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17-084 Professional Turf Management, Repair Blackberry Farm Golf Course Turf following construction of Stevens Creek Phase 2 bank repairCITY OF a CUPERTINO AGREEMENT CITY OF CUPERTINO 10300 Torre Avenue Cupertino, CA 95014 408-777 -3200 THIS AGREEMENT, made and entered into this 1st day of June 2017 is by and between the CITY OF CUPERTINO (Hereinafter "CITY") and Professional Turf Management, P.O. Box 700142, San Jose, CA 95170, phone number 408-315-3865, fax number 408 -899-6094, email mike basile@hotmail.com (Hereinafter "CONTRACTOR"), in consideration of their mutual covenants, the parties agree as follows: CONTRACTOR shall provide or furnish the following specified services and/or materials: Repair Blackberry Farm Golf Course turf following construction of Stevens Creek Phase 2 bank repair, work to include aeration and seeding of areas damaged by on the equipment haul route (approx. 6,950 sf) and at the work zone near hole #9 (approx. 2,250 sf), cleanup of minor excess topsoil at the work zone, finish grading of the work zone, and watering of newly seeded areas (2 hours/day for 2 weeks). If rut repair is needed, ruts will be repaired with clean sand and reseeded. Check box if services are further described in an Exhibit. D EXHIBITS: The following attached exhibits hereby are made part of this Agreement: Iv'/ A-- T ERM: The services and/or materials furnished under this Agreement shall commence on June 15, 2017 and shall be completed no later than July 7, 2017. COMPENSATION: For the full performance of this Agreement, CITY shall pay CONTRACTOR: A sum not to exceed $2,200 without rut repair, and not to exceed $4,200.00 for additional repair work to repair ruts as needed or unforeseen construction damage, and all work performed noted and documented on invoices. California Labor Code, Section 1771 requires the payment of prevailing wages to all workers employed on a Public Works contract in excess of $1,000.00. GENERAL TERMS AND CONDITIONS Hold Harmless. Contractor shall, to the fullest extent allowed by law, indemnify, defend, and hold harmless the City and its officers, officials, agents, employees and volunteers against any and all liability, claims, stop notices, actions, causes of action or demands whatsoever from and against any of them, including any injury to or death of any person or damage to property or other liability of any nature, arising out of, pertaining to, or related to the performance of this Agreement by Contractor or Contractor's employees, officers, officials, agents or independent contractors. Contractor shall not be obligated under this Agreement to indemnify City to the extent that the damage is caused by the sole or active negligence or willful misconduct of City, its agents or employees. Such costs and expenses shall include reasonable attorneys' fees of counsel of City's choice, expert fees and all other costs and fees of litigation. Subcontracting. Contractor has been retained due to their unique skills and Contractor may not substitute another, assign or transfer any rights or obligations under this Agreement. Unless prior Page 1 of 3 Short Form Agreement written consent from City is obtained, only those people whose names are listed this Agreement shall be used in the performance of this Agreement. Assignment. Contractor may not assign or transfer this Agreement, without prior written consent of CITY. Insurance. Contractor shall file with City a Certificate of Insurance consistent with the following requirements Coverage: Contractor shall maintain the following insurance coverage: (1) Workers' Compensation: Statutory coverage as required by the State of California. (2) Liability: Commercial general liability coverage in the following minimum limits: Bodily Injury: $500,000 each occurrence $1,000,000 aggregate -all other Property Damage: $100 ,000 each occurrence $250 ,000 aggregate If submitted, combined single limit policy with aggregate limits in the amounts of $1 ,000 ,000 will be considered equivalent to the required minimum limits shown above. (3) Automotive: Comprehensive automotive liability coverage in the following minimum limits: Bodily Injury: $500,000 each occurrence Property Damage: $100 ,000 each occurrence or Combined Single Limit: $500,000 each occurrence (4) Professional Liability: Professional liability insurance which includes coverage for the professional acts , errors and omissions of Consultant in the amount of at least $1 ,000 ,000. Subrogation