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Home My WebLink AboutGoForth & Marti d.b.a. G/M Business Interiors; 2022-10-19; PWM23-1983FACDocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 19th October PWM23-1983FAC CITY OF CARLSBAD MINOR PUBLIC WORKS CONTRACT POLICE AND FIRE HEADQUARTERS, SHELVING INSTALLATION, FURNITURE RECYCLING, MATERIALS RELOCATION; CONT. NO. 4715 This agreement is made on the ______ day of __________ _, 2022, by the City of Carlsbad, California, a municipal corporation, (hereinafter called "City"), and GoForth & Marti, a California corporation, d.b.a. G/M Business Interiors, whose principal place of business is 11 OW. A. Street, Suite 140, San Diego, CA 9201 0 (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 acqordance 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 Steven Stewart (City Project Manager) PAYMENT. The City shall withhold retention as required by Public Contract Code Section 9203. WAGE RA TES. 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. Police & Fire HQ, Shelving Installation Cont. No. 4715 Page 1 of 8 City Attorney Approved 8/2/2022 DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 PWM23-1983FAC 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. 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 (5) years and that debarment by another jurisdiction is grounds for the City of Carlsbad to disqualify the Contractor or subcontractor from Signature: .,--{h_ "... ~ ~ participating in contract bidding. ~ ~ Print Name:a= Josie Won Danie ____ _ 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 Police & Fire HQ, Shelving Installation Cont. No. 4715 Page 2 of 8 City Attorney Approved 8/2/2022 DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 PWM23-1983FAC 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 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 five (5) working days after receipt of Notice to Proceed. Completion: Contractor agrees to complete work within two hundred (200) working days after receipt of Notice to Proceed. Ill Ill Ill Ill Ill Police & Fire HQ, Shelving Installation Cont. No. 4715 Page 3of 8 City Attorney Approved 8/2/2022 DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 CONTRACTOR'S INFORMATION. Goforth & Marti d.b.a. G/M Business Interiors (name of Contractor) 944352 (Contractor's license number) C61 & D34 3/31/2024 (license class. and exp. date) 1000001979/ 6/30/2023 (DIR registration number/exp. date) PWM23-1983FAC 110 W. A. Street, Suite 140 (street address) San Diego, CA 92010 (city/state/zip) 800-686-6583 (telephone no.) jstierl@gmbi.net (e-mail address) 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 GOFORTH & MARTI, a California corporation d.b.a. G/M Business Interiors By ~ ~ ~rei Josie Wong Donley, Vice 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, Public Works, 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: CINDIE K. McMAHON, City Attorney BY: -;!4 Assistant City Attorney Police & Fire HQ, Sh elving Installation Cont. No. 4715 Page 4 of 8 City Attorney Approved 8/2/2022 DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 PWM23-1983F AC 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 Business Name and Address DIR License No., % of be Subcontracted Registration Classification & Total No. Expiration Date Contract l l ~\)~E, r Total % Subcontracted: -'o __ •~'-•---- The Contractor must perform no less than 50% of the work with its own forces. Police & Fire HQ, Shelving Installation Cont. No. 471 5 Page 5 of 8 City Attorney Approved 8/2/2022 PWM23-1983FAC Police & Fire HQ, Shelving Installation Cont. No. 4715 Page 6 of 8 City Attorney Approved 8/2/2022 EXHIBIT B Police and Fire Headquarters, Shelving Installation and Furniture Recycling Labor only to install Property & evidence shelving and recycle trailer furniture as quoted in the attached quotes dated 09/14/2022 and 09/15/2022. JOB QUOTATION ITEM NO. UNIT QTY DESCRIPTION PRICE 1 Lot 1 Labor to install property & evidence shelving provided by Space Saver under separate contract, includes cost of Labor and Materials Bond $19,856 2 Lot 1 Labor to relocate materials from temporary trailers to office building, recycle furniture in trailers and to breakdown shelving in eight (8) temporary trailers and relocate to office building or to Farmer's building, includes cost of Labor and Materials Bond $39,682 TOTAL* $59,538 *Includes taxes, fees, expenses and all other costs. DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 PWM23-1983FAC -Exhibit "B" (Cont.) Date: SAFETY CENTER -SERVICES ONLY 9/14/2022 Quotation 206006 CITY OF CARLSBAD 1635 FARADAY AVE CARLSBAD (ORION) FIRE DEPT 2560 ORION WAY