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HomeMy WebLinkAboutHaitbrink Asphalt Paving Inc; 2019-01-09; PKRC688'/ \P RECORDED REQUESTED BY CITY OF CARLSBAD AND WHEN RECORDED PLEASE MAIL TO: City Clerk City of Carlsbad 1200 Carlsbad Village Drive Carlsbad, California 92008 DOC# 2019-0204203 111111111111 lllll 11111111111111111111111111111111111111111111111111111 May 29, 2019 02:09 PM OFFICIAL RECORDS Ernest cl Dronenburg, Jr , SAN DIEGO COUNTY RECORDER FEES $0 00 (SB2 Atkins $0 00) PAGES 1 Space above this line for Recorder's use. PARCEL NO: NOTICE OF COMPLETION Notice is hereby given that: 1. The undersigned is owner of the 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 May 7, 2019. 6. The name of the contractor for such work or improvement is Haitbrink Asphalt Paving, Inc. 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. PKRC688, Asphalt Paving Refurbishment at Robertson Ranch East Trait. 8. The location of said property is the pedestrian walkway off of Glen Ave. in the City of Carlsbad. 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 ':::{YJ~ o20 , 2ofl_, accepted the above described work as completed and orderedtt a Notice of Completion be filed. I declare under penalty of perjury that the foregoing is true and correct. Executed on c::S / c9 K , , 20.Jj_, at Carlsbad, California. Q:\Public Works\PW Common\CAPITAL-ACTIVE\PKRC688 Asphalt Paving Refurbishment at Robertson Ranch East Trail\NOC (Public and Private) - PKRC688.doc CITY OF CARLSBAD ACCEPTANCE OF PUBLIC IMPROVEMENTS COMPLETION OF PUBLIC IMPROVEMENTS Haitbrink Asphalt Paving, Inc. has completed the contract work required for Contract No. PKRC688, Asphalt Paving Refurbishment at Robertson Ranch East Trail. City forces have inspected the work and found it to be satisfactory. The work consisted of: IMPROVEMENTS City Asphalt paving refurbishment VALUE $19,592 CERTIFICATION OF COMPLETION OF IMPROVEMENTS 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. , City Manager Date APPROVED AS TO FORM: CELIA BREWER, City Attorney Q \Public Works\PW Common\CAPITAL-ACTIVE\PKRC688 Asphalt Paving Refurbishment at Robertson Ranch East Tra1I\API (Public Works) -PKRC688.doc CITY OF CARLSBAD MINOR PUBLIC WORKS CONTRACT ASPHALT PAVING REFURBISHMENT AT ROBERTSON RANCH EAST TRAIL CONT. NO. PKRC688 Tracking#: This agreement is made on the ;[1th day of---"'_.,-==L.....L.==-=~---· 20.J..9_, by the City of Carlsbad, California, a municipal corporation, (hereinafter called " t "), and Haitbrink Asphalt Paving, Inc. whose principal place of business is 1480 Magnolia Avenue, Corona, CA 92879 (hereinafter called "Contractor"). City and Contractor agree as follows: DESCRIPTION OF WORK. Contractor shall perform all work specified in the Contract documents for the project described by these Contract Documents (hereinafter called "Project"). PROVISIONS OF LABOR AND MATERIALS. Contractor shall provide all labor, materials, tools, equipment, and personnel to perform the work specified by the Contract Documents unless excepted elsewhere in this Contract. CONTRACT DOCUMENTS. The Contract Documents consist of this Contract, exhibits to this Contract, Contractor's Proposal, the Plans and Specifications, the General Provisions, addendum(s) to said Plans and Specifications, and all proper amendments and changes made thereto in accordance with this Contract or the Plans and Specifications, all of which are incorporated herein by this reference. When in conflict, this Contract will supersede terms and conditions in the Contractor's proposal. LABOR. Contractor will employ only skilled workers and abide by all State laws and City of Carlsbad Ordinances governing labor. GUARANTEE. Contractor guarantees all labor and materials furnished and agrees to complete the Project in accordance with directions and subject to inspection approval and acceptance by: Kasia Trojanowska (City Project Manager) WAGE RATES. 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 Sections 1770, 1773 and 1773.1 of the Labor Code. Pursuant to Section 1773.2 of the Labor Code, a current copy of the 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 execution of the Contract. Contractor shall be responsible for insuring compliance with provisions of section 1777.5 of the Labor Code and section 4100 et seq. of the Public Contracts Code, "Subletting and Subcontracting Fair Practices Act." The City Engineer is the City's "duly authorized officer" for the purposes of section 4107 and 4107.5. The provisions of Part 7, Chapter 1, of the Labor Code commencing with section 1720 shall apply to the Contract for work. A contractor or subcontractor shall not be qualified to bid on, be listed in a bid proposal, subject to the requirements of Section 4104 of the Public Contract Code, or engage in the performance of any contract for public work, unless currently registered and qualified to perform public work pursuant to Section 1725.5. This project is subject to compliance monitoring and enforcement by the Department of Industrial Relations. 