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ENC2017-00253 oV C94a A. ' A�� "o r CJ ID °R CHAV'D CITY of CAMPBELL Public Works Department June 14, 2019 Dome Construction Corp. 393 E. Grand Ave. So. San Francisco, CA 94080 SUBJECT: PERMIT NO. ENC 2017-00253 295 E. Hamilton Ave.. Campbell, CA FINAL INSPECTION AND ACCEPTANCE To Whom It May Concern: The City of Campbell has made a final inspection of subject Public Works improvements and finds the work to be acceptable and in conformance with City standards. Accordingly,the City Engineer accepts the improvements. The Remaining 25% of your Faithful Security Performance Deposit in the amount of $1,250.00 is enclosed. If you have any questions, please call me at (408) 866-2165. Sincerely, Syed Wahidi Public Works Inspector Cc: Permit File ENC2017-00253 70 North First Street • Campbell, California 95008 TEL 408.866.2150 • FAX 408.376.0958 TDD 408.866.2790 ........................ ............ ......... ............................... ........................... .............. :.........................I.........,.....: ..................... ..................... ...................................... ........................................... ................................ ................................... CITY OF CAMPBELL VENDOR NO. 10014944 CHECK NO. 273738 Accoimt Purchase Order::. khount:101 2203 CRO53119 1,250.00 FPS REFUND 10014944 DOME CONSTRUCTION III DID CHECK DATE CHECK NO. -.::OF:CAMPBELL -24 CIT:Y Wgl;tg FARGO BANK, N.A. 7.0'NbRTH FIRST STREET 42C[,*MONTGOMERY STREET OG110119 273738 S.A I N.FRANCISCO, CA 94104 1210 CAMPBELL.CALIFORNIA 95008, 0 0 AMOUNT "***1, 280 . 00* 0 VOID AFTER 90 DAYS -n PAY THE SUM OF ONE THOUSAND, TWO HUNDRED FIFTY DOLLARS & ZERO . 03 CENTS TO THE DOME -CONSTRUCTION 2 ORDER 393 E GRAND AVE S SAN FRANCISCO CA 94080. 2 7 3 ? 1811m 1: 12 1000 2 8 1: li 1 2 18 5 S I S[in .... ............. ...................................... ................................ ............................ .............. ....................................... ..................... ........................ ........................................ .......... *See Reverse Side For Easy Opening Instructions* CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 DOME CONSTRUCTION 393 E GRAND AVE S SAN FRANCISCO CA 94080 . , i a Refund'bJe 'Deposit Check Request To Finance Director 3� Check Payable To Dome Construction'Corp ; 1 . Address . ine 1,. :393 E: Grand Ave. j - - 1 City .-San Francisco State:.CA Zip:'94080 } Description' 295�E. Hamilton Ave _ AccouneNumber `101.2203, - Amount $1,250:00 { Account Number 101.2203. Amount i (" -Account Number. 101.540 7448 Amount l I . f (Finance Dept only) Interest Earned'. (Finance•Deptonly), -Total Payable: (ExactAmount), ' 1 - •- f• Purpose: 25% Remaining .FPS Refund , Permit#:.' ENC2017-00253` Receipt#: 272102 Date: 90127/20.17 Receipt#: Date: . i P ! Requested 6y: Title inspector. : bate., i Sye-d Wahidi" . = _ I Approved by: Title Sr.Engineer`' Date: S � Roger Storz' Finance Dept'Only:`, Verified:by: Title' Accounting Clerk II Date: Approved by: title: Accountant Date: _ S`Dean- Instructions . For Ha:ndlin Check hnai1 As is: - 4iiil'in'Attaclied Envelope:. _ Interim L;neck:` wl Need d'By _ Return To:' JoAn'na Thomason Public Works , j (Name) . (Department)" ,Oth`er: Please return check to JoAnna CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR ONE YEAR MAINTENANCE ACCEPTANCE LETTER Encroachment Permit # ENC2017-00253 Property Address 295. E. Hamilton Ave tt Date of Final Inspection: Zl On File: Bonds CD Cash Faithful Performance: $1,250.00 (Remaining 25%) Labor and Material $ Construction Cash Deposit to be released: $ Other overdue deposits to be released (Description): Processed by: /-30 C/ A f inistrator / 1 Reviewed by: Inspector Reviewed by: pys -c,- s, q Land Development Engineer 1 .I:UoAnnaT\Deposit refunds\CHECKLISTS\2 Checklist-I yr Maint.Acceptance.doe(Rev. 10/11) Alp. Encroachment Permit Final Sign Off Encroachment Permit# -- Cl7-oc2�3 Address: L-C� Date of Final Inspection and Acceptance: 9w Inspected by: OK to release deposits: 100% V 75% Comments: OF CqM U 5 7 5 E' G - •UkCHAR�• CITY of CAMPBELL Public Works Department June 11, 2018 Dome Construction Corp. 393 E. Or*and Ave. So. San Francisco, CA 94080 SUBJECT: PERMIT NO. ENC 2017-00253 295 E. Hamilton Ave.. Campbell, CA FINAL INSPECTION AND ACCEPTANCE To Whom It May Concern: The City of Campbell has made a final inspection of subject Public Works improvements and finds the work to be acceptable and in conformance with City standards. Accordingly, the City Engineer accepts the improvements. The one year maintenance period stated in the permit begins as of May 10,2018. The permittee is responsible for the repair and/or replacement of any defective work or failures that occur within one year. The City will inspect the improvements within one year and notify you, in writing, whether or not any repairs are required. 75% of your Faithful Security Performance Deposit in the amount of$3,750.00 and your Construction Cash Deposit for.$500.00 is enclosed. The City will continue to hold 25% of your.$5,000.00 Faithful Performance Surety cash deposit as your Maintenance Surety. If you have any questions, please call me at (408) 866-2165. Sincerely, Syed Wahidi Public Works Inspector Cc: Inspector/Suspense Files Permit File ENC2017-00253 70 North First Street • Campbell, California 95008-1436 TEL 408.866.2150 • FAX 408.376.0958 TDD 408.866.2790 5/22/2018 Fees Associated With 2:43:34PM - L. Case #: ENC2017-00253 Fee Start 77 P. = Trans 12evenue Cr'eafecl: ._ _ -r =r=De t Deserx taan:. T e, Date Date _r . B Date Amonnt` t Ca . �cc°nn 5 N. Due; PCI1 7/l/2017 6/30/2018 Non-Util Plan Ck/Insp<$ 101.740.4722 JT 11/1/2017 700.00 0.00 FPSD 7/1/2017 6/30/2018 F fh I Perk: eeuri =WO. 101.2203 JT 11/1/2017 w5fGFYOTO 0.00 CASH 7/1/2017 6/30/2018 nsri io.s I-1 rGp—mft 101.2203 JT 11/1/2017 1 ora 0.00 PCI1 7/1/2017 6/30/2018 Non-Util Plan Ck/Insp<$ 101..740.4722 JF 11/1/2017 425.00 0.00 Total Due: $0.00 Page 1 of 1 CaseFees..rpt DocuSign Envelope ID:FCAFDCA4-A4AC-43B3-8CA6-2D039B3535D9 Print Form 1 CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No_' GZ��'I DEPT.OFPUBLICWORKS (forworking within the public X-Ref. File L —C)Ida 70 North First Street right-of-way) Application Date 2177 . Campbell, CA 95008 Issued (� Application Expiration Date 2 Ph.(408)866-2150 APN Fx. (408)376-0958 Permit Expiration Date �r APPLICATION-Application is hereby made fora Public Works Permit in Aaccordance ith Campbell Municipal Code,Section 11.04. (Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable.) A. work Address or Tract No.: 295 E Hamilton Ave, CAMPBELL, CA 95008 ..........._____-____..____._.____._.-_.-_J Utility Trench Location: B. Nature of Work: Parking Lot Entrance Re-work for ADA_bT 1p_ 7 R1L -D- 18 I C. Attach four(4)copies of an engineered planshowingthe location and extentof thework,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 totheCityof Campbell Standard Specifications and Details for Public Works Construction;the General Permit 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 in job 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 startingwork.Notice must be given to Public Works at least 24 hours before restarting anywork. Name of Applicant: I Dome Construction Corp/Spencer Velloza _ _ Telephone: 650-416-5600 Address: 393 East Grand Ave, South San Francisco.CA 94080 E-MailAddress: lomebullds.com 24-HOUR EMERGENCY PHONE NUMBER: Is this work being done by the property owners at their own residence? ❑YES ❑ 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 improvemen PC R 5V€�t�`�eMhe public right-of-way. Accepted: Spencer Velloza pe,orti fled& `° 11/2 6/17 (Applicant Permittee) ggs1,)49132B440D... Date Dome Construction Spencer Velloza (On Behalf of Dome) 11/26/17 (Contractor) (Print Name) Date SPECIAL PROVISIONS: 1. Street shall not be open cutfor underground installations. Minimum cuts maybe allowed for connections or exploration holes.Suchcutsmaybe specifically approved by the Inspector prior to cutting. ❑ 2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method E] "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. 'S-W-ZCC_77>4� -� SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO. PERMIT APPLICATION FEE $ 00 772-10Z PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ 107 CONSTRUCTION CASH DEPOSIT $ PLAN CHECK&INSPECTION FEE $ DO -7-DZ 102 EMERGENCY PERMIT FEE $ SID0,00 -7-712-AQ APPROVED FOR ISSUANCE Ll For City Engineer Da e Permit Expires 12 Months After Date of Issuance I DocuSign Envelope ID:FCAFDCA4-A4AC-43B3-8CA6-2D03983535D9 GENERAL PERMIT CONDITIONS 1. 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. S. 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 2006 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 of State 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.gov/water issues/programs/npdes/utilitvvaults.shtml for more information. Applic nt bso�ueycfi 5XS%ponsible for ensuring that all those providing services under the applicant are aware of and abide by all of the above conditions. mw,o a 11/26/17 A .. M1149132B440D... Date: Dome Construction Spencer Velloza(On Behalf of Dome) 11/26/17 Contractor (Print Name) Date: J:\FORMS\Templates\Encroachment Perm its\Encroachment Permit STATIC form2.pdf Rev.03/17 / ........... | ` | �_-�__- �-~~---- `- �----~-^ ~--~-^ ^------- ---~--- | `- ' _-'--_ ---_- _---_'___---'-- - -----~ --- --' - �'-~ -~. / CITY CAMPBELL VENDOR NO. 10014944 cHEcnmn 268233 / `^ 10014944 DOME CONSTRUCTION +TIRST STREET' WNW 87 IT 77 *See Reverse Side For Easy Opening Instructions* CITY OF CAMPBELL 70 NORTH FIRST STREET ! DOME' CONSTRUCTION / i ` asa � asour� AVE . . ' S SAN �rRANCZGCO Cu 94080 - `\ / Encroachment Permit Final Sign Off Encroachment Permit# Pic— 2917-0G�53 Address: ► Date of Final Inspection and Acceptance: 5 AC /g Inspected by: Sky' OK to release deposits: 100% 75% V Comments: i Refundable be posit Check Re u To: Finance Director (11 Check Payable To: DOME Construction I Address- Line 1: 393 E. Grand Ave. Line 2: City: S. San Francisco State: CA Zip: 94080 l Description: 295 E. Hamilton i Account Number: 101.2203 Amount: $44250.00 i Account Number: 101:2203 Amount: i Account Number: 101.540.7448 Amount: j (Finance Dept only) Interest Earned (Finance Dept only) ff Total Payable: (Exact Amount) I Purpose 75% FPS Deposit$ CCD return Permit#: ENC2017-00253 Receipt#.: 272102 Date: 10/27/2017 j Receipt#: Date: Requested by: — ' Title: Inspector. Date: 543�1p, j Syed Wahidi Approved by: V_� Title: Sr.Engineer Date: Roger Storz - I Finance Dept Only: f Verified by: Title: Accounting Clerk 11 Date: I Approved by: Title: Accountant Date: Special Instructions For Handling Check man AS IS: Mall In Attached Envelope: interim'l:necK: Needed By: Return To: JoAnne Thomason Public Works (Name) (Department) Other Please return check to JoAnna CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2017-00253 Name: Dome Construction Property Address: 295 E. Hamilton Ave. Date of Final Inspection: On File: Bonds CD Cash Faithful Performance: $ 5,000.00'F((*7 ®/c&7 3., t—S.