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18-071 Amendment #3 dated 6-21-23 General Fund Human Services Grants Program- Haven to Home1 THIRD AMENDMENT TO GENERAL FUND HUMAN SERVICES GRANT (HSG) FUNDS CITY/NON-PROFIT CONTRACT (Services Only) This Third Amendment to Contract is entered into between WEST VALLEY COMMUNITY SERVICES ("CORPORATION") and the CITY OF CUPERTINO ("CITY") as of July 1, 2023 (the "Effective Date") to amend the General Fund HSG City/Non-Profit Contract (the "Contract") dated July 1, 2020. WITNESSETH WHEREAS, CITY has reserved a portion of its HSG funds to be used on activities that benefit Cupertino’s residents; and, WHEREAS, CITY has agreed to the use by CORPORATION of a portion of CITY’S HSG budget for the Program (as described below) to be operated within CITY for the benefit of low and very low-income households; THEREFORE, the parties agree as follows: 1. Section I, entitled "Program", is deleted in its entirety and replaced with the following: For the period of July 1, 2020 to June 30, 2021, CITY agreed to allocate a portion of its HSG funds to CORPORATION in the sum of Sixty Five Thousand Seven Hundred Eighty Dollars and No. Cents ($65,780) for the purpose of implementing the CORPORATION'S program, as more particularly described in Exhibits A-D to the Contract, and said Exhibits set forth below, as they may be amended or modified, are attached to this Contract and incorporated herein by reference. For the period of July 1, 2021 to June 30, 2022 CITY agrees to allocate a portion of its current HSG funds to CORPORATION in the sum of Sixty Five Thousand Seven Hundred Eighty Dollars and No. Cents ($65,780) for the purpose of implementing the CORPORATION'S Program, as more particularly described in Exhibits A-1, B-1, C-1, and D-1 to the Contract, and said Exhibits set forth below, as they may be amended or modified, are attached to this Contract and incorporated herein by reference. For the period of July 1, 2022 to June 30, 2023 CITY agrees to allocate a portion of its current HSG funds to CORPORATION in the sum of Sixty Five Thousand Seven Hundred Eighty Dollars and No. Cents ($65,780) for the purpose of implementing the CORPORATION'S Program, as more particularly described in Exhibits A-2, B-2, C-2, and D-2 to the Contract, and said Exhibits set forth below, as they may be amended or modified, are attached to this Contract and incorporated herein by reference. For the period of July 1, 2023 to June 30, 2024 CITY agrees to allocate a portion of its current HSG funds to CORPORATION in the sum of Seventy Four Thousand Thirty Four Dollars and Thirty Four Cents ($74,034.34) for the purpose of implementing the CORPORATION'S Program, as more particularly described in Exhibits A-3, B-3, C-3, and D-3 to the Contract, and 2 said Exhibits set forth below, as they may be amended or modified, are attached to this Contract and incorporated herein by reference. Exhibit A-3: Program Description (FY 2023-24) Exhibit B-3: Program Work Plan (FY 2023-24) Exhibit C-3: Proposed Implementation Timeline Schedule (FY 2023-24) Exhibit D-3: Program Budget (FY 2020-21) Exhibit E: Basic Insurance and Bond Requirements For Non-Profit Contracts The total allocation for July 1, 2020 through June 30, 2024 shall not exceed Two Hundred Seventy One Thousand Three Hundred Seventy Four Dollars and Thirty Four Cents ($271,374.34) 2. Exhibits A-3, B-3, C-3, and D-3, including an updated Certificate of Insurance, are attached hereto. 3. Section II, "Term," is deleted in its entirety and replaced with the following: A. The purpose of this Contract is for the CITY to disburse the Grant for eligible activities. B. The term of this Contract (the "Term") will begin on July 1, 2020 and will end on June 30, 2024, unless otherwise amended or terminated earlier pursuant to Section VII, Section VIII, or Section XVI of this Contract. 