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HomeMy WebLinkAboutPalomar Flooring; 2023-09-08; PWM24-2285FACPWM24-2285FAC Fire Station No. 3 Flooring Replacement Page 1 of 9 City Attorney Approved 5/25/2023 CITY OF CARLSBAD MINOR PUBLIC WORKS CONTRACT FIRE STATION NO. 3 FLOORING REPLACEMENT This agreement is made on the ______________ day of _________________________, 2023, by the City of Carlsbad, California, a municipal corporation (hereinafter called "City") and Palomar Flooring, a California corporation whose principal place of business is 6875 Nancy Ridge Drive, Suite B, San Diego, California 92121 (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, as contained in the Standard Specifications for Public Works Construction “Greenbook,” latest edition and including all errata; Part 1 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 Lauren Milliken (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. DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 8th September PWM24-2285FAC Fire Station No. 3 Flooring Replacement Page 2 of 9 City Attorney Approved 5/25/2023 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. CONSTRUCTION MANAGEMENT SOFTWARE. Procore Project Management and Collaboration System. This project may utilize the Owner’s Procore (www.procore.com) online project management and document control platform. The intent of utilizing Procore is to reduce cost and schedule risk, improve quality and safety, and maintain a healthy team dynamic by improving information flow, reducing non-productive activities, reducing rework and decreasing turnaround times. The Contractor is required to create a free web-based Procore user account(s) and utilize web-based training / tutorials (as needed) to become familiar with the system. Unless the Engineer approves otherwise, the Contractor shall process all project documents through Procore because this platform will be used to submit, track, distribute and collaborate on project. If unfamiliar or not otherwise trained with Procore, Contractor and applicable team members shall complete a free training certification course located at http://learn.procore.com/procore- certification-subcontractor. The Contractor is responsible for attaining their own Procore support, as needed, either through the online training or reaching out to the Procore support team. It will be the responsibility of the Contractor to regularly check Procore and review updated documents as they are added. There will be no cost to the Contractor for use of Procore. It is recommended that the Contractor provide mobile access for Windows, iOS located at https://apps.apple.com/us/app/procore-construction-management/id374930542 or Android devices located at https://play.google.com/store/apps/details?id=com.procore.activities with the Procore App installed to at least one on-site individual to provide real-time access to current posted drawings, specifications, RFIs, submittals, schedules, change orders, project documents, as well as any deficient observations or punch list items. Providing mobile access will improve communication, efficiency, and productivity for all parties. The use of Procore for project management does not relieve the contractor of any other requirements as may be specified in the contract documents. 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 DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 PWM24-2285FAC Fire Station No. 3 Flooring Replacement Page 3 of 9 City Attorney Approved 5/25/2023 bidding on public contracts for a period of up to five (5) 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: ________Mark Matthew Johnson ________ 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 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. 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 DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 PWM24-2285FAC Fire Station No. 3 Flooring Replacement Page 4 of 9 City Attorney Approved 5/25/2023 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 forty (40) working days after receipt of Notice to Proceed. Completion: Contractor agrees to complete work within sixty (60) working days after receipt of Notice to Proceed. CONTRACTOR’S INFORMATION. Palomar Flooring 6875 Nancy Ridge Dr., Suite B (name of Contractor) 984058 (street address) San Diego, CA 92121 (Contractor’s license number) C-15 6/30/2025 (city/state/zip) 858-457-1122 (license class. and exp. date) 1001043890 6/30/2024 (telephone no.) mark@palomarfloors.com (DIR registration number and exp. date) (e-mail address) [signatures on following page] DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 PWM24-2285FAC Fire Station No. 3 Flooring Replacement Page 5 of 9 City Attorney Approved 5/25/2023 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 