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Infrastructure Engineering Corporation; 2024-04-01; PSA24-2412UTIL
PSA24-2412UTIL General Counsel Approved Version 12/22/2023 Page 1 AGREEMENT FOR LAKE CALAVERA OUTLET IMPROVEMENTS SERVICES INFRASTRUCTURE ENGINEERING CORPORATION THIS AGREEMENT is made and entered into as of the _____________________ day of _________________________________, 2024, by and between the Carlsbad Municipal Water District, a Public Agency organized under the Municipal Water Act of 1911, and a Subsidiary District of the City of Carlsbad, California, ("CMWD"), and Infrastructure Engineering Corporation, a California corporation ("Contractor”). RECITALS CMWD requires the professional services of a consultant that is experienced in engineering consulting. Contractor has the necessary experience in providing these professional services, has submitted a proposal to CMWD and has affirmed its willingness and ability to perform such work. NOW, THEREFORE, in consideration of these recitals and the mutual covenants contained herein, CMWD and Contractor agree as follows: 1. SCOPE OF WORK CMWD retains Contractor to perform, and Contractor agrees to render, those services (the “Services”) that are defined in Exhibit “A”, attached and incorporated by this reference in accordance with the terms and conditions set forth in this Agreement. 2. TERM This Agreement will be effective for a period of one (1) year from the date first above written. 3. COMPENSATION The total fee payable for the Services to be performed during the initial Agreement term shall not exceed eight thousand seven hundred seventy-five dollars ($8,775). No other compensation for the Services will be allowed except for items covered by subsequent amendments to this Agreement. CMWD reserves the right to withhold a ten percent (10%) retention until CMWD has accepted the work and/or the Services specified in Exhibit “A”. 4. 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. DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 April 1st PSA24-2412UTIL General Counsel Approved Version 12/22/2023 Page 2 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. 5. STATUS OF CONTRACTOR Contractor will perform the Services as an independent contractor and in pursuit of Contractor’s independent calling, and not as an employee of CMWD. Contractor will be under the control of CMWD only as to the results to be accomplished. 6. INDEMNIFICATION Contractor agrees to defend (with counsel approved by CMWD), indemnify and hold harmless CMWD and the City of Carlsbad and its officers, elected and appointed officials, employees and volunteers from and against all claims, damages, losses and expenses including attorney’s fees arising out of the performance of the work described herein caused by any willful misconduct or negligent act or omission of the Contractor, any subcontractor, anyone directly or indirectly employed by any of them or anyone for whose acts any of them may be liable. The parties expressly agree that any payment, attorney’s fee, costs or expense CMWD incurs or makes to or on behalf of an injured employee under the CMWD’s self-administered workers’ compensation is included as a loss, expense or cost for the purposes of this section, and that this section will survive the expiration or early termination of this Agreement. 7. INSURANCE Contractor will obtain and maintain policies of commercial general liability insurance, automobile liability insurance, a combined policy of workers' compensation, employers liability insurance, and professional liability insurance from an insurance company authorized to transact the business of insurance in the State of California which has 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, in an amount of not less than one million dollars ($1,000,000) each, unless otherwise authorized and approved by the Risk Manager or the City Manager. Contractor will obtain occurrence coverage, excluding Professional Liability, which will be written as claims-made coverage. The insurance will be in force during the life of this Agreement and will not be canceled without thirty (30) days prior written notice to CMWD by certified mail. CMWD will be named as additional insured on General Liability which shall provide primary coverage to CMWD. The full limits available to the named insured shall also be available and applicable to CMWD as an additional insured. Contractor will furnish certificates of insurance to CMWD with endorsements to CMWD, prior to CMWD’s execution of this Agreement. DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 PSA24-2412UTIL General Counsel Approved Version 12/22/2023 Page 3 8. NOTICES The name of the persons who are authorized to give written notices or to receive written notice on behalf of CMWD and on behalf of Contractor under this Agreement. For CMWD For Contractor Name Keri Martinez Name Robert Weber Title Senior Engineer Title Project Manager Carlsbad Municipal Water District Address 14271 Danielson Street Address 5950 El Camino Real Poway, CA 92064 Carlsbad, CA 92008 Phone 858-583-6193 Phone 442-200-7376 E-mail rweber@adurra.com Each party will notify the other immediately of any changes of address that would require any notice or delivery to be directed to another address. 