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HomeMy WebLinkAboutExact Construction; 2018-12-17; PKRC686Tracking#: CITY OF CARLSBAD PUBLIC WORKS LETTER OF AGREEMENT CONCRETE ENTRYWAY EXPANSION AT ALGA NORTE DOG PARK: CONTRACT PKRC686 This letter will serve as an agreement between Exact Construction, a sole proprietor (Contractor) and the City of Carlsbad (City). The Contractor will provide all equipment, material and labor necessary to excavate, grade, and compact new concrete walkway to large dog run entrance at Alga Norte Dog Park, per the Contractor's proposal dated November 12, 2018 and City specifications, for a sum not to exceed four thousand four hundred eighty dollars ($4,480.00). This work is to be completed within forty-five 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" (8USC, 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?yemp,ent ~?de s~s 1 ~6_50, et seq .. and Carlsbad Municipal Code Sections 3.32.025, etseg~-~ ___ mIt K9,.,..J.Q1t 6. The Contractor hereby acknowledges that debarment by another jurisdictio~ounds ~e City of Carlsbad to disqualify the Contractor from participating in contract biddin~it . ?~it 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. CONCRETE ENTRYWAY EXPANSION AT ALGA NORTE DOG PARK CONTRACT PKRC686 --1 --City Attorney Approved 2/29/2016 Tracking#: 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: Tim Selke 760-434-2857 Contractor Contact: Aharon Millet 619-254-5497 CONTRACTOR Exact Construction 1195 Angelus Avenue San Diego, CA 92114 619-254-5497 aharon@exactconstruction.org (print name/title) By: (sign here) (print name/title) CITY OF CARLSBAD, a municipc:11 corporation of the State of California By ~Q CHRIS HELTIN Parks & Recreation Director Dated: (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 BY: CONCRETE ENTRYWAY EXPANSION AT ALGA NORTE DOG PARK CONTRACT PKRC686 --2 --City Attorney Approved 2/29/2016 EXACT CONSTRUCTION Ca. Lie. 896546 1195 Angelus Ave. San Diego Ca. 92114 619-254-5497 To: City of Carlsbad Attn: Tim Selke RE: Concrete work needed at City Park Job Location: Alga Norte Dog Park OVERVIEW: Bid Proposal 11/12/2018 Aharon Millet a licensed California contractor with a B class general builder license and a C-8 concrete specialty class license, owner of of Exact Construction proposes to install a .... 256 square foot concrete pad inside the dog run area, near the entrance. Details are as follows .......... . 1. Excavate 4 inches of dirt in the work area. 2. Grade and compact area. 3. Drill into existing perimeter slab and install #3 rebar dowells 18 inches on center. 4. Set forms. 5. Pour and finish concrete. The grand total price for all phases will be ................................................ $4,480 ACORi:I I DAff CMMftlOlt nf> CERTIFICATE OF LIABILITY INSURANCE ~ 09/14/2018 THIS CERTlFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRIIA 11VEL Y 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 certlflcata holder Is an ADDmONAL INSURED, the pollcy(i..) muat have ADDITIONAL INSURED provisions or be enclot9ad. "SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, cettaln pollclN may require an endor'NrMnt. A statement on this c:ertlflc:aw doN not conr.r rfahta to the certlftc:ate holder In lieu of such endoraementfa). l'RODUCER um':""' JORDANNE LOROSON StateFann STATE FARM INSURANCE JACK DALE AGENCY ~ ·--6194371709 I~-.. A. 1001 BA.VE. ~13 ~-JORDANNE.DALE.PlJAROSTATEFARM.COM CORONADO CA 92118 AFF011119tGCOVDAGI! NAICI INIIUltEII A: State Farm General Insurance Company 25151 INSURED ~-: DONWYN AHARON MILLET INIURERC: 1195 ANGELUS AVE. INSUREltD: SAN DIEGO CA 92114 INSURERE: INSURERP: 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. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT V\1TH RESPECT TO IM-IICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. COIIMERaAL GENERAL UAal1Y =• Cl.AIMS MADE • OCCUR >------------ >----------- , __ ...,._..,_ POI.ICY 11:1'1' POLICY EXP EACH OCCURRENCE • PERSONAL & NW INJURY S GEN'l AGGREGAlE LNIT AP1'I..IES PER: GENERALAGGREGAlE $ ·- Fl = • 78r • LOC PRODUCTS -COMP/OP AGG : ,1AU~l'l'~OIIOBl~:til.E!LUA81UTYMUTY:------rvvr1~2!99645~~1404011i1155G55C3---1091ogj:1i4412Dm1tt8lj0041~1111/202011i99U~=~' ,.~,_..