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FD Fire St. Drill Tower Repair Proj. 11227City of San Rafael ♦ California Form of Contract Agreement for Informal Bids for Fire Station Drill Tower Repair Project City Project No. 11227 This Agreement is made and entered into this 23"' day of March 2015 by and between the City of San Rafael (hereinafter called City) and Frank Ruggirello Construction, Inc. (hereinafter called Contractor). Witnesseth, that the City and the Contractor, for the considerations hereinafter named, agree as follows: I - Scope of the Work The Contractor hereby agrees to furnish all of the materials and all of the equipment and labor necessary, and to perform all of the work described in the specifications for the project entitled: Fire Station Drill Tower Repair Project, City Project No. 11227, all in accordance with the requirements and provisions of the Contract Documents as defined in the General Conditions which are hereby made a part of this Agreement. The Contractor further agrees to provide the insurance as specified in the Insurance Requirements Sheet attached hereto as Attachment A. The required additional insured coverage for City under Contractor's liability insurance policy shall be primary with respect to any insurance or coverage maintained by City and shall not call upon City's insurance or self-insurance for any contribution. II- Time of Completion (a) The work to be performed under this Contract shall be commenced within FIVE (5) WORKING DAYS after the date of written notice by the City to the Contractor to proceed. (b) All work shall be completed, including all punchlist work, within TWENTY-FIVE (25) WORKING DAYS and with such extensions of time as are provided for in the General Conditions. III - Liquidated Damages It is agreed that, if all the work required by the contract is not finished or completed by the date set forth in the contract, damage will be sustained by the City, and that it is and will be impracticable and extremely difficult to ascertain and determine the actual damage which the City will sustain in the event of and by reason of such delay; and it is therefore agreed that the Contractor will pay to the City, the sum of $1,200 for each and every working day's delay in finishing the work in excess of the number of working days prescribed above; and the Contractor agrees to pay said liquidated damages herein provided for, and further agrees that the City may deduct the amount thereof from any moneys due or that may become due the Contractor under the contract. IV - The Contract Sum The City shall pay to the Contractor for the performance of the Contract the amounts determined for the total number of each of the units of work in the following schedule completed at the unit price stated. The number of units contained in this schedule is approximate only, and the final payment shall be made for the actual number of units that are incorporated in or made necessary by the work covered by the Contract. NO. ITEM QUANTITY UNITS UNIT PRICE TOTAL PRICE 1. Mobilization 1 1 @................ $ 4,813.00 $ 4,813.00 2. Repair Existing Stucco Exterior 1 1 @ $ 2,841.00 $ 2,841.00 3. Construct Exterior Wood Corners 1 1 @ $,5,872.00 $ 5,872.00„ 4. Repair Existing Stand Pipe 1 1 @ $ 1,861.00 $ 1,861.00 5. Repair Existing Fire Escape 1 1 @ $ 6,379.00 IT $ 6,379.00 6. Treat Existing Wood 1 1 @ $ 234.00 $ 234.00 7. Clean and Paint Entire Structure 1 1 @ $ 18 663.00 $ 18 663.00 8. Electrical Modifications 1 1 @ $ 1,872.00 — $ 1.,872.00 TOTAL BASE BID $42,535.00 V - Progress Payments (a) On no later than the 6th day of every month the Public Works Department shall prepare and submit an estimate covering the total quantities under each item of work that have been completed from the start of the job up to and including the 25th day of the preceding month, and the value of the work so completed determined in accordance with the schedule of unit prices for such items together with such supporting evidence as may be required by the City and/or Contractor. (b) As soon as possible after the preparation of the estimate, the City shall, after deducting previous payments made, pay to the Contractor 95% of the amount of the estimate as approved by the Public Works Department. (c) The Contractor may elect to receive 100% of payments due under the contract from time to time, without retention of any portion of the payment by the public agency, by depositing securities of equivalent value with the public agency in accordance with the provisions of Section 4590 of the Government Code. Such securities, if deposited by the Contractor, shall be valued by the City's Finance Director, whose