18-164 J Marez Ocean Plumbing, Replacing Drinking Fountains at Quinlan Community CenterCIT Y OF
a PUBLIC WORKS CONTRACT
$45,000 OR LESS
CUPERTINO
1. PARTIES
This public works contract ("Contract") is made and entered into on August 10 , 2018
("Effective Date") by and between the City of Cupertino , a municipal corporation ("City"), and
J Marez Ocean Plumbing , a Sole Proprietorship/Individ
("Contractor") for replacing drinking fountains at Quinlan Community Center.
2. SCOPE OF WORK
Contractor will perform and provide all labor, materials, equipment, supplies, transportation and any
other items or work necessary to perform and complete the work required for the Project ("Work"), as
required in the Scope of Work, attached here and incorporated as Exhibit A, and in accordance with
the terms and conditions of this Contract.
3. TIME FOR COMPLETION
3.1 Term. This Contract begins on the Effective Date and ends on March 29, 2019
("Contract Time") unless terminated earlier as provided herein. Contractor's Work shall begin on the
date shown on a written Notice to Proceed ("NTP") and must be fully completed within the Contract
Time or on the date specifically provided in the Notice to Proceed. The City Engineer will not issue a
NTP until the Contract is fully executed by both parties and City has received satisfactory proof of
insurance and any performance and payment bonds that may be required.
3.2 Time is of the essence for Contractor's performance and completion of the Work. Contractor
must have sufficient time, resources, and qualified staff to deliver the work on time.
3.3 Liquidated damages of$ 200.00 will be charged for each day of unexcused delay,
or City may deduct the amount from Contractor's payments. Liquidated damages are based on
reasonably foreseeable consequences of delay and may include intangible losses which the Parties
agree may be difficult to ascertain, such as loss of public confidence in City and its contractors,
interference or loss of use of public facilities, and extended disruption to the public.
4. COMPENSATION
4.1 Maximum Compensation. City will pay Contractor for satisfactory performance of the Work
an amount that will based on actual costs but that will be capped so as not to exceed$ 8,500.00
("Contract Price"), for all of Contractor's direct and indirect costs, including all labor , materials,
supplies, equipment, taxes, insurance, bonds and all overhead costs.
4.2 Invoices and Payments. Contractor must submit an invoice on the first day of each month,
describing the Work performed during the preceding month, itemizing labor, materials, equipment and
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Public Works Contract $45,000/Rev. May 22, 2018
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any incidental costs incurred. Contractor will be paid 95% of the undisputed amounts billed within 30
days after City receives a properly submitted invoice. Any retained amounts will be included with
Contractor's final payment within 60 days of City's acceptance of the Work as complete.
5. INDEPENDENT CONTRACTOR
5.1 Status. Contractor is an independent contractor and not an employee of City . Contractor is
solely responsible for the means and methods of performing the Work and for the persons under this
employment. Contractor is not entitled to worker's compensation or any other City benefits.
5.2 Contractor's Qualifications. Contractor warrants on behalf of itself and its subcontractors that
they have the qualifications and skills to perform the Work in a competent and professional manner and
according to the highest standards and best practices in the industry.
5.3 Permits and Licenses. Contractor warrants on behalf of itself and its subcontractors that they
are properly licensed, registered, and/or certified to perform the Work as required by law, and have
procured a City Business License. Contractor shall possess a California Contractor's License in good
standing for the following classification(s): C-36 , which
must remain valid for the entire Contract Time.
5.4 Subcontractors. Only Contractor's employees are authorized to work under this Contract.
Prior written approval from City is required for any subcontractor, and the terms and conditions of this
Contract will apply to any approved subcontractor.
5.5 Tools, Materials and Equipment. Contractor will supply all tools, materials and equipment
required to perform the Work under this Contract.
5.6 Payment of Taxes. Contractor must pay income taxes on the money earned under this
Contract. Upon City's request, Contractor will provide proof of payment and will indemnify City for
violations pursuant to the indemnification provision of this Contract.
6. CHANGE ORDERS
Amendments and change orders must be in writing and signed by City and Contractor. Contractor's
request for a change order must specify the proposed changes in the Work, Contract Price, and
Contract Time. Each request must include all the supporting documentation, including but not limited
to plans/drawings, detailed cost estimates, and impacts on schedule and completion date.
7. ASSIGNMENTS; SUCCESSORS
Contractor shall not assign, hypothecate, or transfer this Contract or any interest therein, directly or
indirectly, by operation of law or otherwise, without prior written consent of City. Any attempt to do
so will be null and void. Any changes related to the financial control or business nature of Contractor
as a legal entity is considered an assignment of the Contract and subject to City approval, which shall
not be unreasonably withheld. Control means fifty percent (50%) or more of the voting power of the
business entity. This Contract is binding on Contractor, its heirs, successors and permitted assigns
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Public Works Contract $45,000 /Rev. May 22, 2018
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8. PUBLICITY/ SIGNS
Any publicity generated by Contractor for the Project during the Contract Time, and for one year
thereafter must credit City contributions to the Project. The words "City of Cupertino" must be
displayed in all pieces of publicity, flyers, press releases, posters, brochures, interviews, public service
announcements and newspaper articles. No signs may be posted or displayed on or about City
property , except signage required by law or this Contract, without prior written approval from the City.
9. SUBCONTRACTORS
9.1 Contractor must perform all the Work with its own forces, except that Contractor may hire
qualified subcontractors to perform up to 25 % of the Work, provided that each subcontractor
is required by contract to be bound by the provisions of this Contract. Contractor must provide City
with written proof of compliance with this provision upon request.
9.2 City may reject any subcontractor of any tier and bar a subcontractor from performing Work on
the Project, if City in its sole discretion determines that subcontractor's Work falls short of the
requirements of this Contract or constitutes grounds for rejection under Public Contract Code Section
4107. If City rejects a subcontractor, Contractor at its own expense must perform the subcontractor's
Work or hire a new subcontractor that is acceptable to City. A Notice of Completion must be recorded
within 15 days after City accepts the Work if the Contract involves work by subcontractors.
10. RECORDS AND DAILY REPORTS
10.1 Contractor must maintain daily reports of the Work and submit them to City upon request and
at completion of Project. The reports must describe the Work and specific tasks performed, the number
of workers, the hours, the equipment, the weather conditions, and any circumstances affecting
performance. City will have ownership of the reports, but Contractor will be permitted to retain copies.
10.2 If applicable, Contractor must keep a separate set of as-built drawings showing changes and
updates to the Scope of Work or the original drawings as changes occur. Actual locations to scale must
be identified for all major components of the Work, including mechanical, electrical and plumbing
work; HV AC systems; utilities and utility connections; and any other components City determines
should be included in the final drawings of the Project. Deviations from the original drawings must be
shown in detail, and the location of all main runs, piping, conduit, ductwork, and drain lines must be
shown by dimension and elevation.
