses of the owner or owners of any parcel of property immediately adjoining or abutting the parcel of property from which the blasting is to take place, as shown on the most recent tax rolls of the City of Saratoga Springs. Signature of Applicant/Date: Signature of Owner/Date: Received Building Department By: Date Received: $150 Fee Received: Check Number: Check Account Name: Required Approvals/Dates: City Engineer/Date: Approve/Reject Department of Public Safety/Date: Approve/Reject Department of Public Works/Date: Approve/Reject Risk and Safety Management/Date: Approve/Reject (If rejecting, please indicate reasons.) Permit Issued/Date: Rejected/Date: Rejecting Dept: Reasons for Rejection: Notification to Applicant Date:

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