PALOMAR FLOORING, a California corporation CITY OF CARLSBAD, a municipal corporation of the State of California By: By: (sign here) Mark Matthew Johnson, President and Chief Financial Officer Paz Gomez, Deputy City Manager, Public Works, as authorized by the City Manager (print name/title) By: (sign here) Gerasimos Lougiakis, Secretary (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: CINDIE K. McMAHON, City Attorney BY: _____________________________ Deputy City Attorney DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 PWM24-2285FAC Fire Station No. 3 Flooring Replacement Page 6 of 9 City Attorney Approved 5/25/2023 EXHIBIT A LISTING OF SUBCONTRACTORS BY GENERAL CONTRACTOR Set forth below is the full name and location of the place of business of each subcontractor 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 subcontractor for each subcontract. NOTE: The Contractor understands that if it fails to specify a subcontractor 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 Type of Work to be Subcontracted Business Name and Address DIR Registration No. License No., Classification & Expiration Date % of Total Contract Total % Subcontracted: _______________ The Contractor must perform no less than 50% of the work with its own forces. DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 N/A 0N/AN/A 0 N/A PWM24-2285FAC Fire Station No. 3 Flooring Replacement Page 7 of 9 City Attorney Approved 5/25/2023 EXHIBIT B Fire Station No. 3 Flooring Replacement Contractor shall provide all materials, tools and labor required to remove carpet flooring throughout and replace with Luxury Vinyl Tile (LVT) at Fire Station No. 3 located at 3465 Trailblazer Way, Carlsbad, California. All work shall be consistent with the Contractor’s proposal dated August 16, 2023, and is attached to this agreement as Exhibit C. Scope: - Demo existing floors, carbide scrape all adhesive off the floor. - Remove and replace all big furniture in rooms. - Perform TH Moisture tests. - Furnish and install Avalon “Wood Series” Color Oak Taupe (Approx 2,150 SF). - Furnish and install carpet in TV room (Approx 460 SF). - Furnish and install Tarkett 6” Rubber Cove Base, Black. Notes: - Contractor shall maintain good housekeeping practices throughout the duration of the project and will leave the site in a clean and workmanlike manner. - All work must be coordinated so as not to interfere with the operations of the fire station. - Work to be scheduled during business hours. JOB QUOTATION ITEM NO. UNIT QTY DESCRIPTION PRICE 1 LS 1 Remove carpet and install new LVT flooring throughout fire station Avalon Wood Series Color: Oak Taupe 6” x 48” x 5mm LVT Planks $23,360 TOTAL* $23,360 *Includes taxes, fees, expenses and all other costs. DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 Palomar Flooring 6875 Nancy Ridge Dr Suite B San Diego, CA 92121 Name / Address City of Carlsbad 405 Oak Avenue Carlsbad, CA 92008 PROJECT 2465 Trailblazer Way Carlsbad, CA 442-252-1165 Description Lockbox: I Gate Code: I Demo and disposal of existing glue down carpet at main desk area, hallways, dorm rooms2150 SF Provide labor to install 6" covebase 620 LF Remove millworks base 620 LF Demo and disposal of existing carpet at TV room 460 SF Provide labor to install vinyl plank glue down, main desk, hallways, dorm rooms 2150 SF Provide labor to install 6" covebase 620 LF Provide labor to install carpet tile at TV room 460 SF Provide floor prep labor (estimate) ***Please note that the prep estimate is just an estimated price. If any additional materials and labor is needed then a change order will be required*** Provide Catalina Avalon Series Core Select 20 mil Color W 105 Oak Taupe 2250 SF Provide adhesive for vinyl plank *PLEASE NOTE: Estimate Date Estimate# 8/16/2023 4602-1109-R Project Qty U/M Total 1,600.00 1,550.00 400.00 345.00 6,900.00 1,550.00 400.00 800.00 6,750.00 680.00 Due to effects of the COVID-19 Pandemic, there is a likeliehood that we will experience unanticipated delays in the manufacturing and shipping of materials, and to a lesser extent cost increases, as a result of factory closings across the globe. Please consider this to be our formal notice of potential delays to our performance through no fault of our own and that are beyond our control. We will diligently seek to minimize to the best of our ability, the effects of these delays on our work. ~ d Palomar Flooring accepts checks, Visa and MasterCard as payment of deposits and invoices. A 3% convenience fee will apply toall payments paid with credit card. Phone# Fax# Web Site Total (858)457-1122 (858) 457-1188 www.palomaoffice@palomarflo ...Estimate valid for 30 days Signature Date ----- Page 8 of 9 PWM24-2285FAC Exhibit "C" DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 Palomar