CARLSBAD STEVE STEWART CA 92008 Phone: (760)602-7543 Fax: CARLSBAD STEVE STEWART CA 92010 Phone: (760)602-7543 Fax: Systems O Desk Units O Tables O Files O Chairs O Storage O Ancillary 1 . GRAND TOTAL $19,856.00 206006 IS FOR G/M LABOR TO INSTALL SPACE SAVER PRODUCT PURCHASED SEPARATELY BY THE CITY OF CARLSBAD QUOTE VALID THROUGH 9.30.2022 ****ALL INSTALLATION LABOR IS QUOTED AS PREVAILING WAGE LABOR**** ****NOTE THE "ASSEMBLY LABOR" IS TAXABLE**** ORDER FOR G/M INSTALLATION OF SPACE SAVER PRODUCT ONLY PRODUCT TYPE: LABOR SERVICES ONLY FOR: CITY OF CARLSBAD SAFETY CENTER G/M SCOPE OF WORK: 1) INSTALL SHELVING UNITS PER DRAWING IN ONE SINGLE PHASE. ALL TRASH AND SHIPPING DEBRIS WILL BE REMOVED AND DISPOSED OF UNLESS ON SITE ARRANGEMENTS HAVE BEEN MADE BY THE CUSTOMER. THE AREA AND DELIVERY PATH IN WHICH NEW CONSOLES OR COMPONENTS ARE TO BE INSTALLED SHALL BE FREE AND CLEAR OF DEBRIS AND Account Executive: Michelle Philbin(mphilbin@gmbi.net) AMA: Kaylie Card(kcard@gmbi.net) 800-686-6583 619-236-0500 Fax: 619-236-0550 G/M Business Interiors 110 W. A Street, Suite 140, San Diego CA, 921 01 http://www.gmbi.net Project PAS: Page: 1 of 3 DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 OBSTRUCTIONS PRIOR TO ARRIVAL TO THE PROJECT SITE. PWM23-1983FAC -Exhibit "B" (Cont.) 2) ALL WORK TO BE COMPLETED DURING NORMAL BUSINESS HOURS OF MONDAY THROUGH FRIDAY FROM 7AM TO 5PM 3) ALL LABOR TO COMPLY WITH LOCAL UNION/PREVAILING WAGE RATES AND RULES. G/M Quotation # 206006 Manufacturer Model# Delivery Method List LOT SPACESAVER(INTERMOU~ SHELVING .00 Hot Rush Date Non-Tax Install PREVAILING WAGE SERVICES ONLY 19,570.00 I o salesTa, Exempt LOT HUB INSURANCE BOND .00 Hot Rush Date Non-Tax Install $286.00 HUB INTERNATIONAL INSURANCE BOND .00 ] 0 s,1es Ta, Exempt Account Executive: Michelle Philbin(mphilbin@gmbi.net) AMA: Kaylie Card(kcard@gmbi.net) 800-686-6583 619-236-0500 Fax: 619-236-0550 G/M Business Interiors 110 W. A Street, Suite 140, San Diego CA, 92101 http://www.gmbi.net List Ext Sell Sell Ext .00 .00 .00 Taxable Install Freight Design Fee .00 .00 .00 .00 286.00 286.00 Taxable Install Freight Design Fee .00 .00 .00 Project PAS: Page: 2 of 3 I I DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 PWM23-1983FAC -Exhibit 11811 (Cont.) __ _ Featured Product of the Month Zeph Chair etHermanMiller GIM accepts credit cards at 0% for purchases up to $10,000 Purchases over $10,000 requires a surcharge of2.75% .. Services (Taxable) Freight (Taxable) Services (Non-Taxable) Project App. Spec. (Non-Taxable) Taxable Subtotal: Non-Taxable Subtotal: Sales Tax (7.750%) Terms: Net 30 Days, 90% Due at Substantial Delivery 90% Terms: 10%@ Punchlist 10% $286.00 $0.00 $0.00 $19,570.00 $0.00 $286.00 $19,570.00 $0.00 $19,856.00 $17,870.40 $1 ,985.60 I have reviewed the quote, the bill of materials, the drawings {if applicable), the color cards {if applicable), and other associated exhibits for my order. • I approve the colors, fabrics. and finishes as previously selected and correct as shown on the attached exhibit. • I am satisfied that the product I have selected is the correct size and is suitable and will perform for its intended purpose. • I am aware this product is manufactured to order and is not returnable to G/M or to the manufacturer. • I understand that legal title to the product will transfer upon delivery to my commercial or residential location and all associated labor is taxable until title transfers. • I am aware additional costs charged for inside delivery. staging. setting in place, assembly. leveling. cleaning, polishing, recycling of waste materials are separately stated and are elected as an additional contract option. ■ I am aware of the grand total price of this contract as shown on this quote. • This quote is valid for 30 days Signature Print Name Account Executive: Michelle Philbin(mphilbin@gmbi.net) AMA: Kaylie Card(kcard@gmbi.net) 800-686-6583 619-236-0500 Fax: 619-236-0550 G/M Business Interiors 110 W. A Street, Suite 140, San Diego CA, 92101 http://www.gmbi.net Date Project PAS: Page: 3 of 3 DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 PWM23-1983FAC-Exhibit "B" (Cont.) ' cl(,1/t(.;~ 'f'IA..Y vJork..r~" '. ~ ,.. .. Project ID / Who & Where Date: CITY OF CARLSBAD-POLICE/FIRE ADD-ON 9/15/2022 Quotation 193505 CITY OF CARLSBAD 1635 FARADAY AVE CARLSBAD (ORION) POLICE DEPARTMENT 2560 ORION WAY CARLSBAD STEVE STEWART CA 92008 Phone: (760)602-7543 Fax: CARLSBAD STEVE STEWART Systems O Desk Units O Tables O Files O Chairs GRAND TOTAL Product Summary/ Scope of Work QUOTE FOR RELOCATION SERVICES: CITY OF CARLSBAD - REFERENCE: DIR PROJECT ID 395399 CONTRACT NO: PWM22-1675FAC ***PREVAILING WAGE & CERTIFIED PAYROLL*** PURCHASE ORDER#: SCOPE OF WORK: CA Phone: Fax: 0 Storage 1.) G/M TO DISASSEMBLE FURNITURE FROM TRAILERS 2, 5, 6 AND 7 FOR DECOMMISSION. 