10.3 Contractor must maintain complete and accurate accounting records of its Work, in accordance
with generally accepted accounting principles, which must be available for City review and audit, kept
separate from other records, and maintained for four years from the date of City's final payment.
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11. INDEMNIFICATION
11.1 To the fullest extent allowed by law, and except for losses caused by the sole and active
negligence or willful misconduct of City personnel, Contractor shall indemnify, defend, and hold
harmless City, its City Council, boards and commissions, officers, officials, employees, agents ,
servants, volunteers and consultants ("Indemnitees"), through legal counsel acceptable to City, from
and against any and all liability, damages , claims, stop notices, actions, causes of action , demands,
charges, losses and expenses (including attorney fees, legal costs and expenses related to litigation and
dispute resolution proceedings), of every nature arising directly or indirectly from this Contract or in
any manner relating to any of the following:
(a) Breach of contract, obligations, representations or warranties;
(b) Performance or nonperformance of the Work or of any obligations under the Contract by
Contractor, its employees, agents, servants, subcontractors or subcontractors;
( c) Payment or nonpayment by Contractor or its subcontractors or sub-subcontractors for Work
performed on or off the Project Site; and
(d) Personal injury , property damage, or economic loss resulting from the work or performance of
Contractor or its subcontractors or sub-subcontractors.
11.2 Contractor must pay the costs City incurs in enforcing this provision. Contractor must accept a
tender of defense upon receiving notice from City of a third-party claim, in accordance with California
Public Contract Code Section 9201. At City's request, Contractor will assist City in the defense of a
claim, dispute or lawsuit arising out of this Contract.
11.3 Contractor's duties under this entire Section are not limited to Contract Price, Workers '
Compensation or other employee benefits, or the insurance and bond coverage required in this
Contract. Nothing in the Contract shall be construed to give rise to any implied right of indemnity in
favor of Contractor against City or any other Indemnitee.
11.4 Contractor's payments may be deducted or offset to cover any money the City lost due to a
claim or counterclaim arising out of this Contract, a purchase order or other transaction.
12. INSURANCE
Contractor shall comply with the Insurance Requirements, attached and incorporated here as Exhibit
B. Contractor must provide satisfactory proof of insurance and maintain it for the Contract Time or
longer as required by City. City will not execute the Contract until City has approved receipt of
satisfactory certificates of insurance and endorsements evidencing the type, amount, class of operations
covered, and the effective and expiration dates of coverage. Failure to comply with this provision may
result in City, at its sole discretion and without notice, purchasing insurance at Contractor's expense,
deducting the costs from Contractor's compensation, or terminating the Contract.
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Public Works Contract $45,000 /Rev . May 22, 2018
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13. COMPLIANCE WITH LAWS
13.1 General Laws. Contractor shall comply with all laws and regulations applicable to this
Contract. Contractor will promptly notify City of changes in the law or other conditions that may affect
the Project or Contractor's ability to perform. Contractor is responsible for verifying the employment
status of employees performing the Work, as required by the Immigration Reform and Control Act
13.2 Labor Laws.
(a) Contracts of $1,000 or more are subject to the requirements of the California Labor Code,
including but not limited to:
(i) Prevailing wage laws under Labor Code Section 1775 , which require Contractor
to pay prevailing wages applicable in Santa Clara County for each craft,
classification , or type of worker needed to perform the Work , including health ,
pension and vacation. The prevailing wage rates are on file with the City
Engineer's office and are available online at http://www.dir.ca.gov/DLSR;
(ii) Apprenticeship requirements under Labor Code Section 1777 .5 for Contacts
$30,000 or more;
(iii) Maintain certified payroll records in accordance with Labor Code Sections 1776
and 1812, and electronically submit them to the Labor Commissioner as
required by the regulations of California, Department of Industrial Relations
("DIR");
(iv) Comply with DIR Monitoring, Enforcement and Registration requirements of
Labor Code Section 1725.5 .
(b) Contractor must compensate workers who are paid less than prevailing wages or required to
work more than a legal day's work. Contractor will also be required to pay City a penalty of
$ 200.00 per worker for each day of vio lation.
(c) As required by Labor Code Section 1861, by signing this Contract Contractor certifies as
follows: "I am aware of Labor Code Section 3700 which requires every employer to be insured
against liability for workers' compensation or to undertake self-insurance in accordance with
the provisions of that code, and I will comply with such provisions before commencing the
Work on this Contract."
13.3 Discrimination Laws. Contractor shall not discriminate on the basis of race , religious creed ,
color, ancestry, national origin, ethnicity, handicap , disability , marital status , pregnancy, age, sex,
gender, sexual orientation, gender identity, Acquired-Immune Deficiency Syndrome (AIDS) or any
other protected classification. Contractor shall comply with all anti-discrimination laws , including
Government Code Sections 12900 and 11135, and Labor Code Sections 1735, 1777 and 3077.5.
Consistent with City policy prohibiting harassment and discrimination, Contractor understands that
harassment and discrimination directed toward a job applicant, an employee, a City employee, or any
other person, by Contractor or Contractor's employees or sub-contractors wi ll not be tolerated.
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13.4 Conflicts of Interest. Contractor, its employees, subcontractors , servants and agents, may not
have, maintain or acquire a conflict of interest in relation to this Contract in violation of law , including
Government Code section l 090 and Government Code section 81000 and their accompanying
regulations. No officer, official , employee, consultant, or other agent of the City ("City
Representative") may have, maintain, or acquire a "financia l interest" in the Contract, as that term is
defined by state law , or in violation of a City ordinance or policy while serving as a City
Representative or for one year thereafter. Contractor, its employees , subcontractors, servants and
agents warrant they are not employees of City or have any relationship with City officials, officers or
employees that creates a conflict of interest. Contractor may be required to file a conflict of interest
form if it makes certain governmental decisions or serves in a staff capacity , as defined in section
18700 of the California Code of Regulations. Contractor agrees to abide by City rules governing gifts
to public officials and employees.
13.5 Remedies. Any violation of Section 13 constitutes a material breach and may result in City
suspending payments, requiring reimbursement, or terminating the Contract. City reserves all rights
and remedies under the law and this Contract, including seeking indemnification.
14. BONDS
For contracts of $25,000 or more, Contractor must obtain a payment bond and a performance bond,
each in the penal sum of 100% of the Contract Price, using the Bond Forms attached and incorporated
here as Exhibit C. Each bond must be issued by a surety admitted in California, with a financial rating
from A.M. Best Company of Class A-or higher, or as otherwise acceptable to City. If an issuing surety
cancels a bond or becomes insolvent, Contractor must provide a substitute bond from a surety
acceptable to City within seven calendar days after written notice from City. If Contractor fails to do
so , City may in its sole discretion and without prior notice, purchase bonds at Contractor's expense,
deduct the cost from payments due Contractor, or terminate the Contract. City will not execute the
Contract nor issue the NTP until the required bonds are submitted.