Flooring 687 5 Nancy Ridge Dr Suite B San Diego, CA 92121 Name/ Address City of Carlsbad 405 Oak Avenue Carlsbad, CA 92008 Provide 6" cove base 620 LF 442-252-1165 Description Provide allowance for carpet tile at TV room-Product and Color TBD 460 SF *PLEASE NOTE: Lockbox: I Gate Code: I Estimate Date Estimate# 8/16/2023 4602-1109-R Project Qty U/M Total 1,395.00 990.00 Due to effects of the COVID-19 Pandemic, there is a likeliehood that we will experience unanticipated delays in the manufacturing and shipping of materials, and to a lesser extent cost increases, as a result of factory closings across the globe. Please consider this to be our formal notice of potential delays to our performance through no fault of our own and that are beyond our control. We will diligently seek to minimize to the best of our ability, the effects of these delays 011 our work. ~ Palomar Flooring accepts checks, Visa and MasterCard as payment of deposits and invoices. A 3% convenience fee will apply to all payments paid with credit card. Phone# Fax# Web Site Total $23,360.00 (858)457-1122 (858)457-1188 www.palomaoffice@palomarflo ...Estimate valid for 30 days Signature Date ____ _ Page 9 of 9 PWM24-2285FAC Exhibit "C" (Cont.) DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD/YYYY) _____, ~ 8/8/2023 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 1NAM~'.''" Kim Tarbell Valley Center Insurance Agency, Inc. r1J8Ntro Extl: 760-749-0622 I (AfC, No): 760-749-0628 27525 Valley Center Rd, Suite B t:•mMO~ kim@vciainc.com ADDRESS: I INSURER(S) AFFORDING COVERAGE NAIC# Valley Center CA 92082 INSURER A: WEST AMERICAN INS CO 44393 INSURED INSURER B: OHIO SECURITY INS CO 24082 Palomar Flooring INSURER C: 6875 Nancy Ridge Dr Ste B INSURER D: INSURER E: San Diego CA 92121 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. 'r-rR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDITTYY) (MMto□iv'm-> LIMITS .K COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 □ CLAIMS-MADE 00 OCCUR UAMAC>t: I U Kt:N I t:U $ 500,000 PREMISES (Ea occurrence) MED EXP (Any one person) $ 15,000 -A BKW56254145 05/26/2023 05/26/2024 PERSONAL & ADV INJURY $ 2,000,000 -GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 R □PRO-OLoc $ 4,000,000 POLICY JECT PRODUCTS -COMP/OP AGG OTHER: $ AUTOMOBILE LIABILITY (Ea accidenti""VLL LUm I $ 1,000,000 -.K ANY AUTO BODILY INJURY (Per person) $ B OWNED -SCHEDULED BAS56254145 05/26/2023 05/26/2024 BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS --HIRED NON-OWNED (P~'f~~~id1e~t)""'"v~ $ AUTOS ONLY AUTOS ONLY --$ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ -EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION lsrATUTE I 11¥RM· AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE □ N/A E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L. DISEASE -EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Carlsbad ACCORDA CE WITH THE POLICY PROVISIONS, Land Development Engineering Carlsbad CA 92008 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 .-) I J COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY EXTENSION This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SUBJECT NON-OWNED AIRCRAFT NON-OWNED WATERCRAFT PROPERTY DAMAGE LIABILITY-ELEVATORS llfilsK EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) MEDICAL PAYMENTS EXTENSION EXTENSION OF SUPPLEMENTARY PAYMENTS • COVERAGES A AND B ADDITIONAL INSURSDS -BY CONTRACT, AGREEMENT OR PERMIT PRIMARY AND NON-CONTRIBUTORY-ADDITIONAL INSURED EXTENSION ADDITIONAL INSUREDS -EXTENDED PROTECTlON OF YOUR "LIMITS OF INSURANCE" WHO IS AN INSURED • INCIDENTAL MEDICAL ERRORS/MALPRACTICE AND WHO IS AN INSURED " FELLOW EMPLOYEE EXTENSION • MANAGEMENT EMPLOYEES NEWLY FORMED ORADDITIONALLY ACQUIRED ENTITIES FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES ~ KNOWLEDGE OF OCCURRENCE, OFFENSE, CLAIM OR SUIT 'II LIBERALIZATION CLAUSE Iii BODILY INJURY REDEFINED EXTENDED PROPERTY DAMAGE WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US - WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU @ 2013 Liberty Mulual Insurance CG 8810 0413 Includes copyrighted rnalerlal of Insurance Services Office; Inc., with its permission. CG88101413 PAGE; 2 2 2 2 .. 