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. ASPHALT PAVING REFURBISHMENT AT ROBERTSON RANCH EAST TRAIL CONT. NO. PKRC688 Page 1 of 6 City Attorney Approved 9/27/2016 Tracking#: FALSE CLAIMS. Contractor hereby agrees that any contract claim submitted to the City must be asserted as part of the contract process as set forth in this agreement and not in anticipation of litigation or in conjunction with litigation. Contractor acknowledges that California Government Code sections 12650 et seq., the False Claims Act, provides for civil penalties where a person knowingly submits a false claim to a public entity. These provisions include false claims made with deliberate ignorance of the false information or in reckless disregard of the truth or falsity of the information. The provisions of Carlsbad Municipal Code sections 3.32.025, 3.32.026, 3.32.027 and 3.32.028 pertaining to false claims are incorporated herein by reference. Contractor hereby acknowledges that the filing of a false claim may subject the Contractor to an administrative debarment proceeding wherein the contractor may be prevented from further bidding on public contracts for a period of up to five years and that debarment by another jurisdiction is grounds for the City of Carlsbad to disqualify the Contractor or,bcozra~or from partici~ating in con~ct bidding. Signature / ~ • ~~,cJD Print Name: H""'I€_ Q:.\:_ L REQUIRED INSURANCE. The successful contractor shall provide to the City of Carlsbad, a Certification of Commercial General Liability and Property Damage Insurance and a Certificate of Workers' Compensation Insurance indicating coverage in a form approved by the California Insurance Commission. The certificates shall indicate coverage during the period of the contract and must be furnished to the City prior to the start of work. The minimum limits of liability insurance are 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. Commercial General Liability Insurance of Injuries including accidental death, to any one person in an amount not less than ........ $1,000,000 Subject to the same limit for each person on account of one accident in an amount not less than ....... $1,000,000 Property damage insurance in an amount of not less than ........ $1,000,000 Automobile Liability Insurance in the amount of $1,000,000 combined single limit per accident for bodily injury and property damage. In addition, the auto policy must cover any vehicle used in the performance of the contract, used onsite or offsite, whether owned, non-owned or hired, and whether scheduled or non- scheduled. The automobile insurance certificate must state the coverage is for "any auto" and cannot be limited in any manner. The above policies shall have non-cancellation clauses providing that thirty (30) days written notice shall be given to the City prior to such cancellation. The 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. WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY. Workers' Compensation limits as required by the California Labor Code. Workers' Compensation will not be required if Contractor has no employees and provides, to City's satisfaction, a declaration stating this. BUSINESS LICENSE. The Contractor and all subcontractors are required to have and maintain a valid City of Carlsbad Business License for the duration of the contract. ASPHALT PAVING REFURBISHMENT AT ROBERTSON RANCH EAST TRAIL CONT. NO. PKRC688 Page 2 of 6 City Attorney Approved 9/27/2016 Tracking#: INDEMNITY. The Contractor shall assume the defense of, pay all expenses of defense, and indemnify and hold ham,less the City, and its officers and employees, 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 the Contract or work; or from any failure or alleged failure of Contractor to comply with any applicable law, rules or regulations including those related to safety and health; and from any and all claims, loss, damages, injury and liability, howsoever the same may be caused, resulting directly or indirectly from the nature of the work covered by the Contract, except for loss or damage caused by the sole or active negligence or willful misconduct of the City. The expenses of defense include all costs and expenses including attorneys' fees for litigation, arbitration, or other dispute resolution method. JURISDICTION. 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. Start Work: Contractor agrees to start within 15 working days after receipt of Notice to Proceed. Completion: Contractor agrees to complete work within 60 working days after receipt of Notice to Proceed. CONTRACTOR'S INFORMATION. II II II II II II II Haitbrink Asphalt Paving, Inc. (name of Contractor) 517707 (Contractor's license number) C-12 & A, 9/30/2019 (license class. and exp. date) 1000009534 (DIR registration number) 6/30/2019 (DIR registration exp. date) ASPHALT PAVING REFURBISHMENT AT ROBERTSON RANCH EAST TRAIL CONT. NO. PKRC688 Page 3 of 6 1480 Magnolia Avenue ( street address) Corona, CA 92879 (city/state/zip) 951-273-0111 (telephone no.) (fax no.) haitbrinkdan@gmail.com (e-mail address) City Attorney Approved 9/27/2016 Tracking#: AUTHORITY. The individuals executing this Agreement and the instruments referenced in it on behalf of Contractor each represent and warrant that they have the legal power, right and actual authority to bind Contractor to the terms and conditions of this Agreement. CONTRACTOR I ( sign here~ / (-'-11.JTe'\'\. t44-;~.,/ ~ I ~••/)GJ'-4 (print name/title) (print name/title) CITY OF CARLSBAD, a municipal corporation of the State of California By· ,Jn CHRIS~ Parks & Recreation Director If required by City, proper notarial acknowledgment of execution by Contractor must be attached. If a corporation, Agreement