15. UTILITIES, TRENCHING AND EXCAVATION
15.1 Contractor must call the Underground Service Alert ("USA") 811 hotline and request marking
of utility locations before digging or commencing Work. For underground service alerts for street
lighting and traffic signal conduits, City's Service Center must be called at (408) 777-3269.
Government Code Section 4215 requires Contractor to notify City and Utility in writing if it discovers
utilities or utility facilities not identified in the Contract.
15.2 Pursuant to Government Code Section 7104, Contractor must stop work, notify City in writing ,
and wait for instructions if one of the conditions below is found at the worksite. City will work with
Contractor to amend the Contract or issue a change order if the discovered conditions materially
change the Work/Performance, Contract Time or Contract Price.
(a) Material believed to be hazardous waste under Health and Safety Code Section 25117 , and
which requires removal to a Class I, Class II, or Class III disposal site pursuant to law ;
(b) Subsurface or latent physical conditions at the Project worksite differing from those
indicated by information about the worksite made available to Contractor; and
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(c) Unknown physical conditions at the Project worksite of any unusual nature , materially
different from those ordinarily encountered and from those generally recognized as inherent
in the character of the Work.
15.3 For contracts $25 ,000 or higher that require excavation or involve trenches five feet or more in
depth , Contractor must submit a detailed plan for City approval , per Labor Code Section 6705 prior to
commencing work. The plan must show the design of shoring, bracing, sloping and other provisions
for worker protection from caving ground and other hazards. The protective system must comply with
all Construction Safety Orders. If the plan varies from shoring system standards, it must be prepared
by a registered civil or structural engineer.
16. URBAN RUNOFF MANAGEMENT
16.1 All Work must fully comply with federal , state and local laws and regulations concerning storm
water management. Contractor must avoid creating excess dust when breaking asphalt or concrete and
during excavation and grading. If water is used for dust control, Contractor will use only the amount of
water necessary to dampen the dust. Contractor will take all steps necessary to keep wash water out of
the streets , gutters and storm drains. Prior to the start of the Work, Contractor will implement erosion
and sediment controls to prevent pollution of storm drains , and must upgrade and maintain these
controls based on weather conditions or as otherwise required by City. These controls must be in place
during the entire Contract Time and must be removed at the end of construction and completion of the
Work. Such controls must include , but will not be limited to, the following requirements:
(a) Install storm drain inlet protection devices such as sand bag barriers , filter fabric fences, and
block and gravel filters at all drain inlets impacted by construction. During the annual rainy
season , October 15 through June 15 , storm drain inlets impacted by construction work must be
filter-protected from onsite de-watering activities and saw-cutting activities. Shovel or vacuum
saw-cut slurry and remove from the Work site;
(b) Cover exposed piles of soil or construction material with plastic sheeting. Store all construction
materials in containers;
( c) Sweep and remove all materials from paved surfaces that drain to streets , gutters and storm
drains prior to rain and at the end of each work day. When the Work is completed, wash the
streets, collect and dispose of the wash water off site in lawful manner;
(d) After breaking old pavement, remove debris to avoid contact with rainfall/runoff;
( e) Maintain a clean work area by removing trash , litter, and debris at the end of each work day
and when Work is completed. Clean up any leaks , drips , and other spills as they occur.
16.2 These requirements must be used in conjunction with the California Stormwater Quality
Association and California Best Management Practices Municipal and Construction Handbooks , local
program guidance materials from municipalities, and any other applicable documents on stormwater
quality controls for construction. Contractor's failure to comply with this Section will result in the
issuance of noncompliance notices , citations , Work stop orders and regulatory fines .
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Public Works Contract $45 ,000 /Rev . May 22, 2018
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17. PROJECT COORDINATION
City Project Manager. City assigns Ken Tanase as
the City representative for all purposes under this Contract, with authority to require compliance with
the Scope of Work. City may substitute Project Managers at any time and without prior notice to
Contractor.
Contractor Project Manager. Subject to City approval, Contractor assigns Johnny Marez
-------------------as its single representative for all purposes under
this Contract, with the responsibility to ensure progress with the Work. Contractor's Project Manager
is responsible for coordinating and scheduling the Work and must regularly update the City Project
Manager about the status and any delays with the Work, consistent with the Scope of Work. Any
substitutions must be approved in writing by City.
18. ABANDONMENT AND TERMINATION
18.1 City may abandon or postpone the Project or parts therefor at any time. Contractor will be
compensated for satisfactory Work performed through the date of abandonment and will be given
reasonable time to close out the Work. With City's pre-approval in writing, the time spent in closing
out the Work will be compensated up to 10% of the total time expended in performing the Work.
18.2 City may terminate the Contract for cause or without cause at any time. Contractor will be paid
for satisfactory Work rendered through the termination date and will be given reasonable time to close
out the Work.
18.3 Final payment will not be made until Contractor delivers the Work and provides records
documenting the Work, products and deliverables completed. Nothing in the Section below is intended
to delay, abridge or bar City's right under this Section.
19. GOVERNING LAW, VENUE AND DISPUTE RESOLUTION
This Contract is governed by the laws of State of California. Venue for any legal action shall be the
Superior Court of the County of Santa Clara, California. The dispute resolution procedures of Public
Contract Code Section 20104, incorporated here by reference, apply to this Contract and Contractor is
required to continue the Work pending resolution of any dispute. Prior to filing a lawsuit, Contractor
must comply with the claim filing requirements of the California Government Code. If the Parties elect
arbitration, the arbitrator's award must be supported by law and substantial evidence and include
detailed written findings of law and fact.
20. ATTORNEY FEES
If City initiates legal action, files a complaint or cross-complaint, or pursues arbitration, appeal, or
other proceedings to enforce its rights or a judgment in connection with this Contract, the prevailing
party will be entitled to reasonable attorney fees and costs.
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21. SIGNS/ADVERTISEMENT
No signs may be displayed on or about City's property, except signage which is required by law or by
the Contract, without City's prior written approval as to size, design and location.
22. THIRD PARTY BENEFICIARIES
There are no intended third party beneficiaries of this Contract.
23. WAIVER
Neither acceptance of the Work nor payment thereof shall constitute a waiver of any contract
provision. City waiver of any breach shall not constitute waiver of another provision or breach .
