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L.C. Paving and Sealing Inc; 2021-06-22; PWM21-1453TRAN
CITY OF CARLSBAD MINOR PUBLIC WORKS CONTRACT AVENIDA ENCINAS ASPHALT CONCRETE (AC) REPAIR PWM21-1453TRAN This agreement is made on the ______ day of ___________ , 2021, by the City of Carlsbad, California, a municipal corporation, (hereinafter called "City"), and LC. Paving & Sealing, Inc., a California corporation, whose principal place of business is 620 Alpine Way, Escondido, CA 92029 (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: Matt Paxson (City Project Manager). PAYMENT. The City shall withhold retention as required by Public Contract Code Section 9203. 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. Avenida Encinas AC Repair Page 1 of 9 City Attorney Approved 1/20/2020 DocuSign Envelope ID: 750CE814-E4F2-4C4A-8DB5-E434C5D31C12 22nd June PWM21-1453TRAN 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 ors ontr t r m participating in contract bidding. Signature: Print Name: 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. Avenida Encinas AC Repair Page 2 of 9 City Attorney Approved 1/20/2020 DocuSign Envelope ID: 750CE814-E4F2-4C4A-8DB5-E434C5D31C12 PWM21-1453TRAN 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 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 sixty (60) working days after receipt of Notice to Proceed. Completion: Contractor agrees to complete work within thirty (30) working days after receipt of Notice to Proceed. CONTRACTOR'S INFORMATION. Ill Ill Ill Ill Ill Ill Ill L.C Paving & Sealing, Inc. (name of Contractor) 621610 (Contractor's license number) A, B, C-12 8/31/2022 (license class. and exp. date) 1000004325 (DIR registration number) 6/30/2024 (DIR registration exp. date) Avenida Encinas AC Repair Page 3 of 9 620 Alpine Way (street address) Escondido, CA 92029 (city/state/zip) 760-752-1743 (telephone no.) 760-752-1674 (fax no.) Shawn@Lcpaving.com (e-mail address) City Attorney Approved 1/20/2020 DocuSign Envelope ID: 750CE814-E4F2-4C4A-8DB5-E434C5D31C12 PWM21-1453TRAN 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 L.C. PAVING & SEALING, INC., a Califor · By: Jose A. Salinas, President & CFO (print name/title) By: (sign here) (print name/title) CITY OF CARLSBAD, a municipal corporation of the State of California By: Paz Gomez, Deputy City Manager as authorized by the City Manager 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 BY: -------------Assistant City Attorney Avenida Encinas AC Repair Page 4 of 9 City Attorney Approved 1/20/2020 DocuSign Envelope ID: 750CE814-E4F2-4C4A-8DB5-E434C5D31C12 PWM21-1453TRAN 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 \ltt4G Total% Subcontracted: The Contractor must perform no less than fifty percent (50%) of the work with its own forces. Avenida Encinas AC Repair Page 5 of 9 City Attorney Approved 1/20/2020 DocuSign Envelope ID: 750CE814-E4F2-4C4A-8DB5-E434C5D31C12 PWM21-1453TRAN EXHIBIT B Avenida Encinas AC Repair Contractor shall provide all materials, equipment and labor required to remove and replace a 48' x 75' (3,600 square feet) section of asphalt spanning curb to curb at 5451 Avenida Encinas. Contractor's work includes but not limited to: calling for utility location, placing advanced warning signs of road closure 2 weeks prior to excavation, providing all traffic control during the project, saw cutting and removal of existing asphalt and cold mix, compacting the subgrade, lifting and compacting base material to 6" in depth, filling any voids under the surrounding curb and gutter with 2 sack slurry, leveling valve cans to final grade, application of SS1 H tack coat prior to asphalt installation, pave road at 6" using standard Greenbook specifications, install paint striping to restore area to its original condition. Contractor shall apply for a no-fee right-of-way permit, submit a traffic control plan for approval and will provide all traffic control required for work to be completed. All work shall be performed in accordance with the City of Carlsbad's Engineering Standards, the 2018 Standard Specifications for Public Works Construction (Greenbook), 2018 Caltrans Standard Plans and Caltrans Specifications and California Manual on Uniform Traffic Control Devices. JOB QUOTATION ITEM UNIT QTY DESCRIPTION PRICE NO. 1 LS 1 Mobilization $3,400.00 2 LS 1 Traffic Control $5,489.10 3 EA 135 NC Removal, Fine Grade Existing