3 3 3 5 6 6 7 7 7 7 7 8 6 Page 1 of 8 DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 1o With respect to coverage afforded by this endorsement, the provisions of the policy apply unless modified by the endorsement. A. NON-OWNED AIRCRAFT Under Paragraph 2. Exclusions of Section I • Coverage A • Bodily Injury And Property Damage Liability, exclusion g. Aircraft, Auto Or Watercraft does not apply to an aircraft provided: 1, It Is not owned by any Insured; 2. it is hired, chartered or loaned with a trained paid crew; 3. The pilot In command holds a currently effective certificate, Issued by the duly constituted authority of the United States of America or Canada, designating her or him a commercial or airline pilot; and 4. It Is not being used to carry persons or property for a charge. However, the Insurance afforded by this provision does not apply If there is available to the Insured other valid and collectible Insurance, whether primary, excess (other than Insurance written to apply specifically In excess of this policy), contingent or on any other basis, that would also apply to the loss covered under this provision. NON-OWNEO WATERCRAFT Under Paragraph 2, Exclusions of Section i • Coverage A• Bodily Injury And Property Damage Liability, Subparagraph (2) of exclusion g, Aircraft, Auto Or Watercraft Is replaced by lhe following: This exclusion does not apply to: (2) A watercraft you do not own that Is: (a) Less than 52 feet long; and (b) Not being used to carry persons or property for a charge. C. PROPERTY DAMAGE LIABILITY • ELEVATORS 1. Under Paragraph 2. Exclusions of Section I• Coverage A• Bodily Injury And Property Damage Liabil- ity, Subparagraphs (3), (4) ·and (6) of exclusion j. Damage To Property do not apply If such "property damage" results from the use of elevators. For ihe purpose of this provision, elevators do not Include vehicle lifts. Vehicle lifts are lifts or hoists used In automobile service or repair operations, 2. The following Is added to Section IV • Commercial General Llabllity Conditions, Condition 4. Other Insurance, Paragraph b. Excess Insurance: The Insurance afforded by this provision of this endorsement Is excess over any property insurance, whether primary, excess, contingent or on any other basis. D. EXTENDED DAMAGE TO PROPERTY RENTED TO YOU {Tenant's Property Damage) If Damage To Premises Rented To You Is not otherwise excluded from this Coverage Part: 1, Under Paragraph 2. Exclusions of Section I• Coverage A -Bodily Injury and Property Damage Liability: a. The fourth from the last paragraph of exclusion J. Damage To Property Is replaced by the follow• Ing: Paragraphs (1), {3) and (4) of this exclusion do not apply to "property damage" (other than damage by fire, lightning, explosion, smoke, or leakage from an automatic fire protection system) to: (I) Premises rented to you for a period of 7 or fewer consecutive days; or {II) Contents that you rent or lease as part of a premises rental or lease agreement for a period of more than 7 days, Paragraphs (1), {3) and (4) of this exclusion do not apply to "property damage" to contents of premises rented to you for a period of 7 or fewer consecutive days. A separate limit of insurance applies to this coverage as described In Section Iii " Limits of Insurance. © 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office, lno,, with Its permission. Page 2 of B DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 b. The last paragraph of subsection 2, Exclusions is replaced by the following: Exclusions c, through n. do not apply to damage by fire, lightning, explosion, smoke or leakage from automatic fire protection systems to premises while rented to you or temporarily occupied by you with permission of the owner. A separate limit of Insurance applies to Damage To Premises Rented To You as described in Section Ill • Limits Of Insurance. 2. Paragraph 6, under Section Ill • Limits Of Insurance Is replaced by the followlng: 6. Subject to Paragraph 5. above, the Damage To Premises Rented To You Limit Is the most we will pay under Coverage A for damages because of "property damage" to: a. Any one premise: (1) While rented to you: or (2) Whlle rented to you or temporarily occupied by you with permission of the owner for damage by fire, llghtnlng, explosion, smoke or leakage from automatic protection sys- tems; or b. Contents that you rent or lease as part of a premises rental or lease agreement. 3. As regards coverage provided by this provision D. EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) • Paragraph 9.a, of Definitions Is replaced with the following: 9.a. A contract for a lease of premises. However, that portion of the contract for a lease of premises that ·Indemnifies any person or organization for damage by fire, lightning, explosion, smoke, or leakage from automatic fire protection systems to premises while rented to you or temporarily occupied by you with the permission of the owner, or for damage· to contents of such premises that are Included In your premises rental or lease agreement, is not an "Insured contract". E. MEDICAL PAYMENTS EXTENSION If Coverage C Medical Payments is not otherwise excluded, the Medical Payments provided by this policy are amended as follows: Under Paragraph 1, Insuring Agreement of Section I~ Coverage C • Medical Payments, Subparagraph (b) of Paragraph a. Is replaced by the following: (b) The expenses are incurred and reported within three years of the date of the accident; and F. EXTENSION OF SUPPLEMENTARY PAYMENTS • COVERAGES A AND B 1. Under Supplementary Payments • Coverages A and B, Paragraph 1,b. is replaced by the following: b. Up to $3,000 for cost of ball bonds required because of accidents or traffic law vlolallons arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applles. We do not have to furnish these bonds. 