26. WARRANTY
Contractor warrants that materials and equipment used will be new, of good quality, and free from
defective workmanship and materials, and that the Work will be free from material defects not intrinsic
in the design or materials. All Work, materials and equipment should pass to City free of claims, liens
or encumbrances. Contractor warrants the Work and materials for one year from the date of City's
acceptance of the Work as complete ("Warranty Period"), except when a longer guarantee is provided
by a supplier, manufacturer or is required by this Contract. During the Warranty Period, Contractor
will repair or replace any Work defects or materials, including damage that arises from Contractor's
Warranty Work, except any wear and tear or damage resulting from improper use or maintenance.
27. ENTIRE CONTRACT
Th is Contract and the attachments, documents, and statutes attached, referenced, or expressly
incorporated herein, including authorized amendments or change orders constitute the final and
complete contract between City and Contractor with respect to the Work and the Project. No oral
contract or implied covenant will be enforceable against City. If any attachment or incorporated
provisions conflict or are inconsistent with the terms of this Contract, the Contract terms will control.
28. SEVERABILITY IP ARTIAL INVALIDITY
If a court finds any term or provision of this Contract to be illegal, invalid or unenforceable, the legal
portion of said provision and all other contract provisions will remain in full force and effect.
28. SURVIVAL
The contract provisions which by their nature should survive the Contract or Completion of Project,
including without limitation all warranties, indemnities, payment obligations, insurance and bonds,
shall remain in full force and effect after the Work is completed or Contract ends.
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29. INSERTED PROVISIONS
Each provision and clause required by law to be inserted in this Contract will be deemed to be included
and will be inferred herein. Either party may request an amendment to cure mistaken insertions or
omissions of required provisions.
30. CAPTIONS
The captions, titles, and headings in this Contract are for convenience only and may not be used in the
construction or interpretation of the Contract or for any other purpose.
31. COUNTERPARTS
This Contract may be executed in counterparts, each of which is an original and all of which taken
together shall form one single document.
20. NOTICES
A ll notices, requests, and approvals must be sent in writing to the persons below and will be
considered effective on the date of personal delivery, the date confirmed by a reputable overnight
delivery service, on the fifth calendar day after deposit in the United States Mail, postage prepaid,
registered or certified, or the next business day following electronic submission:
To City of Cupertino:
10300 Torre Avenue, Cupertino CA 95014
Attention: Ken Tanase -------------
Copy to: Carl Valdez
Email: kent@cupertino.org
30. VALIDITY OF CONTRACT
To Contractor:
J Marez Ocean Plumbing
Attention: Johnny Marez -------------
Copy to: -------------Em ail: oceanplum@msn.com
This Contract is valid and enforceable only if (a) it complies with the purchasing and contract
provisions of Cupertino Municipal Code Chapters 3.22 and 3.23, (b) is signed by the City Manager or
an authorized designee, and (c) is approved for form by the City Attorney's Office.
32. EXECUTION
The persons signing below warrant they have the authority to enter into this Contract and to legally
bind their respective Parties. If Contractor is a corporation , signatures from two officers of the
corporation are required pursuant to California Corporations Code Section 313.
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IN WITNESS WHEREOF, the parties have caused this Co ntract to be executed as of the Execution
Date first above written.
CONTRACTOR J Marez Ocean Plumbing
Sole Proorietorshio/Ind
By: ~Nl!4c~
Title: Owner ~
Signature D~~ ?5;;;:-
0~ 1 / zo I 8
CITY OF CUPERTINO,
a Municipal Corporation
Title: Director of Public Works
Signature Date: 6;;/ ( 'f ( ( ~ r 7
APPROVED AS TO FORM: 'f<;!-?!j jJ g -/l '1 -I j
~() v<lrurr ~-g _ }7 -19
Cu 1tino City Attorney
l}-,t.,t_J-, on . g 1-. i-3,o
r O it) l ~ , w2)
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Public Works Contract $45,000 /Rev. May 22, 2018
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EXH I BIT 11 A11
PH; 925-597-3227 Plumbing Bid #154 July 22 2018
J.MAREZ / OCEAN PLUMBING CONSTRUCTION
5508 Round Tree Dr #0 Concord, Ca 94521 Calif Lie; #695831 -1994
To;
C ity Of Cupertino
10300 Torre Ave
Cupertino, Ca 95014
Job;
Quinlan Community Center
10185 N Stel!ing Rd
Cupe11ino, Ca 95014
Job Description; To remove & replace 2-existing water drinking fountain with 2-new Halsey Taylor HydroBoost,
bottle filling station & Single ADA cooler,
#1} To perform & provide 2 new Halsey Taylor HydroBoost, bottle filling station & single ADA cooler.
#2) To provide & install new modification of existing in -wall plumbing sewer drain & water line to accommodate
new water drinking fountain.
#3} To perform & provide Sheet rock repairs.
#4) To perform & provide all additional plumbing materials in order to completed job.
#5)
Total Bid Price $8'500.00
Than k's For The Opportunity In Working With You;
J. Marez/ Ocean Plumbing
Johnny Marez / July 22 2018
PUBLIC WORKS CONSTRUCTION CONTRACTS
Small Projects -$45,000
Insurance Requirements: Exhibit B
Contractor shall procure and maintain for the duration of the contract, and for jive years following the completion of
the Project, insurance against claims for injuries to persons or damages to property which may arise from or in
connection with the performance of the work hereunder by Contractor, its agents, representatives, employees or
subcontractors.
MINIMUM SCOPE AND LIMIT OF INSURANCE
Coverage shall be at least as broad as:
~ Commercial General Liability (CGL): Insurance Services Office (ISO) Form CG 00 01 covering CGL on an
"occurrence" basis, written on a comprehensive general liability form, and must include coverage for liability
~ arising from Contractor's or Subcontractor's acts or omissions, including Contractor's protected coverage,
'V blanket contractual, products and completed operations, vehicle coverage and employer's non-ownership liability
(\.).. coverage , with limits of at least $2,000,000 per occurrence. The CGL policy must protect against any and all
;()'\ ' liability for personal injury, death, property damage or destruction, and personal and advertising injury. If a general
ggregate limit applies, either the general aggregate limit shall apply separately to this project/location (ISO CG
25 03 or 25 04) or the general aggregate limit shall be twice the required occurrence limit.
a. It shall be a requirement under this agreement that any available insurance proceeds broader than or in excess
of the specified minimum insurance coverage requirements and/or limits shall be made available to the
Additional Insured and shall be (1) the minimum coverage/limits specified in this agreement; or (2) the broader
coverage and maximum limits of coverage of any insurance policy, whichever is greater.
b. Additional Insured coverage under Contractor's policy shall be "primary and non-contributory," will not seek
contribution from City's insurance/self-insurance, and shall be at least as broad as ISO CG 20 01 04 13
c. The limits of insurance required may be satisfied by a combination of primary and umbrella or excess
insurance, provided each policy complies with the requirements set forth in this Contract. Any umbrella or
excess insurance shall contain or be endorsed to contain a provision that such coverage shall also apply on a
primary and non-contributory basis for the benefit of City before the City's own insurance or self-insurance
shall be called upon to protect City as a named insured.