-G 0, j* Labor and Material: $ Construction Cash Deposit to be releasedti 'S00.00 Other overdue deposits to be released (Description): Processed by: �� .✓—� ��?iz� A inistrator Reviewed by: Inspector I Reviewed by: Land Development Engineer J:UoAnnaT\Deposit refunds\CHECKLISTS\Hamilton 295.doc(Rev. 10/11) PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1,2017 TO: Finarfce PUBLIC WORKS FILE NO. ENC2017-00253 PROPERTY ADDRESS 295 E.Hamilton Avenue Please collect&receipt for the following monies: ACCT.— ITEM AMOUNTS LAND.DEVELOPMENT a,P 4722 Encroachment Permit Application Fee Non-Utility Encroachment Permit Ma'or Z 10 000 $425.00 $425.00 Minor Encroachment Permit< io oo0 $240.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $240.00 Inspection Fee Minimum Charge per Location $420.00 Street Tree Planting/Removal N/C 2203 $500 per Tree Planting Deposit Required) 500.00/tree 22031 Plan Check Deposit 2%of Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 47221 Grading&Drainage Plan Review Single Family Lot $295.00 Site<10,000 s.f. $885.00 Site>_10,000 s.f.<0.5 Acre $1,185.00 Site>_0.5 Acre $1,772.00 4722 NPDES Review C3 Requirements) For projects not required to submit numeric sizing $175.00 For projects required to submit numeric sizing Impervious Area 10,000 S .Ft to 1 Acre $740.00 Impervious Area 1 Acre or more $965.00 4722 For oroiects sent to Consultant for review Consultant Cost+20% 4722 Additional treatment facilities 315 ea Plan Check&Inspection Fee(Non-Utility) 4722 En r.Est.<$250 000 14%of Engineer's Estimate $700.00 4722 En r.Est.z 250 000 and 5 500 000 $35,000.00+8%of Engineers Estimate 4722 En r.Est. > 500 000 $55,000.00+7%of Engineers Estimate 2203 Emergency Cash Deposit 4%of En r.Est.* $500 min/$10 000 Max $500.00 2203 Faithful Performance Security FPS 100%of ENGR.EST.* $5,000.00 2203 Labor and Materials Security 100%of ENGR.EST.* 4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00 (Multi-Res$2,385.00) All Other 2 650.00 4722 Parcel Ma 4 Lots or Less 4 200.00+ 90/lot 4722 Final Tract Ma 5 or More Lots 5 115.00+ 124/lot 2203 Monumentation Security 100%of Ci 's Monumentation Estimate 4920 Parkland Dedication Fee 75%/25%Due Upon Cert.of Occupancy) 4722 Lot Line Ad'ustment Includes Certificate of Compliance) 1 990.00 4722 Vacation of Public Streets&Easements $2,700.00 4722 Certificate of Compliance $1,970.00 4722 Certificate of Correction $590.00 4722 Document Recording Fees 15.00/first vage 3 ea.Additional 4722 Private Improvement in Public ROW $100.00 4722 A roved Plan Revision Fee 100/sheet 4722 Appeal Filing Fee $200.00 730.4924 Notice of Improvement Obligation Pa ment 4722 Assessment Segregation or Reapportionment First Split $940.00 Each Additional Lot $295.00 511.7424 Postage MISCELLANEOUS` - Other Please Specify) *Engineers Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $6,625.00 NAME OF APPLICANT 5ffjqjZK. N)rej"JA NAME OF PAYOR Dome Construction CorpPHONE1-650-416-5600 ADDRESS 393 East Grand Ave South San Francisco zip 94080 FOR RECEIVEf),":BY CITY CLERK , e ONLY 10 1:\Land Uev\Plan CMct Cam mend\1-gpeciflc Pnj—-ANve Projoa In Progress\H erelkan Ave E 29svessVe-zle . i Sa y CAMPBELL REC3 D; Ca;q .2w.& PA bDO£ CeAR2q TODAVS GR: 1+3d? REGISTER DATE: ice 27d7 TIME: d.w DESCRIPTION AMOUNT CWTINEK2017AGM3 ERR agAD FILMS , 22 00 0 EMT D: Rmo ERR & mGD FILING SO.ao qe D: bore RE RESIT - !S !SG m OUST 3:295E +SEA! AVE . RE +mgl - S1 b.mG m TOTAL DUE: SS,62300 TENDERED: 16,625.00 < CHAR: «m CHECK $6,625.00 REF mw 13427 ' ® DATE(MM/DD/YYYY) A Ro CERTIFICATE OF LIABILITY INSURANCE F,0/25/2017 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 terns 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 endorsements . PRODUCER CONTACT NAME: Arthur J.Gallagher&Co. PHONE IFAX Insurance Brokers of CA, Inc. LIC#0726293 E-MAIL One Almaden Boulevard, Suite 960 San Jose CA 95113 INSURERS AFFORDING COVERAGE NAIC# INSURER A:Hartford Fire Insurance Com an -4, 19682 INSURED J INSURERB:Sentinel Insurance Company Lt 11000 Dome Construction Corporation INSURER C 393 East Grand Avenue South San Francisco, CA 94080 INSURERD: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:833207936 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 ADDLISUBR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MMIDD MMIDD A X COMMERCIAL GENERAL LIABILITY Y Y 83UENOD1172 1/1/2017 1/1/2018 EACH OCCURRENCE $1,000,000 DA 3E To RENTED CLAIMS-MADE �X OCCUR PREM SES Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY�JECT 7 LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY Y Y 83UENOD1173 1/1/2017 1/1/2018 Ea aaGden SINGLE LIMIT $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE X AUTOS ONLY X AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION Y 83WEOD1171 1/1/2017 1/1/2018 X STATUTE ETH AND EMPLOYERS'LIABILITY Y/Nl/ ANY PROPRIETORIPARTNER/EXECUTIVE — 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,maybe attached If more space Is required) RE:Job#170317;Stanford Blood Center(Precon), Project Location:295 E. Hamilton Ave., Campbell, CA 95008, Permit No.:TBD All work in the public right-of-way. Additional Insured and Waiver of Subrogation(where required by written contract, per attached forms): City of Campbell, its officers, employees and volunteers are named as additional insured.The Insurance coverage afforded to the Additional Insured is primary. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Campbell THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 70 N.First St. ACCORDANCE WITH THE POLICY PROVISIONS. Campbell CA 95008 AUTHORIZED REPRESENTATIVE ice CdAy . ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ex ce VU -0 � - W Policy No.:83UENOD1172 Policy Term: 01101/2017 to 01/01/2018 have all your rights and duties under this Coverage 5. Nonowned Watercraft Part. With respect to watercraft you do not own that is less e. Unnamed Subsidiary than 51 feet long and is not being used to carry Any subsidiary, and subsidiary thereof, of yours persons for a charge, any person is an insured while which is a legally incorporated entity of which you operating such watercraft with your permission. Any own a financial interest of more than 50% of the other person or organization responsible for the voting stock on the effective date of the Coverage conduct of such person is also an insured, but only Part with respect to liability arising out of the operation of the watercraft, and only if no other insurance of any The insurance afforded herein for any subsidiary not named in this Coverage Part as a named kind is available to that person or organization for this liability. insured does not apply to injury or damage with respect to which an insured under this Coverage However, no person or organization is an insured with Part is also an insured under another policy or respect to: would be an insured under such policy but for its a. "Bodily injury" to a co-"employee" of the person termination or the exhaustion of its limits of operating the watercraft; or insurance. b. "Property damage"to property owned by, rented to, 3. Newly Acquired or Formed Organization in the charge of or occupied by you or the employer Any organization you newly acquire or form, other than of any person who is an insured under this a partnership, joint venture or limited liability company, provision. and over which you maintain financial interest of more -K6. Additional Insureds When Required By Written than 50% of the voting stock, will qualify as a Named Contract, Written Agreement Or Permit Insured if there is no other similar insurance available The following person(s) or organization(s) are an to that organization. However: additional insured when you have agreed, in a written a. Coverage under this provision is afforded only until contract, written agreement or because of a permit the 180th day after you acquire or form the issued by a state or political subdivision, that such organization or the end of the policy period, person or organization be added as an additional whichever is earlier; insured on your policy, provided the injury or damage b. Coverage A does not apply to "bodily injury" or occurs subsequent to the execution of the contract or "property damage" that occurred before you agreement. acquired or formed the organization; and A person or organization is an additional insured under c. Coverage B does not apply to "personal and this provision only for that period of time required by advertising injury" arising out of an offense the contract or agreement. committed before you acquired or formed the However, no such person or organization is an insured organization. under this provision if such person or organization is 4. Mobile Equipment included as an insured by an endorsement issued by With respect to mobile equipment registered in your us and made a part of this Coverage Part. name under any motor vehicle registration law, any a. Vendors person is an insured while driving such equipment Any person(s) or organization(s) (referred to below along a public highway with your permission.Any other as vendor), but only with respect to "bodily injury" person or organization responsible for the conduct of or "property damage" arising out of"your products" such person is also an insured, but only with respect to which are distributed or sold in the regular course liability arising out of the operation of the equipment, of the vendor's business and only if this Coverage and only if no other insurance of any kind is available Part provides coverage for "bodily injury" or to that person or organization for this liability. However, "property damage" included within the "products- no person or organization is an insured with respect to: completed operations hazard". a. 'Bodily injury" to a co-"employee" of the person (1) The insurance afforded the vendor is subject to driving the equipment; or the following additional exclusions: b. 