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17-062 Telfer Pavement Technologies, LLC, 2017 Pavement Maintenance Project - Phase 2, Project No. 2017-110DOCUMENT 00520 CONTRACT Project No . 2017-110 po .j..;01 -=t--soci THIS CONTRACT, dated this )---1--day of ~ , 2017 , by and between Telfer Pavement Technologies LLC whose place of business is located at 4522 Parker Ave Suite 350, McClellan CA, 95652 ("Contractor"), and the CITY OF CUPERTINO, a Municipal Corporation of the State of California ("City") acting under and by virtue of the authority vested in the City by the laws of the State of California. WHEREAS, City, on the 2J th day of /Vl~(Ll) Project: , 2017 awarded to Contractor the following PROJECT NUMBER 2017-110 2017 PAVEMENT MAINTENANCE PROJECT -PHASE 2 NOW, THEREFORE, in consideration of the mutual covenants hereinafter set forth, Contractor and City agree as follows : Article 1. Work 1.1 Contractor shall complete all Work specified in the Contract Documents, in accordance with the Specifications, Drawings, and all other terms and conditions of the Contract Documents . Article 2. Agency and Notices to City 2.1 City has d es ignated Roger Lee, Assistant Director, Public Works , to act as City's Authorized Representati ve(s), who will represent City in perfo1ming City's duties and responsibilities and exercising City's rights and authorities in Contract Documents. City may change the individual(s) acting as City's Authorized Representative(s), or delegate one or more specific functions to one or more specific City's Representatives, including without limitation engineering, architectural , inspection and general administrative functions , at any time with notice and without liability to Contractor. Each City's Representative is the beneficiary of all Contractor obligations to City, including without limitation, all releases and indemnities. 2.2 All notices or demands to City under the Contract Documents shall be to City's Authorized Representative at: 10300 Torre Avenue, Cupe11ino , California 95014 or to such other person(s) and address(es) as City shall provide to Contractor. Article 3. Contract Time and Liquidated Damages 3 .1 Contract Time. The Contract Time will commence to run on the date indicated in the Notice to Proceed . City may give a Notice to Proceed at any time within 30 Days after the Notice of Award. Contractor shall not do any Work at the Site prior to the date on which the Contract Time commences to run. Contractor shall achieve Final Completion of the entire Work and be ready for Final Payment in accordance with Section 00700 (General Provisions) within 45 working days as provided in Document 00700 (General Provisions) City of Cupertino 00520 -I Co ntract 20 17 Pavement Maintenance Project -Phase 2 Project No. 2017-110 3.2 Liquidated Damages. City and Contractor reco g nize that time is of the essence of this Contract and that City will suffer financial lo ss in the form of contract administration expenses (such as project management and consultant expenses), if all or any part of the Work is not completed within the times specified above, plus any extensions thereof allowed in accordance with the Contract Documents . Consistent with Document 00700 (General Provisions), Contractor and City agree that because of the nature of the Project, it would be impractical or extremely difficult to fix the amount of actual damages incurred by City because of a delay in completion of all or any part of the Work. Accordingly, City and Contractor agree that as liquidated damages for delay Contractor shall pay City: 3 .2.1 $1,500 for each Calendar Day that expires after the time specified herein for Contractor to achieve Substantial Completion as specified above. 3 .2.2 $1,500 for each Calendar Day that expires after the time specified herei n for Contractor to achieve Final Completion of the entire Work as specified above. 3.2.3 $150.00 per day for failure to replace traffic striping as required by Document 01010, Section 6 . 3 .2.4 $500.00 per day for failure to place temporary pavement markings as required by Document 01010, Section 6. 3 .2.5 $5,000 for each occurrence of a vio lation of Document 00800, Section 1. 7 WORK DAYS AND HOURS. 3.2 .6 Three Months Salary for each Key Personnel named in Contractor's SOQ pursuant to A1iicle 2 .G of Document 00450 (Statement of Qualifications for Construction Work) who leaves the Project and/or Contractor replaces at any point before Final Completion, for any reason whatsoever,-that Contractor can demonstrate to City's satisfaction is beyond Contractor's control. Liquidated damages shall apply cumulatively and, except as provided below, shall be presumed to be the damages suffered by City resulting from delay in completion of the Work. 3 .3 Liquidated damages for delay shall only cover administrative, overhead, interest on bonds , and general loss of public use damages s uffered by City as a result of delay. Liquidated damages shall not cover the cost of completion of the Work, damages re s ultin g from defective Work, lost re ve nu es or costs of substitute facilities , or damages suffered by others who then seek to recover their damages from City (for example, delay claims of other contractors , subcontractors, tenants, or other third- pa1ties), and defense costs thereof. Article 4. Contract Sum 4.1 City shall pay Contractor the Contract Sum for completion of Work in accordance with Contract Documents as set fotih in Co ntractor 's Bid, attached hereto: See Exhibit "A" attached Cit y of Cupe1tino 00520 - 2 Contract 20 17 Pav ement Maintenance Project -Pha se 2 Project No.2017-110 Article 5. Contractor's Representations In order to induce City to enter into this Contract, Contractor makes the following representations and warranties: 5 .1 Contractor has visited the Site and has examined thoroughly and understood the nature and extent of the Contract Documents, Work, Site, locality, actual conditions, as-built conditions, and all local conditions, and federal, state and local laws and regulations that in any manner may affect cost, progress, performance or furnishing of Work or which relate to any aspect of the means, methods, techniques, sequences or procedures of construction to be employed by Contractor and safety precautions and programs incident thereto. 5.2 Contractor has examined thoroughly and understood all repo1ts of exploration and tests of subsurface conditions, as-built drawings, drawings, products specifications or reports , available for Bidding purposes, of physical conditions, including Underground Facilities , or which may appear in the Drawings. Contractor accepts the determination set forth in these Documents and Document 00700 (General Provisions) of the limited extent of the infonnation contained in such materials upon which Contractor may be entitled to rely. Contractor agrees that except for the information so identified, Contractor does not and shall not rely on any other information contained in such rep01ts and drawings . 5 .3 Contractor has conducted or obtained and has understood all such examinations, investigations , explorations, tests , reports and studies (in addition to or to supplement those referred to in Section 5 .2 of this Document 00520) that pertain to the subsurface conditions, as-built conditions, underground facilities, and all other physical conditions at or contiguous to the Site or otherwise that may affect the cost, progress, performance or furnishing of Work, as Contractor considers necessary for the performance or furnishing of Work at the Contract Sum, within the Contract Time and in accordance with the other terms and conditions of the Contract Documents, including specifically the provisions of Document 00700 (General Provisions); and no additional examinations, investigations, explorations, tests , repo1ts , studies or simi.Jar information or data are or will be required by Contractor for such purposes . 5.4 Contractor has correlated its knowledge and the results of all such observations, examinations, investigations, explorations, tests, repo1ts and studies with the terms and conditions of the Contract Documents. 5 .5 Contractor has given City prompt written notice of all conflicts, errors, ambiguities , or discrepancies that it has discovered in or among the Contract Documents and as-built drawings and actual conditions and the written resolution thereof through Addenda issued by City is acceptable to Contractor. 5 .6 Contractor is duly organized, existing and in good standing under applicable state law , and is duly qualified to conduct business in the State of California. 5 .7 Contractor has duly authorized the execution, delivery and performance of this Contract, the other Contract Documents and the Work to be performed herein . The Contract Documents do not violate or create a default under any instrument, contract, order or decree binding on Contractor. City of Cupe1tino 005 20 -3 Contract 201 7 Pav ement Maintenanc e Proj ect -Ph ase 2 Project No. 2017-110 5 .8 Contractor has listed Subcontractors pursuant to the Subcontractor Listing Law, California Public Contracting Code §4100 et seq . in document 00340 (Subcontractors List) Article 6. Contract Documents 6 .1 Contract Documents consist of the following documents , including all changes, addenda, and modifications thereto: Document 00002 Signature Page Document 00003 Project Directory Document 00012 Caltrans/City Cross-Reference Table Document 00100 Adve1tisement For Bids Document 00200 Instructions to Bidders Document 00210 Indemnity and Release Agreement Document 00400 Bid Form Document 00411 Bond Accompanying Bid Document 00430 Subcontractors List Document 00450 Statement of Qualifications Document 00481 Non-Collusion Affidavit Document 00482 Bidder Certifications Document 00520 Contract Document 00530 Insurance Forms Document 00610 Construction Performance Bond Document 00620 Construction Labor and Material Payment Bond Document 00630 Guaranty Document 00650 Agreement and Release of Any and All Claims Document 00660 Substitution Request Form Document 00670 Reliable Contractor Declaration Form Document 00700 General Conditions Document 00800 Special Conditions Document 00820 Traffic Control Requirements Document 00821 Insurance Document 00822 Apprenticeship Program Document 00850 Technical Specifications Document 00860 General Requirements Attachment A Work Hour Restrictions Addenda(s) Drawings/Plans 6.2 There are no Contract Documents other than those listed in this Document 00520, A1ticle 6. The Contract Documents may only be amended , modified or supplemented as provided in Document 00700 (General Provisions). Article 7. Miscellaneous 7. I Terms used in this Contract are defined in Document 00700 (General Provisions) and will have the meaning indicated therein. 7.2 It is understood and agreed that in no instance are the persons signing this Contract for or on behalf of City or acting as an employee, agent, or representative of City, liable on this Contract or any of the Contract Documents, or upon any warranty of authority, or otherwise, and it is fmther understood and City of Cupe1tino 005 20 -4 Contract 2 017 Pavement Maintenance Proje ct -Phase 2 Project No. 2017-110 agreed that liability of the City is limited and confined to such liability as authorized or imposed by the Contract Documents or applicable law . 7.3 Contractor shall not assign any portion of the Contract Documents, and may subcontract po1tions of the Contract Documents only in compliance with the Subcontractor Listing Law, California Public Contracting Code §4100 et seq . 7.4 The Contract Sum includes all allowances (if any). 7 .5 In entering into a public works contract or a subcontract to supply goods, services or materials pursuant to a public works contract, Contractor or Subcontractor offers and agrees to assign to the awarding body all rights , title and interest in and to all causes of action it may have under Section 4 of the Clayton Act (15 U .S .C . §15) or under the Cartwright Act (Chapter 2 (commencing with Section 16700) of Part 2 of Division 7 of the Business and Professions Code), arising from purchases of goods, services or materials pursuant to the public works contract or the subcontract. This assignment shall be made and become effective at the time City tenders final payment to Contractor, without fmther acknowledgment by the paities . 7 .6 Copies of the general prevailing rates of per diem wages for each craft, classification, or type of worker needed to execute the Contract, as determined by Director of the State of California Depaitment of Industrial Relations , are deemed included in the Contract Documents and on file at City 's office, or may be obtained of the State of California web site http://www.dir.ca.gov/DLSR/PWD/Northern.html and shall be made available to any interested party on request. Pursuant to Section 1861 of the Labor Code, Contractor represents that it is aware of the provisions of Section 3700 of the Labor Code which require every employer to be insured against liability for workers' compensation or to unde1take self-insurance in accordance with the provisions of that Code, and Contractor shall comply with such provisions before commencing the performance of the Work of the Contract Documents. 7 .7 Should any pa1t, tern1 or provision of this Contract or any of the Contract Documents, or any document required herein or therein to be executed or delivered , be declared invalid , void or unenforceable , all remaining pa1ts , terms and provisions shall remain in full force and effect and shall in no way be invalidated , impaired or affected thereby . If the provisions of any law causing such invalidity, illegality or unenforceability may be waived, they are hereby waived to the end that this Contract and the Contract Documents may be deemed valid and binding contracts, enforceable in accordance with their terms to the greatest extent permitted by applicable law. In the event any provision not otherwise included in the Contract Documents is required to be included by any applicable law, that provision is deemed included herein by this reference( or, if such provision is required to be included in any paiticular portion of the Contract Documents, that provision is deemed included in that po1tion). 