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HomeMy WebLinkAboutCarlsbad Village Lock and Key; 2019-08-13; PWL20-837GSRECORDED REQUESTED BY CITY OF CARLSBAD AND WHEN RECORDED PLEASE MAIL TO: City Clerk City of Carlsbad 1200 Carlsbad Village Drive Carlsbad, California 92008 DOC# 2019-0509777 11111111111111111111\I IIII IIII\I 1111111111111111111111111 IIIII IIII IIII Nov 06, 2019 11 :03 AM OFFICIAL RECORDS Ernest J. Dronenburg, Jr., SAN DIEGO COUNTY RECORDER FEES $0.00 (S82 Atkins $0 00) PAGES 1 Space above this line for Recorder's use. PARCEL NO: 214-010-97-00 NOTICE OF COMPLETION Notice is hereby given that: 1. The undersigned is owner ofthe interest or estate stated below in the property hereinafter described. 2. The full names of the undersigned are City of Carlsbad, a municipal corporation. 3. The full address of the undersigned is 1200 Carlsbad Village Drive, Carlsbad, California 92008. 4. The nature of the title of the undersigned is: In fee. 5. A work or improvement on the property hereinafter described was completed on October 18, 2019. 6. The name of the contractor for such work or improvement is Carlsbad Village Lock & Key. 7. The property on which said work or improvement was completed is in the City of Carlsbad, County of San Diego, State of California, and is described as follows: Project No. PWL20-837GS, Project Name Carlsbad Water Recycling Facility Lock Replacement. 8. The street address of said property is 6220 Avenida Encinas, Carlsbad, CA 92011, in the City of Carlsbad. CITY OF C RLSBAD \'/.I.._( 11£~ Elq.;""IQ. tJv -'\\7' Scott Chadwi , ity Manager VERIFICATION OF CITY CLERK I, the undersigned, say: I am the City Clerk of the City of Carlsbad, 1200 Carlsbad Village Drive, Carlsbad, California, 92008; the City Manager of said City on N ovenber I 5,f , 20_1i_, accepted the above described work as completed and ordered that a Notice of Completion be filed. I declare under penalty of perjury that the foregoing is true and correct. Executed on N{lyfmJx.r /s-t , 2o_JJ_, at Carlsbad, California. CITY OF CARLSBAD 1 ~ / llect11c Gcme1 Dep(ll-1 c(·+1 'fi/ BARBARA ENGLESON 1 <./ C Jei >-(' City Clerk er Q:\Public Works\General Services\Agreements & Contracts\Carlsbad Village Lock & Key\Carlsbad Water Recycling Facility Lock Replacement -PWL20- 837GS\4. NOC\2.NOC (Public and Private) -revised 2019-02-07.docx CITY OF CARLSBAD ACCEPTANCE OF PUBLIC IMPROVEMENTS COMPLETION OF PUBLIC IMPROVEMENTS Carlsbad Village Lock & Key has completed the contract work required for PWL20-837GS - Carlsbad Water Recycling Facility Lock Replacement. City forces have inspected the work and found it to be satisfactory. The work consisted of: IMPROVEMENTS To replace door lock cylinders and associated hardware at the Carlsbad Water Recycling Facility. VALUE $2,005.90 CERTIFICATION OF COMPLETION OF IMPROVEMENTS John orks Manager CITY MANAGER'S ACCEPTANCE OF PUBLIC IMPROVEMENTS The construction of the above described contract is deemed complete and hereby accepted. The City Clerk is hereby authorized to record the Notice of Completion and release the bonds in accordance with State Law and City Ordinances. The City of Carlsbad is hereby directed to commence maintaining the above described improvements. W Scottadwi Date APPROVED AS TO FORM: CELIA BREWER, City Attorney Q \Public Works\General Services\Agreements & Contracts\Carlsbad Village Lock & Key\Carlsbad Water Recycling Facility Lock Replacement -PWL20-837GSl4. NOC\3.API (Public Works) -revised 2019-02-07.docx PWL20-837GS CITY OF CARLSBAD PUBLIC WORKS LETTER OF AGREEMENT Carlsbad Water Recycling Facility Lock Replacement This letter will serve as an agreement between Carlsbad Village Lock & Key, Inc., a California corporation (Contractor) and the City of Carlsbad (City). The Contractor will provide all equipment, material and labor necessary to replace door lock cylinders and associated hardware at the Carlsbad Water Recycling Facility, per Exhibit A, Band City specifications, for a sum not to exceed two thousand five dollars and ninety cents ($2,005.90). This work is to be completed within sixty (60) working days after issuance of a Purchase Order. ADDITIONAL REQUIREMENTS 1. City of Carlsbad Business License 2. The Contractor shall assume the defense of, pay all expenses