'Property damage"to property owned by, rented to, This insurance does not apply to: in the charge of or occupied by you or the employer (a) 'Bodily injury" or "property damage" for of any person who is an insured under this which the vendor is obligated to pay provision. damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; Page 10 of 18 HG 00 01 06 05 (b) Any express warranty unauthorized by you; c. Lessors of Land or Premises (c) Any physical or chemical change in the Any person or organization from whom you lease product made intentionally by the vendor; land or premises, but only with respect to liability (d) Repackaging, except when unpacked solely arising out of the ownership, maintenance or use of for the purpose of inspection, demonstration, that part of the land or premises leased to you. testing, or the substitution of parts under With respect to the insurance afforded these instructions from the manufacturer, and then additional insureds the following additional repackaged in the original container; exclusions apply: (e) Any failure to make such inspections, This insurance does not apply to: adjustments, tests or servicing as the vendor 1. Any "occurrence" which takes place after you has agreed to make or normally undertakes cease to lease that land; or to make in the usual course of business, in connection with the distribution or sale of the 2. Structural alterations, new construction or products; demolition operations performed by or on behalf of such person or organization. (f) Demonstration, installation, servicing or d. Architects, Engineers or Surveyors repair operations, except such operations performed at the vendor's premises in Any architect, engineer, or surveyor, but only with connection with the sale of the product; respect to liability for "bodily injury", "property (g) Products which, after distribution or sale by damage" or "personal and advertising injury" you, have been labeled or relabeled or used caused, in whole or in part, by your acts or as a container, part or ingredient of any omissions or the acts or omissions of those acting other thing or substance by or for the on your behalf: vendor; or (1) In connection with your premises; or (h) 'Bodily injury" or "property damage" arising (2) In the performance of your ongoing operations out of the sole negligence of the vendor for performed by you or on your behalf. its own acts or omissions or those of its With respect to the insurance afforded these employees or anyone else acting on its additional insureds, the following additional behalf. However, this exclusion does not exclusion applies: apply to: This insurance does not apply to "bodily injury", (i)The exceptions contained in Sub- "property damage" or "personal and advertising paragraphs(d) or(f); or injury" arising out of the rendering of or the failure (ii) Such inspections, adjustments, tests or to render any professional services by or for you, servicing as the vendor has agreed to including: make or normally undertakes to make in 1. The preparing, approving, or failing to prepare the usual course of business, in or approve, maps, shop drawings, opinions, connection with the distribution or sale of reports, surveys, field orders, change orders or the products. drawings and specifications; or (2) This insurance does not apply to any insured 2. Supervisory, inspection, architectural or person or organization, from whom you have engineering activities. acquired such products, or any ingredient, part e. Permits Issued By State Or Political or container, entering into, accompanying or Subdivisions containing such products. b. Lessors of Equipment Any state or political subdivision, but only with respect to operations performed by you or on your (1) Any person or organization from whom you behalf for which the state or political subdivision lease equipment; but only with respect to their has issued a permit. liability for bodily injury", property damage or With respect to the insurance afforded these "personal and advertising injury" caused, in additional insureds, this insurance does not apply whole or in part, by your maintenance, operation or use of equipment leased to you by such to: person or organization. (1) "Bodily injury", "property damage" or "personal (2 to the and advertising injury" arising out of operations ) With respect e insurance afforded to these additional insureds this insurance does not performed for the state or municipality; or apply to any "occurrence" which takes place (2) 'Bodily injury" or "property damage" included after the equipment lease expires. within the "products-completed operations hazard". HG 00 0106 05 Page 11 of 18 f. Any Other Party c. Persons or organizations making claims or bringing Any other person or organization who is not an "suits". insured under Paragraphs a. through e. above, but 2. General Aggregate Limit only with respect to liability for "bodily injury", The General Aggregate Limit is the most we will pay "property damage" or "personal and advertising for the sum of: injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting a. Medical expenses under Coverage C; on your behalf: b. Damages under Coverage A, except damages (1) In the performance of your ongoing operations; because of "bodily injury" or "property damage" (2) In connection with your premises owned by or included in the "products-completed operations rented to you; or hazard"; and (3) In connection with "your work" and included c. Damages under Coverage B. within the "products-completed operations 3. Products-Completed Operations Aggregate Limit hazard", but only if The Products-Completed Operations Aggregate Limit (a) The written contract or agreement requires is the most we will pay under Coverage A for damages you to provide such coverage to such because of "bodily injury" and "property damage" additional insured; and included in the "products-completed operations (b) This Coverage Part provides coverage for hazard". "bodily injury" or "property damage" included 4. Personal and Advertising Injury Limit within the "products-completed operations Subject to 2. above, the Personal and Advertising hazard". Injury Limit is the most we will pay under Coverage B With respect to the insurance afforded to these for the sum of all damages because of all "personal additional insureds, this insurance does not apply and advertising injury" sustained by any one person or to: organization. 'Bodily injury", "property damage" or "personal and 5. Each Occurrence Limit advertising injury" arising out of the rendering of, or Subject to 2. or 3. above, whichever applies, the Each the failure to render, any professional architectural, Occurrence Limit is the most we will pay for the sum engineering or surveying services, including: of: (1) The preparing, approving, or failing to prepare a. Damages under Coverage A; and or approve, maps, shop drawings, opinions, b. Medical expenses under Coverage C reports, surveys, field orders, change orders or because of all "bodily injury" and "property damage" drawings and specifications; or arising out of any one"occurrence". (2) Supervisory, inspection, architectural or engineering activities. 6. Damage To Premises Rented To YouLimit The limits of insurance that apply to additional insureds Subject to 5. above, the Damage To Premises Rented under this provision is described in Section III —Limits To You Limit is the most we will pay under Coverage A Of Insurance. for damages because of"property damage"to any one How this insurance applies when other insurance is premises, while rented to you, or in the case ofdamage by fire, lightning or explosion, while rented to available to the additional insured is described in the you or temporarily occupied by you with permission of Other Insurance Condition in Section 1V— Commercial the owner. General Liability Conditions. In the case of damage by fire, lightning or explosion, No person or organization is an insured with respect to the the Damage to Premises Rented To You Limit applies conduct of any current or past partnership,joint venture or to all damage proximately caused by the same event, limited liability company that is not shown as a Named whether such damage results from fire, lightning or Insured in the Declarations. explosion or any combination of these. SECTION 111 —LIMITS OF INSURANCE 7. Medical Expense Limit 1. The Most We will Pay Subject to 5. above, the Medical Expense Limit is the The Limits of Insurance shown in the Declarations and most we will pay under Coverage C for all medical the rules below fix the most we will pay regardless of expenses because of "bodily injury" sustained by any the number of: one person. a. Insureds; 8, How Limits Apply To Additional Insureds b. Claims made or"suits"brought; or If you have agreed in a written contract or written agreement that another person or organization be Page 12 of 18 HG 00 0106 05 added as an additional insured on your policy, the (3) Cooperate with us in the investigation or most we will pay on behalf of such additional insured is settlement of the claim or defense against the the lesser of: "suit"; and a. The limits of insurance specified in the written (4) Assist us, upon our request, in the enforcement of contract or written agreement;or any right against any person or organization which b. The Limits of Insurance shown in the Declarations. may be liable to the insured because of injury or Such amount shall be a part of and not in addition to damage to which this insurance may also apply. Limits of Insurance shown in the Declarations and d. Obligations At The Insureds Own Cost described in this Section. No insured will, except at that insured's own cost, The Limits of Insurance of this Coverage Part apply voluntarily make a payment, assume any separately to each consecutive annual period and to any obligation, or incur any expense, other than for first remaining period of less than 12 months, starting with the aid, without our consent. beginning of the policy period shown in the Declarations, e. Additional Insureds Other Insurance unless the policy period is extended after issuance for an If we cover a claim or "suit" under this Coverage additional period of less than 12 months. In that case, the Part that may also be covered by other insurance additional period will be deemed part of the last preceding available to an additional insured, such additional period for purposes of determining the Limits of Insurance. insured must submit such claim or "suit" to the SECTION IV — COMMERCIAL GENERAL LIABILITY other insurer for defense and indemnity. CONDITIONS However, this provision does not apply to the 1. Bankruptcy extent that you have agreed in a written contract or Bankruptcy or insolvency of the insured or of the written agreement that this insurance is primary insured's estate will not relieve us of our obligations and non-contributory with the additional insured's under this Coverage Part. own insurance. 