must be signed by one corporate officer from each of the following two groups: Group A Chairman, President, or Vice-President Group B Secretary, Assistant Secretary, CFO or Assistant Treasurer 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 ASPHALT PAVING REFURBISHMENT AT ROBERTSON RANCH EAST TRAIL CONT. NO. PKRC688 Page 4 of 6 City Attorney Approved 9/27/2016 CALIFORNIA ALL-PURPOSE CERTIFICATE OF 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 _R_iv_e...;.r...;.s....;id--'e ______ _ } On 12/7/2018 before me, Tammy L. Long, Notary Public (Here insert name and tltle of the officer) personally appeared _H_u_n_te_r_H_a_itb_r_in_k ________________ _ who proved to me on the basis of satisfactory evidence to be the person(-s-) whose name(-s-)@Ja.re subscribed to the within instrument and acknowledged to me that ~he/they executed the same in~er/their authorized capacity(ies), and that by ~er/their signature(-s-) on the instrument the person(~, or the entity upon behalf of which the person(s-} acted, executed the instrument. I certify under PENAL TY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. \MTNESS my hand and official seal. Nola~ (Notary Public Seal) ~ ~ ~ ~ INSTRUCTIONS FOR COMPLETING THIS FORM ADDITIONAL OPTIONAL INFORMATION Thisfom1 complies with current California statutes regarding notary wording and, DESCRIPTION OF THE ATTACHED DOCUMENT if needed, should be completed and attached to the document. Acknowledgments from other states may be completed for documenls being sent lo that state so long as the wording does no/ require the California notary to violate California notaty City of Carlsbad Contract #PKRC688 law. (Title or description of attached document) Paving at Robertsons Ranch East Trail (Title or description of attached document continued) Number of Pages _6_ Document Date 12/7/2018 CAPACITY CLAIMED BY THE SIGNER □ Individual ( s) 0 Corporate Officer President (Title) D Partner(s) D Attorney-in-Fact □ Trustee(s) □ Other _________ _ • State and County information must be the State and County where the document signer(s) personally appeared before the notary public for acknowledgment. • Date of notarization must be the date that the signer(s) personally appeared which must also be the same date the acknowledgment is completed. • The notary public must print his or her name as it appears within his or her commission followed by a comma and then your title (notary public). • Print the name(s) of document signer(s) who personally appear at the time of notarization. • Indicate the correct singular or plural forms by crossing off incorrect forms (i.e. he/she/they, is /are) or circling the correct forms. Failure to correctly indicate this information may lead to rejection of document recording. • The notary seal impression must be clear and photographically reproducible. Impression must not cover text or lines. If seal impression smudges, re-seal if a sufficient area permits, otherwise complete a different acknowledgment form. • Signature of the notary public must match the signature on file with the office of the county clerk. ❖ Additional information is not required but could help to ensure this acknowledgment is not misused or attached to a different document. ❖ Indicate title or type of attached document, number of pages and date. ❖ Indicate the capacity claimed by the signer. If the claimed capacity is a corporate officer, indicate the title (i.e. CEO, CFO, Secretary). • Securely attach this document to the signed document with a staple. CALIFORNIA ALL-PURPOSE CERTIFICATE OF 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 _R_iv_e_r_s_id_e ______ _ } On 12/7/2018 before me, Tammy L. Lo?R~t~?~~~J~a:t?iU~officer) personally appeared _B_a_r_ba_r_a_H_a_itb_r_in_k ________________ _ who proved to me on the basis of satisfactory evidence to be the person(-s-) whose name(-s-)(@are subscribed to the within instrument and acknowledged to me that he~they executed the same in hi~their authorized capacity(ies), and that by hi~their signature(-s-) on the instrument the person(~, or the entity upon behalf of which the person(s} acted, executed the instrument. I 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. Nota,y~ .... I ~ T,,,,,,, L. LONG • COMM.I 22232•5 i ·. · NOTAIIY PUIUC-CALIFOIINIA ' AIVEASIOE CouetTY I MJ Co-. E1tt11 NOVEMIER 2•. 2011 (Notary Public Seal) INSTRUCTIONS FOR COMPLETING THIS FORM ADDITIONAL OPTIONAL INFORMATION Thisfom, complies with current Cal!fornia statutes regarding notary wording and, DESCRIPTION OF THE ATTACHED DOCUMENT if needed. sho11/d be completed and attached lo the document. Acknowledgments City of Carlsbad Contract #PKRC688 (Title or description of attached document) Paving at Robertsons Ranch East Trail (Title or description of attached document continued) Number of Pages _6_ Document Date 12/7/2018 CAPACITY CLAIMED BY THE SIGNER □ Individual (s) 0 Corporate Officer Secretary I Treasurer (Title) □ Partner(s) □ Attorney-in-Fact □ Trustee(s) □ Other __________ _ from other states 11101 be completed for documents being sent to that stale so long as the wording does not require the California notary to violate Cal!fornia notary /me • State and County information must be the State and County where the document signer(s) personally appeared before the notary public for acknowledgment. • Date of notarization must be the date that