of defense, and indemnify and hold harmless the City, and its agents, officers, officials, employees, and volunteers from all claims, loss, damage, injury and liability of every kind, nature and description, directly or indirectly arising from or in connection with the performance of this Contract or work; or from any failure or alleged failure of the contractor to comply with any applicable law, rules or regulations including those relating to safety and health; except for loss or damage which was caused solely by the active negligence of the City; and from any and all claims, loss, damage, injury and liability, howsoever the same may be caused, resulting directly or indirectly from the nature of the work covered by this Contract, unless the loss or damage was caused solely by the active negligence of the City. The expenses of defense include all costs and expenses, including attorney's fees for litigation, arbitration, or other dispute resolution method. 3. Contractor shall furnish policies of general liability insurance, automobile liability insurance and a combined policy of workers compensation and Employers' Liability in an insurable amount of not less than one million dollars ($1,000,000) each, unless a lower amount is approved by the Risk Manager or the City Manager. Said policies shall name the City of Carlsbad as an additional insured. The full limits available to the named insured shall also be available and applicable to the City as an additional insured. Insurance is to be placed with California admitted insurers that have a current Best's Key Rating of not less than "A-:VII",; OR with a surplus line insurer on the State of California's List of Approved Surplus Line Insurers (LASLI) with a rating in the latest Best's Key Rating Guide of at least "A:X"; OR an alien non-admitted insurer listed by the National Association of Insurance Commissioners (NAIC) latest quarterly listings report. Proof of all such insurance shall be given by filing certificates of insurance with contracting department prior to the signing of the contract by the City. 4. The Contractor shall be aware of and comply with all Federal, State, County and City Statues, Ordinances and Regulations, including Workers Compensation laws (Division 4 California Labor Code) and the "Immigration Reform and Control Act of 1986" (BUSC, Sections 1101 through 1525), to include but not limited to, verifying the eligibility for employment of all agents, employees, subcontractors and consultants that are included in this Contract. 5. The Contractor may be subject to civil penalties for the filing of false claims as set forth in the California False Claims Act, G:ment Code sections 12650, et seq., and Carlsbad Municipal Code Sections 3.32.025, et seq. ~ init _____ init 6. The Contractor hereby acknowledges that debarment by another jurisdiction is grounds for the City of Carlsbad to disqualify the Contractor from participating in contract bidding. W---init ___ init 7. The Contractor agrees and hereby stipulates that the proper venue and jurisdiction for resolution of any disputes between the parties arising out of this agreement is San Diego County, California. Carlsbad Water Recycling Facility Lock Replacement - 1 -City Attorney Approved 2/29/2016 PWL20-837GS 8. The general prevailing rate of wages, for each craft or type of worker needed to execute the contract, shall be those as determined by the Director of Industrial Relations pursuant to the Section 1770, 1773 and 1773.1 of the California Labor Code. Pursuant to Section 1773.2 of the California Labor code, a current copy of applicable wage rates is on file in the office of the City Engineer. Contractor shall not pay less than the said specified prevailing rates of wages to all workers employed by him or her in the execution of the work covered by this Letter of Agreement. Contractor and any subcontractors shall comply with Section 1776 of the California Labor Code, which generally requires keeping accurate payroll records, verifying and certifying payroll records, and making them available for inspection. Contractor shall require any subcontractors to comply with Section 1776. 