Materials, 6" A/C $27,280.80 Paving 4 LS 1 Pavement Marking and Striping $1,463.10 TOTAL* $37,633.00 *Includes taxes, fees, expenses and all other costs. Avenida Encinas AC Repair Page 6 of 9 City Attorney Approved 1/20/2020 DocuSign Envelope ID: 750CE814-E4F2-4C4A-8DB5-E434C5D31C12 Avenida Encinas AG Repair EXHIBIT B (Continued) Page 7 of 9 PWM21-1453TRAN City Attorney Approved 1/20/2020 DocuSign Envelope ID: 750CE814-E4F2-4C4A-8DB5-E434C5D31C12 EXHIBIT C LABOR AND MATERIALS BOND Bond No. CMGP00004510 Premium: $941.00 PWM21-1453TRAN WHEREAS, the City Council of the City of Carlsbad, State of California, has awarded to LC. Paving & Sealing, Inc. (hereinafter designated as the "Principal"), a Contract for: AVENIDA ENCINAS AC REPAIR CONTRACT NO. PWM21-1453TRAN in the City of Carlsbad, in strict conformity with the drawings and specifications, and other Contract Documents now on file in the Office of the City Clerk of the City of Carlsbad and all of which are incorporated herein by this reference. WHEREAS, Principal has executed or is about to execute said Contract and the terms thereof require the furnishing of a bond, providing that if Principal or any of its subcontractors shall fail to pay for any materials, provisions, provender or other supplies or teams used in, upon or about the performance of the work agreed to be done, or for any work or labor done thereon of any kind, the Surety on this bond will pay the same to the extent hereinafter set forth. NOW, THEREFORE, WE, LC. Paving & Sealing, Inc., as Principal, (hereinafter designated as the "Contractor''), and Argonaut Insurance Company as Surety, are held firmly bound unto the City of Carlsbad in the sum of thirty-seven thousand six hundred thirty-three dollars ($37,633), said sum being an amount equal to : One hundred percent (100%) of the total amount payable under the terms of the Contract by the City of Carlsbad, and for which payment well and truly to be made we bind ourselves, our heirs, executors and administrators, successors, or assigns, jointly and severally, firmly by these presents. THE CONDITION OF THIS OBLIGATION IS SUCH that if the Contractor or his/her subcontractors fail to pay for any materials, provisions, provender, supplies, or teams used in, upon, for, or about the performance of the work contracted to be done, or for any other work or labor thereon of any kind, consistent with California Civil Code section 9100, or for amounts due under the Unemployment Insurance Code with respect to the work or labor performed under this Contract, or for any amounts required to be deducted, withheld, and paid over to the Employment Development Department from the wages of employees of the contractor and subcontractors pursuant to section 13020 of the Unemployment Insurance Code with respect to the work and labor, that the Surety will pay for the same, and, also, in case suit is brought upon the bond, reasonable attorney's fees, to be fixed by the court consistent with California Civil Code section 9554. This bond shall inure to the benefit of any of the persons named in California Civil Code section 9100, so as to give a right of action to those persons or their assigns in any suit brought upon the bond. Surety stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Contract, or to the work to be performed hereunder or the specifications accompanying the same shall affect its obligations on this bond, and it does hereby waive notice of any change, extension of time, alterations or addition to the terms of the contract or to the work or to the specifications. Avenida Encinas AC Repair Page 8 of 9 City Attorney Approved 1/20/2020 DocuSign Envelope ID: 750CE814-E4F2-4C4A-8DB5-E434C5D31C12 PWM21-1453TRAN In the event that Contractor is an individual, it is agreed that the death of any such Contractor shall not exonerate the Surety from its obligations under this bond. SIGNED AND SEALED, this __ 9t_h ____ day of _____ J_u_n_e ______ _, 2021 Argonaut Insurance Company c/o CMGIA -20335 Ventura Blvd., Ste. 426 Woodla s Hills CA 91364 (SEAL) rety By:~~~::==-- (Signature) Stephanie Hope Shear, Attorney-in-Fact (Print Name & Title) (SEAL AND NOTARIAL ACKNOWLEDGEMENT OF SURETY-ATTACH ATTORNEY-IN-FACT CERTIFICATE) APPROVED AS TO FORM: CELIA A. BREWER City Attorney By: Assistant City Attorney Avenida Encinas AC Repair Page 9 of 9 City Attorney Approved 1/20/2020 DocuSign Envelope ID: 750CE814-E4F2-4C4A-8DB5-E434C5D31C12 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 San Diego ) before me, Marisa Haas, Notary Public (insert name and title of the officer) personally appeared _J_o_s_e_A_._S_a_li_n_a_s ____________________ _ who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. 