2. Duties In The Event Of Occurrence, Offense, Claim f. Knowledge Of An Occurrence, Offense, Claim Or Suit Or Suit a. Notice Of Occurrence Or Offense Paragraphs a. and b. apply to you or to any You or any additional insured must see to it that we additional insured only when such "occurrence", offense, claim or"suit"is known to: are notified as soon as practicable of an "occurrence" or an offense which may result in a (1) You or any additional insured that is an claim.To the extent possible, notice should include: individual; (1) How, when and where the "occurrence" or (2) Any partner, if you or an additional insured is a offense took place; partnership; (2) The names and addresses of any injured (3) Any manager, if you or an additional insured is a persons and witnesses; and limited liability company; (3) The nature and location of any injury or damage (4) Any "executive officer" or insurance manager, if arising out of the"occurrence"or offense. you or an additional insured is a corporation; b. Notice Of Claim (5) Any trustee, if you or an additional insured is a If a claim is made or "suit" is brought against any trust; or insured, you or any additional insured must: (6) Any elected or appointed official, if you or an (1) Immediately record the specifics of the claim or additional insured is a political subdivision or "suit"and the date received; and public entity. This duty applies separately to you and any additional (2) Notify us as soon as practicable. insured. You or any additional insured must see to it that we 3. Legal Action Against Us receive written notice of the claim or suit' as soon as practicable. No person or organization has a right under this c. Assistance And Cooperation Of The Insured Coverage Part: You and any other involved insured must: a. To join us as a party or otherwise bring us into a "suit"asking for damages from an insured; or (1) Immediately send us copies of any demands, b. To sue us on this Coverage Part unless all of its notices, summonses or legal papers received in connection with the claim or"suit' terms have been fully complied with. (2) Authorize us to obtain records and other A person or organization may sue us to recover on an agreed settlement or on a final judgment against an information; insured; but we will not be liable for damages that are not payable under the terms of this Coverage Part or HG 00 0106 05 Page 13 of 18 that are in excess of the applicable limit of insurance. (7) When You Add Others As An Additional An agreed settlement means a settlement and release Insured To This Insurance of liability signed by us,the insured and the claimant or Any other insurance available to an additional the claimant's legal representative. insured. 4. Other Insurance However, the following provisions apply to other If other valid and collectible insurance is available to insurance available to any person or the insured for a loss we cover under Coverages A or organization who is an additional insured under B of this Coverage Part, our obligations are limited as this coverage part. follows: (a) Primary Insurance When Required By a. Primary Insurance Contract This insurance is primary except when b. below This insurance is primary if you have agreed applies. If other insurance is also primary, we will in a written contract or written agreement share with all that other insurance by the method that this insurance be primary. If other described in c, below. insurance is also primary, we will share with b. Excess Insurance all that other insurance by the method described in c.below. This insurance is excess over any of the other insurance, whether primary, excess, contingent or (b) Primary And Non-Contributory To Other on any other basis: Insurance When Required By Contract (1) Your Work If you have agreed in a written contract, written agreement, or permit that this That is Fire, Extended Coverage, Builder's Risk, insurance is primary and non-contributory Installation Risk or similar coverage for "your with the additional insured's own insurance, work"; this insurance is primary and we will not (2) Premises Rented To You seek contribution from that other insurance. That is fire, lightning or explosion insurance for Paragraphs (a) and (b) do not apply to other premises rented to you or temporarily occupied insurance to which the additional insured has by you with permission of the owner; been added as an additional insured. (3) Tenant Liability When this insurance is excess, we will have no That is insurance purchased by you to cover duty under Coverages A or B to defend the insured your liability as a tenant for "property damage" against any "suit" if any other insurer has a duty to to premises rented to you or temporarily defend the insured against that "suit'. If no other occupied by you with permission of the owner; insurer defends, we will undertake to do so, but we (4) Aircraft, Auto Or Watercraft will be entitled to the insured's rights against all those other insurers. If the loss arises out of the maintenance or use When this insurance is excess over other of aircraft, "autos" or watercraft to the extent not insurance, we will pay only our share of the amount subject to Exclusion g. of Section I —Coverage of the loss, if any,that exceeds the sum of: A—Bodily Injury And Property Damage Liability; (5) Property Damage to Borrowed Equipment or (1) The total amount that all such other insurance Use Of Elevators would pay for the loss in the absence of this insurance; and If the loss arises out of "property damage" to (2) The total of all deductible and self-insured borrowed equipment or the use of elevators to amounts under all that other insurance. the extent not subject to Exclusion j. of Section I - Coverage A - Bodily Injury And Property We will share the remaining loss, if any, with any Damage Liability; other insurance that is not described in this Excess Insurance provision and was not bought specifically (6} When You Are Added As An Additional to apply in excess of the Limits of Insurance shown Insured To Other Insurance in the Declarations of this Coverage Part. Any other insurance available to you covering c. Method Of Sharing liability for damages arising out of the premises or operations, or products and completed If all of the other insurance permits contribution by operations, for which you have been added as equal shares, we will follow this method also. Under an additional insured by that insurance; or this approach each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. Page 14 of 18 HG 00 0106 05 If -any of the other insurance does not permit insured will bring "suit" or transfer those rights to us contribution by equal shares, we will contribute by and help us enforce them. limits. Under this method, each insurer's share is b. Waiver Of Rights Of Recovery (Waiver Of based on the ratio of its applicable limit of Subrogation) insurance to the total applicable limits of insurance of all insurers. If the insured has waived any rights of recovery 5. Premium Audit against any person or organization for all or part of any payment, including Supplementary Payments, a. We will compute all premiums for this Coverage we have made under this Coverage Part, we also Part in accordance with our rules and rates. waive that right, provided the insured waived their b. Premium shown in this Coverage Part as advance rights of recovery against such person or premium is a deposit premium only. At the close of organization in a contract, agreement or permit that each audit period we will compute the earned was executed prior to the injury or damage. premium for that period and send notice to the first 9. When We Do Not Renew Named Insured. The due date for audit and If we decide not to renew this Coverage Part, we will retrospective premiums is the date shown as the mail or deliver to the first Named Insured shown in the due date on the bill. If the sum of the advance and Declarations written notice of the nonrenewal not less audit premiums paid for the policy period is greater than 30 days before the expiration date. than the earned premium, we will return the excess to the first Named Insured. If notice is mailed, proof of mailing will be sufficient c. The first Named Insured must keep records of the proof of notice. SECTION V—DEFINITIONS information we need for premium computation, and send us copies at such times as we may request. 1. "Advertisement" means the widespread public 6. Representations dissemination of information or images that has the purpose of inducing the sale of goods, products or a. When You Accept This Policy services through: By accepting this policy,you agree: a. (1) Radio; (1) The statements in the Declarations are accurate (2) Television; and complete; (3) Billboard; (2) Those statements are based upon- (4) Magazine; representations you made to us; and (3) We have issued this policy in reliance upon your (5) Newspaper; or representations. b. Any other publication that is given widespread b. Unintentional Failure To Disclose Hazards public distribution. If unintentionally you should fail to disclose all However, "advertisement"does not include: hazards relating to the conduct of your business a. The design, printed material, information or images that exist at the inception date of this Coverage contained in, on or upon the packaging or labeling Part, we shall not deny coverage under this of any goods or products; or Coverage Part because of such failure. b. An interactive conversation between or among 7. Separation Of Insureds persons through a computer network. Except with respect to the Limits of Insurance, and any 2. "Advertising idea" means any idea for an rights or duties specifically assigned in this Coverage "advertisement". Part to the first Named Insured,this insurance applies: 3. "Asbestos hazard" means an exposure or threat of a. As if each Named Insured were the only Named exposure to the actual or alleged properties of Insured; and asbestos and includes the mere presence of asbestos b. Separately to each insured against whom claim is in any form. made or"suit"is brought. 4. "Auto"means a land motor vehicle,trailer or semitrailer 8. Transfer Of Rights Of Recovery Against Others To designed for travel on public roads, including any Us attached machinery or equipment. But "auto" does not a. Transfer of Rights Of Recovery include"mobile equipment". If the insured has rights to recover all or part of any 5. 