9. City Contact: Charles Balteria 760-434-2949 Contractor Contact: Craig Pahl, 760-434-6600 CONTRACTOR Carlsbad Village Lock & Key, Inc., a California corporation 3138 Roosevelt Street, Suite E Carlsbad, CA 92008 P: 760-434-6600 F: N/A cvlkco3@gmail.com By: (D ~µ;~w (sign here)=-= ,L'--R..\\-E:_, L. ~A"-.\ (print name/title) By: (sign here) (print name/title) CITY OF CARLSBAD, a municipal corporation of the State of California By: Dated: Public Works nager (Proper notarial acknowledgment of execution by Contractor must be attached. Chairman, president or vice-president and secretary, assistant secretary, CFO or assistant treasurer must sign for corporations. Otherwise, the corporation must attach a resolution certified by the secretary or assistant secretary under corporate seal empowering the officer(s) signing to bind the corporation.) APPROVED AS TO FORM: CELIA A. BREWER, City Attorney See Attached Acknowledgment BY: Carlsbad Water Recycling Facility Lock Replacement -2 -City Attorney Approved 2/29/2016 CALIFORNIA. ALLEPURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189 A notary pubiic or other rfficer completi~g 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~ ':---.._ ) 1~\~o ) . . On _J__:~ Lz-( q before me,\.,..e&\\. e. ~do'\,C) Q_\fucc:\ f\~':-f ~ Date Here lnse~~e and Title of the Officer personally appeared o1 ,' ch-e. l 112_ L ,pa., h J ______ _ Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. , . ·1 certify under PENAL TY OF PERJURY under the laws · of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. ! Sign Place Notary Seal Above ---------------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(ies) Claimed by Signer(s) Signer's Name: ____________ _ Signer's Name: ____________ _ □ Corporate Officer -Title(s): ______ _ □ Corporate Officer -Title(s): ______ _ □ Partner -□ Limited □ General □ Partner -□ Limited □ General □ Individual □ Attorney in Fact □ Individual □ Attorney in Fact □ Trustee □ Guardian or Conservator □ Trustee □ Guardian or Conservator □Other: ______________ _ □ Other: ____________ _ Signer Is Representing: ________ _ Signer Is Representing: ©2014 National Notary Association• www.N::it,, ,:g • 1-800-US NOTARY (1-800-876-6827) Item #5907 PWL20-837GS EXHIBIT A Carlsbad Water Recycling Facility Lock Replacement Contractor to provide all materials, tools and labor necessary to re-key eight (8) doors, replace twelve (12) lock cylinders and associated hardware at the Carlsbad Water Recycling Facility located at 6220 Avenida Encinas, Carlsbad, CA 92011. Scope of Work shall consist of all items mentioned in the contractor's proposal dated June 25, 2019 and is attached to this document as Exhibit "B". SCOPE OF WORK AND FEE DESCRIPTION PRICE Carlsbad Water Recycling Facility Lock Replacement $2,005.90 TOTAL $2,005.90 *Includes taxes, fees, expenses and all other costs. Carlsbad Water Recycling Facility Lock Replacement Page 3 of 4 City Attorney Approved 9/27/16 Carlsbad Vllage Loci: and Key 3138 Roosevelt St Sule E Carlsbad, Ca 92008 Office Phone 760-434 6600 c-.t:co3@gmalcom BIi To Cly Of Carlsbad / Facatles 405 Oak Ave Carlsbad. CA 92008 Merchandise EXHIBIT B PWL20-837GS Estimate Estimate Number: El90625263 06/25/2019 Due o n Rece~t 2,005.90 Michele Pahl Estimate Date: Payment Terms: Estimate Amount: created By: Ship To Cly Of Carlsbad I Facllilles 405 Oal:Ave Carlsbad. CA 92008 9.00 97.30 X 875.70 Schlage VfQP SDGE AAl6 Cylnders, (2-Gate, and l -SDG& E Room). 3.00 132.70 X 398.10 Merchandise LOO lll.00 X lll.00 Schlage double C)1inder Deadbolt • gate. Rel:ey 8.00 19.00 152.00 Labor LOO 202.50 202.50 to Install T~Charge LOO 65.00 65.00 ----- Keys 25.00 3.50 X 87.50 Comments: Subtotal. $1,891.80 Carlsbad Water Dept -Charles Tax Rate Rate 7.75% Tax Rate Amount: 114.10 Estimate Amount $2,005.90 Carlsbad Water Recycling Facility Lock Replacement Page 4 of 4 ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD/YYYY) ~ 07/19/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(sl. PRODUCER CONTACT Jennifer Joiner NAME: State Farm Hugh Kollar, License #OD62232 r.