2. Paragraph 1.d. Is replaced by the following: d. All reasonable expenses Incurred by the Insured at our request to assist us In the Investigation or. defense of the claim or "suit", . Including actual loss _of earnings up to $500 a day because of Ume off from work. G. ADDITIONAL INSUREDS • BY CONTRACT, AGREEMENT OR PERMIT 1. Paragraph 2. under Section II • Who Is An Insured Is amended to Include as an Insured any person or organization whom you have agreed to add as an additional Insured In a written contract, written agreement or permit. Such person or organization Is an additional Insured but only with respect to liability for "bodily Injury", "property damage" or "personal and advertising injury" caused In whole or In part by; a. Your acts or omissions, or the acts or omissions of those acting on your behalf, In the performance of your on going operations for the additional Insured that are the subject of tha written contract or written agreement provided that the "bodily Injury" or "property damage" occurs, or the "per- sonal and advertising Injury" Is committed, subsequent to the signing of such written contract or written agreement; or • ® 2013 Liberty Mutual Insurance CG 88 10 0413 Includes copyrighted material of Insurance Services Office, Inc,, with lls permission. Page 3 of 8 DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 b. Premises or facllltles rented by you or used by you; or c. The maintenance, operation or use by you of equipment rented or leased to you by such person or organization; or d. Operations performed by you or on your behalf for which the state or political subdivision has Issued a permit subject to the following additional provisions: (1) This Insurance does not apply to "bodily Injury", "property damage", or "personal and ad- vertising Injury" arising out of the operations performed for the state or political subdivision; (2) This Insurance does not apply to "bodily Injury" or "property damage" Included within the "completed operations hazard". (3) Insurance applies to premises you own, rent, or control but only with respect to the following hazards; (a) The existence, maintenance, repair, construction, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, street banners, or decorations and similar expo- sures; or (b) The construction, erection, or removal of elevators: or (c) The ownership, maintenance, or use of any elevators covered by this Insurance. 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 Insur- ance 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. With respect to Paragraph 1.a. above, a person's or organization's status as an additional Insured under this endorsement ands when: (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 lnsured(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. With respect to Paragraph 1.b. above, a person's or organization's status as an additional Insured under this endorsement ands when their written contract or written agreement with you for such premises or facilities ends, With respects to Paragraph 1,c. above, this Insurance does not apply to any "occurrence" which takes place after the equipment rental or lease agreement has expired or you have returned such equipment to the lessor, The Insurance provided by this endorsement applies only If the written contract or written agreement is signed prior to the "bodily Injury" or "property damage". We have no duty to defend an additional Insured under this endorsement until we receive written notice of a "suit" by the additional Insured as required In Paragraph b. of Condition 2. Duties In the Event Of Occurrence, Offense, Claim Or Sult under Section IV • Commercial General Llablllty Condi- tions. © 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office, Inc., with Its permission. Page 4 of 8 DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 2. With respect to the Insurance provided by this endorsement, the following are added to Paragraph 2. Exclusions under Section I "Coverage A -Bodily Injury And Property Damage Liability: This Insurance does not apply to: a. "Bodlly Injury" or "property damage" arising from the sole negligence of the additional Insured. b. "Bodily Injury" or "property damage" that occurs prior to you commencing operations at the location where such "bodlly Injury" or "property