'Bodily injury"means physical: payment, including Supplementary Payments, we a. Injury; have made under this Coverage Part, those rights b. Sickness; or are transferred to us. The insured must do nothing c. Disease after loss to impair them. At our request, the sustained by a person and, if arising out of the above, mental anguish or death at any time. HG 00 0106 05 Page 15 of 18 Named Insured:Dome Construction Corporation Policy No.:83QENOD1173 COMMERCIAL AUTOMOBILE Policy Term:01/01/2017 to 01/01/2018 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 (1) The agreement requires you to 'insured" under any other automobile policy or would be an "insured" under provide direct primary insurance for such a policy but for its termination or the lessor and 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: (a) That is a partnership or joint (1) Paragraph A.1. -WHO IS AN INSURED - 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 B. Employees as Insureds ownership, maintenance or use of a covered "auto." Paragraph A.1. -WHO IS AN INSURED - of SECTION II - LIABILITY COVERAGE is amended to add: 02011,The Hartford (Includes copyrighted material Form HA 9916 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 primary, we will share with all that other If you have agreed in a written contract 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 tb) 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, amounts under all that other insurance. Suitor Loss We will share the remaining loss, if any, by the If you have agreed in a written contract or written agreement that another method described in Other Insurance 5.d.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 9916 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. LOANILEASE 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 BA - 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 in Paragraphs(1)and(2)above;or ©2011,The Hartford (Includes copyrighted material Form HA 9916 0312 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 1N 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. - accessories used with such equipment) DUTIES IN THE EVENT OF ACCIDENT,CLAIM, that reproduces, receives or transmits SUIT OR LOSS - of SECTION IV - BUSINESS signals which at the AUTO CONDITIONS that you must notify us of audio, visualor data si time of"loss is: g an "accident'applies only when the "accident"is (mown 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 "auto"to you. "bodily injury" or "property damage" is 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 9916 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 except as follows: combustion engine to charge one or more 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.If 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," 02011,The Hartford (Includes copyrighted material Form HA 9916 0312 of ISO Properties, Inc., with its permission.) Page 5 of 5 Policy No.: 83WEOD1171 . .....,.VlrKet-, Policy Term:01/61/2017 to 01/01/2018 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 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.) 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 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE Person or Organization Job Description AS REQUIRED BY WRITTEN CONTRACT. Countersigned by Authorized Representative Form WC 04 03 06 (1) Printed in U.S.A. Process Date: Policy Expiration Date: ° Dome Construction General Liability - 83UENOD1172 Automobile - 83UENOD1173 THIS ENDORSEMENT CHANCES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO CERTIFICATE HOLDER(S) This policy is subject to the following additional If notice is mailed, proof of mailing to the last known Conditions: mailing address of the certificate holder(s) on file with A. If this policy is cancelled by the Company, other the agent of record or the Company will be sufficient than for nonpayment of premium, notice of such proof of notice. cancellation will be provided at least thirty (30) Any notification rights provided by this endorsement days in advance of the cancellation effective date apply only to active certificate holder(s) who were to the certificate holder(s) with mailing addresses issued a certificate of insurance applicable to this on file with the agent of record or the Company. policy's term. B. If this policy is cancelled by the Company for Failure to provide such notice to the certificate nonpayment of premium, or by the insured, notice holder(s) will not amend or extend the date the of such cancellation will be provided within (10) cancellation becomes effective, nor will it negate days of the cancellation effective date to the cancellation of the policy. Failure to send notice shall certificate holder(s) with mailing addresses on file impose no liability of any kind upon the Company or its with the agent of record or the Company. agents or representatives. Form IH 0313 0611 Page 1 of 1 © 2011,The Hartford 0 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO CERTIFICATE HOLDER(S) Policy Number: 83 WE OD1171 Endorsement Number: Effective Date: 01/01/17 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: DOME CONSTRUCTION CORPORATION 393 E GRAND AVE S.SAN FRANCISCO, CA 94080 This policy is subject to the following additional If notice is mailed, proof of mailing to the last known Conditions: mailing address of the certificate holder(s) on file A. If this policy is cancelled by the Company, other with the agent of record or the Company will be than for non-payment of premium, notice of such sufficient proof of notice. cancellation will be provided at least thirty (30) Any notification rights provided by this endorsement days in advance of the cancellation effective apply only to active certificate holder(s) who were date to the certificate holder(s) with mailing issued a certificate of insurance applicable to this addresses on file with the agent of record or the policy's term. Company. Failure to provide such notice to the certificate B. If this policy is cancelled by the Company for holder(s) will not amend or extend the date the non-payment of premium, or by the insured, cancellation becomes effective, nor will it negate notice of such cancellation will be provided cancellation of the policy. Failure to send notice within ten (10) days of the cancellation effective shall impose no liability of any kind upon the date to the certificate holder(s) with mailing Company or its agents or representatives. addresses on file with the agent of record or the Company. Form WC 99 03 94 Printed in U.S.A. Process Date: Policy Expiration Date: 01/01/18 ©2011,The Hartford (Z-' INSURANCE REQUIREMENTS CHECKLIST Permit# C-N_�- -o�ct-1 - � 3 CIP Project# The following insurance is required of all 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 1 and work being performed under contract for Capital Improvement Projects. Limits C mmercial 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. cK Policy expiration date 1 Automotive Liability: t�, "Any Auto" checked on certificate Y-44,000,000 per accident for bodily injury and property damage ❑ Policy expiration date Workers'Compensation and Employer's Liability 71- Waiver of Subrogation clause Y-$1,000,000 per accident for bodily! or disease ❑/"'ftlicy 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 Additional Insured Endorsement The 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: cancellation area of certificate'edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR should say: C.\Documents and Settings�oannat\Desktop\Insurance Info\Insurance Requirements Cklist REV 3.13.doc(Revised 3.13) -1- Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. C -ram Name: SA:6.,NAIC# 1( SS Rating: Authorized in CA: Name: NAIC# IIQj)Q Rating: Authorized in CA: Name: NAIC# Rating: Authorized in CA: Name: NAIC# Rating: Authorized in CA: Ap S � ❑ Campbell Business License# Expiration: Contractors License# E�(o ��p Class: Expiration: Insurance Certificate Reviewed Ini ials 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 C ® DATE(MM/DD/YYYY) A C" CERTIFICATE OF LIABILITY INSURANCE 1/3/2018 THIS CERTIFICATE IS ISSUED AS X MATTEW1OF'INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE iDOES NOT,AFFIRMATIVELY ORAEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSLIBANCE.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 endorsements. PRODUCER CONTACT NAME: Arthur J. Gallagher&Co. PHONE FAX Insurance Brokers of CA, Inc. LIC#0726293 Arc NO One Almaden Boulevard,Suite 960 E-MAILDRESS: San Jose CA 95113 RECEIVED A INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Hartford Fire Insurance Company 19682 INSURED INSURER B:Sentinel Insurance Company Ltd 11000 Dome Construction Corporation. ublic Works Administratio NSURERC:. 393 East Grand Avenue P South San Francisco;CA 94080 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1 0401 7331 2 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 POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MMIDD/YYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY Y Y 83UENOD1172 1/1/2018 1/1/2019 EACH OCCURRENCE $1,000,000 CLAIMS-MADE ❑X OCCUR PREMISES(Ea occurence $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY E JECOT- LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: { $ A AUTOMOBILE LIABILITY Y Y 83UENOD1173 1/1/2018 1/1/2019 ECOMBINED a accident SINGLE $1,000,000 X ANY AUTO - BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED ODAMAGE X AUTOS ONLY X AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED ± RETENTION$ $ B WORKERS COMPENSATION Y 83WEOD1171 1/1/2018 1/1/2019 X AND EMPLOYERS'LIABILITY Y/N STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICERIMEMBEREXCLUDED? N NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) RE:Job#170317;Stanford Blood Center(Precon), Project Location:295 E. Hamilton Ave., Campbell;CA 95008, Permit No.:TBD All work in the public right-of-way. Additional Insured and Waiver of Subrogation (where required by written contract,per attached forms):City of Campbell,its officers, employees and volunteers are named as additional insured.The Insurance coverage afforded to the Additional Insured is primary. D, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Campbell THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 70 N. First St.. ACCORDANCE WITH THE POLICY PROVISIONS. Campbell CA 95008 AUTHORIZEDfREPRESENTATIVE _ e:7: ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Named Insured: Dome Construction Corporation Policy No.: 83UENOD1172 Policy Term: 01/0112018 to 01/01/20,19 have all your rights and duties under this Coverage 5. Nonowned Watercraft Part. With respect to watercraft you do not own that is less e, Unnamed Subsidiary than 51 feet long and is not being used to carry Any