2. Automobile Liability: ISO Form CA 00 01 covering any auto (Code 1), or if Contractor has no owned autos, then
hired autos (Code 8) and non-owned autos (Code 9), with limit no less than $1,000,000 per accident for bodily
injury and property damage.
V3. \f~rkers' Compensation: As required by the State of California, with Statutory Limits, and
· ~fuployer's Liability Insurance of no less than $1,000,000 per accident for bodily injury or disease, or as otherwise
required by statute. If Contractor is self-insured, Contractor must provide a Certificate of Permission to Self-Insure,
dul~thorized by the DIR .
. Dsi NI A if box checked ( c_ontra_ctor provides written verification it has no employees).
4. Pro~ional Liability with limits no less than $1,000,000 per occurrence or claim, and $2,000,000 aggregate.
~ NI A if box checked (Contract is not design/build).
5. Builder's Risk. Course of Construction insurance utilizing an "All Risk" (Special Perils) coverage form , with
limi~ual to the completed value of the project and no coinsurance penalty provisions.
~ NI A if box checked (Project does not involve construction or improvements/installations to property).
Insurance Requirements/or Construction Contracts -$45,000 Version: Nov 2017
\/
6 . Contractors' Pollution Legal Liability and/or Asbestos Legal L iability and/or Errors and Omissions with limits
no less than $1,000,000 per occurrence or claim, and $2,000,000 policy aggregate .
:gf NIA if bo x checked (Project does not involve environmental hazards).
If Contractor maintains broader coverage and/or higher limits than the minimums shown above , City re quires and
shall be entitled to the broader coverage and/or higher limits maintained by the contrac tor. Any available insurance
proceeds in excess of the specified minimum limits o f insurance and coverage shall be available to the City.
Self-Insured Rete1itions. Self-insured retentions must be declared to and approved by City . At City's option , either:
(1) Contractor shall cause the insurer to reduce or eliminate self-insured retentions as respects City, its officers,
officials, employees, and volunteers; or (2) Contractor shall provide a financial guarantee satisfactory to City
guaranteeing payment of losses and related investigations, claim administration , and defense expenses. The policy
language shall provide, or be endorsed to provide, that the self-insured retention may be satisfied by either the named
insured or the City .
OTHER INSURANCE PROVISIONS
The insurance policies are to contain, or be endorsed to contain, the following provisions:
Additional Insured Status
The City of Cupertino, its City Council, officers, officials, employees, agents, servants and volunteers are to be covered
as additional insureds on the CGL policy with respect to liability arising out of the Services performed by or on behal f
of Contractor including materials, parts, or equipment furnished. Endorsement of CGL coverage shall be at least as
broad as ISO Form CG 20 l O 11 85 or if not available, through the addition of both CG 20 l 0, CG 20 26, CG 20 3;3,
or CG 20 38; and CG 20 37 if a later edition is used.
Primary Co verage
For any claims related to this Project, Contractor's insurance coverage shall be "primary and non-contributory" and
at least as broad as ISO CG 20 01 04 13 with respect to City, its officers, officials, employees and volunteers, and shall
not seek contribution from City's insurance. If the limits of insurance are satisfied in part by Umbrella/Excess
Insurance, the Umbrella/Excess Insurance shall contain or be endorsed to contain a provision that such coverage shall
also apply on a "primary and non-contributory" basis for the benefit of City.
Notice of Cancellation
Each insurance policy required shall provide that coverage shall not be canceled, except with notice to the City. Each
certificate of insurance must state that the coverage afforded by the policy is in force and will not be reduced, cancelled
or allowed to expire without at least 30 days advance written notice to City, unless due to non-payment of premiums,
in whic h case ten days advance written notice must be provided to City. Such notice must be sent to City via certified
mail and addressed to the attention of the City Manager.
Builder's Risk
Contractor may submit Builder's Risk insurance in the form of Course of Construction coverage, which shall name
the City as a loss payee , as its interest may appear. The Builder's Risk policy must be issued on an occurrence basis,
for all-risk coverage on a 100% completed value basis on the insurable portion of the Project, with no coinsurance
penalties, and for the benefit of City. If the Project does not involve new or major reconstruction, City may elect, acting
in its sole discretion , to accept an Installation Floater policy instead of Builder's Risk. For such projects, the Property
installation Floater shall include improvement, remodel , modification, alterat ion, conversion or adjustment to existing
buildings, structures, processes, machinery and equipment, and shall provide property damage coverage for any
building, structure, machinery or equipment damaged, impaired, broken, or destroyed during the performance of the
Work, including during transit, installation, and testing at the City's site.
Insurance Require ments for Co nstr uction Co ntracts -$45,000 Version: Nov 2017
2
Wai ver of S ubrogation
Each required pol icy must include an endorsement providing that the carrier agrees to waive any right of subrogation
it may have again st City. Contractor agrees to waive rights o f subrogation which any insurer of Contractor may acquire
1 I !\,.§"om Co ntractor by virtue of the pa yment of any loss . Contractor agrees to obtain any endorsement that may be
I\\ 'l:P'necessa ry to affec t this wa iver of subrogat ion. The Workers' Compensation policy shall be endorsed with a waiver of
V subrogation in favor of the City for all work performed by the Contractor, its employees, agents and subcontractors .
A ccep tability of Insurers Vb.h-~ g,,-,-5 l ~'/ flP
Insurance must be issued by insurers acceptable t ity and licensed to do business in the State of California, and each
insurer must have an A.M. Best's financial strength rating of"A" or better and a financial size rating of"VII" or better.
Verification of Co verage
Contractor shall furnish the City with original certificates and amendatory endorsements, or copies of the applicable
insurance language, effecting coverage required by this contract. All certificates and endorsements are to be received
and approved by the City before work commences . The City reserves the right to require complete, certified copies
of all required insurance policies, including endorsements, required by these specifications, at any time .
Subcontracto rs
Contractor shall require and verify t hat all subcontractors maintain insurance meeting all the requirements stated
herein, and Contractor shall ensure that City is an addit ional insured on insurance required from subcontractors. For
CGL coverage subcontractors shall provide coverage with a form at least as broad as CG 20 38 04 13.
Surety Bonds
As required by Contract and described in the Contract Documents . The Payment and Performance Bonds shall be in a
sum equal to the Contract Price . If the Performance Bond provides for a one-year warranty a separate Maintenance
Bond is not necessary . If the warranty period specified in the Contract is for longer than one year a Maintenance Bond
equal to 10% of the Contract Price is required. Bonds shall be duly executed by a responsible corporate surety,
authorized to issue such bonds in the State of California and secured through an authorized agent with an office in
California .