the signer(s) personally appeared which must also be the same date the acknowledgment is completed. • The notary public must print his or her name as it appears within his or her commission fi.)llowed by a comma and then your title (notary public). • Print the name(s) of document signer(s) who personally appear at the time of notarization. • Indicate the correct singular or plural forms by crossing off incorrect forms (i.e. he/she/they, is Iara) or circling the correct forms. Failure to correctly indicate this information may lead to rejection of document recording. • The notary seal impression must be clear and photographically reproducible. Impression must not cover text or lines. If seal impression smudges, re-seal if a sufficient area permits, otherwise complete a different acknowledgment form. • Signature of the notary public must match the signature on file with the office of the county clerk ❖ Additional information is not required but could help to ensure this acknowledgment is not misused or attached to a different document. ❖ Indicate title or type of attached document, number of pages and date. ❖ Indicate the capacity claimed by the signer. If the claimed capacity is a cotpornte officer, indicate the title (i.e. CEO, CFO, Secretary). • Securely attach this document to the signed document with a staple. Tracking#: EXHIBIT A LISTING OF SUBCONTRACTORS BY GENERAL CONTRACTOR Set forth below is the full name and location of the place of business of each sub-contractor whom the Contractor proposes to subcontract portions of the Project in excess of one-half of one percent of the total bid, and the portion of the Project which will be done by each sub-contractor for each subcontract. NOTE: The Contractor understands that if it fails to specify a sub-contractor for any portion of the Project to be performed under the contract in excess of one-half of one percent of the bid, the contractor shall be deemed to have agreed to perform such portion, and that the Contractor shall not be permitted to sublet or subcontract that portion of the work, except in cases of public emergency or necessity, and then only after a finding, reduced in writing as a public record of the Awarding Authority, setting forth the facts constituting the emergency or necessity in accordance with the provisions of the Subletting and Subcontracting Fair Practices Act (Section 4100 et seq. of the California Public Contract Code). If no subcontractors are to be employed on the project, enter the word "NONE." SUBCONTRACTORS Portion of Project to Business Name and Address DIR Registration License No., % of be Subcontracted No. Classification & Total Expiration Date Contract C!..Yl'.l.U-.fi'\\ C>..t\d e...."''""' f' Ii(.. ~Q..V.t..M,U\.)-MA.l'v-u .. ' "-t..L-u t.U\.A ... '\ ~ ,_ l -Z..I 3S-0/o S'°""'"v-r"-t -z.n-o1 t,0o..1Lr w~ c.+-. -t1i.. \ ooooS'--t ~St.. Cwr 'tl3o/ l&t M-U'\i k-. ~ "t 'l..~'-{ Total % Subcontracted: __ 8_-S-_1)~~=0-• __ The Contractor must perform no less than fifty percent (50%) of the work with its own forces. ASPHALT PAVING REFURBISHMENT AT ROBERTSON RANCH EAST TRAIL CONT. NO. PKRC688 Page 5 of6 City Attorney Approved 9/27/2016 EXHIBITB SCOPE OF WORK Tracking#: Haitbrink Asphalt Paving, Inc. will refurbish asphalt along pedestrian walkway at Robertson Ranch East Trail. All work shall be performed in accordance with attached proposal. ITEM UNIT QTY DESCRIPTION PRICE NO. : 1 $22.85/SF 550 • Remove failing asphalt paving • Haul asphalt waste off site • Install new 3" asphalt in designated areas $12,567.50 2 LS 1 • Crackfill cracks ¼" and larger prior to seal $3,000.00 3 $1.15/SF 3,500 • Install type 1 slurry asphalt walkway • Not responsible for any slipping on steep grade after slurry • Excludes TRMSS, REAS & RPMS slurries $4,025.00 TOTAL* $19,592.50 *Includes taxes, fee's, expenses and all other costs. Agreement shall not exceed $19,592.50. ASPHALT PAVING REFURBISHMENT AT ROBERTSON RANCH EAST TRAIL CONT. NO. PKRC688 Page 6 of 6 City Attorney Approved 9/27/2016 HAITBRINK ASPHALT PAVING INC. 1480 MAGNOLIA AVE Corona, CA 92879 951-273-0111 STATE CONTRACTOR'S LICENSE# 517707 PROPOSAL/CONTRACT BID TO: CITY OF CARLSBAD JOB DESCRIPTION: MISC ASPHALT PATCHING, SEAL COAT AND CRACK Fill LOCATION: PEDESTRIAN WALKWAY AT ROBINSON RANCH (TOILL BROS) DATE: 11/12/2018 ITEM DESCRIPTION QUANTITY UNIT REMOVE FAILING ASPHALT PAVING AND REPLACE DIR# 1000009534 BID No. 2729 FAX No. ATTN: KEVIN UNIT PRICE TOTAL 1 WITH 3" NEW ASPHALT AND HAUL OFF SITE 550 SF $ 22.85 $ 12,567.50 CRACKFILL CRACKS 1/4" AND LARGER PRIOR TO 2 SEAL 1 LS $ 3,000.00 $ 3,000.00 TYPE 1 SLURRY ASPHALT WALKWAY (NOT RESPONSIBLE FOR ANY SLIPPING ON STEEP GRADE AFTER SLURRY) EXCLUDES TRMSS,REAS & 3 RPMS SLURRIES 3,500 SF $ 1.15 $ 4,025.00 $ - TOTAL $ 19,592.50 ALL WOR K INCLUDES PREVAILING WAGES EXCLUDES: TESTING, ENGINEERING, INSPECTION, PERMITS, PERMIT FEES, SEAL COAT, PRIME COAT, WEED KILL, WET/SATURA- TED SOIL, CEMENT TREATED BASE, IMPORT/EXPORT OF DIRT, STRIPING, REDWOOD HEADER, ADDITIONAL MOVE INS, DAMAGE TO ANY UNMARKED UTILITIES OR BOXES AND PIPES, WATER, WATER METER,DEMO,TRAFFIC CONTROL OR PLANS ADJUSTMENT OF ANY UTILITIES OR BOXES, OR SPECIFICALLY STATED HEREIN. THE PRICES QUOTED IN THIS PROPOSAL ARE BASED UPON THE USE OF THIS FORM AND ITS TERMS AND CONDITIONS AS THE GOVERNIG CONTRACT AND ON THE PREMISE THAT EACH PHASE OF THE WORK CAN BE COMPLETED