4. All terms, covenants and conditions stated in the CONTRACT, which are not herein amended, remain in full force and effect. [Signatures on following page.] Page 3 of 12 Second Amendment to Below Market Rate (BMR) Affordable Housing Fund (AHR) City/Non-Profit Contract IN WITNESS WHEREOF, the parties have executed this First Amendment as of the Effective Date. CORPORATION: CITY: WEST VALLEY COMMUNITY CITY OF CUPERTINO, a municipal SERVICES OF SANTA CLARA COUNTY, benefit corporation a California nonprofit public corporation ___________________________________ __________________________________ Sujatha Venkatraman Date Pamela Wu Date Executive Officer City Manager APPROVED AS TO FORM AND ATTEST: LEGALITY: ___________________________________ _________________________________ Christopher Jensen Date Kirsten Squarcia Date City Attorney City Clerk EXPENDITURE DISTRIBUTION PO # 2021-096 100-72-712-600-623 Original Contract: $65,780.00 Amendment #1: $65,780.00 Amendment #2: $65,780.00 Amendment #3 $74,034.34 Total: $271,374.34 Sujatha Venkatraman Jun 21, 2023 Christopher D. Jensen Jun 21, 2023 Jun 21, 2023 Page 4 of 12 Second Amendment to Below Market Rate (BMR) Affordable Housing Fund (AHR) City/Non-Profit Contract EXHIBIT A-3 PROGRAM DESCRIPTION FY 2023-24 Agency Name: West Valley Community Services of Santa Clara County Inc. DUNS: Not Applicable (Only for CDBG) Executive Officer: Sujatha Venkatraman Program Manager: Benaifer Dastoor Program # (For Office Use Only) 100-72-712 600-623 Street Address: 10104 Street Vista City: Cupertino State: CA Zip Code: 95014 Telephone number: 408-255-8033 Fax Number: Manager E-mail sujathav@wvcommunityservices. org Name of Program: Haven to Home Program Location: 10104 Vista Drive. Cupertino, CA 95014 Program Description: West Valley Community Services' (WVCS) Haven to Home (HTH) program is based on the Housing-First methodology that vulnerable and at-risk homeless individuals are more responsive to interventions and social services support after they are placed in their own housing, rather than living in temporary/transitional facilities or housing. The main goals of this program are to help homeless clients secure permanent housing, maintain employment, and enhance income opportunities. The clients receive intensive case management designed to provide easy access to resources at one location. Case Management uses a strength-based and mentoring approach in helping struggling families and individuals move out of crisis towards self-sufficiency by helping them build their own safety net. Haven to Home aims at ending homelessness by coordinating multilevel services and leveraging resources in the community. Page 5 of 12 Second Amendment to Below Market Rate (BMR) Affordable Housing Fund (AHR) City/Non-Profit Contract EXHIBIT B-3 PROGRAM WORK PLAN FY 2023-24 AGENCY NAME: West Valley Community Services of Santa Clara County Inc. PROGRAM NAME: Haven to Home Objectives Benchmarks for Each Quarter 1st 2nd 3rd 4th TOTAL Supportive Services and Case Management 25 18 18 14 75 Total Beneficiaries 25 18 18 14 75 Page 6 of 12 Second Amendment to Below Market Rate (BMR) Affordable Housing Fund (AHR) City/Non-Profit Contract EXHIBIT C-3 PROPOSED IMPLEMETATION TIMELINE SCHEDULE FY 2023-24 AGENCY NAME: West Valley-Community Services of Santa Clara County Inc. PROGRAM NAME: Haven to Home Activity Number & Description Activity # Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 1. Page 7 of 12 Second Amendment to Below Market Rate (BMR) Affordable Housing Fund (AHR) City/Non-Profit Contract EXHIBIT D-3 PROGRAM BUDGET FY 2023-24 AGENCY NAME: West Valley Community Services of Santa Clara County Inc. PROGRAM NAME: Haven to Home Proposed Program Expenses FY 23-24 Salaries/Benefits/Payroll/Taxes $63,685.00 Office Supplies Communication Publications/Printing/Advertising Travel Rent/Lease/Mortgage Utilities Insurance Equipment Rental/Maintenance Audit/Legal/Professional Services (for CDBG portion only) Direct Services (Funding for specific service such as a meal, ride) $6,315.00 Contracted Services Other (Admin) $4,034.34 Total Expenses $75,034.34 Page 8 of 12 Second Amendment to Below Market Rate (BMR) Affordable Housing Fund (AHR) City/Non-Profit Contract EXHIBIT E BASIC INSURANCE AND BOND REQUIREMENTS FOR NON-PROFIT CONTRACTS Definition of Contractor: The "Contractor" as the word is used in this Exhibit E is the party contracting with the City of Cupertino for the direct distribution of HSG funds. Indemnity The Contractor shall indemnify, defend, and hold harmless