7 .8 This Contract and the Contract Documents shall be deemed to have been entered into in the County of Santa Clara, State of California, and governed in all respects by California law ( excluding choice of law rules). The exclusive venue for all disputes or litigation hereunder shall be in Santa Clara County. Both paities hereby waive their rights under California Code of Civil Procedure Section 394 to file a motion to transfer any action or proceeding arising out of the Contract Documents to another venue. Contractor accepts the Claims Procedure in Document 00700, A1ticl e 12 , established under the California Government Code, Titl e 1, Division 3 .6, Pait 3 , Chapter 5 . City of Cupertino 005 2 0 -5 Contract 2 017 Pavement Maint enanc e Proj ec t -Pha se 2 Project No.2017-110 IN WITNESS WHEREOF the partie s have executed this Contract in quadruplicate the day and year first above written. 2017 PAVEMENT MAINTENANCE PROJECT -Phase 2 CITY: CITY OF CUPERTINO, a Municipal Corporation of the State of California City Clerk: Grace Schmidt Approved as to form by City Attorney: k0A ~ City Attorney I hereby certify, under penalty of perjury , that Timm Borden, Director of Public Works of the City of Cupertino was duly authorized to execute this document. Dated : t./ /l_-7/J7 ~' of Poii\ie Wocks of the City of Cupertino, a Municipal Corporation of the State of California Designated Representative: Name: Roger Lee Title: Assistant Director of Public Works - Address: 10300 Torre Ave, Cu pertino , CA 95014 Phone : 408-777-3354 Facsimile: 408-777-3333 AMOUNT: $49 0,247.65 ACCOUNT NUMBER: 270 -85 -82 1 900-921 FILE NO .: 20 17-110 CONTRACTOR: [Please print name here] Title: V?. 0-f S \\,\YY~ t',. M\C.YO (!ip.Q.ttlf~1;S [If Corporation: Chairman , ~esident, or Vice President] By ~ -~ [Please print name here] Title: l7o e:c.:h,< v C f? ... cf:, I , ~ l,J" cl<---=j~ [If Corporation: Secretary, Assistant Secretary, Chi ef Financial Officer, or Assistant Treasurer] State Contractor's License No .. Classification Expiration Date Taxpayer ID~'£ f N-'±1-:;:::r-4z~i~ Name:S +-e..ehe.Y\ E. C ls~\\ Title: VP cf sl~YY(j 2: Mit-yp ()pe>4-f,~1t_J Address: 45"2.2... 'fg,,rk,v ,1-ve../ Bli,.71!0, sJe. 35o Mc.d~ll~, CA ~S 65 L Phone: Of (I, 3,'[3 f 7: 56 Facsimile: Or I b 3~ '1 40 ¥~ NOT ARY ACKNOLEDGEMENT I R EQUIRED. IF A CORPORATION, CORPORATE SEAL AND CORPORATE NOTARY ACKNOWLEDEMENT AND FEDERAL TAX ID ARE REQUIRED. IF NOT A CORPORATION SOCIAL SECURITY NO. IS REQUIRED City of Cup ertino 00520 -6 Co ntract 2 0 I 7 Pavement Maintenance Project -Phase 2 Project No . 2017-110 END OF DO C UME NT C it y o f C upertino 00 52 0 -7 C ontract 2 01 7 Paveme nt Ma inte na nce Proj ect -Phase 2 ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of Sacr am ento On Ap r il 3, 201 7 before me, Rick Ar ias -Notary Public (insert name and title of the officer) personally appeared Step h en E. Olsen who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted , executed the instrument. I certify under PENAL TY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. {Seal) RICK~IAS Comm. -#2104102 111 Notary Public• California ~ So lano County I • C°!"m: Ex~lr~ Mu 2~ 20~9 SCHEDULE OF BID PRICES BASE BID ITEMS EXHlBITA Project No. 2017-110 All Bid items , including lump sums and unit prices, must be filled in completely. Quote in figures only, unless words are specifically requested . ITEM DESCRIPTION UNIT EST . QNTY UNIT COST TOTAL 1 Traffic Control LS 1 q4 t:Jco-q ~ ,(;t()- 2 Rubberized Chio Seal SY 51661 4·~) S" h) / Ct ·~-~ .@.S ... 3 Double Conventional Chio Seal SY 1040 i/r, ' -11,; &,4()- 4 Micro Surfacina SY 51661 J,9X: l l'h, ~ ~x '-lS ... 5 Conventional Type 2 Slurry SY 15942 l. l() -')~ srn .;)C 6 Install Blue RPM's @ Fire Hvdrant EA 40 J <, -~¥") ... 7 4 11 White (Thermo) LF 2200 /) /,,{) 1 ?;'J()"" 8 8" White (Thermo LF 1400 '·· ·-( LJDo - 12" White Cros_swalk/Umit Line ~-L,\ -~ ~l [i, _;)~\ 9 (Thermo) LF 925 10 24" White <Thermo) LF 470 l .~D :~ \\3\,- 11 24" Yellow (Thermo) LF 360 7;30 -'") ( ,-:.J g - 12 Striolna Detail 4 (Markers) LF 1960 o ,G,D \ I ·1l<i .- 13 Strioina Detail# 13 (Markers) LF 2220 (\ --~() I .\ \ti~ 14 Strioina Detail# 23 (Ma rkers ) LF 200 3 ,-(,()(':.-- 15 Strioina Detail #25 LF 1480 0 (,,, q(,.,:)- 16 StrioinQ Detail# 38 <Thermo & Ma rk ers) LF 510 i . I T'\ ~(o\ ·- 17 Strioina Detail# 39 (Preformed Thermo) LF 5220 t\7, ~en~.- Striping Detail # 39A (Preform ed 0 -0S I 18 Thermo) LF 2020 \ ~ 13' ·- 19 Arrow Tvoe IV (Preformed Thermo) EA 7 ,..._:)4t), '< ~xr-i- Arrow Type VI (Preformed Thermo) ' 20 RiQht Lane Drop EA 3 ,<;J)i">-I _.:::;t:f)- 21 "25" Leaend (Thermo) EA 1 ..-....11n~ -~,o--- 22 "30" Leaend (Preformed Thermo) . EA 4 r:JJO.._ ~'-tt>- 23 "35" Leaend (Preformed Thermo) EA 1 r,.} jt) ~ .:)\D- "Bike Rider with person" Symbol -Left ),-..1 \ --/.::J . \/) --24 facina(Preformed Thermo) EA 10 Bike Lane Arrow (Preformed Thermo) L--J,--I 25 EA 10 j .~J "()- 26 "STOP" Leaend (Preformed Thermo) EA 7 _17(;"" l q:,;_r:;;:- 27 "PED" Leaend (Preformed Thermo) EA 5 --OS, ..--,J . '1)~ i . r.1 D ':)- 5 ~ 28 "XING" Leaend <Preformed Thermo) EA ~T7~-j 3,s..- TOTAL 4 Cit). ;)47, /(') ' City of Cupertino Bid Form 2017 Pav eme nt Maintenance Project -Phase 2 00400 -3 CI T Y OF El Proj ect No. 2017 -1 IO C U PERT I NO INSURANCE AGREEMENT A. Contractor is aware of the provisions of Section 3700 of the Labor Code, which requires every emp loyer to be insured against liability for worker's compensation or undertake self- insurance in accordance with the provisions of that Code, and will comply with such provisions before commencing the performance of the work of this Contract. B . Contractor and all subcontractors will carry worker's compensation insurance for the protection of its employees during the progress of the work. The insurer shall waive its rights of subrogation against the City, the City 's officers, agents and employees and shall issue an endorsement to the policy evidencing same. C. Contractor shall carry at all times, on all operations hereunder, commercial general liability insurance, automobile liability insurance and builder's all risk insurance. All insurance coverage shall be in amounts required by the City and shall be evidenced by the issuance of a certificate in a form prescribed by the City and shall be underwritten by insurance companies satisfactory to the City for all operations, sub-contract work , contractual obligations, product or completed operations , all owned vehicles and non-owned vehicles. Said insurance coverage obtained by the Contractor, excepting worker's compensation coverage, shall name the City, its engineer , and each of its directors , officers , agents and employees , as determined by the City, as additional insureds on said policies . Insurers must be licensed to do business in the State of California. The Insurers must also have an "A " policyholder 's rating and a financial rating of at least Class VII in accordance with the current Best's Guide Rating or that is otherwise acceptable to the City . D. Before Contractor performs any work at, or prepares or delivers materials to , the site of construction, Contractor shall furnish certificates of insurance evidencing the foregoing insurance coverages and such certificates shall provide the name and policy number of each carrier and policy and that the insurance is in force and will not be canceled or modified without thirty (30) days written notice to the City . Contractor shall maintain all of the foregoing insurance coverages in force until the work under this Contract is fully completed. The requirement for carrying the foregoing insurance shall not derogate from the provisions for indemnification of the City by Contractor under this Contract and for the duration of the warranty period . Notwithstanding nor diminishing the obligations of Contractor with respect to the foregoing , Contractor shall maintain in full force and effect during the life of this Contract, the following insurance in amounts not less than the amounts specified and having a Best 's Guide Rating of A, Class VII or better or that is otherwise acceptable to the City. City of C up ertino 2 017 P avement Mai ntenance Proj ect -Phase 2 Insurance Forms 00530 - 2 Project No . 20 I 7-1 I 0 LIMITS Worker's Compensation & Employers' Liability General Liability -commercial general liability; including provisions for contractual liability, personal injury, independent contractors and products -completed operations hazard. Automobile Liability -comprehensive covering owned, non-owned and hired automobiles. City of Cupertino 2017 Pavement Maintenance Project -Phase 2 00530 -3 In accordance with the Worker's Compensation Act of the State of California -Worker's comp "statutory" per CA Law; Employers' Liability $ I ,000,000 per occurrence. Combined single limit of $2.0 million per occurrence; $4.0 million in the aggregate Combined single limit of$ I .0 million per occurrence . Insurance Forms C I TY O F g Project No . 2017-110 CUPERTINO INSURANCE AGREEMENT A. Contractor is aware of the provisions of Section 3700 of the Labor Code, which requires every employer to be insured against liability for worker 's compensation or undertake self- insurance in accordance with the provisions of that Code, and will comply with such provisions before commencing the performance of the work of this Contract. B. Contractor and all subcontractors will carry worker's compensation insurance for the protection of its employees during the progress of the work . The insurer shall waive its rights of subrogation against the City, the City's officers , agents and employees and shall issue an endorsement to the policy evidencing same. C. Contractor shall carry at all times , on all operations hereunder, commercial general liability insurance, automobile liability insurance and builder 's all risk insurance. All insurance coverage shall be in amounts required by the City and shall be evidenced by the issuance of a certificate in a form prescribed by the City and shall be underwritten by insurance companies satisfactory to the City for all operations , sub-contract work , contractual obligations , product or completed operations, all owned vehicles and non-owned vehicles. Said insurance coverage obtained by the Contractor, excepting worker's compensation coverage, shall name the City, its engineer, and each of its directors , officers , agents and employees , as determined by the City , as additional insureds on said policies. Insurers must be licensed to do business in the State of California. The Insurers must also have an "A" policyholder 's rating and a financial rating of at least Class VII in accordance with the current Best 's Guide Rating or that is otherwise acceptable to the City. D . Before Contractor performs any work at , or prepares or delivers materials to , the site of construction, Contractor shall furnish certificates of insurance evidencing the foregoing insurance coverages and such certificates shall provide the name and policy number of each cmrier and policy and that the insurance is in force and will not be canceled or modified without thirty (30) days written notice to the City. Contractor shall maintain all of the foregoing insurance coverages in force until the work under this Contract is fully completed. The requirement for carrying the foregoing insurance shall not derogate from the provisions for indemnification of the City by Contractor under this Contract and for the duration of the warranty period. Notwithstanding nor diminishing the obligations of Contractor with respect to the foregoing , Contractor shall maintain in full force and effect during the life of this Contract, the following insurance in amounts not less than the amounts specified and ha ving a Best's Guide Rating of A, Class VII or better or that is otherwise acceptable to the City. C ity of Cupe1tino 2017 Pavement Maintenance Project -Phase 2 In s ur ance Form s 00530 -2 Proj ec t No. 201 7-110 LIMITS Worker 's Compensation & Employers ' Liability General Liability -commercial general liability; including provisions for contractual liability, personal injury , independent contractors and products -completed operations hazard . Automobile Liability -comprehensive covering owned, non-owned and hired automobiles. \ ~\~y-~o..\JE.~~+~e..0\."'o\c,J;~~,LL~ (Contractor 's N am e) C ity of C up ertino 2 017 Paveme nt M a int e na nce Proj ect -Ph ase 2 Date d : 00 53 0 -3 In accordance with th e Worker 's Comp ensation Act of the State of California -Worker 's comp "statutory" per CA Law; Emplo yers ' Liability $1 ,000 ,000 per occurrence. Combined single limit of $2.0 million per occurrence; $4.0 million in the aggregate Combined single limit of$1.0 million per occurrence. 4/3 2011- In s ura nce Form s ACORD. CERTIFICATE OF LIABILITY INSURANCE 4 /30/2018 I DATE (MMIDDIYYYY) ~ 4/14/2 0 I 7 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 t erms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER LOCKTON COMPANIES NAi.1~~l,I 5847 SAN FELIPE, SUITE 320 Wc.'No Extl: I fJVC Nol : HOUSTON T X 77057 E-MAIL 866-260-3538 ADORE"": INSURER/SI AFFORDING COVERAGE NAIC # INSURER A : ACE Ameri can Insurance Comoanv 22667 INSURED Telfer Pavement Technologies, LLC INSURER B: National F ire and Marine Insurance Co 20079 1428034 2829 Lakeland Drive INSURERC : Agri General Insu ran ce Co moanv 42757 Flowood MS 39232 IN,;ttRER D : IN"URER E : INSURER F : COVERAGES CERTIFICATE NUMBER· 14617937 REVISION NUMBER-XXXXXXX THIS IS TO CERTIFY TH AT THE P O LI C IE S OF IN S UR A NCE LISTED BELOW HAVE BEEN ISS UED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDI CATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CO NDITIO N OF A NY CONTRACT OR OTHER DOCUMENT WITH RE SPECT TO WHICH THI S CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, TH E IN SURAN CE A FFO RDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS A ND CONDITIONS OF SUCH PO LI C IE S. LI M ITS SHOWN MAY HAVE BEEN REDUCED B Y PAI D CLAIMS . INSR TYPE OF INSURANCE ADDL SUBR POLI CY NUMBER lrPOLICY EFF I I ~k?hJ8)'.M!:;1 LIMITS LTR IN SD WVD MM/DDIYYYY A ..x COMMERCIAL GENERAL LIABILITY y y XSLG2786600 1 4/30/20 I 7 4 /30/2018 EACH OCCURRENCE s 2 ,000 ,000 D CLAIMS-MA DE[x] OCCUR DAMAGE TO RENTED I--PREMISES fEa occu rrence, s xxxxxxx MED EXP (Anv one oersonl I S XXXXXXX '-- s 1,000 ,000 PERSONAL & ADV INJURY '--s 4 ,000 ,000 GEN'LAGGREGATE LIMIT APPLIES PER : GENE RAL AGG REG ATE R (K]PRO-DLoc s 2,000,000 PO LI CY JECT PR ODUCTS -COMP/OP AGG OTHER: s A AUTOMOBILE LIABILITY y y 1SAH09055496 4/30/20 17 4 /30/20 18 COMBINED SINGLE LI MIT s 2 000 000 Ea accident) A ..x. ANY AU TO ISAH09055502 4/30/20 17 4 /30/20 18 BODILY INJUR Y (Per person) s xxxxxxx -OWNED SCHEDULED BODILY IN JURY (Per accident s xxxxxxx AU TOS ONLY AUTOS ~ HIRED ~ NON-OWN ED l iP~?