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ENC2019-00042 a <K) Reply all m ' Delete Junk Block Please Close Encroachment Permits a, Roger Storz 0) Wed 8/21/2019 8:30 AM JoAnna Thomason;Syed Wahidi Hi JoAnna, a f The work associated with the following encroachment permits is complete and the a permits should be closed out. No deposit was taken, so there is nothing to refund. I L • ENC2019-00042 - Repair work at the First Street Garage... • ENC2019-00154 - Crane lift in the City Parking Lot at 300 Orchard City Drive6d Thank you, i ,ov'C,q iA Roger Storz, PE Senior Civil Engineer c o Land Development Manager I, City of Campbell I Public Works Department 70 N. First Street I Campbell, CA 95008 www.city)fcamr2be II.corYi 1 408 866-2-190 b rogers@campbellca.gov i Ready for Online Permits? Create your account today_ CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No.: ENC2019-00042 DEPT.OF PUBLIC WORKS (for working within the X-Ref. File 70 North First Street public rig t-of-way) Application Date 2/27/2019 Campbell,CA 95008 Issued �J Ph.(408)866-2150 v Application Expiration Date Fx. (408)376-0958 �� !i`1 APN 412-07-019 Permit Expiration Date L� APPLICATION-Application isherebymade fora Public Works Permitinaccor ncewi h Campbell Municipal Code,Section 11.04.(Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable.) A. WorkAddress: First Street Parking Garage (S First Street) B. Nature of Work/Utility Waterproofing and concrete repair Trench Location: IZI No Fee Permit for work related to City Project Project Name: First Street Parking Garage C. Attach four(4)copies of an engineered plan showing the location and extent of the work, and four(4)copies of the preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer,said plan becomes a part of this permit. D. All workshall conform tothe City ofCampbell Standard Specifications and Details for P u b(ic Works Construction;the General Perm it Conditions listed on the reverse side;and the Special Provisions for this permit,listed below.Failure to abide by these conditions and provisions may result injob shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work. NameofApplicant: Jonel Porta,Agent for Water Tower Fee Owner, LLC Telephone: 408-427-2142 Address: 339 S. San Antonio Road, Suite 2B, Los Altos, CA 94022 E-Mail Address: jporta@fourcornersproperties.com 24-HOUR EMERGENCY PHONE NUMBER: 408-427-2142 Is this work being done by the property owners at their own residence? ❑ Yes V No The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell,its officers,agents,and employees free,safe and harmless from any claim or demand for damages resulting from the work covered by this permit. The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the information.Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all damages arising out of improvements completed' th public right-of ay. Accepted: 6 IV( '5 (Applicant Permittee) (sign) Date (Contractor) (Print Name) Date SPECIAL PROVISIONS: 1. Street shall not be open cut for underground installations.Minimum cuts maybe allowed for connections or exploration holes.Suchcutsmaybe s nrifirally 3pl)rnvpd hV thp Inspertnr Priar to rutting. 2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A",unless otherwise approved by the Engineer. 3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two(2)copies of the cut sheets sent to the Public Works Department before starting work. 4. Per Section 4216 of the Government Code this permit is not valid for excavations until Underground Service Alert(USA)has been notified and the inquiry identification number has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO. 5. Prior to any work,the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way,which shall be recorded. 6. Public Notification Requirements: 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO. PERMIT APPLICATION FEE $ PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK&INSPECTION FEE $ TECHNOLOGY FEE TRAFFIC $ TRAFFIC CONTROL REVIEW APPROVED FOR ISSUANCE ZLl For City Engineer Date Permit Expires 12 Months After Date of Issuance d d GENERAL PERMIT CONDITIONS I. The Permittee must provide evidence of insurance and Additional Insured Endorsements as required by the City.Insurance shall be maintained for the duration of the permit work. 2. A Construction Cash Deposit is required.Changes will be made against this deposit if there Is an emergency call-out,overtime inspection or when City ordered barricading is required.Any such costs in excess of the deposit will be billed to the Permittee. 3. Refund of the construction cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. A one-year maintenance period and surety are required.Such period will begin on date of written acceptance by the City.Surety posted shall be equal to 25%of the original Faithful Performance Security. 5. Submit project schedule 10(ten)days prior to proposed start of work.Additional lead time may be required for work within City facilities and downtown Campbell. 6. The Permittee must request in writing a final inspection and acceptance of the work upon completion.Acceptance by the City will be made in writing to the Permittee. 7. Maintain safe pedestrian and vehicular crossings and free access to private driveways,bus stops,fire hydrants,.and water valves. 8: A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures,detours,_and street closures.This plan must be reviewed and approved prior to any lane closures. 9. A Construction Traffic Control Plan shall conform to the most recent version of the California Manual on Uniform Traffic Control Devices(MUTCD). 10. Replace,as directed by the City Engineer,any damaged or removed improvements in accordance with City Standards and Specifications at the sole expense of the Permittee as expeditiously as possible. 11. Sawcut for all PCC or AC removals.All PCC removals shall be to the nearest scoremark and new PCC shall be doweled to existing improvements. 12, Prior approval of inspector is required for any work proposed after normal working hours,on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate, 13. 'Work on arterials and collectors may require the use of changeable message.boards.Adequate signing and barricading is required on the job site.Failure to provide such signing and barricading may result in the City s providing signing and barricades and charging the cost(including all labor and materials)against the construction cash deposit.. 14. Compaction testing of subgrade,base rock,and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 15. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction.Contractor or Permittee shall provide a phone number at which they can be contacted,outside the hours of 8:00 a.m.to 4:00'p.m.and on weekends. 16. No storage of materials or equipment will be allowed near the edge of the pavement,the traveled way,or within the shoulderline which would create a hazardous condition to the public. 17. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a separate permit may be required,nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 18. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any,other public agency. 19. This permit is not transferable.Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 20. Call back(call out)due to emergencies regarding this permit shall be at the current overtime rate with a three(3)hour minimum charge per occurrence, 21. Pursuant to Chapter 14.02 of the Campbell Municipal Code,applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water.Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention.Program. 22. If the public Interest requires a modification of,or a departure from the permit,plans;special provisions and/or specifications,the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made. 23. Permittee must provide advance notification to all parties that may be affected by the permit activities.Notification shall be reviewed by the City prior to distribution and include dates of work•and a contact name and a phone number. 24. Applicant shall remove water from utility vaults in accordance with the requirements ofState Water Resources Control Board Water Quality Order WQ 2014-0174- DWQ. Said vault water shall not be discharged into the City of Campbell's storm drain system. See http://www.waterboards.ca.goy/water issues/programs/npdes/utilitvvaults shtml for more information. Applicant is hereby responsible for ensuring that all those providing se ' es under the applicant are aware of and abide by all of the above conditions. Poi 4ic Applicant Date: MAZ Contractor (Print Name) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit 12919 1 l ® DATE(MMIDD/YYYY) ACCORo CERTIFICATE OF LIABILITY INSURANCEF5/24/2019 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: Certificate Department Arthur J. Gallagher&Co. PHONE 925-299-1112 FAX No):925-953-6270 Insurance Brokers of California, Inc. LIC#0726293A/C.No Ext 3697 Mt. Diablo Blvd, Suite 300 ADDRESS: CertRequests@ajg.com Lafayette CA 94549 INSURERS AFFORDING COVERAGE NAIC# INSURER A:American Guarantee and Liability Ins Co 26247 INSURED BIGHTAY-01 INSURER B:Redwood Fire and Casualty Insurance Co 11673 Bigham Taylor Roofing Corporation 22721 Alice Street INSURER c:Associated Industries Insurance Co,Inc 23140 Hayward, CA 94541 INSURER D:Zurich American Insurance Company 16535 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1352212636 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 ADDLSUBRTYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDDIYYW MMIDD/YYYY LIMITS EXP LTR C X COMMERCIAL GENERAL LIABILITY Y AES1039126-02 5/28/2018 5/28/2019 EACH OCCURRENCE $1,000,000 �OCCUR DAMAGE TO RENTED CLAIMS-MADE PREMISES Ea occurrence $100,000 X $5,000 PD DED/OC MED EXP(Any one person) $EXCLUDED PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ D AUTOMOBILE LIABILITY BAP 0149380-00 5/28/2018 5/28/2019 COMBINED SINGLE LIMIT $1,000,000 Ea accident JX ANY AUTO - BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED Ix NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident Comp/Coll: $1,000 Ded A UMBRELLA LIAB X OCCUR SXS0118937-03 5/28/2018 5/28/2019 EACH OCCURRENCE $10,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000 DED I X I RETENTION$Mil $ B WORKERS COMPENSATION Y BIWC914608 6/28/2018 5/28/2019 X STATUTE EORH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE:300 Orchard City Dr.,Campbell,CA. ADDITIONAL INSURED(S):Water Tower Fee Owner,LLC,and Advisors Asset Services California, INC DBA:Colliers International Real Estate Management Services(CA),Inc.and their respective members,partners,officers and directors,subsidiaries,affiliates,employees and agents and City of Campbell,its officers,employees and volunteers. �-tZ- CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The City of Campbell 70 N. FirsSt. AUTHORIZED REPRESENTATIVE Campbell, CA 95008 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD THIS CERTIFICATE SUPERSEDES PREVIOUSLY ISSUED CERTIFICATE POLICY NUMBER:AES1039126-02 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONALINSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZAJION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location(s) Of Covered Operations All persons or organizations where required by written contract with the Named Insured Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section 11 — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" "property damage"occurring after: caused, in whole or in part, by: 1. All work, including materials, parts or equip- 1. Your acts or omissions;or ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project(other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s).at the location of the the additional insured(s) at the location(6) desig- covered operations has been completed;or nated above. 