damage" occurs. c. "Bodily Injury", "property damage" or "personal and advertising injury" arising out of the render- ing of, or the failure to render, any professional architectural, engineering or surveying services, Including: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or (2) Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any Insured allege negligence or other wrongdoing In the supervision, hiring, employment, training or monitoring of others by that Insured, if the "occur- rence" which caused the "bodily Injury" or "property damage", or the offense which caused the "personal and advertising Injury", Involved the rendering of, or the failure to render, any professional archltectaral, engineering or surveying services. d, "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 lnsured(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. e. Any person or organization specifically designated as an additional Insured for ongoing operations by a separate ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS endorsement ls- sued by us and made a part of this policy. 3. 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 wlll pay on behalf of the additional Insured Is the amount of Insurance: a, Required by the contract or agreement; or b, Available under the applicable Limits of Insurance shown In the Declarations; whichever Is less. This endorsement shall not increase the appllcable Limits of Insurance shown In the Declarat!o ns. H. PRIMARY AND NON-CONTRIBUTORY ADDITIONAL INSURED EXTENSION This provision applies to any person or organization who quallfles as an additional Insured under any form or endorsement under this policy .. Condition 4. Other Insurance of SECTION IV • COMMERCIAL GENERAL LIABILITY CONDITIONS Is amend- ed as follows: a. The following Is added to Paragraph a. Primary Insurance: If an additional lnsured's policy has an other Insurance provision making its policy excess, and you have agreed In a written contract or written agreement to provide the addltlonal Insured coverage on a primary and noncontributory basis, this policy shall be primary and we will not seek contribution from the additional lnsured's pollcy for damages we cover. ® 2013 Liberty Mutual Insurance CG88100413 Includes copyrighted material of Insurance Services Office, Inc., with 11s permission, Page 5 of 8 DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 ---) b. The following is added to Paragraph b. Excess Insurance: When a written contract or written agreement, other than a premises lease, facllltles rental contract or agreement, an equipment rental or lease contract or agreement, or permit Issued by a state or political subdivision between you and an additional Insured does not require this Insurance to be primary or primary and non-contributory, this insurance is excess over any other Insurance for which Iha addi- tional Insured is designated as a Named Insured. Regardless of the written agreement between you and an additional insured, this Insurance Is excess over any other Insurance whether primary, excess, contingent or on any other basis for which the additional Insured has been added as an additional Insured on other policies. ADDITIONAL INSUREDS -EXTENDED PROTECTION OF YOUR "LIMITS OF INSURANCE" This provision applies to any person or organization who qualifies as an additional Insured under any form or endorsement under this policy. 1. The following Is added to Condition 2. Duties In The Event Of Occurrence, Offense, Claim or Sult: An additional Insured under this endorsement will as soon as practicable: a. Give written notice of an "occurrence" or an offense that may result In a claim or "suit" under this insurance to us; b. Tender the defense and Indemnity of any claim or "suit" lo all Insurers whom also have insurance available to the additional Insured; and c. Agree to make available any other insurance which the additional insured has for a loss we cover under this Coverage Part. d. We have no duly to defend or Indemnify an additional Insured under this endorsement until gj we receive written notice of a "suit" by the additional Insured. 2. The limits of insurance applicable to the additional Insured are those specified In a written contract or written agreement or the limits of Insurance as stated In the Declarations of this policy and defined In Section Ill • Limits of Insurance of this policy, whichever are less. These limits are Inclusive of and not In addition to the limits of Insurance available under this policy. J. WHO IS AN INSURED -INCIDENTAL MEDICAL ERRORS/ MALPRACTICE WHO IS AN INSURED • FELLOW EMPLOYEE EXTENSION • MANAGEMENT EMPLOYEES Paragraph 2.a.