decision on valuation of the securities shall be final. VI - Acceptance and Final Payment (a) Upon receipt of written notice that the work is ready for final inspection and acceptance, the Engineer shall within five (5) working days make such inspection. (b) Before final payment is due the Contractor shall submit evidence satisfactory to the Engineer that all payrolls, material bills, and other indebtedness connected with work have been paid, except that in case of disputed indebtedness or liens the Contractor may submit in lieu of evidence of payment a surety bond satisfactory to the City guaranteeing payment of all such disputed amounts when adjudicated in cases where such payment has not already been guaranteed by surety bond. (c) The making and acceptance of the final payment shall constitute a waiver of all claims by the City, other than those arising from any of the following: (1) unsettled liens; (2) faulty work appearing within twelve (12) months after final payment; (3) requirements of the specifications; or (4) manufacturers' guarantees. It shall also constitute a waiver of all claims by the Contractor, except those previously made and still unsettled. (d) If after the work has been substantially completed, full completion thereof is materially delayed through no fault of the Contractor, and the Engineer so certifies, the City shall, upon certificate of the Engineer, and without terminating the Contract, make payment of the balance due for that portion of the work fully completed and accepted. Such payment shall be made under the terms and conditions governing final payment, except that it shall not constitute a waiver of claims. IN WITNESS WHEREOF, City and Contractor have caused their authorized representatives to execute this Agreement the day and year first written above. CITY OF SAN RAFAEL: m` Nader Mansourian Public Works Director CONTRACTO for r c— PERFORMANCE BOND BOND NO. K08963174 EXECUTED IN DUPLICATE CALIFORNIA PUBLIC WORK 00. $723 Premium: ...,., KNOW ALL MEN 6Y THESE PRESENTS: That we FRC, INC. and WESTCHESTER FIRE INSURANCE COMPANY a corporation organized and existing under the laws of the State of PENNSYLVANIA authorized to transact surety business in the State of California, are held and firmly bound unto CITY OF SAN RAFAEL in the sum of FORTY TWO THOUSAND FIVE HUNDRED THIRTY FIVE AND NO/100........................... .............................................................................................................................. Dollars ($ 42,535.00 Principal, Surety, and Obligee, for the payment of which we bind ourselves, our legal representatives, successors and assigns, jointly and severally, firmly by these presents. WHEREAS, Principal has entered into a contract with Obligee, dated _ MARCH Zi for FIRE STATION DRILL TOWER REPAIR PROJECT, CITY PROJECT NO. 11227 copy of which contract is by reference made a part hereof. zu�q NOW, THEREFORE, If Principal shall faithfully perform such contract or shall indemnify and save harmless the Obligee from all cost and damage by reason of Principal's failure so to do, then this obligation shall be null and void; otherwise it shall remain In full force and effect. No right of action shall accrue under this bond to or for the use of any person other than the said Obligee. Signed, sealed and dated APRIL 2 2015 FRC, INC eal) FRANK R RUGGIRELLO PRESIDENT Principal WESTCHESTER FIRE INSURANCE COMPANY $y CLAY THOMPSON Attorney -in -Fact CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189 S�i<�Fi\ �•�'Y- L � L ^Y - -i -Z � � � - � � _ _�L'Z\ � .G.\ � �^`•�•Y���i Li L -'i L A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California ) County of NAPA ) On APRIL 2, 2015 before me, K. M. WILLBACK, NOTARY PUBLIC Date Here Insert Name and Title of the Officer personally appeared CLAY THOMPSON Name(s) of Signer(y) who proved to me on the basis of satisfactory evidence to be the person(g) whose name(4 is/KKK subscribed to the within instrument and acknowledged to me that he/xk%%= executed the same in his/hath& authorized capacitykb*, and that by hisAxxthiRk signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. . WILLBACK5.n��K. sion # 2057918 z .