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 ISO Properties, Inc.,2004 Page 1 of 1 POLICY NUMBER:AES1039126-02 COMMERCIAL GENERAL LIABILITY CG 20,37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL. INSURED - OWNERS, LESSEES, 0 R, CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the follo"'ving: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations ALL PERSONS OR ORGANIZATIONS WHERE WRITTEN CONTRACT WITH THE NAMED INSURED REQUIRES ADDITIONAL INSURED COMPLETED OPERATIONS. Information required to complete this Schedule, if not shovAi above,will be shown iri the,Declarations. Section 11 — Who Is An Insured* is amended to ,include as an additional insured the. person(s) or organization(s) shown in the Schedule, but only with respect to liabilRyfor-"bo0ily injury"or"property dam- age" caused, in whole or in part, by "your Work" at the location designated and described in the sche- dule of this endor§em'q' nt;perfom16d for that addi- tional insured and, included in the "products- completed operations hazard". CG 20 37 07 04 C)JSO,Propertles, Inc., 2004 Page'.1-of I 131 POLICY NUMBERAES1039126-02 COMMERCIAL GENERAL LIABILITY NX GL 009 08 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON-CONTRIBUTING INSURANCE (THIRD-PARTY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Third Party; All persons or organizations where required by written contract with the Named Insured (Absence of a specifically named Third Party above means that the provisions of this endorsement apply as required by written contractual agreement with any Third Party for whom you are performing work.) Paragraph 4.of SECTION IV;COMMERCIAL GENERAL LIABILITY CONDITIONS is replaced by the following: 4. Other Insurance: With respect to the Third Party shown above,this insurance is primary and non-contributing. Any and all other valid and collectable insurance available to such Third Party in respect of work performed by you under written contractual agreements with said Third Party for loss covered by this policy,shall in no Instance be considered as primary,co-insurance,or contributing insurance. Rather,any such other insurance shall be considered excess over and above the insurance provided by this policy, NX GIL 009 08 09 Page I of 1 . Includes copyrighted material of Insurance Services Office, Inc.,with its permission WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 04 10A(Ed 07-07) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA BLANKET BASIS We have the right to recover our payments from anyone liable for an injury covered by this policy- We VAII not enforce our right against tho person or organization named in the Schedule, (This agreement applies only to the extent that you perform work under a written contract that requires you W obtain this agreement from us.) The additional prernium for this endorsement shall be 2.00 %of the total policy premium otherwise dL1Q on such remuneration. The rninimum premium for this endorsement is Schedule Person or Organization Job Description ALL ORGANIZATIONS FOR WHOM THE WAIVER OF SUBROGATION IS ALL CALIFORNIA OPERATIONS ISSUED This endorsement ui�,,qes the pcAtry to which it is attached and is eff�xrive on the date issued unless athnrwlsnstvted (The information below is required only when this endorsement is issued subsequent to preparation of the pollay.) Endorsement Effective 5/28/2018 Policy No. BIWC914608 Endorsement No. 1 Instired RIGI 1AM TAYLOR ROOFING CORP. PrWiLIM S Insui-ance Company Countersigned by Redwood FiFLarld Casualty Insurwice Company WC 99 04 10A (Ed 07 07) AGENCY'CUSTOMER ID: LOC#: ADDITIONAL REMARKS SCHEDULE Page of AGENCY a NAMED INSURED POLICY NUMBER CARRIER EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: Additional Information GENERAL LIABILITY: *Additional Insured if required by written contract per attached form CG20100704[ONGO] *Additional Insured if required by written contract per attached form CG20370704[COOP] *Coverage is Primary/Non-Contributory if required by written contract per form NX GL 009 08 09 WORKERS'COMPENSATION(CA): *Waiver of Subrogation if required by written contract per attached form WC990410A 0707 California EXCESS LIABILITY: *Underlying Policies:General Liability,Automobile Liability,and Employers'Liability ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ]IT ROOF BIGHAM TA.YLOR ROOFING CORP. NOT TRANSFERABLE PLEASE POST IN A`CONSPICUOUS PLACE, B,USINESS,LICENSE C�7Y�OF CAMPBELL p� ''(408)866 2174 ESTABLISHED: 09l05t2001 EXP DATE: 04/30/2020 LICENSE NO. 018111 LOCATION: 22721 ALICE ST HAYWARD,CA 94541 " �^ i TYPE OF BUSINESS BUSINESS: BIGHAM-TAYLOR ROOFING CORD, � � ��ONT ROOFISIDINGISHEET METAL-OUT OF OWNER: STEPHEN.EMMETT BIGHAM T01NN. The person,firm,or corporation named above isrgranted this"business license pursuant to the provisions of the City Business License = Ordinances to engage in,carry on,or conduct the business,trade,calling,profession.exhibition,or occupation described above. Issuance of the license is nonaCen with the city zondorsement ing egujations.r certification fTh spaense sance ltssued witho h Pth&ordinances or laws,nor an assurance that the t verification that the licensee s subject proposed use is in conformance to or exempt from the licensing by the State of California. Valid�o'nly'within the City of Campbell city limits. CITY MUST BE NOTfFIED ON ANY CHANGE IN OWNERSHIP,LOCATION,OR CLOSURE.' " ANNUAL TAX PAYMENT DUE ON OR BEFORE THE EXPIRATION DATE:RENEWAL NOTICE NOT REQUIRED. BT.e ROOF 22721 ,dice Street - Hayward, CA 94541 a License#431631 n (510) 886-0197 • www.btroof.com, INSURANCE REQUIREMENTS CHECKLIST � �� d r 1m Permit# ��`�� CIP Project# Consultant/Contractor: 1 L) V, The following insurance is required of all consultants/contractors working in the ity of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These " insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: i $1,000,000.per occurrence, and $1,000,000 general aggregate limit applying separately to the project, or ❑ $2,000,000 general aggregate limit. q Policy expiration date `6 Automotive Liability: 4' "Any Auto" checked on certificate ,,tY $1,000,000 per accident for bodily injury and property damage ❑ 'Policy expiration date Workers' Compensation and Employer's Liability ❑ Waiver of Subrogation clause ,-cl' $1,000,000 per accident for bodily injury or disease -d Policy expiration date Course of Construction (if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies dditional Insured Endorsement: he City, its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area should say: Should any of the above described policies be cancelled before the expiration date thereof,notice will be delivered in accordance with the policy provisions. Workers' Compensation Insurance Sheet Submitted For General Contractor ❑ For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev Jan 2018) Pagel Acceptability of Ihsurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: &°Ap � ��" AIC# Rating: n Authorized in CA: Name: OtS`A�NAIC# 3 Rating: PrIl XV Authorized in CA: V. Name: AS&P-- NAIC# 7-33 Rating: 1 C Authorized in CA: Name: Av,&�iC—"NAIC# lw �J� Rating: Authorized in CA: Campbell Business License# �, Expiration: �d ago, Contractors License# �� '3 Class:G expiration: ,�' :�O ;10 Insurance Certificate Reviewed Z7, Z$ I' �njaIs Date; Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 ® DATE(MMIDDIYYYY) ACvIJRO CERTIFICATE OF LIABILITY INSURANCE 4/29/2019 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 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: Charlene Reynolds Pentarlsk Insurance Services LLC PHONE FAX CA License No. OG47886 AIc No Ext:408-418-2741 A/C No:408-418-2721 2033 Gateway Place, Suite 150 ADDRESS: creynolds@pentarisk.com San Jose CA 95110 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Travelers Indemnity Company of CT 25682 INSURED 1081 INSURER B:Travelers Property Casualty Company of America 25674 F T G Builders, Inc. INSURER C:Aspen American Insurance Company 43460 2975 Scott Blvd., Suite 100 Santa Clara CA 95054 INSURERD: INSURER,E: INSURER F: COVERAGES CERTIFICATE NUMBER:1463394058 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. I Y LTR. TYPE OF INSURANCE INSD WVD POLICY NUMBER MM DD LTR IYYYY D MM DIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y CO-2N738274 3/1/2019 3/1/2020 EACH OCCURRENCE $2.000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea occurrence $300,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $2,000,000 -GEN'L AGGREGATE LIMIT APPLIES PER:, _ GENERAL AGGREGATE $4,000,000 POLICY ]JECT LOC PRODUCTS-COMP/OP AGG $4,000,000 X OTHER: Ded$5,000 $ B AUTOMOBILE LIABILITY Y BA-2N728219 3/1/2019 3/1/2020 COMBINED SINGLE LIMIT $ Ea accident 1 000 000 Ix ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS X AUTOSED PeOra PE cRdentDAMAGE $ C UMBRELLA LIAB OCCUR CX005GV19 3/1/2019 3/1/2020 EACH OCCURRENCE $10,000,000 X X EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000 DED I X I RETENTION$Nor,. $ B WORKERS COMPENSATION UB-2N731236 3/1/2019 3/1/2020 X PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE F N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE:Maintenance Contract 1 300 Orchard City Drive,Campbell CA 95008 Water Tower Fee Owner,LLC,and Advisors Asset Services California,Inc., DBA:Colliers International Real Estate Management Services(CA),Inc.and their respective members,partners,officers and directors,subsidiaries,affiliates,employees and agents and City of Campbell,its officers,employees and volunteers are added as additional insureds as required by written contract for General Liability and Auto Liability,per attached.General Liability and Auto Liability evidenced herein are Primary&Non-Contributory to other insurance available to the additional insureds as required by written contract,per attached.Notice of Cancellation to Others is provided in accordance with the policies provisions including 10 day notice for non-payment of premium. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Colliers International 111'N. Market Street, Suite 820 San Jose CA 95113 AUTHORIZED REPRESENTATIVE t ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Insured: F T G Builders, Inc. Policy No. BA-2N728219 COMMERCIAL AUTO Effective: 03/01/2019 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY WITH OTHER INSURANCE This endorsement modifies insurance provided underthe following: BUSINESS AUTO COVERAGE FORM PROVISIONS 2. The following is added to Paragraph B.S., Other 1. The following is added to Paragraph'A.1.c., Who Insurance of SECTION IV — BUSINESS AUTO Is An Insured; of SECTION II — LIABILITY CONDITIONS: COVERAGE: Regardless of the provisions of paragraph a. and This includes any person or organization who you paragraph d. of this part S. Other Insurance, this are required under a written contract ,or insurance is primary to and non-contributory with agreement between you and that person or applicable other insurance under which an organization, that is signed by .you before the additional insured person or organization is the "bodily injury" or "property damage" occurs and first named insured when the written contract or that is in effect during the policy period, to name agreement between you and that person or as an additional insured for Liability Coverage, organization, that is signed by you before the but only for damages to which this insurance "bodily injury" or "property damage" occurs and applies and only to the extent of that person's or that is in effect during the policy period, requires organization's liability for the conduct of another this insurance to be primary and non-contributory. "insured". CA T4 74 08 17 ©2016 The Travelers Indemnity Company.All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc.with its permission. Insured: F T G Builders, Inc. Policy No.CO-2N738274 COMMERCIAL GENERAL LIABILITY Effective:03/01/2019 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AMENDMENT - OTHER INSURANCE CONDITION AND MEANING OF OTHER INSURANCE, OTHER INSURER AND INSURER This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PROVISIONS sion to not buy insurance, for any reason, in 1. The following replaces the part of the first para- which case the insured will be deemed to be graph of Paragraph 4., Other Insurance, of the provider of other insurance; or SECTION IV — COMMERCIAL GENERAL LI- (v) Any similar risk transfer or risk management ABILITY CONDITIONS that precedes'Paragraph method. a" Other insurance does not include umbrella insur- If valid and collectible other insurance is available ance, or excess insurance, that was bought spe- to the insured for a loss we cover under Cover- cifically to apply in excess of the Limits of Insur- ages A or B of this Coverage Part, our obligations ance shown in the Declarations of this Coverage are limited as described in Paragraphs a. and b. Part: below. As used anywhere in this Coverage Part, other As used anywhere in this Coverage Part, other insurer means a provider of other insurance. As insurance means insurance, or the funding of used in Paragraph c. below, insurer means a pro- losses, that is provided by, through or on behalf vider of insurance. of: (i) Another insurance company; 2• The first Subparagraph (2)of Paragraph 4.11J., Ex- cess Insurance, of SECTION IV — COMMER- (ii) Us or any of our affiliated insurance compa- CIAL GENERAL LIABILITY CONDITIONS re- nies, except when the Non cumulation of garding any other primary insurance available to Each Occurrence Limit provision of Para- . you is deleted. graph 5, of Section III — Limits Of Insurance or the Non cumulation of Personal and Adver- 3. The following is added to Paragraph 4.b., Excess tising Injury Limit provision of Paragraph 4. of Insurance, of SECTION IV — COMMERCIAL Section III — Limits of Insurance applies be- GENERAL LIABILITY CONDITIONS: cause the Amendment - Non Cumulation Of This insurance is excess over any of the other Each Occurrence Limit Of Liability and Non insurance, whether