2.) G/M TO RELOCATE STAFF-PACKED BOXES FROM TRAILER 10 & 11 BACK TO THE BUILDING. 92010 (760)602-7543 O Ancillary $39,682.00 3.) G/M TO BREAK DOWN THE SHELVING IN TRAILER 10 & 11 , RELOCATE & STAGE AT FARMERS BUILDING. 1 4.) G/M TO RELOCATE FURNITURE FROM POLICE CAPTIAN FROM TRAILER 4 TO THE BUILDING ON THE 2ND FLOOR PER FLOOR. 5.) G/M TO REPLINSH FURNITURE FROM THE OFFICE INTRAILER 4 FROM TRAILERS 2, 5 OR 6 FOR PHASE 2. 6.) (JUNE 2023) G/M TO RELOCATE FURNITURE FROM TRAILERS 8 AND 9 BACK TO THE BUILDING AT THE END OF PHASE 2. 7.) (JUNE 2023) G/M TO DISASSEMBLE FURNITURE FROM TRAILERS 1 AND 4 FOR DECOMMISSION. HUB INTERNATIONAL LABOR AND MATERIALS BOND -$572.00 Manufacturer Model# Delivery Method List LOT G/M MAC SERVICES SERVICES San Diego War .00 Account Executive: Jorge Araujo (iarauio@gmbi.net) AMA: Chris Rabara(crabara@gmbi.net) 800-686-6583 619-236-0500 Fax: 619-236-0550 G/M Business Interiors 110 W. A Street, Suite 140, San Diego CA, 92101 http://www.gmbi.net List Ext .00 Project PAS: Sell Sell Ext .00 .00 Page: 1 of 3 DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 Hot Rush Date Non-Tax Install SEE SCOPE OF WORK 39,110.00 □Sales Tax Exempt Manufacturer Model# Delivery Method List LOT HUB INSURANCE BOND .00 Hot Rush Date Non-Tax Install INSURANCE BOND 572.00 o sales Tax Exempt Account Executive: Jorge Araujo(iarauio@gmbi.net) AMA: Chris Rabara(crabara@gmbi.net) 800-686-6583 619-236-0500 Fax: 619-236-0550 G/M Business Interiors 110 W. A Street, Suite 140, San Diego CA, 92101 http://www.gmbi.net Taxable Install Freight Design Fee .00 .00 .00 I . . . List Ext Sell Sell Ext .00 .00 .00 Taxable Install Freight Design Fee .00 .00 .00 I Project PAS: Page: 2 of 3 DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 Featured Product of the Month Zeph Chair Cl Herman Miller ~-=::,f"""'ll!!!I GIM accepts credit cards at 0% for purchases up to $10,000 llill:'.::.lil...:l:3 Purchases over $10,000 requires a surcharge of 2.75% . . • · · Product Subtotal: . . . Services (Taxable) Freight (Taxable) Services (Non-Taxable) Project App. Spec. (Non-Taxable) Sales Tax (7.750%) Net 30 Days 100% $0.00 $0.00 $0.00 $39,682.00 $0.00 $0.00 $39,682.00 $0.00 $39,682.00 $39,682.00 I have reviewed the quote, the bill of materials, the drawings (if applicable), the color cards (if applicable), and other associated exhibits for my order. a I approve the colors, fabrics. and finishes as previously selected and correct as shown on the attached exhibit. o I am satisfied that the product I have selected is the correct size and is suitable and will perform for its intended purpose. c I am aware this product is manufactured to order and is not returnable to G/M or to the manufacturer. " I understand that legal title to the product will transfer upon delivery to my commercial or residential location and all associated labor is taxable until title transfers. • I am aware additional costs charged for inside delivery, staging. setting in place, assembly. leveling. cleaning, polishing, recycling of waste materials are separately stated and are elected as an additional contract option. c I am aware of the grand total price of this contract as shown on this quote. m This quote is valid for 30 days. Approved by: Signature Print Name Account Executive: Jorge Araujo Oarauio@gmbi.net) AMA: Chris Rabara(crabara@gmbi.net) 800-686-6583 619-236-0500 Fax: 619-236-0550 G/M Business Interiors 110 W. A Street, Suite 140, San Diego CA, 92101 http://www.gmbi.net Date Project PAS: Page: 3 of 3 DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 ISSUED IN ONE ORIGINAL COUNTERPART PAYMENT BOND ONLY ORIGINAL EXHIBIT C LABOR AND MATERIALS BOND PWM23-1 983FAC BOND NO. 1001 188933 PREMIUM: $581.00 i-lE PREMIUM IS PREO!CATEO ON . HE FINAL CONTRACT PRICE ANO 3 SUBJECT TO ADJUSTMENT. WHEREAS, the City Council of the City of Carlsbad, State of California, has awarded to Go Forth & Marti d.b.a. G/M Business Interi ors (hereinafter designated as the "Prin cipal"), a Contract for: POLICE AND FIRE HEADQUARTERS, SHELVING INSTALLATION AND FURNITURE RECYCLING CONTRACT NO. 4715 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, Prin cipal has executed or is about to execute said Contract and the terms thereof require the furnishin g 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, GoForth & Marti d.b.a. G/M Business Interiors, as Principal, (hereinafter designated as the "Contractor"), and U.S. Specialty Insurance Company as Surety, are held firmly bound unto the City of Carlsbad in the sum