IN ONE (1) MOVE IN. ADD- ITIONAL MOVES ARE $4,500.00 __ EACH. WHEN SIGNED BY THE BUYER AND HAITBRINK ASPHALT PAVING INC., THIS WILL CONSTITUTE A FIRM CONTRACT BETWEEN BOTH PARTIES HERE TO. THIS PROPOSAL WILL BE GOOD FOR ONE (1) MONTH FROM DATE ABOVE. TERMS: NET CASH PAYMENT ON COMPLETED JOBS OR PROGRESS BILLING FOR WORK PERFORMED ARE DUE ON THE 10TH OF THE MONTH UNLESS OTHERWISE INDICATED. PRICES ARE SUBJECT TO CHANGE DUE TO ANY INCREASE COST OF ASPHALT MATERIAL PASSED ON BY THE SUPPLIER. IN THE CASE OF LITIGATION THE PREVALING PARTY SHALL BE ENTITLED TO ALL REASONBLE ATTORNEY FEES AND COST. BUYER: __________________________ _ BY: Dan Gelinas HAITBRINK ASPHALT PAVING INC -------------- DATE: BY ----------------- ------------------ ACORD8 CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDNYYY) ~ 12/14/2018 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Venbrook Insurance Services CA Lie 0D80832 CONTACT NAME: 6320 Canoga Avenue112th Floor PHONE 818-598-8900 I FAX 818-598-8910 Air a.1-~-.. \• !A/C Nol: Woodland Rills, CA 9 367 ~~D~~S,;: INSURER(S) AFFORDING COVERAGE NAIC# www.venbrook.com CA Lie No. 0080832 INSURER A: Executive Risk Indemnity Inc 35181 INSURED INSURER B: Federal Insurance Company 20281 Haitbrink As~halt Paving, Inc. INSURERC: Naviqators Specialty Insurance Company 36056 P.O. Box 23 9 Corona CA 92878 INSURER D: Insurance Company of the West 27847 INSURER E: INSURERF: COVERAGES CERTIFICATE NUMBER· 45935353 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 ,.,,.n wvn POLICY NUMBER !MM/DDNYYYl !MM/DD/YYYYl LIMITS A ,..:L_ COMMERCIAL GENERAL LIABILITY ✓ ✓ 54309863 12/15/2018 6/15/2020 EACH OCCURRENCE $1 000.000 ~ CLAIMS-MADE W OCCUR DAMAGE TO RENTED PREMISES /Ea occurrence l $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 Fl □PR~ □LOC $2 000.000 POLICY JECT PRODUCTS -COMP/OP AGG OTHER: $ B AUTOMOBILE LIABILITY ✓ ✓ 54309862 12/15/2018 6/15/2020 ~E~~~~d~~llNGLE LIMIT $1 000 000 ~ J_ ANY AUTO BODILY INJURY (Per person) $ -OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS ~ -HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY r Per accident\ $ ~ -$ C UMBRELLA LIAB HOCCUR LA 18EXCZOOVL VIC 12/15/2018 6/15/2020 EACH OCCURRENCE $1 000 000 ~ ✓ EXCESS LIAB CLAIMS-MADE AGGREGATE $1 000 000 I DED I I RETENTION$ $ D WORKERS COMPENSATION ✓ WSD 5030914 02 8/1/2018 8/1/2019 I PER I I OTH- AND EMPLOYERS" LIABILITY / STATUTE ER Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE GJ E.L. EACH ACCIDENT $1000000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L. DISEASE -EA EMPLOYEE $1 nnn nnn ~m~~~tif8~ on/OPERATIONS below E.L. DISEASE -POLICY LIMIT $1 000 000 DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) •10 day notice of cancellation for non-payment of premium, 30 days for all other. •• SEE ATTACHED ADDENDUM•• CERTIFICATE HOLDER CANCELLATION Ci~ of Carlsbad SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 12 0 Carlsbad Villa~e Drive ACCORDANCE WITH THE POLICY PROVISIONS. Carlsbad, CA 920 8 AUTHORIZED REPRESENTATIVE t)/4e~(PaP4._.> I (WH) Adrianna Padilla © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 45935353 I 18-20 GL/AL/EX/CP;lB-19 WC/CPL (WH) Adrianna Padilla I 12/14/2018 l:lJ:07 PM (PST) ! Page 1 of 11 AGENCY CUSTOMER ID: -------------------- LO C #: ------- ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED Venbrook Insurance Services CA Lie 0D80832 Haitbrink As~halt Paving, Inc. P.O. Box 23 9 POLICY NUMBER Corona CA 92878 CARRIER I NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability (03/16) HOLDER: City of Carlsbad ADDRESS: 1200 Carlsbad Village Drive Carlsbad, CA 92008 RE: Contract No. PKRC688 -Asphalt Paving Refurbishment at Robertson Ranch East Trail City of Carlsbad are named as Additional Insured under the General Liability and Automobile Liability policy if required by written contract with the Named Insured but only for coverages and limits provided by the policy and the additional insured endorsement. Primary and Non-Contributory coverage applies to Automobile Liability. Waiver of Subrogation applies to Automobile Liability and Workers Compensation. *10 Days Notice of Cancellation for Non-Payment of Premium, 30 Days All Others. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDENDUM 45935353 I 18-20 GL/AL/EX/CP;lB-19 WC/CPL (WH) Adrianna Padilla I 12/14/2018 1:10:07 PM (PST) I Page 2 of 11 Haitbrink Asphalt Paving, Inc. / POLICY NUMBER: 54309863 COMMERCIAL GENERAL LIABILITY CG 2010 0413 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 SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations WHERE REQUIRED BY WRITTEN CONTRACT. ALL LOCATIONS WHERE REQUIRED BY WRITTEN CONTRACT. Cit~ of Carlsbad 12 0 Carlsbad Villa~e Drive Carlsbad, CA 920 8 Information reauired 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. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. 