primary, excess, contingent or Cumulation Of Personal and Advertising In- on any other basis, that is available to the insured jury Limit endorsement is included,in this pol- when the insured is added as an additional in- icy; sured under any other policy, including any um- (iii)Any risk retention group; brella or excess policy. (iv)Any self-insurance method or program, in- eluding any failure to buy insurance, or deci- r CG D4 20 07 08 ©The Travelers Companies, Inc. Page 1 of 1 Insured: F T G Builders, Inc. Policy No. CO-2N738274 COMMERCIAL GENERAL LIABILITY Effective:03/01/2019 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BLANKET ADDITIONAL INSURED (CONTRACTORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. WHO IS AN INSURED —(Section II) is amended c) The insurance provided to the additional in- to include any person or organization that you sured does not apply to "bodily injury" or agree in a "written contract requiring insurance" "property damage" caused by "your work" to include as an additional insured on this Cover- and included in the "products-completed op- age Part, but: erations hazard" unless the "written contract a) Only with respect to liability for"bodily injury", requiring insurance" specifically requires you "property damage" or"personal injury"; and to provide such coverage for that additional insured, and then the insurance provided to b) If, and only to the extent that, the injury or the additional insured applies only to such damage is caused by acts or omissions of "bodily injury" or "property damage" that oc- you or your subcontractor in the performance curs before the end of the period of time for of "your work" to which the "written contract which the "written contract requiring insur- requiring insurance" applies. The person or ance" requires you to provide such coverage organization does not qualify as an additional or the end of the policy period, whichever is insured with respect to the independent acts earlier. or omissions of such person or organization. 3. The insurance provided to the additional insured 2. The insurance provided to the additional insured by this endorsement is excess over any valid and by this endorsement is limited as follows: collectible "other insurance", whether primary, a) In the event that the Limits of Insurance of excess, contingent or on any other basis, that is this Coverage Part shown in the Declarations available to the additional insured for a loss we exceed the limits of liability required by the cover under this endorsement. However, if the "written contract requiring insurance", the in- "written contract requiring insurance" specifically surance provided to the additional insured requires that this insurance apply on a primary shall be limited to the limits of liability re- basis or a primary and non-contributory basis, quired by that "written contract requiring in- this insurance is primary to "other insurance" surance". This endorsement shall not in- available to the additional insured which covers crease the limits of insurance described in that person or organization as a named insured Section III—Limits Of Insurance. for such loss, and we will not share with that b) The insurance provided to the additional in- "other insurance". But the insurance provided to the additional insured by this endorsement still is sured does not apply to bodily injury prop- excess over any valid and collectible "other in- of the rendering or "personal injury" arising out surance", whether primary, excess, contingent or of the of, or failure to render, any on any other basis, that is available to the addi- professional architectural, engineering or sur- tional insured when that person or organization is veying services, including: an additional insured under such "other insur- I. The preparing, approving, or failing to ance". prepare or approve, maps, shop draw- 4. As a condition of coverage provided to the ings, opinions, reports, surveys, field or- additional insured by this endorsement: ders or change orders, or the preparing, approving, or failing to prepare or ap- a) The additional insured must give us written prove, drawings and specifications; and notice as soon as practicable of an "occur- I!. Supervisory, inspection, architectural or rence" or an offense which may result in a claim. To the extent possible, such notice engineering activities. should include: CG D2 46 08 05 0 2005 The St. Paul Travelers Companies, Inc. Page 1 of 2 COMMERCIAL GENERAL LIABILITY i. How,1 when and where the "occurrence" any provider of'other insurance"which would or offense took place; cover the additional insured for a loss we ii. The names and addresses of any injured cover under this endorsement. However, this persons and witnesses; and condition does not affect whether the insur- ance provided to the additional insured by iii. The nature and location of any injury or this endorsement is primary to 'other insur- damage arising out of the "occurrence"or ance" available to the additional insured offense. which covers that person or organization as a b) If a claim is made or"suit" is brought against named insured as described in paragraph 3. the additional insured, the additional insured above. .must: 5. The following definition is added to SECTION V. L Immediately record the specifics of the —DEFINITIONS: claim or."suit"and the date received; and "Written contract requiring insurance" means ii. Notify us as soon as practicable. that part of any written contract or agreement The additional insured must see to it that we under which you are required to include a receive written notice of the claim or"suit" as person or organization as an additional in- sured on this Coverage Part, provided that soon as practicable. the "bodily injury" and "property damage" oc- c) The additional insured must immediately curs and the "personal injury" is caused by an send us copies of all legal papers received in offense committed: connection with the claim or "suit", cooperate a. After the signing and execution of the with us in the investigation or settlement of contract or agreement by you; the claim or defense against the "suit", and otherwise comply with all policy conditions. b. While that part of the contract or d) The additional insured must tender the de- agreement is in effect; and fense and indemnity of any claim or "suit' to c. Before the end of the policy period. Page 2 of 2 C 2005 The St. Paul Travelers Companies, Inc. CG D2 46 08 05 ® DATE(MMIDD/YYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE 5/14/2019 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 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: Charlene Reynolds Pentarisk Insurance Services LLC PHONE FAX CA License No. OG47886 AIC No Ext:408-418-2741 A/c No):408-418-2721 2033 Gateway Place, Suite 150 ADSs: creynolds@pentarisk.com San Jose CA 95110 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Travelers Indemnity Company of CT 25682 INSURED 1081 INSURER B:Travelers Property casualty company of America 25674 F T G Builders, Inc. INSURER C:Aspen American Insurance Company 43460 2975 Scott Blvd., Suite 100 Santa Clara CA 95054 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1944964382 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR IY POLICY NUMBER MM/DDYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY Y CO-2N738274 3/1/2019 3/1/2020 EACH OCCURRENCE $2,000,000 DAMAGE TO CLAIMS-MADE 1K OCCUR —PREMISES(Ea occcu ante) $300,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - GENERAL AGGREGATE $4,000,000 POLICY[X]JECT LOC PRODUCTS-COMP/OP AGG $4,000,000 X OTHER: Ded$5,000 $ B AUTOMOBILE LIABILITY Y BA-2N728219 3/1/2019 3/1/2020 COMBINED SINGLE LIMIT Ea accident $1 000 000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ IAUTOS Per accident C UMBRELLA LIAB I OCCUR CX005GV19 3/1/2019 3/1/2020 EACH OCCURRENCE $10,000,000 X EXCESS LABXCLAIMS-MADE AGGREGATE $10,000,000 DED I X I RETENTION$None $ B WORKERS COMPENSATION Y UB-2N731236 3/1/2019 3/1/2020 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER ❑EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE:Maintenance Contract 1 300 Orchard City Drive,Campbell CA 95008 City of Campbell,Water Tower Fee Owner,LLC,and Advisors Asset Services California,Inc., DBA:Colliers International Real Estate Management Services (CA),Inc.and their respective members,partners,officers and directors,subsidiaries,affiliates,employees and agents and City of Campbell,its officers, employees and volunteers are added as additional insureds as required by written contract for General Liability and Auto Liability,per attached.General Liability and Auto Liability evidenced herein are Primary&Non-Contributory to other insurance available to the additional insureds as required by written contract,per attached.Notice of Cancellation to Others is provided in accordance with the policies provisions including 10 day notice for non-payment of premium. Waiver(if Subrogation for Workers Compensation is granted in favor of the additional insureds as required by written contract,per attached. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Campbell 70 N. First Street Campbell CA 95008 AUTHORIZED REPRESENTATIVE d/ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Insured: F T G Builders, Inc. Policy No. BA-2N728219 COMMERCIAL AUTO Effective:03/01/2019 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED ® PRIMARY AND NON-CONTRIBUTORY WITH OTHER INSURANCE This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM PROVISIONS 2. The following is added to Paragraph B.S., Other 1. The following is added to Paragraph A.1.c., Who Insurance of SECTION IV — BUSINESS AUTO Is An Insured, of SECTION II — LIABILITY CONDITIONS: COVERAGE: Regardless of the provisions of paragraph a. and This includes any person or organization who you paragraph d. of this part S. Other Insurance, this are required under a written contract or insurance is primary to and non-contributory with agreement between you and that person or applicable other insurance under which an organization, that is signed by you before the additional insured person or organization is the "bodily injury" or "property damage" occurs and first named insured when the written contract or that is in effect during the policy period, to name agreement between you and that person or as an additional insured for Liability Coverage, organization, that is signed by you before the but only for damages to which this insurance "bodily injury" or "property damage" occurs and applies and only to the extent of that person's or that is in effect during the policy period, requires organization's liability for the conduct of another this insurance to be primary and non-contributory. "insured". CA T4 74 08 17 ©2016 The Travelers Indemnity Company.All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc.with its permission. Insured: F T G Builders, Inc. Policy No.CO-2N738274 COMMERCIAL GENERAL LIABILITY Effective:03/01/2019 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. .AMENDMENT - OTHER INSURANCE CONDITION AND MEANING OF OTHER INSURANCE, OTHER INSURER AND INSURER This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PROVISIONS sion to not buy insurance, for any reason, in 1. The following replaces the part of the first para- which case the insured will be deemed to be graph of Paragraph 4., Other Insurance, of the provider of other insurance; or SECTION IV — COMMERCIAL GENERAL LI- (v) Any similar risk transfer or risk management ABILITY CONDITIONS that precedes Paragraph method. a•: Other insurance does not include umbrella insur- If valid and collectible other insurance is available ance, or excess insurance, that was bought spe- to the insured for a loss we cover under Cover- cifically to apply in excess of the Limits of Insur- ages A or B of this Coverage Part, our obligations ance shown in the Declarations of this Coverage are limited as described in Paragraphs a. and b. Part. below. As used anywhere in this Coverage Part, other As used anywhere in this Coverage Part, other insurer means a provider of other insurance. As insurance means insurance,, or the funding of used in Paragraph c. below, insurer means a pro- losses, that is provided by, through or on behalf vider of insurance. of: (i) Another insurance company; 2• The first Subparagraph (2) of Paragraph 4.b., Ex- cess Insurance, of SECTION IV — COMMER- (ii) Us or any of our affiliated insurance compa- CIAL GENERAL LIABILITY CONDITIONS re- nies, except when the Non .cumulation of garding any other primary insurance available to Each Occurrence Limit provision of Para- you is deleted. graph 5. of Section III — Limits Of Insurance or the Non cumulation of Personal and Adver- 3. The following is added to Paragraph 4.b., Excess tising Injury Limit provision of Paragraph 4. of Insurance, of SECTION IV — COMMERCIAL Section III — Limits of Insurance applies be- GENERAL LIABILITY