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HomeMy WebLinkAboutScott Fence; 2019-04-11; PWM19-747GSRECORDED REQUESTED BY CITY OF CARLSBAD AND WHEN RECORDED PLEASE MAIL TO: City Clerk City of Carlsbad 1200 Carlsbad Village Drive Carlsbad, California 92008 DOC# 2019-0266790 111111111111 lllll 111111111111111 lllll lllll lllll lllll 111111111111111111 Jul 05, 2019 11 :35 AM OFFICIAL RECORDS Ernest J. 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: 204-010-05-00 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 June 20, 2019. 6. The name of the contractor for such work or improvement is Scott Fence. 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. PWM19-747GS, Project Name: 405 Oak Ave Fence Replacement. 8. The street address of said property is 405 Oak Ave., Carlsbad, CA 92008, in the City of Carlsbad. CITY / ~LSBAD ¥ Scott Cha . , Ci 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 "J'v I~ I , 20_.!j_, accepted the above described work as completed and ordered that a Notic of Completion be filed. I declare under penalty of perjury that the foregoing is true and correct. Executed on _Jt~V~1J--'-~• 20 I C-f, at Carlsbad, California. City Clerk Q:\Public Works\General Services\Agreements & Contracts\Scott Fence\405 Oak Ave Fence Replacement -PWM19-747GSINOCl2.NOC -405 Oak Ave Fence Replacement -PWM19-747GS.docx CITY OF CARLSBAD ACCEPTANCE OF PUBLIC IMPROVEMENTS COMPLETION OF PUBLIC IMPROVEMENTS Scott Fence has completed the contract work required for PWM19-747GS -405 Oak Ave Fence Replacement. City forces have inspected the work and found it to be satisfactory. The work consisted of: IMPROVEMENTS Remove and dispose of existing chain link fence and replace with 8-foot high screened chain link fence. VALUE $22,750 CERTIFICATION OF COMPLETION OF IMPROVEMENTS John~h~ Manager Date 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 improvements. Ji' ¥ Scott Chadw APPROVED AS TO FORM: CELIA BREWER, City Attorney f ) directed to commence maintaining the above described Date By: __ ___;;::a-=:;...~...___,,-..,._;;:::, ___ _ Deputy City Attorney Q \Public Works\General Services\Agreements & Contracts\Scott Fence\405 Oak Ave Fence Replacement -PWM19-747GSINOC13.API -405 Oak Ave Fence Replacement - PWM19-747GS.docx PWM19-747GS 405 Oak Ave/CRT Fence Replacement Page 1 of 6 City Attorney Approved 1/25/2019 CITY OF CARLSBAD MINOR PUBLIC WORKS CONTRACT 405 OAK AVENUE / COSTAL RAIL TRAIL FENCE REPLACEMENT This agreement is made on the ______________ day of _________________________, 2019, by the City of Carlsbad, California, a municipal corporation, (hereinafter called "City"), and Scott Fence dba Stilson Kent Scott, a sole proprietorship, whose principal place of business is 1255 Distribution Way, Vista, CA 92081 (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: John Maashoff 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. DocuSign Envelope ID: C32C0A49-C836-4AE8-A2A8-E52E89B2BCA6 April11th PWM19-747GS 405 Oak Ave/CRT Fence Replacement Page 2 of 6 City Attorney Approved 1/25/2019 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 subcontractor from participating in contract bidding. Signature: ___________________________________ Print Name: Stilson Kent Scott___________________________ 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. INDEMNITY. The Contractor shall assume the defense of, pay all expenses of defense, and indemnify and hold harmless 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 DocuSign Envelope ID: C32C0A49-C836-4AE8-A2A8-E52E89B2BCA6 PWM19-747GS 405 Oak Ave/CRT Fence Replacement Page 3 of 6 City Attorney Approved 1/25/2019 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 ten (10) working days after receipt of Notice to Proceed. Completion: Contractor agrees to complete work within fifteen (15) working days after receipt of Notice to Proceed. CONTRACTOR’S INFORMATION. Scott Fence dba Stilson Kent Scott 1255 Distribution Way (name of Contractor) 