of fifty-nine thousand five hundred thirty-eight dollars ($59,538), 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 Garlsbad, 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 w ith California Civil Code section 9554. This bond shall inure to the benefit of any of the persons named in Californ ia 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. Police & Fire HQ Shelving Installation Cont. No. 4715 13 of 14 City Attorney Approved 8/2/2022 DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 .. ... PWM23-1983FAC 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. S IGNED AND SEALED, this 10th day of October I 2022 Goforth & Marti OBA _G_/_M_B_u_s_in-'-'e--'-s-'--s _I n_te_r_io_rs ______ (SEAL) (Principal) By ~gna~1}~ t By: U.S. Specialty Insurance Company (Surety) (SEAL) ., ,, .. ... .. .. ......... ·,",_ . ,~. . ,,.. .-_..--}. \I·.\ / Julia B . .Sal~'?_ • : (Signature) Attorney In Fact 1oS\e. ~O\\'j~\,e,\-> \Jf?,l[O . ,,,·.·, ......... / (SEAL AND NOTARIAL ACKNOWLEDGEMENT OF SURETY -ATTACH ATTORNEY-lf\J• ·n FACT CERTIFICATE) .. , APPROVED AS TO FORM: CINDIE K. McMAHON, City Attorney By: -t~ Assistant City Attorney ' .... ) ' '\ ·. ·>. l • • .. ' . . . , . . . . ' .· ' . . . ........ t ~ Police & Fire HQ Shelving Installation Cont. No. 4715 14 of 14 City Attorney Approved 8/2/2022 DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 TOKIO MARI NE HCC POWER OF ATTORNEY AMERICAN CONTRACTORS INDEMNITY COMPANY TEXAS BONDING COMPANY UNITED STATES SURETY COMPANY U.S. SPECIALTY INSURANCE COMPANY KNOW ALL MEN BY THESE PRESENTS: That American Contractors Indemnity Company, a California corporation, Texas Bonding Company, an assumed name of American Contractors Indemnity Company, United States Surety Company, a Maryland corporation and U.S. Specialty Insurance Company, a Texas corporation (collectively, the "Companies"), do by these presents make, constitute and appoint: KENNETH A. COATE or JULIA B. BALES of RIVERSIDE, CALIFORNIA its true and lawful Attorney(s)-in-fact, each in their separate capacity if more than one is named above, with full power and authority hereby conferred in its name, place and stead, to execute, acknowledge and deliver any and all bonds, recognizances, undertakings or other instruments or contracts of suretyship to include riders, amendments, and consents of surety, providing the bond penalty does not exceed *****Ten Million***** Dollars ( ***$10,000,000.00*** ). This Power of Attorney shall expire without further action on January 31"1, 2024. This Power of Attorney is granted under and by authority of the following resolutions adopted by the Boards of Directors of the Companies: Be it Resolved, that the President, any Vice-President, any Assistant Vice-President, any Secretary or any Assistant Secretary shall be and is hereby vested with full power and authority to appoint any one or more suitable persons as Attorney(s)-in-Fact to represent and act for and on behalf of the Company subject to the following provisions: Attorney-in-Fact may be given full power and authority for and in the name of and on behalf of the Company, to execute, acknowledge and deliver, any and all bonds, recognizances, contracts, agreements or indemnity and other conditional or obligatory undertakings, including any and all consents for the release of retained percentages and/or final estimates on engineering and construction contracts, and any and all notices and documents canceling or terminating the Company's liability thereunder, and any such instruments so executed by any such Attorney-in-Fact shall be binding upon the Company as if signed by the President and sealed and effected by the Corporate Secretary. Be it Resolved, that the signature of any authorized officer and seal of the Company heretofore or hereafter affixed to any power of attorney or any certificate relating thereto by facsimile, and any power of attorney or certificate bearing facsimile signature or facsimile seal shall be valid and binding upon the Company with respect to any bond or undertaking to which ii is attached. IN WITNESS WHEREOF, The Companies have caused this instrument to be signed and their corporate seals to be hereto affixed, this 23rd day of September, 2021. AMERICAN CONTRACTORS INDEMNITY COMPANY TEXAS BONDING COMPANY UNITED STATES SURETY COMPANY U.S. SPECIAL TY INSURANCE COMPANY (J1~;:"c"lb~,.. ~~~i,•z~, ~~'\l'"~"~,,; 111~~::::,,1v,..; ~ \ .... ~,_.+., 1.•o~--~OC'~ ½ii;, ....... /f.(>~ ~ ..... ~, ,o~ t .. U. 0 ~ .... la',:,{, G ~" ... ,i -~ \ f., al fo ~ .... \\ ~~-~ I~; ~;~l,;: l]J i *' ..,!• .. Y,:.. ,j.~ :.-<.~ ~ ;,•11;0.~':.-•' ~'l;'o,~'1-" ~ "•;,;·· • .,, .... 