(1) of Section II • Who Is An Insured Is replaced with the following: (1) "Bodily Injury" or "personal and advertising Injury": (a) To you, to your partners or members (if you are a partnership or Joint venture), to your members (If you are a limited liability company), to a co-"employee" while In the course of his or her employ- ment or performing duties related to the conduct of your business, or to your other "volunteer workers" while performing duties related to the conduct of your business; (b} To the spouse, child, parent, brother or sister of that co-"employee" or "volunteer worker" as a consequence of Paragraph (1) (a) above; (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the Injury described in Paragraphs (1) (a) or (b) above; or (d) Arising out of his or her providing or falling to provide professional health care services. However, If you are not In the business of providing professional health care services or providing profes- sional health care personnel to others, or if coverage for providing professional health care ser- vices Is not otherwise excluded by separate endorsement, this provision {Paragraph (d)) does not apply. Paragraphs (a) and (b) above do not apply to "bodily Injury" or "personal and advertising Injury" caused by an "employee" who is acting In a supervisory capacity for you. Supervisory capacity as used herein means the "employee's" job responsibilities assigned by you, includes the direct supervision of other "employ- ees" of yours. However, none of these "employees" are Insureds for "bodily injury" or "personal and © 2013 Liberty Mutual Insurance CG88100413 Includes copyrighted material of Insurance Services Office, Inc,, with Its permission, Page 6 of 8 DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 advertising injury" arising out of their willful conduct, which Is defined as the purposeful or willful Intent to cause "bodily Injury" or "personal and advertising Injury", or caused In whole or In part by their Intoxica- tion by liquor or controlled substances. The coverage provided by provision J. Is excess over any other valld and collectable Insurance available to your "employee". K, NEWLY FORMED OR ADDITIONALLY ACQUIRED ENTITIES Paragraph 3. of Section II • Who Is An Insured is replaced by the following: 3, Any organization you newly acquire or form and over which you maintain ownership or majority Interest, will qualify as a Named Insured If there Is no other similar Insurance avallable to that organization. However: • a. Coverage under this provision is afforded only until the expiration of the policy period in which the entity was acquired or formed by you: b. Coverage A does not apply to "bodily Injury" or "property damage" that occurred before you acquired or formed the organization; and c. Coverage B does not apply to "personal and advertising Injury" arising out of an offense committed before you acquired or formed the organization. d, Records and descriptions of operations must be maintained by the first Named Insured. No person or·organlzatlon Is an Insured with respect to the conduct of any current or past partnership, joint venture or limited Ilablllty company that Is not shown as a Named Insured In the Declarations or quallfles as an Insured under this provision. L. FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES Under Section IV -Commercial General Liability Conditions, the following Is added to Condition 6. Repre" sentatlons: Your failure lo disclose all hazards or prior "occurrences" existing as of the inception date of the policy shall not prejudice the coverage afforded by this policy provided such failure to disclose all hazards or prior "occurrences" Is not Intentional. M. KNOWLEDGE OF OCCURRENCE, OFFENSE, CLAIM OR SUIT Under Sectlon IV -Commerclel General Liability Conditions, the following Is added to Condition 2. Duties In The Event of Occurrence, Offense, Claim Or Sult: Knowledge of an "occurrence", offense, olalm or "suit" by an agent, servant or "employee" of any Insured shall not In Itself constitute knowledge of the Insured unless an Insured listed under Paragraph 1, of Section II • Who Is An Insured or a person who has been designated by them to receive reports of "occurrences", offenses, claims or "suits" shall have received such notice from the agent, servant or "employee". N. LIBERALIZATION CLAUSE If we revise this Commercial General Liablllty Extension Endorsement to provide more coverage without additional premium charge, your pollcy will automatically provide the coverage as of the day the revision Is effective in your state. 