~fc~~t?AMAGE '--AU TOS ONLY >--AU TO S ONLY s xxxxxxx s xxxxxxx B ..K UMBRELLA LIAB ~OCCUR y y 42-UM0-302493-02 4 /30/20 17 4/30/2018 EACH OCCURRENCE s I 0,000,000 EXC ESS LIAB CLA IMS-MADE AGGR EGATE s I 0 ,000,000 DED I I RETENTION s s xxxxxxx A WORKERS COMPENSATiON y WLRC49114539 tOS) 4/30/20 17 4 /30/20 18 X I mruTE I IOTH-AND EMPLOYERS' LIABILITY YI N ER C ANY PROPRIETOR/PARTNER/EXECUTIVE [ill WLRC64409530 TN) 4/30/20 17 4 /30/2018 E.L EACH ACCIDENT s 1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Ma ndatory In NH) E.L DISEASE· EA EMPLOYEE s 1,000 ,000 If yes, describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.l. DISEASE· POLICY LIMIT I s DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101 , Additional Remarks Schedule, may be attached if more space is required) THIS CER TIFI CATE SUP ER SEDES ALL PREVIOUS LY ISSUED CER TIFI CA TES FOR THIS HOLD ER , APP LI CABL E TO THE CAR RIER S LI STED AND THE PO LI CY TERM (S) REFERENCED . Re : Project No. 20 17-11 0. 20 1 7 Pa veme nt Maint e nance Project Phase 2 . Additional insured in favor of The City of Cupertino, its engineers, and each of it s directors, officers, agents and e mployees on all policies (except workers' compensation/el) where and to the extent requ ire d by written contract. Allfu:li cies (except workers' compensation/el) contain a special e ndorsement with '~rirnary and noncontributory" word ing . Excess Follow Fonn Liabi li ty Insura nce is excess of the un erlying schedule that includes Gene ral Liabili ty, Auto Liabili ty and Workers' ompensation/Employers Li abil ity . CERTIFICATE HOLDER 14617937 Ci ty of Cupertino Attentio n : Timm Borden 10300 Torre Avenue C u pertino CA 95014 ACORD 25 (2016/03) CANCELLATION See Attachment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELI VER ED IN ACCORDANCE WITH THE POLICY PROVISIONS . AUTHORIZED REPRESENTATIVE . All rights reserved The ACORD name and logo are registered marks of ACORD CONTINUATION DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS (Use only if more space is required) A ll policies include a blanket notice of canc e llation to certificate holders endorsement, pro v iding for 30 days' advance notice if the policy is canc e ll ed by the company other than for nonp ay ment of premium , l O days ' notice if th e policy is cance ll e d for nonpayment of premium . Notice is se nt to certificate holders with ma iling addresses on file with the agent or the co mp any. The end o rse ment do es not provide for notice of cancellation if th e nam ed in s ured requests cancellation. ACORD 25 (2016/03) Cert ificate Holder ID : 14617937 All policies (except Workers' Compensation/EL) include a blanket automatic Additional Insured endorsement [provision] that confers Additional Insured status to the certificate holder only if there is a written contract between the named insured and the certificate holder that requires the named insured to name the certificate holder as an Add itional Insured . In the absence of such a contractual obligation on the part of the named insured , the certificate holder is not an Additional Insured under the policy . All policies include a blanket automatic Waiver of Subrogation endorsement [provision] that provides this feature only when there is a written contract between the named insured and the cert ificate holder that requires it. In the absence of such a contractual obligation on the part of the named insured , the Waiver of Subrogation feature does not apply. Mi sce ll aneous Attachment : MS 15965 Master ID: 1428034, Certificate fD: 14617937 ACORD. CERTIFICATE OF LIABILITY INSURANCE 4/30/20 17 I DATE (MM/DD/YYYY) ~ 4/14/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER . IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER LOCKTON COMPANIES ~~~it" 5847 SAN FELIPE, SU ITE 320 W/:',"tfo , Extl : j f,vc, Nol: HOUSTON T X 77057 ioMd"~~SS: 866-260-3538 INSURERISI AFFnRDING COVERAGE NAIC # INSURER A : ACE American Insurance Comnanv 22667 INSURED Telfer Pavement Technologies, LLC INSURER B : National Fire and Marine Insurance Co 20079 142 82 18 2829 Lakeland Drive INSURER C: Flowood MS 39232 INSUR ER D: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER· 1462 7586 REVISION NUMBER· XXXXXXX 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, EXC LU S IONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER ,~i7b'ii'W{y ,t;"~hJgM~i LIMITS LTR INSD WVD ~ COMMERCIA L GENERAL LIABILITY y y EACH OCCURRENCE s 2 000 000 A ~ CLAIMS-MAD E [x] OCCUR XSLG27852099 4 /30/20 16 4 /30/20 17 ~~~~H?E:~~biEr?.ncel s xxxxxxx f-- MED EXP (Anv one oersonl s xxxxxxx PERSONAL & ADV INJURY s 1.000 000 -s 4,000 000 GEN'L AGGR EGATE LIMIT APPLIES PER: GENERAL AGG REG ATE =i [Kl PR O-DLOC s 2,000 000 POLICY JECT PRODUCTS -COMP/OP AGG OTHER: $ A AUTOMOBILE LIABILITY y y I SAH09042684 4 /30/20 16 4 /30/20 17 COMBINED SINGLE LI MIT s 2,000 000 ltEa accidenfl A .x ANY AUTO ISAH09042696 4/30/20 I 6 4 /30/20 17 BODIL y INJURY (Per pe rson) s xxxxxxx OWN ED -SCHEDULED BOD IL y INJURY (Per acc id ent s xxxxxxx f--AUTOS ONLY -AU TOS HIRED NON -O WNED PROPERTY DAMAGE s xxxxxxx f--AUTOS ON LY ,__ AUTOS ONLY Per accident\ s xxxxxxx B X UMBRELLA LIAS Fl~CCUR y y 42-UM0-302493 -0 1 4/30/2016 4/30/20 17 EACH OCCURR ENC E s JO 000 ,000 - EXCESS LIAS CLAIMS-MADE AGGREGATE s 10 000,000 OED I I RETE NTION s s xxxxxxx WORKERS COMPENSATION ' -· WLRC486059 l 6 X I ~~:TUTE I ·1°:t A AND EMPLOYERS' LIABILITY Y/N y 4/30/20 16 4 /30/2017 ANY PROPRIETOR/PARTNER/EXECUTIVE [ill N/A E.L EACH ACCIDENT s I 000 000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE· EA EMPLOYEE $ I 000 000 If yes, describe under I 000 ,000 DESCRIPTION OF OPERATIONS below E.l. DISEASE· POLICY LIMIT s DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101 , Additional Remarks Schedule, may be attached if more space is required) Re: Projec t No. 20 17-11 0, 20 17 Pavement Ma intenance Proj ec t Phase 2. Additional in sured in favor of The City of Cupertino, its en~iJ1 eers, and eac h of its direc tors, officers, agent s and employees on all policies (except workers' compensa tion/el) where and to th e ex te nt reqtred by writt en contract. A II J::hcies (exce pt workers' compensa tion/e l) contain a specia l endorse ment w ith '~rimary and noncontributory" wording. Excess Fo llow Fonn Liability nsura nce is excess of th e un er lying schedule th at includes Genera l Liability, A uto Liability ao d Wo rk ers' ompensa ti on/Employers Liability. . CERTIFICATE HOLDER 14627586 City of Cupertino Attention: Timm Borden 10300 Torre Avenue Cupertin o CA 95014 ACORD 25 (2016/03) CANCELLATION See Attachment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS . AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD CONTINUATION DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADOED BY ENDORSEMENT/SPECIAL PROVISIONS (Use only if more space is required) All policies include a blanket notice of cancellation to certificate holders endorsement, providing for 30 days' advance notice if the policy is cancelled by the company other than for nonpayment of premium, 10 days' notice if the policy is cancelled for nonpayment of premium. Notice is sent to certificate holders with mailing addresses on file with the agent or the company. The endorsement does not provide for notice of cancellation if the named insured requests cancellation. ACORD 25 (2016/03) Certificate Hold er ID: 14627586 All policies (except Workers ' Compensation/EL) include a blanket automatic Additional Insured endorsement [provision] that confers Additional Insured status to the certificate holder only if there is a written contract between the named insured and the certificate holder that requires the named insured to name the certificate holder as an Additional Insured . In the absence of such a contractual obligation on the part of the named insured, the certificate holder is not an Additional Insured under the policy . All policies include a blanket automatic Waiver of Subrogation endorsement [provision] that provides this feature only when there is a written contract between the named insured and the certificate holder that requires it. In the absence of such a contractual obligation on the part of the named insured , the Waiver of Subrogation feature does not apply. Miscell aneo us Attachment : MS 15965 Master ID: 142821 8, Certificate ID: 14627586 Named Insured Schedule Ergon, Inc. Ergon -West Virginia, Inc. Ergon Refining, Inc . Ergon BioFuels, LLC Ergon BioSciences, Inc. Ergon Asphalt & Emulsions, Inc. Crafco, Inc. Paragon Technical Services, Inc. Paving Maintenance Supply, Inc. Telfer Pavement Technologies, LLC Ergon Terminaling, Inc. Ergon Oil Purchasing, Inc. Ergon -Baton Rouge, Inc. Ergon -Ironton, LLC Ergon -Knoxville, Inc. Ergon -St. James, Inc. Ergon -Texas Pipeline, Inc. Ergon Acquisition Corp. Ergon Foundation, Inc. Ergon Securities, Inc. Big Valley, LLC Ergon Properties, Inc. ISO Panels, Inc. Magnolia Marine Transport Company Ergon Marine & Industrial Supply, Inc. Ergon Trucking, Inc. Diversified Technology, Inc. LLWR, LLC M & L Properties, LLC Mirror Lake Building, LLC Mirror Lake Land Company Pearl Street Parking LLC PruGON Properties LLC Crafco (Wuxi) Pavement Preservation Equipment Co., Ltd. Ergon -Latin America, LLC Miscellaneous Attachment : M522286 Master ID : 1407257, Certificate ID: 14546793 Ergon -Asia, Inc. Ergon Asia (Hong Kong) Limited Ergon Mexico S de R.L. de C.V. Ergon International, Inc. (Formerly Ergon Europe, MEA, Inc.) Bay Harbour Development, LLC Grand Harbour Development, LLC Specialty Process Fabricators, Inc. Ergon Energy Associates, LLC Ergon Energy Partners, LP Flowood Oil, LLC Ergon Exploration, Inc. Ergon Production, Inc. MSLATX Pipeline Company Kearney Park Farms, Inc. Lampton-Love, Inc. Lacox Propane Gas Company Blossman L. P. Gas Service, Inc. Harrell Gas, Inc. Lacox, Inc. Lampton-Love Gas Company Lampton-Love of Magee, Inc. Lampton-Love of Pelahatchie, Inc. Liquefied Petroleum Gas Management, Inc. Allgas, Inc. Allgas, Inc., of Montgomery Allgas, Inc., of TN Magnolia Gas, Inc. Natchez Butane, Inc. Petroleum Distributor of Jackson, Inc. Progas Inc. Southern Propane, Inc. Starkville L.P. Gas, Inc. Process Oils, Inc. Chemical Marketing Associates DBA Process Oils, Inc. Telfer Geosynthetics Telfer Highway Technologies, LLC Telfer Oil Company Continental Western Transportation Co., Inc. Miscellaneous Attachment : M522286 Master ID : 1407257, Certificate ID : 14546793 Ergon-Frazier Development I, LL C Bunge -Ergon Renewable Energy, LLC Ergon Asphalt Products -Coolidge, Inc. (Dissolved 10/8/2010) Ergon Asphalt Products, Inc. Lampton -Love Trucking, Inc. Mainstreet Builders, Inc. (Corporation dissolved 6/30/10) Pearl Street Properties, Inc. (Dissolved 08/11/2010) Solquim, C.A. (Sold March 2007) Flowood Properties LLC (Dissolved 01/23/2007) Georgia Emulsions, LLC (dissolved 10/21/2010) Bunge-Ergon Vicksburg, LLC Ergon Ethanol, Inc. Ergon Asphalt & Emulsions, Inc . dba Ergon Armor Ergon Maintenance Services, A Division of Ergon Terminaling, Inc. Mi sce ll aneo us Attachm en t : M522286 Mas ter ID : 14 072 57, Certificate ID : 14546793 CITY OF fl CUPERTINO ADDITIONAL INSURED ENDORSEMENT and ENDORSEMENT OF PRIMARY INSURANCE and NOTICE OF POLICY CANCELLATION ENDORSEMENT l'rojccl No. 2017-1 IO Project Title and Number: ________________________ _ In consideration of the policy premium and notwithstanding any inconsistent statement in the policy to which this Endorsement is attached or any other Endorsement attached thereto, it is agreed as follows: The City of Cupertino ("City") and its directors, officers, engineers , agents and employees , and all public agencies from whom permits will be obtained and their directors , officers, engineers, agents and employees, and the State of California, and its officers, agents and employees, are hereby declared to be additional insureds under the tem1s of this policy , but only with respect to the operations of the Contractor at or upon any of the premises of the City in connection with the Contract with the City, or acts or omissions of the additional insureds in co1rnection with, but limited to its general supervision or inspection of said operations. The insurance afforded by this policy is primary insurance , and no additional insurance held or owned by the designated additional insured(s) shall be called upon to cover a loss under said additional policy . Cnnccllation Notice. The insurance afforded by this policy shall not be suspended, voided, canceled, reduced in coverage or in limits, or materially altered, except after thirty (30) days ' prior written notice by certilied mail, return receipt requested, has been given to the City of Cupertino ("City "). Such notice shall be addressed to the City as indicated below. POLICY INFORMATION 1. Insurance Company: Ace American Insurance Company 2. Iilsurance Policy Number: ISAH09042696 & 1SAH09042684 3. Effective Date of'this Enclorsement:_4......,/'""'3'""0"--/ _______________ 20--16_ 4. Insured: Ergon, Inc. All notices herein provided to be given by the Insurance Company to the City in connection v.iith this policy and these Endorsements , shall be mailed to or delivered to the City at I 0300 Torre Avenue; Cupertino , California 95014. I, __ T_i_m_K_e_ll~y _____________________ (print/type name) Cily ofCuperlino :zo 17 Pnvemcnt Mnintennnce Project -Phnsc 2 Insurance Forms 00530 - 6 Project No. 2017-110 warrant that I have authority to bind the below listed Insurance Company and by my signature hereon do so bind this Company. ~----_: JM_: _ Signature of Authorized Representative: ______ ··_-_() __________ _ (Original signature required on all Endorsements furnished to the District) Names of Agent/Agency: Lockton Companies Title: President Address: 584 7 San Felipe, Suite 320 Telephone: -113.:458::2.5=5'-'-1 __ _ Facsimile: -------- City of Cupertino 2017 Pavement Maintenance Project -Phase 2 Insurance Forms 00530 -7 l l I j ~ r ! l ! ! ' ; i l I ! i I l f i i i I I I f f I I I I f l i f I I I I I I I i f i CITY OF a CUPERTINO COMPREHENSIVE GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY ENDORSEMENT OF AGGREGATE LIMITS OF INSURANCE PER PROJECT Project No. 2017-11 O Project Title and Number: _______________________ _ In consideration of the policy premium and notwithstanding any inconsistent statement in the policy to which this Endorsement is attached or any other Endorsement attached thereto, it is as follows: This Endorsement modifies the insurance provided under the General Liability Coverage part of the below-referenced policy of insurance. The general aggregate limit under LIMITS OF INSURANCE applies separately lo the project described as POLICY INFORMATION I. Insurance Company: Ace American Insurance Company 2. Insurance Policy Number:--=--X.:..::S::..:L::...:G=2.:....78=-5=-2=-0=-9::...:9=------------------ 3. Effective Date of this Endorsement:---'4'-'--/3::::.0.:::;/'-----------------20 _16_ 4. Insured : Ergon, Inc .. 