the City of Cupertino (hereinafter "City"), its officers, agents and employees from any loss, liability, claim, injury or damage arising out of, or in connection with performance of this Contract by Contractor and/or its agents, employees or subcontractors, excepting only loss, injury or damage caused solely by the acts or omissions of personnel employed by the City. It is the intent of the parties to this Contract to provide the broadest possible coverage for the City. The Contractor shall reimburse the City for all costs, attorneys' fees, expenses and liabilities incurred with respect to any litigation in which the Contractor is obligated to indemnify, defend and hold harmless the City under this Contract. Insurance Without limiting the Contractor's indemnification of the City, the Contractor shall provide and maintain at its own expense, during the term of this Contract, or as may be further required herein, the following insurance coverages and provisions: A. Evidence of Coverage Prior to commencement of this Contract, the Contractor shall provide on the City's own form or a form approved by the City's Insurance Manager an original plus one copy of a Certificate of Insurance certifying that coverage as required herein has been obtained and remains in force for the period required by this Contract. The contract number and program name must be stated on the Certificate of Insurance. The City's Special Endorsement form shall accompany the certificate. Individual endorsements executed by the insurance carrier may be substituted for the City's Special Endorsement form if they provide the coverage as required. In addition, a certified copy of the policy or policies shall be provided by the Contractor upon request. This verification of coverage shall be sent to the address as shown on the City's Certificate of Insurance form and to the Community Development Department at the address set forth in this Contract at Section VI. PROGRAM COORDINATION, Paragraph C., NOTICES. The Contractor shall not issue a Notice to Proceed with the work under this Contract until it has obtained all insurance required and such insurance has been approved by the City. This approval of insurance shall neither relieve nor decrease the liability of the Contractor. B. Notice of Cancellation of Reduction of Coverage All policies shall contain a special provision for thirty (30) days prior written notice of any cancellation or reduction in coverage to be sent to the Community Development Department, 10300 Torre Avenue, Cupertino, CA 95014. Page 9 of 12 Second Amendment to Below Market Rate (BMR) Affordable Housing Fund (AHR) City/Non-Profit Contract C. Qualifying Insurers All policies shall be issued by companies which hold a current policy holder's alphabetic and financial size category rating of not less than A VIII, according to the current Best's Key Rating Guide, unless otherwise approved by the City's Insurance Manager. D. Insurance Required 1. Comprehensive General Liability Insurance - for bodily injury (including death) and property damage which provides limits of not less than one million dollars ($1,000,000) combined single limit (CSL) per occurrence. OR 2. Commercial General Liability Insurance - for bodily injury (including death) and property damage which provides limits as follows: a. General limit per occurrence - $1,000,000 b. General limit aggregate - $2,000,000 c. Products/Completed Operations- $1,000,000 aggregate d. Personal Injury limit - $1,000,000 If coverage is provided under a Commercial General Liability Insurance form, the carrier shall provide the City Insurance Manager with a quarterly report of the amount of aggregate limits expended to that date. If over 50% of the aggregate limits have been paid or reserved, the City may require additional coverage to be purchased by the Contractor to restore the required limits. 