=: Notary Public - California D Z Napa County My Comm. Expires Feb 14, 2018 Place Notary Seal Above I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature �C�, Signature of Notary Public OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: Document Date: Number of Pages: Signer(s) Other Than Named Above: Capacity(lies) Claimed by Signer(s) Signer's Name: ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: Signer's Name: ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: ©2014 National Notary Association • www.NationalNotary.org - 1 -800 -US NOTARY (1-800-876-6827) Item #5907 EXECUTED IN DUPLICATE PAYMENT BOND CALIFORNIA PUBLIC WORK KNOW ALL MEN BY THESE PRESENTS, That we, FRC, INC. and WESTCHESTER FIRE INSURANCE COMPANY a corporation organized and existing under the laws of the State of PENNSYLVANIA surety business in the State of California, as Surety, are held and firmly bound unto CITY OF SAN RAFAEL -- sum of FORTY TWO THOUSAND FIVE HUNDRED THIRTY FIVE AND NO/100 ._. ...._... _�.. BOND NO K08963174 Premium: Included in pert bond .�..... , as Principal, and authorized to transact, .. , as Obligee, in the Dollars ($_42,535,00 for the payment whereof, well and truly to be made, said Principal and Surety bind themselves, their heirs, administrators, successors and assigns, jointly and severally, firmly by these presents. WHEREAS, the abo-bounded Principal has entered into a contract, a copy of which contract Is by reference made a part hereof, dated bwith the obllpee for FIRE STATION DRILL TOWER REPAIR PROJECT„ CITY PROJECT NO, 11227 NOW, THEREFORE, if the above -bounded Principal or his subcontractors shall fall to pay any of the persons named in Section 3181 of the Civil Code of the State of California, or amounts due under the Unemployment Insurance Code wlth respect to work or labor performed by any such claimant, or any amounts required to be deducted, withheld and paid over to the Franchise Tax Board from the wages of employees of the Principal or his sub -contractors pursuant to Section 18805 of the Revenue and Taxation Code, with respect to such work and labor, Surety will pay for the same. In an agreeable amount not exceeding the amount specified in this bond, and also, in. case suit Is brought upon this bond, a reasonable attorney's fee, to be fixed by the court, This bond shall Inure to the benefit of any and all persons, companies or corporations entitled to file claims under Section 3181 of the Civil Code of the State of California, so as to give a right of action to them or their assigns in any suit brought upon this bond. Signed, sealed and dated this 2 day of APRIL 2015 FRC, INC Principal By NK FRAR.RUGGIRELLO PRESIDENTu _ „_..,...,.........,,._...,., WESTCHESTER FIRE INSURANCE COMPANY Surety By CLAY THOMPSON Attorney -in -Fact CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT •. A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California ) County of NAPA ) On APRIL 2, 2015 before me, K. M. WILLBACK, NOTARY PUBLIC Date Here Insert Name and Title of the Officer personally appeared CLAY THOMPSON Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(a) whose name(4 is/NKK subscribed to the within instrument and acknowledged to me that he/-qIIexecuted the same in his/kit adh& authorized capacity(ias), and that by hiskmAheix signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. K. M. WILLBACK Commission #t 2057918 Z .'� Notary Public - California Z Z Napa County > ..,,MI,Comm. Expires Feb 14, 2018 Place Notary Seal Above I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. SignatureIiIJC�C-��al 16Signature of Notary Public OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: Document Date: Number of Pages: Signer(s) Other Than Named Above: Capacity(lies) Claimed by Signer(s) Signer's Name: ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: Signer's Name: ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: ©2014 National Notary Association - www.NationalNotary.org -1-800-US NOTARY (1-800-876-6827) Item #5907 i I Power of WESTCHESTER FIRE INSURANCE COMPANY Attorney Know all men by these presents: That WESTCHESTER FIRE INSURANCE COMPANY, a corporation of the Commonwealth of Pennsylvania pursuant to the following Resolution, adopted by the Board of Directors of the said Company on December 11, 2006, to wit: "RESOLVED, that the following authorizations relate to the execution, for and on behalf of the Company, orbonds, undertakings, recognisances, contracts and other written commitments of the Company entered into the ordinary course of business (each a "Written Commitment"): (1) Each of the Chairman, the President and the Vice Presidents of the Company is hereby authorized to execute my Written Commitment for and on behalf of the Company, under the seal of the Company or otherwise (2) Each duly appointed attorney-in-fact of the Company is hereby authorized to execute any Written Commitment for and on behalf of the Company, under the seal of the Company or otherwise, to the extent that such action Is authorized by the grant of powers provided for to such persons written appointment as such atwmay-in-fact . (3) Each of the Chairman. the President and the Vitt Presidents of the Company is hereby authorized, for and on behalf of the Company, to appoint in writing any person the attomey-m-fact of the Company with full power and authority to execute, for and on behalf of the Company, under the seal of the Company or otherwise, such Written Commitments of the Company as may be specified in such written appointment, which specification may be by general type or class of Written Commitments or by specification of one or more particular Written Commitments. (4) Each of the Chairman, the President and Vice Presidents of the Company in hereby authorized, for and on behalf of the Company, to delegate in writing any other officer of the Company the authority to execute, for and on behalf of the Company, under the Company's seal or otherwise, such Written Commitments of the Company as are specified in such wrinan delegation, which specification may be by general type or class of Wnnen Commitments or by specification of ane or more particular Written Commitments. (3) The signature of any officer or other person executing any Written Commitment or appointment or delegation pursuant to this Resolution, and the seal of the Company, may be affixed by facsimile on such Written Commitment or written appointment or delegation. FURTHER RESOLVED, that the foregoing Resolution shall not be deemed to be an exclusive statement of the powers and authority of officers, employees and other persons to act for and on behalf of the Company, and such Resolution shall not limit or otherwise affect the exercise of any such power or atrdronty otherwise validly granted or vested Does hereby nominate, constitute and appoint Bryan Richmond, Clay Thompson, Jeffrey Erickson, Karen M Willback, Robert E Chovick, all of the City of NAPA, California, each individually if there be more than one named, its true and lawful attorney-in-fact, to make, execute, seal and deliver on its behalf, and as its act and deed any and all bonds, undertakings, recognizances, contracts and other writings in the nature thereof in penalties not exceeding Ten million dollars & zero cents ($10,000,000.00) and the execution of such writings in pursuance of these presents shall be as binding upon said Company, as fully and amply as if they had been duly executed and acknowledged by the regularly elected officers of the Company at its principal office, IN WITNESS WHEREOF, the said Stephen M. Haney, Vice -President, has hereunto subscribed his name and affixed the Corporate seal of the said WESTCHESTER FIRE INSURANCE COMPANY this 27 day of March 2015. WESTCHESTER FIRE INSURANCE COMPANY w Stephen M. Haney. Vice President COMMONWEALTH OF PENNSYLVANIA COUNTY OF PHILADELPHIA ss. On this 27 day of March, AD. 2015 before me, a Notary Public of the Commonwealth of Pennsylvania in and for the County of Philadelphia came Stephen M. Haney ,Vice -President of the WESTCHESTER FIRE INSURANCE COMPANY to me personally known to be the individual and officer who executed the preceding instrument, and he acknowledged that he executed the same, and that the seal affixed to the preceding instrument is the corporate seal of said Company; that the said corporate seal and his signature were duly affixed by the authority and direction of the said corporation, and that Resolution, adopted by the Board of Directors of said Company, referred to in the preceding instrument, is now in force. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed my official seal at the City of Philadelphia the day and year first above written. 1, the undersigned Assistant Secretary of the WESTCHESTER FIRE INSURANCE COMPANY, do hereby certify that the original POWER OF ATTORNEY, of which the foregoing is a substantially true and correct copy, is in full force and effect. In witness whereof, I have hereunto subscribed my name as Assistant Secretary, and affixed the corporate seal of the Corporation, this day of 60n4i J, 0/s , will:amt L KeRy. Astil►irlr9ttt m my, THIS POWER OF ATTORNEY MAY NOT BE USED TO EXECUTE ANY BOND WITH AN INCEPTION DATE AFTER June 17, 2016. DocuGard 104546 contains a security pantograph, blue background, heat -sensitive ink, coin -inactive tvaterrnark, and rnicrotext printing on border. �eNApNMRAt1rHO 1100ye VAM � ROTANALSEAL p y.�r � FOPANDr PAA -v a�� I"°e•.