5 . Additional Insured: City of Cupertino, its directors, officers, agents and employees. All notices herein provided lo be given by the Insurance Company to the City in connection with this policy and this Endorsement, sha ll be mailed lo or delivered to the City at I 0300 Torre A venue; Cupe11ino, California 95014. I, Tim Kelly (print/type name) warrant that I have authority to bind the below I i~ted Insuranc e Company and by my signature hereon do so bind this Company. ~"--ft t{Ytf . Signature or Authorized Repres entati ve:. ______ ··_-_~------------ (Original signature required on all Endorsements fi.rrnished to the District) Names of Agent/Agency: Lockton Companies Address: 5847 San Felipe, Suite 320 Ha1Jstan, Texas 77057 City of Cupertino 2017 Pavement Maintenance Project -Phase 2 00530 -8 Title: President Telephone: 713-458-25.-=5'-'1 __ _ Facsimile: -------- Insuranc e Forms CITY OF a CUPERTINO WAIVER OF SUBROGATION ENDORSEMENT WORKER'S COMPENSATION INSURANCE Project No. 2017-110 Project Title and Number : _______________________ _ In consideration of the policy premium and notwithstanding any inconsistent statement in the policy to which this Endorsement is attached or any other Endorsement attached thereto, it is agr eed as follows: It is agreed that with respect to such insurance as is afforded by the policy , the Insurance Company waives any right of subrogation against the City of Cupe1tino, and each or its di1:ectors , officers , agents , consultants and employees by reason of any payment made on account or injury, including death resulting therefrom, sustained by any employee of the insured , arising out of the performance of the above-referenced Contract. POLICY INFORlvIA TION I. Insurance Company: Ace American Insurance Company 2. Insurance Policy Numb er: WLR C48605916 ------~~---------------- 3. Effective Dale of this Endorsement:__.4*'/....,3,...Qf./-/ _______________ 20-16... 4. Insured: Ergon, Inc. All notices herein provided to be given by the Insurance Company lo the City in connection with this policy and this Endorsement, shall be mailed to or delivered to the City at I 0300 Torre Avenue; Cupertino , Californi a 95014 . I, Tim Kelly (print/type name) warrant that I have authority lo bind the be low l_isted Insuranc e Company and by my signature hereon do so bind this Company. c.5?:~J~ Signatme of Authorized Representative: __________________ _ (Original signature required on all Endorsements furnished to the District) Names of Agent/Agency: Lockton Companies Title: President Address: 5847 San Felipe, Suite 320 Telephone: 713-458-25_5_1 __ Houston, Texas 77057 Facsimile: -------- City or Cupertino 2017 Pavement Maint enance Pr~jcct -Phase 2 Insuranc e Porms 00530 -9 NON-CONTRIBUTORY ENDORSEMENT FOR ADDITIONAL INSUREDS Named Insured Ergon, Inc. Endorsement Number 11 Policy Symbol I Policy Number I Polley Period Effective Date of Endorsement ISA H09042684 04/30/2016 TO 04/30/2017 Issued By (Name of Insurance Company) ACE American Insurance Company Insert the pohcy number. The remainder of the Information Is to be completed only when this endorsement Is Issued subsequent to the preparallon of the policy , THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Organization BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM AUTO DEALERS COVERAGE FORM Schedule Any additional insured with whom you have agreed to provide such non- contributory insurance, pursuant to and as required under a written contract executed prior to the date of loss. Additional Insured Endorsement (If no Information is filled in, the schedule shall read: "All persons or ent/Ues added as addllionel insureds through an endorsement with the term "Additional Insured" in the Ut!e) For organizations that are listed in the Schedule above that are also an Additional Insured under an endorsement attached to this policy, the following is added to the Other Insurance Condition under General Conditions: If other insurance is available to an insured we cover under any of the endorsements listed or described above (the "Additional Insured"} for a loss we cover under this policy, this insurance wlll apply to such loss on a primary basis and we will not seek contribution from the other insurance available to the Additional Insured . i r r ! l t I [ k I d-~+="f: I Authorized Represe~tative I DA-21886b (06/14) Page 1 of 1 [ i ! NON-CONTRIBUTORY ENDORSEMENT FOR ADDITIONAL INSUREDS Named Insured Ergon, Inc. Endorsement Number 13 Policy Symbol I Policy Number I Polley Period Effective Date of Endorsement ISA H09042696 04/30/2016 TO 04/30/2017 Issued By (Name of Insurance Company) ACE American Insurance Company lnS<!rl the policy number, The remainder of the Information Is to be _completed only when this endorsement ,s Issued subsequent to the preparatlon of the policy . THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM AUTO DEALERS COVERAGE FORM Schedule Organization Additional Insured Endorsement Any addition<!! insured with whom you have agreed to provide such non- contributory insurance, pursuant to and as required under a written contract executed prior to the date of loss . (If no Information Is filled in, the schedule shall read: 'All persons or entitles added as additional insureds through an endorsement with the term "Additional Insured" In the title) For organizations that are listed in the Schedule above that are also an Additional Insured under an endorsement attached to this policy, the following is added to the Other Insurance Condition under General Conditions: If other insurance is available to an insured we cover under any of the endorsements listed or described above (the "Additional Insured") for a loss we cover under this policy, this insurance will apply to such loss on a primary basis and we will not seek contribution from the other insurance available to the Additional Insured. DA-21886b (06/14) _-r~+M .. CJ{·.,,. -0 Authorized Representative Page 1 of 1 I f ! I i I ! l NON-CONTRIBUTORY ENDORSEMENT FOR ADDITIONAL INSUREDS Named Insured Endorsemenl NlR'Tlber Ergon, Inc. 28 Polley Syirbol I Policy Number I Polley P01lod .Effective Oete of Endorsement XSL G27852099 04/30/2016 to 04/30/2017 Issued By {Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder of Iha lnfonmafl011 Is to ba comp lated only -..t,an this endorsement Is Issued subsequent to the preparation or tho policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: EXCESS COMMERCIAL GENERAL LIABILITY POLICY schegu1e Organization Addiljonal Insured Endorsement Any additional Insured with whom you have agreed to provide such non- contributory Insurance, pursuant to and as required under a written contract executed prior to the date of loss. (If no Information Is fl/led In, the schedule shall read; "All persons or entities added as additional Insureds through an endorsement with the term ''Add/Ilona/ Insured" In the title) For organizations that are listed in the Schedule above that are also an Additional Insured under an endorsement attached to this policy, the following is added to Section IV.4: If other insurance is available to an insured we cover under any of the endorsements listed or described above (the "Addlllonal Insured") for a loss we cover under this policy, this Insurance will apply to such loss and is primary (subject to satisfaction of the "retained limit"), meaning that we will not seek contribution from the other insurance available to the Additional Insured. Your "retained limit" still applies to such loss, and we will only pay the Additional Insured for the "ultimate net loss" in excess of the "retained limit" shown in the Declarations of this policy. Authorized Representative XS-2028Ba (05/14) ©2014 n Page 1 of 1 I I I I I i i f I Named Insured Ergon, Inc. ADDITIONAL INSUR ED -OWNERS, LESSEES OR CONTRAC TORS -SCHEDULED PERSON OR ORGANIZATION End or sem ent Nu mbe r 1 Policy Symbol I Pol icy Numb er I Policy Period Effect ive Date of Endorsement XSL G27852099 04/30/2016 to D4/30/2017 Iss ue d By (N ame of Insurance Comp any) ACE American Insurance Company Insert Iha pol icy number. The 1emalnder of the Jnformallon Is lo be comp leted only wh en lh ls endorsement Is Issued sub se qu ent to the preparafi on of the poli cy . THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This Endorsement modifies insurance provided under the following: EXCESS COMMERCIAL GENERAL LIABILITY POLICY SCHEDULE Name Of Additi onal Insured Person(s) Or Oraanlzatlon(s): Locatlon(s) Of Covered Operations Any Owner, Lessee or Contractor whom you have agreed All locations where you are performing operations to Include as an additional insured under a written contract, for such additional insured pursuant to any such provided such contract was executed prior to the date of written contract. loss. Information required to complete th is 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 organiza - tion(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 : 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; In the performance of your ongoing operations for the add itional insured(s) at the location(s) designated above. 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 wh ich you are required by the contract or agreement to provide for such add itional Insured . B. With respect to the insurance afforded to these additional insureds , the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials , parts or equ ipment furnished in connection with such work , on the project (other than service , maintenance or repairs) to be performed by or on behalf of the additional lnsured(s) at the location of the covered operations has been completed; or XS -21168a (04/13) Copyright , Insurance Services Office, Inc ., 2012 Page 1 of 2 I i l i i I i l I ! 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. With respect to the insurance afforded to these additional insureds, the following is added to Section Ill - Limits Of Insurance And Retained Limit: 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 qeclarations. _-,,, ?,~ ~ft--,~~: Authorized Representative XS -21168a (04/13) Copyright, Insurance Services Office, Inc., 2012 Page 2of 2 Named Insu red Ergon, Inc. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -COMPLETED OPERATIONS Endorsemen l Nu mber 2 Policy Symbol I Pol ley Number I Polley Period Effective Date of Endorsement XSL G27852099 04/30/2016 to 04/30/2017 Issued By (Name of Insurance Company) ACE American Insurance Company Ins ert the policy numbe r. The rema1nd~r of the lnformallon Is lo be comp leted only when this endorsement Is iss ued subsequent to lhe preparation of the policy . THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This Endorsement modifies Insurance provided under the following: EXCESS COMMERCIAL GENERAL LIABILITY POLICY SCHEDULE Name Of Additional Insured Person(s) Or Oraanizatlon(s): Location And Descrlotion Of Completed Operations Any person or organization whom you have agreed to All locations where you perform work for such additional include as an add itional insured under a written insured pursuant to any such written contract. contract, provided such contract was executed prior to the date of los 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 organiza- tlon(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 endorse- ment performed for that additional insured and included In the "products-completed operat ions 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 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 Ill - Limits Of Insurance And Retained Limit: 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., XS-21164a (04/13) Includes copyrighted material of Insurance Services Office, Inc., with Its permission . Page 1 of 1 f I l I I I I I 1 ! I t f ! NOTICE TO OTHERS ENDORSEMENT -SCHEDULE Named Insured Ergon, Inc. Endorsement Nu mb er 12 Policy Symbol I Poll ey Number I Poll ey Period Effective Date of Endorsement ISA H09042684 04/30/2016 TO 04/30/2017 Issued By (Nam e of In surance Company ) ACE American Insurance Company .. Insert the policy nu mbe r. The rema ind er of th e Informatio n 1s to be comp leted on ly whe n this endorsemen t 1s issued subsequent to the preparation of the policy. THI S ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CARE F U L LY. A. If we cancel the Policy prior to its expiration date by notice to you or the first Named insured for any reason other than nonpayment of premium, we will endeavor, as set out below, to send written notice of cancellation, via such electronic or other form of notification as we determine, to the persons or organizations listed in the schedule that you or your representative provide or have provided to us (the "Schedule"). You or your representative must provide us with the physical and/or e-mail address of such persons or organizations, and we will utilize such e-mail address or physical address that you or your representative provided to us on such Schedule. B. The Schedule must be initially provided to us within 15 days after: i. The beginning of the Policy period , if this endorsement is effective as of such date; or ii. This endorsement has been added to the Policy, if this endorsement is effective after the Policy period commences. C. The Schedule must be in an electronic format that is acceptable to us; and must be accura te . D. Our delivery of the notification as described in Paragraph A. of th is endorsement will be based on the most recent Schedule in our records as of the date the notice of cancellation is mailed or delivered to the first Named Insured. E. We will endeavor to send or deliver such notice to the e-mail address or physical address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable to the Policy. F. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any kind upon us, our agents or representatives , will not extend any Policy cancellation date and will not negate any cancellation of the Policy . G. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any incorrect information that you or your representative provide to us. If you or your representative does not provide us with a Schedule, we have no responsibility for taking any action under this endorsement. In addition, if neither you nor your representative provides us with e-mail and physical address information with respect to a particular person or organization, then we shall have no responsibility for taking action with regard to such person or entity under this endorsement. H. We may arrange with your representative to send such notice in the event of any such cancellation. I. You will cooperate with us in providing the Schedule, or in causing your representative to provide the Schedule . J. This endorsement does not apply in the event that you cancel the Policy. ALL-32687 (05/11) Page 1 of2 I I ! I t l ' ' f I I ~ i ! ') I I I I I r 1 I 1 ! i f j I l ! I l i i i f ~ ! I I f i All other terms and conditions of the Policy remain unchanged. :.: . ·. ·::· .. -.·., ' \~~ ~ , __ ' . ::·. ' .. Authorized Representative I l f ; ALL-32687 (05/11) Page 2 of 2 NOTICE TO OTHERS ENDORSEMENT-SCHEDULE Named In sured Ergon, Inc. Endorse ment Number 30 Policy Symbol I Policy Number I Policy Period Effective Date of Endorsement XSL 827852099 04/30/2016 TO 04/30/2017 Issued By (Name of Insurance Company) ACE American Insurance Company In sert the policy number. The rem ainder of the Information 1s to be completed only when this endorsement 1s Issued su bsequent to the preparati on of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. A. If we cancel the Policy prior to its expiration date by notice to you or the first Named insured for any reason other than nonpayment of premium, we will endeavor, as set out below, to send written notice of cancellation, via such electronic or other form of notification as we determine , to the persons or organizations listed in the schedule that you or your representative provide or have provided to us (the "Schedule"). You or your representative must provide us with the physical and/or e-mail address of such persons or organizations, and we will utilize such e-mail address or physical address that you or your representative provided to us on such Schedule. B. The Schedule must be initially provided to us within 15 days after: i. The beginning of the Policy period, if this endorsement is effective as of such date; or Ii. This endorsement has been added to the Policy, if this endorsement is effective after the Policy period commences . C. The Schedule must be in an electronic format that is acceptable to us; and must be accurate . D. Our delivery of the notification as described in Paragraph A. of this endorsement will be based on the most recent Schedule in our records as of the date the notice of cancellation is mailed or delivered to the first Named Insured. E. We will endeavor to send or deliver such notice to the e-mail address or physical address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable to the Policy. F. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy. G. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any incorrect information that you or your representative provide to us. If you or your representative does not provide us with a Schedule, we have no responsibility for taking any action under this endorsement. In addition, if neither you nor your representative provides us with e-mail and physical address information with respect to a particular person or organization, then we shall have no responsibility for taking action with regard to such person or entity under this endorsement. H. We may arrange with your representative to send such notice in the event of any such cancellation. I. You will cooperate with us in providing the Schedule, or in causing your representative to provide the Schedule. J. This endorsement does not apply in the event that you cancel the Policy. ALL-326 87 (05/11) Page 1 of 2 All other terms and conditions of the Policy remain unchanged . :.. .... '. ;J-.'~--·., . ~ ·., r , :·' 4 _. Authorized Representative ALL-32687 (05/11) Page 2 of 2 } ' f ) ! l ' i l l l I ; I r I ! ' i l j I I i I ! I I l l I l i ! t I ' ~ i I ~ ! i ~ ' DESIGNATED PROJECT(S) GENERAL AGGREGATE LIMIT Named Insured Endorsemenl Number Ergon, Inc. 14 Polley Symbol I Polley Number I Pol ley Period Effe ctive Date of En dorsement XSL G27852099 04/30/2016 to 04/30/20 17 Iss ued By (Name of lnS1Jrance Company} ACE American Insurance Company Insert the policy number. The rema inder of the Jnfo nmallon Is to be completed only when this endorsa menl Is Issued subse qu en t to Iha prepara ti on of lhe policy, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies all insurance provided under the following: EXCESS GENERAL LIABILITY POLICY SCHEDULE: Designated Project(s): each project for which the Insured has agreed, pursuant to a written contract signed prior to the date lo ss, to provide a separate Designated Project Agg rega te Limit under th is policy . Designated Project General Aggregate Limit: $6,000,000 A. Subject to and eroding the General Aggregate Limit shown in the Declarations, for all sums which the Insured becomes legally obligated to pay as damages caused by "occurrences" under COVERAGE A (SECTION I) which can be attributed only to ongoing operations at the Designated Project(s) shown in the Schedule above : 1 . A separate Designated Project General Aggregate Limit applies to each Designated Project shown in the Schedule, and that limit is equal to the amount of the Designated Project General Aggregate Limit shown in the Schedule above . 2. The Designated Project General Aggregate Limit is the most we will pay for the sum of all damages under COVERAGE A, except damages because of "bodlly Injury• or "property damage" included in the "products-completed operations hazard", which damages can be attributed only to ongoing operations at a single Designated Project, regardless of the number of: a . Insureds ; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bring ing "suits ". 3. Any payments made under COVERAGE A for damages shall reduce the Designated Project General Aggregate Limit for that Designated Project and shall also reduce and erode the General Aggregate Limit shown In the Declarations. XS-29893 (05/10) Page 1 of 2 lndudes copyrighted mater ial or Insurance Services Office, Inc. with its pennlss lon 4 . The limits shown In the Declarations for Each Occurrence and Damage to Premises Rented to You continue to apply . However, such limits will be subject to the Designated Project General Aggregate Limit, as well as the General Aggregate Limit shown In the Declarations . B. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under COVERAGE A (SECTION I) which cannot be attributed to ongoing operations at a Designated Project: 1. Any payments made under COVERAGE A for damages shall reduce the amount available under the General Aggregate Limit or the Products-Completed Operations Aggregate Limit, whichever Is applicable ; and 2. Such payments shall not reduce the Designated Project General Aggregate Lim it. C. When coverage for llablllty arising out of the "products-completed operations hazard" is provided, any payments for damages because of "bodily Injury'' or "property damage" Included in the "products-completed operations hazard" wlll reduce the Products-Completed Operations Aggregate Limit, and will not reduce the General Aggregate Limit nor the Designated Project General Aggregate Limit. D. If any one or more of your Designated Projects has been abandoned, delayed, or abandoned and then restarted, or if the authorized contracting parties deviate from plans, blueprints, designs, specifications or tlmetables , the project will still be deemed to be the same Designated Project. E. The provisions of Limits Of Insurance (SECTION Ill) not otherwise modified by this endorsement shall continue to apply as stipulated. Authorized Representative XS-29893 (05/10) Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc. with its permission Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number ERGON, INC . 2829 LAKELAND DRIVE Policy Number FLOWOOD MS 392327611 Symbol: WLR Number. C48605916 Policy Period Effective Date of Endorsement 04-30-2016 TO 04-30-2017 04-30-2016 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the oolicv number. The rema inder of the information is to be completed only whan this endorsement is Issu ed subsequent to the preparation of the oo li cv . TEXAS WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by the policy because Texas is shown in item 3.A. of the Information Page. We have the right to recover our payments from anyone liable for an injury covered by this policy . We will not enforce our right against the person or organization named in the Schedule, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract to obtain this waiver from us. This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. The premium for this endorsement is shown in the schedule. 1. Schedule Specific Waiver Name of person or organization: ( X ) Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: ALL TEXAS OPERATIONS 3. Premium: The premium charge for this endorsement shall be 2 . 0 percent of the premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. 4. Advance Premium: $1,768 Authorized Representative WC 42 03 048 (06/14) © Copyright 2014 National Council on Compensation Insurance, In c. All Rights Reserved. I I i I I l J I ! ! ! I Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number ERGON, INC. 2829 LAKELAND DRIVE Polley Number FLOWOOD MS 392327611 Symbol: WLR Number : C48605916 Policy Period Effective Date of Endorsement 04-30-2016 TO 04-30-2017 04-30-2016 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The rema inder of the Information is to be completed onlv when this endorsement is issued subseouent to the preparation of the policv. UT AH WAIVER OF SUBROGATION ENDORSEMENT This endorsement applies only to the insurance provided by the policy because Utah is shown in Item 3.A. of the Information Page. We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the schedule. Our waiver of rights does not release your employees' rights against third parties and does not release our authority as trustee of claims against third parties. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. Authorized Agent WC 43 03 05 (10/00) Ptd. in U.S.A. I I I f I i ! l i i i l I Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number ERGON, INC. 2829 LAKELAND DRIVE Policy Number .FLOWOOD MS 392327611 Symbol: WLR Number: C48605916 Policy Period Effective Date of Endorsement 04-30-2016 TO 04-30-2011 04-30-2016 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the Information is ·to be completed onlv when this endorsement Is issued subsequent to the preparation of the policv . WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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. This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY , NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A .. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. Authorized Representative WC 00 0313 (11/05} Ptd. U .S.A. Copyright 1982-83, National Council on Compensation I l I I ! ! I ! l I ! i I I i i ' I I I l I l ! ! I Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number ERGON, INC. 2829 LAKELAND DRIVE Policy Number FLOWOOD MS 392327611 Symbol: WLR Number. C48605916 Polley Period Effective Date of Endorsement 04-30-2016 TO 04-30-2017 04-30-2016 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the Information is to be comoleted onlv when th is endorsement Is Issued subseauent to the oreoaration of the pol icy. CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page . We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract to obtain this waiver from us. You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. Schedule 1. ( Specific Waiver 2. 3. Name of person or organization: ( x ) Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. Operations: Premium: The premium charge for this endorsement shall be ·2 . 0 percent of the California premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described . 