9. CONFLICT OF INTEREST Contractor shall file a Conflict of Interest Statement with the City Clerk in accordance with the requirements of the CMWD Conflict of Interest Code. The Contractor shall report investments or interests as required in the CMWD Conflict of Interest Code. Yes ☐ No ☒ 10. COMPLIANCE WITH LAWS Contractor will comply with all applicable local, state and federal laws and regulations prohibiting discrimination and harassment and will obtain and maintain a City of Carlsbad Business License for the term of this Agreement. 11. CALIFORNIA AIR RESOURCES BOARD (CARB) ADVANCED CLEAN FLEETS REGULATIONS Contractor’s vehicles with a gross vehicle weight rating greater than 8,500 lbs. and light-duty package delivery vehicles operated in California may be subject to the California Air Resources Board (CARB) Advanced Clean Fleets regulations. Such vehicles may therefore be subject to requirements to reduce emissions of air pollutants. For more information, please visit the CARB Advanced Clean Fleets webpage at https://ww2.arb.ca.gov/our-work/programs/advanced-clean-fleets. 12. TERMINATION CMWD or Contractor may terminate this Agreement at any time after a discussion, and written notice to the other party. CMWD will pay Contractor's costs for services delivered up to the time of termination, if the services have been delivered in accordance with the Agreement. 13. CLAIMS AND LAWSUITS By signing this Agreement, Contractor agrees it may be subject to civil penalties for the filing of false claims as set forth in the California False Claims Act, Government Code sections 12650, et seq., and Carlsbad Municipal Code Sections 3.32.025, et seq. Contractor further acknowledges that debarment by another jurisdiction is grounds for CMWD to terminate this Agreement. DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 PSA24-2412UTIL General Counsel Approved Version 12/22/2023 Page 4 14. JURISDICTIONS AND VENUE Contractor agrees and stipulates that the proper venue and jurisdiction for resolution of any disputes between the parties arising out of this Agreement is the State Superior Court, San Diego County, California. 15. ASSIGNMENT Contractor may assign neither this Agreement nor any part of it, nor any monies due or to become due under it, without the prior written consent of CMWD. 16. AMENDMENTS This Agreement may be amended by mutual consent of CMWD and Contractor. Any amendment will be in writing, signed by both parties, with a statement of estimated changes in charges or time schedule. 17. ENTIRE AGREEMENT This Agreement, together with any other written document referred to or contemplated by it, along with the purchase order for this Agreement and its provisions, embody the entire Agreement and understanding between the parties relating to the subject matter of it. In case of conflict, the terms of the Agreement supersede the purchase order. Neither this Agreement nor any of its provisions may be amended, modified, waived or discharged except in a writing signed by both parties. This Agreement may be executed in counterparts. 18. 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. [signatures on the following page] DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 PSA24-2412UTIL General Counsel Approved Version 12/22/2023 Page 5 CONTRACTOR, CARLSBAD MUNICIPAL WATER DISTRICT, a Public Agency organized under the Municipal Water Act of 1911, and a Subsidiary District of the City of Carlsbad INFRASTRUCTURE ENGINEERING CORPORATION, a California corporation By: By: (sign here) Vicki V. Quiram, General Manager, as authorized by the Executive Manager Robert Weber, Vice-President (print name/title) By: (sign here) (print name/title) If required by CMWD, 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, Secretary, President, or Assistant Secretary, Vice-President 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, General Counsel By: _____________________________ Assistant General Counsel DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 PSA24-2412UTIL General Counsel Approved Version 12/22/2023 Page 6 EXHIBIT A SCOPE OF SERVICES AND FEE Contractor will incorporate construction red-lines into final as-built drawings for CIP 5054 Lake Calavera Outlet Improvements for submittal to Department of Safety of Dams and City project files. The scope of services assumes an estimated 45 hours and consultant rate $195/hr. for a total of $8,775 for this project. All CAD files shall be submitted to CMWD upon completion of the scope of services. DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? INSR ADDL