CONDITIONS: cause the Amendment - Non Cumulation Of This insurance is excess over any of the other Each Occurrence Limit Of Liability and Non insurance, whether primary, excess, contingent or Cumulation Of Personal and Advertising In- on any other basis, that is available to the insured jury Limit endorsement is included in this pol- when the insured is added as an additional in- icy; sured under any other policy, including any um- (Ili)Any risk retention group; brella or excess policy. (iv)Any self-insurance method or program, in- cluding any failure to buy insurance, or deci- CG D4 20 07 08 ©The Travelers Companies,Inc. Page 1 of 1 Insured: F T G Builders, Inc. Policy No.C0-21\1738274 COMMERCIAL GENERAL LIABILITY Effective:03/01/2019 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BLANKET ADDITIONAL INSURED (CONTRACTORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. WHO IS AN INSURED — (Section II) is amended c) The insurance provided to the additional in- to include any person or organization that you sured does not apply to "bodily injury" or agree in a "written contract requiring insurance" "property damage" caused by "your work" to include as an additional insured on this Cover- and included in the "products-completed op- age Part, but: erations hazard" unless the "written contract a) Only with respect to liability for"bodily injury", requiring insurance" specifically requires you "property damage" or"personal injury"; and to provide such coverage for that additional insured, and then the insurance provided to b) If, and only to the extent that, the injury or the additional insured applies only to such damage is caused by acts or omissions of "bodily injury" or "property damage" that oc- you or your subcontractor in the performance curs before the end of the period of time for of "your work" to which the "written contract which the "written contract requiring insur- requiring insurance" applies. The person or ance" requires you to provide such coverage organization does not qualify as an additional or the end of the policy period, whichever is insured with respect to the independent acts earlier. or omissions of such person or organization. 3. The insurance provided to the additional insured 2. The insurance provided to the additional insured by this endorsement is excess over any valid and by this endorsement is limited as follows: collectible "other insurance", whether primary, a) In the event that the Limits of Insurance of excess, contingent or on any other basis, that is this Coverage Part shown in the Declarations available to the additional insured for a loss we exceed the limits of liability required by the cover under this endorsement. However, if the "written contract requiring insurance", the in- written contract requiring insurance' specifically surance provided to the additional insured requires that this insurance apply on a primary shall be limited to the limits of liability re- basis or a primary and non-contributory basis, quired by that "written contract requiring in- this insurance is primary to "other, insurance" surance". This endorsement shall not in- available to the additional insured which covers crease the limits of insurance described in that person or organization as a named insured Section III— Limits Of Insurance. for such loss, and we will not share with that "other insurance". But the insurance provided to b) The insurance provided to the additional in- the additional insured by this endorsement still is sured does not apply to "bodily injury", "prop- excess over any valid and collectible "other in- of damage" or "personal injury" arising out surance", whether primary, excess, contingent or of the rendering of, or failure to render, any on any other basis, that is available to the addi- professional architectural, engineering or sur- tional insured when that person or organization is veying services, including: an additional insured under such "other insur- L The preparing, approving, or failing to ance". prepare or approve, maps, shop draw- 4. As a condition of coverage provided to the ings, opinions, reports, surveys, field or- additional insured by this endorsement: ders or change orders, or the preparing, approving, or failing to prepare or ap- a) The additional insured must give us written prove, drawings and specifications; and notice as soon as practicable of an "occur- rence" or an offense which may result in a ii. Supervisory, inspection, architectural or claim. To the extent possible, such notice engineering activities. should include: CG D2 46 08 05 0 2005 The St. Paul Travelers Companies, Inc. Page 1 of 2 COMMERCIAL GENERAL LIABILITY L How, when and where the 'occurrence" any provider of'other insurance"which would or offense took place; cover the additional insured for a loss we ii. The names and addresses of any injured cover under this endorsement. However, this persons and witnesses; and condition does not affect whether the insur- ance provided to the additional insured by iii. The nature and location of any injury or this endorsement is primary to 'other insur- damage arising out of the 'occurrence" or ance" available to the additional insured offense. which covers that person or organization as a b) If a claim'is made or"suit' is brought against named insured as described in paragraph 3. the additional insured, the additional insured above. must: 5. The following definition is added to SECTION V. L Immediately record the specifics of the —DEFINITIONS: claim or"suit' and the date received; and "Written contract requiring insurance" means ii. Notify us as soon as practicable. that part of any written contract or agreement The additional insured must see to it that we under which you are required to include a receive written notice of the claim or"suit' as person or organization as an additional in- soon as practicable. sured on this Coverage Part, provided that the "bodily injury" and "property damage" oc- c) The additional insured must immediately curs and the "personal injury" is caused by an send us copies of all legal papers received in offense committed: connection with the claim or "suit', cooperate a. After the signing and execution of the with us in the investigation or settlement of contract or agreement by you; the claim or defense against the "suit", and otherwise comply with all policy conditions. b. While that part of the contract or d) The additional insured must tender the de- agreement is in effect; and fense and indemnity of any claim or "suit' to c.. Before the end of the policy period. a Page 2 of 2 0 2005 The St. Paul Travelers Companies, Inc. CG D2 46 08 05 TRAVELERS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 03 76 ( A)— POLICY NUMBER: UB-2N731236 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA (BLANKET WAIVER) We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. The additional premium for this endorsement shall be % of the California workers' compensation pre- mium. Schedule Person or Organization Job Description As required by written contract All locations as required by written contract This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective-03/01/2019 Policy No. UB-2N731236 �^A^,-- mnt No.1 Insured :mium Insurance Company Countersigned by Travelers Property Casualty Company of America DATE OF ISSUE: 03 -01-19 ST ASSIGN: Page 1 of 1 47_ INSURANCE REQUIREMENTS CHECKLIST Permit# CIP Project# 4 Consultant/Contractor: Co The following insurance is required of all consultants/contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These . insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects.' Limits Commercial General Liability for bodily, personal injury and property damage: $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000-general aggregate limit. _�L Policy expiration date Automotive Liability: PCO "Any Auto" checked on certificate 1,000,000 per accident for bodily injury and property damage ❑ 'Policy expiration date Workers' Compensation and Employer's Liability o Waiver of Subrogation clause 7Er $1,000,000 per accident for bodily injury or disease Policy expiration date Course of-Construction (if required in Special Provisions) ❑ ompleted value of the project Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies VA ditional Insured Endorsement: Th e City, its officers, employees and volunteers are named as additional insured. ® (Reference Project Location/Permit Number) The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area should say: m�Should any of the above described policies be cancelled before the expiration date thereof,notice will V be delivered in accordance with the policy provisions. Workers' Compensation Insurance Sheet Submitted —1-a- For General Contractor ❑ For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Revlan 2018) Page 1 Acceptability of.lnsurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: � ll � NAIC#ZS Rating: !`Y�c Authorized in CA: Name: NAIC# S�_ 11'\ Rating: 'Authorized in CA: Name: NAIC# Rating: Authorized in CA: Name: NAIC# Rating: Authorized in CA: ❑ Campbell Business License# Expiration: Contractors License# Class: 6 Expiration: &—(-/ o f 2 l . l Insurance Certificate Reviewed t 1 Oln'tials Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 I ' LANDSER-01 MONIMUNIZ ,4cof�>o� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 5/14/2019 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). CONTACT PRODUCER NAME: NFP Property&Casualty Services,Inc. PHONEFAX 160 West Santa Clara Street (A/C,No,Ext►:(408)792-5400 (A/c,No):(408)792-3670 Suite 575 ADDRESS: San Jose,CA 95113 INSURER S AFFORDING COVERAGE NAIC# INSURER A:Hartford Casualty Insurance Company 29424 INSURED INSURER B:Com west Insurance Company 12177 Land Services Landscape Contractors,Inc. INSURERC: 901 Brown Rd. INSURERD: Fremont,CA 94539 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD MMIDDIYYYY MMIDD/YYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 57UUNOK7842 2/1/2019 2/1/2020 DAMAGE TO RENTED 300,000 X X PREMISES Ea occurrence $ MED EXP(Any oneperson) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ®JECT LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 Ea accident $ JX ANY AUTO X X 57UUNOK7842 2/1/2019 2/1/2020 BODILY INJURY Per erson $ OWNED SCHEDULED AUTOS ONLYN AUTOS BODILY INJURY Per accident $ AUTOS ONLY AUUTOS ONELYY Pe�accidentDAMAGE $ A UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 X EXCESS LIAB CLAIMS-MADE 57HHUOK7843 2/1/2019 2/1/2020 AGGREGATE $ 5,000,000 DED I X RETENTION$ 10,000 $ B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X STATUTE I ER ❑ ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N X WCV5901229 2/1/2019 2/1/2020 1,000,000 OFFICERIMEMBER EXCLUDED? NIA E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE:Per Written Contract/Agreement with the Named Insured. The City,its officers,employees and volunteers are named as Additional Insured as respects to General Liability per form HG 00 01 09 16 attached.GL Primary And Non-Contributory wording applies per form HG 00 0109.16 attached.GL Waiver of Subrogation applies per form HG 00 0109 16 attached.Auto Additional Insured applies per form HA 99 16 03 12 attached.Auto Waiver of Subrogation applies per form HA 99 16 03 12 attached.Auto Primary And Non Contributory wording applies per form HA 99 16 03 12 attached.Worker's Comp Waiver of Subrogation applies per form WC 99 03 13 attached. Form CIR Attached. NC. )_0 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City of Campbell THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Y P ACCORDANCE WITH THE POLICY PROVISIONS. 