4. Minimum Premium : $0 Authorized Agent WC 99 03 22 i I j I j I i f l ! I f I l f ! l f l I , I i I ' l f I l l I i f l I • I WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Named Insured Endorsement Number Ergon, Inc. 37 Polley Symbol l Polley Number I Polley Period Effective Dale of Endorsement XSL 827852099 04/30/2016 to 04/30/2017 Issued By (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder of the informahon Is lo be completed only when this endorsement 1s Issued subsequent lo the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: EXCESS COMMERCIAL GENERAL LIABILITY POLICY SCHEDULE Name of Person or Organization: Any person or organization against whom you have agreed to waive your right of recovery in a written contract, provided such contract was executed prior to the date of loss. We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and Included in the "products-completed operations hazard". This waiver applies only lo Iha person "'organl>atlon shown In Iha d"..".bov":;2-~ Authorized Agent XS-6W34 {09/95) Ptd. In U.S.A. Page 1 of 1 Named Insured Ergon, Inc. ADDITIONAL INSURED - DESIGNATED PERSONS OR ORGANIZATIONS Endorsement Number 4 Policy Symbol I Policy Number I Po licy Period Effective Dale of Endorsement ISA H09042684 04/30/2016 to 04/30/2017 Issued By {Name of Insurance Company) ACE American Insurance Company In se rt the policy numbe r. The rememder of the mformat1on 1s to be completed only when th is endorsement Is Issued subsequent to the preparation of the poli cy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM AUTO DEALERS COVERAGE FORM MOTOR CARRIER COVERAGE FORM EXCESS BUSINESS AUTO COVERAGE FORM EXCESS TRUCKERS COVERAGE FORM Additlonal lnsured(s): Any person or organization whom you have agreed to include as an additional insured under a written contract, provided such contract was executed prior to the date of loss. A. For a covered "auto," Who Is Insured is amended to include as an "insured," the persons or organizations named in this endorsement. However, these persons or organizations are an "insured" only for "bodily Injury" or "property damage" resulting from acts or omissions of: 1. You. 2. Any of your "employees" or agents. 3. Any person operating a covered "auto" with permission from you, any of your "employees" or agents. B. The persons or organizations named in this endorsement are not liable for payment of your premium. DA-9U74b (06/14) Page 1 of 1 I t r ! J l ~ [ ! 1 ! l I I I ! I I I I WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS Named Insured Ergon, Inc. Endorsement Number 19 Policy Symbol I Policy Number I Polley Period Effective Date of Endorsem ent ISA H09042684 04/30/2016 TO 04/30/2017 Issued By (Name of Insurance Company) ACE American Insurance Company Ins er t the policy number. The rema inder of the Information 1s to be completed only when this endorsement Is Issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This Endorsement modifies insurance provided under the following; BUSINESS AUTO COVERAGE FORM MOTOR CARRIERS COVERAGE FORM AUTO DEALERS COVERAGE FORM We waive any right of recovery we may have against the person or organization shown in the Schedule below because of payments we make for injury or damage arising out of the use of a covered auto. The waiver applies only to the person or organization shown in the SCHEDULE. SCHEDULE Any person or organization against whom you have agreed to waive your right of recovery in a written contract, provided such contract was executed prior to the date of loss. DA-13115a (06/14) Page 1 of 1 I I I ~ ' r ; I I I ! I ! f l I I I Named Insured Ergon, Inc. ADDITIONAL INSURED - DESIGNATED PERSONS OR ORGANIZATIONS Endors ement Number 7 Polley Symbol I Polley Number I Polley Period Effective Date of Endorsement ISA H09042696 04/30/2016 to 04/30/2017 Issued By (Name of In surance Company) ACE American Insurance Company . . In sert th e policy number. The remainder of the information Is to be completed on ly when this endorsement 1s iss ued subsequent to the prepa ra tion of th e policy • THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM AUTO DEALERS COVERAGE FORM MOTOR CARRIER COVERAGE FORM EXCESS BUSINESS AUTO COVERAGE FORM EXCESS TRUCKERS COVERAGE FORM Additional lnsured(s): Any person or organization whom you have agreed to include as an additional Insured under a written contract, provided such contract was executed prior to the date of loss. A. For a covered "auto," Who Is Insured is amended to include as an "insured," the persons or organizations named in this endorsement. However, these persons or organizations are an "insured" only for "bodily Injury" or "property damage" resulting from acts or omissions of: 1. You . 2. Any of your "employees" or agents. 3. Any person operating a covered "auto" with permission from you, any of your "employees" or agents . B. The persons or organizations named in this endorsement are not liable for payment of your premium. DA-9U74b (06/14) Page 1 of 1 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS Named Insured Ergon, Inc. Endorsement Number 20 Policy Symbol I Polley Number I Policy Period Effective Date of Endorsement ISA H09042696 04/30/2016 TO 04/30/2017 Issued By (Name of Insurance Company) ACE American Insurance Company . . Insert the policy number. The remainder of the Information Is to be completed only when this endorsement 1s issued subsequent to the preparallon of the policy . THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This Endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIERS COVERAGE FORM AUTO DEALERS COVERAGE FORM We waive any right of recovery we may have against the person or organization shown in the Schedule below because of payments we make for injury or damage arising out of the use of a covered auto. The waiver applies only to the person or organizatlon shown in the SCHEDULE. SCHEDULE Any person or organization against whom you have agreed to waive your right of recovery in a written contract, provided such contract was executed prior to the date of loss. DA-13115a (06/14) Page 1 of 1 I I I 1 ; I I ; ! l ! l ! l I I l I I ! I I r l ! I i I f J DOCUMENT 00630 GUARANTY Project No.2017-110 TO THE CITY OF CUPERTINO, a Municipal Corporation of the State of California ("City"), for construction of 2017 PAVEMENT MAINTENANCE PROJECT-PHASE 2 CUPERTINO, CALIFORNIA The undersigned guarantees all construction performed on this Project and also guarantees all material and equipment incorporated therein. Contractor hereby grants to City for a period of one year following the date of Final Acceptance, or such longer period specified in the Contract Documents, its unconditional warranty of the quality and adequacy of all of the Work including, without limitation, all labor, materials and equipment provided by Contractor and its Subcontractors of all tiers in connection with the Work. · Neither final payment nor use or occupancy of the Work performed by the Contractor shall constitute an acceptance of Work not done in accordance with this Guaranty or relieve Contractor of liability in respect to any express warranties or responsibilities for faulty materials or workmanship. Contractor shall remedy any defects in the Work and pay for any damage resulting therefrom, which shall appear within one year, or longer if specified, from the date of Final Acceptance. If within one year after the date of Final Acceptance, or such longer period of time as may be prescribed by laws or regulations, or by the terms of Contract Documents, any Work is found to be defective, Contractor shall promptly, without cost to City and in accordance with City's written instructions, correct such defective Work. Contractor shall remove any defective Work rejected by City and replace it with Work that is not defective, and satisfactorily correct or remove and replace any damage to other Work or the work of others resulting therefrom . If Contractor fails to promptly comply with the terms of such instructions, or in an emergency where delay would cause serious risk of loss or damage, City may have the defective Work corrected or the rejected Work removed and replaced. Contractor shall pay for all claims, costs, losses and damages caused by or resulting from such removal and replacement. Where Contractor fails to correct defective Work, or defects are discovered outside the correction period, City shall have all rights and remedies granted by law. Inspection of the Work shall not relieve Contractor of any of its obligations under the Contract Documents. Even though equipment, materials, or Work required to be provided under the Contract Documents have been inspected, accepted, and estimated for payment, Contractor shall, at its own expense, replace or repair any such equipment, material, or Work found to be defective or otherwise not to comply with the requirements of the Contract Documents up to the end of the guaranty period. All abbreviations and definitions of terms used in this Agreement shall have the meanings set forth in the Contract Documents, including, without means of limitation, Section 00700 (General Conditions). The foregoing Guaranty is in addition to any other warranties of Contractor contained in the Contract Documents, and not in lieu of, any and all other liability imposed on Contractor under the Contract Documents and at law with respect to Contractor's duties, obligations, nd performance under the Contract Documents. In the event of any conflict or inconsistency between te of this Guarani)'. an~an warranty or obligation of the Contractor under the Contract Documents or at law, sue · ~ffl or co ~t esolved in favor of the higher level of obligation of the Contractor. ~ ~ ..L <"\" \ ~ \ ~ \(__\~e.y ,CMJ~,e.\,\_, ~L~ (::),ti5,~ I LLC.. Contractor's Namel/-$"2-2..... .pow~ {tve ·i SJ~. 3 ~ 0 Address lf/ ( McCle.H~n,CA q5b~Z. 3 2.ol1- City/State/Zip City of Cupertino 2017 Pavement Maintenance Project -Phase 2 Date END OF DOCUMENT 00630 -I Guaranty / Proj ec t No 2017-110 Document 00670 Reliable Contractor Declaration Form STATE OF CALIFORNIA DEPARTMENT OF RESOURCES RECYCLING AND RECOVERY (CalRecycle) RELIABLE CONTRACTOR DECLARATION CalRecycle 168 (Revised 9/16) This form must be completed and submitted to the Department of Resources Recycling and Recovery (CalRecycle) prior to authorizing a contractor(s) to commence work. Failure to provide this documentation in a timely manner may result in nonpayment of funds to the contractor(s). This form is intended to help the CalRecycle's Grantees comply with the Reliable Contractor Declaration (formerly Unreliable List) requirement of their Terms and Conditions . · The Reliable Contractor Declaration (formerly Unreliable List) provision requires the following: Prior to authorizing a contractor(s) to commence work under the Grant, the Grantee shall submit to CalRecycle a declaration signed under penalty of perjury by the contractor(s) stating that within the preceding three (3) years, none of the events listed in Section 17050 of Title 14, California Code of Regulations, Natural Resources, Division 7, has occurred with respect to the contractor(s). Please see the reverse of this page, or refer to the California Code of Regulations (www.calregs.com). If any of the events listed in Section 17050 have occurred , disclosure is required but will not necessarily result in CalRecycle refusing to approve the contractor. A signed statement explaining the facts and circumstances of the events must be attached to and submitted with this form. Contractor: Complete the form and send original to the Grantee . Grantee: Scan the form and upload it to the grant in CalRecycle's Grant Management System.f or f urther instruction about logging into the Grant Management System and uploading this form, reference the Procedures and Requirements. Retain the original form in your grant file . ' .. GRA_-~-T~~-E~lf':J_F_O_R ___ ~-.A-T-~0-N-_--------------~--_-, .----~-----------------, GRANTEE NAME: -·-----·--1 GRAN ~ N~MBER: -----------------·- PRIMARY CONT ACT NAME: j ·--------------------______ I CONT~CTORINFqRMATION . --. -.. -. -l --CONTRACTORN AME : ,~\¼'< Yo, .. :~Q_"N'\~11\t ~e_c\\~t)\CJ'~~-,LL-_C.... _______ --r i AUTHORIZED CONTRACTOR REPRESENTATIVE NAME : MAILINGADDRESS : 4~2....'2--f>~rk-t-Y /fve.,,.J 81"ij 1Pbl 5+~.3S"o Me-Cle.flan ~ CA--95652.- As the authorized representative of the above identified contractor, I declare under penalty of perjury und e r th e laws of the State of California that within th e ·pre ced ing three (3) years , none of the events · listed in Section 17050 of Title 14 , California Code of Regulations, Natu ral Resources, Division 7, has occurred with respect to the above identified contractor. · Alternatively, as the authorized representative of the above identified contractor, I declare under penalty of perjury under the laws of the State of California th at within the preceding three (3) years , if any of the events listed in Section 17050 of Title 14, California Code of Regulations, Natural Resources , Division 7 , has occurred with respect to the above identified contractor, I have disclosed all such occurrence s in an attached sign ed sta tement that explains the facts and circumstances of the listed events. City of C u pertino 2017 Pavem ent Maintenance Pha se 2 Reli abl e Contrac tor D eclaration Form Project No 2017-110 ST ATE OF CALIFORNIA DEP ARTM EN T OF RESOURCES REC YCLING AND RECOVERY (CalRe cycle ) RELIABLE CONTRACTOR DECLARATION CalRec ycle 168 (Revised 9/16) Title 14 CCR, Division 7, Chapter 1 Article 5. Unreliable Contractors , Subcontractors, Borrowers and Grantees Section 17050 . Grounds for Placement on Unreliable List The following are grounds for a finding that a contractor, any subcontractor that provides services for a CalRecycle agreement, grantee or borrower is unreliable and should be placed on the CalRecycle Unreliable Contractor, Subcontractor, Grantee o r Borro wer List ("Unreliable List"). The presence of one of these grounds shall not automatically result in placement on the Unreliable List. A finding must be made by the Executive Director in accordance with section 17054 , and there must be a final decision on any appeal that may be filed in accordance with section 17055 et seq . (a) Disallowance of any and/or all claim(s) to CalRecycle due to fraudulent cla ims or reporting ; or (b) The filing of a civil action by the Attorney General for a violation of the False Claims Act, Government Code section 12650 et. seq ; or (c) Default on a CalRecycle loan , as evidenced by w rit ten notice from CalRecycle staff provided to the borrower of the def ault; or (d) Foreclosure upon real property loan collateral or repossession of personal property loan collateral by CalRecycle ; or (e) Filing voluntary or involuntary bankruptcy, where there is a finding based on substantial evidence , that the bankruptcy interfered with the CalRecycle contract , subcontract, grant or loan ; or (f) Breach of the terms and conditions of a previous CalRecycle contract , any subcontract for a CalRecycle agreement , grant , or loan , resulting in termination of the CalRecycle contract , subcontract , grant or loan by the CalRecycle or prime contractor ; or (g) Placement on the CalRecycle's chronic violator inventory established pu rsuant to Publ ic Resources Code section 44104 for any owner