Waiver. Contractor agrees that in the event of loss due to any of the perils for which it has agreed to provide comprehensive general and automotive liability insurance, Contractor shall look solely to its insurance for recovery. Contractor hereby grants to City, on behalf of any insurer providing comprehensive general and automotive liability insurance to either Contractor or City with respect to the services of Contractor herein, a waiver of any right to subrogation which any such insurer of said Contractor may acquire against City by virtue of the payment of any loss under such insurance. Termination of Agreement. The City reserves the right to terminate this Agreement with or without cause with a seven (7)-day notice. The Contractor may terminate this Agreement with or without cause with a seven (7)-day written notice. Page 2 of3 Short Form Agreement Non-Discrimination. No discrimination shall be made in the employment of persons under this Agreement because of the race, color, national origin, ancestry, religion, gender or sexual orientation of such person Interest of Contractor. It is understood and agreed that this Agreement is not a contract of employment in the sense that the relationship of master and servant exists between City and undersigned. At all times, Contractor shall be deemed to be an independent contractor and Contractor is not authorized to bind the City to any contracts or other obligations in executing this Agreement. Contractor certifies that no one who has or will have any financial interest under this Agreement is an officer or employee of City. City shall have no right of control as to the manner Contractor performs the services to be performed. Nevertheless, City may, at any time, observe the manner in which such services are being performed by the contractor. The Contractor shall comply with all applicable Federal, State, and local laws and ordinances including, but not limited to, unemployment insurance benefits, FICA laws, and the City business license ordinance. Changes. No changes or variations of any kind are authorized without the written consent of the City. CONTRACT CO-ORDINATOR and representative for CITY shall be: NAME: b~ ~ DEPARTMENT: .ylJ-c_ -f-~ ~~ This Agreement shall become effective upon its execution by CITY , in witness thereof, the parties have executed this Agreement the day and year first written above. CITY OFCUlilNc;>: By ~ J£c/\ Title Q tv V\ ~ v--Title : -PcviL I IY\(ViJvt..~t Mwic,..~~( APPROVALS EXPENDITURE DISTRIBUTION DEPARTMENT HEAD DATE 427-90-881 900-905 $4,200.00 CITY ATTORNEY APPROVED AS TO FORM Page 3 of 3 Short Form Agreement ~C?,_RD@ CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DD/YYYY) 6/1/2017 THIS CERTIFICATE IS ISSUED AS A MATIER 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 pollcy(les) must 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 ~X~E'.'"1 VOLPATTI INSURANCE SERVICES INC i.l.J8NN~ Extl: ( 925) 243-0131 !1NCNol:(925)243-0132 511 Leisure Street fo~bs:rick@volpatti.com Livermore, CA 94551 INSURER(S) AFFORDING COVERAGE NAIC# License#:OE40809 INSURER A: Scottsdale Insurance Company 41297 INSURED Professional Turf Management, Inc. INSURER B : Falls Lake Fire & Casualty Company 24538 INSURER C: California Capital Insurance Company 13544 PO Box 700142 IN SURER D : San Jose, CA 95170 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES . LIM ITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SuBR 1J~~g~) 1J~~g~) LTR INSR wvo POLICY NUMBER LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1 000,000 ~ UAMA(;t: I ~I "c" I cu X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence} $ 100,000 I CLAIMS-MADE CK] OCCUR MED EXP (Any one person) $ 5 000 A CPS2609259 04/01/2017 04/01/2018 PERSONAL & ADV INJURY $ 1,000,000 -y GENERAL AGGREGATE $ 2,000,000 ,__ GEN'L AGGREGATE LI MIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 2,000,000 n rxl PRO-nLOC $ POLICY JECT AUTOMOBILE LIABILITY (E~'";,~~id~D trlNuLt: LIM/ I ant $ - ANY AUTO BODILY INJURY (Per person) $ -ALL OWNED -SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ --NON-OWNED FFROPERTY DAMAGE HIRED AUTOS AUTOS Per accident) $ ,__ - $ UMBRELLA LIAS ~, OCCUR EACH OCCURRENCE $ ~ EXCESS LIAB CLAIMS -MA DE AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION X I WC STATU-I jOTH- AND EMPLOYERS' LIABILITY TORY LIMITS ER Y/N 1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE [xJ y E.l. EACH ACC IDENT $ OFFICER/MEMBER EXCLUD ED ? N/A FLA005003-00 04/01/17 04/01/18 (Mandatory In