subsidiary, and subsidiary thereof, of yours persons for a charge, any person is an insured while which is a legally incorporated entity of which you operating such watercraft with your permission. Any own a financial interest of more than 50% of the other person or organization responsible for the voting stock on the effective date of the Coverage conduct of such person is also an insured, but only Part. with respect to liability arising out of the operation of the watercraft, and only if no other insurance of any The insurance afforded herein for any subsidiary kind is available to that person or organization for this not named in this Coverage Part as a named liability. insured does not apply to injury or damage with respect to which an insured under this Coverage However, no person or organization is an insured with Part is also an insured under another policy or respect to: would be an insured under such policy but for its a. "Bodily injury" to a co-"employee" of the person termination or the exhaustion of its limits of operating the watercraft; or insurance. b. "Property damage" to property owned by, rented to, 3. Newly Acquired or Formed Organization in the charge of or occupied by you or the employer Any organization you newly acquire or form, other than of any person who is an insured under this a partnership, joint venture or limited liability company, provision. and over which you maintain financial interest of more 6. Additional Insureds When Required By Written than 50% of the voting stock, will qualify as a Named Contract, Written Agreement Or Permit Insured if there is no other similar insurance available The following person(s) or organization(s) are an to that organization. However: additional insured when you have agreed, in a written a. Coverage under this provision is afforded only until contract, written agreement or because of a permit the 180th day after you acquire or form the issued by a state or political subdivision, that such organization or the end of the policy period, person or organization be added as an additional whichever is earlier; insured on your policy, provided the injury or damage b. Coverage A does not apply to "bodily injury" or occurs subsequent to the execution of the contract or "property damage" that occurred before you agreement. acquired or formed the organization; and A person or organization is an additional insured under c. Coverage B does not apply to "personal and this provision only for that period of time required by advertising injury" arising out of an offense the contract or agreement. committed before you acquired or formed the However, no such person or organization is an insured organization. under this provision if such person or organization is 4. Mobile Equipment included as an insured by an endorsement issued by us and made a part of this Coverage Part. With respect to mobile equipment' registered in your name under any motor vehicle registration law, any a. Vendors person is .an insured while driving such equipment Any person(s) or organization(s) (referred to below along a public highway with your permission.Any other as vendor), but only with respect to "bodily injury" person or organization responsible for the conduct of or "property damage" arising out of "your products" such person is also an insured, but only with respect to which are distributed or sold in the regular course liability arising out of the operation of the equipment, of the vendor's business and only if this Coverage and only if no other insurance of any kind is available Part provides coverage for "bodily injury" or to that person or organization for this liability. However, "property damage" included within the "products- no person or organization is an insured with respect to: completed operations hazard". a. "Bodily injury" to a co-"employee" of the person (1) The insurance afforded the vendor is subject to driving the equipment;or the following additional exclusions: b. "Property damage"to property owned by, rented to, This insurance does not apply to: in the charge of or occupied by you or the employer (a) "Bodily injury" or "property damage" for of any person who is an insured under this which the vendor is obligated to pay provision. damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; Page 10 of 18 HG 00 01 06 05 (b) Any express warranty unauthorized by you; c. Lessors of Land or Premises (c) Any physical or chemical change in the Any person or organization from whom you lease product made intentionally by the vendor; land or premises, but only with respect to liability (d) Repackaging, except when unpacked solely arising out of the ownership, maintenance or use of for the purpose of inspection, demonstration, that part of the land or premises leased to you. testing, or the substitution of parts under With respect to the insurance afforded these instructions from the manufacturer, and then additional insureds the following additional repackaged in the original container; exclusions apply: (e) Any .failure to, make such inspections, This insurance does not apply to: adjustments, tests or'servicing as the vendor 1. Any "occurrence" which takes place after you has agreed to make or normally undertakes cease to lease that land; or to make in the usual course of business, in connection with the distribution.or sale of the 2. Structural alterations, new construction or products; demolition operations performed by or on behalf of such person or organization. (f) Demonstration, installation, servicing or repair operations, except such operations d Architects, Engineers or Surveyors performed at the vendor's premises in Any architect, engineer, or surveyor, but only with connection with the sale of the product; respect to liability for "bodily injury", "property (g) Products which, after distribution or sale by damage" or "personal and advertising injury" you, have been labeled or relabeled or used caused, in whole or in part, by your acts or as a container, part or ingredient of any omissions or the acts or omissions of those acting other thing or substance by or for the on your behalf: vendor; or (1) In connection with your premises; or (h) "Bodily injury" or "property damage" arising (2) In the performance of your ongoing operations out of the sole negligence of the vendor for performed by you or on your behalf. its own acts or omissions or those of its With respect to the insurance afforded these employees or anyone else acting on its additional insureds, the following additional behalf. However, this exclusion does not exclusion applies: apply to: This insurance does not apply to "bodily injury", (i) The exceptions contained in Sub- .'property' damage" or "personal and advertising paragraphs (d) or (f); or injury" arising out of the rendering of or the failure (ii) Such inspections, adjustments, tests or to render any professional services by or for you, servicing as the vendor has agreed to including: make or normally undertakes to make in 1. The preparing, approving, or failing to prepare the usual course of business, in or approve, maps, shop drawings, opinions, connection with the distribution or sale of reports, surveys, field orders, change orders or 'the products. drawings and specifications; or (2) This insurance does not apply to any insured 2. Supervisory, inspection, architectural or person or organization, from whom you have engineering activities. acquired such products, or any ingredient, part e. Permits Issued By State Or Political or container, entering into, accompanying or containing such products. Subdivisions b. Lessors of Equipment Any state or political subdivision, but only with respect to operations performed by you or on your (1) Any person or organization from whom you behalf for which the state or political subdivision lease equipment; but only with respect to their has issued a permit. liability for "bodily injury", "property damage" or With respect to the insurance afforded these "personal and advertising injury" caused, in whole or in part, by your maintenance,operation additional insureds, this insurance does not apply or use of equipment leased to you by such to: person or organization. (1) "Bodily injury", "property damage" or "personal (2) With respect to the insurance afforded to these and advertising injury" arising out of operations additional insureds this insurance does not performed for the state or municipality; or apply to any "occurrence" which takes place (2) "Bodily injury" or "property damage" included after the equipment lease expires. within the "products-completed operations hazard". HG 00 01 06 05 Page 1.1 of 18 f. Any Other Party c. Persons or organizations making claims or bringing Any other person or organization who is not an "suits". insured under Paragraphs a. through e. above, but 2. General Aggregate Limit only with respect to liability for "bodily injury", The General Aggregate Limit is the most we will pay "property damage" or "personal and advertising for the sum of: injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting a. Medics! expenses under Coverage C; on your behalf: b. Damages under Coverage A, except damages (1) In the performance of your ongoing operations; because of "bodily injury" or "property damage" included in the 'products-completed operations (2) In connection with your premises owned by or hazard"; and rented to you; or c. Damages under Coverage B. (3) In connection with "your work" and included within the "products-completed operations 3. Products-Completed Operations Aggregate Limit hazard", but only if The Products-Completed Operations Aggregate Limit (a) The written contract or agreement requires is the most we will pay under Coverage A for damages you to provide such coverage to such because of "bodily injury" and "property damage" additional insured; and included in the "products-completed operations hazard". (b) This Coverage Part provides coverage for "bodily injury" or "property damage" included 4. Personal and Advertising Injury Limit within the "products-completed operations Subject to 2. above, the Personal and Advertising hazard". Injury Limit is the most we will pay under Coverage B With respect to the insurance afforded to these for the sum of all damages because of all "personal additional insureds, this insurance does not apply and advertising injury" sustained by any one person or to: organization. "Bodily injury", "property damage" or "personal and 5. Each Occurrence Limit advertising injury" arising out of the rendering of, or Subject to 2, or 3, above, whichever applies,.the Each the failure to render, any professional architectural, Occurrence Limit is the most we will pay for the sum engineering or surveying services, including: of: (1) The preparing, approving, or failing to prepare a. Damages under Coverage A; and or approve, maps, shop drawings, opinions, b. Medical expenses under Coverage C reports, surveys, field orders, change orders or because of all "bodily injury" and "property damage" drawings and specifications; or arising out of anyone"occurrence". (2) Supervisory, inspection, architectural or engineering activities. 