1/ "•m111f'I\\ tfllm"I'"'~ '"IHUlll'I"'/' "''"'' '1t "'~ State of California County of Los Angeles By: Daniel P. Aguilar, Vice President A Notary Public or other officer completing this certificate verifies only the identity of the indivfdual who signed the document to which this certificate is attached, and not the truthfulness, accurac , or validi of that document On this 23rd day of September, 2021, before me, D. Littlefield, a notary public, personally appeared Daniel P. Aguilar, Vice President of American Contractors Indemnity Company, Texas Bonding Company, United States Surety Company and U.S. Specialty Insurance Company who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature on the instrument the person, or the entity upon behalf of which the person 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. i············ WITNESS my hand and offi . I seal. i. Neu~ ~~~E:~1~om1a 1 ,,,, " -Lo, AA1•i.1 County I l Con1mlsslon I/ 2320307 Signature --~--1.-~~1;1>11.~;=~~--(seal) MyCOfflm.[xpir".wi31,2o24 I, Kio Lo, Assistant Secretary o American Contractors Indemnity Company, Texas Bonding Company, United States Surety Company and U.S. Specialty Insurance Company, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney, executed by said Companies, which is still in full force and effect; furthermore, the resolutions of the Boards of Directors, set out in the Power of Attorney are in full force and effect. In Witness Whereof, I have hereunto set my hand and affixed the seals of said Companies at Los Angeles, California this ___ day of OCT 1 Q 2022 , ___ . Corporate Seals Bond No. I QO \ I BPf\ 2>3 Agency No. _2_0_55 _____ _ > HCCSMANPOA09/2021 visit tmhcc.com/surety for more information DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 CALIFORNIA ACKNOWLEDGMENT CIVIL CODE § 1189 ~ 1~ 1□ IJOlsilOOOO:C D [)'![Jl;l[JIOOtlt1880080 D D IJi0888008()cW [) 9@fflll00! J D D [JO~ ll0808880008lffllililll!OOO 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 Riverside } On ___ O_C_T_l_0_2_02_2 ___ before me, ____ R_. _Ba_l_de_r_a-'s,_N_o_ta_ry.,__P_ub_l_ic ______ _ Date Here Insert Name and Title of the Officer personally appeared ____________ J_u_lia_B_._B_a_le_s ______________ _ Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person{5}-whose name(s}-is/are-subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/ti:letf authorized capacity(tes), and that by his/herftt=leif. signature(sl on the instrument the person(sh or the entity upon behalf of which the person(s) acted, executed the instrument. R. BALDERAS :1 COMM. #2305953 ;ii NOTARY PUBLIC -CAl.tfORNIA l'ii RMRSIOE COUNTY 1 My Comm. Expires Sept. 26, 2023 Place Notary Seal and/or Stamp 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 and official seal. Signature Signature of Notary Public OPTIONAL Completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: ___________________________ _ Document Date: _____________________ Number of Pages: ____ _ Signer(s) Other Than Named Above: _______________________ _ Capacity(ies) Claimed by Signer(s) Signer's Name: ____________ _ Signer's Name: ____________ _ □ Corporate Officer -Title(s): ______ _ D Corporate Officer -Title(s): ______ _ □ Partner -□ Limited □ General □ Partner -□ Limited □ General □ Individual □ Attorney in Fact □ Individual □ Attorney in Fact □ Trustee □ Guardian or Conservator □ Trustee □ Guardian or Conservator D Other: □ Other: Signer is Representing: _________ _ Signer is Representing: _________ _ OlJ □ a B@:o:ooc ll :000@080il a••• a B1J000808D! a r081 *l808001 a c1 .-.c : [):008081 a a coo8000fJ80801J000001J1 am ©2019 National Notary Association INSR ADDLSUBRLTRINSR WVD DATE (MM/DD/YYYY) 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) COMMERCIAL GENERAL LIABILITY 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 INSURER(S) AFFORDING COVERAGE NAIC # Y / N N / A (Mandatory in NH) ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? EACH OCCURRENCE $ DAMAGE TO RENTED $PREMISES (Ea occurrence)CLAIMS-MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ $ PRO- OTHER: LOCJECT COMBINED SINGLE LIMIT $(Ea accident) BODILY INJURY (Per person) $ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS AUTOS ONLYHIRED PROPERTY DAMAGE $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 LIMIT $DESCRIPTION OF OPERATIONS below POLICY NON-OWNED 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 any 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. The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03) ACORDTM CERTIFICATE OF LIABILITY INSURANCE National Union Fire Ins Co of Pittsburg New Hampshire Insurance Company Hiscox Insurance Company Inc. 5/04/2022 EPIC Insurance Midwest 560 5th