Special Risks or Circ umstances
City reserves the right to modify these requirements, based on the nature of the risk, prior experience, insurer, coverage,
or other circumstances.
Insurance Requirements for Construction Contracts -$45,000 Version: Nov 201 7
3
ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDNYYY)
~ 3/8/2018
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(les) 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 CON 1Ai;1 Pac ifi c Pro's In surance NAME :
Pacifi c Pro's In surance Age ncy wg~o Extl : 71 4-909-075 5 I FAX {AJC Nol :
5200 Warn er Av e, St e. 102 ~~cf~ss: kim@pacificpr os in s.co m
INSURER{S)AFFORDING COVERAGE NAIC #
Huntington Beac h CA 92649-40 06 INSURER A: Am Trust Intl Und, Ltd -AAl 780074
I NSURED INSURER B : Natio nal Uni o n fir e In s Co of Pitts 19445
Jo hnny Ma rez INSURER c : lntegon National Insurance Co 29742
DBA: J M arez Ocea n Plumbing INSURERD :
55 08 Ro undtree Dr Apt D INSURERE :
Co nco rd CA 945 21-392 1 INSURERF :
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 . NOTW ITHSTANDING ANY REQUIREMENT , TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIF ICATE MAY BE ISSUED OR MAY PERTAIN , THE INSURANCE AFFORDED BY THE POLICIES DESCR IBED HEREIN IS SUBJECT TO ALL THE TERMS ,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES . LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS .
INSR TYPE OF INSURANCE ADDL 'SUBR ,&~lc\%Y~ ~~lt\ii~Yl LIMITS LTR '"'"n l\11/\ffl POLICY NUMBER
X COMMERCIAL GENERAL LIABILITY EACH OCCURR ENCE $ 1,000,000 V
-D CLAIMS-MADE [Z] OCCUR
UAMAGE TO Kt:N I t:U
PR EM ISES CE a occu rrence l $ 100,000
-XNl 07 964 500 \/"
MED EXP (Any one pe rs on) $ 5,000
A X X 02/07 /2 018 02/07 /201 <jl PERSO NAL & ADV IN JJRY $ 1,000,000 --
GEN 'L AGG RE GATE LI M IT APPLIES PER : G ENERAL AGG RE GATE $ 2,000,000 V
fXj PO LI CY D iB,:: OLoc PRO DU CTS -COMP/O P AGG $ 2,000,000 r~
OTHER : $ \
AUTOMOBILE LIABILITY -(E~~~d~~l f lNGLE LI MI T $ 1,000,000 v '
AN Y AUTO ~ODIL Y INJJRY (Per pe rson ) $ -O'M'lED X SC HEDU LED 2006 10210 2 v 02/07 /201 .,... C X X 02/07/2018 BODIL Y INJJRY (Per accident ) $ I AUTOS ONLY -~~i~gv\NED X H IRED PROPERTY DA MAGE $ I AUTO S ONLY ~ AUTO S ON LY CPer acci dent!
IY -' / -,
UMBRELLA LIAB H OCCUR Ef.CH OCCUR REN CE I $ 2,000,00~
8 x EXCESS LIAB CLAIM S-MADE EBUOl 5630241 02/07/2018 02/07/201 9 L 'AGGREGATE l $ 2,000,000 J
DED I I RETENT ION $ \.. $ /
WORKERS COMPENSATION I PER I I OTH-
AND EMPLOYERS' LIABILITY STATUTE ER
Y/N
ANYPROPR IETOR/PARTNER/EXECUTI VE D N/A E.L. EACH ACC IDEN T $
OFF I CERIMEMBER EXC LU DE D?
(Mandatory In NH) E.L. DI SEASE -EA EMPLO YEE $
g~;t~:'f5n8~ ~'}do"PER AT IONS be lo w E.L. DISEASE -POL ICY LI M IT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is r equired)
V
RE: ln sured 's Ope ratio ns in Califo rni a
/C ity of Cupertino, including its City Co uncil, boa rd s and co mmi ss io ns, o ffi ce rs, offici als, ag ents, e mploye es, co n sultants and v oluntee rs are additio nal insured w ith
res pects t o Ge neral Li ability and Auto. Prim ary Wordin g and Waiv er of Subr oga ti o n applies as pe r the attac hed endo rse ments.
"S ubj ect to th e po licy t erm s, ex clu sio ns & co nditio ns·•
CERTIFICATE HOLDER CANCELLATION
City of Cupertino SHOULD ANY OF TH E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREO F, NOTICE WILL BE DELIVERED IN
ken t@cupertino.org ACCORDANCE WITH TH E POLICY PROVISIONS.
10555 Mary Avenue
Cupertino CA 95014 AUTHORIZED REPRESENTATIVE
Rh o nda Ho lt
I
@ 1988-2015 ACORD CO RPORATION. All rights re se rved.
A CORD 25 (2016/03) The ACORD name a n d logo are registe red marks o f ACORD
Total 12 Month Policy Premium $1,157.76
Discounts Applied
Policy Level
Important Notice
Business Experience
Package Discount
Our Company offers multiple programs in California to eligible insureds. A lower rate or better coverage may be available
to you . If you are a member of an association and would like your policy reviewed to assure you are receiving the best
possible rate, please contact your agent or our call center at 1-877-468-3466.
Additional Policy Information
Additional Insured
City Of Cupertino
10555 Mary Ave, Cupertino, CA 95014
Tier 8
Disclosure of Possible Additional Charges
The amounts below are authorized for use in this state . However, they are only charged if they apply to your policy.
Acquisition Expense $20.00
Additional Insured Charge $25.00
Additional Insured Charge -Blanket
CA Vehicle Assessment and Fraud
Fee
$1,000.00
$1 .76
Cancellation Charge
Convenience Fee
Federal Filing Fee
Form E Filing Charge
FR Filing Charge
Late Charge
Nonsufficient Funds Charge
$10.00
$5 .00
$50.00
$50.00
$50.00
$10.00
$25.00
Reinstatement Charge -Federal Filing $50.00
Reinstatement Charge -No Federal $20.00
Filing
UIIA Fee $50.00
Waiver of Subrogation
Waiver of Subrogation -Blanket
Forms and Endorsements
Endorsement Edition
10141 01012014
10146 01012014
10149 01012014
10150 01012014
10379 01012014
11332 07012014
10039CA (06012014)
$25.00
$1,000 .00
ADDITIONAL INSURED COVERAGE
HIRED AUTO COVERAGE
NON-OWNERSHIP LIABILITY COVERAGE
NUCLEAR ENERGY LIABILITY EXCLUSION
WAIVER OF SUBROGATION
COMMERCIAL AUTO POLICY
Authorized Signature
lntegon National Insurance Company
This Endorsement Applies Only If
Form Number 10141 (01012014) Appears on the Declarations Page .