70 N.First St Campbell,CA 95008 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID:LANDSER-01 MONIMUNIZ LOC#: 1 ACOR;Dr ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED NFP Property&Casualty Services, Inc. 901 Bro nI Rd,Landscape Contractors,Inc. POLICY NUMBER Fremont,CA 94539 SEE PAGE 1 CARRIER NAIC CODE EE PAGE 1 SEE P 1 EFFECTNE DATE:SEE PAGE 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance CIR FORM CONTRACTUAL INSURANCE REQUIREMENTS The attached Certificate of Insurance is provided as part of our service to our client,the Insured. If special endorsements have been provided,they also are indicated attached.You may find that these documents do not comply with all the terms and conditions of the underlying contract between the Certificate Holder and the Insured due to the insurance company's insuring conditions, limitations,exclusions and other terms. If you have any questions,.please contact the undersigned. NFP Property and Casualty Services,Inc. 160 West Santa Clara Street,Suite#575 CA License#0F15715 TELEPHONE:408.792.5400 FAX:408.792.3670 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD a Insured: Gachina Landscape Management, Inc. Policy#57 UUN OK7439 Our obligation to defend an insured's indemnitee liability company), to a co-"employee" and to pay for attorneys' fees and necessary while in the course of his or her litigation expenses as Supplementary Payments employment or performing duties ends when: related to the conduct of your a. We, have used up the applicable limit of business, or to your other "volunteer insurance in the payment of judgments or workers" while performing duties settlements; or related to the conduct of your b. The conditions set forth above, or the terms of business; the agreement described in Paragraph f. (b) To the spouse, child, parent, brother or above, are no longer met. sister of that co-"employee" or that SECTION II—WHO IS AN INSURED "volunteer worker" as a consequence of Paragraph (1)(a)above; 1. If you are designated in the Declarations as: (c) For which there is any obligation to a. An individual, you and your spouse are share damages with or repay someone insureds, but only with respect to the conduct else who must pay damages because of a business of which you are the sole of the injury described in Paragraphs owner. (1)(a)or(1)(b)above; or b. A partnership or joint venture, you are an (d) Arising out of his or her providing or insured. Your members, your partners, and failing to provide professional health their spouses are also insureds, but only with care services. respect to the conduct of your business. If you are not in the business of providing c. A limited liability company, you are an professional health care services: insured. Your members are also insureds, but (a) Subparagraphs (1)(a), (1)(b) and (1)(c) only with respect to the conduct of your above do not apply to any "employee" business. Your managers are insureds, but or"volunteer worker" providing first aid only with respect to their duties as your services; and managers. d. An organization other than a partnership,joint (b) Subparagraph (1)(d) above does not venture or limited liability company, you are apply to any nurse, emergency medical technician or paramedic employed by an insured. Your "executive officers" and you to provide such services. directors are insureds, but only with respect to their duties as your officers or directors. Your (2) "Property damage"to property: stockholders are also-insureds, but only with (a) Owned, occupied or used by, respect to their liability as stockholders. (b) Rented to, in the care, custody or e. A trust, you are an insured. Your trustees are control of, or over which physical also insureds, but only with respect to their control is being exercised for any duties as trustees. purpose by 2. Each of the following is also an insured: you, any of your "employees", "volunteer a. Employees And Volunteer Workers workers", any partner or member (if you Your "volunteer workers" only while are a partnership or joint venture), or any member (if you are a limited liability performing duties related to the conduct of company). your business, or your "employees", other than either your"executive officers"(if you are b. Real Estate Manager an organization other than a partnership,joint Any person (other than your "employee" or venture or limited liability company) or your "volunteer worker"), or any organization while managers (if you are a limited liability acting as your real estate manager. company), but only for acts within the scope of their em to ment b c. Temporary Custodians Of Your Property p y y you or while performing duties related to the conduct of Any person or organization having proper your business. temporary custody of your property if you die, but only: However, none of these "employees" or"volunteer workers"are insureds for: (1) With respect to liability arising out of the (1) "Bodily injury"or"personal and advertising maintenance or use of that property; and injury": (2) Until your legal representative has been appointed. (a) To you, to your partners or members (if d. Legal Representative If You Die you are a partnership or joint venture), g p to your members (if you are a limited Your legal representative if you die, but only HG 00 01 09 16 with respect to duties as such. That 5. Additional Insureds When Required By representative will have all your rights .and Written Contract, Written Agreement Or duties under this Coverage Part. Permit e. Unnamed Subsidiary The following person(s) or organization(s) are an Any subsidiary, and subsidiary thereof, of additional insured when you have agreed, in a yours which is a legally incorporated entity of written contract, written agreement or.because of which you own a financial interest of more a permit issued by a state or political subdivision, than 50% of the voting stock on the effective that such person or organization be added as an date of the Coverage Part. additional insured on your policy, provided the injury or damage occurs subsequent to the The insurance afforded herein for any execution of the contract or agreement. subsidiary not named in this Coverage Part as a named insured does not apply to injury A person or organization is an additional insured or damage with respect to which such insured under this provision only for that period of time is also a named insured under another policy required by the contract or agreement. or would be a named insured under such However, no such person or organization is an policy but for its termination or the exhaustion insured under this provision if such person or of its limits of insurance. organization is included as an insured by an 3. Newly Acquired Or Formed Organization endorsement issued by us and made a part of Any organization you newly acquire or form, this Coverage Part. other than a partnership, joint venture or limited a. Vendors liability company, and over which you maintain Any person(s) or organization(s) (referred to financial interest of more than 50% of the voting below as vendor), but only with respect to stock, will qualify as a Named Insured if there is "bodily injury" or "property damage" arising no other similar insurance available to that out of"your products"which are distributed or organization. However: sold in the regular course of the vendor's a. Coverage under this provision is afforded only business and only if this Coverage Part until the 180th day after you acquire or form provides coverage for "bodily injury" or the organization or the end of the policy "property damage" included within the period, whichever is earlier; "products-completed operations hazard". b. Coverage A does not apply to "bodily injury" (1) The insurance afforded the vendor is or "property damage" that occurred before subject to the following additional you acquired or formed the organization; and exclusions: c. Coverage B does not apply to "personal and This insurance does not apply to: advertising injury" arising out. of an offense . (a) "Bodily injury" or"property damage"for committed before you acquired or formed the which the vendor is obligated to pay organization. damages by reason of the assumption 4. Nonowned Watercraft of liability in a contract or agreement. This exclusion does not apply to With respect to watercraft you do not own that is liability for damages that the vendor a less than 51 feet long and is not being used to would have in the absence a the carry persons for a charge, any person is an contract a agreement; insured while operating such watercraft with your permission. Any other person or organization (b) Any express warranty unauthorized by responsible for the conduct of such person is you; also an insured, but only with respect to liability (c) Any physical or chemical change in the arising out of the operation of the watercraft, and product made intentionally by the only if no other insurance of any kind is available vendor; to that person or organization for this liability. (d) Repackaging, except when unpacked However, no person or organization is an insured solely for the purpose of inspection, with respect to: demonstration, testing, or the a. "Bodily injury" to a co-"employee" of the substitution of parts under instructions person operating the watercraft; or from the manufacturer, and then b. "Property damage" to property owned by, repackaged in the original container; rented to, in the charge of or occupied by you (e) Any failure to make such inspections, or the employer of any person who is an adjustments, tests or servicing as the insured under this provision. vendor has agreed to make or normally Page 12 of 21 undertakes to make in the usual This insurance does not apply to: course of business, in connection with 1. Any "occurrence" which takes place after the distribution or sale of the products; you cease to lease that land; or (f) Demonstration, installation, servicing 2. Structural alterations, new construction or or repair operations, except such demolition operations performed by or on operations performed at the vendor's behalf of such person or organization. premises in connection with the sale of the product; d. Architects, Engineers Or Surveyors (g) Products which, after distribution or Any architect, engineer, or surveyor, but only sale by you, have been labeled or with respect to liability for "bodily injury", relabeled or used as a container, part "property damage" or "personal and or ingredient of any other thing or advertising injury" caused, in whole or in part, substance by or for the vendor; or by your acts or omissions or the acts or (h) "Bodily injury" or "property damage" omissions of those acting on your behalf: arising out of the sole negligence of the (1) In connection with your premises; or vendor for its own acts or omissions or (2) In the performance of your ongoing those of its employees or anyone else operations performed by you or on your acting on its behalf. However, this behalf. exclusion does not apply to: With respect to the insurance afforded these (i)The exceptions contained in Sub- additional insureds, the following additional paragraphs (d) or(f); or exclusion applies: (ii) Such inspections, adjustments, This insurance does not apply to "bodily tests or servicing as the vendor has injury", "property damage" or "personal and agreed to make or normally advertising injury" arising out of the rendering undertakes to make in the usual of or the failure to render any professional course of business, in connection services by or for you, including: with the distribution or sale of .the 1. The preparing, approving, or failing to products. prepare or approve, maps, shop drawings, (2) This insurance does not apply to any opinions, reports, surveys, field orders, insured person or organization, from change orders or drawings and whom you have acquired such products, specifications; or or any ingredient, part or container, 2. Supervisory, inspection, architectural or entering into, accompanying or containing engineering activities. . such products. This exclusion applies even if the claims b. Lessors Of Equipment against any insured allege negligence or (1) Any person(s) or organization(s) from other wrongdoing in the supervision, hiring, whom you lease equipment; but only with employment, training or monitoring of others respect to their liability for "bodily injury", by that insured, if the "occurrence" which "property damage" or "personal and caused the "bodily injury" or "property advertising injury" caused, in whole or in damage", or the offense which caused the part, by your maintenance, operation or "personal and advertising injury", involved the use of equipment leased to you by such rendering of or the failure to render any person(s)or organization(s). professional services by or for you. (2) With respect to the insurance afforded to e. 