581918 (street address) Vista, CA 92081 (Contractor’s license number) B, C-13 11/30/2019 (city/state/zip) 760-598-0070 (license class. and exp. date) 1000002709 (telephone no.) 760-598-0098 (DIR registration number) 6/30/19 (fax no.) scottfencewefence@yahoo.com (DIR registration exp. date) (e-mail address) /// /// /// /// /// /// /// /// /// /// /// /// /// /// DocuSign Envelope ID: C32C0A49-C836-4AE8-A2A8-E52E89B2BCA6 PWM19-747GS 405 Oak Ave/CRT Fence Replacement Page 4 of 6 City Attorney Approved 1/25/2019 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, SCOTT FENCE dba STILSON KENT SCOTT, a sole proprietorship CITY OF CARLSBAD, a municipal corporation of the State of California By: By: (sign here) Stilson Kent Scott, Owner Paz Gomez, Deputy City Manager, Public Works as authorized by the City Manager (print name/title) By: (sign here) (print name/title) 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 Group B Chairman, President, or Vice-President 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 BY: _____________________________ Deputy City Attorney DocuSign Envelope ID: C32C0A49-C836-4AE8-A2A8-E52E89B2BCA6 PWM19-747GS 405 Oak Ave/CRT Fence Replacement Page 5 of 6 City Attorney Approved 1/25/2019 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 be Subcontracted Business Name and Address DIR Registration No. License No., Classification & Expiration Date % of Total Contract Total % Subcontracted: _______________ DocuSign Envelope ID: C32C0A49-C836-4AE8-A2A8-E52E89B2BCA6 NoneNone 0 None NoneNone PWM19-747GS 405 Oak Ave/CRT Fence Replacement Page 6 of 6 City Attorney Approved 1/25/2019 EXHIBIT B SCOPE OF WORK Contractor to provide all materials, tools and labor necessary to remove and dispose of the existing chain link fence along the westerly property line of 405 Oak Avenue. Existing fence posts shall be cut off at the ground surface. Install new fence posts and 8’ high 9-gauge knuckle twist chain link fence with top and bottom tension wire. Fence posts shall be 2-7/8” diameter, all fencing shall be galvanized finish. New fencing shall be fitted with wind screet, color green. Contractor will provide a temporary fence, as required to secure the property, during the time the fence is removed and when it is reinstalled. All materials and workmanship shall conform to the 2018 edition of the Standard Specifications for Public Works Construction (Greenbook), the San Diego Regional Standard Drawing M-06, dated 12/17/18, and the City of Carlsbad Engineering Standards. JOB QUOTATION ITEM NO. UNIT QTY DESCRIPTION PRICE 1 LF 325 Remove and dispose of existing chain link fence and replace with 8-foot high screened chain link fence. $22,750 TOTAL* $22,750 *Includes taxes, fees, expenses and all other costs. DocuSign Envelope ID: C32C0A49-C836-4AE8-A2A8-E52E89B2BCA6 SCOTFEN-01 SGONZALEZ ACORD• CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDNYYY) ~ 03/04/2019 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 A LTER 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 License# 0757776 ~2~1~cT Jennifer Kenyon HUB International Insurance Services Inc. Ft8~Jo, Ext): (858) 255-3258 I rt~. No):(951) 231 -2572 9855 Scranton Road, Suite 100 San Diego, CA 92121 ~or.ifd~cc-cal.cpu@hubinternational.com INSURERIS\ AFFORDING COVERAGE NAIC # INSURER A , HDI Global Insurance Comoanv 41343 INSURED INSURER 8 : National Union Fire Insurance Company of Pittsburgh, PA 19445 Scott Fence INSURER c : Falls Lake Fire & Casualtv Comoanv 15884 dba: Stilson Kent Scott 1255 Distribution Way INSURER D: Vista, CA 92081 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. l~f~ TYPE OF INSURANCE ~B.m-~i POLICY NUMBER POLICY EFF POLICY EXP LIMITS IMM/nnNVVVI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 -=i CLAIMS-MADE [K] OCCUR ~~~~~EbJ9c~~'g~r?ence\ 100,000 X IG20X000275-01 03/07/2019 03/07/2020 $ f--5,000 MED EXP /Anv one oersonl $ --PERSONAL & ADV INJURY $ 1,000,000 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ ~ POLICY [K] m?r □ LOC PRODUCTS -COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY f-- fE~~~~~~,flNGLE LIMIT $ 1,000,000 X ANY AUTO GA20X000509-01 03/07/2019 03/07/2020 BODIL y INJURY /Per person) $ -OWNED -SCHEDULED -AUTOS ONLY -AUTOS BODILY INJURY (Per accident) $ -~LR-M's ONLY -~8ro~~1.