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED
All the provisions of this Policy apply except as modified by this endorsement
Any coverage afforded under PART A> LIABILITY COVERAGE of this Policy for a covered auto shall also apply to the
individual or organization listed on the Declarations Page as an additional insured subject to the following provisions:
1. We will pay compensatory damages for which the additional insured is legally liable due to bodily injury or property
damage caused by an accident arising out of the operation of an auto covered under PART A > LIABILITY
COVERAGE. We will pay under this endorsement only if those damages arise out of the acts or omissions of an
insured as defined under PART A and then only to the extent of that liability.
2. The designation of an additional insured on the Declarations Page shall not increase our limits of liability under
PART A of this Policy .
3. We also agree with you that insurance provided by this agreement will be excess insurance over any other applicable
insurance, self-insurance or bond .
4. All language in the LIMITS OF LIABILITY section of this Policy referencing a permissive operator is deleted.
lntegon National Insurance Company
This Endorsement Applies Only If
Form Number 10379 (01012014) Appears on the Declarations Page.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF SUBROGATION
All /isior.:is-of his P ~licy apply except as modified by this endorsement.
P ~llcy No.: 2006102102
This'°eA docs..emer.:i t-is-i~ to: Johnny Marez
GENERAL PROVISIONS
OUR RIGHT TO RECOVER PAYMENT section will not apply to:
City Of Cupertino
10555 Mary Ave
Cupertino, CA 95014
Effective: 2/7/2018 (12:01 A.M .)
POLICY NUMBER: XN10796~ COMMERCIAL GENERAL LIABILITY
NXGL 189 0511
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSUREDS -
OWNERS, LESSEES OR CONTRACTORS
This endorsement modifies insurance provided under the following :
COMMERCIAL GENERAL LIABILITY COVERAGE PART
Policy Number: XN107964500 Endorsement Effective: 02/07/18 12:01 a.m.
Named Insured: Counter Signed By:
JOHNNY MAREZ
J MAREZ OCEAN PLUMBING "ry {(t, ;x, ·'\ ,'··~
'i' ····~"-·" .
l_;;;0, . · .. ·. ::j.j
. . . ~. . .~ . .
SCHEDULE
Name of Person or Organization:
Any person or organization that the named insured is obligated by virtue of a written contract or
Agreement to provide insurance s uch as is afforded by this policy.
Location:
(If no entry appears above , information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
A . Section II -Who Is An Insured is amended to include as an insured the person or organization shown
in the Schedule, but only to the extent that the person or organization shown in the Schedule is held
liab le for your acts or omiss ions arising out of your ongoing operations performed for that insured.
B. With respect to the insurance afforded to these additional insureds, the follow ing exclusion is added:
2. Exclusions
This insurance does not apply to "bodi ly injury" or "property damage" occurring after:
(1) All work, inc luding materials, parts or equipment furnished in connection with such work, on
the project (other than services , maintenance or repairs) to be performed by or on behalf of
the additional insured(s) at the site of the covered operations has been completed: or
(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. The words "you " and "your" refer to the Named Insured shown in the Declarations.
NX GL 189 05 11 Page 1 of 2
Includes copyrighted material of Insurance Services Office, Inc., with its permission
COIVIVERCIAL GENERAL LIABILITY
NX GL 189 0511
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
D. The following a-e added to SECTION V -DEANITIONS:
''Your work" means work or operations ~ormed by you or on your behalf, and materials, parts or
equipment furnished in connection with such work or operations.
E. Toe following a:lditional puviSions appy to any entity that is an insured by the terms of this
endorsement:
1. PrimaryWording
With respect to the Third Party sho\M1 above, this insurance is primary and non-contril:l.Jting. Any
and all other valid aid collectalje insurance available to sud1 Third Party in respect of wok
perfonned by you underwritten caitractual agreements with said Third Party fa-loss CO\A3f'ed by
this policy, shall in no instance be caisidered as primay, CCrinsurance, a-cootributing inst.ranee.
Rather, any such other insurance shall be caisidered excess <JI/er and above the insi..rance
i,:rovided by this policy.
2. Waiwr of &Jtroaation
If required by written contract a-agreement: We waive any right of recovery we may have against
an entity that is an additional insured per the terms of this endorsement because of payments we
make for injury or darlage arising out of "you work'' done under a contract with that person or
organization.
NXGL 189 0511 Page 2of2
Includes copyrighted material of lnsurarce Services Office, Ire., with its penniSSion
v
Poli~O
Insured Name: J MAREZ OCEAN PLUMBING
COMMERICAL GENERAL LIABILITY
CG 20 3707 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -
COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Additional Insured Person(s) or Location and Description of Completed
Organization(s): Operations
CITY OF CUPERTINO, ITS OFFICERS, MISC PLUMBING WORK ON THEIR BUILDINGS -
OFFICIALS, AGENTS AND EMPLOYEES, HE IS DOING THE WORK
VARIOUS LOCATIONS THROUGHOUT
10555 MARY AVENUE, CUPERTINO CA 95014 CUPERTINO, CA
Information required to complete this Schedule, 1f not shown above, will be shown 1n the declarations
Section II -Who is an Insured is amended to include as an additional insured the person(s) or
organization(s) shown in the Schedule, but only w ith respect to liability for "bodi ly injury" or "Property
damage" caused, in whole or in part, by "your work" at the location designated and described in the
schedule of this endorsement performed for that additional insured and included in the "products-
completed operations hazard".
CG 20 37 07 04 Copyright lso Properties , Inc .. 2004
In sured
Page 1 of 1
National General >)
Auto, Home & Heal th In surance
Policy Number:
Named Insured:
PO Box 3199 • Wnston Salem , NC 27102-3199 Johnny Marez
OBA J MAREZ OCEAN PLUMBING
Policy Period: 12:01 A.M.