'Permits Issued By State Or Political these additional insureds this insurance Subdivisions does not apply to any "occurrence" which Any state or political subdivision, but only with takes place after the equipment lease respect to operations performed by you or on expires. your behalf for which the state or political c. Lessors Of Land Or Premises subdivision has issued a permit. Any person or organization from whom you With respect to the insurance afforded these lease land or premises, but only with respect additional insureds, this insurance does not to liability arising out of the ownership, apply to: maintenance or use of that part of the land or (1) "Bodily injury", "property damage" or premises leased to you. "personal and advertising injury" arising With respect to the insurance afforded these out of operations performed for the state additional insureds the following additional or municipality; or exclusions apply: HG 00 01 09 16 Page 13 of 21 (2) "Bodily injury" or "property damage" by that insured, if the "occurrence" which included within the "products-completed caused the "bodily injury" or "property operations hazard". damage", or the offense which caused the f. Any Other Party "personal and advertising injury", involved the rendering of or the failure to render any Any other person or organization who is not professional services by or for you. an additional insured under Paragraphs a.. through e. above, but only with respect to The limits of insurance that apply to additional liability for "bodily injury", "property damage" insureds is described in Section III — Limits Of or"personal and advertising injury" caused, in Insurance. whole or in part, by your acts or omissions or How this insurance applies when other insurance the acts or omissions of those acting on your is available to the additional insured is described behalf: in the Other Insurance Condition in Section IV — (1) In the performance of your ongoing Commercial General Liability Conditions. operations; No person or organization is an insured with respect (2) In connection with your premises owned to the conduct of any current or past partnership, by or rented to you; or joint venture or limited liability company that is not (3) In connection with "your work" and shown as a Named Insured in the Declarations. included within the. "products-completed SECTION III—LIMITS OF INSURANCE operations hazard", but only if 1. The Most We Will Pay (a) The written contract or agreement The Limits of Insurance shown in the requires you to provide such coverage -Declarations and the rules below fix the most we to such additional insured; and will pay regardless of the number of: (b) This Coverage Part provides coverage a. Insureds; for"bodily injury" or"property damage" b. Claims made or"suits" brought; or included within the "products- completed operations hazard". c. Persons or organizations making claims or However: bringing"suits".(1) The insurance afforded to such additional 2. General Aggregate Limit insured only applies to the extent The General Aggregate Limit is the most we will permitted by law; and pay for the sum of: (2) If coverage provided to the additional a. Medical expenses under Coverage C; insured is required by a contract or b. Damages under Coverage A, except agreement, the insurance afforded to such damages because of "bodily injury" or additional insured will not be broader than "property damage" included in the "products- that which you are required by the contract completed operations hazard"; and or agreement to provide for such c. Damages under Coverage B. additional insured. 3. Products-Completed Operations Aggregate With respect to the insurance afforded to Limit these additional insureds, this insurance does . The Products-Completed Operations Aggregate not apply to: Limit is the most we will pay under Coverage A "Bodily injury", "property damage" or for damages because of "bodily injury" and "personal and advertising injury" arising out of "property damage" included in the "products- the rendering of, or the failure to render, any completed operations hazard". professional architectural, engineering or surveying services, including: 4. Personal And Advertising Injury Limit (1) The preparing, approving, or failing to Subject to 2. above, the Personal and prepare or approve, maps, shop drawings, Advertising Injury Limit is the most we will pay opinions, reports, surveys, field orders, under Coverage B for the sum of all damages change orders or drawings and because of all "personal and advertising injury" specifications; or sustained by any one person or organization. (2) Supervisory, inspection, architectural or 5. Each Occurrence Limit engineering activities. Subject to 2. or 3. above, whichever applies, the This exclusion applies even if the claims Each Occurrence Limit is the most we will pay for against any insured allege negligence or the sum of: other wrongdoing in the supervision, hiring, a. Damages under Coverage A; and employment, training or monitoring of others Page 14 of 21 HG 00 01 09 16 Insured: Gachina Landscape Management, Inc. Policy#57 UUN OK7439 contract or written_ agreement that this b. Excess Insurance insurance is primary and non-contributory This insurance is excess over any of the other with the additional insured's own insurance. insurance, whether primary, excess, f. Knowledge Of An Occurrence, Offense, contingent or on any other basis: Claim Or Suit (1) Your Work Paragraphs a. and b. apply to you or to any That is Fire, Extended Coverage, Builder's additional insured only when such Risk, Installation Risk or similar coverage "occurrence", offense, claim or"suit" is known for"your work"; to: (2) Premises Rented To You (1) You or any additional insured that is an individual; That is fire, lightning or explosion insurance for premises rented to you or (2) Any partner, if you or the additional temporarily occupied by you with insured is a partnership; permission of the owner; (3) Any ,manager, if you or the additional (3) Tenant Liability insured is a limited liability company; That is insurance purchased by you to (4) Any "executive officer" or, insurance cover your liability as a tenant for manager, if you or the additional insured is "property damage" to premises rented to a corporation; you or temporarily occupied by you with (5) Any trustee, if you or the additional permission of the owner; insured is a trust; or (4) Aircraft, Auto Or Watercraft (6) Any elected or appointed official, if you or If the loss arises out of the maintenance or the additional insured is a ,political use of aircraft, "autos" or watercraft to the subdivision or public entity. extent not subject to Exclusion g. of This duty applies separately to you and any Section I — Coverage .A — Bodily Injury additional insured. And Property Damage Liability; 3. Legal Action Against Us (5) Property Damage To Borrowed No person or organization has a right under this Equipment Or Use Of Elevators Coverage Part: If the loss arises out of"property damage" a. To join us as a party or otherwise bring us to borrowed equipment or the use of into a "suit" asking for damages from an elevators to the extent not subject to insured; or Exclusion j. of Section I - Coverage A - Bodily Injury And Property Damage b. To sue us on this Coverage Part unless all of Liability; its terms have been fully complied with. A person or organization may sue us to recover (6) When You Are Added As An AdditionalInsured To Other Insurance on an agreed settlement or on a final judgment against an insured; but we will not be liable for Any other insurance available to you damages that are not payable under the terms of covering liability for damages arising out this Coverage Part or of the premises or operations, or products that are in excess of the applicable limit of and completed operations, for which you insurance. An agreed settlement means a have been added as an additional insured settlement and release of liability signed by us, by that insurance; or the insured and the claimant or the claimant's (7) When You Add Others As An legal representative. Additional Insured To This Insurance 4. Other Insurance Any other insurance available to an If other valid and ' collectible insurance is additional insured. available to the insured for a loss we cover under However, the following provisions apply to Coverages A or B of this Coverage Part, our other insurance available to any person or obligations are limited as follows: organization who is an additional insured a. Primary Insurance under this coverage part. This insurance is primary except when b. (a) Primary Insurance When Required below applies. If other insurance is also By Contract primary, we will share with all that other This insurance is primary if you have insurance by the method described in c. agreed in a written contract or written below. agreement that this insurance be primary. If other insurance is also Page 16 of 21 primary, we will share with all that 5. Premium Audit other insurance by the method a. We will compute all premiums for this described in c. below. Coverage Part in accordance with our rules -� (b) Primary And Non-Contributory To and rates. Other Insurance When Required By b. Premium shown in this Coverage Part as Contract advance premium is a deposit premium only. If you have agreed in a written At the close of each audit period we will contract, written agreement, or permit compute the earned premium for that period that this insurance is primary and non- and send'notice to the first Named Insured. contributory with the additional The due date for audit and retrospective insured's own insurance, this insurance premiums is the date shown as the due date is primary and we will not, seek on the bill. If the sum of the advance and contribution from that other insurance. audit premiums paid for the policy period is Paragraphs (a) and (b) do not apply to greater than the earned premium, we will other insurance to which the additional return the excess to the first Named Insured. insured has been added as an additional c. The first Named Insured must keep records of insured. the information we need for premium When this insurance is excess, we will have computation, and send us copies at such no duty under Coverages A or B to defend times as we may request. the insured against any "suit" if any other 6. Representations insurer has a duty to defend the insured a. When You Accept This Policy against that"suit". If no other insurer defends, we will undertake to do so, but we will be By accepting this policy, you agree: entitled to the insured's rights against all (1) The statements in the Declarations are those other insurers. accurate and complete; When this insurance is excess over other (2) Those statements are based upon insurance, we will pay only our share of the representations you made to us; and amount of the loss, if any, that exceeds the (3) We, have issued this policy in reliance sum of: upon your representations. (1) The total amount that all such other b. Unintentional Failure To Disclose Hazards insurance would pay for the loss in the If unintentionally you should fail to disclose all absence of this insurance; and hazards relating to the conduct of your (2) The total of all deductible and self-insured business that exist at the inception date of amounts under all that other insurance. this Coverage Part, we shall not deny We will share the remaining loss, if any, with coverage under this Coverage Part because any other insurance that is not described in of such failure. this Excess Insurance provision and was not 7. Separation Of Insureds bought specifically to apply in excess of the Except with respect to the Limits of Insurance, Limits of Insurance shown in the Declarations and any rights or duties specifically assigned in of this Coverage Part. this Coverage Part to the first Named Insured, c. Method Of Sharing this insurance applies: If all of the other insurance permits a. As if each Named Insured were the only contribution by equal shares, we will follow Named Insured; and this method also. Under this approach each b. Separately to each insured against whom insurer contributes equal,amounts until it has claim is made or"suit"is brought. paid its applicable limit of insurance or none of the loss remains,whichever comes first. 8. Transfer Of Rights Of Recovery Against If any of the other insurance does not permit - Others To Us contribution by equal shares, we will a. Transfer Of Rights Of Recovery contribute by limits. Under this method, each If the insured has rights to recover all or part insurer's share is based on the ratio of its of any payment, including Supplementary applicable limit of insurance to the total Payments, we have made under this applicable limits of insurance of all insurers. Coverage Part, those rights are transferred to us. The insured must do nothing after loss to HG 00 01 09 16 Insured: Gachina Landscape Management, Inc. Policy#57 UUN OK7439 impair them. At our request, the insured will other motor vehicle insurance law where it is bring "suit" or transfer those rights to us and licensed or principally garaged. help us enforce them. However, "auto" does not include "mobile b. Waiver Of Rights Of Recovery (Waiver Of equipment". Subrogation) 5. "Bodily injury"means physical: If the insured has waived any rights of a. Injury; recovery against any person or organization for all or part of any payment, including b. Sickness; or Supplementary Payments, we have made c. Disease under this Coverage.Part, we also waive that sustained by a person and, if arising out of the right, provided the insured waived their rights above, mental anguish or death at any time. of recovery against such person or organization in a contract, agreement or 6. "Coverage territory" means: permit that was executed prior to the injury or a. The United States of America (including its damage. territories and possessions), Puerto Rico and 9. When We Do Not Renew Canada; If we decide not to renew this Coverage Part, we b. International waters or airspace, but only if will mail or deliver to the first Named Insured the injury or damage occurs in the course of shown in the Declarations written notice of the travel or transportation between any places nonrenewal not less than 30 days before the included in a. above; or expiration date. c. All other parts of the world if the injury or If notice is mailed, proof of mailing will 'be damage arises out of: sufficient proof of notice. (1) Goods or products made or sold by you in SECTION V—DEFINITIONS the territory described in a. above; 1. "Advertisement" means the widespread public (2) The activities of a person whose home is dissemination of information or images that has in the territory described in a. above, but is the purpose of inducing the sale of goods, away for a short time on your business; or products or services through: (3) "Personal and advertising injury" offenses a. (1) Radio; that take place through the Internet or similar electronic means of communication (2) Television; provided the insured's responsibility to pay (3) Billboard; damages is determined in the United States of (4) Magazine; America (including its territories and possessions), (5) Newspaper; or Puerto Rico or Canada, in a "suit" on the merits according to the substantive law in such territory or b. Any other publication that is given widespread in a settlement we agree to. public distribution. 