3. For either type of insurance, coverage shall include: a. Premises and Operations b. Products/Completed Operations with limits of one million dollars ($1,000,000) per occurrence/ aggregate to be maintained for two (2) years following acceptance of the work by the City. c. Contractual Liability expressly including liability assumed under this Contract. d. Personal Injury liability. e. Independent Contractors' (Protective) liability. f. Severability of Interest clause providing that the coverage applies separately to each insured except with respect to the limits of liability. Page 10 of 12 Second Amendment to Below Market Rate (BMR) Affordable Housing Fund (AHR) City/Non-Profit Contract 4. For either type of insurance, coverage shall include the following endorsements, copies of which shall be provided to the City: a. Additional Insured Endorsement: Such insurance as is afforded by this policy shall also apply to the City of Cupertino, and members of the City Council, and the officers, agents and employees of the City of Cupertino, individually and collectively, as additional insureds. b. Primary Insurance Endorsement: Such insurance as is afforded by the additional insured endorsement shall apply as primary insurance, and other insurance maintained by the City of Cupertino, its officers, agents, and employees shall be excess only and not contributing with insurance provided under this policy. c. Notice of Cancellation or Change of Coverage Endorsement: This policy may not be cancelled nor the coverage reduced by the Company without 30 days prior written notice of such cancellation or reduction in coverage to the City of Cupertino at the address shown on the Certificate of Insurance. d. Contractual Liability Endorsement: This policy shall apply to liability assumed by the insured under written contract with the City of Cupertino. e. Personal Injury Endorsement: The provisions of this policy shall provide Personal Injury coverage. f. Severability of Interest Endorsement: The insurance afforded by this policy shall apply separately to each insured that is seeking coverage or against whom a claim is made or a suit is brought, except with respect to the Company's limit of liability. 5. Comprehensive Automobile Liability Insurance for bodily injury (including death) and property damage which provides total limits of not less than one million dollars ($1,000,000) combined single limit per occurrence applicable to all owned, non-owned and hired vehicles. 6. Worker's Compensation and Employer's Liability Insurance for: a. Statutory California Workers' Compensation coverage including a broad form all- states endorsement. Page 11 of 12 Second Amendment to Below Market Rate (BMR) Affordable Housing Fund (AHR) City/Non-Profit Contract b. Employer's Liability coverage for not less than one million dollars ($1,000,000) per occurrence for all employees engaged in services or operations under this Contract. c. Inclusion of the City and its governing board(s), officers, representatives, agents, and employees as additional insureds, or a waiver of subrogation. 7. Professional Errors and Omissions Liability Insurance This type of insurance should be provided by persons/entities you contract with to provide you with professional services. a. Limits of not less than one million dollars ($1,000,000). b. If this policy contains a self retention limit, it shall not be greater than ten thousand dollars ($10,000) per occurrence/event. c. This coverage shall be maintained for a minimum of two (2) years following termination of this Contract. The City must first approve any exceptions to the above requirements. 8. Bond Requirements Fidelity Bond - Before receiving compensation under this Contract, Contractor will furnish City with evidence that all officials, employees, and agents handling or having access to funds received or disbursed under this Contract, or authorized to sign or countersign checks, are covered by a BLANKET FIDELITY BOND in an amount of AT LEAST fifteen percent (15%) of the maximum financial obligation of the City cited herein. If such bond is cancelled or reduced, Contractor will notify City immediately, and City may withhold further payment to Contractor until proper coverage has been obtained. Failure to give such notice may be cause for termination of this Contract, at the option of the City. 9. Special Provisions The following provisions shall apply to this Contract: a. The foregoing requirements as to the types and limits of insurance coverage to be maintained by the Contractor