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 2010 0413 © Insurance Services Office, Inc., 2012 Page 1 of 2 45935353 I 18-20 GL/AL/EX/CP;l8-19 WC/CPL I (WH) Adrianna Padilla I 12/14/2018 1,10,07 PM (PST) I Page 3 of 11 C. With respect to the insurance afforded to these additional insureds, the following is added to Section Ill -Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 2010 0413 45935353 ] 18-20 GL/AL/EX/CP;lB-19 WC/CPL I (WH) Adrianna Padilla I 12/14/2018 1:10:07 PM (PST) / Page 4 of 11 Haitbrink Asphalt Paving, Inc. POLICY NUMBER:54309863 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 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 PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations . WHERE REQUIRED BY WRITTEN CONTRACT, BUT ONLY ALL LOCATIONS WHERE REQUIRED BY WRITTEN CONTRACT. WHERE THE CONTRACT SPECIFIES COVERAGE FOR COMPLETED OPERATIONS. Citd of Carlsbad 12 0 Carlsbad Villa~e Drive Carlsbad, CA 920 8 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" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section Ill -Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 37 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 45935353 I 18-20 GL/AL/EX/CP;l8-19 WC/CPL I (WH) Adrianna Padilla I 12/14/2018 1,10,07 PM (PST) I Page 5 of 11 Haitbrink Asphalt Paving, Inc. POLICY NUMBER:54309863 COMMERCIAL GENERAL LIABILITY 10-02-2461 (Ed. 7-15) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY INSURANCE FOR SCHEDULED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Additional Insured: WHERE REQUIRED BY WRITTEN CONTRACT. City of Carlsbad 1200 Carlsbad Village Drive Carlsbad, CA 920CJ8 SCHEDULE Location Of Covered Operations: ALL LOCATIONS (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) With respect only to the Additional Insured and at the Location Of Covered Operations shown in the Schedule, the following is added to SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, Paragraph 4. Other Insurance and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to the Additional Insured with respect to the Location Of Covered Operations shown in the Schedule under this policy provided that: (1) The Additional Insured is a named insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the Additional Insured. 10-02-2461 (Ed. 7-15) Includes copyrighted material of Insurance Services Office, Inc., with its permission. 45935353 I 18-20 GL/AL/EX/CP;lB-19 WC/CPL I (WH) Adrianna Padilla I 12/14/2018 1:10:07 PM (PST) I Page 6 of 11 Page 1 of 1 Haitbrink Asphalt Paving, Inc. 54309863 Section IV-Commercial General Liability Conditions 8. Transfer Or Waiver Of Rights Of Recovery Against Others To Us We will waive the right of recovery we would otherwise have had against another person or organization, for loss to which this insurance applies, provided the insured has waived their rights of recovery against such person or organization in a contract or agreement that is executed before such loss. To the extent that the insured's rights to recover all or part of any payment made under this Cover-age Part have not been waived, those rights are transferred to us. The insured must do nothing after loss to impair them. At our request, the insured will bring "suit" or transfer those rights to us and help us enforce them. This condition does not apply to Coverage C. Citv of Carlsbad 1200 Carlsbad Village Drive Carlsbad, CA 92008 Executive Risk Indemnity, Inc. Commercial General Liability Coverage Form Form 10-02-1800 (Rev. 09-17) 45935353 I 18-20 GL/AL/EX/CP;18-19 WC/CPL I (WH) Adrianna Padilla I 12/14/2018 1'10,07 PM (PST) I Page 7 of 11 Haitbrink Asphalt Paving, Inc. 54309862 COMMERCIAL AUTOMOBILE 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 This endorsement modifies the Business Auto Coverage Form. 1. EXTENDED CANCELLATION CONDITION Paragraph A.2. b. -CANCELLATION -of the COMMON POLICY CONDITIONS form IL 00 17 is deleted and replaced with the following: b. 60 days before the effective date of cancellation if we cancel for any other reason. 2. BROAD FORM INSURED A. Subsidiaries and Newly Acquired or Formed Organizations As Insureds The Named Insured shown in the Declarations is amended to include: 1. Any legally incorporated subsidiary in which you own more than 50% of the voting stock on the effective date of the Coverage Form. However, the Named Insured does not include any subsidiary that is an "insured" under any other automobile policy or would be an "insured" under such a policy but for its termination or the exhaustion of its Limit of Insurance. 2. Any organization that is acquired or formed by you and over which you maintain majority ownership. However, the Named Insured does not include any newly formed or acquired organization: (a) That is an "insured" under any other automobile policy; (b) That has exhausted its Limit of Insurance under any other policy; or (c) 180 days or more after its acquisition or formation by you, unless you have given us written notice of the acquisition or formation. Coverage does not apply to "bodily injury" or "property damage" that results from an "accident" that occurred before you formed or acquired the organization. B. Employees as Insureds Paragraph A.1. -WHO IS AN INSURED -of SECTION II -LIABILITY COVERAGE is amended to add the following: d. Any "employee" of yours while using a covered "auto" you don't own, hire or borrow in your business or your personal affairs. C. Lessors as Insureds Paragraph A.1. -WHO IS AN INSURED -of SECTION II -LIABILITY COVERAGE is amended to add the following: e. The lessor of a covered "auto" while the "auto" is leased to you under a written agreement if: ( 1) The agreement requires you to provide direct primary insurance for the lessor; and (2) The "auto" is leased without a driver. Such leased "auto" will be considered a covered "auto" you own and not a covered "auto" you hire. However, the lessor is an "insured" only for "bodily injury" or "property damage" resulting from the acts or omissions by: 1. You; 2. Any of your "employees" or agents; or 3. Any person, except the lessor or any "employee" or agent of the lessor, operating an "auto" with the permission of any of 1. and/or 2. above. D. Persons And Organizations As Insureds Under A Written Insured Contract Paragraph A.1 -WHO IS AN INSURED -of SECTION II -LIABILITY COVERAGE is amended to add the following: f. Any person or organization with respect to the operation, maintenance or use of a covered "auto", provided that you and such person or organization have agreed under an express provision in a written "insured contract", written agreement or a written permit issued to you by a governmental or public authority to add such person or organization to this policy as an "insured". However, such person or organization is an "insured" only: Form: 16-02-0292 (Rev. 11-16) Page 1 of 3 "Includes copyrighted material of Insurance Services Office, Inc. with its permission" 45935353 I 18 · 20 GL/AL/EX/CP; 18-19 WC/CPL I (WH) Adrianna Padilla I 12/14/2018 1: 10: 07 PM {PST) I Page B of 11 (1) with respect to the operation, maintenance or use of a covered "auto"; and (2) for "bodily injury" or "property damage" caused by an "accident" which takes place after: (a) You executed the "insured contract" or written agreement; or (b) The permit has been issued to you. 3. FELLOW EMPLOYEE COVERAGE EXCLUSION B.5. -FELLOW EMPLOYEE -of SECTION II -LIABILITY COVERAGE does not apply. 4. PHYSICAL DAMAGE -ADDITIONAL TEMPORARY TRANSPORTATION EXPENSE COVERAGE Paragraph A.4.a. -TRANSPORTATION EXPENSES -of SECTION Ill -PHYSICAL DAMAGE COVERAGE is amended to provide a limit of $50 per day for temporary transportation expense, subject to a maximum limit of $1,000. 5. AUTO LOAN/LEASE GAP COVERAGE Paragraph A. 4. -COVERAGE EXTENSIONS -of SECTION Ill -PHYSICAL DAMAGE COVERAGE is amended to add the following: c. Unpaid Loan or Lease Amounts In the event of a total "loss" to a covered "auto", we will pay any unpaid amount due on the loan or lease for a covered "auto" minus: 1. The amount paid under the Physical Damage Coverage Section of the policy; and 2. Any: a. Overdue loan/lease payments at the time of the "loss"; b. Financial penalties imposed under a lease for excessive use, abnormal wear and tear or high mileage; c. Security deposits not returned by the lessor: d. Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance purchased with the loan or lease; and e. Carry-over balances from previous loans or leases. We will pay for any unpaid amount due on the loan or lease if caused by: 1. Other than Collision Coverage only if the Declarations indicate that Comprehensive Coverage is provided for any covered "auto"; 2. Specified Causes of Loss Coverage only if the Declarations indicate that Specified Causes of Loss Coverage is provided for any covered "auto"; or 3. Collision Coverage only if the Declarations indicate that Collision Coverage is provided for any covered "auto. 6. RENT AL AGENCY EXPENSE Paragraph A. 4. -COVERAGE EXTENSIONS -of SECTION Ill -PHYSICAL DAMAGE COVERAGE is amended to add the following: d. Rental Expense We will pay the following expenses that you or any of your "employees" are legally obligated to pay because of a written contract or agreement entered into for use of a rental vehicle in the conduct of your business: MAXIMUM WE WILL PAY FOR ANY ONE CONTRACT OR AGREEMENT: 1. $2,500 for loss of income incurred by the rental agency during the period of time that vehicle is out of use because of actual damage to, or "loss" of, that vehicle, including income lost due to absence of that vehicle for use as a replacement; 2. $2,500 for decrease in trade-in value of the rental vehicle because of actual damage to that vehicle arising out of a covered "loss"; and 3. $2,500 for administrative expenses incurred by the rental agency, as stated in the contract or agreement. 4. $7,500 maximum total amount for paragraphs 1., 2. and 3. combined. 7. EXTRA EXPENSE -BROADENED COVERAGE Paragraph A.4. -COVERAGE EXTENSIONS -of SECTION Ill -PHYSICAL DAMAGE COVERAGE is amended to add the following: e. Recovery Expense We will pay for the expense of returning a stolen covered "auto" to you. 8. AIRBAG COVERAGE Paragraph B.3.a. -EXCLUSIONS -of SECTION Ill -PHYSICAL DAMAGE COVERAGE does not apply to the accidental or unintended discharge of an airbag. Coverage is excess over any other collectible insurance or warranty specifically designed to provide this coverage. 9. AUDIO, VISUAL AND DATA ELECTRONIC EQUIPMENT -BROADENED COVERAGE Paragraph C.1.b. -LIMIT OF INSURANCE -of SECTION Ill -PHYSICAL DAMAGE is deleted and replaced with the following: b. $2,000 is the most we will pay for "loss" in any one "accident" to all electronic equipment that reproduces, receives or transmits audio, visual or data signals which, at the time of "loss", is: (1) Permanently installed in or upon the covered "auto" in a housing, opening or other location that is not normally used by the "auto" manufacturer for the installation of such equipment; (2) Removable from a permanently installed housing unit as described in Paragraph 2.a. above or is an integral part of that equipment; or (3) An integral part of such equipment. 