~cl1~LMT~J~•~7~50~.000~===1 / !Z AHY AUTO BODA. Y INJURY (P• peraon) S >--~~ ONLY -~D BODLY INJURY (Per ac:cilllft) S HIRED -NC>N--OV'MED l'KUl"ERlYLJAMN.t .._ AUTOS ONLY _ AUTOS ONLY • s ....,_ u•RELLA LIAII H OCCUR EXCEIS LIAII ~ EACH OCCURRENCE • AGGREGATE • OED I Inc IS • WORKERS COlll'BISATION AND EIIPLOYERS' LIUIU1Y y I H N« PROPRIETOR/PARTNERIEXECUTIVE • OFFICERIUEMBER EXCLUDED? NI A E.L EACH ACCDENT s (llandllarylnNH) E.L DISEASE· EA EIIPLOYEE S lr-,dNatleinlar DESCRIPTION OF OPERATIONS b1bw 1!.L OISEASE • P0UCY LNIT S DE8CRIP1ION OFOPERAllONSILOCATIONS/VEHICLES (ACORD 111,Adllllotlll.....,_ Sclledule, ma, lleallacllNI If-apace le,..._, CERTIFICATE HOLDER THE CITY OF CARLSBAD 799 PINE AVE t 200 CARLSBAD CA 9200&-2428 ACORD 21 (2018103) CANCELLATION C 1111-2011 ACORD CORPORATION. Al rights ,_.,.,eel, The ACORD name and logo.,. reg red marb of ACORD ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD/YYYY) i......,......-9/14/2018 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 ~~:~~CT Customer Service Department Target Insurance Services f.~~N.t ~~,. (800) 450-8013 I FAX iAJC Nol: (866) 227-3052 xCert 6630 Flanders Drive ~~lJ~ss: Certif ica tes@premieragencyservices . com INSURERISl AFFORDING COVERAGE NAIC# San Diego CA 92121 INSURER A :Associated Industries Ins Co Inc 23140 INSURED INSURER B :Homeland Ins Co of New York 34452 Exact Construction INSURERC: 1195 Angelus Avenue INSURER D: INSURER E: San Diego CA 92114 INSURERF: COVERAGES CERTIFICATE NUMBER·GL/PL 18-19 REVISION NUMBER· THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR ,~gJ55~ ,:~i-i~i~. LTR ,.,~n un,n POLICY NUMBER LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 f--D CLAIMS-MADE [i] OCCUR ~~~~~~J9E:~~uEr?encel A f-- $ 100,000 X AES104135602 8/2/2018 8/2/2019 MED EXP (Any one person) $ 5,000 f-- PERSONAL & ADV INJURY $ 1,000,000 f-- GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 Fl 0PRO-DLoc 2,000,000 POLICY JECT PRODUCTS -COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY fE~~~~~~llNGLE LIMIT $ - ANY AUTO BODILY INJURY (Per person) $ -ALL OWNED -SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ f---NON-OWNED ;p~~~~~Je~t?AMAGE HIRED AUTOS AUTOS $ f---$ UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ f-- EXCESS LIAB CLAIMS-MADE AGGREGATE $ OED I I RETENTION$ $ WORKERS COMPENSATION T PER T TOTH- AND EMPLOYERS' LIABILITY STATUTE ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE • EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L. DISEASE -EA EMPLOYEI $ ~m:~ftir8~ ~~~PERATIONS below E.L. DISEASE -POLICY LIMIT $ B Pollution Liability 793-00-80-01-0000 5/9/2018 5/9/2019 Policy Aggregate $1,000,000 Contractors Pollution $1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) City of Carlsbad is named as Additional Insured per the attached Endorsement. *Additional Insured status is subject to all policy terms, exclusions and conditions* CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Carlsbad THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATTN: Parks & Recreation ACCORDANCE WITH THE POLICY PROVISIONS. 799 Pine Avenue Suite 200 Carlsbad, CA 92008 AUTHORIZED REPRESENTATIVE ~•~ .. H *Account Carl/ALYV -© 1988-2014ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) INS025 1?014011 The ACORD name and logo are registered marks of ACORD / POLICY NUMBER: AES1041356 02 COMMERCIAL GENERAL LIABILITY NX GL 009 08 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON-CONTRIBUTING INSURANCE (THIRD-PARTY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Third Party: All persons or organizations where required by written contract with the Named Insured (Absence of a specifically named Third Party above means that the provisions of this endorsement apply as required by written contractual agreement with any Third Party for whom you are performing work.) Paragraph 4. of SECTION IV: COMMERCIAL GENERAL LIABILITY CONDITIONS is replaced by the following: 4. Other Insurance: With respect to the Third Party shown above, this insurance is primary and non-contributing. Any and all other valid and collectable insurance available to such Third Party in respect of work performed by you under written contractual agreements with said Third Party for loss covered by this policy, shall in no instance be considered as primary, co-insurance, or contributing