~~N,_t ~••· 760-730-9110 l FAX iAJc Nol: 760-730-9112 A" 527 Carlsbad Village Drive ~tD~~ss: jennifer@hughkollar.com Carlsbad, CA 92008 INSURER!Sl AFFORDING COVERAGE NAIC# INSURER A: State Farm General Insurance Company 25151 INSURED INSURER B: Carlsbad Village Lock and Key, Inc. INSURER C: 3138 Roosevelt St, Ste E INSURER D: Carlsbad, CA 92008-3020 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER· REVISION NUMBER· THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE ,.,en WHn POLICY NUMBER IMM/DD/YYYYl 1MM/DD/YYYYl LIMITS lX COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 ~ CLAIMS-MADE [Z] OCCUR DAMAGE TO RENTED 300,000 PREMISES !Ea occurrence\ $ ~ MED EXP (Any one person) $ 10,000 A y 90-EH-U697-3 02/15/2019 02/15/2020 PERSONAL & ADV INJURY $ 2,000,000 ~ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 / :zi □PRO-□LOG 4,000,000 POLICY JECT PRODUCTS -COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY y 469 3369-B 15-55 02/15/2019 08/15/2019 yE~~~~~~~t?NGLE LIMIT $ -ANY AUTO BODILY INJURY (Per person) $ 1,500,000 -OWNED X SCHEDULED A BODILY INJURY (Per accident) s 1,500,000 -AUTOS ONLY AUTOS HIRED NON-OWNED ;p~~~~c~:~t?AMAGE $ 1,100,000 -AUTOS ONLY -AUTOS ONLY $ UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ - EXCESS LIAB CLAIMS-MADE AGGREGATE $ OED I I RETENTION $ s WORKERS COMPENSATION XI ~ifTuTE I I OTH- AND EMPLOYERS' LIABILITY ER Y/N 1,000,000 A ANY PROPRIETOR/PARTNER/EXECUTIVE □ y 90-EH-U672-0 02/15/2019 02/15/2020 E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L. DISEASE -EA EMPLOYEE $ 1,000,000 If yes, describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER IS ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Carlsbad I CMWD ACCORDANCE WITH THE POLICY PROVISIONS. c/o EXIGIS Insurance Compliance Services AUTHORIZED REPRESENTATIVE PO Box 4668 -ECM #35050 New York, NY 10163-4668 Jert111fer Joirter I © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.12 03-16-2016 Policy No. 90-EH-U697-3 CMP-4786.1 Page 1 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CMP-4786.1 ADDITIONAL INSURED -OWNERS, LESSEES, OR CONTRACTORS (Scheduled) This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 90-EH-U697-3 Named Insured: CARLSBAD VILLAGE LOCK AND KEY, INC. 3138 ROOSEVELT ST, STE E CARLSBAD, CA 92008-3020 Name And Address Of Additional Insured Person Or Organization: CITY OF CARLSBAD/ CMWD C/O EXIGIS INSURANCE COMPLIANCE SERVICES PO BOX 4668 -ECM #35050 NEW YORK, NY 10163-4668 1. SECTION II -WHO IS AN INSURED of SECTION II -LIABILITY is amended to in- clude, as an additional insured, any person or organization shown in the Schedule, but only with respect to liability for "bodily injury", "property damage", or "personal and advertis- ing injury" caused, in whole or in part, by: a. Ongoing Operations (1) Your acts or omissions; or (2) The acts or omissions of those acting on your behalf; in the performance of your ongoing opera- tions for that additional insured; or b. Products -Completed Operations "Your work" performed for that additional insured and included in the "products- completed operations hazard". However, Paragraph 1. above is subject to the following: a. The insurance afforded to the additional insured only applies to the extent permit- ted by law; b. If coverage provided to the additional in- sured is required by a contract or agree- ment, the insurance provided to the additional insured will not be broader than that which you are required by the contract or agreement to provide for such addition- al insured; and c. If the contract or agreement between you and the additional insured is governed by California Civil Code Section 2782 or 2782.05, the insurance provided to the additional insured is the lesser of that which: (1) Is allowed for the satisfaction of a de- fense or indemnity obligation by Cali- fornia Civil Code Section 2782 or 2782.05 for your sole liability; or (2) You are required by contract or agreement to provide for such addi- tional insured. We have no duty to defend or indemnify the additional insured under this endorsement un- til a claim or "suit" is tendered to us. ©, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. CONTINUED 2. Any insurance provided to the additional in- sured shall only apply with respect to a claim made or a "suit" brought for damages for which you are provided coverage. 