~ Fte?~a:~di;,it~AMAGE s $ B UMBRELLA LIAS MOCCUR EACH OCCURRENCE s 5,000,000 -BE11921858-00 03/07/2019 03/07/2020 5,000,000 X EXCESS LIAS CLAIMS-MADE AGGREGATE s OED I X I RETENTION$ 0 $ C WORKERS COMPENSATION X I ~¥frnTE I I OTH-AND EMPLOYERS' LIABILITY ER Y/N X FLA005898-01 06/01/2018 06/01/2019 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE CY] E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A 1,000,000 (Mandatory In NH) E.l. DISEASE -EA EMPLOYEE $ ~~;~~ftfrJ~ o'~'6PERA TIONS 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) City of Carlsbad is Additional Insured with regard to General Liability when required by written contract per the attached endorsement form CG2010 04/13. Waiver of Subrogation with regard to Workers Compensation applies when required by written contract per the attached endorsement form WC040306 04/84. Should the policies be cancelled before the expiration date, Hub International Insurance Services Inc. (Hub), independent of any rights which may be afforded within the policies to the certificate holder named below, will provide to such certificate holder notice of such cancellation within thirty (30) days of the cancellation date, except in the event the cancellation is due to non-payment of premium, in which case Hub will provide to such certificate holder notice of such cancellation within ten (10) days of the cancellation date. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Carlsbad/CMWD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. c/o EXIGIS Insurance Compliance Services P.O. Box 4668 -ECM #35050 New York, NY 10163-4668 AUTHORIZED REPRESENTATIVE I ~aL;u__ ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: IG20X000275 01 00 CA NAMED INSURED: Scott Fence dba: Stilson Kent Scott POLICY TERM: 03/07/2019 to 03/07/2020 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 (Blkt) 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 Blanket as required by written contract and effective Primary Insurance applies: It is agreed that such during the policy period as stated on the policy insurance as is afforded by this policy for the declarations. benefit of the additional insured shown shall be primary insurance, and any other insurance maintained by the additional insured(s) shall be excess and noncontributory as respects any claim, loss or liability allegedly arising out of the operations of the named insured or its subcontractors, provided however that this insurance will not apply to any claim loss or liability which is determined to be solely the result of the additional insured's negligence or solely the additional insured's responsibility. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II -Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. 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 20 10 0413 (Blkt) © Insurance Services Office, Inc., 2012 Page 1 of 2 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 20 10 04 13 (81kt) 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 2.5% of the California workers' compensation premium otherwise due on such remuneration. Person or Organization Blanket Waiver of Subrogation Schedule Job Description As respects to all CA jobs performed by the named insured during the policy period where by written contract a waiver of subrogation is required prior to the commencement of work. 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 06-01-2018 Insured Stilson, Kent Scott (An Individual) Policy No. FLA005898-01 Insurance Company Falls Lake Fire & Casualty Company Endorsement No. Countersigned By ______________________ _ ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.