NH) E.L. DISEASE -EA EMPLOYE, $ 1,000,000 If ts, describe under D SCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,000 Commercial Inland Contractors Equip. C Marine 3-MIA-1-026769 6/23/2016 6/23/2017 $213,275 Deductible $500 DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (Attach ACORD 101, Addilional Remarks Schedule, if more space is required) The City of Cupertino, its directors, officers, agents, consultants and employees are named as additional insured in regard to General Liability and Primary/Non-Contributory wording is attached to this policy . Waiver of Subrogation in regard to workers compensation in favor of City of Cupertino. The issuing insurer will endeavor to mail 30 days written notice of cancellation. CERTIFICATE HOLDER City of Cupertino 10300 Torre Avenue Cupertino, CA 95014 CANCELLATION 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 ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD SCOTTSDALE INSURANCE COMPANY® ENDORSEMENT NO. ------- ATTACHED TO AND ENDORSEMENT EFFECTIVE DATE FORMING APART OF (12:01 A.M. STANDARD TIME) NAMED INSURED AGENT NO. POLICY NUMBER CPS2609259 04/01/2017 PROFESSIONAL TURF MANAGEMENT, INC. 040AO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART With respect to this endorsement, SECTION II -WHO IS AN INSURED is amended to include as an addit ional in- sured any person or organization whom you are required to add as an additiona l insured on this policy under a writ- ten contract, written agreement or written permit which must be: a. Currently in effect or becoming effective during the term of the policy; and b. Executed prior to the "bodily injury," "property damage," or "personal and advertising injury." The insurance provided to these additional insureds is lim- ited as follows: 1. That person or organization is an additional in- sured only with respect to liability for "bodily injury," "property damage" or "persona l and adver- tising injury" caused, in whole or in part , by: a. Your acts or omissions; or b. The acts or omissions of those acting on your behalf. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. 2. With respect to the insurance afforded to these ad- ditional insureds, the following exclusions are added to item 2. Exclusions of SECTION I - COVERAGES: This insurance does not apply to "bodily injury," "property damage" or "personal and advertising in- jury" occurring after: a. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, mainte- nance or repairs) to be performed by or on be- half of the additional in sured(s) at the location of the covered operations has been com- pleted; or b. That portion of ''your work" out of which the in- jury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a princi- pal as a part of the same project. 3. The limits of insurance applicable to the additional insured are those specified in the written contract, written agreement or written permit or in the Decla - rations for this policy, whichever is less . These lim- its of insurance are inclusive of, and not in addition to, the Limits of Insurance shown in the Declara- tions for this policy. 4. Coverage is not provided for "bodily injury," "prop- erty damage," or "personal and advertising injury" arising out of the so le negligence of the additional insured. 5. The insurance provided to the additional insured does not apply to "bodily injury," "property dam- age," or "personal and advertising injury" arising out of an architect's, engineer's or surveyor's ren- dering of or failure to render any professional serv- ic es including: Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc., 2004 GLS-150s (7-06) Page 1 of2 AGENT a. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, re- ports, surveys, field orders, change orders or drawings and specifications; and b. Supervisory, inspection, architectural or engi- neering activities. 