6. Damage To Premises Rented To You Limit The limits of insurance that apply to additional insureds Subject to 5. above, the Damage To Premises Rented under this provision is described in Section III — Limits To You Limit is the most we will pay under Coverage A Of Insurance. for damages because of"property damage" to any one premises, while rented to you, or in the case of How this insurance applies when other insurance is damage by fire, lightning or explosion, while rented to available to the additional insured is described in the you or temporarily occupied by you with permission of Other Insurance Condition in Section IV— Commercial the owner. General Liability Conditions. In the case of damage by fire, lightning or explosion, No person or organization is an insured with respect to the the Damage to Premises Rented To You Limit applies conduct of any current or past partnership,joint venture or to all damage proximately caused by the same event, limited liability company that is not shown as a Named whether such damage results from fire, lightning or Insured in the Declarations. explosion or any combination of these. SECTION III —LIMITS OF INSURANCE 7. Medical Expense Limit 1. The Most We will Pay Subject to 5. above, the Medical Expense Limit is the The Limits,of Insurance shown in the Declarations and most we will pay under Coverage C for all medical the rules below fix the most we will pay regardless of expenses because of "bodily injury" sustained by any the number of: one person. a. Insureds; 8. How Limits Apply To Additional Insureds b. Claims made or"suits" brought; or If you have agreed in a written contract or written agreement that another person or organization be Page 12 of 18 HG 00 0106 05 added as an additional insured on your policy, the (3) Cooperate with us in the investigation or most we will pay on behalf of such additional insured is settlement of the claim or defense against the the lesser of: "suit"; and a. The limits of insurance specified in the written (4) Assist us, upon our request, in the enforcement of contract or written agreement; or any right against any person or organization which b. The Limits of Insurance shown in the Declarations. may be liable to the insured because of injury or Such amount shall be a part of and not in addition to damage to which this insurance may also apply. Limits of Insurance shown in the Declarations and d. Obligations At The Insureds Own Cost described in this Section. No insured will, except at that insured's own cost, The Limits of Insurance of this Coverage Part apply voluntarily, make a payment, assume any separately to each consecutive annual period and to any obligation, or incur any expense, other than for first remaining period of less than 12 months, starting with the aid, without our consent. beginning of the policy period shown in the Declarations, e. Additional Insureds Other Insurance unless the policy period is extended after issuance for an If we cover a claim, or "suit" under this Coverage additional period of less than 12 months.. In that case, the Part that may also be covered by other insurance additional period will be.deemed part of the last preceding available to an additional insured, such additional period for purposes of determining the Limits of Insurance. insured must submit such claim or "suit" to the SECTION IV — COMMERCIAL GENERAL LIABILITY other insurer for defense and indemnity. CONDITIONS' However, this provision does not apply to the 1. Bankruptcy extent that you have agreed in a written contract or Bankruptcy or. insolvency .of the insured or of the written agreement that this insurance is primary insured's estate will not relieve us of our obligations and non-contributory with the additional insured's under this Coverage Part. own insurance. 2. Duties In The Event Of Occurrence, Offense, Claim f. Knowledge Of An Occurrence, Offense, Claim Or Suit Or Suit a. Notice Of Occurrence Or Offense Paragraphs a. and b. apply to you or to any You or any additional insured must see to it that we additional insured only .,when such ."occurrence", offense, claim or"suit" is known to: are notified as soon as practicable of an "occurrence" or an offense which may result in, a (1) You or any additional insured that is an claim.To the extent possible, notice.should include: individual; (1) How, when and where the "occurrence" or (2) Any partner, if you or an additional.insured is a offense took place; partnership; . (2) The names and addresses of any injured (3) Any manager, if you or an additional insured is.a persons and witnesses; and limited liability company; (3). The nature and location of any injury or damage (4) Any "executive officer" or insurance manager, if arising out of the"occurrence"or offense. you or an additional in is a corporation; b. Notice Of Claim (5) Any trustee, if you or an additional insured is a If a claim is made or "suit" is brought against any trust; or insured, you or any additional insured must: (6) Any elected or appointed official, if you or an (1) Immediately record the specifics of the claim or additional insured is a political subdivision or public entity. "suit" and the date received;and This duty applies separately to you and any additional (2) Notify us as soon as practicable.' insured. You or any additional insured must see to it that we 3. Legal Action Against Us receive written notice of,the claim or suit as soon as practicable. No 'person or organization has a right under this c. Assistance and Cooperation Of The Insured Coverage Part: a, To join us as a party or otherwise bring us into a You and,any other involved insured must: "suit"asking for damages from an insured; or (1) Immediately send us copies of any demands, b, ,To sue. us on this Coverage Part unless all of its notices, summonses or legal papers received in terms have been fully complied with. connection with the claim or"suit"; A person or organization may sue us to recover on an (2) Authorize us to obtain records and other agreed settlement or on a final judgment against an. information; insured; but we will not be liable for damages that are not payable under the terms of this Coverage Part or HG 00 0106 05 Page 13 of 18 that are in excess of the applicable limit of insurance. (7) When You Add Others As An Additional An agreed settlement means a settlement and release Insured To This Insurance of liability signed by us, the insured and the claimant or Any other insurance available to an additional the claimant's legal representative. insured. 4. Other Insurance However, the following provisions apply to other If other valid and collectible insurance is available to insurance available to any person or the insured for a loss we cover under Coverages A or organization who is an additional insured under B of this Coverage Part, our obligations are limited as this coverage part. follows: (a) Primary Insurance When Required By a. Primary Insurance Contract This insurance is primary except when b. below This insurance is primary if you have agreed applies. If other insurance is also primary, we will in a written contract or written agreement share with all that other insurance by the method . that this insurance be primary. If other described in c. below. insurance is also primary, we will share with b. Excess Insurance all that other insurance by the method This insurance is excess over any of the other described in c.below. insurance, whether primary, excess, contingent or (b) Primary And Non-Contributory To Other on any other basis: Insurance When Required By Contract (1) Your Work If you have agreed in a written contract, written agreement, or permit that this That is Fire, Extended Coverage, Builder's Risk, insurance is primary and non-contributory Installation Risk or similar coverage for "your with the additional insured's own insurance, work"; this insurance is primary and we will not (2) Premises Rented To You seek contribution from that other insurance. That is fire, lightning or explosion insurance for Paragraphs (a) and (b) do not apply to other premises rented to you or temporarily occupied insurance to which the additional insured has by you with permission of the owner; been added as an additional insured. (3) Tenant Liability When this insurance is excess, we will have no That is insurance purchased by you to cover duty under Coverages A or B to defend the insured your liability as a tenant for "property damage" against any "suit" if any other insurer has a duty to to premises rented to you or temporarily defend the insured against that "suit". If no other occupied by you with permission of the owner; insurer defends, we will undertake to do so, but we (4) Aircraft, Auto Or Watercraft will be entitled to the insured's rights against all those other insurers. If the loss arises out of the maintenance or use When this insurance is excess over other of aircraft, "autos" or watercraft to the extent not insurance, we will pay only our share of the amount subject to Exclusion g. of Section I —Coverage of the loss, if any,that exceeds the sum of: A—Bodily Injury And Property Damage Liability; (5) Property Damage to Borrowed Equipment Or (1) The total amount that all such other insurance Use Of Elevators would pay for the loss in the absence of this insurance; and If the loss arises out of "property damage" to (2) The total of all deductible and self-insured borrowed equipment or the use of elevators to the extent not subject to Exclusion j. of Section I amounts under all that other insurance. - Coverage A - Bodily Injury And Property We will share the remaining loss, if any, with any Damage Liability; other insurance that is not described in this Excess (6) When You Are Added As An Additional Insurance provision and was not bought specifically Insured To Other Insurance to apply in excess of the Limits of Insurance shown in the Declarations of this Coverage Part. Any other insurance available to you covering C. Method Of Sharing liability for damages arising out of the premises or' operations, or products and completed If all of the other insurance permits contribution by operations, for which