and any approval of said insurance by the City or its insurance consultant(s) are not intended to and shall not in any manner limit or qualify the liabilities and obligations otherwise assumed by the Contractor pursuant to this Contract, including but not limited to the provisions concerning indemnification. b. The City acknowledges that some insurance requirements contained in this Contract may be fulfilled by self-insurance on the part of the Contractor. However, this shall not in any way limit liabilities assumed by the Contractor under this Contract. The City shall approve any self-insurance in writing. Page 12 of 12 Second Amendment to Below Market Rate (BMR) Affordable Housing Fund (AHR) City/Non-Profit Contract c. The City reserves the right to withhold payments to the Contractor in the event of material noncompliance with the insurance requirements outlined above. d. If the Contractor fails to maintain such insurance as is called for herein, the City must order the Contractor to immediately suspend work at Contractor's expense until a new policy of insurance is in effect. 05/16/2023 Anixter & Oser, Inc. License 0E28888 205 San Marin Drive Novato CA 94945-1227 Robin Brazell (415) 898-1600 robin@properlyinsured.com West Valley Community Services of Santa Clara County 10104 Vista Drive Cupertino CA 95014 Philadelphia Ind Ins Co 18058 Nova Casualty Compay 42552 CL2351631233 A Professional Liability Sexual/Physical Abuse Y PHPK2553043 06/01/2023 06/01/2024 1,000,000 500,000 20,000 1,000,000 2,000,000 2,000,000 A PHPK2553043 06/01/2023 06/01/2024 1,000,000 Medical Expense 5,000 A PHUB863436 06/01/2023 06/01/2024 2,000,000 2,000,000 B Y CF1-WK-10000414-00 12/31/2022 12/31/2023 1,000,000 1,000,000 1,000,000 Certificate holder is named as additional insured per form CG 2026.Coverage is primary and non-contributory form PI-GL-005. City of Cupertino Cupertino City Hall 10300 Torre Ave Cupertino CA 95014 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page of ADDITIONAL INSURED – DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following 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 Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. PHPK2553043 City of Cupertino its officers, officials, and employees 620 PI-GL-005 (07/12) Page of Includes copyrighted material of Insurance Services Office, Inc., with its permission. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED PRIMARY AND NON-CONTRIBUTORY INSURANCE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Effective Date: Name of Person or Organization (Additional Insured): SECTION II – WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the endorsement Schedule, but only with respect to liability for “bodily injury,” “property damage” or “personal and advertising injury” arising out of or relating to your negligence in the performance of “your work” for such person(s) or organization(s) that occurs on or after the effective date shown in the endorsement Schedule. This insurance is primary to and non-contributory with any other insurance maintained by the person or organization (Additional Insured), except for loss resulting from the sole negligence of that person or organization. This condition applies even if other valid and collectible insurance is available to the Additional Insured for a loss or ”occurrence” we cover for this Additional Insured. The Additional Insured’s limits of insurance do not increase our limits of insurance, as described in SECTION III – LIMITS OF INSURANCE. All other terms, conditions, and exclusions under the policy are applicable to this endorsement and remain unchanged. City of Cupertino, Cupertino City Hall 06/01/2014 24 INSURED 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 Policy No. Endorsement No. Insured Premium $ Insurance Company Countersigned By CF1-WK-10000414-00 12-31-22 001 NOVA Casualty Company WEST VALLEY COMMUNITY SERVICES INCL. 1998 by the Workers’ Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB’s California Workers’ Compensation Insurance Forms Manual 1999. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be % of the California workers’ compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR 2 WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER PRIOR TO A LOSS. POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page of ADDITIONAL INSURED – DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following 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 Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. PHPK2553043 City of Cupertino 420 PI-GL-005 (07/12) Page of Includes copyrighted material of Insurance Services Office, Inc., with its permission. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED PRIMARY AND NON-CONTRIBUTORY INSURANCE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Effective Date: Name of Person or Organization (Additional Insured): SECTION II – WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the endorsement Schedule, but only with respect to liability for “bodily injury,” “property damage” or “personal and advertising injury” arising out of or relating to your negligence in the performance of “your work” for such person(s) or organization(s) that occurs on or after the effective date shown in the endorsement Schedule. This insurance is primary to and non-contributory with any other insurance maintained by the person or organization (Additional Insured), except for loss resulting from the sole negligence of that person or organization. This condition applies even if other valid and collectible insurance is available to the Additional Insured for a loss or ”occurrence” we cover for this Additional Insured. The Additional Insured’s limits of insurance do not increase our limits of insurance, as described in SECTION III – LIMITS OF INSURANCE. All other terms, conditions, and exclusions under the policy are applicable to this endorsement and remain unchanged. City of Cupertino, Cupertino City Hall 06/01/2014 24 General Fund Human Services Grants Program- Haven to Home Final Audit Report 2023-06-22 Created:2023-06-21 By:City of Cupertino (webmaster@cupertino.org) Status:Signed Transaction ID:CBJCHBCAABAAWtwFVMAILX6BpjxISqE7sVYZ6sJoEgR_ "General Fund Human Services Grants Program- Haven to Hom e" History Document created by City of Cupertino (webmaster@cupertino.org) 2023-06-21 - 4:19:40 PM GMT- IP address: 35.229.54.2 Document emailed to Araceli Alejandre (aracelia@cupertino.org) for approval 2023-06-21 - 4:21:26 PM GMT Document approved by Araceli Alejandre (aracelia@cupertino.org) Approval Date: 2023-06-21 - 5:03:48 PM GMT - Time Source: server- IP address: 73.170.104.117 Document emailed to sujathav@wvcommunityservices.org for signature 2023-06-21 - 5:03:49 PM GMT Email viewed by sujathav@wvcommunityservices.org 2023-06-21 - 5:50:00 PM GMT- IP address: 73.223.28.233 Signer sujathav@wvcommunityservices.org entered name at signing as Sujatha Venkatraman 2023-06-21 - 5:50:35 PM GMT- IP address: 73.223.28.233 Document e-signed by Sujatha Venkatraman (sujathav@wvcommunityservices.org) Signature Date: 2023-06-21 - 5:50:37 PM GMT - Time Source: server- IP address: 73.223.28.233 Document emailed to christopherj@cupertino.org for signature 2023-06-21 - 5:50:39 PM GMT Email viewed by christopherj@cupertino.org 2023-06-21 - 6:00:10 PM GMT- IP address: 104.47.74.126 Signer christopherj@cupertino.org entered name at signing as Christopher D. Jensen 2023-06-21 - 6:00:45 PM GMT- IP address: 136.24.22.111 Document e-signed by Christopher D. Jensen (christopherj@cupertino.org) Signature Date: 2023-06-21 - 6:00:47 PM GMT - Time Source: server- IP address: 136.24.22.111 Document emailed to Pamela Wu (pamelaw@cupertino.org) for signature 2023-06-21 - 6:00:48 PM GMT Email viewed by Pamela Wu (pamelaw@cupertino.org) 2023-06-21 - 6:01:30 PM GMT- IP address: 104.47.74.126 Document e-signed by Pamela Wu (pamelaw@cupertino.org) Signature Date: 2023-06-22 - 2:55:39 AM GMT - Time Source: server- IP address: 64.165.34.3 Document emailed to Kirsten Squarcia (kirstens@cupertino.org) for signature 2023-06-22 - 2:55:40 AM GMT Email viewed by Kirsten Squarcia (kirstens@cupertino.org) 2023-06-22 - 3:06:16 AM GMT- IP address: 104.47.74.126 Document e-signed by Kirsten Squarcia (kirstens@cupertino.org) Signature Date: 2023-06-22 - 3:06:25 AM GMT - Time Source: server- IP address: 64.165.34.3 Agreement completed. 2023-06-22 - 3:06:25 AM GMT