6. Any coverage provided hereunder will be excess over any other valid and collectible insurance avai l- able to the additional insured whether primary, ex- cess, contingent or on any other basis unless a written contract specifically requires that this insur ance be primary . When this insurance is excess, we will have no du- ty under SECTION I • COVERAGES to defend the additional insured against any "suit" if any other in - surer has a duty to defend the additional insured against that "suit." If no other insurer defends, we will undertake to do so, but we will be entitled to the additional insured's rights against all those oth- er insurers. I AUTHORIZED REPRESENTATIVE . DATE Includes copyrighted material of ISO Properties, Inc., with Its permission . Copyright, ISO Properties, Inc., ¢004 GLS-150s (7-06) Page 2 of2 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: ' COMMERCIAL GENERAL LIABILllY COVERAGE PART PRODUCTS/ COMPLETED OPERATIONS LIABILllY COVERAGE PART The following is added to the Other Insurance Condi- tion and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek con- tribution from any other insurance available to an additional insured under your policy provided that: (2) You have agreed in writing in a contract or agreement that this insurance would be pri- mary and would not seek contribution from any other insurance available to the additional insured. (1) The additional insured is a Named Insured under such other insurance; and CG 20 01 0413 Copyright, Insurance Services Offic'e, Inc., 2012 AGENT Page 1 of1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA WC 0403 06 Ed. 4-84 We have the right to recover our payments from anyone liab le for an injury covered by this policy. We will not enforce our right against the person or organizatio n named in the Schedu le . (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us .) You must maintain payroll records accurate ly segregating the remuneration of your employees whi le engaged in the work described in the Schedule. The additional premium for this endorsement shall be §.% of the California workers' compensation premium otherwise due on such remuneration . Schedule Person or Organization Job Description The City of Cupertino/ Blackberry Farm Golf Course 10300 Torre Avenue Job Address: 22100 Stevens Creed Blvd Cupertino, CA 95014 Cupertino, CA 95014 Starting Date of Job : On going Estimated Duration : On going Specific work performed : Turf Maintenance Number of employees: 2 Estimated payroll : $100,000 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated (The information below is required only when this endorsement Is issued subsequent to preparation of the policy.) Endorsement Effective 04 -01 -2017 Insured Professiona l Turf Management, Inc. (A Corp) Policy No . FLA005003 -00 Insurance Company Falls Lake Fire & Casualty Company Endorsement No. 1 ACORD® VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE I DATE (MM/DD/YYYY) ~ 06/09/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. This form is used to report coverages provided to a single specific vehicle or equipment. Do not use this form to report liability coverage provided to multiple vehicles under a single policy. Use ACORD 25 for that purpose. PRODUCER CONTACT Eric Uyeda NAME : StateFann JOE FRANGIEH PHONE 408-793-8303 I FAX IA/C No Extl: {A/C No): 408-793-8304 A . 120 W CAMPBELL AVE STE A E~AIL eric.uyeda.wecg@statefarm.com ADDRESS: CAMPBELL, CA 95008 PRODUCER CUSTOMER ID#: INSURER($) AFFORDING COVERAGE NAIC# INSURED INSURER A: State Farm Mutual Automobile Insurance Company 25178 BASILE, MICHAEL INSURERS : DBA PROFESSIONAL TURF MGT INSURERC : 1310 SADDLE RACK ST APT 302 INSURERD: SANJOSE CA 95126-5105 INSURERE : DESCRIPTION OF VEHICLE OR EQUIPMENT YEAR I MAKE/ MANUFACTURER I Edge MODEL I BODY TYPE VEHICLE IDENTIFICATION NUMBER 2013 Ford SportWG 2FMDK3JC1 DBA83377 DESCRIPTION SERJAL NUMBER COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICY(IES) OF INSURANCE LISTED BELOW HAS/HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD(S) 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 POLICY(IES) DESCRIBED HEREIN IS/ARE SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). INSR ADD"L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YYYY) DATE (MM/DD/YYYY) LIMITS ~ VEHICLE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ A 191 4357-D04-05G 04/04/2017 10/04/2017 BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ GENERAL LIABILITY EACH OCCURENCE $ R OCCURRENCE GENERAL AGGREGATE $ CLAIMS MADE MEDICAL PMNTS $ 10,000 INSR LOSS POLICY EFFECTIVE POLICY EXPIRATION LTR PAYEE TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YYYY) DATE (MM/DD/YYYY) LIMITS / DEDUCTIBLE X VEH COLLISION LOSS 0 ACV 0 AGREED AMT $ LIMIT G >--191 4357-D04-05G 04/04/2017 10/04/2017 0 STATEDAMT D $ 500 DED X VEH COMP LJ VEH OTC [!