�. f Vut.ry matte 1, the undersigned Assistant Secretary of the WESTCHESTER FIRE INSURANCE COMPANY, do hereby certify that the original POWER OF ATTORNEY, of which the foregoing is a substantially true and correct copy, is in full force and effect. In witness whereof, I have hereunto subscribed my name as Assistant Secretary, and affixed the corporate seal of the Corporation, this day of 60n4i J, 0/s , will:amt L KeRy. Astil►irlr9ttt m my, THIS POWER OF ATTORNEY MAY NOT BE USED TO EXECUTE ANY BOND WITH AN INCEPTION DATE AFTER June 17, 2016. DocuGard 104546 contains a security pantograph, blue background, heat -sensitive ink, coin -inactive tvaterrnark, and rnicrotext printing on border. FRCINCO-01 SKERR A�R,fl" CERTIFICATE OF LIABILITY INSURANCE DATO/YYYY) 4//13/213/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License # 0303587. CONTACT NAME: ISU Sander Jacobs Cassayre Insurance Services PHONE 707 252-8822 11 FAX 707 253-8255 3200 Villa Lane LAIC, No. Ext,: ( ) I (AIC, Not: i ) Na CA 94558 E-MAIL Napa, P ADDRESS: info@sanderjacobs.com I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Fire Station Drill Tower Repair Project, City Project No. 11227 When required by written contract the City of San Rafael, its officers, employees, agents and volunteers are Included as Additional Insured per policy form CG2033 07/04. Coverage is Primary per policy forms GAC3649CG attached. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of San Rafael AUTHORIZED REPRESENTATIVE Dept ofk Works 1515 P.O. Box 151560 ISan Rafael, CA 94916-1660 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Great American Assurance Co. 26344 INSURED INSURER B: Golden Eagle Ins. Corporation 10836 FRC, Inc. INSURER c: STATE COMPENSATION INS. FUND OF CA 35076 1 1360 Industrial Ave, Suite D INSURER D: Petaluma, CA 94952 INSURER E: g INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE AUDL SUHR' INSD WVD POLICY NUMBER POLICY EFF POLICY EXP (MMIDDfYYYY) IMMIDDIYYYYi LIMITS _ A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,0001 CLAIMS -MADE I—XI OCCUR X GLP1862533 06/03/2014 06/03/2015 1 UAMAUE rU RENTED PREMISES (Ea occurrence) $ 50 0001 r 1 MED EXP (Any one person) $ 01 1 PERSONAL& ADV INJURY $ 1,000,0001 GEN'LAGGREGATE LIMIT APPLIESPER: GENERAL AGGREGATE $ 2,000,0001 POLICY JET LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: Deductible $ 5,0001 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea aaident) 1x000,0001 B X ANY AUTO BA2986514 06/03/2014 06/03/2015 1 BODILY INJURY (Per person) $ 1 ALL OWNED SCHEDULED 1 BODILY INJURY $ I AUTOS AUTOS (Per accident) HIREDAUTOSNON-OWNED AUTOS PROPERTY DAMAGE $ I (Per accident) 1 X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 3,000,000 A EXCESS LIAR CLAIMS -MADE UMB1862632 06/03/2014 06/03/2015 1 AGGREGATE $ 3,000,000 I X I 10,000 DED RETENTION $ $ WORKERS COMPENSATION 1 STATUTE I 1 OERH AND EMPLOYERS' LIABILITY C ANY PROPRIETORIPARTNER/EXECUTIVE YIN 69251112214 X 10/01/2014 10/01/20151 E. L. EACH ACCIDENT $ I 1,000,0001 OFFICER/MEMBER EXCLUDED? � N I A (Mandatory In NH) 1 E.L. DISEASE - EA EMPLOYEE $ 1 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Fire Station Drill Tower Repair Project, City Project No. 11227 When required by written contract the City of San Rafael, its officers, employees, agents and volunteers are Included as Additional Insured per policy form CG2033 07/04. Coverage is Primary per policy forms GAC3649CG attached. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of San Rafael AUTHORIZED REPRESENTATIVE Dept ofk Works 1515 P.O. Box 151560 ISan Rafael, CA 94916-1660 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name Of Additional Insured Person(s) Or Organization(s): City of San Rafael Dept of Public Works PO Box 151560 San Rafael, CA 94915-1560 SCHEDULE Location(s) Of Covered Operations For work performed by insured during this policy period only at the following project: Fire Station Drill Tower Repair Project, City Project No. 11227 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 0I ORIGINAL POLICY Policy # GLP1862533 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, PRIMARY NON-CONTRIBUTORY INSURANCE ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE FORM GAC 3649CG (Ed, 11 06) This insurance is primary to any other insurance held by third parties with respect to work performed by you under written contractual agreements with such third parties and any other insurance which may be available to such third parties shall be non—contributory, GAC 3649CG (Ed, 11/06) XS From:Susan S. Seva FaxID:ISU Sander Jacobs Date:4/8/2015 9:28:29 AM Page: 2 of 4 FRCINCO-01 SSEVA ACORO I DATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 418/2015 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). .......... ­­ ... ............... PRODUCER License # 0303587 CONTACTNAME: ISU Sander Jacobs Cassayre Insurance Services PHONE. .8822 FAX, 3200 Villa Lane No FxW (707) 252 (A/C No); (707) 253-8255 'Napa, CA 94558 E-MAIL ADDRESS: info@sanderjacobs.com INSURER(S) AFFORDING COVERAGE NAIC 9 INSURER A: Great American Assurance Co. 26344 INSURED INSURER B: Golden Eagle Ins. Corporation 10836 FRC, Inc._LNSURER C: STATE COM P E N-S..ATr'ON INS. FUND OF CA 35076 ...................... 