JOHNNY MAREZ
OBA J MAREZ OCEAN PLUMBING
APTD
5508 ROUNDTREE DR
CONCORD CA 94521
2/7/2018 -2/7/2019
Date of Notice:
Policy Underwritten By:
lntegon National
Insurance Company
2/8/2018
24 Hour Claim Reporting: 1-800-468-3466
For Policy Information: 1-877-468-3466
www.MyNatGenPolicy.com
Your Agent:
Pacific Pro's Insurance Agency
9199 Cockatoo Ave
Fountain Valley CA 92649
(714) 909-0755
CA COMMERCIAL VEHICLE DECLARATIONS PAGE
Endorsement Effective 2/8/2018
The following changes were made to your policy -Coverage(s) Updated
Drivers, Employees and Household Residents
#1 Johnny Marez
Driver Status License #
Owner Driver XXX0180
Lie state
CA
Date of Birth Gender
6/21/1958 Male
Insured Vehicle(s) and Schedule of Coverages
Marital Status Driver Pts
Single 0
Yrs. Licensed
43
#1 2004 GMC SIERRA C2500 HEAVY DUTY VIN : Usage: Business Radius : 200
Garaging Location:
Policy Coverage Level
Coverages Provided
Bodily Injury/ Property Damage -
Combined Single Limit
Medical Payments
Uninsured/ Underinsured Motorist
Combined Single Limit
Additional Policy Coverages
Hired Auto
Non-Ownership Liability
1 GTHC24U64E378836-Use Only
G8A425
94521
Schedu ledAuto
Limits/Deductibles
$1,000,000 Combined Single Limit
$1,000 Each Person/ Each Accident
$500,000 Combined Single Limit
Total for this Vehicle
Limits/Deductibles
$1,000,000 Combined Single Limit
$1 ,000 ,000 Combined Single Limit
Combined Vehicle Premium
Combined Policy Coverages Premium
Acquisition Expense
Additional Insured Charge
CA Vehicle Assessment and Fraud Fee
Total 12 Month Policy Premium
10039CA (06012014)
Premium
$738.00
$6 .00
$125 .00
$869.00
Premium
$128.00
$89.00
$869.00
$217.00
$20.00
$25.00
$1 .76
$1,132.76
Discounts Applied
Policy Level
Business Experience
Package Discount
Important Notice
Our Company offers multiple programs in California to eligible insureds. A lower rate or better coverage may be available
to you. If you are a member of an association and would like your policy reviewed to assure you are receiving the best
possible rate, please contact your agent or our call center at 1-877-468-3466.
Additional Policy Information
Additional Insured
City Of Cupertino
10555 Mary Ave, Cupertino, CA 95014
Tier 8
Disclosure of Possible Additional Charges
The amounts below are authorized for use in this state . However, they are only charged if they apply to your policy.
Acquisition Expense $20.00
Additional Insured Charge $25 .00
Additional Insured Charge -Blanket $1,000 .00
CA Vehicle Assessment and Fraud $1 .76
Fee
Cancellation Charge
Convenience Fee
Federal Filing Fee
Form E Filing Charge
FR Filing Charge
Late Charge
Nonsufficient Funds Charge
Reinstatement Charge -Federal Filing
Reinstatement Charge -No Federal
Filing
$10.00
$5.00
$50.00
$50.00
$50.00
$10.00
$25.00
$50.00
$20.00
UIIA Fee
Waiver of Subrogation
Waiver of Subrogation -Blanket
Forms and Endorsements
Endorsement
10141
10146
10149
10150
Edition
01012014
01012014
01012014
01012014
10039CA (06012014)
$50.00
$25.00
$1,000 .00
ADDITIONAL INSURED COVERAGE
HIRED AUTO COVERAGE
NON-OWNERSHIP LIABILITY COVERAGE
NUCLEAR ENERGY LIABILITY EXCLUSION
11332 07012014 COMMERCIAL AUTO POLICY
Authorized Signature
10039CA (06012014)
lntegon National Insurance Company
This Endorsement Applies Only If
Form Number 10141 (01012014) Appears on the Declarations Page.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED
All the provisions of this Policy apply except as modified by this endorsement.
Any coverage afforded under PART A> LIABILITY COVERAGE of this Policy for a covered auto shall also apply to the
individual or organization listed on the Declarations Page as an additional insured subject to the following provisions:
1. We will pay compensatory damages for which the additional insured is legally liable due to bodily injury or property
damage caused by an accident arising out of the operation of an auto covered under PART A > LIABILITY
COVERAGE. We will pay under this endorsement only if those damages arise out of the acts or omissions of an
insured as defined under PART A and then only to the extent of that liability.
2. The designation of an additional insured on the Declarations Page shall not increase our limits of liability under
PART A of this Policy .
3. We also agree with you that insurance provided by this agreement will be excess insurance over any other applicable
insurance, self-insurance or bond.
4. All language in the LIMITS OF LIABILITY section of this Policy referencing a permissive operator is deleted.
State of California
County of Santa Clara
City of Cupertino
Contractor/Consultant Affidavit of No Employees
I, the undersigned, declare as follows:
I am an independent contractor and the owner of ~Ao.re.Z-keo...u ~&rA7iio
I wish to enter into a services contract with the City of Cupertfuo. I am fully aware of the provisions
of section 3700 of the California Labor Code, which requires every employer to provide Workers'
Compensation coverage for employees in accordance with the provisions of that Code. I am also
aware that I must provide proof of workers' compensation insurance to the City of Cupertino for any
and all employees I may have, pursuant to Section 12 of the City of Cupertino's contract.
I hereby certify that I do not have any employees nor will I have any employees working for me or
my business during the term of any service contract with the City of Cupertino. I am not required to
have Workers' Compensation insurance.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true
and correct.
Executed on this O 'I day of A <A Q-California.
SIGNATURE
Revised 1.05.18
Declaration of Sole Proprietorship
DECLARATION AND ADDENDUM TO ALL CQNTRACTS ENTERED INTO OR BID
AWARDED TO: it&t.r,;;z./0£(?:W ~.oj hereinafter "Organization"
For the purpose of inducing the City of Cupertino ("City") to enter into any contracts with
Organization, or to go forward with any contracts awarded to Organization, I declare as
follows:
I am the authorized representative of Organization, an independent contractor for the purposes
of workers' compensation and labor laws in the State of California. This Organization will hire
no employees for work required for any bid awarded or any contract entered into with the City.
All work required will be performed personally and solely by me.
If the Organization hires employees to perform this contract or any portion thereof, the
Organization shall obtain workers' compensation insurance and provide proof of such coverage
to the City.
If the Organization hires a subcontractor to perform this contract or any portion thereof, and the
subcontractor has employees, then the Organization shall require its subcontractor to obtain
workers' compensation insurance coverage. In the alternative, the Organization shall obtain
workers' compensation insurance coverage on behalf of the subcontractor's employees.
This document constitutes a declaration by the Organization against its financial interest,
relative to any claims that it may assert under the applicable workers' compensation and/or
labor laws against the City relating to any bid awarded or contract entered into with this
Organization. The Organization shall defend, indemnify and hold harmless the City from any
and all liability, claims, demands, causes of action, charges, damages, injuries, fees including
attorney fees, costs and expense that may be asserted or established by any person or entity in
the event the Organization hires an employee in violation of this addendum.
I agree that this declaration shall constitute an addendum to any bid awarded or any contract
entered into with this Organization. I declare under penalty of perjury under the laws of the
State of California that the foregoing is true and correct.
~~ QC\ Z.o Ll;
~ ~ s?~~~v -~~~
AUTHORIZED RESPRESENTA TIVE
Revised, 01.05.18