} ACV 0 AGREED AMT $ LIMIT D 191 4357-D04-05G 04/04/2017 10/04/2017 D D STATEDAMT s 250 OED PROPERTY D ACV 0 AGREED AMT LIMIT = BASIC Fl BROAD $ D RC 0 STATED AMT $ OED SPECIAL D c- REMARKS (INCLUDING SPECIAL CONDITIONS/ OTHER COVERAGES) (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) ADDITIONAL INTEREST CANCELLATION Select one of the following: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED ~ The additional interest described below has been added to the policy(ies) listed herein by policy number(s). BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE A request has been submitted lo add the add itional interest desaibed below to the policy(ies) DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. lisled herein bv onlicv number(sl. VEHICLE I EQUIPMENT INTEREST: I I LEASED I I FINANCED DESCRIPTION OF THE ADDITIONAL INTEREST NAME AND ADDRESS OF ADDITIONAL INTEREST ~ ADDITIONALINSURED Fl LOSS PAYEE Blackbeny Farm Golf Course LENDER'S LOSS PAYEE 22100 Stevens Creek Blvd LOAN/ LEASE NUMBER Cupertino, CA 95014 AUTHORIZED REPRESENTATIVE ~tigMldbyc.arlllaCCW.~ Camille Cowley DN:~c.ow\ey.oa&ae f1m1~ou. ~~-c-US I O:u:2D1.SD2..18 1(tOIS;3 1-03'00" © 1997-2010 ACORD CORPORATION. All rights reserved. ACORD 23 (2010/05) The ACORD name and logo are registered marks of ACORD 1004361 142987.2 01-28-2013 ACORD® VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE I DATE (MM/DD/YYYY) ~ 06/09/2017 THIS CERTIFICATE IS ISSUED AS A MATIER 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 BElWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. This form is used to report coverages provided to a single specific vehicle or equipment. Do not use this form to report liability coverage provided to multiple vehicles under a single policy. Use ACORD 25 for that purpose. PRODUCER CONTACT Eric Uyeda NAME: StateFarm JOE FRANGIEH PHONE 408-793-8303 I FAX IA/C No Ext\: IA/C Nol: 408-793-8304 A . 120 W CAMPBELL AVE STE A E-MAIL eric.uyeda .wecg@statefarm .com ADDRESS: CAMPBELL, CA 95008 PRODUCER CUSTOMER JO #: INSURER($) AFFORDING COVERAGE NAJC# INSURED INSURER A: State Farm Mutual Automobile Insurance Company 25178 BASILE, MICHAEL INSURERB: OBA PROFESSIONAL TURF MGT INSURERC: 1310 SADDLE RACK ST APT 302 INSURER D: SAN JOSE CA 95126-5105 INSURERE : DESCRIPTION OF VEHICLE OR EQUIPMENT YEAR I MAKE/MANUFACTURER I F150 MODEL I BODY TYPE VEHICLE IDENTIFICATION NUMBER 2012 FORD Pickup 1 FTFW1CF7CFB95742 DESCRIPTION SERIAL NUMBER COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICY(IES) OF INSURANCE LISTED BELOW HAS/HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD(S) 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 POLICY(IES) DESCRIBED HEREIN IS/ARE SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). INSR ADD"L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MM/OD/YYYY) DATE (MM/DD/YYYY) LIMITS ~ VEHICLE LIABILITY COMBINED SINGLE LIMIT $ BODILY INJURY (Per person) $ 1,000,000 A 273 4810-A07-05B 01/07/2017 07/07/2017 BODILY INJURY (Per accident) $ 1,000,000 PROPERTY DAMAGE $ 1,000,000 GENERAL LIABILITY EACH OCCURENCE $ R OCCURRENCE GENERAL AGGREGATE $ CLAIMS MADE MEDICAL PMNTS $ 10,000 INSR LOSS POLICY EFFECTIVE POLICY EXPIRATION LTR PAYEE TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YYYY) DATE (MM/DO/YYYY) LIMITS/ DEDUCTIBLE X VEH COLLISION LOSS [!)ACV 0 AGREED AMT $ LIMIT G >--273 481 O-A07 -058 01/07/2017 07/07/2017 D STATED AMT D $ 500 DED X VEH COMP LJ VEH OTC [!)ACV 0 AGREED AMT $ LIMIT D t--273 4810-A07-05B 01/07/2017 07/07/2017 D D STATED AMT $ 250 OED PROPERTY 0ACV 0 AGREED AMT $ LIMIT t-- BASIC Fl BROAD 0RC 0 STATEDAMT $ OED t-- SPECIAL D t-- REMARKS (INCLUDING SPECIAL CONDITIONS/ OTHER COVERAGES) (Attach ACORD 101, Additional Remarks Schedule, If more space is required) ADDITIONAL INTEREST CANCELLATION Select one of the following: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED ==i The additional interest described below has been added to lhe policy(ies) listed herein by policy number(s). BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE A request has been submitted to add the additional inlerest described below to the policy(ies) DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. listed herein bv oolicv numberlsl. VEHICLE/ EQUIPMENT INTEREST: I I LEASED I I FINANCED DESCRIPTION OF THE ADDITIONAL INTEREST NAME AND ADDRESS OF ADDITIONAL INTEREST ~ ADDITIONAL INSURED Fl LOSS PAYEE Blackberry Farm Golf Course LENDER'S LOSS PAYEE 22100 Stevens Creek Blvd LOAN / LEASE NUMBER Cupertino, CA 95014 AUTHORIZED REPRESENTATIVE ~sqwlbjc.n&Co.l,y Camille Cowley DN:oi~ee Cow\q. o=Slale Farm IMlnnce. o.,,. rrrul"Cl!lrriile~.k5ae@,b1,ebrm.,;a,\csl!S I oare:2D1~.oz.1a 10.oi,:J1 -Oll1lD' © 1997-2010 ACORD CORPORATION. All nghts reserved. ACORD 23 (2010/05) The ACORD name and logo are registered marks of ACORD 1004361 142987.2 01 -28-2013