1360 Industrial Ave, Suite D INSURER D: Petaluma, CA 94952 INSURER E: INSURER F; COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE PCLICNES DESCRIBED HEREIN IS SUBJECT" TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR' �ADDL SUBRI "I POLICY EFF ___F0_L1CY EXP MAG LTR TYPE OF INSURANCE INSD POLICY NUMBER IMMMDNYYY) IMMIDD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEE 10 REN I ED S 1,000,000 DA CLAIMS -MADE ]OCCUR X GLP1862533 06103r12014 06103/2015 . PREMISESI Ea occurrence I S 50,000 . ......... i I MED EXP (Any one person} Is a PERSONAL & ADV INJURY 5 1,000,000 GEN'L AGGREGATE LIMIT AP� PL1 IE1S PER: GENERAL AGGREGATE S 2,000,006 . POLICY FX] PECTRO- JI LOC 111 PRODUCTS - COMPIOP AGG S 2,000,000 OTi Deductible I $ 5,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT La accident) 1,000 000 13 X ANY AUTO BA2986514 06/0312014 06103/2015 BODIL!!!�URY (Per persc,r) ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) NON -OWNED PROP­ERTV_5A_k4AGE HIRED AUTOS AUTOS IPeracdc it} y. X UMBRELLA LIAR OCCUR ....... . .. . .................. EACH OCCURRENCE: S 3,000,000 EXCESS LIAR Ci MADE A 1XI UMB1862532 06/0312014 06/0312015 3,000,000 AGGREGATE Di I X I RFTFNT IONS 10, 00 0 S WORKERS COMPENSATION .- .. I X OTi 1 � I AND EMPLOYERS'LIABILITY YIN C ANY PROPMETOWPARTNEFUEXECUTIVE 169251`1122`14 STATUTE .. 10/0112014 10101120`15 1,000,000 EACH ACCIDENT S OFFIC RWEMBEREXCLUDED? [�]�NIA Mandl�'tory in NH) . ...... . .... E.L. DISEASE i EMPLOYEE S If es, desr.robe under D SCRIPTION OF OPERATIONS below E.L.01SEME POUCYLINIII S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Fire Station Drill Tower Repair Project, City Project No. 11227 When required by written contract the City of San Rafael, its officers, employees, agents and volunteers are included as Additional Insured per policy form CG2033 07/04. Coverage Is Primary per policy forms GAC3649CG attached. APR - 9 2015 Time: CERTIFICATE HOLDER CANCELLATION Gly Cli f,fulu City o an Rafbibl SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of San Rafael AUTHORIZED REPRESENTATIVE Dept of PublIck Works P.O. Box 151560 ,San Rafael, CA 94915-1560 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD P,rom:Susan S. Seva P'ax1D:1SU Sander Jacobs Date:4/8/'L01b S:ZU:ZS AM Page: 3 of 4 ORIGINAL POLICY Policy # GLP1862533 CG 20 33 (Ed, 07 04) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. SECTION 11 - WHO IS AN INSURED is amended to include as an Additional Insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an Additional In- sured on your policy. Such person or or- ganization is an Additional Insured only with respect to liability for "bodily injury," "prop- erty damage" or "personal and advertising in- jury" caused, in whole or in part, by: 1. your acts or omissions; or 2, the acts or omissions of those acting on your behalf; in the performance of your ongoing oper- ations for the Additional Insured. A person's or organization's status as an Ad- ditional Insured under this endorsement ends when your operations for that Additional In- sured are completed, B. With respect to the insurance afforded to these Additional Insureds, the following addi- tional exclusions apply: This insurance does not apply to: 1. "Bodily injury," "property damage" or "per- sonal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. the preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or draw- ings and specifications; or b, supervisory, inspection, architectural or engineering activities. 2. "Bodily injury," or "property damage" oc- curring after: a. all work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the Additional Insured(s) at the location of the covered operations has been completed; or b, that portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than an- other contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project Copyright, ISO Properties, Inc., 2004 CG 20 33 (Ed 07/04) XS From:Susan S. Seva F'axTD:TSU Sander Jacobs Date:4/8/2015 9:28:29 AM Page: 4 of 4 ORIGINAL POLICY Policy # GLP1862533 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, PRIMARY NON-CONTRIBUTORY INSURANCE ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE FORM GAC 3649CG lEd, 11 06) This insurance is primary to any other insurance field by third parties with respect to work performed by you under written contractual agreements with such third parties and any other insurance which may be available to such third parties shall be non—contributory. GAC 3649CG (Ed. 11/06) XS