or operator of a solid waste facili ty ; or (h) The person , or any partner, member, officer, director, responsible managing officer, or responsible managing employee of an entity has been convicted by a court of competent jurisdiction of any charge of fraud , bribery, collusion , conspiracy, or any act in violation of any state or federal antitrust law in connection with the bidd i ng upon , award of, or performance under any CalRecycle contract, subcontract, grant or loan; or (i) The person or entity is on the list of unreliable persons or en ti ties , or sim ilar list, of any other federal or California state agency ; or 0) The person or entity has violated an Order issued in accordance with section 18304; or, (k) The person or entity has directed or transported to , has o r accepted waste tires at , a site where the operator is required to have but does not have a waste tire facility permit; or, (I) The person or entity has transported waste tires without a waste tire hauler registration ; or , (m) The person or ent ity has had a solid waste facility or waste tire perm it or a waste tire hauler registration denied , suspended or revoked : or, (n) The person or entity has abandoned a site or taken a similar action which resulted in corrective action or the expenditure of funds by Cal Recycle to remediate , clean , or aba te a nuisance at the site ; or (o) The following are additional grounds for a finding that , a person or entity described below should be placed on the Unreliable List: (1) The person or entity ow ned 20% or more of an entity o n the Un reliable List at the time of the activity that resulted in its placement on the Unreliable List; (2) The person held the pos ition of officer director, manager, partner, trustee , or any other management position with s ignificant control (Principal Manager) in an entity on the Unreliable List at the time of the activity that resulted in its placement on the Unrel iable List ; (3) The entity includes a Pri ncipal Manager who : 1 . Was a Principal Manager in an entity o n the Unreliable List at the time of the activity that resul ted in its placement on the Unreliable List: or. 2. Ow ned 20% or more of an entity on th e Unreliable List at the time of the activity that resulted in its placement on the Unreliable List; (4) The en ti ty has a person who owns 20% or more of the en tity , if that person : 1 . Was a Principal Manager in an entity on the Unreliable List at the time of the activity that resulted in its placemen t on the Unreliable List ; or, 2 . Owned 20% or more of an entity on the Unreliable List at the time of the activity that resulted in its placement on the Unreliable List. (5) The entity ha s another entity which owns 20% or more of the entity, if that other entity: 1. Is on the Unreliable List; or, 2 . Owned 20% or more of an entity on the Unreliable List at the time of the act ivity that resulted in its placement on the Unreliable List (6) Subsection (o) is not inte nded to apply to a person or entity that purchases or otherwise obtains an entity on the Unrel iable List subsequent to its placement on the Unreliable List. C ity of C upertino 201 7 Pavem e nt Maintenance phase 2 Reli able Co ntracto r Declaration form Bond Number: 929644150 DOCUMENT 00610 CONSTRUCTION PERFORMANCE BOND Project No. 2017-110 THIS CONSTRUCTION PERFORMANCE BOND ("Bond") is dated ______ , is in the penal sum of Four Hundred Ninety Thousand Two Hundred Forty-Seven Dollars and Sixty-Five Cents ($490 ,247 .65) [which is one hundred percent of the Contract Price], and is entered into by and between the parties listed below to ensure the faithful performance of the Construction Contract listed below. This Bond consists of this page and the Bond Terms and Conditions, paragraphs 1 through 12, attached to this page. Any singular reference to Telfer Pavement Technologies, LLC ("Contractor"), Western Surety Company ("Surety"), the City of Cupertino, a Municipal Corporation of the State of California ("City") or other party shall be considered plural where applicable. CONTRACTOR: Telfer Pavement Technologies, LLC Name 4522 Parker Avenue, Building 700, Suite 350 Address McClellan, CA 95652 City/State/Zip CONSTRUCTION CONTRACT: SURETY: Western Surety Company Name 333 S . Wabash Avenue Principal Place of Business Chicago , IL 60604 City/State/Zip 2017 PAVEMENT MAINTENANCE PROJECT-PHASE 2 PROJECT NUMBER 2017-110 at Cupertino, California. DATED Ape; 1 3 CONTRACTOR AS PRINCIPAL , 20 Ji_ in the Amount of$_4_9_0_,2_4_7_.6_5 _______ (the "Penal Sum") Company: (C rp. Signature:-1,L....J.~~~,a.~:.....,...I.J.4'4~(_--- Name and Title: T< ~\\-e..."'-t.. 0 ~-e)I"\_ Name and Title : Brod ric Buckle _ \/.£ o-f: S\~'{Y~ %. M.,t l(b ~~~~J Attorney-in-Fact =s_o_tt-re-11-"1-n.;...su_r_a_n_c_e_, P-.-o-_--B_o_x_1_4 __ 9 __ 0_, -J-a-ck-s_o_n_, .,..M.,.._..S. 39215--14 90 BOND TERMS AND CONDITIONS l. Contractor and Surety, jointly and severally, bind themselves, their heirs, executors, administrators, successors and assigns to City for the complete and proper performance of the Construction Contract, which is incorporated herein by reference. 2 . If Contractor completely and properly performs all of its obligations under the Construction Contract, Surety and Contractor shall have no obligation under this Bond. 3. If there is no City Default, Surety's obligation under this Bond shall arise after: 3 .1 City has declared a Contractor Default under the Construction Contract pursuant to the terms of the Construction Contract; and 3.2 City has agreed to pay the Balance of the Contract Sum : 3.2.1 To Surety in accordance with the terms of this Bond and the Construction Contract; or City of Cupertino Construction Performance Bond 2017 Pavement Maintenance Project -Phase 2 00610-I Project No . 2017-110 3.2 .2 To a contractor selected to perform the Construction Contract in accordance with the tenns of this Bond and the Construction Contract. 4. When City has satisfied the conditions of paragraph 3, Surety shall promptly (within 30 days) and at Surety's expense elect to take one of the following actions: 4.1 Arrange for Contractor, with consent of City, to perform and complete the Construction Contract (but City may withhold consent, in which case the Surety must elect an option described in paragraphs 4.2, 4.3 or 4.4, below); or 4.2 Undertake to perform and complete the Construction Contract itself, through its agents or through independent contractors; provided, that Surety may not select Contractor as its agent or independent contractor without City's consent; or 4.3 Undertake to perform and complete the Construction Contract by obtaining bids from qualified contractors acceptable to City for a contract for performance and completion of the Construction Contract, and, upon determination by City of the lowest responsible bidder, arrange for a contract to be prepared for execution by City and the contractor selected with City's concurrence, to be secured with perfonnance and payment bonds executed by a qualified surety equivalent to the bonds issued on the Construction Contract; and, if Surety's obligations defined in paragraph 6, below, exceed the Balance of the Contract Sum, then Surety shall pay to City the amount of such excess; or 4.4 Waive its right to perform and complete, arrange for completion, or obtain a new contractor and with reasonable promptness under the circumstances, and, after investigation and consultation with City, determine in good faith its monetary obligation to City under paragraph 6, below, for the performance and completion of the Construction Contract and, as soon as practicable after the amount is determined, tender payment therefor to City with full explanation of the payment's calculation . If City accepts Surety's tender under this paragraph 4.4, City may still hold Surety liable for future damages then unknown or unliquidated resulting from the Contractor Default. If City disputes the amount of Surety's tender under this paragraph 4.4, City may exercise all remedies available to it at law to enforce Surety 's liability under paragraph 6, below. 5. If Surety does not proceed as provided in paragraph 4, above, then Surety shall be deemed to be in default on this Bond ten days after receipt of an additional written notice from City to Surety demanding that Surety perform its obligations under this Bond . At all times City shall be entitled to enforce any remedy available to City at law or under the Construction Contract including, without limitation, and by way of example only, rights to perform work, protect work, mitigate damages, advance critical work to mitigate schedule delay, or coordinate work with other consultants or contractors. 6. Surety's monetary obligation under this Bond is limited by the Amount of this Bond identified herein as the Penal Sum. This monetary obligation shall augment the Balance of the Contract Sum. Subject to these limits, Surety's obligations under this Bond are commensurate with the obligations of Contractor under the Construction Contract. Surety's obligations shall include, but are not limited to: 6 .1 The responsibilities of Contractor under the Construction Contract for completion of the Construction Contract and correction of defective work; 6.2 The responsibilities of Contractor under the Construction Contract to pay liquidated damages, and for damages for which no liquidated damages are specified in the Construction Contract, actual damages caused by non-performance of the Construction Contract including, but not limited to, all valid and proper backcharges, offsets, payments, indemnities, or other damages; 6.3 Additional legal, design professional and delay costs resulting from Contractor Default or resulting from the actions or failure to act of the Surety under paragraph 4, above (but excluding attorney's fees incurred to enforce this Bond). City of Cupertino Construction Performance Bond 2017 Pavement Maintenance Project -Phase 2 00610-2 Project No. 2017-110 7. No right of action shall accrue on this Bond to any person or entity other than City or its successors or assigns. 8. Surety hereby waives notice of any change, alteration or addition to the Construction Contract or to related subcontracts, purchase orders and other obligations, including changes of time. Surety consents to all terms of the Construction Contract, including provisions on changes to the Contract. No extension of time, change, alteration, modification, deletion, or addition to the Contract Documents, or of the work required thereunder, shall release or exonerate Surety on this Bond or in any way affect the obligations of Surety on this Bond. 9. Any proceeding, legal or equitable, under this Bond shall be instituted in any court of competent jurisdiction where a proceeding is pending between City and Contractor regarding the Construction Contract, or in the courts of the County of Santa Clara, or in a court of competent jurisdiction in the location in which the work is located. Communications from City to Surety under paragraph 3.1 of this Bond shall be deemed to include the necessary contracts under paragraph 3.2 of this Bond unless expressly stated otherwise. 10. All notices to Surety or Contractor shall be mailed or delivered (at the address set forth on the signature page of this Bond), and all notices to City shall be mailed or delivered as provided in Document 00520 (Contract). Actual receipt of notice by Surety, City or Contractor, however accomplished, shall be sufficient compliance as of the date received at the foregoing addresses. 11. Any provision in this Bond conflicting with any statutory or regulatory requirement shall be deemed deleted herefrom and provisions conforming to such statutory requirement shall be deemed incorporated herein. 12 . Definitions. 12.1 Balance of the Contract Sum: The total amount payable by City to Contractor pursuant to the terms of the Construction Contract after all proper adjustments have been made under the Construction Contract, for example, deductions for progress payments made, and increases/decreases for approved modifications to the Construction Contract. 12.2 Construction Contract: The contract between City and Contractor identified on the signature page of this Bond, including all Contract Documents and changes thereto. 12.3 Contractor Default: Material failure of Contractor, which has neither been remedied nor waived, to perform or otherwise to comply with the terms of the Construction Contract including, but not limited to, "default" or any other condition allowing a termination for cause as provided in Document 00700 (General Conditions). 12.4 City Default: Material failure of City, which has neither been remedied nor waived, to pay Contractor progress payments due under the Construction Contract or to perform other material terms of the Construction Contract, if such failure is the cause of the asserted Contractor Default and is sufficient to justify Contractor termination of the Construction Contract. END OF DOCUMENT City of Cupertino Construction Performance Bond 20 I 7 Pavement Maintenance Project -Phase 2 00610 - 3 ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of Californ ia County of Sacram ento On April 3, 201 7 before me, Rick Ari as -Notary Public (insert name and title of the officer) personally appeared St eph en E. Ol se n who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENAL TY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. (Seal) RICK ARIAS Comm. 12104102 111 Notary Public• California~ Solano County .. Comm . Expires Ma r 21, 2019 Bond Number: 929644150 Project No. 2017-110 DOCUMENT 00620 CONSTRUCTION LABOR AND MATERIAL PAYMENT BOND THIS CONSTRUCTION LABOR AND MATERIAL PAYMENT BOND ("Bond") is dated---=~..,,,._--,--...,.,,..,..,,.