insurance. Rather, any such other insurance shall be considered excess over and above the insurance provided by this policy. NX GL 009 08 09 Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission POLICY NUMBER: AES 1041356 02 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: All persons or organizations where required by written contract with the Named Insured Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV -Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products- completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 • POLICY NUMBER:AES1041356 02 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person(s) or Location and Description of Completed Oraanization(s): Ooerations All persons or organizations where written contract with the Named Insured requires additional insured completed operations coverage. This form does not apply to your work on residential orooertv Information required to complete this Schedule if not shown above will be shown in the Declarations. 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" or "property dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 • COMMERCIAL GENERAL LIABILITY CG 20 33 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 II -Who Is An Insured is amended to include as an additional insured any person or or- ganization 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 addi- tional insured on your policy. Such person or or- ganization is an additional insured only with re- spect 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. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are com- pleted. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the render- ing of, or the failure to render, any professional architectural, engineering or surveying servic- es, including: a. The preparing, approving, or failing to pre- pare or approve, maps, shop drawings, opi- nions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. 2. "Bodily injury'' or "property damage" occurring after: a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than ser- vice, maintenance or repairs) to be per- formed by or on behalf of the additional in- sured(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 another contractor or subcontrac- tor engaged in performing operations for a principal as a part of the same project. CG 20 33 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 D POLICYHOLDER COPY STATE -....UMFF~SA-IUN INSUAAI\JCE P.O. BOX 8192, PLEASANTON, CA 94588 FUND ISSUE DATE: 09-14-2018 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE GROUP: CITY OF CARLSBAD PARKS & RECREATION ADMIN 799 PINE AVE STE 200 CARLSBAD CA 92008-2428 SP POLICY NUMBER: 1974447-2018 CERTIFICATE ID: 48 CERTIFICATE EXPIRES: 08-01-2019 08-01-2018/08-01-2019 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. ~-IC:t! £/ IL,,. xll~ Authorized Representative President and CEO UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPENSATION LAW. EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2018-09-14 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF CARLSBAD PARKS & RECREATION AOMIN ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-01-2014 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER MILLET, DONWYN AHARON EXACT CONSTRUCTION SP 1195 ANGELUS AVE SAN DIEGO CA 92114 (REV.7-2014) PRINTED [JG3,CS) 09-14-2018 SP CERTHOLDER COPY STATE ...,QMPEN':,A-ION INSUl=IA"'J:::E P.O. BOX 8192, PLEASANTON, CA 94588 FUND ISSUE DATE: 09-14-2018 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE GROUP: CITY OF CARLSBAD PARKS & RECREATION ADMIN 799 PINE AVE STE 200 CARLSBAD CA 92008-2428 SP POLICY NUMBER: 1974447-2018 CERTIFICATE ID: 48 CERTIFICATE EXPIRES: 08-01-2019 08-01-2018/08-01-2019 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. ~tl-fii:/ tL-~ .di~ Authorized Representative President and CEO UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPENSATION LAW. EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2018-09-14 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF CARLSBAD PARKS & RECREATION ADMIN ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-01-2014 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER MILLET, DONWYN AHARON EXACT CONSTRUCTION SP 1195 ANGELUS AVE SAN DIEGO CA 92114 (REV.7-2014) [JG3,CS] PRINTED 09-14-2018 SP