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. Signature 1~ I b ~ (Seal) -e e «r: e e dh1t •¼1 MARISA ANN HAAS otary Public -California : San Diego County ! Commission# 2306519 omm. Expires Sep 24, 2023 DocuSign Envelope ID: 750CE814-E4F2-4C4A-8DB5-E434C5D31C12 Bond No. CMGP00004510 Argonaut Insurance Company Deliveries Only: 225 W. Washington, 24th Floor Chicago, IL 60606 United States Postal Service: P.O. Box 469011, San Antonio, TX 78246 POWER OF ATTORNEY KNOW ALL MEN BY 1HESE PRESENTS: That the Argonaut Insurance Company, a Corporation duly organized and existing under e laws of the State of Illinois and having its principal office in the County of Cook, Illinois does hereby nominate, constitute and appoint: Gabriella Grady Shilo Lee Losino, Stephanie Hope Shear, Elizabeth Santos, Stacey Garcia, ~ttbp\y Dionisio Their true and lawful agent(s) and attorney(s)-in-fact, each in their separate capacity if more than one is named above, tp mtlce, execute, seal and deliver for and on its behalf as surety, and as its act and deed any and all bonds, contracts, agreements of indemnity anil,gtber derf!ikings in suretyship provided, however, that the penal sum of any one such instrument executed hereunder shall not exceed the sum of: $15 000 000 00 This Power of Attorney is granted and is signed and sealed under and by the authority of the fo!J,Wing''li,esolutlon adopted by the Board of Directors of Argonaut Insurance Company: "RESOLVED, That the President, Senior Vice President, Vice President, Assistant Vice l'~si ~t, !lecretary, Treasurer and each of them hereby is authorized to execute powers of attorney, and such authority can be executed by use of fa<1$Ulifl.&signature, which may be attested or acknowledged by any officer or attorney, of the Company, qualifying the attorney or attorneys named in the give ower of attorney, to execute in behalf of, and acknowledge as the act and deed of the Argonaut Insurance Company, all bond undertakings an;l'colJtacts suretyship, and to affix the corporate seal thereto." IN WITNESS WHEREOF, Argonaut Insurance Company has caused its CYffirn s(!\l to be hereunto affixed and these presents to be signed by its duly authorized officer on the 8th day of May, 2017. STATE OF TEXAS COUNTY OF HARRIS SS: by: Argonaut Insurance Company Josbua C. Betz , Senior Vice President On this 8th day of May, 2017 A.D., befd&,e me, !ljNotary Public of the State of Texas, in and for the County of Harris, duly commissioned and qualified, came 1HE ABOVE OFFICER OFT CQMl?ANY, to me personally known to be the individual and officer described in, and who executed the preceding instrument, and he .idem ow ~dgcd the execution of same, and being by me duly sworn, deposed and said that he is the officer of the said Company aforesaid, and thllt the seiff.1ffixed to the preceding instrument is the Corporate Seal of said Company, and the said Corporate Seal and his signature as officer wer~duly affixed and subscribed to the said instrument by the authority and direction of the said corporation, and that Resolution adopted by the Board o irectc;s of said Company, referred to in the preceding instrument is now in force. IN TESTIMON1. WHffltBOF, I have hereunto set my hand, and affixed my Official Seal at the County of Harris, the day and year first above written. (Notary Public) I, the undersigned Officer of the Argonaut Insurance Company, Illinois Corporation, do hereby certify that the original POWER OF ATTORNEY of which the foregoing is a ·full, true and correct copy is still in full force and effect and has not been revoked. IN WITNESS WHEREOF, I have hereunto set iuy hand, and affixed the Seal of said Company, on the _2fu__ day of ____ T,_un==e ___ ~, 2021 . James Bluzard , Vice President-Surety IF YOU HAVE QUESTIONS ON AUTHENTICITY OF TIDS DOCUMENT CALL (833) 820 -9137. DocuSign Envelope ID: 750CE814-E4F2-4C4A-8DB5-E434C5D31C12 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189 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 Los Angeles On __ ____.J.._U"'-N:....:;_•-=-0..:::9'-2=-0=2::..;;1_ before me, ____ L_u_ca_s_P_a_tte_r_so_n_, N_o_t_ary_P_ub_li_c _______ ~ Date Here Insert Name and Title of the Officer personally appeared ____________ s_te~p_h_a_ni_e_H_o~p_e_S_h_ea_r ___________ _ Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. Place Notary Seal Above 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 a~ Signature _____ ~~~~=.