7. "Employee" includes a "leased worker". However, advertisement does not include: "Employee" does not include a "temporary a. The design, printed material, information or worker". images contained in, on or upon the 8. "Employment-Related Practices"means: packaging or labeling of any goods or products; or a. Refusal to employ that person; b. An interactive conversation between or b. Termination of that person's employment; or among persons through a computer network. c. Employment-related practices, policies, acts 2. "Advertising idea" means any idea for an or omissions, such as coercion, demotion, .'advertisement". evalua defamation, harassment reassignment, hum liation, 3. "Asbestos hazard" means an exposure or discrimination or malicious prosecution threat of exposure to the actual or alleged directed a that person. properties of asbestos and includes the mere presence of asbestos in any form. 9. "Executive officer" means a person holding any of the officer positions created by your charter, 4. "Auto" means: constitution, by-laws or any other similar a. A land motor vehicle, trailer or semitrailer governing document. designed for travel on public roads, including 10."Hostile fire" means one which becomes any attached machinery or equipment; or uncontrollable or breaks out from where it was b. Any other land vehicle that is subject to a intended to be. compulsory or financial responsibility law or Page 18 of 21 Insured: Gachina Landscape Management, Inc. COMMERCIAL AUTOMOBILE Policy#57 UUN OK7439 HA 99 16 03 12 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL AUTOMOBILE BROAD FORM ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM To the extent that the provisions of this endorsement provide broader benefits to the "insured" than other provisions of the Coverage Form, the provisions of this endorsement apply. 1. BROAD FORM INSURED d. Any "employee" of yours while using a A. Subsidiaries and Newly Acquired or covered "auto" you don't own, hire or Formed Organizations borrow in your business or your The Named Insured shown in the personal affairs. Declarations is amended to include: C. Lessors as Insureds (1) Any legal business entity other than a Paragraph A.1. -WHO IS AN INSURED - of partnership or joint venture, formed as a Section II - Liability Coverage is amended to subsidiary in which . you have an add: ownership interest of more than 50% on e. The lessor of a covered "auto"while the the effective date of the Coverage Form: "auto" is leased to you under a written However, the Named Insured does not agreement if: include any subsidiary that is an "insured" under any other automobile (1) The agreement requires you to policy or would be an "insured" under provide direct primary insurance for the lessor and such a policy but for its termination or the exhaustion of its Limit of Insurance. (2) The"auto" is leased without a driver. (2) Any organization that is acquired or Such a leased "auto" will be considered a formed by you and over which you covered "auto" you own and not a covered maintain majority ownership. However, "auto"you hire. the Named Insured does not include any D. Additional Insured if Required by Contract newly formed or acquired organization: (1) Paragraph A.1. -WHO IS AN INSURED (a) That is a partnership or joint - of Section II - Liability Coverage is venture, amended to add: (b) That is an "insured" under any other f. When you have agreed, in a written policy, contract or written agreement, that a (c) That has exhausted its Limit of person or organization be added as Insurance under any other policy, or an additional insured on your (d) 180 days or more after its business auto policy, such person or acquisition or formation by you, organization is an "insured", but only unless you have given us notice of to the extent such person or the acquisition or formation. organization is liable for "bodily Coverage does not apply to "bodily injury" or "property damage" caused injury" or "property damage"that results by the conduct of an "insured" under from an "accident" that occurred before paragraphs a. or b. of Who Is An you formed or acquired the organization: Insured with regard to the ownership, maintenance or use of a B. Employees as Insureds covered"auto." Paragraph A.1. -WHO IS AN INSURED -of SECTION II - LIABILITY COVERAGE is amended to add: ©2011, The Hartford(Includes copyrighted material Form HA 99 16 0312 of ISO Properties, Inc.,with its permission.) Page 1 of 5 The insurance afforded to any such E. Primary and Non-Contributory if additional insured applies only if the Required by Contract "bodily injury" or "property damage" Only with respect to insurance provided to occurs: an additional insured in 1.D. - Additional (1) During the policy period, and Insured If Required by Contract, the (2) Subsequent to the execution of such following provisions apply: written contract, and (3) Primary Insurance When Required By (3) Prior to the expiration of the period Contract of time that the written contract This insurance is primary if you have requires such insurance be provided agreed in a written contract or written to the additional insured. agreement that this insurance be (2) How Limits Apply primary. If other` insurance is also If you have agreed in a written contract primary, we will share with all that other insurance by the method described in or written agreement that another Other Insurance 5.d. person or organization be added as an additional insured on your policy, the (4) Primary And Non-Contributory To Other most we will pay on behalf of such Insurance When Required By Contract additional insured is the lesser of: If you have agreed in a written contract (a) The limits of insurance specified in or written agreement that this insurance the written contract or written is primary and non-contributory with the agreement; or additional insured's own insurance, this insurance is primary and we will not (b) The Limits of Insurance shown in seek contribution from that other the Declarations. insurance. Such amount shall be a part of and not Paragraphs(3) and (4) do not apply to other in addition to Limits of Insurance shown insurance to which the additional insured in the Declarations and described in this has been added as an additional insured. Section. When this insurance is excess, we will have no (3) Additional Insureds Other Insurance duty to defend the insured against any "suit" if If we cover a claim or "suit" under this any, other insurer has a duty to defend the Coverage Part that may also be covered insured against that "suit". If no other insurer by other insurance available to an defends, we will undertake to do so, but we will additional insured, such additional be entitled to the insured's rights against all insured must submit such claim or"suit" those other insurers. to the other insurer for defense and When this insurance is excess over other indemnity. insurance, we will pay only our share/of the However, this provision does not apply amount of the loss, if any, that exceeds the sum to the extent that you have agreed in a of: written contract or written agreement (1) The total amount that all such other that this insurance is primary and non- insurance would pay for the loss in the contributory with the additional insured's absence of this insurance; and own insurance. (2) The total of all deductible and self-insured (4) Duties in The Event Of Accident, Claim,Suitor Loss amounts under all that other insurance. We will share the remaining loss, if any, by the If you have agreed in a written contract method described in Other Insurance 5.d. or written agreement that another person or organization be added as an 2. AUTOS RENTED BY EMPLOYEES additional insured on your policy, the Any "auto" hired or rented by your "employee" additional insured shall be required to on your behalf and at your direction will be comply with the-provisions in LOSS considered an"auto"you hire. CONDITIONS 2. - DUTIES IN THE The OTHER INSURANCE Condition is amended EVENT OF ACCIDENT, CLAIM , SUIT by adding the following: OR LOSS — OF SECTION IV — BUSINESS AUTO CONDITIONS, in the same manner as the Named Insured. ©2011, The Hartford (Includes copyrighted material Form HA 99 16 0312 of ISO Properties, Inc.,with its permission.) Page 2 of 5 If an "employee's" personal insurance also 5. PHYSICAL DAMAGE . - ADDITIONAL applies on an excess basis to a covered "auto" TEMPORARY TRANSPORTATION EXPENSE hired or rented by your "employee" on your COVERAGE behalf and at your direction, this insurance will Paragraph.AA.a. of SECTION III - PHYSICAL be primary to the "employee's" personal DAMAGE COVERAGE is amended to provide a insurance. limit of $50 per day and a maximum limit of 3. AMENDED FELLOW EMPLOYEE EXCLUSION $1,000. EXCLUSION 5. - FELLOW EMPLOYEE - of 6. LOAN/LEASE GAP COVERAGE SECTION II - LIABILITY COVERAGE does not Under SECTION III - PHYSICAL DAMAGE apply if you have workers' compensation COVERAGE, in the event of a total "loss" to a insurance in-force covering all of your covered "auto", we will pay your additional legal "employees". obligation for any difference between the actual Coverage is excess over any other collectible cash value of the "auto" at the time of the "loss" insurance. and the"outstanding balance"of the loan/lease. 4. HIRED AUTO PHYSICAL DAMAGE COVERAGE "Outstanding balance" means the amount you If hired "autos" are covered "autos" for Liability owe on the loan/lease at the time of "loss" less Coverage and if Comprehensive, Specified any amounts representing taxes; overdue Causes of Loss, or Collision coverages are payments; penalties, interest or charges provided under this Coverage Form for any resulting from overdue payments; additional "auto" you own, then the Physical Damage mileage charges; excess wear and tear charges; Coverages provided are extended to "autos"you lease termination fees; security deposits not hire or borrow, subject to the following limit. returned by the lessor; costs for extended warranties, credit life Insurance, health, accident The most we will pay for "loss" to any hired or disability insurance purchased with the loan or "auto" is: lease; and carry-over balances from previous (1) $100,000; loans or leases. (2) The actual cash value of the damaged or 7. AIRBAG COVERAGE stolen property at the time of the"loss"; or Under Paragraph B. EXCLUSIONS - of (3) The cost of repairing or replacing the SECTION III - PHYSICAL DAMAGE damaged or stolen property, COVERAGE, the following is added: whichever is smallest, minus a deductible. The The exclusion relating to mechanical breakdown deductible will be equal to the largest deductible does not apply to the accidental discharge of an applicable to any owned "auto" for that airbag. coverage. No deductible applies to"loss"caused g, ELECTRONIC EQUIPMENT - BROADENED by fire or lightning. Hired Auto Physical Damage COVERAGE coverage is excess over any other collectible insurance. Subject to the above limit, deductible a. The exceptions to Paragraphs B.4 - and excess provisions, we will provide coverage EXCLUSIONS - of SECTION III - PHYSICAL equal to the broadest coverage applicable to any DAMAGE COVERAGE are replaced by the covered"auto"you own. following: We will also cover loss of use of the hired "auto" Exclusions 4.c. and 4.d. do not apply to if it results from an "accident", you are legally equipment designed to be operated solely liable and the lessor incurs an actual financial by use of the power from the "auto's" loss, subject to a maximum of $1000 per electrical system that, at the time of"loss", "accident". is: This extension of coverage does not apply to (1) Permanently installed in or upon