SUBRLTRINSDWVD PRODUCER CONTACTNAME: FAXPHONE(A/C, No):(A/C, No, Ext): E-MAILADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION$ PER OTH-STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 1/9/2024 (703) 827-2277 (703) 827-2279 25615 Infrastructure Engineering Corporation Infrastructure Engineering 9665 Chesapeake Drive, Suite 230 San Diego, CA 92123 25623 25674 20079 A 1,000,000 630-5X487435 1/1/2024 1/1/2025 1,000,000 Contractual Liab.15,000 1,000,000 2,000,000 2,000,000 1,000,000B 810-5X558309 1/1/2024 1/1/2025 15,000,000C CUP-5X642114 1/1/2024 1/1/2025 15,000,000 10,000 C UB-5X489557 1/1/2024 1/1/2025 1,000,000 N 1,000,000 1,000,000 D Professional Liab.42-EPP-306878-06 1/1/2024 Per Claim/Aggregate 2,000,000 RE: ALL PROJECTS/OPERATIONS The City of Carlsbad is included as additional insured with respect to General Liability, Automobile Liability, and Umbrella Liability when required by written contract. General Liability, Automobile Liability, and Umbrella Liability are primary and non-contributory over any existing insurance and limited to liability arising out of the operations of the named insured and when required by written contract. General Liability, Automobile Liability, Workers Compensation, and Umbrella Liability policies include a waiver of subrogation in favor of the additional insureds where permissible by state law and when required by written contract. 30-day Notice of Cancellation will be issued for the General Liability, Automobile Liability, Workers Compensation, Umbrella Liability, and Professional Liability policies in accordance with policy terms and conditions. City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services New York, NY 10163-4668 ARDURRA-01 EMORRIS Ames & Gough 8300 Greensboro Drive Suite 980 McLean, VA 22102 admin@amesgough.com Charter Oak Fire Insurance Company A++ (XV) Phoenix Insurance Company A++, XV Travelers Property Casualty Company of America National Fire & Marine Insurance Company X 1/1/2025 X X X X X X X X DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy Number: 810-5X558309DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED – PRIMARY AND NON-CONTRIBUTORY WITH OTHER INSURANCE © 2016 The Travelers Indemnity Company. All rights reserved. Includes copyrighted material of Insurance Services Office, Inc. with its permission. Page 1 of 1CA T4 74 02 16 This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM PROVISIONS 1.The following is added to Paragraph A.1.c., Who Is An Insured, of SECTION ll – COVERED AUTOS LIABILITY COVERAGE: This includes any person or organization who you are required under a written contract or agreement between you and that person or organization, that is signed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, to name as an additional insured for Covered Autos Liability Coverage, but only for damages to which this insurance applies and only to the extent of that person's or organization's liability for the conduct of another "insured". 2.The following is added to Paragraph B.5., Other Insurance of SECTION IV – BUSINESS AUTO CONDITIONS: Regardless of the provisions of paragraph a. and paragraph d. of this part 5. Other Insurance, this insurance is primary to and non-contributory with applicable other insurance under which an additional insured person or organization is the first named insured when the written contract or agreement between you and that person or organization, that is signed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, requires this insurance to be primary and non-contributory. Policy Number: 810-5X558309DocuSign Envelope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olicy Number: P-630-5X487435DocuSign Envelope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ocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Policy # P-630-5X487435DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 � TRAVELERSJ WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 03 76 ( A) - POLICY NUMBER: UB-5X489557-24-43-G WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -CALIFORNIA (BLANKET WAIVER) 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. The additional premium for this endorsement shall be % of the California workers' compensation pre- mium. Schedule Person or Organization Job Description 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: 1/1/2024 Insured Insurance Company: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICADATE OF ISSUE: Policy No.UB-5X489557-24-43-G Endorsement No. Premium Countersigned by ___________ _ ST ASSIGN: Page 1 of 1 Any Person Or Organization For Which The Insured Has Agreed by Written Contract Executed Prior to Loss To Furnish This Waiver DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3 Any Person Or Organization For Which The Insured Has Agreed by Written Contract Executed Prior to Loss To Furnish This Waiver UB-5X489557 DocuSign Envelope ID: 3F04A1A6-C28F-481C-B468-7E6C7B0C79D3