0, BODILY INJURY REDEFINED Under Section V • Definitions, Definition 3. Is replaced by the following: 3. "Bodily Injury" means physical Injury, sickness or disease sustained by a person. This Includes mental anguish, mental Injury, shock, fright or death that results from such physical. Injury, sick- ness or disease. © 2013Llberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office, Inc., with Its permission. Page 7 of 8 DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 P. EXTENDED PROPERTY DAMAGE Exclusion a. of COVERAGE A. BOOIL Y INJURY AND PROPERTY DAMAGE LIABILITY ls replaced by the following: a. Expected Or Intended Injury "Bodily Injury" or "property damage" expected or Intended from the standpoint of the Insured. This exclusion does not apply to "bodily injury" or "property damage" resulting from the use of reasonable force to protect persons or property. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US -WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU Under Section IV -Commercial General Liability Conditions, the following Is added to Condition 8. Trans• fer Of Rights Of Recovery Against Others To Us: We waive any right of recovery we may have against a person or organization because of payments we make for Injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and Included In the "products-completed operations hazard" provided: 1. You --and that person or organization have agreed in writing in a contract or agreement that you waive such rights against that person or organization; and 2. The Injury or damage occurs subsequent to the execution of the written contract or written agree-ment. © 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office, Inc., with Its permission. Page 8 of 8 © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER ACORD 25 (2016/03) AUTHORIZED REPRESENTATIVE CANCELLATION DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE LOCJECTPRO-POLICY GEN'L AGGREGATE LIMIT APPLIES PER: OCCURCLAIMS-MADE COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence)$DAMAGE TO RENTEDEACH OCCURRENCE $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $RETENTIONDED CLAIMS-MADE OCCUR $ AGGREGATE $ EACH OCCURRENCE $ UMBRELLA LIAB EXCESS LIAB DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) INSRLTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)LIMITS PERSTATUTE OTH-ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $ $ $ ANY PROPRIETOR/PARTNER/EXECUTIVE If yes, describe underDESCRIPTION OF OPERATIONS below (Mandatory in NH)OFFICER/MEMBER EXCLUDED? WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY Y / N AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED HIRED AUTOS ONLY NON-OWNEDAUTOS ONLY AUTOS AUTOS ONLY COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE $ $ $ $ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE 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. INSDADDL WVDSUBR N / A $ $ (Ea accident) (Per accident) OTHER: THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEDREPRESENTATIVE 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: INSURED PHONE(A/C, No, Ext): PRODUCER ADDRESS:E-MAIL FAX(A/C, No): CONTACTNAME: NAIC # INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : INSURER(S) AFFORDING COVERAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Acct#:2936172 8/14/2023 USI Insurance Services, LLC 844-290-49082502 N Rocky Point Drive Tampa, FL 33607 BBSIcerts@locktonaffinity.com Ace American Insurance Co.22667 Barrett Business Services, Inc.L/C/F PALOMAR FLOORING6875 NANCY RIDGE DRIVE - STE BSAN DIEGO, CA 92121 A X C51335302 6/1/2023 6/1/2024 X 2,000,000 2,000,000 2,000,000 Policy State = CA Waiver of Subrogation in favor of certificate holder when required by written contract All Projects with the City 30-Day Notice of Cancellation Waiver of Subrogation in favor of the city. City Of Carlsbad/CMWD C/o EXIGIS Insurance Compliance ServicesP.O. Box 947Murrieta, CA 92564 DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290 ACORD® I ~ I ~ □ □ ~ ~ Fl □ □ ~ ~ ~ ~ ~ ~ ~ ~ H I I I I I □ a<' i..-4--a..-~ Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number Policy Number Symbol: WLR Number: Policy Period TO Effective Date of Endorsement Issued By (Name of the Insurance Company) Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. 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, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract to obtain this waiver from us. You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. Schedule 1.( ) Specific Waiver Name of person or organization: ( ) Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2.Operations: 3. Premium: The premium charge for this endorsement shall be percent of the California premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. 4.Minimum Premium: _______________________________________ Authorized Agent WC 90 03 75 (05/18) ALL CALIFORNIA OPERATIONS 1.0 $0 Barrett Business Services, Inc. L/C/F PALOMAR FLOORING 6875 NANCY RIDGE DRIVE - STE B SAN DIEGO, CA 92121 C51335302 6/1/2023 6/1/2024 8/14/2023 Ace American Insurance Co. X DocuSign Envelope ID: F666F26C-B3D3-422A-B971-334A9FFAB290