Street, Suite 202 Grand Rapids, MI 49504 Kris Hughes - certificatesgrr@epicbrokers.com Goforth & Marti Inc. dba GM Business GM Business Interiors 1099 W. La Cadena Dr. Riverside, CA 92501 19445 23841 10200 A X X X X X X 5180177 03/01/2022 03/01/2023 1,000,000 300,000 25,000 1,000,000 2,000,000 2,000,000 A X X X 2961606 03/01/2022 03/01/2023 1,000,000 A B N X 80756387 (CA) WC014122637 03/01/2022 03/01/2022 03/01/2023 03/01/2023 X 1,000,000 1,000,000 1,000,000 C Professional Liab ANE405372522 03/01/2022 03/01/2023 1,000,000 Certificate holder is named as additional insured as respects to General and Auto Liability (on a primary and non-contributory basis) as required by written contract; Waiver of subrogation is issued in favor of certificate holder as respects to General Liability, Auto Liability and Workers Compensation, as required by written contract; All policies contain a 30 day notice of cancellation (10 for non-pay) subject to policy terms and conditions; GL additional insured endorsement includes ongoing and completed ops. (See Attached Descriptions) City of Carlsbad / CMWD c/o EXIGIS Insurance Compliance Services PO Box 4668 - ECM #35050 New York, NY 10163-0000 1 of 2 #S3991153/M3529866 GMBUSINClient#: 164812 KWI01 DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 I I t--D □ t-- t-- t-- Fl n n t-- t--~ ~ ~ t--- t--H I I I I I □ I SAGITTA 25.3 (2016/03) DESCRIPTIONS (Continued from Page 1) City of Carlsbad is included as Additional Insured with respects to General Liability as required by contract or written agreement. A waiver of subrogation is included for Workers Compensation as required by contract or written agreement. 30 days notice of cancellation. 2 of 2 #S3991153/M3529866 DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? INSR ADDL SUBRLTRINSD WVD 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 5/4/2022 License # 0757776 (818) 257-7459 25674 GoForth & Marti Inc.; GM Business Interiors 1099 West La Cadena Drive Riverside, CA 92501 10,000,000A CUP 0T277407 22 NF 3/1/2022 3/1/2023 10,000,000 10,000 City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services P.O. Box 4668 - ECM #35050 New York, NY 10163-4668 GOFO&MA-02 KSHYAMALA HUB International Insurance Services Inc. 600 Corporate Pointe Suite 600 Culver City, CA 90230 Jorge Iniguez Jorge.Iniguez@hubinternational.com Travelers Property Casualty Company of America X X X DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 ACORD" I ~ I ~ □ □ ~ ~ ~ □ □ ~ ~ ~ ~ ~ ~ ~ ~ H I I I I I □ I ‚•› »†…–ﬁ›»‡»†‹ »””»‰‹•“» ”–ﬁ‡› ¿ ¿ﬁ‹ –” –·•‰§ –•››«»… ‹– § ˝ ˛˝ ˝ —˙ —˝ ˛ ˛¸˙ ˝¸˛ ˛ ˛ˇ¸˛ ¸˛ ˛ ˛ ˛ ‚•› »†…–ﬁ›»‡»†‹ ‡–…•”•»› •†›«ﬁ¿†‰» ﬁ–“•…»… «†…»ﬁ ‹‚» ”–··–'•†„ ¸˝˝˝ ¸ ˚˛ ˛ ˝¸ ˝¸˛ ŁØº łæº «‹‚–ﬁ•ƒ»… ˛»ﬁ»›»†‹¿‹•“» –ﬁ–«†‹»ﬁ›•„†¿‹«ﬁ» ł •† ˝‹¿‹»› ‚»ﬁ»·•‰¿·» —¿„» –” ˝ ˙ ˚˛ –“»ﬁ¿„» ‚– › †›«ﬁ»… •› ¿‡»†…»… ‹– ¿…… …†§ »ﬁ ›–† –ﬁ –ﬁ„¿†•ƒ¿‹•–† ›‚–'† •† ‹‚» ›‰‚»…«·» ¿–“» ‹– '‚–‡ §–« »‰–‡» –·•„¿‹»… ‹– •†‰·«…» ¿› ¿† ¿……•‹•–†¿· •†›«ﬁ»… «†…»ﬁ ‹‚•› –·•‰§ ¿› ¿ ﬁ»›«·‹ –” ¿†§ ‰–†‹ﬁ¿‰‹ –ﬁ ¿„ﬁ»»‡»†‹ §–« »†‹»ﬁ •†‹– '‚•‰‚ ﬁ»ﬂ«•ﬁ»› §–« ‹– ”«ﬁ†•›‚ •†›«ﬁ¿†‰» ‹– ‹‚¿‹ »ﬁ›–† –ﬁ –ﬁ„¿†•ƒ¿‹•–† –” ‹‚» ‹§» ﬁ–“•…»… § ‹‚•› –·•‰§ «‹ –†·§ '•‹‚ ﬁ»›»‰‹ ‹– ·•¿•·•‹§ ¿ﬁ•›•†„ –«‹ –” «›» –” ¿ ‰–“»ﬁ»… ¿«‹– –'»“»ﬁ ‹‚» •†›«ﬁ¿†‰» ﬁ –“•…»… '•·· †–‹ »¤‰»»… ‹‚» ·»››»ﬁ –” ł‚» ‰–“»ﬁ¿„» ¿†…æ–ﬁ ·•‡•‹› –” ‹‚•› –·•‰§ –ﬁ ł‚» ‰–“»ﬁ ¿„» ¿†…æ–ﬁ ·•‡•‹› ﬁ»ﬂ«•ﬁ»… § ›¿•… ‰–†‹ﬁ¿‰‹ –ﬁ ¿„ﬁ»»‡»†‹ ˛˝ ææ 22 2961606 ˛ œ ˛ ¸˝˝˝ ˛˛˝ ¸ ˛ ˝¸˛ —˙ —˝¸˛ — ˙ —˛˝ ˛ ˛˘ ˛ ˙¸ ˛ ˛¸˙ ¸ —˛˚ ˝¸˛ ˝¸˝ ¸ ˙ ¨ ˝¸—˛˝ ˛ ˛˘˝ ˙ ˛˝ ¸ ¸˝ ˚˛¸ DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 ~------------ ‚•›»†…–ﬁ›»‡»†‹»””»‰‹•“»”–ﬁ‡›¿¿ﬁ‹–” –·•‰§–•››«»…‹– § ‚•› »†…–ﬁ›»‡»†‹ ‡–…•”•»› •†›«ﬁ¿†‰» ﬁ –“•…»… «†…»ﬁ ‹‚» ”–··–'•†„ ¸˝˝˝ ¸ ˚˛ ˛ ·· –‹‚»ﬁ ‹»ﬁ‡› ¿†… ‰–†…•‹•–†› ﬁ»‡¿•† «†‰‚¿†„»… «‹‚–ﬁ•ƒ»… ˛»ﬁ»›»†‹¿‹•“» –ﬁ Ø º łæ –«†‹»ﬁ›•„†¿‹«ﬁ» ł•† ˝‹¿‹»› ‚»ﬁ»·•‰¿·» ˝ ˛˝ ˝ —˙ —˝ ˛ ˛¸˙ ˝¸˛ —˛˛˙ ˝ ˛ ˝¸˛˝ ˝»‰‹•–† ˚ «›•†»›› «‹– –†…•‹•–†› »†»ﬁ¿· –†…•‹•–†› º ‹‚»ﬁ †›«ﬁ¿†‰» ‰ •› ¿‡»†…»… § ‹‚» ¿……•‹•–† –” ‹‚» ”–··–'•†„ ›»†‹»†‰» ‚» •†›«ﬁ¿†‰» ¿””–ﬁ…»… «†…»ﬁ ‹‚•› –·•‰§ ‹– ¿† ¿……•‹•–†¿· •†›«ﬁ»… '•·· ¿·§ ¿› ﬁ•‡¿ﬁ§ •†›«ﬁ¿†‰» ”–ﬁ ›«‰‚ ¿……•‹•–†¿· •†›«ﬁ»… '‚»ﬁ» ›– ﬁ»ﬂ«•ﬁ»… «†…»ﬁ ¿† ¿„ﬁ»»‡»†‹ »¤»‰«‹»… ﬁ•–ﬁ ‹– ‹‚» …¿‹» –” ¿‰‰•…»†‹ » '•·· †–‹ ¿› ¿†§ •†›«ﬁ»ﬁ ‹‚¿‹ ‚¿› •››«»… –‹‚»ﬁ •†›«ﬁ¿†‰» ‹– ›«‰‚ ¿……•‹•–†¿· •†›«ﬁ»… ‹– ‰–†‹ﬁ•«‹» ‹– ‹‚» ›»‹‹·»‡»†‹ –” ·–›› ¿ﬁ•›•†„ –«‹ –” ›«‰‚ ¿‰‰•…»†‹ ˛˝ ææ 22 ŒŒŒ ˛ œ ˛ ¸˝˝˝ ˛˛˝ ¸ ˛ ˝¸˛ —˙ —˝¸˛ — PDF created with pdfFactory Pro trial version www.pdffactory.com DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 ˝ ˛˝ ˝ —˙ —˝ ˛ ˛¸˙ ¸˝˝˝ ¸ ˚˛ ˛ ŒŁØ łŒæ º ¸˛˘ ˛—˛˝˚ ˛˝ ‚•› »†…–ﬁ›»‡»†‹ »””»‰‹•“» ”–ﬁ‡› ¿ ¿ﬁ‹ –” –·•‰§ –•››«»… ‹– § ‚•› »†…–ﬁ›»‡»†‹ ‡–…•”•»› •†›«ﬁ¿†‰» ﬁ–“•…»… «†…»ﬁ ‹‚» ”–··–'•†„ ˚˛ ˛˝˛ ˛˝ ˛˚˛˙ ˝ ˛˝ ¸˝ ł ł ‚» ‰–†‹ﬁ¿‰‹ –ﬁ ¿„ﬁ»»‡»†‹ '¿› »†‹»ﬁ»… •†‹– ﬁ•–ﬁ ‹– ¿†§ ¿‰‰•…»†‹ –ﬁ ·–›› – '¿•“»ﬁ –” ‹‚» ﬁ•„‚‹ –” ﬁ»‰–“»ﬁ§ '•·· …•ﬁ»‰‹·§ –ﬁ •†…•ﬁ»‰‹·§ ¿·§ ‹– §–«ﬁ »‡·–§»»› –ﬁ »‡·–§»»› –” ‹‚» »ﬁ›–† –ﬁ –ﬁ„¿†•ƒ¿‹•–† ¿†… '» ﬁ»›»ﬁ“» –«ﬁ ﬁ•„‚‹› –ﬁ ·•»† ‹– » ﬁ»•‡«ﬁ›»… ”ﬁ–‡ ¿†§ ﬁ»‰–“»ﬁ§ ”«†…› –‹¿•†»… § ¿†§ •†¶«ﬁ»… »‡·–§»» ˝»‰‹•–† ˚ «›•†»›› «‹– –†…•‹•–†› –›› –†…•‹•–†› º ﬁ¿†›”»ﬁ –” ˛•„‚‹› –” ˛»‰–“»ﬁ§ „¿•†›‹ ‹‚»ﬁ› ‹– ¸› •› ¿‡»†…»… ‹– ¿…… ‚» ¿‰‰•…»†‹ –ﬁ ·–›› •› …«» ‹– –»ﬁ¿‹•–†› «†…»ﬁ‹¿»† •† ¿‰‰–ﬁ…¿†‰» '•‹‚ ‹‚» ‰–†‹ﬁ¿‰‹ »¤•›‹•†„ »‹'»»† §–« ¿†… ›«‰‚ »ﬁ›–† –ﬁ –ﬁ„¿†•ƒ¿‹•–† ¿†… –'»“»ﬁ '» '•·· '¿•“» ¿†§ ﬁ•„‚‹ –” ﬁ»‰–“»ﬁ '» ‚¿“» ¿„¿•†›‹ ¿†§ »ﬁ›–† –ﬁ –ﬁ„¿†•ƒ¿‹•–† '•‹‚ '‚–‡ §–« ‚¿“» »†‹»ﬁ»… •†‹– ¿ ‰–†‹ﬁ¿‰‹ –ﬁ ¿„ﬁ»»‡»†‹ »‰¿«›» –” ¿§‡»†‹› '» ‡¿» «†…»ﬁ ‹‚•› –“»ﬁ¿„» –ﬁ‡ ¿ﬁ•›•†„ –«‹ –” ¿† ¿‰‰•…»†‹ –ﬁ ·–›› •” ææ 22 ŒŒŒ ˛ œ ˛ ¸˝˝˝ ˛˛˝ ¸ ˛ ˝¸˛ —˙ —˝¸˛ — PDF created with pdfFactory Pro trial version www.pdffactory.com DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 ~11 POLICY NUMBER: ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s)Location And Description Of Completed Operations COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 37 04 13 Page 1 of 1Insurance Services Office, Inc., 2012 A.Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". However: 1.The insurance afforded to such additional insured only applies to the extent permitted by law; and 2.If coverage provided to the additional insured is required by a contract or agree- ment,theinsuranceaffordedtosuchaddi- tional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B.With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1.Required by the contract or agreement; or 2.Available under the applicable Limits of Insu- rance shown in the Declarations; whichever is less. This endorsement shall not increase the appli- cable Limits of Insurance shown in the Decla- rations. GL518-01-77 ANY PERSON OR ORGANIZATION WHOM YOU BECOME OBLIGATED TO INCLUDE AS AN ADDITIONAL INSURED AS A RESULT OF ANY CONTRACT OR PER THE CONTRACT OR AGREEMENT. AGREEMENT YOU HAVE ENTERED INTO. PDF created with pdfFactory Pro trial version www.pdffactory.com PDF created with pdfFactory Pro trial version www.pdffactory.com DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 □ —˙¸˛ ˛ ˛ ˙ ˝˛˝ ˝ —˙ —˝ ˛ ˛¸˙ ˛˛ —˛˚˙¸˝ ‚•›»†…–ﬁ›»‡»†‹‡–…•”•»›•†›«ﬁ¿†‰»ﬁ–“•…»…«†…»ﬁ‹‚»”–··–'•†„ ˛˛˙˚˛—˛ˇ¸˛˙˚˛—˛ —¸˙˚˛—˛ —˛¸˝æ——˛˝˙˚˛—˛ ˝¸ «‡»ﬁ –” ¿§›ø –‹•‰» ł”†–»†‹ﬁ§¿»¿ﬁ›¿–“»•†”–ﬁ‡¿‹•–†ﬁ»ﬂ«•ﬁ»…‹–‰–‡·»‹»‹‚•›˝‰‚»…«·»'•··»›‚–'†•†‹‚»»‰·¿ﬁ¿‹•–†›¿›¿·•‰¿·»‹–‹‚•›»†…–ﬁ›»‡»†‹ –ﬁ¿†§›‹¿‹«‹–ﬁ•·§»ﬁ‡•‹‹»…ﬁ»¿›–†–‹‚»ﬁ‹‚¿††–†¿§‡»†‹–”ﬁ»‡•«‡‹‚»†«‡»ﬁ–”…¿§›ﬁ»ﬂ«•ﬁ»…”–ﬁ†–‹•‰»–”‰¿†‰»··¿‹•–†¿›ﬁ–“•…»…•†¿ﬁ¿„ﬁ¿‚–”»•‹‚»ﬁ‹‚»–‡‡–†—–·•‰§–†…•‹•–†–ﬁ¿›¿‡»†…»…§¿†¿·•‰¿·»›‹¿‹»‰¿†‰»··¿‹•–†»†…–ﬁ›»‡»†‹•›•†‰ﬁ»¿›»…‹–‹‚»†«‡»ﬁ –”…¿§››‚–'†•†‹‚»˝‰‚»…«·»¿–“» –§ﬁ•„‚‹†›«ﬁ¿†‰»˝»ﬁ“•‰»›””•‰»†‰—¿„» –” ºŁØØ PDF created with pdfFactory Pro trial version www.pdffactory.com DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 □ —˙¸˛˛˛˙ ‚•› »†…–ﬁ›»‡»†‹ ‡–…•”•»› •†›«ﬁ¿†‰» ﬁ –“•…»… «†…»ﬁ ‹‚» ”–··–'•†„ ˛ ˛ ˙ ˚˛ —˛ —¿„»–” —˛˛˙ ˛¸˛˙ ˛ ˝¸˛ †›«ﬁ¿†‰» ˝»ﬁ“•‰»› ””•‰» †‰ —˛¸˝æ— —˛˝ ˙ ˚˛ —˛ ˝ ˛˝ ˝ —˙ —˝ ˛ ˛¸˙ ‚» ”–··–'•†„ •› ¿……»… ‹– ‹‚» ‹‚»ﬁ †›«ﬁ¿†‰» –†…•‹•–† ¿†… ›«»ﬁ›»…»› ¿†§ ﬁ–“•›•–† ‹– ‹‚» ‰–†‹ﬁ¿ﬁ§ —ﬁ•‡¿ﬁ§ †… –†‰–†‹ﬁ•«‹–ﬁ§ †›«ﬁ¿†‰» ‚•› •†›«ﬁ¿†‰» •› ﬁ•‡¿ﬁ§ ‹– ¿†… '•·· †–‹ ›»» ‰–†‹ﬁ•«‹•–† ”ﬁ–‡ ¿†§ –‹‚»ﬁ •†›«ﬁ¿†‰» ¿“¿•·¿·» ‹– ¿† ¿……•‹•–†¿· •†›«ﬁ»… «†…»ﬁ §–«ﬁ –·•‰§ ﬁ –“•…»… ‹‚¿‹ ł ‚» ¿……•‹•–†¿· •†›«ﬁ»… •› ¿ ¿‡»… †›«ﬁ»… «†…»ﬁ ›«‰‚ –‹‚»ﬁ •†›«ﬁ¿†‰» ¿†… ł ˙–« ‚¿“» ¿„ﬁ»»… •† 'ﬁ•‹•†„ •† ¿ ‰–†‹ﬁ¿‰‹ –ﬁ ¿„ﬁ»»‡»†‹ ‹‚¿‹ ‹‚•› •†›«ﬁ¿†‰» '–«·… » ﬁ•‡¿ﬁ§ ¿†… '–«·… †–‹ ›»» ‰–†‹ﬁ•« ‹•–† ”ﬁ–‡ ¿†§ –‹‚»ﬁ •†›«ﬁ¿†‰» ¿“¿•·¿·» ‹– ‹‚» ¿……•‹•–†¿· •†›«ﬁ»… ºŁØØ DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 —˙ ¸˛ †›«ﬁ¿†‰» ˝»ﬁ“•‰»› ””•‰» †‰ Ł —¿„» –” ˚˛ ˛˝˛ ˛˝ ˛˚˛˙ ˝ ˛˝ ¸˝ ˛ ˛ ˙ º ‚•› »†…–ﬁ›»‡»†‹ ‡–…•”•»› •†›«ﬁ¿†‰» ﬁ –“•…»… «†…»ﬁ ‹‚» ”–··–'•†„ ˛ ˛ ˙ ˚˛ —˛ —˛¸˝æ— —˛˝ ˙ ˚˛ —˛ ˝¸ ¿‡» ” —»ﬁ›–† ﬁ ﬁ„¿†•ƒ¿‹•–† †”–ﬁ‡¿‹•–† ﬁ»ﬂ«•ﬁ»… ‹– ‰–‡·»‹» ‹‚•› ˝‰‚»…«·» •” †–‹ ›‚–'† ¿–“» '•·· » ›‚–'† •† ‹‚» »‰·¿ﬁ¿‹•–†› º ‚» ”–··–'•†„ •› ¿……»… ‹– —¿ﬁ¿„ﬁ¿‚ Ł ﬁ¿†›”»ﬁ ” ˛•„‚‹› ” ˛»‰–“»ﬁ§ „¿•†›‹ ‹‚»ﬁ› – ¸› –” ˝»‰ ‹•–† ˚ –†…•‹•–†› » '¿•“» ¿†§ ﬁ•„‚‹ –” ﬁ»‰–“»ﬁ§ '» ‡¿§ ‚¿“» ¿„¿•†›‹ ‹‚» »ﬁ›–† –ﬁ –ﬁ„¿†•ƒ¿‹•–† ›‚–'† •† ‹‚» ˝‰‚»…«·» ¿–“» »‰¿«›» –” ¿§‡»†‹› '» ‡¿» ”–ﬁ •†¶«ﬁ§ –ﬁ …¿‡¿„» ¿ﬁ•›•†„ –«‹ –” §–«ﬁ –†„–•†„ –»ﬁ¿ ‹•–†› –ﬁ §–«ﬁ '–ﬁ …–†» «†…»ﬁ ¿ ‰–†‹ﬁ¿‰‹ '•‹‚ ‹‚¿‹ »ﬁ›–† –ﬁ –ﬁ„¿†•ƒ¿‹•–† ¿†… •†‰·«…»… •† ‹‚» ﬁ–…«‰‹›‰–‡·»‹»… –»ﬁ¿‹•–†› ‚¿ƒ¿ﬁ… ‚•› '¿•“»ﬁ ¿·•»› –†·§ ‹– ‹‚» »ﬁ›–† –ﬁ –ﬁ„¿†•ƒ¿‹•–† ›‚–'† •† ‹‚» ˝‰‚»…«·» ¿–“» ºŁØØ —¸˛˝¸ —— ˛ ˛ ˛ ˛ ˙¸ ˛ DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 □ ‚•› »†…–ﬁ›»‡»†‹ »””»‰‹•“» ”–ﬁ‡› ¿ ¿ﬁ‹ –” –·•‰§ –•››«»… ‹– § ˝ ˛˝ ˝ —˙ —˝ ˛ ˛¸˙ ˝ ˝¸˛ ł—»ﬁ —ﬁ–¶»‰‹ –ﬁ —»ﬁ –‰¿‹•–† „„ﬁ»„¿‹» •‡•‹ ŁŒŒŁ łæ —¿„» –” ‚•› »†…–ﬁ›»‡»†‹ ‡–…•”•»› •†›«ﬁ¿†‰» ﬁ–“•…»… «†…»ﬁ ‹‚» ”–··–'•†„ ˛ ˛ ˙ ˚˛ ˛ ˙–«ﬁ –·•‰§ •› ¿‡»†…»… ‹– •†‰·«…» »•‹‚»ﬁ ¿ —»ﬁ —ﬁ–¶»‰‹ »†»ﬁ ¿· „„ﬁ»„¿‹» •‡•‹ ¿ —»ﬁ –‰¿‹•–† »†»ﬁ¿· „„ﬁ»„¿‹» •‡•‹ –ﬁ ¿ —»ﬁ —ﬁ–¶»‰‹ ¿†… —»ﬁ –‰¿‹•–† »†»ﬁ¿· „„ﬁ»„¿‹» •‡•‹ —·»¿›» ›»·»‰‹ –†·§ –†» –” ‹‚» ”–··–'•†„ ¯ ˆ —»ﬁ —ﬁ–¶»‰‹ »†»ﬁ¿· „„ﬁ»„¿‹» •‡•‹ ¯ ˆ —»ﬁ –‰¿‹•–† »†»ﬁ¿· „„ﬁ»„¿‹» •‡•‹ ¯ ˆ —»ﬁ —ﬁ–¶»‰‹ ¿†… —»ﬁ –‰¿‹•–† »†»ﬁ¿· „„ﬁ»„¿‹» •‡•‹ ˛ ˝ ¨˝ ˛ ˝ ˛˝ ˝ ˚ ˛ ˝ ¨˝ ˛ ˝ ˛˝ ˝ ˚ ˝ ˝ ˝¸˛ •› ¿‡»†…»… ‹– •†‰·«…» ‹‚» ”–··–'•†„ ‚» •‡•‹› –” †›«ﬁ¿†‰» ¿†… ‹‚» ﬁ«·»› »·–' ”•¤ ‹‚» ‡–›‹ '» '•·· ¿§ ﬁ»„¿ﬁ…·»›› –” ‹‚» †«‡»ﬁ –” ¿†›«ﬁ»…› ·¿•‡› ‡¿…» –ﬁ ›«•‹› ﬁ –«„‚‹ –ﬁ ‰—»ﬁ›–†› –ﬁ –ﬁ„¿†•ƒ¿‹•–†› ‡¿•†„ ‰·¿•‡› –ﬁ ﬁ•†„•†„ ›«•‹› ‚» »†»ﬁ¿· „„ﬁ»„¿‹» •‡•‹ •› ‹‚» ‡–›‹ '» '•·· ¿§ ”–ﬁ ‹‚» ›«‡ –” ¿»…•‰¿· »¤»†›»› «†…»ﬁ –“»ﬁ¿„» ¿‡¿„»› «†…»ﬁ –“»ﬁ¿„» »¤‰»‹ …¿‡¿„»› »‰¿«›» –” –…•·§ •†¶«ﬁ§ –ﬁ ﬁ–»ﬁ‹§ …¿‡¿„» •†‰·«…»… •† ‹‚» ﬁ–…«‰‹›‰–‡·»‹»… –»ﬁ¿‹•–†› ‚¿ƒ¿ﬁ… ¿†… ‰¿‡¿„»› «†…»ﬁ –“»ﬁ¿„» ‚» —ﬁ–…«‰‹›–‡·»‹»… »ﬁ¿‹•–†› „„ﬁ »„¿‹» •‡•‹ •› ‹‚» ‡–›‹ '» '•·· ¿§ «†…»ﬁ –“»ﬁ¿„» ”–ﬁ …¿‡¿„»› »‰¿«›» –” –…•·§ •†¶«ﬁ§ ¿†… ﬁ–»ﬁ‹§ …¿‡¿„» •†‰·«…»… •† ‹‚» ﬁ–…«‰‹›‰–‡·»‹»… –»ﬁ¿‹•–†› ‚¿ƒ¿ﬁ… ˝«¶»‰‹ ‹– ¿–“» ‹‚» —»ﬁ›–†¿· ¿†… …“»ﬁ‹•›•†„ †¶«ﬁ§ •‡•‹ •› ‹‚» ‡–›‹ '» '•·· ¿§ «†…»ﬁ –“»ﬁ¿„» ”–ﬁ ‹‚» ›«‡ –” ¿·· …¿‡¿„»› »‰¿«›» –” ¿·· »ﬁ›–†¿· ¿†… ¿…“»ﬁ‹•›•†„ •†¶«ﬁ§ ›«›‹¿•†»… § ¿†§ –†» »ﬁ›–† –ﬁ –ﬁ„¿†•ƒ¿‹•–† º˝«¶»‰‹ ‹– –ﬁ ¿–“» '‚•‰‚»“»ﬁ ¿·•»› ‹‚» ¿‰‚ ‰‰«ﬁﬁ»†‰» •‡•‹ •› ‹‚» ‡–›‹ '» '•·· ¿§ ”–ﬁ ‹‚» ›«‡ –” ¿¿‡¿„»› «†…»ﬁ –“»ﬁ¿„» ¿†… »…•‰¿· »¤»†›»› «†…»ﬁ –“»ﬁ¿„» ˛˝ ææ 2 ºŁØØ ˛ œ ˛ ¸˝˝˝ ˛˛˝ ¸ ˛ ˝¸˛ —˙ —˝¸˛ — ¨ PDF created with pdfFactory Pro trial version www.pdffactory.com DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 ŁŒŒŁ łæ —¿„» –” «‹‚–ﬁ•ƒ»… ˛»ﬁ»›»†‹¿‹•“» –ﬁ–«†‹»ﬁ›•„†¿‹«ﬁ» ł•† ˝‹¿‹»› ‚»ﬁ»·•‰¿·» »‰¿«›» –” ¿·· –…•·§ •†¶«ﬁ§ ¿†… ﬁ –»ﬁ‹§ …¿‡¿„» ¿ﬁ•›•†„ –«‹ –” ¿†§ –†» –‰‰«ﬁﬁ»†‰» Œ ˝«¶»‰‹ ‹– º ¿–“» ‹‚» ¿‡¿„» ‹– —ﬁ»‡•›»› ˛»†‹»… – ˙–« •‡•‹ •› ‹‚» ‡–›‹ '» '•·· ¿§ «†…»ﬁ –“»ﬁ¿„» »‰¿«›» –” ﬁ–»ﬁ‹§ …¿‡¿„» ‹– ¿†§ –†» ﬁ»‡•›»› '‚•·» ﬁ»†‹»… ‹– §–« –ﬁ •† ‹‚» ‰¿›» –” …¿‡¿„» § ”•ﬁ» '‚•·» ﬁ»†‹»… ‹– §–« –ﬁ ‹»‡–ﬁ¿ﬁ•·§ –‰‰«•»… § §–« '•‹‚ »ﬁ‡•››•–† –” ‹‚» –'†»ﬁ Ø ˝«¶»‰‹ ‹– º ¿–“» ‹‚» »…•‰¿· ¤»†›» •‡•‹ •› ‹‚» ‡–›‹ '» '•·· ¿§ «†…»ﬁ –“»ﬁ¿„» ”–ﬁ ¿·· ‡»…•‰¿· »¤»†›»› »‰¿«›» –” –…•·§ •†¶«ﬁ§ ›«›‹¿•†»… § ¿†§ –†» »ﬁ›–† Ł ˝«¶»‰‹ ‹– º Œ ¿†…æ–ﬁ Ø ¿–“» ‹‚» —»ﬁ —ﬁ–¶»‰‹ „„ﬁ»„¿‹» •‡•‹ •› ‹‚» ‡–›‹ '» '•·· ¿§ «†…»ﬁ –“»ﬁ¿„»› ¿†… ‰–‡•†»… ”–ﬁ ‹‚» ›«‡ –” ¿¿‡¿„»› «†…»ﬁ –“»ﬁ¿„» ¿‡¿„»› «†…»ﬁ –“»ﬁ¿„» ¿†… ‰»…•‰¿· ¤»†›»› «†…»ﬁ –“»ﬁ¿„» ¿ﬁ•›•†„ –«‹ –” ¿†§ ›•†„·» —ﬁ–¶»‰‹ …»›‰ﬁ•»… ¿–“» ˝«¶»‰‹ ‹– º Œ ¿†…æ–ﬁ Ø ¿–“» ‹‚» —»ﬁ –‰¿‹•–† „„ﬁ»„¿‹» •‡•‹ •› ‹‚» ‡–›‹ '» '•·· ¿§ «†…»ﬁ –“»ﬁ¿„»› ¿†… ‰–‡•†»… ”–ﬁ ‹‚» ›«‡ –” ¿¿‡¿„»› «†…»ﬁ –“»ﬁ¿„» ¿‡¿„»› «†…»ﬁ –“»ﬁ¿„» ¿†… ‰»…•‰¿· »¤»†›»› «†…»ﬁ –“»ﬁ¿„» ¿ﬁ•›•†„ –«‹ –” ‹‚» ¿†§ ›•†„·» –‰¿‹•–† …»›‰ﬁ•»… ¿–“» ‚» •‡•‹› –” †›«ﬁ¿†‰» –” ‹‚•› –“»ﬁ¿„» —¿ﬁ‹ ¿·§ ›»¿ﬁ¿‹»·§ ‹– »¿‰‚ ‰–†›»‰«‹•“» ¿††«¿· »ﬁ•–… ¿†… ‹– ¿†§ ﬁ»‡¿•†•†„ »ﬁ•–… –” ·»›› ‹‚¿† ‡–†‹‚› ›‹¿ﬁ‹•†„ '•‹‚ ‹‚» »„•††•†„ –” ‹‚» –·•‰§ »ﬁ•–… ›‚–'† •† ‹‚» »‰·¿ﬁ¿‹•–†› «†·»›› ‹‚» –·•‰§ »ﬁ•–… •› »¤‹»†…»… ¿”‹»ﬁ •››«¿†‰» ”–ﬁ ¿† ¿……•‹•–†¿· »ﬁ•–… –” ·»›› ‹‚¿† ‡–†‹‚› † ‹‚¿‹ ‰¿›» ‹‚» ¿……•‹•–†¿· »ﬁ•–… '•·· » …»»‡»… ¿ﬁ‹ –” ‹‚» ·¿›‹ ﬁ»‰»…•†„ »ﬁ•–… ”–ﬁ «ﬁ –›»› –” …»‹»ﬁ‡•†•†„ ‹‚» •‡•‹› –” †›«ﬁ¿†‰» ‚» •‡•‹› –” †›«ﬁ¿†‰» ›‚–'† •† ‹‚» »‰·¿ﬁ¿‹•–†› ¿ﬁ» …»·»‹»… •† ‹‚»•ﬁ »†‹•ﬁ»‹§ ¿†… ﬁ»·¿‰»… § ‹‚» •‡•‹› –” †›«ﬁ¿†‰» ›»‹ ”–ﬁ‹‚ »·–' •‡•‹› –” †›«ﬁ¿†‰» »†»ﬁ¿· „„ﬁ»„¿‹» •‡•‹ ¿‰‚ ‰‰«ﬁﬁ»†‰» •‡•‹ —ﬁ–…«‰‹›–‡·»‹»… »ﬁ¿‹•–†› „„ﬁ»„¿‹» •‡•‹ —»ﬁ›–†¿· œ …“»ﬁ‹•›•†„ †¶«ﬁ§ •‡•‹ ¿‡¿„» ‹– —ﬁ»‡•›»› ˛»†‹»… ‹– ˙–« »…•‰¿· ¤»†›» •‡•‹ —»ﬁ —ﬁ–¶»‰‹ »†»ﬁ¿· „„ﬁ»„¿‹» •‡•‹ —»ﬁ –‰¿‹•–† »†»ﬁ¿· „„ﬁ»„¿‹» •‡•‹ –ﬁ —»ﬁ —ﬁ–¶»‰‹ ¿†… —»ﬁ –‰¿‹•–† »†»ﬁ¿· „„ﬁ»„¿‹» •‡•‹ ˚˝ ˚ ˝ •› ¿‡»†…»… ‹– •†‰·«…» ‹‚» ”–··–'•†„ –‰¿‹•–† ‡»¿†› ﬁ»‡•›»› •†“–·“•†„ ‹‚» ›¿‡» –ﬁ ‰–††»‰‹•†„ ·–‹› –ﬁ ﬁ»‡•›»› '‚–›» ‰–††»‰‹•–† •› •†‹»ﬁﬁ«‹»… –†·§ § ¿ ›‹ﬁ»»‹ ﬁ–¿…'¿§ '¿‹»ﬁ'¿§ –ﬁ ﬁ•„‚‹–”'¿§ ﬁ¿•·ﬁ–¿… ·· –‹‚»ﬁ ‹»ﬁ‡› ¿†… ‰–†…•‹•–†› –” ‹‚•› –·•‰§ ﬁ»‡¿•† ‹‚» ›¿‡» º PDF created with pdfFactory Pro trial version www.pdffactory.com DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 03/01/2022 WC 080-75-6387 GOFORTH & MARTI - DBA: GM BUSINESS INTERIORS NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. DocuSign Envelope ID: 5FDFA4D8-803E-4E4E-B3D8-F56EEC2F20A9 BLANKET WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM Issued to By forms a part of Policy No. We have a right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against any person or organization with whom you have a written contract that requires you to obtain this agreement from us, as regards any work you perform for such person or organization. The additional premium for this endorsement shall be 2 . 00 % of the total estimated workers compensation premium for this policy. WC 04 03 61 (Ed. 11/90) /4tt~ Countersigned by _____________________________ _ Authorized Representative