you have been added as equal shares, we will follow this method also. Under an additional insured by that insurance; or this approach each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. Page 14 of 18 HG 00 01 06 05 If any of the other insurance does not permit insured will bring "suit" or transfer those rights to us contribution by equal shares, we will contribute by and help us enforce them. limits. Under this method, each insurer's share is b. Waiver Of Rights Of Recovery (Waiver Of based on the ratio of its applicable limit of Subrogation) insurance to the total applicable limits of insurance of all insurers. If the insured has waived any rights of recovery against any person or organization for all or part of 5. Premium Audit any payment, including Supplementary Payments, a. We will compute all premiums for this Coverage we have made under this Coverage Part, we also Part in accordance with our rules and rates. waive that right, provided the insured waived their b. Premium shown in this Coverage Part as advance rights of recovery against such person or premium is a deposit premium only. At the close of organization in a contract, agreement or permit that each audit period we will compute the earned was executed prior to the injury or damage. premium for that period and send notice to the first 9. When We Do Not Renew Named Insured. The due date for audit and If we decide not to renew this Coverage Part, we will retrospective premiums is the date shown as the mail or deliver to the first Named Insured shown in the due date on the bill. If the sum of the advance and Declarations written notice of the nonrenewal not less audit premiums paid for the policy period is greater than 30 days before the expiration date: than the earned premium, we will return the excess to the first Named Insured. If notice is mailed, proof of mailing will be sufficient c. The first Named Insured must keep records of the proof of notice. information we need for premium computation, and SECTION V—DEFINITIONS send us copies at such times as we may request. 1. "Advertisement" means the widespread public 6. Representations dissemination of information or images that has the a. When You Accept This Policy purpose of inducing the sale of goods, products or services through: By accepting this policy, you agree: a. (1) Radio; (1) The statements in the Declarations are accurate (2) Television; and complete; (3) Billboard; (2) Those statements are based upon (4) Magazine; representations you made to us; and (3) We have issued this policy in reliance upon your (5) Newspaper; or representations. b. Any other publication that is given widespread b. Unintentional Failure To Disclose Hazards public distribution. If unintentionally you should fail to disclose all However, "advertisement'does not include: hazards relating to the conduct of your business a. The design, printed material, information or images that exist at the inception date of this Coverage contained in, on or upon the packaging or labeling Part, we shall not deny coverage under this of any goods or products; or Coverage Part because of such failure. b. An interactive conversation between or among 7. Separation Of Insureds persons through a computer network. Except with respect to the Limits of Insurance, and any 2. "Advertising idea" means any idea for an rights or duties specifically assigned in this Coverage "advertisement". Part to the first Named Insured, this insurance applies: 3. "Asbestos hazard" means an exposure or threat of a. As if each Named Insured were the only Named exposure to the actual or alleged properties of Insured; and asbestos and includes the mere presence of asbestos b. Separately to each insured against,whom claim is in any form. made or"suit" is brought. 4. "Auto" means a land motor vehicle, trailer or semitrailer 8. Transfer Of Rights Of Recovery Against Others To designed for travel on public roads, including any Us attached machinery or equipment. But "auto" does not include"mobile equipment". a. Transfer of Rights Of Recovery 5. "Bodily injury" means physical: If the insured has rights to recover all or part of any payment, including Supplementary Payments, we a. Injury; have made under this Coverage Part, those rights b. Sickness; or are transferred to us. The insured must do nothing c. Disease after loss to impair them. At our request, the sustained by a person and, if arising out of the above, mental anguish or death at any time. HG 00 01 06 05 Page 15 of 18 Named Insured:Dome Construction Corporation Policy No.:83UENOD1173 COMMERCIAL AUTOMOBILE Policy Term: 01/01/2018 to 0110112019 HA 99 16 0312 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.I. -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 donduct 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 B. Employees as Insureds ownership, maintenance or use of a 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 03 12 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 or written agreement that another insurance by the method described in 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 (b) The Limits of Insurance shown in insurance is primary and we will not the Declarations. seek contribution from that other 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, amounts under all that other insurance. Suitor Loss If you have agreed in a written contract We will share the remaining loss, if any, by the or written agreement that another method described in Other Insurance 5.d. 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. OO 2011, The Hartford (Includes copyrighted material Form HA 99 16 03 12 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 loanflease. 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 "ions" to any hired or disability insurance purchased with the loan or "auto" is: lease; and carry-over balances from previous (1) $1'00,000; 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 in Paragraphs (1)and (2)above; or @2011, The Hartford (Includes copyrighted material Form HA 99 16 0312 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. - accessories used with such equipment) DUTIES IN THE EVENT OF ACCIDENT,CLAIM, that reproduces, receives or transmits SUIT OR LOSS - of SECTION IV - BUSINESS audio, visual or data signals which, at the AUTO CONDITIONS that you must notify us of 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 "auto"to you. "bodily injury" or "property damage" is 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 providedunder time of total loss. Regardless of the number of this Coverage Form, then such Physical Damage Coverages are amended as follows: autos.deemed a total loss, the most we will pay under this Vehicle Wrap Coverage provision for a.If 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 180 Properties, Inc., with its permission.) Page 5 of 5 Named Insured: Dome Construction Corporation Policy No.: 83WEOD1171 Policy Term: 01/01/2018 to 01/01/2019 -° THIS ENDORSEMENT CHANGES THE.POLICY. PLEASE READ IT CAREFULLY. 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.) 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 % of the California workers' compensation premium otherwise due on such.remuneration. SCHEDULE Person or Organization Job Description AS REQUIRED BY WRITTEN CONTRACT. Countersigned by Authorized Representative Form WC 04 03 06 (1) Printed in U.S.A. Process Date: Policy Expiration Date: Dome construction General Liability - 83UENOD1172 Automobile - 83i]Eh'OD1173 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, NOTICE OF CANCELLATION TO CERTIFICATE H2OLCER(S) This policy is subject to the following additional If notice is mailed, proof of mailing to the last known Conditions: mailing address of the certificate holder(s) on file with A: If this policy is cancelled by the Company, other the agent of record or the Company will be sufficient than for nonpayment of premium, notice of such proof of notice. . cancellation will be provided at least thirty (30). Any notification rights provided .by this endorsement days in advance of the cancellation, effective date apply only to active certificate holder(s) who were to the certificate. holder(s) with mailing addresses issued a certificate of insurance applicable to this on file with the agent of record or the Company., policy's term. B. If this policy is cancelled by the Company for Failure to provide such notice to the certificate nonpayment of premium, or by the insured, notice holder(s) will not amend or extend the date the of such cancellation will be provided within ('i0) cancellation becomes effective, nor will it negate days of the cancellation effective date to the cancellation of the policy. Failure to send notice shall certificate holder(s) with mailing addresses on file impose no liability of any kind upon the Company or its with the agent of record or the Company. agents or representatives. Form IH 03 13 0611 Page 1 of 1 O 2011,The Hartford THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO CERTIFICATE HOLDER(S) Policy Number: 83 WE OD1171 Endorsement Number: Effective Date: 01/01/2018 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: DOME CONSTRUCTION CORPORATION 393 E GRAND AVE S.SAN FRANCISCO, CA 94080 This policy is subject to the following additional If notice is mailed, proof of mailing to the last known Conditions: mailing address of the certificate holder(s) on file A. If this policy is cancelled by the Company, other with the agent of record or the Company will be than for non-payment of premium, notice of such sufficient proof of notice. cancellation will be provided at least thirty (30) Any notification rights provided by this endorsement days in advance of the cancellation effective apply only to active certificate holder(s) who were date to the certificate holder(s) with mailing issued a certificate of insurance applicable to this addresses on file with the agent of record or the policy's term. Company. Failure to provide such notice to the certificate B. If this policy is cancelled by the Company for' holder(s) will not amend or extend the date the non-payment of premium, or'by the insured, cancellation becomes effective, nor will it negate notice of such cancellation will be provided cancellation of the policy. Failure to send ,notice. within ten (10) days of the cancellation effective shall impose no liability of any kind upon the date to the certificate holder(s) with mailing Company or its agents or representatives. addresses on file with the agent of record or the Company. Form WC 99 03 94 Printed in U.S.A. Process Date: Policy Expiration Date: 01/01/19 ©2011,The Hartford