•· is in the penal sum Four Hundred Ninety Thousand Two Hundred Forty-Seven Dollars and Sixty-Five Cents ($490,247 .65) [one hundred percent of the Contract Price], and is entered into by and between the parties listed below to ensure the payment of claimants under the Construction Contract listed below. This Bond consists of this page and the Bond Terms and Conditions, paragraphs I through 14, attached to this page. Any singular reference to Telfer Pavement Technologies, LLC ("Contractor"), Western Surety Company ("Surety"), the City of Cupertino, a Municipal Corporation of the State of California ("City") or other party shall be considered plural where applicable. CONTRACTOR: SURETY: Telfer Pavement Technologies, LLC Western Surety Company Name Name 4522 Parker Avenue, Building 700, Suite 350 333 S . Wabash Avenue Address McClellan , CA 95652 Principal Place of Business Chicago, IL 60604 City/State/Zip City/State/Zip CONSTRUCTION CONTRACT: 2017 PAVEMENT MAINTENANCE PROJECT -PHASE 2 PROJECT NUMBER 2017-110 at Cupertino, California. DATED P?il 3 , 20Jl in the Amount of$_4_9_0~,2_4_7_.6_5 _______ (the "Penal Sum") CONTRACTOR AS PRINCIPAL SURETY Company: Company: (Co e Signature:-=--c..+-=i!~'--"'~f--6-__.,,~~L----Signature: f ,L Name and Title: t'e..;s?Y\.-e."'-\::.. \)\s.-e.Y'\.. Name and Title: Brody Eric Buckley \J ·S>, ~£--Sh.w:::c:~ ~ N't<:.x::o ()~~Attorney-in-Fact G lk-B_o_tt-re_l....:cl 1-n-su_r_a_n-ce-.-p-_-o-. -B-ox-1-49_0_,_J_a_c-ks_o_n_, -M-S-39215-'l 490 BOND TERMS AND CONDITIONS I. Contractor and Surety, jointly and severally, bind themselves, their heirs, executors, administrators, successors and assigns to City and to Claimants, to pay for labor, materials and equipment furnished for use in the performance of the Construction Contract, which is incorporated herein by reference. 2. With respect to City, this obligation shall be null and void if Contractor: 2.1 Promptly makes payment, directly or indirectly, for all sums due Claimants; and 2.2 Defends, indemnifies and holds harmless City from all claims, demands, liens or suits by any person or entity who furnished labor, materials or equipment for use in the performance of the Construction Contact, provided City has promptly notified Contractor and Surety (at the address set forth on the signature page of this Bond) of any claims, demands, liens or suits and tendered defense of such claims, demands, liens or suits to Contractor and Surety, and provided there is no City Default. 3. With respect to Claimants, this obligation shall be null and void if Contractor promptly makes payment, directly or indirectly through its Subcontractors, for all sums due Claimants . If Contractor or its Subcontractors, however, fail to pay any of the persons named in Section 3 I 81 of the California Civil Code, or amounts due City of Cupertino Construction Labor and Material Payment Bond 2017 Pavement Maintenance Project -Phase 2 00620 -I Project No. 2017-110 under the Unemployment Insurance Code with respect to Work or labor performed under the Contract, or for any amounts required to be deducted, withheld, and paid over to the Employment Development Department from the wages of employees of Contractor or Subcontractors pursuant to Section 13020 of the Unemployment Insurance Code, with respect to such Work and labor, then Surety shall pay for the same, and also, in case suit is brought upon this Bond, a reasonable attorney's fee, to be fixed by the court. 4. Consistent with the California Mechanic 's Lien Law, Civil Code §3082, et seq., Surety shall have no obligation to Claimants under this Bond unless the Claimant has satisfied all applicable notice requirements. 5. Surety's total obligation shall not exceed the amount of this Bond, and the amount of this Bond shall be credited for any payments made in good faith by Surety under this Bond. 6. Amounts due Contractor under the Construction Contract shall be applied first to satisfy claims, if any, under any Construction Performance Bond and second, to satisfy obligations of Contractor and Surety under this Bond. 7. City shall not be liable for payment of any costs, expenses, or attorney's fees of any Claimant under this Bond, and shall have under this Bond no obligations to make payments to, give notices on behalf of, or otherwise have obligations to Claimants under this Bond. 8. Surety hereby waives notice of any change, including changes of time, to the Construction Contract or to related subcontracts, purchase orders and other obligations. Surety further hereby stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Construction Contract, or to the Work to be performed thereunder, or materials or equipment to be furnished thereunder or the Specifications accompanying the same, shall in any way affect its obligations under this Bond, and it does hereby waive any requirement of notice or any such change, extension of time, alteration or addition to the terms of the Construction Contract or to the Work or to the Specifications or any other changes . 9. Suit against Surety on this Bond may be brought by any Claimant, or its assigns, at any time after the Claimant has furnished the last of the labor or materials, or both, but, per Civil Code §3249, must be commenced before the expiration of six months after the period in which stop notices may be filed as provided in Civil Code §3184. IO. All notices to Surety or Contractor shall be mailed or delivered (at the address set forth on the signature page of this Bond), and all notices to City shall be mailed or delivered as provided in Document 00520 (Contract). Actual receipt of notice by Surety, City or Contractor, however accomplished, shall be sufficient compliance as of the date received at the foregoing addresses. 11. This Bond has been furnished to comply with the California Mechanic's Lien Law including, but not limited to, Civil Code §§3247, 3248, et seq. Any provision in this Bond conflicting with said statutory requirements shall be deemed deleted herefrom and provisions conforming to such statutory or other legal requirements shall be deemed incorporated herein. The intent is that this Bond shall be construed as a statutory bond and not as a common law bond. 12. Upon request by any person or entity appearing to be a potential beneficiary of this Bond, Contractor shall promptly furnish a copy of this Bond or shall permit a copy to be made. 13. Contractor shall pay to persons performing labor in and about Work provided for in the Contract Documents an amount equal to or more than the general prevailing rate of per diem wages for (I) work of a similar character in the locality in which the Work is performed and (2) legal holiday and overtime work in said locality. The per diem wages shall be an amount equal to or more than the stipulated rates contained in a schedule that has been ascertained and determined by the Director of the State Department of Industrial Relations and City to be the general prevailing rate of per diem wages for each craft or type of workman or mechanic needed to execute this Contract. Contractor sh al I also cause a copy of this determination of the prevailing rate of per diem wages to be posted at each Site. City of Cupertino Construction Labor and Material Payment Bond 2017 Pavement Maintenance Project -Phase 2 00620-2 Project No.2017-110 14 . Definitions. 14.1 Claimant: An individual or entity having a direct contract with Contractor or with a Subcontractor of Contractor to furnish labor, materials or equipment for use in the performance of the Contract, as further defined in California Civil Code §3181. The intent of this Bond shall be to include without limitation in the terms "labor, materials or equipment" that part of water, gas, power, light, heat, oil, gasoline, telephone service or rental equipment used in the Construction Contract, architectural and engineering services required for performance of the Work of Contractor and Contractor's Subcontractors, and all other items for which a stop notice might be asserted. The term Claimant shall also include the Unemployment Development Department as referred to in Civil Code §3248(b). 14.2 Construction Contract: The contract between City and Contractor identified on the signature page of this Bond, including all Contract Documents and changes thereto. 14.3 City Default: Material failure of City, which has neither been remedied nor waived, to pay the Contractor as required by the Construction Contract, provided that failure is the cause of the failure of Contractor to pay the Claimants and is sufficient to justify termination of the Construction Contract. END OF DOCUMENT City of Cupertino Construction Labor and Material Payment Bond 20 I 7 Pavement Maintenance Project -Phase 2 00620 -3 Western Surety Company POWER OF ATTORNEY APPOINTING INDIVIDUAL ATTORNEY-IN-FACT Know All i\lcn By These Presents, Thal WESTERN SURETY COMPANY, a South Dakota corporation. is a duly organized and existing corporation having its principal office in the City of Sioux Falls. and Stale of South Dakota. and that it docs by vinuc of !he signature and seal herein affixed hereby make, constitute and appoint Jim A Armstrong, Jerry G Veazey Jr, Jerry Eugene Horner Jr, Jason J Young, Trina Cobb, Linda D Whittington, Peggy L Jackson, Amanda Jean Charfauros, Brody Eric Buckley, Angela Bullie, Stephen Wesley Price Jr, Individually of Jackson , MS , ils true and lawful Allorney(s)-in-Facl with full power and aulhorily hereby conferred 10 sign, seal and execute for and on ils behalf bonds, undenakings and other obligatory instruments or similar nature -In Unlimited Amounts - and to bind ii lherehy as fully and to !he same e .~lent as if such instruments were signed hy a duly authorized oflkcr of the corporation and all the acts of said Attorney. pursuant lo the authority herehy given, arc herchy ralilied and confirmed. This Power or Anorney is made and executed pursuant 10 and by authority of the By-Law printed on the reverse hereof, duly adopted, as indicated , by the shareholders of !he corporation . In Witness Whereof. WESTERN SURETY COMPANY has caused these presents 10 be signed hy its Vice President and its corporate seal 10 be hereto affixed on this 28th day of May, 2015. Stale of South Dakota County of Minnehaha WESTERN SURETY COMPANY On this 28th day of May. 1015, before rne personally came Paul T. Brunat. lo me known. who. being hy me duly sworn, did depose and say: that he resides in the City of Sioux Falls , State of South Dakota; that he is the Vice President of WESTERN SURETY COMPANY described in and which executed the above instrument; that he knows !he seal of said corporation; thal the seal affixed to the said instrument is such corporate seal; that ii was so affixed pursuant to aulhorily given by the Bo ard of Directors of said corporation and that he signed his name lhcrelo pursuant to like authority, and acknowledges sa me lo be the act and deed of s.1id corporation . My commission expires February I:!, :!021 .................. , ................................. + j S. EICH $ $~NOTARY PUBUC~j :~SOUTH DAKOTA~: ......................... ~ .................... . CERTIFICATE S. Eich. Notary Public I. L. Nelson , Assistant Secretary of WESTERN SURETY COMPANY do hereby cenify 1ha1 the Power of Anorney hercinabove sci fonh is still in force . and funhcr cenify 1hat the Ry -L,w of 1he corporation printed on 1he reverse hereof is siill in force. In testimony whereof I have hercunlo subscribed my name and ai'lixcd the seal of the said corporation this ______ day of ______________ _ WESTERN SURETY COMPANY Form F~280 -7-20l2 Authorizing By-Law ADOPTED BY THE SHAREHOLDERS OF WESTERN SURETY COMPANY This Power of Allorney is made and executed pursuant to and hy authority or the following By-Law duly adopted by the shareholders or the Company . Section 7 . All bonds. policies, undertakings, Powers or Attorney. or other obligations of the corporation shall he executed in the corporate name of the Company by the President, Secretary, and Assistant Secretary, Treasurer, or any Vice President, or by such other oflicers as the Board or Directors may authorize. The President. any Vice President, Secretary, any Assistant Secretary , or the Treasurer may appoint Attorneys in Fact or agents who shall have authority to issue bonds, policies , or undertakings in the name of the Company. The corporate seal is not necessary for the validity of any bonds, policies, undertakings, Powers of Attorney or other obligations or the corporation . The signature of any such officer and the corporate seal may be printed by facsimile . CALIFORNIA ALL-PURPOSE ACKNOWLEDGEMENT Civil Code § 1189 A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfullness, accuracy or validity of that document. ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• State of Mississippi County of _H_in_d_s ________ _ } on March 30, 2017 before me, Peggy L. Jackson , Notary Public Name and Trtie of Notary Date personally appeared _B_ro_d..._y_E_r_ic_B_uc_k_le-'y'------------------------------ Name and or Names of Slgner(s) Who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. ••••a•• .. •• ··o· f Mi ss·,·· •• ··~ ----,S •• /~ 0'{ \.. JAc,t-&/,o··. _: i; <v0 u>o ~ \ • Q_ -t-• . . : * NOTARY P U BLIC *: : I D No . 1 6818 : ~ MY CO MM IS SION EXPIR ES : •. A U G .11 ,20 1 8 : • • • • ;S,,I ~-~ ~~ • •: • •.• lvos cou':··· . . . . Place Not:.,·pubJic· S:a1 Above OPTIONAL _____________ ....._____ -------------------- Though the information below is not raquired by law, it may prove valuable to the persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document. Description of Attached Document Title or Type of Document Performance and Payment Bond Document Date _N_/_A ___________________ Number of Pages: 9 including this form Signer's Name: Brody Eric Buckley D Individual D Corporate Officer -Title(s): _______ _ D Partner -D Limited D General D Guardian or Conservator l8l Attorney-in-Fact D Trustee D Other: -----------Signer is representing ____ _ Western Surety Company RIGHTTHUMIJPRINT OF SIGNER Top ol lhumb D Individual D Corporate Officer -Title(s):. _______ _ D Partner -D Limited D General D Guardian or Conservator D Attorney-in-Fact D Trustee D Other: -----------Signer is representing ____ _ RIGHTTHUMBl'RINT OF SIGNER Topol lhumb ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of Sacr am ento On Ap r il 3, 201 7 before me, Ri ck Arias -Not ary Public (insert name and title of the officer) personally appeared Steph en E. Olsen who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENAL TY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand a rcial seal. (Seal) RICK ARIAS • . . f Comm. #2104102 ~ Notary Public. California l!: So lano County 1 • Co.mm . Expires M!r 2~, 20}~