3. With respect to the insurance afforded to the additional insured, the following is added to SECTION II -LIMITS OF INSURANCE: If coverage provided to the additional insured is required by contract or agreement, the most we will pay on behalf of the additional insured will be the lesser of the amount of insurance: a. Required by the contract or agreement; or b. Available under the applicable Limits Of Insurance shown in the Declarations. This endorsement shall not increase the ap- plicable Limits Of Insurance shown in the Declarations. 4. With respect to the insurance afforded to the additional insured, the following is added to Paragraph 3. Duties In The Event Of Occur- rence, Offense, Claim Or Suit of SECTION II -GENERAL CONDITIONS: The additional insured must: a. See to it that we are notified as soon as practicable of an "occurrence" or an of- fense which may result in a claim. To the extent possible, notice should include: (1) How, when and where the "occur- rence" or offense took place; (2) The names and addresses of any in- jured persons and witnesses; and CMP-4786.1 CMP-4786.1 Page 2 of 2 (3) The nature and location of any injury or damage arising out of the "occur- rence" or offense; b. Tender the defense and indemnity of any claim or "suit" to us and to all other insur- ers who may have insurance potentially available to the additional insured; and c. Agree to make available any other insur- ance the additional insured has for de- fense or damages for which we would provide coverage under SECTION II - LIABILITY. 5. With respect to the insurance afforded the ad- ditional insured, the following replaces SEC- TION II -LIABILITY of Paragraph 7. Other Insurance of SECTION I AND SECTION II - COMMON POLICY CONDITIONS: a. This insurance is primary to and will not seek contribution from any other insurance available to the additional insured, provided that the additional insured is a named in- sured under such other insurance. b. Regardless of any agreement between you and the additional insured, this insur- ance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional in- sured has been added as an additional in- sured on other policies. There will be no refund of premium in the event this endorsement is cancelled. All other policy provisions apply. 1007033 148011 08-21-2014 ©, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. StateFamt STATE FARM°' A. 000 Old Rlv8r Road Bal<erslield CA 93311-9501 CITY OF CARLSBAD/ CMWD A C/O EXIGIS INSURANCE COMPLIANCE SERVICES PO BOX 4668 -ECM #35050 NEW YORK, NY 10163-4668 DATE OF NOTICE: CODE: 24372 NOTE: PLEASE NOTIFY STATE FARM AT THE ADDRESS LISTED AT THE TOP, LEFT CORNER OF THIS PAGE REGARDING ANY CHANGE OF ADDRESS INFORMATION. [ ADDITIONAL INSURED'S NOTICE o_F_c_o_v_E_R_A_G_E ______________________ ______. Slate Farm Mutual Automobile Insurance Company NAMED INSURED: POLICY NO: 469 3369-B15-55 0775·FB2F-A COVERAGE: ,.. CARLSBAD VILLAGE LOCK & KEY, INC YR/MAKE/MODEL: 2017 FORD TRANSIT 250 VIN/CAMPER: 1 FTYR2CM9HKA34201 AGENT NAME: Hugh Kollar, 55-0775 SI AND PD LIABILITY 0 ~ :; :g "" 3138 ROOSEVELT ST, STE E CARLSBAD, CA 92008-3020 AGENT PHONE: 760-730-9110 ENDORSEMENT NO: 6028BU POLICY EFFECTIVE 07/19/2019 i POLICY MESSAGES: ,. The policy includea a leas payable clause protecting the additional insured'• Interest In the de&oribed oar to the ex!ent ot the insurance ~ provided and subject to all policy provisions. The additional insured will be given 20 daya notice If the poficy Is terminated. Until such notioe ;; is provided, rt shall be presumed that the required renewaJ premiums h.3.ve been poid. The ;1dditiona1 insured must notify us within 1 O d..1ys of ~ any ohange of interest or ownership coming to their attention. Failure to do so will render this policy nllll and void. ~ FRT WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) 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 5 % of the California workers' compensation premium ---- otherwise due on such remuneration. Person or Organization CITY OF CARLSBAD/ CMWD Schedule Job Description WAIVER OF SUB C/O EXIGIS INSURANCE COMPLIANCE SERVICES PO BOX 4668 -ECM #35050 NEW YORK, NY 10163-4668 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective o 7 / 1 9 / 2 o 1 9 Insured CARLSBAD VILLAGE LOCK & KEY, INC 3138 ROOSEVELT ST, STE E CARLSBAD, CA 92008-3020 WC 04 03 06 (Ed. 4-84) Policy No . .9 0-ER -=-D--672-o Endorsement No. Insurance Company State Farm Fire and Casualty Company Countersigned By Je11J11fer Jo/Mer 1007722 124282.1 09-28-2015