10. GLASS REPAIR -WAIVER OF DEDUCTIBLE Form: 16-02-0292 (Rev. 11-16) Page 2 of 3 "Includes copyrighted material of Insurance Services Office, Inc. with its permission" 45935353 \ 18-20 GL/AL/EX/CP;l8-19 WC/CPL \ (WH) Adrianna Padilla \ 12/14/2018 1,10,07 PM (PST) \ Page 9 of 11 Under Paragraph D. -DEDUCTIBLE -of SECTION Ill -PHYSICAL DAMAGE COVERAGE the following is added: No deductible applies to glass damage if the glass is repaired rather than replaced. 11. TWO OR MORE DEDUCTIBLES Paragraph D.-DEDUCTIBLE -of SECTION Ill - PHYSICAL DAMAGE COVERAGE is amended to add the following: If this Coverage Form and any other Coverage Form or policy issued to you by us that is not an automobile policy or Coverage Form applies to the same "accident", the following applies: 1. If the deductible under this Business Auto Coverage Form is the smaller (or smallest) deductible, it will be waived; or 2. If the deductible under this Business Auto Coverage Form is not the smaller (or smallest) deductible, it will be reduced by the amount of the smaller (or smallest) deductible. 12. AMENDED DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS Paragraph A.2.a. -DUTIES IN THE EVENT OF AN ACCIDENT, CLAIM, SUIT OR LOSS of SECTION IV -BUSINESS AUTO CONDITIONS is deleted and replaced with the following: a. In the event of "accident", claim, "suit" or "loss", you must promptly notify us when the "accident" is known to: (1) You or your authorized representative, if you are an individual; (2) A partner, or any authorized representative, if you are a partnership; (3) A member, if you are a limited liability company; or (4) An executive officer, insurance manager, or authorized representative, if you are an organization other than a partnership or limited liability company. Knowledge of an "accident", claim, "suit" or "loss" by other persons does not imply that the persons listed above have such knowledge. Notice to us should include: (1) How, when and where the "accident" or "loss" occurred; (2) The "insured's" name and address; and (3) To the extent possible, the names and addresses of any injured persons or witnesses. 13. WAIVER OF SUBROGATION Paragraph A.5. -TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US of SECTION IV -BUSINESS AUTO CONDITIONS is deleted and replaced with the following: 5. We will waive the right of recovery we would otherwise have against another person or organization for "loss" to which this insurance applies, provided the "insured" has waived their rights of recovery against such person or organization under a contract or agreement that is entered into before such "loss". To the extent that the "insured's" rights to recover damages for all or part of any payment made under this insurance has not been waived, those rights are transferred to us. That person or organization must do everything necessary to secure our rights and must do nothing after "accident" or "loss" to impair them. At our request, the insured will bring suit or transfer those rights to us and help us enforce them. 14. UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS Paragraph B.2. -CONCEALMENT, MISREPRESENTATION or FRAUD of SECTION IV -BUSINESS AUTO CONDITIONS -is deleted and replaced with the following: If you unintentionally fail to disclose any hazards existing at the inception date of your policy, we will not void coverage under this Coverage Form because of such failure. 15. AUTOS RENTED BY EMPLOYEES Paragraph B.5. -OTHER INSURANCE of SECTION IV -BUSINESS AUTO CONDITIONS - is amended to add the following: e. Any "auto" hired or rented by your "employee" on your behalf and at your direction will be considered an "auto" you hire. If an "employee's" personal insurance also applies on an excess basis to a covered "auto" hired or rented by your "employee" on your behalf and at your direction, this insurance will be primary to the "employee's" personal insurance. 16. HIRED AUTO -COVERAGE TERRITORY Paragraph B.7.b.(5). -POLICY PERIOD, COVERAGE TERRITORY of SECTION IV - BUSINESS AUTO CONDITIONS is deleted and replaced with the following: (5) A covered "auto" of the private passenger type is leased, hired, rented or borrowed without a driver for a period of 45 days or less; and 17. RESULTANT MENTAL ANGUISH COVERAGE Paragraph C. of -SECTION V -DEFINITIONS is deleted and replaced by the following: "Bodily injury" means bodily injury, sickness or disease sustained by any person, including mental anguish or death as a result of the "bodily injury" sustained by that person. Form: 16-02-0292 (Rev. 11-16) Page 3 of 3 "Includes copyrighted material of Insurance Services Office, Inc. with its permission" 45935353 I 18-20 GL/AL/EX/CP;lS-19 WC/CPL I (WH) Adrianna Padilla I 12/14/2018 1:10:07 PM (PST) I Page 10 of 11 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC99 0634 (Ed. 8-00) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -BLANKET 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.) The additional premium for this endorsement shall be 3% of the California Workers' Compensation premium otherwise due. Person or Organization ANY PERSON/ORO WHEN REQUIRED BY WRITTEN CONTRACT Policy Number:WSD 5030914 02 Endorsement Effective: 08/01/2018 WC99 06 34 (Ed. 8-00) Schedule Job Description All CA Operations insured: Haitbrink Asphalt Paving, Inc. Coverage Provided by: Insurance Company of the West 45935353 I 18-20 GL/AL/EX/CP;18-19 WC/CPL I (WH) Adrianna Padilla I 12/14/2018 1,10,07 PM (PST) I Page 11 of 11