any "auto" you hire or borrow from any of your the covered"auto'; "employees", partners (if you are a partnership), (2) Removable from a housing unit members (if you are a limited liability company), which is permanently installed in or members of their households. or upon the covered"auto"; (3) An integral part of the same unit housing any electronic equipment described a in Paragraphs(1)and (2)above; or ©2011, The Hartford (Includes copyrighted material Form HA 99 16 03 12 of ISO Properties, Inc.,with its permission.) Page 3 of 5 (4) Necessary for the normal If another Hartford Financial Services Group, operation of the covered"auto"or Inc. company policy or coverage form that is not the monitoring of the covered an automobile policy or coverage form applies to "auto's"operating system. the same"accident", the following applies: b.Section III — Version CA 00 01 03 10 of the (1) If the deductible under this Business Auto Business Auto Coverage Form, Physical Coverage Form is the smaller (or smallest) Damage Coverage, Limit of Insurance, deductible, it will be waived; Paragraph C.2 and Version CA 00 01 10 01 of (2) If the deductible under this Business Auto the Business Auto Coverage Form, Physical Coverage Form is not the smaller (or Damage Coverage, Limit of Insurance, smallest) deductible, it will be reduced' by Paragraph C are each amended to add the the amount of the smaller (or smallest) following: deductible. $1,500 is the most we will pay for"loss" in 12. AMENDED DUTIES IN THE EVENT OF any one "accident" to all electronic ACCIDENT, CLAIM,SUIT OR LOSS equipment(other than equipment designed solely for the reproduction of sound, and The requirement in LOSS CONDITIONS 2.a. - a DUTIES IN THE EVENT OF ACCIDENT,CLAIM, accessories used with such equipment) SUIT OR LOSS - of SECTION IV - BUSINESS that reproduces, receives or transmits AUTO CONDITIONS that you must notify us of audio, visual or data signals which, at the time of"loss", is: an "accident" applies only when the"accident" is known to: (1) Permanently installed in or upon the covered "auto" in a housing, (1) You, if you are an individual; opening or other location that is not (2) A partner, if you are a partnership; normally used by the "auto" (3) A member, if you are a limited liability manufacturer for the installation of company; or such equipment; (4) An executive officer or insurance manager, if (2) Removable from a permanently you are a corporation. installed housing unit as described 13. UNINTENTIONAL FAILURE TO DISCLOSE in Paragraph 2.a. above or is an HAZARDS integral part of that equipment; or (3)An integral part of such equipment. If you unintentionally fail to disclose any hazards existing at the inception date of your policy, we c.For each covered "auto", should loss be limited will not deny coverage under this Coverage to electronic equipment only, our obligation to Form because of such failure. pay for, repair, return or replace damaged or 14. HIRED AUTO -COVERAGE TERRITORY stolen electronic equipment will be reduced.by the applicable deductible shown in the Paragraph e. of GENERAL CONDITIONS 7. - Declarations, or $250, whichever deductible is POLICY PERIOD, COVERAGE TERRITORY - less. of SECTION IV - BUSINESS AUTO 9. EXTRA EXPENSE - BROADENED CONDITIONS is replaced by the following: COVERAGE e. For short-term hired "autos", the coverage Under Paragraph A. -COVERAGE-of SECTION territory with respect to Liability Coverage is III - PHYSICAL DAMAGE COVERAGE, we will anywhere in the world provided that if the pay for the expense of returning a stolen covered "insured's" responsibility to pay damages for "bodily injury" or "property damage" is "auto"to you. determined in a "suit,"the"suit" is brought in 10. GLASS REPAIR-WAIVER OF DEDUCTIBLE the United States of America, the territories Under Paragraph D.-DEDUCTIBLE-of SECTION and possessions of the United States of III - PHYSICAL DAMAGE COVERAGE, the America, Puerto Rico or Canada or in a following is added: settlement we agree to. No deductible applies to glass damage if the 15. WAIVER OF SUBROGATION glass is repaired rather than replaced. TRANSFER OF RIGHTS OF RECOVERY 11. TWO OR MORE DEDUCTIBLES AGAINST OTHERS TO US - of SECTION IV - Under Paragraph D.-DEDUCTIBLE-of SECTION BUSINESS AUTO CONDITIONS is amended by III - PHYSICAL DAMAGE COVERAGE, the adding the following: following is added: ©2011, The Hartford (Includes copyrighted material Form HA 99 16 03 12 of ISO Properties, Inc.,with its permission.) Page 4 of 5 We waive any right of recovery we may have c.Regardless of the number of autos deemed a against any person or organization with whom total loss, the most we will pay under this you have a written contract that requires such Hybrid, Electric, or Natural Gas Vehicle waiver because of payments we make for Payment Coverage provision for any one damages under this Coverage Form. "loss" is $10,000. 16. RESULTANT MENTAL ANGUISH COVERAGE For the purposes of the coverage provision, The definition of "bodily injury in SECTION V- a.A "non-hybrid" auto is defined as an auto that DEFINITIONS is replaced by the following: uses only an internal combustion engine to "Bodily injury" means bodily injury, sickness or move the auto but does not include autos disease sustained by any person, including powered solely by electricity or natural gas. mental anguish or death resulting from any of b.A "hybrid" auto is defined as an auto with an these. internal combustion engine and one or more 17. EXTENDED CANCELLATION CONDITION electric motors; and that uses the internal Paragraph 2. of the COMMON POLICY combustion engine and one or more electric CONDITIONS - CANCELLATION - applies motors to move the auto, or the internal combustion engine to charge one or more except as follows: electric motors,which move the auto. If we cancel for any reason other than 19. VEHICLE WRAP COVERAGE nonpayment of premium, we will mail or deliver to the first Named Insured written notice of In the event of a total loss to an "auto"for which cancellation at least 60 days before the effective Comprehensive, Specified Causes of Loss, or date of cancellation. Collision coverages are provided under this 18. HYBRID, ELECTRIC, OR NATURAL GAS Coverage Form, then such Physical Damage VEHICLE PAYMENT COVERAGE Coverages are amended to add the following: In addition to the actual cash value of the "auto", In the event of a total loss to a "non-hybrid" auto we will pay up to $1,000 for vinyl vehicle wraps for which Comprehensive, Specified Causes of which are displayed on the covered "auto" at the Loss, or Collision coverages are provided under time of total loss. Regardless of the number of this Coverage Form, then such Physical autos deemed a total loss, the most we will pay Damage Coverages are amended as follows: under this Vehicle Wrap Coverage provision for a.lf the auto is replaced with a "hybrid" auto or any one "loss" is $5,000. For purposes of this an auto powered solely by electricity or natural coverage provision, signs or other graphics gas, we will pay an additional 10%, to a painted or magnetically affixed to the vehicle are maximum of$2,500, of the "non-hybrid" auto's not considered vehicle wraps. actual cash value or replacement cost, whichever is less, b.The auto must be replaced and a copy of a bill of sale or new lease agreement received by us within 60 calendar days of the date of"loss," ©2011, The Hartford (Includes copyrighted material Form HA 99 16 0312 of ISO Properties, Inc., with its permission.) Page 5 of 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 03 13 C (Ed. 7-09) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT — CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this ( agreement from us.) I You must maintain payroll records accurately segregating the remuneration of your employees while _$ engaged in the work described in the Schedule. The additional premium for this endorsement shall be $ 500 Schedule Any person or organization that you perform work for that is liable for an injury, covered by this policy,that prior to the injury has written contract requiring a waiver of our right to recover from them. Person or Organization Job Description P r E I } i I kd t i 1 This endorsement changes the policy to which It is attached and is effective on the date Issued unless otherwise stated. (The Information below Is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Insurance Company Countersigned by, WC990313C (Ed. 7-09) PCEASE POST IN A GONSPtCIIOUS PLACE NOT TRANSFERABLE BUSINESS :,LICENSE,; '11YaOP AfVfPBEIt, h r (408j 866 2174 ESTABLISHED: 04/14l201�.1 EXP DATE 03131t2020 �_ LIC,ENSE.NO ,026217 . LOCATION: 901 BROWN RD ` z z 7t{ 5 a :EREMONT CA 94539, t3 ; ,/ BUSINESS: LANDSERVICES LANDSCAP,1EZ—NTRS I TYPE' BUSINESS OWNER:'. DEAN;RITCFiIE rxi fr s ',CONT,4RACTORSPECIALTRADE-b. a TOWN z�fix, of The;person;firm,or.co oration named above r granted tf ishbusine`ss license.pursuant to the,provisrons of the City'Business License Ordinances to e`ngag�,carry on or conduct theQs6ss trade,calling,profession;exhibition or occupation•described above. Issuance of,the license is not an,endorsement,nor certification of compiiance.with other ordinances or laws;nor an'assurance that-the .proposed use is in"conformance with'the,city,zoning regulations :This licejise is;issued without Verification that the licensee is subject to or exempt from the licensing.by.the State of Cahforma. Valid o ywjthirl the,City.of Campbell city.limits. CITY MUST BE NOTIFIED ON ANY CHANGE`IN•OWNERSHIP,LOCATION,OR CLOSURE. ANNUAL TAX PAYMENT DUE ON OR BEFORE THE EXPIRATION DATE.RENEWAL NOTICE.NOT REQUIRED. . INSURANCE REQUIREMENTS CHECKLIST yZ Permit# �i ��^O� CIP Project# Consultant/Contractor: Lo The following insurance is required of all consultants/contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits ommercial General Liability for bodily, personal injury and property damage: ❑ $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or a $2,000,000 general aggregate limit. j❑ Policy expiration date 7`Auutomotive Liability: h- "Any Auto" checked on certificate per accident for bodily injury and property damage �P$11,000,000 olicy expiration date Workers' Compensation and Employer's Liability ❑ Waiver of Subrogation clause Q �� —$1,000,000 per accident for bodily injury or disease ❑ Policy expiration date Course of Construction if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liabilit licies Additional Insured Endorsement: (� ❑The City, its officers, employees and volunteers are narhed as additional insured. / (Reference Project Location/Permit Number)g-- The insurance coverage afforded to the Additional Insured is primary insurance. a Cancellation area should say: Should any of the above described policies be cancelled before the expiration date thereof,notice will ® be delivered in accordance with the policy provisions. Workers' Compensation Insurance Sheet Submitted For General Contractor ❑ For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Revlan 2018) Page 1 Acceptability of Insurer(s) o Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: NAIC# Rating: V � Authorized in CA: �f Namep..�t�J �1� � NAIC# j Rating: \ Authorized in CA: f Name: NAIC# Rating: Authorized in CA: Name: NAIC# Rating: Authorized in CA: bell Business License# �Z� ?�`� Expiration: �'�.C�tr p p /� _ z� ❑ Contractors License # Class2 Expiration: Insurance Certificate Reviewed V'5 nitia ate Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 JoAnna Thomason From: Roger Storz Sent: Tuesday, May 14, 2019 8:02 AM To: 'Jonel Porta';JoAnna Thomason Subject: RE: Encroachment Permit application and COIs Hi Jonel, If you do work within the City of Campbell you are required to have a City Business License. It is a pretty standard thing among cities. Regards, Roger -----Original Message----- From:Jonel Porta [mailto:iporta@fourcornersproperties.com] Sent: Monday, May 13, 2019 6:31 PM To:JoAnna Thomason Cc: Roger Storz Subject: Re: Encroachment Permit application and COls WARNING:This email originated from an external sender! Thank you for the email. I'll work on the insurance languag I business license?Their businesses are not located in the City of Campbell... Sent from my iPhone >On May 13, 2019, at 5:30 PM,JoAnna Thomason <'o� ann > Hi Roger, I reviewed the insurances for the three subs. >They all need Subrogation Waivers for their Worker's Comp,The >Certificate Holder on all three certificates should be The City of >Campbell,70 N. First St., Campbell, CA 95008 They all need a City of >Campbell Business License >The wording for Land Services Landscape Contractors needs to include the wording underlined on the sample attached. >Other than that,they are good to go regarding insurance and licenses. >Thanks >JoAnna >JoAnna Thomason >Office Specialist >City of Campbell Public Works Department >70 N. First Street Campbell, CA 95008 www.citVofcampbell.com 1