=---<'-#--'-------~------- Signature of Notary Public ----------------oPTIONAL---------------- Though this section is optional, completing this information can deter alteration of the docum fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: ____________ _ Number of Pages: ___ Signer(s) Other Than Capacity(ies) Claimed by Signer(s) Signer's Name:---------------:.,,,,-- □ Corporate Officer -Title(s): -----:::,,-""'--- □ Partner -□ Limited □ General Signer's Name: ____________ _ □ Corporate Officer -Title(s): ______ _ □ Partner -□ Limited □ General □ Individual □ Attorne · □ Individual □ Attorney in Fact DG □ Trustee □ Guardian or Conservator □ Other: ______________ _ Signer Is Representing: _________ _ ©2014 National Notary Association· www.NationalNotary.org • 1-800-US NOTARY (1-800-876-6827) Item #5907 DocuSign Envelope ID: 750CE814-E4F2-4C4A-8DB5-E434C5D31C12 02/22/2021 HARTLEY CYLKE PACIFIC-#0574253 INSURANCE SERVICES, INC. 2747 UNIVERSITY AVENUE SAN DIEGO CA 92104-4068 JANA CLARK (619) 295-5155 (619) 291-0912 jana@hcpacinsurance.com L.C. Paving & Sealing, Inc. 620 Alpine Way Escondido CA 92029 TRAVELERS PROPERTY & CASUALTY CO OF AMERICA 25674 CLEAR SPRING PROPERTY & CASUALTY CO PALOMAR SPECIALTY INSURANCE CO CL2121968482 A Y Y DT22CO0S13576ATIL21 02/18/2021 02/18/2022 1,000,000 300,000 5,000 1,000,000 2,000,000 2,000,000 A Y Y 8100S0955232126G 02/18/2021 02/18/2022 1,000,000 Medical payments 5,000 A CUP0S1373832126 02/18/2021 02/18/2022 4,000,000 4,000,000 B Y CSWC00024401 09/12/2020 09/12/2021 1,000,000 1,000,000 1,000,000 A INLAND MARINE QT6300S1069IL21 02/18/2021 02/18/2022 RENTED/LEASED EQP $100,000 *10 day notice of cancellation for non-payment of premium shall apply. 30 days written notice of cancellation for all other reasons. *City of Carlsbad/CMWD shall be named Additional Insured on a Primary and Non-Contributory basis. A Waiver of Subrogation applies as required by written contract. (Endorsements to follow.) RE: All Projects. City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services P.O. Box 4668 - ECM #35050 New York NY 10163-4668 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED?(Mandatory in NH) DESCRIPTION OF OPERATIONS belowIf yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCEDAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIREDAUTOS ONLY by the Workers’ Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB’s California Workers’ Compensation Insurance Forms Manual 1999. 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 9/12/2020 12:01 AM Policy No. CS-WC- 000244-01 Endorsement No. 1 Insured L.C. Paving & Sealing, Inc Premium $2,625 Insurance Company Clear Spring Property and Casualty Company Countersigned by WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) 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 2.50 % of the California workers’ compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION Any Person or Organization for which the insured has agreed by written contract executed prior to loss to furnish this waiver. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 06 (Ed. 8-84) WC 00 04 06 (Ed. 8-84) © 1983 National Council on Compensation Insurance, Inc. 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 9/12/2020 Policy No. CS-WC- 000244-01 Endorsement 1 Insured L.C. Paving & Sealing, Inc Premium $2,625 Insurance Company Countersigned by Clear Spring Property and Casualty Company PREMIUM DISCOUNT ENDORSEMENT The premium for this policy and the policies, if any, listed in Item 3 of the Schedule may be eligible for a discount. This endorsement shows your estimated discount in Items 1 or 2 of the Schedule. The final calculation of premium discount will be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating is not subject to premium discount. SCHEDULE 1.STATE ESTIMATED ELIGIBLE PREMIUM $116,878 FIRST NEXT NEXT $5,000 $95,000 $400,000 BALANCE CA $5,000 $100,000 $500,000 0.0%10.9%12.6%14.4% 2. AVERAGE PERCENTAGE DISCOUNT: 10.796034% 3. OTHER POLICIES: 4. If there are no entries in Items 1, 2 and 3 of the Schedule, see the Premium Discount Endorsement attached to your policy number: