19-149 Lewis & Tibbitts, Inc., 2019 Minor Asphalt Repairs ProjectContract
This public works contract ("Contract") is entered into by and between the City of Cupertino
City"), a municipal corporation, and Lewis &Tibbitts, Inc ("Contractor"), for work on the 2019
Minor Asphalt Repairs Project ("Project").
The parties agree as follows:
1. Award of Contract. In response to the Notice Inviting Bids, Contractor has submitted a
Bid Proposal and accompanying Bid Schedule, a copy of which is attached for convenience
as Exhibit A, to perform the Work to construct the Project. On August 5, 2019, City
authorized award of this Contract to Contractor for the amount set forth in Section 4 below.
2. Contract Documents. The Contract Documents incorporated into this Contract include
and are comprised of all of the documents listed below. The definitions provided in Article 1
of the General Conditions apply to all of the Contract Documents, including this Contract:
2.1 Notice Inviting Bids;
2.2 Instructions to Bidders;
2.3 Addenda, if any;
2.4 Bid Proposal and attachments thereto;
2.5 Contract;
2.6 Payment Bond, and Performance Bond;
2.7 General Conditions;
2.8 Special Conditions;
2.9 Project Plans and Specifications;
2.10 Change Orders, if any;
2.11 Notice of Award;
2.12 Notice to Proceed;
2.13 City of Cupertino Standard Details; and
2.14 The following: No Other Documents
3. Contractor's Obligations. Contractor will perform all of the Work required for the Project,
as specified in the Contract Documents. Contractor must provide, furnish, and supply all
things necessary and incidental for the timely performance and completion of the Work,
including all necessary labor, materials, supplies, tools, equipment, transportation, onsite
facilities and utilities, unless otherwise specified in the Contract Documents. Contractor
must use its best efforts to diligently prosecute and complete the Work in a professional
and expeditious manner and to meet or exceed the performance standards required by the
Contract Documents.
4. Payment. As full and complete compensation for Contractor's timely performance and
completion of the Work in strict accordance with the terms and conditions of the Contract
Documents, City will pay Contractor$92,970.00 ("Contract Price")for all of Contractor's
direct and indirect costs to perform the Work, including all labor, materials, supplies,
equipment, taxes, insurance, bonds and all overhead costs, in accordance with the
payment provisions in the General Conditions.
5. Time for Completion. Contractor will fully complete the Work for the Project within 25 or
working days from the commencement date given in the Notice to Proceed ("Contract
Time"). All work shall be complete prior to October 2019. By signing below, Contractor
expressly waives any claim for delayed early completion.
2019 Minor Asphalt Repairs Project CONTRACT
Project#2019-111 Pagel
6. Liquidated Damages. If Contractor fails to complete the Work within the Contract Time,
City will assess liquidated damages in the amount of$500.00 per day for each day of
unexcused delay in completion, and such liquidated damages may be deducted from City's
payments due or to become due to Contractor under this Contract.
7. Labor Code Compliance.
7.1 General. This Contract is subject to all applicable requirements of Chapter 1 of
Part 7 of Division 2 of the Labor Code, including requirements pertaining to wages,
working hours and workers' compensation insurance, as further specified in Article
9 of the General Conditions.
7.2 Prevailing Wages. This Project is subject to the prevailing wage requirements
applicable to the locality in which the Work is to be performed for each craft,
classification or type of worker needed to perform the Work, including employer
payments for health and welfare, pension, vacation, apprenticeship and similar
purposes. Copies of these prevailing rates are available online at
http://www.dir.ca.gov/DLSR.
7.3 DIR Registration. City may not enter into the Contract with a bidder without proof
that the bidder and its Subcontractors are registered with the California Department
of Industrial Relations to perform public work pursuant to Labor Code section
1725.5, subject to limited legal exceptions.
8. Workers' Compensation Certification. Pursuant to Labor Code section 1861, by signing
this Contract, Contractor certifies as follows: "I am aware of the provisions of Labor Code
section 3700 which require 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 performance of the
Work on this Contract."
9. Conflicts of Interest. Contractor, its employees, Subcontractors and agents, may not
have, maintain or acquire a conflict of interest in relation to this Contract in violation of any
City ordinance or requirement or in violation of any California law, including Government
Code section 1090 et seq., or the Political Reform Act, as set forth in Government Code
section 81000 et seq. and its accompanying regulations. No officer, official, employee,
consultant, or other agent of the City("City Representative") may have, maintain, or acquire
a"financial interest" in the Contract, as that term is defined under the Political Reform Act
Government Code section 81000, et seq., and regulations promulgated thereunder); or
under Government Code section 1090, et seq.; or in violation of any City ordinance or
requirement while serving as a City Representative or for one year thereafter. Any violation
of this Section constitutes a material breach of the Contract.
10. Independent Contractor. Contractor is an independent contractor under this Contract and
will have control of the Work and the means and methods by which it is performed. Contractor
and its Subcontractors are not employees of City and are not entitled to participate in any health,
retirement, or any other employee benefits from City.
2019 Minor Asphalt Repairs Project CONTRACT
Project#2019-111 Page 2
11. Notice. Any notice, billing, or payment required by or pursuant to the Contract Documents
must be made in writing, signed, dated and sent to the other party by personal delivery,
U.S. Mail, a reliable overnight delivery service, or by email as a PDF file. Notice is deemed
effective upon delivery, except that service by U.S. Mail is deemed effective on the second
working day after deposit for delivery.. Notice for each party must be given as follows:
City:
Name. City of Cupertino
Address: 10300 Torre Avenue
City/State/Zip: Cupertino, CA 95014
Phone: 408-777-3354
Attn: Jo Anne Johnson
Email:joannej@cupertino.org
Copy to: pwinvoices@cupertino.org
Contractor:
Name: Lewis and Tibbitts, Inc
Address: 1470 Industrial Ave
City/State/Zip: ban Jose, Ca
Phone: 408-925-0220
Attn: Buster Segura
Email: egura ig .com
Copy to:
12. General Provisions.
12.1 Assignment and Successors. Contractor may not assign its rights or obligations
under this Contract, in part or in whole, without City's written consent. This
Contract is binding on Contractor's and City's lawful heirs, successors and
permitted assigns,
12.2 Third Party Beneficiaries. There are no intended third party beneficiaries to this
Contract.
12.3 Governing Law and Venue. This Contract will be governed by California law and
venue will be in the Santa Clara County Superior Court, and no other place.
Contractor waives any right it may have pursuant to Code of Civil Procedures
Section 394, to file a motion to transfer any action arising from or relating to this
Contract to a venue outside Santa Clara County, California.
12.4 Amendment. No amendment or modification of this Contract will be binding
unless it is in a writing duly authorized and signed by the parties to this Contract,
12.5 Integration. This Contract and the Contract Documents incorporated herein,
including authorized amendments or Change Orders thereto, constitute the final,
complete, and exclusive terms of the agreement between City and Contractor.
12.6 Severability. If any provision of the Contract Documents, or portion of a provision,
is determined to be illegal, invalid, or unenforceable, the remaining provisions of
the Contract Documents will remain in full force and effect.
2019 Minor Asphalt Repairs Project CONTRACT
Project#2019-111 Page 3
12.7 Iran Contracting Act. If the Contract Price exceeds $1,000,000, Contractor
certifies, by signing below, that it is not identified on a list created under the Iran
Contracting Act, Public Contract Code §2200 et seq. (the"Act"), as a person
engaging in investment activities in Iran, as defined in the Act, or is otherwise
expressly exempt under the Act.
12.8 Authorization. Each individual signing below warrants that he or she is authorized
to do so by the party that he or she represents, and that this Contract is legally
binding on that party. If Contractor is a corporation, signatures from two officers of
the corporation are required pursuant to California Corporation Code section 313.
Signatures are on the following page.]
2019 Minor Asphalt Repairs Project CONTRACT
Project#2019-111 Page 4
The parties agree to this Contract as witnessed by the signatures below:
CONTRACTOR
Lewis and Tibbitts, Inc CITY OF CUPERTINO
insert full name of Contractor above> A Municipal,Co—io-ration
By By j—
Name Buster Segura Roger Lee
Title President Director of Public f rks
Date 8/1612019 Date
By Cu"
Name S m) E R
Title SECRETARY
Date Q(2'fi 119
APPROVED AS TO FORM:
By
ce `
ale
Name
City Attorney
s'
3nr
Date
ATTEST:
Grace Schmidt
City ClerkDate.
Contract Amount: C1 2- ,q 0
P.O. No.
Account No. 2`70 35 - 2/'I- 700-7a2
END OF CONTRACT
2019 Minor Asphalt Repairs Project CONTRACT
Project#2019-111 Page 5
DATE(MMIDD/YYYY)
AC"R" CERTIFICATE OF LIABILITY INSURANCEF8/9/2019
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 CONTACT
NAME: Raft and Sharma
Woodruff-Sawyer&Co. PHONE FAX
50 California Street, Floor 12 A/c No Ex :415-391-2141 AD No):415-989-9923
San Francisco CA 94111 ADDRIESS; rsharma woodruffsa er.com
INSURERS AFFORDING COVERAGE NAIC#
INSURER A: Hartford Fire Insurance Company 19682
INSURED LEWIAND-01 INSURER B: Hartford Underwriters Insurance Company 30104
Lewis and Tibbitts, Inc. INSURERC: Hartford Casualty Insurance Company 294241470IndustrialAvenue
San Jose CA 95112 INSURER D: Hartford Accident&Indemnity22357
INSURER E:
INSURER F
COVERAGES CERTIFICATE NUMBER:853621228 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR I TYPE OF INSURANCE
ADDL SUER POLICY
POLICY NUMBER MMIDD/YEFF POLICYYYYMMDD EXPLTR LIMITS
B X COMMERCIAL GENERALLIABILITY Y Y 57UEAZM1413 1/1/2019 11112020V EACH OCCURRENCE 1,000,000
DAMAGE TO RENTEDCLAIMS-MADE 1XI OCCUR PREMISES Ea occurrence $300,000
MED EXP(Any one person) $10,000
PERSONAL&ADV INJURY $1,000,000
1
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
JECT LOC PRODUCTS 2,000,000POLICY
OTHER:
A AUTOMOBILE LIABILITY Y Y 57UEAZM1416 1/1/2019 1/1/2 COMBINED SINGLE LIMIT
Ea Ea accident 1,000,000
X ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
X HIRED X NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY Per accident
j
C X UMBRELLA JAB X OCCUR Y Y 57RHAZM1556 1/1/2019 1/1I2020 EACH OCCURRENCE 2,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE 2,000,00
DED RETENTION$
D WORKERS COMPENSATION Y 57WEAPK7544 1/1/2019 1/1/2020 X STATUTE ERH
AND EMPLOYERS'LIABILITY YIN
ANYPROPRIETOR/PARTNER/EXECUTIVE
N/A
E.L.EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED?
Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 i
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
I
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required)
Project#2019-111:2019 Minor Asphalt Repairs Project.The City of Cupertino including its City Council,boards and commissions,officers,officials,agents,
employees,consultants and volunteers are additional insured are named additional insured per form attached.Coverage is primary&non-contributory per the
attached.A waiver of subrogation applies per the attached.XCU,Separation of the Insured is included in the policy form..
CERTIFICATE HOLDER 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.
City of Cupertino, Dept of Public Works
10300 Torre Ave
Cupertino CA 95014
AUTHORIZED REPRESENTATIVE
1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
COMMERCIAL AUTOMOBILE
Policy Number: 57UEAZM1416 HA 99 16 03 12
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
COMMERCIAL AUTOMOBILE BROAD FORM
ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
To the extent that the provisions of this endorsement provide broader benefits to the "insured" than other
provisions of the Coverage Form, the provisions of this endorsement apply.
1. BROAD FORM INSURED d. Any "employee" of yours while using a
A. Subsidiaries and Newly Acquired or covered "auto" you don't own, hire or
Formed Organizations borrow in your business or your
The Named Insured shown in the personal affairs.
Declarations is amended to include: C. Lessors as Insureds
1) Any legal business entity other than a Paragraph A.1. - WHO IS AN INSURED - of
partnership or joint venture, formed as a Section II - Liability Coverage is amended to
subsidiary in which you have an add:
ownership interest of more than 50% on e. The lessor of a covered "auto" while the
the effective date of the Coverage Form. auto" is leased to you under a written
However, the Named Insured does not agreement if:
include any subsidiary that is an
insured" under any other automobile
1) The agreement requires you to
policy or would be an "insured" under provide direct primary insurance for
the lessor and
such a policy but for its termination or
the exhaustion of its Limit of Insurance. 2) The "auto"is leased without a driver.
2) Any organization that is acquired or Such a leased "auto" will be considered a
formed by you and over which you covered "auto" you own and not a covered
maintain majority ownership. However, auto" you hire.
the Named Insured does not include any D. Additional Insured if Required by Contract
newly formed or acquired organization: 1) Paragraph A.1. - WHO IS AN INSURED
a) That is a partnership or joint of Section II - Liability Coverage is
venture, amended to add:
b) That is an "insured" under any other f. When you have agreed, in a written
policy, contract or written agreement, that a
c) That has exhausted its Limit of person or organization be added as
Insurance under any other policy, or an additional insured on your
d) 180 days or more after its business auto policy, such person or
acquisition or formation by you, organization is an "insured", but only
unless you have given us notice of to the extent such person or
the acquisition or formation.organization is liable for "bodily
Coverage does not apply to "bodily injury" or "property damage" caused
injury" or "property damage" that results by the conduct of an "insured" under
from an "accident" that occurred before paragraphs a. or b. of Who Is An
you formed or acquired the organization. Insured with regard to the
B. Employees as Insureds ownership, maintenance or use of a
covered "auto."
Paragraph A.1. - WHO IS AN INSURED - of
SECTION II - LIABILITY COVERAGE is
amended to add:
2011, The Hartford (Includes copyrighted material
Form HA 99 16 03 12 of ISO Properties, Inc., with its permission.) Page 1 of 5
The insurance afforded to any such E. Primary and Non-Contributory if
additional insured applies only if the Required by Contract
bodily injury" or "property damage" Only with respect to insurance provided to
occurs: an additional insured in 1.D. - Additional
1) During the policy period, and Insured If Required by Contract, the
2) Subsequent to the execution of such following provisions apply:
written contract, and 3) Primary Insurance When Required By
3) Prior to the expiration of the period Contract
of time that the written contract This insurance is primary if you have
requires such insurance be provided agreed in a written contract or written
to the additional insured. agreement that this insurance be
2) How Limits Apply primary. If other insurance is also
If you have agreed in a written contract
primary, we will share with all that other
or written agreement that another
insurance by the method described in
person or organization be added as an
Other Insurance 5.d.
additional insured on your policy, the 4) Primary And Non-Contributory To Other
most we will pay on behalf of such Insurance When Required By Contract
additional insured is the lesser of: If you have agreed in a written contract
a) The limits of insurance specified in or written agreement that this insurance
the written contract or written is primary and non-contributory with the
agreement; or additional insured's own insurance, this
b) The Limits of Insurance shown in
insurance is primary and we will not
seek contribution from that other
the Declarations.insurance.
Such amount shall be a part of and not Paragraphs (3) and (4) do not apply to other
in addition to Limits of Insurance shown insurance to which the additional insured
in the Declarations and described in this has been added as an additional insured.
Section.
When this insurance is excess, we will have no
3) Additional Insureds Other Insurance duty to defend the insured against any "suit" if
If we cover a claim or "suit" under this any other insurer has a duty to defend the
Coverage Part that may also be covered insured against that "suit". If no other insurer
by other insurance available to an defends, we will undertake to do so, but we will
additional insured, such additional be entitled to the insured's rights against all
insured must submit such claim or "suit" those other insurers.
to the other insurer for defense and When this insurance is excess over other
indemnity. insurance, we will pay only our share of the
However, this provision does not apply amount of the loss, if any, that exceeds the sum
to the extent that you have agreed in a of:
written contract or written agreement 1) The total amount that all such other
that this insurance is primary and non- insurance would pay for the loss in the
contributory with the additional insured's absence of this insurance; and
own insurance.
2) The total of all deductible and self-insured
4) Duties in The Event Of Accident, Claim, amounts under all that other insurance.
Suit or Loss
We will share the remaining loss, if any, by the
If you have agreed in a written contract method described in Other Insurance 5.d.
or written agreement that another
person or organization be added as an 2. AUTOS RENTED BY EMPLOYEES
additional insured on your policy, the Any "auto" hired or rented by your "employee"
additional insured shall be required to on your behalf and at your direction will be
comply with the provisions in LOSS considered an "auto"you hire.
CONDITIONS 2. - DUTIES IN THE The OTHER INSURANCE Condition is amended
EVENT OF ACCIDENT, CLAIM , SUIT by adding the following:
OR LOSS — OF SECTION IV —
BUSINESS AUTO CONDITIONS, in the
same manner as the Named Insured.
2011, The Hartford (Includes copyrighted material
Form HA 99 16 03 12 of ISO Properties, Inc., with its permission.) Page 2 of 5
If an "employee's" personal insurance also 5. PHYSICAL DAMAGE - ADDITIONAL
applies on an excess basis to a covered "auto" TEMPORARY TRANSPORTATION EXPENSE
hired or rented by your "employee" on your COVERAGE
behalf and at your direction, this insurance will Paragraph AA.a. of SECTION III - PHYSICAL
be primary to the "employee's" personal DAMAGE COVERAGE is amended to provide a
insurance. limit of $50 per day and a maximum limit of
3. AMENDED FELLOW EMPLOYEE EXCLUSION 1,000.
EXCLUSION 5. - FELLOW EMPLOYEE - of 6. LOAN/LEASE GAP COVERAGE
SECTION II - LIABILITY COVERAGE does not Under SECTION III - PHYSICAL DAMAGE
apply if you have workers' compensation COVERAGE, in the event of a total "loss" to a
insurance in-force covering all of your covered "auto", we will pay your additional legal
employees". obligation for any difference between the actual
Coverage is excess over any other collectible cash value of the "auto" at the time of the "loss"
insurance. and the"outstanding balance"of the loan/lease.
4. HIRED AUTO PHYSICAL DAMAGE COVERAGE Outstanding balance" means the amount you
If hired "autos" are covered "autos" for Liability owe on the loan/lease at the time of "loss" less
Coverage and if Comprehensive, Specified any amounts representing taxes; overdue
Causes of Loss, or Collision coverages are payments; penalties, interest or charges
provided under this Coverage Form for any resulting from overdue payments; additional
auto" you own, then the Physical Damage mileage charges; excess wear and tear charges;
Coverages provided are extended to "autos" you lease termination fees; security deposits not
hire or borrow, subject to the following limit. returned by the lessor; costs for extended
warranties, credit life Insurance, health, accident
The most we will pay for "loss" to any hired or disability insurance purchased with the loan or
auto" is: lease; and carry-over balances from previous
1) $100,000; loans or leases.
2) The actual cash value of the damaged or 7. AIRBAG COVERAGE
stolen property at the time of the"loss"; or Under Paragraph B. EXCLUSIONS - of
3) The cost of repairing or replacing the SECTION III - PHYSICAL DAMAGE
damaged or stolen property, COVERAGE, the following is added:
whichever is smallest, minus a deductible. The The exclusion relating to mechanical breakdown
deductible will be equal to the largest deductible does not apply to the accidental discharge of an
applicable to any owned "auto" for that airbag.
coverage. No deductible applies to "loss" caused g, ELECTRONIC EQUIPMENT - BROADENED
by fire or lightning. Hired Auto Physical Damage COVERAGE
coverage is excess over any other collectible
insurance. Subject to the above limit, deductible a. The exceptions to Paragraphs BA -
and excess provisions, we will provide coverage EXCLUSIONS - of SECTION III - PHYSICAL
equal to the broadest coverage applicable to any DAMAGE COVERAGE are replaced by the
covered "auto" you own.following:
We will also cover loss of use of the hired "auto" Exclusions 4.c. and 4.d. do not apply to
if it results from an "accident", you are legally equipment designed to be operated solely
liable and the lessor incurs an actual financial by use of the power from the "auto's"
loss, subject to a maximum of $1000 per electrical system that, at the time of"loss",
accident". is:
This extension of coverage does not apply to 1) Permanently installed in or upon
any "auto" you hire or borrow from any of your the covered "auto";
employees", partners (if you are a partnership), 2) Removable from a housing unit
members (if you are a limited liability company), which is permanently installed in
or members of their households. or upon the covered "auto";
3) An integral part of the same unit
housing any electronic
equipment described in
Paragraphs (1)and (2)above; or
2011,The Hartford (Includes copyrighted material
Form HA 99 16 03 12 of ISO Properties, Inc.,with its permission.) Page 3 of 5
4) Necessary for the normal If another Hartford Financial Services Group,
operation of the covered "auto"or Inc. company policy or coverage form that is not
the monitoring of the covered an automobile policy or coverage form applies to
auto's"operating system.the same "accident",the following applies:
b.Section III — Version CA 00 01 03 10 of the 1) If the deductible under this Business Auto
Business Auto Coverage Form, Physical Coverage Form is the smaller (or smallest)
Damage Coverage, Limit of Insurance, deductible, it will be waived;
Paragraph C.2 and Version CA 00 01 10 01 of 2) If the deductible under this Business Auto
the Business Auto Coverage Form, Physical Coverage Form is not the smaller (or
Damage Coverage, Limit' of Insurance, smallest) deductible, it will be reduced by
Paragraph C are each amended to add the the amount of the smaller (or smallest)
following: deductible.
1,500 is the most we will pay for "loss" in 12. AMENDED DUTIES IN THE EVENT OF
any one "accident" to all electronic ACCIDENT, CLAIM, SUIT OR LOSS
equipment (other than equipment designed
solely for the reproduction of sound, and
The requirement in LOSS CONDITIONS 2.a. -
accessories used with such equipment) DUTIES IN THE EVENT OF ACCIDENT,CLAIM,
that reproduces, receives or transmits
SUIT OR LOSS - of SECTION IV - BUSINESS
AUTO CONDITIONS that you must notify us ofaudio, visual or data signals which, at the
time of"loss", is: an "accident" applies only when the "accident" is
known to:
1) Permanently installed in or upon
the covered "auto" in a housing,
1) You, if you are an individual;
opening or other location that is not 2) A partner, if you are a partnership;
normally used by the "auto" 3) A member, if you are a limited liability
manufacturer for the installation of company; or
such equipment;
4) An executive officer or insurance manager, if
2) Removable from a permanently you are a corporation.
installed housing unit as described 13. UNINTENTIONAL FAILURE TO DISCLOSE
in Paragraph 2.a. above or is an
HAZARDS
integral part of that equipment; or
3)An integral part of such equipment.If you unintentionally fail to disclose any hazards
existing at the inception date of your policy, we
c.For each covered "auto", should loss be limited will not deny coverage under this Coverage
to electronic equipment only, our obligation to Form because of such failure.
pay for, repair, return or replace damaged or 14. HIRED AUTO -COVERAGE TERRITORY
stolen electronic equipment will be reduced by
the applicable deductible shown in the Paragraph e. of GENERAL CONDITIONS 7. -
Declarations, or $250, whichever deductible is POLICY PERIOD, COVERAGE TERRITORY -
less. of SECTION IV - BUSINESS AUTO
9. EXTRA EXPENSE - BROADENED CONDITIONS is replaced by the following:
COVERAGE e. For short-term hired "autos", the coverage
Under Paragraph A. -COVERAGE -of SECTION territory with respect to Liability Coverage is
III - PHYSICAL DAMAGE COVERAGE, we will anywhere in the world provided that if the
pay for the expense of returning a stolen covered insured's" responsibility to pay damages for
auto"to you.
bodily injury" or "property damage" is
determined in a "suit,"the "suit" is brought in
10. GLASS REPAIR-WAIVER OF DEDUCTIBLE the United States of America, the territories
Under Paragraph D.- DEDUCTIBLE-of SECTION and possessions of the United States of
III - PHYSICAL DAMAGE COVERAGE, the America, Puerto Rico or Canada or in a
following is added: settlement we agree to.
No deductible applies to glass damage if the 15. WAIVER OF SUBROGATION
glass is repaired rather than replaced. TRANSFER OF RIGHTS OF RECOVERY
11. TWO OR MORE DEDUCTIBLES AGAINST OTHERS TO US - of SECTION IV -
Under Paragraph D.-DEDUCTIBLE-of SECTION BUSINESS AUTO CONDITIONS is amended by
III - PHYSICAL DAMAGE COVERAGE, the adding the following:
following is added:
2011, The Hartford (Includes copyrighted material
Form HA 99 16 03 12 of ISO Properties, Inc., with its permission.) Page 4 of 5
We waive any right of recovery we may have c.Regardless of the number of autos deemed a
against any person or organization with whom total loss, the most we will pay under this
you have a written contract that requires such Hybrid, Electric, or Natural Gas Vehicle
waiver because of payments we make for Payment Coverage provision for any one
damages under this Coverage Form.loss" is$10,000.
16. RESULTANT MENTAL ANGUISH COVERAGE For the purposes of the coverage provision,
The definition of "bodily injury" in SECTION V- a.A "non-hybrid" auto is defined as an auto that
DEFINITIONS is replaced by the following: uses only an internal combustion engine to
Bodily injury" means bodily injury, sickness or move the auto but does not include autos
disease sustained by any person, including powered solely by electricity or natural gas.
mental anguish or death resulting from any of b.A "hybrid" auto is defined as an auto with an
these. internal combustion engine and one or more
17. EXTENDED CANCELLATION CONDITION electric motors; and that uses the internal
combustion engine and one or more electric
Paragraph 2. of the COMMON POLICY motors to move the auto, or the internal
CONDITIONS - CANCELLATION - applies combustion engine to charge one or more
except as follows: electric motors,which move the auto.
If we cancel for any reason other than 19. VEHICLE WRAP COVERAGE
nonpayment of premium, we will mail or deliver
to the first Named Insured written notice of In the event of a total loss to an "auto" for which
cancellation at least 60 days before the effective Comprehensive, Specified Causes of Loss, or
date of cancellation. Collision coverages are provided under this
18. HYBRID, ELECTRIC, OR NATURAL GAS
Coverage Form, then such Physical Damage
VEHICLE PAYMENT COVERAGE Coverages are amended to add the following:
In addition to the actual cash value of the "auto",
In the event of a total loss to a "non-hybrid" auto we will pay up to $1,000 for vinyl vehicle wraps
for which Comprehensive, Specified Causes of which are displayed on the covered "auto" at the
Loss, or Collision coverages are provided under time of total loss. Regardless of the number of
this Coverage Form, then such Physical
autos deemed a total loss, the most we will pay
Damage Coverages are amended as follows:
under this Vehicle Wrap Coverage provision for
a.lf the auto is replaced with a "hybrid" auto or any one "loss" is $5,000. For purposes of this
an auto powered solely by electricity or natural coverage provision, signs or other graphics
gas, we will pay an additional 10%, to a painted or magnetically affixed to the vehicle are
maximum of$2,500, of the "non-hybrid" auto's not considered vehicle wraps.
actual cash value or replacement cost,
whichever is less,
b.The auto must be replaced and a copy of a bill
of sale or new lease agreement received by us
within 60 calendar days of the date of"loss,"
2011, The Hartford (Includes copyrighted material
Form HA 99 16 03 12 of ISO Properties, Inc., with its permission.) Page 5 of 5
Policy No. 57UEAZM1416
Paragraph a. above does not apply to fuels, 5. That part of any other contract or agreement
lubricants, fluids, exhaust gases or other similar pertaining to your business (including an
pollutants" that are needed for or result from the indemnification of a municipality in connection
normal electrical, hydraulic or mechanical with work performed for a municipality) under
functioning of the covered "auto" or its parts, if: which you assume the tort liability of another to
1) The "pollutants" escape, seep, migrate or pay for "bodily injury" or "property damage" to a
are discharged, dispersed or released third party or organization. Tort liability means a
directly from an "auto" part designed by its liability that would be imposed by law in the
manufacturer to hold, store, receive or absence of any contract or agreement; or
dispose of such "pollutants"; and 6. That part of any contract or agreement entered
2 The "bodilyinjury", 9e or"property damage" into, as part of your business, pertaining to the
covered pollution cost or expense" does rental or lease, by you or any of your
not arise out of the operation of any employees", of any "auto". However, such
equipment listed in Paragraph 6.b. or 6.c. contract or agreement shall not be considered an
of the definition of"mobile equipment". insured contract" to the extent that it obligates
you or any of your "employees" to pay for
Paragraphs b. and c. above do not apply to
accidents" that occur away from premises
property damage"to any "auto" rented or leased
by you or any of your"employees".
owned by or rented to an "insured" with respect
to "pollutants" not in or upon a covered "auto" if: An "insured contract" does not include that part of
a) The "pollutants" or any property in
any contract or agreement:
which the "pollutants" are contained a. That indemnifies a railroad for "bodily injury"
are upset, overturned or damaged as a or "property damage" arising out of
result of the maintenance or use of a construction or demolition operations, within
covered "auto"; and 50 feet of any railroad property and affecting
b) The discharge, dispersal, seepage,
any railroad bridge or trestle, tracks,
migration, release or escape of the
roadbeds, tunnel, underpass or crossing;
pollutants" is caused directly by such b. That pertains to the loan, lease or rental of an
upset, overturn or damage. auto" to you or any of your "employees", if
E. "Diminution in value" means the actual or perceived
the "auto" is loaned, leased or rented with adriver; or
loss in market value or resale value which results
from a direct and accidental "loss". c. That holds a person or organization engaged
in the business of transporting property by
F. "Employee" includes a "leased worker". "Employee"auto" for hire harmless for your use of a
does not include a "temporary worker". covered "auto" over a route or territory that
G. "Insured" means any person or organization person or organization is authorized to serve
qualifying as an insured in the Who Is An Insured by public authority.
provision of the applicable coverage. Except with 1. "Leased worker" means a person leased to you by a
respect to the Limit of Insurance, the coverage labor leasing firm under an agreement between you
afforded applies separately to each insured who is and the labor leasing firm to perform duties related
seeking coverage or against whom a claim or "suit" to the conduct of your business. "Leased worker"
is brought. does not include a "temporary worker".
H. "Insured contract" means: J. "Loss" means direct and accidental loss or damage.
1. A lease of premises; K. "Mobile equipment" means any of the following types
2. A sidetrack agreement; of land vehicles, including any attached machinery
3. Any easement or license agreement, except in or equipment:
connection with construction or demolition 1. Bulldozers, farm machinery, forklifts and other
operations on or within 50 feet of a railroad; vehicles designed for use principally off public
4. An obligation, as required by ordinance, to roads;
indemnify a municipality, except in connection 2. Vehicles maintained for use solely on or next to
with work for a municipality; premises you own or rent;
3. Vehicles that travel on crawler treads;
CA 00 01 10 13 Insurance Services Office, Inc., 2011 Page 11 of 12
Policy No. 57 UEA ZM1413
Our obligation to defend an insured's indemnitee liability company), to a co-"employee"
and to pay for attorneys' fees and necessary while in the course of his or her
litigation expenses as Supplementary Payments employment or performing duties
ends when:related to the conduct of your
a. We have used up the applicable limit of business, or to your other "volunteer
insurance in the payment of judgments or workers" while performing duties
settlements; or
related to the conduct of your
b. The conditions set forth above, or the terms of
business;
the agreement described in Paragraph f. b) To the spouse, child, parent, brother or
above, are no longer met. sister of that co-"employee" or that
SECTION II—WHO IS AN INSURED
volunteer worker" as a consequence
of Paragraph (1)(a) above;
1. If you are designated in the Declarations as: c) For which there is any obligation to
a. An individual, you and your spouse are share damages with or repay someone
insureds, but only with respect to the conduct else who must pay damages because
of a business of which you are the sole of the injury described in Paragraphs
owner. 1)(a) or(1)(b) above; or
b. A partnership or joint venture, you are an d) Arising out of his or her providing or
insured. Your members, your partners, and failing to provide professional health
their spouses are also insureds, but only with care services.
respect to the conduct of your business. If you are not in the business of providing
c. A limited liability company, you are an professional health care services:
insured. Your members are also insureds, but a) Subparagraphs (1)(a), (1)(b) and (1)(c)
only with respect to the conduct of your above do not apply to any "employee"
business. Your managers are insureds, but or "volunteer worker" providing first aid
only with respect to their duties as your services; and
managers.
d. An organization other than a partnership,joint
b) Subparagraph (1)(d) above does not
company, you are
apply to any nurse, emergency medical
venture or limited liability p y, y technician or paramedic employed by
an insured. Your "executive officers" and
you to provide such services.
directors are insureds, but only with respect to
their duties as your officers or directors. Your 2) "Property damage"to property:
stockholders are also insureds, but only with a) Owned, occupied or used by,
respect to their liability as stockholders. b) Rented to, in the care, custody or
e. A trust, you are an insured. Your trustees are control of, or over which physical
also insureds, but only with respect to their control is being exercised for any
duties as trustees. purpose by
2. Each of the following is also an insured: you, any of your "employees", "volunteer
a. Employees And Volunteer Workers workers", any partner or member (if you
are a partnership or joint venture), or any
Your "volunteer workers" only while member (if you are a limited liability
performing duties related to the conduct of company).
your business, or your "employees", other
than either your"executive officers" (if you are b. Real Estate Manager
an organization other than a partnership, joint Any person (other than your "employee" or
venture or limited liability company) or your volunteer worker"), or any organization while
managers (if you are a limited liability acting as your real estate manager.
company), but only for acts within the scope c. Temporary Custodians Of Your Property
of their employment by you or while
performing duties related to the conduct of Any person or organization having proper
your business.temporary custody of your property if you die,
but only:
However, none of these "employees" or
volunteer workers"are insureds for: 1) With respect to liability arising out of the
1) "Bodily injury" or"personal and advertising
maintenance or use of that property; and
injury": 2) Until your legal representative has been
a) To you, to your partners or members (if
appointed.
you are a partnership or joint venture), d. Legal Representative If You Die
to your members (if you are a limited Your legal representative if you die, but only
HG 00 01 09 16 Page 11 of 21
with respect to duties as such. That 5. Additional Insureds When Required By
representative will have all your rights and Written Contract, Written Agreement Or
duties under this Coverage Part. Permit
e. Unnamed Subsidiary The following person(s) or organization(s) are an
Any subsidiary, and subsidiary thereof, of additional insured when you have agreed, in a
yours which is a legally incorporated entity of written contract, written agreement or because of
which you own a financial interest of more a permit issued by a state or political subdivision,
than 50% of the voting stock on the effective that such person or organization be added as an
date of the Coverage Part. additional insured on your policy, provided the
injury or damage occurs subsequent to the
The insurance afforded herein for any execution of the contract or agreement.
subsidiary not named in this Coverage Part
as a named insured does not apply to injury A person or organization is an additional insured
or damage with respect to which such insured under this provision only for that period of time
is also a named insured under another policy required by the contract or agreement.
or would be a named insured under such However, no such person or organization is an
policy but for its termination or the exhaustion insured under this provision if such person or
of its limits of insurance.organization is included as an insured by an
3. Newly Acquired Or Formed Organization endorsement issued by us and made a part of
Any organization you newly acquire or form,
this Coverage Part.
other than a partnership, joint venture or limited a. Vendors
liability company, and over which you maintain Any person(s) or organization(s) (referred to
financial interest of more than 50% of the voting below as vendor), but only with respect to
stock, will qualify as a Named Insured if there is bodily injury" or "property damage" arising
no other similar insurance available to that out of"your products"which are distributed or
organization. However: sold in the regular course of the vendor's
a. Coverage under this provision is afforded only business and only if this Coverage Part
until the 180th day after you acquire or form provides coverage for "bodily injury" or
the organization or the end of the policy property damage" included within the
period, whichever is earlier;products-completed operations hazard".
b. Coverage A does not apply to "bodily injury" 1) The insurance afforded the vendor is
or "property damage" that occurred before subject to the following additional
you acquired or formed the organization; and exclusions:
c. Coverage B does not apply to "personal and This insurance does not apply to:
advertising injury" arising out of an offense a) "Bodily injury" or "property damage" for
committed before you acquired or formed the which the vendor is obligated to pay
organization. damages by reason of the assumption
4. Nonowned Watercraft of liability in a contract or agreement.
This exclusion does not apply to
With respect to watercraft you do not own that is liability for damages that the vendor
less than 51 feet long and is not being used to would have in the absence of the
carry persons for a charge, any person is an contract or agreement;
insured while operating such watercraft with your
permission. Any other person or organization b) Any express warranty unauthorized by
responsible for the conduct of such person is you;
also an insured, but only with respect to liability c) Any physical or chemical change in the
arising out of the operation of the watercraft, and product made intentionally by the
only if no other insurance of any kind is available vendor;
to that person or organization for this liability. d) Repackaging, except when unpacked
However, no person or organization is an insured solely for the purpose of inspection,
with respect to: demonstration, testing, or the
a. "Bodily injury" to a co-"employee" of the substitution of parts under instructions
person operating the watercraft; or
from the manufacturer, and then
b. "Property damage" to property owned by,
repackaged in the original container;
rented to, in the charge of or occupied by you e) Any failure to make such inspections,
or the employer of any person who is an adjustments, tests or servicing as the
insured under this provision.vendor has agreed to make or normally
Page 12 of 21 HG 00 01 09 16
undertakes to make in the usual This insurance does not apply to:
course of business, in connection with 1. Any "occurrence" which takes place after
the distribution or sale of the products; you cease to lease that land; or
f) Demonstration, installation, servicing 2. Structural alterations, new construction or
or repair operations, except such demolition operations performed by or on
operations performed at the vendor's behalf of such person or organization.
premises in connection with the sale of
the product;
d. Architects, Engineers Or Surveyors
g) Products which, after distribution or Any architect, engineer, or surveyor, but only
sale by you, have been labeled or with respect to liability for "bodily injury",
relabeled or used as a container, part property damage" or "personal and
or ingredient of any other thing or advertising injury" caused, in whole or in part,
substance by or for the vendor; or by your acts or omissions or the acts or
h "Bodilyin ur or "property dama e"
omissions of those acting on your behalf:
y g
1) In connection with your premises; orarisingoutofthesolenegligenceofthe
vendor for its own acts or omissions or 2) In the performance of your ongoing
those of its employees or anyone else operations performed by you or on your
acting on its behalf. However, this behalf.
exclusion does not apply to:With respect to the insurance afforded these
i) The exceptions contained in Sub- additional insureds, the following additional
paragraphs (d) or(f); or exclusion applies:
ii) Such inspections, adjustments, This insurance does not apply to "bodily
tests or servicing as the vendor has injury", "property damage" or "personal and
agreed to make or normally advertising injury" arising out of the rendering
undertakes to make in the usual of or the failure to render any professional
course of business, in connection services by or for you, including:
with the distribution or sale of the 1. The preparing, approving, or failing to
products. prepare or approve, maps, shop drawings,
2) This insurance does not apply to any opinions, reports, surveys, field orders,
insured person or organization, from change orders or drawings and
whom you have acquired such products, specifications; or
or any ingredient, part or container, 2. Supervisory, inspection, architectural or
entering into, accompanying or containing engineering activities.
such products.This exclusion applies even if the claims
b. Lessors Of Equipment against any insured allege negligence or
1) Any person(s) or organization(s) from other wrongdoing in the supervision, hiring,
whom you lease equipment; but only with employment, training or monitoring of others
respect to their liability for "bodily injury", by that insured, if the "occurrence" which
property damage" or "personal and caused the "bodily injury" or "property
advertising injury" caused, in whole or in damage", or the offense which caused the
part, by your maintenance, operation or personal and advertising injury", involved the
use of equipment leased to you by such rendering of or the failure to render any
person(s) or organization(s). professional services by or for you.
2) With respect to the insurance afforded to e. Permits Issued By State Or Political
these additional insureds this insurance Subdivisions
does not apply to any "occurrence" which Any state or political subdivision, but only with
takes place after the equipment lease respect to operations performed by you or on
expires. your behalf for which the state or political
c. Lessors Of Land Or Premises subdivision has issued a permit.
Any person or organization from whom you With respect to the insurance afforded these
lease land or premises, but only with respect additional insureds, this insurance does not
to liability arising out of the ownership, apply to:
maintenance or use of that part of the land or 1) "Bodily injury", "property damage" or
premises leased to you. personal and advertising injury" arising
With respect to the insurance afforded these out of operations performed for the state
additional insureds the following additional or municipality; or
exclusions apply:
HG 00 01 09 16 Page 13 of 21
2) "Bodily injury" or "property damage" by that insured, if the "occurrence" which
included within the "products-completed caused the "bodily injury" or "property
operations hazard". damage", or the offense which caused the
f. Any Other Party personal and advertising injury", involved the
Any other person or organization who is not
rendering of or the failure to render any
an additional insured under Paragraphs a.professional services by or for you.
through e. above, but only with respect to The limits of insurance that apply to additional
liability for "bodily injury", "property damage" insureds is described in Section III — Limits Of
or"personal and advertising injury" caused, in Insurance.
whole or in part, by your acts or omissions or How this insurance applies when other insurance
the acts or omissions of those acting on your is available to the additional insured is described
behalf: in the Other Insurance Condition in Section IV —
1) In the performance of your ongoing Commercial General Liability Conditions.
operations;No person or organization is an insured with respect
2) In connection with your premises owned to the conduct of any current or past partnership,
by or rented to you; or joint venture or limited liability company that is not
3) In connection with "your work" and
shown as a Named Insured in the Declarations.
included within the "products-completed SECTION III—LIMITS OF INSURANCE
operations hazard", but only if 1. The Most We Will Pay
a) The written contract or agreement The Limits of Insurance shown in the
requires you to provide such coverage Declarations and the rules below fix the most we
to such additional insured; and will pay regardless of the number of:
b) This Coverage Part provides coverage a. Insureds;
for"bodily injury" or "property damage" b. Claims made or"suits" brought; or
included within the "products-
completed operations hazard". c. Persons or organizations making claims or
bringing "suits".
However:
2. General Aggregate Limit
1) The insurance afforded to such additional
insured only applies to the extent The General Aggregate Limit is the most we will
permitted by law; and pay for the sum of:
2) If coverage provided to the additional a. Medical expenses under Coverage C;
insured is required by a contract or b. Damages under Coverage A, except
agreement, the insurance afforded to such damages because of "bodily injury" or
additional insured will not be broader than property damage" included in the "products-
that which you are required by the contract completed operations hazard"; and
or agreement to provide for such c. Damages under Coverage B.
additional insured.
3. Products-Completed Operations Aggregate
With respect to the insurance afforded to Limit
these additional insureds, this insurance does
not apply to:
The Products-Completed Operations Aggregate
Limit is the most we will pay under Coverage A
Bodily injury", "property damage" or for damages because of "bodily injury" and
personal and advertising injury" arising out of property damage" included in the "products-
the rendering of, or the failure to render, any completed operations hazard".
professional architectural, engineering or
surveying services, including: 4. Personal And Advertising Injury Limit
1) The preparing, approving, or failing to
Subject to 2. above, the Personal and
prepare or approve, maps, shop drawings, Advertising Injury Limit is the most we will pay
opinions, reports, surveys, field orders, under Coverage B for the sum of all damages
change orders or drawings and because of all "personal and advertising injury"
specifications; or sustained by any one person or organization.
2) Supervisory, inspection, architectural or 5. Each Occurrence Limit
engineering activities. Subject to 2. or 3. above, whichever applies, the
This exclusion applies even if the claims Each Occurrence Limit is the most we will pay for
against any insured allege negligence or
the sum of:
other wrongdoing in the supervision, hiring, a. Damages under Coverage A; and
employment, training or monitoring of others
Page 14 of 21 HG 00 01 09 16
b. Medical expenses under Coverage C a. Notice Of Occurrence Or Offense
because of all "bodily injury" and "property You or any additional insured must see to it
damage" arising out of any one"occurrence". that we are notified as soon as practicable of
6. Damage To Premises Rented To You Limit an "occurrence" or an offense which may
result in a claim. To the extent possible,
Subject to 5. above, the Damage To Premises notice should include:
Rented To You Limit is the most we will pay
under Coverage A for damages because of 1) How, when and where the "occurrence" or
property damage" to any one premises, while offense took place;
rented to you, or in the case of damage by fire, 2) The names and addresses of any injured
lightning or explosion, while rented to you or persons and witnesses; and
temporarily occupied by you with permission of 3) The nature and location of any injury or
the owner. damage arising out of the "occurrence" or
In the case of damage by fire, lightning or offense.
explosion, the Damage to Premises Rented To b. Notice Of Claim
You Limit applies to all damage proximately
caused by the same event, whether such If a claim is made or "suit" is brought against
damage results from fire, lightning or explosion any insured, you or any additional insured
or any combination of these.
must:
7. Medical Expense Limit
1) Immediately record the specifics of the
claim or"suit" and the date received; and
Subject to 5. above, the Medical Expense Limit is
the most we will pay under Coverage C for all 2) Notify us as soon as practicable.
medical expenses because of "bodily injury" You or any additional insured must see to it
sustained by any one person. that we receive written notice of the claim or
8. How Limits Apply To Additional Insureds suit"as soon as practicable.
If you have agreed in a written contract or written
c. Assistance And Cooperation Of The
agreement that another person or organization
Insured
be You and any other involved insured must:
added as an additional insured on your policy, 1) Immediately send us copies of any
the most we will pay on behalf of such additional demands, notices, summonses or legal
insured is the lesser of: papers received in connection with the
a. The limits of insurance specified in the written claim or"suit";
contract or written agreement; or 2) Authorize us to obtain records and other
b. The Limits of Insurance shown in the information;
Declarations. 3) Cooperate with us in the investigation or
Such amount shall be a part of and not in settlement of the claim or defense against
addition to Limits of Insurance shown in the the"suit"; and
Declarations and described in this Section. 4) Assist us, upon our request, in the
The Limits of Insurance of this Coverage Part apply enforcement of any right against any person
separately to each consecutive annual period and to or organization which may be liable to the
any remaining period of less than 12 months, insured because of injury or damage to
starting with the beginning of the policy period which this insurance may also apply.
shown in the Declarations, unless the policy period d. Obligations At The Insureds Own Cost
is extended after issuance for an additional period of
less than 12 months. In that case, the additional
No insured will, except at that insured's own
cost, voluntarily make a payment, assumeperiodwillbedeemedpartofthelastpreceding
period for purposes of determining the Limits of any obligation, or incur any expense, other
than for first aid, without our consent.
Insurance.
SECTION IV — COMMERCIAL GENERAL
e. Additional Insureds Other Insurance
LIABILITY CONDITIONS If we cover a claim or "suit" under this
1. Bankruptcy
Coverage Part that may also be covered by
other insurance available to an additional
Bankruptcy or insolvency of the insured or of the insured, such additional insured must submit
insured's estate will not relieve us of our such claim or "suit" to the other insurer for
obligations under this Coverage Part. defense and indemnity.
2. Duties In The Event Of Occurrence, Offense, However, this provision does not apply to the
Claim Or Suit extent that you have agreed in a written
HG 00 01 09 16 Page 15 of 21
contract or written agreement that this b. Excess Insurance
insurance is primary and non-contributory This insurance is excess over any of the other
with the additional insured's own insurance. insurance, whether primary, excess,
f. Knowledge Of An Occurrence, Offense, contingent or on any other basis:
Claim Or Suit 1) Your Work
Paragraphs a. and b. apply to you or to any That is Fire, Extended Coverage, Builder's
additional insured only when such Risk, Installation Risk or similar coverage
occurrence", offense, claim or"suit" is known for"your work";
to:
2) Premises Rented To You
1) You or any additional insured that is an
That is fire, lightning or explosionindividual;
2) Any partner, if you or the additional
insurance for premises rented to you or
insured is a partnership;
temporarily occupied by you with
permission of the owner;
3) Any manager, if you or the additional 3) Tenant Liability
insured is a limited liability company;
That is insurance purchased by you to
4) Any "executive officer" or insurance
cover your liability as a tenant for
manager, if you or the additional insured is property damage" to premises rented to
a corporation; you or temporarily occupied by you with
6) Any trustee, if you or the additional permission of the owner;
insured is a trust; or 4) Aircraft, Auto Or Watercraft
6) Any elected or appointed official, if you or If the loss arises out of the maintenance or
the additional insured is a political use of aircraft, "autos" or watercraft to the
subdivision or public entity. extent not subject to Exclusion g. of
This duty applies separately to you and any Section I — Coverage A — Bodily Injury
additional insured. And Property Damage Liability;
3. Legal Action Against Us 5) Property Damage To Borrowed
No person or organization has a right under this Equipment Or Use Of Elevators
Coverage Part:If the loss arises out of"property damage"
a. To join us as a party or otherwise bring us to borrowed equipment or the use of
into a "suit" asking for damages from an elevators to the extent not subject to
insured; or Exclusion j. of Section I - Coverage A -
Bodily Injury And Property Damage
b. To sue us on this Coverage Part unless all of
Liability;
its terms have been fully complied with.
A person or organization may sue us to recover
6) When You Are Added As An Additional
on an agreed settlement or on a final judgment
Insured To Other Insurance
against an insured; but we will not be liable for Any other insurance available to you
damages that are not payable under the terms of covering liability for damages arising out
this Coverage Part or of the premises or operations, or products
that are in excess of the applicable limit of and completed operations, for which you
insurance. An agreed settlement means a have been added as an additional insured
settlement and release of liability signed by us, by that insurance; or
the insured and the claimant or the claimant's 7) When You Add Others As An
legal representative. Additional Insured To This Insurance
4. Other Insurance Any other insurance available to an
If other valid and collectible insurance is additional insured.
available to the insured for a loss we cover under However, the following provisions apply to
Coverages A or B of this Coverage Part, our other insurance available to any person or
obligations are limited as follows: organization who is an additional insured
a. Primary Insurance under this coverage part.
This insurance is primary except when b. a) Primary Insurance When Required
below applies. If other insurance is also By Contract
primary, we will share with all that other This insurance is primary if you have
insurance by the method described in c. agreed in a written contract or written
below. agreement that this insurance be
primary. If other insurance is also
Page 16 of 21 HG 00 01 09 16
primary, we will share with all that 5. Premium Audit
other insurance by the method a. We will compute all premiums for this
described in c. below. Coverage Part in accordance with our rules
b) Primary And Non-Contributory To and rates.
Other Insurance When Required By b. Premium shown in this Coverage Part as
Contract advance premium is a deposit premium only.
If you have agreed in a written At the close of each audit period we will
contract, written agreement, or permit compute the earned premium for that period
that this insurance is primary and non- and send notice to the first Named Insured.
contributory with the additional The due date for audit and retrospective
insured's own insurance, this insurance premiums is the date shown as the due date
is primary and we will not seek on the bill. If the sum of the advance and
contribution from that other insurance. audit premiums paid for the policy period is
Paragraphs (a) and (b) do not apply to greater than the earned premium, we will
other insurance to which the additional return the excess to the first Named Insured.
insured has been added as an additional c. The first Named Insured must keep records of
insured. the information we need for premium
When this insurance is excess, we will have computation, and send us copies at such
no duty under Coverages A or B to defend times as we may request.
the insured against any "suit" if any other 6. Representations
insurer has a duty to defend the insured a. When You Accept This Policy
against that "suit". If no other insurer defends,
we will undertake to do so, but we will be By accepting this policy, you agree:
entitled to the insured's rights against all 1) The statements in the Declarations are
those other insurers. accurate and complete;
When this insurance is excess over other 2) Those statements are based upon
insurance, we will pay only our share of the representations you made to us; and
amount of the loss, if any, that exceeds the 3) We have issued this policy in reliance
sum of: upon your representations.
1) The total amount that all such other b. Unintentional Failure To Disclose Hazards
insurance would pay for the loss in the If unintentionally you should fail to disclose allabsenceofthisinsurance; and
hazards relating to the conduct of your
2) The total of all deductible and self-insured business that exist at the inception date of
amounts under all that other insurance. this Coverage Part, we shall not deny
We will share the remaining loss, if any, with coverage under this Coverage Part because
any other insurance that is not described in of such failure.
this Excess Insurance provision and was not 7. Separation Of Insureds
bought specifically to apply in excess of the Except with respect to the Limits of Insurance,
Limits of Insurance shown in the Declarations
of this Coverage Part. and any rights or duties specifically assigned in
this Coverage Part to the first Named Insured,
c. Method Of Sharing this insurance applies:
If all of the other insurance permits a. As if each Named Insured were the only
contribution by equal shares, we will follow Named Insured; and
this method also. Under this approach each b. Separately to each insured against whominsurercontributesequalamountsuntilithas
paid its applicable limit of insurance or none
claim is made or"suit" is brought.
of the loss remains,whichever comes first. 8. Transfer Of Rights Of Recovery Against
If any of the other insurance does not permit
Others To Us
contribution by equal shares, we will a. Transfer Of Rights Of Recovery
contribute by limits. Under this method, each If the insured has rights to recover all or part
insurer's share is based on the ratio of its of any payment, including Supplementary
applicable limit of insurance to the total Payments, we have made under this
applicable limits of insurance of all insurers. Coverage Part, those rights are transferred to
us. The insured must do nothing after loss to
HG 00 01 09 16 Page 17 of 21
impair them. At our request, the insured will other motor vehicle insurance law where it is
bring "suit" or transfer those rights to us and licensed or principally garaged.
help us enforce them. However, "auto" does not include "mobile
b. Waiver Of Rights Of Recovery (Waiver Of equipment".
Subrogation)5. "Bodily injury" means physical:
If the insured has waived any rights of a. Injury;
recovery against any person or organization
for all or part of any payment, including b. Sickness; or
Supplementary Payments, we have made c. Disease
under this Coverage Part, we also waive that sustained by a person and, if arising out of the
right, provided the insured waived their rights above, mental anguish or death at any time.
of recovery against such person or
organization in a contract, agreement or
6. "Coverage territory" means:
permit that was executed prior to the injury or a. The United States of America (including its
damage. territories and possessions), Puerto Rico and
9. When We Do Not Renew Canada;
If we decide not to renew this Coverage Part, we b. International waters or airspace, but only if
will mail or deliver to the first Named Insured the injury or damage occurs in the course of
shown in the Declarations written notice of the travel or transportation between any places
nonrenewal not less than 30 days before the
included in a. above; or
expiration date. c. All other parts of the world if the injury or
If notice is mailed, proof of mailing will be
damage arises out of:
sufficient proof of notice. 1) Goods or products made or sold by you in
SECTION V—DEFINITIONS the territory described in a. above;
1. "Advertisement" means the widespread public 2) The activities of a person whose home is
dissemination of information or images that has in the territory described in a. above, but is
the purpose of inducing the sale of goods, away for a short time on your business; or
products or services through: 3) "Personal and advertising injury" offenses
a. (1) Radio; that take place through the Internet or
similar electronic means of communication
2) Television;
provided the insured's responsibility to pay
3) Billboard; damages is determined in the United States of
4) Magazine; America (including its territories and possessions),
5) Newspaper; or Puerto Rico or Canada, in a "suit" on the merits
according to the substantive law in such territory or
b. Any other publication that is given widespread in a settlement we agree to.
public distribution.
7. "Employee" includes a "leased worker".
However, "advertisement" does not include: Employee" does not include a "temporary
a. The design, printed material, information or worker".
images contained in, on or upon the 8, "Employment-Related Practices" means:
packaging or labeling of any goods or
a. Refusal to employ that person;products; or
b. An interactive conversation between or b. Termination of that person's employment; or
among persons through a computer network. c. Employment-related practices, policies, acts
2. "Advertising idea" means any idea for an or omissions, such as coercion, demotion,
advertisement". evaluation, reassignment, discipline,
defamation, harassment, humiliation,
3. "Asbestos hazard" means an exposure or discrimination or malicious prosecution
threat of exposure to the actual or alleged directed
a
that person.
properties of asbestos and includes the mere
presence of asbestos in any form. 9. "Executive officer" means a person holding any
of the officer positions created by your charter,4. "Auto" means: constitution, by-laws or any other similar
a. A land motor vehicle, trailer or semitrailer governing document.
designed for travel on public roads, including 10."Hostile fire" means one which becomes
any attached machinery or equipment; or uncontrollable or breaks out from where it was
b. Any other land vehicle that is subject to a intended to be.
compulsory or financial responsibility law or
Page 18 of 21 HG 00 01 09 16
Policy No 57WEAPK7544
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF OUR RIGHT TO RECOVER FROM
OTHERS ENDORSEMENT - CALIFORNIA
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not
enforce our right against the person or organization named in the Schedule. (This agreement applies only to the
extent that you perform work under a written contract that requires you to obtain this agreement from us.)
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in
the work described in the Schedule.
The additional premium for this endorsement shall be % of the California workers' compensation premium
otherwise due on such remuneration.
SCHEDULE
Person or Organization Job Description
All persons and/or orginizations that are required
by written contract or agreement with the
insured,executed prior to the accident or loss.
That a waiver of subrogation be provided under
this policy for work performed by you for that
person and/or organization
Cass Hamann
Countersigned by
Authorized Representative
Form WC 04 03 06 1) Printed in U.S.A.
Process Date: Policy Expiration Date:
Bond No. 30079836
Payment Bond Premium: Included in
Performance Bond
The City of Cupertino ("City") and Lewis and Tibbitts, Inc. ("Contractor") have entered into a
contract, dated August 5 2019("Contract")for work on the 2019 Minor Asphalt
Repairs Project("Project"). The Contract is incorporated by reference into this Payment Bond
Bond").
1. General. Under this Bond, Contractor as principal and Western Surety Company
its surety("Surety"), are bound to City as obligee in an amount not less than$92,970.00,
under California Civil Code sections 9550, et seq., to ensure payment to authorized
claimants. This Bond is binding on the respective successors, assigns, owners, heirs, or
executors of Surety and Contractor.
2. Surety's Obligation. If Contractor or any of its Subcontractors fails to pay a person
authorized in California Civil Code section 9100 to assert a claim against a payment bond,
any amounts due under the Unemployment Insurance Code with respect to work or labor
performed under the Contract, or any amounts required to be deducted, withheld, and paid
over to the Employment Development Department from the wages of employees of
Contractor and its Subcontractors, under California Unemployment Insurance Code section
13020,with respect to the work and labor, then Surety will pay the obligation.
3. Beneficiaries. This Bond inures to the benefit of any of the persons named in California
Civil Code section 9100, so as to give a right of action to those persons or their assigns in
any suit brought upon this Bond. Contractor must promptly provide a copy of this Bond
upon request by any person with legal rights under this Bond.
4. Duration. If Contractor promptly makes payment of all sums for all labor, materials, and
equipment furnished for use in the performance of the Work required by the Contract, in
conformance with the time requirements set forth in the Contract and as required by
California law, Surety's obligations under this Bond will be null and void. Otherwise,
Surety's obligations will remain in full force and effect.
5. Waivers. Surety waives any requirement to be notified of alterations to the Contract or
extensions of time for performance of the Work under the Contract. Surety waives the
provisions of Civil Code sections 2819 and 2845. City waives the requirement of a new
bond for any supplemental contract under Civil Code section 9550. Any notice to Surety
may be given in the manner specified in the Contract and delivered or transmitted to Surety
as follows:
Attn: Paul Kitchell
Address: Western Surety Company, 555 Mission Street, Suite 200
City/State/Zip: San Francisco, CA 94105
Phone: (415)932-7500
Fax: (415)932-7185
Email: Paul.Kitchellta)cnasurety.com
6. Law and Venue. This Bond will be governed by California law, and venue for any dispute
pursuant to this Bond will be in the Santa Clara County Superior Court, and no other place.
Surety will be responsible for City's attorneys'fees and costs in any action to enforce the
provisions of this Bond.
2019 Minor Asphalt Repairs Project PAYMENT BOND
Project#2019-111 Page 6
Bond No. 30079836
7. Effective Date; Execution. This Bond is entered into and is effective on August 8
201a.
SURETY: Western Surety Company
Business Name
r
Nancy L. Hamilton,Attorney-in-Fact
Name/Title
Date: August 8, 2019
Attach Acknowledgment with Surety's Notary Seal and Power of Attorney.)
CONTRACTOR: Lewis and Tibbitts, Inc.
Bus' ess Name
s/
Buster Segura, President
Name/Title
Date: tJ LI-2 Y
s/
Name/Title
END OF PAYMENT BOND
2019 Minor Asphalt Repairs Project PAYMENT BOND
Project#2019-111 Page 7
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§1189
r•.cx.,_dcs.s:c,r.r c x.r,i.ecc r c ;c-. .-- -- r,ca
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 San Francisco
On All I"4before me, Nerissa S. Bartolome, Notary PublicOn
Date Here Insert Name and Title of the Officer
personallyappeared Nancy L. Hamilton-------------------------------------------------------------------------------------------------------
Name(s)of Signer(s)
who proved to me on the basis of satisfactory evidence to be the person( whose name($) is/ire
subscribed to the within instrument and acknowledged to me that be/she/they executed the same in
11s/her/their authorized capacity(ies),and that by hir./her/tlir signature(s)on the instrument the personK,
or the entity upon behalf of which the personXacted, 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.
NERISSAS.BARTOLOME WITNESS my hand and official seal.
Notary Public-CaliforniaI
San Francisco County z
Commission N 2290576 j d
My Comm.Expires Jun 24,2023 Signature
Signature of Notary Public
Place Notary Seal Above
OPTIONAL
Though this section is optional, completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document: Document Date:
Number of Pages: Signer(s) Other Than Named Above:
Capacity(lies) Claimed by Signer(s)
Signer's Name: Nancy L. Hamilton ----------------------- er's Name:
O Corporate Officer — Title(s): - Co r to Of Title(s):
Partner — Limited General Partner — invited Gen
Individual CU Attorney in Fact Individual ttor In Fact
Trustee El Guardian or Conservator I Trustee a or Conservator
Other: Other:
Signer Is Representing: Signer epresenting:
02014 National Notary Association -www.NationalNotary.org - 1-800-US NOTARY(1-800-876-6827) Item#5907
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CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT 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 truthfulness,accuracy,or validity of that document.
State of California 1
County of SANTA CLARA J}
On
8/12/19
before me,
RHONDA L. O'NEAL-FULTZ
Dote Here Insert Name and Title of the Officer
personally appeared -- BUSTER SEGURA AND NO OTHERS ---------------------------------
Name(s)of Signer(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
RHONDA L.O'NEAL-FULTZ laws of the State of California that the foregoing
NotaryPublic-California
r paragraph is true and correct.
z Santa Clara County y
CommiExpiresO 7,2 WITNESS my hand and official seal.118
My Comm.Expires Oct 7,2021
J
Signat
Place Notary Seal and/or Stamp Above jUilattIrp Af Notary Public
OPTIONAL
Completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document: --Payment Bond 30079836-City of Cupertino-- p
Document Date: 08-Aug-2019 Number of Pages: 2
Nancy Hamilton ---Signer(s) Other Than Named Above: - y iI
Capacity(ies) Claimed by Signer(s)
Signer's Name: Buster Segura Signer's Name: Nancy Hamilton
M Corporate Officer—Title(s): PuC§dmt Corporate Officer—Title(s):
Partner— Limited General Partner— Limited General
Individual Attorney in Fact Individual Attorney in Fact
Trustee Guardian of Conservator Trustee Guardian of Conservator
Other: Other:
Signer is Representing: Signer is Representing:
02017 National Notary Association
California All-Purpose Acknowledgment
The so-called"all-purpose"acknowledgment wording,as prescribed in Still,however,any acknowledged document notarized and filed or
California Civil Code Section 1189(a),is mandatory for all acknowledgments recorded in California must bear only an all-purpose certificate.
taken in the state,whether the acknowledger is signing as an individual or
a representative(partner,corporate officer,attorney in fact,trustee,etc.).State law requires the"all-purpose"certificate wording to be used exactly
Law permits California Notaries to use an out-of-state acknowledgment
as it appears in statute.
form on a document that will be filed in that other state or U.S.jurisdiction, The optional section at the bottom can deter alteration of the document
but only if"the form does not require the Notary to determine or certify or fraudulent reattachment of this form to an unintended document.The
that the signer holds a particular representative capacity or to make other insertions in this section are not required by law.Failure to fill out this
determinations and certifications not allowed by California law"(Civil Code section will not affect the validity of the certificate.
Section 1189[cl.
Instructions:
Q NAME OF COUNTY where m SIGNER(S)OTHER THAN
Notary performs notarization. NAMED IN SPACE 4.Since all
Q DATE OF NOTARIZATION.
signers might not be named on the
same notarial certificate,insert name(s)
Actual month,day and year in which CALIFORNIA—PURPOSE ACKNOWLEDGMENT CIVIL CODE1HE9 of signer(s)here that appear(s)or will
signer(s)appear(s)before Notary. ry ,I"rom«.m,N. ..;,,_ mlfi °-'RlbeJ ry:ItM1c ncnLdw°agnecMerl°mm Ip appear on other certificates—as many asn^wllltli Nrs ce^M1mle is atladied,anJ net ha W Orlulness,ac"sry.0 vdltllly aI Jra'.J°ulment
Q NAME AND TITLE OF space allows.If there are a large number
9mteel Cahrpmia
tos a of signers,a notation such as"Mary SmithNOTARIZINGOFFICER.In the case nryvr lweies O
of a Notary,"Notary Public"would be QOn auNw,eon bel., 0 Pat x Jones,tJofara Wbic and 28 other signers"will suffice.If none,
Dale Na-I^ ^N°m and r,l,°,
the title. Pars IlyaPme ,. 146081 T.Smifh insert"no other signers."
NameP,ersmne=la,
Q NAME(S)OF SIGNER(S) wh°pmxtlmme°nN°basis°rseLL sbryeNtleKelobeNepe oMslw°enemesllLamsAutlbetl D NAME(S)OF SIGNER(S)from
IR the wlNln Insmvne.1 end ecMmwletlgetl IR me Nat helsheAhey—.ed me same In hSArerlmd,
appearing before Notary.Initials and uh°deh ,.apdmatbyhied.—h"9°`°m"'°nlheln"m m"ap"°Ma,."me n°" space 4 whose capacity and representeduponbehallRfwhkhIna,d fl,.t b acted,e,ecNed me Inzeument
spelling of name(s)should agree with entity follow. ,
c y undur PENALTY OF PERJURY and m r
name(s)signed on document and ID card. p, ---Iaw.°ythe9mte°reamnml °"^elemg,9
CAPACITY CLAIMED BY1a.1thisW anditR
Line through any remaining space. N ""
W NESSmyhantlande elalseal VSIGNER.Check appropriate box to
Q SIGNATURE OF NOTARY 919namre Pat indicate whether signer is signing as
exactly as name appears on commissioning OPTIONAL
individual,(on his or herown'behalf),ormpALo
in ace 3 and in seal.mPleamR,Ar-^l-rm°n°^°°ndete,°Aar°^°^R,I^°°°°pm°al°, aWiGrporate officer'(1ndirate corporatepapers, P A,pdr,knrrm,ro,mmRn°alnlenaeddr
Dezctlpti RyAtlaNedDOcumenl title),partner(indicate whether"limited"
Q NOTARY SEAL IMPRINT, eLrTpeulDpDmenn r9rarif Deed Q
Doe,.—Date: duly 19.2011 Numbey 9 one or"general"partner),attorney in fact,
clearly and legibly affixed. SE—N)Omer hanNamedAbnve no r sr lers Wa
trustee,guardian/conservator,or in
Cepeciryllesl Glelmetl by 51
SPACES 7-14 ARE OPTIONAL. oI9""'=Nam r(J @f 1`4ritn m GDi9ne,a"ame: another capacity.
C°ry°r°te Omcer—ThIC(sk C°ry°rete omcer—TIEe(sk
PaRner— Limited O General Partner—O Ll d D General
Omission of information here will lndMd.1 pA'a,la ol[°uryala rN'W.., oEaarJlanmCm yat°r DESCRIPTION OF OTHER
not affect the document's validity. 51°elsRepe ep"pA: s,°°R°pe°ndn9:CAPACITY(IES).A single capacity,
However,completing these spaces can n ,,.,,, x, F such as"executor,"may be indicated
deter alteration of the document or zoly n nal Notary AsmcWt n
here;or a multiple capacity,such as
fraudulent reattachment of this form corporate officer signing for partnership
to on unintended document in which corporation is partner."
Q TITLE OR TYPE OF C)NAME OF PERSON OR LEGAL
DOCUMENT notarized,such as ENTITY that signer is representing.
Grant Deed." It could,for example,be the name
Q DATE OF DOCUMENT notarized. of an absent person represented by
Most but not all documents will have a attorney in fact.It could be the name
date,usually at the top or following the of a condominium association,such
signature.If none,insert"No Date." as"Blue Lagoon Condo Assn."Or it
could be multiple entities,such as"XYZ
Q NUMBER OF PAGES in the Corp.,partner in Mutual Enterprises,a
notarized document.This may point out partnership."
fraudulent addition or removal of pages.
Do not count the certificate as a page.
However,the certificate will be regarded as
a page by recording officials in assessing NATIONAL
recording fees. J!AkNOTARY
AREDD IATION® ASSOCIATION
9350 De Soto Ave.,Chatsworth, CA 91311-4926 1 1-800-876-6827 1 National Notary.org
02017 National Notary Association Item#05907
Western Surety Company
POWER OF ATTORNEY APPOINTING INDIVIDUAL ATTORNEY-IN-FACT
Know All Men By These Presents,That 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 State of South Dakota,and that it does by virtue of the signature and seal herein affixed hereby
make,constitute and appoint
Charles R Shoemaker, Nancy L Hamilton, Roger C Dickinson, Stanley D Loar, Mark
M Munekawa, Joan DeLuca, Kelly Holtemann, Nerissa S Bartolome, Alicia Dass, Patrick
R Diebel,Yvonne Roncagliolo, Thomas E Hughes,Valerie Garcia, Sara Ridge, Individually
of Novato and San Francisco,CA,its true and lawful Attomey(s)-in-Fact with full power and authority hereby conferred to sign,seal and execute for and on
its behalf bonds,undertakings and other obligatory instruments of similar nature
In Unlimited Amounts -
and to bind it thereby as fully and to the same extent as if such instruments were signed by a duly authorized officer of the corporation and all the acts of said
Attorney,pursuant to the authority hereby given,are hereby ratified and confirmed.
This Power of Attorney is made and executed pursuant to and by authority of the By-Law printed on the reverse hereof,duly adopted,as indicated,by
the shareholders of the corporation.
In Witness Whereof, WESTERN SURETY COMPANY has caused these presents to be signed by its Vice President and its corporate seal to be
hereto affixed on this 2nd day of May,2019.
WESTERN SURETY COMPANY
daQy S..._•,..,4p y
DPµ `
r aul T.Bruflat,Vice President
State of South Dakota
ss
County of Minnehaha
On this 2nd day of May,2019,before me personally came Paul T.Bruflat,to me known,who,being by 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 the seal of said corporation;that the seal affixed to the said instrument is such corporate seal;that it was so affixed
pursuant to authority given by the Board of Directors of said corporation and that he signed his name thereto pursuant to like authority,and acknowledges
same to be the act and deed of said corporation.
My commission expires s$
NOTARYPUBLIC
J.MOHR
June 23,2021
s SOUTH DAKOTA srrr 6S
i
J.Mohr,Notary Public
CERTIFICATE
I, L.Nelson,Assistant Secretary of WESTERN SURETY COMPANY do hereby certify that the Power of Attorney hereinabove set forth is still in
i
force,and further certify that the By-Law of the corporation printed on the reverse hereof is still in force. In testimony whereof I have hereunto subscribed
my name and affixed the seal of the said corporation this 8th day of August,2019.
5"aET};,' WESTERN SURETY COMPANY
Ogq J o
v*.SEAS-.'•=
wumwoaN`
L.Nelson,Assistant Secretary
Form F4280-7-2012
Go to www.cnasurety.com >Owner/Obligee Services>Validate Bond Coverage,if you want to verify bond authenticity.
Authorizing By-Law
ADOPTED BY THE SHAREHOLDERS OF WESTERN SURETY COMPANY
This Power of Attorney is made and executed pursuant to and by authority of the following By-Law duly adopted by the shareholders
of the Company.
Section 7. All bonds, policies, undertakings, Powers of Attorney, or other obligations of the corporation shall be executed in the
corporate name of the Company by the President, Secretary, and Assistant Secretary, Treasurer, or any Vice President, or by such other
officers as the Board of 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 of the
corporation. The signature of any such officer and the corporate seal may be printed by facsimile.
Request for Taxpayer
Form Give Form to the
Rev.November2017) Identification Number and Certification requester. Do not
Department of the Treasury send to the IRS.
Internal Revenue Service Go to www.irs.gov/FormW9 for instructions and the latest information.
1 Name(as shown on your income tax return).Name Is required on this line;do not leave this line blank.
Lewis and Tibbitts,Inc
2 Business name/disregarded entity name,if different from above
M 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1.Check only one of the 4 Exemptions(codes apply only to
following seven boxes. certain entities,not individuals;see
a instructions on page 3):
C ElIndividual/sole proprietor or C Corporation S Corporation Partnership Trust/estate
single-member LLC Exempt payee code(if any)j
Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)
p 2 Note:Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting
N LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
code(if any)another LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC that
n o is disregarded from the owner should check the appropriate box for the tax classification of Its owner.w
V Other(see instructions) Applles to accounts maintained outside the U.S.)j
da 5 Address(number,street,and apt,or suite no.)See instructions. Requester's name and address(optional)W
CID 1470 Industrial Ave
6 City,state,and ZIP code
San Jose,CA 95112
7 List account number(s)here(optional)
Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid Social security number
backup withholding.For individuals,this is generally your social security number(SSN.However,for a T -resident alien,sole proprietor,or disregarded entity,see the instructions for Part I,later.For other
entities,it is your employer identification number(EIN).If you do not have a number,see How to get a
TIN,later, or
Note:If the account is in more than one name,see the instructions for line 1.Also see What Name and Employer identification number
Number To Give the Requester for guidelines on whose number to enter.
9 4 - 2 1 9 5 1 6 0
Certification
Under penalties of perjury,I certify that:
1.The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and
2.I am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding;and
3.1 am a U.S.citizen or other U.S.person(defined below);and
4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct.
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid,
acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments
other than interest and dividends,you are not requ ed to sign the certification,but you must provide your correct TIN.See the instructions for Part II,later.
Sign Signature of
Here U.S.person Date 8/12/2019
Form 1099-DIV(dividends,including those from stocks or mutualGeneralInstructions it
funds)
Section references are to the Internal Revenue Code unless otherwise
noted.Form 1099-MISC(various types of income,prizes,awards,or gross
proceeds)
Future developments.For the latest information about developments
Form 1099-B(stock or mutual fund sales and certain otherrelatedtoFormW-9 and its instructions,such as legislation enacted
transactions by brokers)after they were published,go to www.irs.gov/FormW9.
Form 1099-S(proceeds from real estate transactions)
Purpose of Form Form 1099-K(merchant card and third party network transactions)
An individual or entity(Form W-9 requester)who is required to file an Form 1098(home mortgage interest),1098-E(student loan interest),
information return with the IRS must obtain your correct taxpayer 1098-T(tuition)
identification number(TIN)which may be your social security number Form 1099-C(canceled debt)
SSN),individual taxpayer identification number(ITIN),adoption Form 1099-A(acquisition or abandonment of secured property)
taxpayer identification number(ATIN),or employer identification number
EIN),to report on an information return the amount paid to you,or other Use Form W-9 only if you are a U.S.person(including a resident
amount reportable on an information return.Examples of information alien),to provide your correct TIN.
returns include,but are not limited to,the following. If you do not return Form W-9 to the requester with a TIN,you might
Form 1099-INT(interest earned or paid) be subject to backup withholding.See What is backup withholding,
later.
Cat.No.10231X Form W-9(Rev.11-2017)
Performance Bond Bond No. 30079836
Premium: $930.00
The City of Cupertino ("City") and Lewis and Tibbitts, Inc. ("Contractor") have entered into a
contract, dated August 5 12019 ("Contract")for work on the 2019 Minor Asphalt
Repairs Project("Project"). The Contract is incorporated by reference into this Performance
Bond ("Bond").
1. General. Under this Bond, Contractor as Principal and Western Surety Company
its surety("Surety"), are bound to City as obligee for an amount not less than $92,970.00 to
ensure Contractor's faithful performance of its obligations under the Contract. This Bond is
binding on the respective successors, assigns, owners, heirs, or executors of Surety and
Contractor.
2. Surety's Obligations. Surety's obligations are co-extensive with Contractor's obligations
under the Contract. If Contractor fully performs its obligations under the Contract, including
its warranty obligations under the Contract, and Contractor has timely provided a warranty
bond as required under the Contract. Surety's obligations under this Bond will become null
and void upon City's acceptance of the Project, excluding any exceptions to acceptance, if
any. Otherwise Surety's obligation will remain in full force and effect until expiration of the
one year warranty period under the Contract.
3. Waiver. Surety waives any requirement to be notified of and further consents to any
alterations to the Contract made under the applicable provisions of the Contract
Documents, including changes to the scope of Work or extensions of time for performance
of Work under the Contract. Surety waives the provisions of Civil Code sections 2819 and
2845.
4. Application of Contract Balance. Upon making a demand on this Bond, City will make
the Contract Balance available to Surety for completion of the Work under the Contract.
For purposes of this provision, the Contract Balance is defined as the total amount payable
by City to Contractor as the Contract Price minus amounts already paid to Contractor, and
minus any liquidated damages, credits, or back charges to which City is entitled under the
terms of the Contract.
5. Contractor Default. Upon written notification from City of Contractor's termination for
default under Article 13 of the Contract General Conditions,time being of the essence,
Surety must act within the time specified in Article 13 to remedy the default through one of
the following courses of action:
5.1 Arrange for completion of the Work under the Contract by Contractor, with City's
consent, but only if Contractor is in default solely due to its financial inability to complete the
Work;
5.2 Arrange for completion of the Work under the Contract by a qualified contractor
acceptable to City, and secured by performance and payment bonds issued by an admitted
surety as required by the Contract Documents, at Surety's expense; or
5.3 Waive its right to complete the Work under the Contract and reimburse City the
amount of City's costs to have the remaining Work completed.
6. Surety Default. If Surety defaults on its obligations under the Bond, City will be entitled to
recover all costs it incurs due to Surety's default, including legal, design professional, or
delay costs.
2019 Minor Asphalt Repairs Project PERFORMANCE BOND
Project#2019-111 Page 8
Bond No. 30079836
7. Notice. Any notice to Surety may be given in the manner specified in the Contract and
sent to Surety as follows:
Attn: Paul Kitchell
Address: Western Surety Company- 555 Mission Street, Suite 200
City/State/Zip: San Francisco. CA 94105
Phone: (415)932-7500
Fax: (415)932-7185
Email: Paul, Kitchell(&cnasurety.com
8. Law and Venue. This Bond will be governed by California law, and venue for any dispute
pursuant to this Bond will be in the Santa Clara County Superior Court, and no other place.
Surety will be responsible for City's attorneys'fees and costs in any action to enforce the
provisions of this Bond.
9. Effective Date; Execution. This Bond is entered into and effective on
August 8 12019 .
SURETY: Western Surety Company
Business Name
sl
Nancy L. Hamilton, Attorney-in-Fact
Name/Title [print]
Acknowledgment with Notary Seal for Surety and Surety's Power of Attorney must be attached.)
CONTRACTOR: Lewis and Tibbitts, Inc.
Busin ss Name
s/
Buster Segura, President
Name/Title
Date:
s/
Name/Title
Date:
END OF PERFORMANCE BOND
2019 Minor Asphalt Repairs Project PERFORMANCE BOND
Project#2019-111 Page 9
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189
r,rec,rdrzrisr,r,r,r r,,,>.r s„,cc•.cc rcc, c•ra;ic-rc csm.,..=c ca
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 San Francisco
G Nerissa S. Bartolome, Notar PublicOnltll;j before me,y
Date Here Insert Name and Title of the Officer
personally appeared Nancy L. Hamilton-------------------------------------------------------------------------------------------------------
Name(s)of Signer(s)
who proved to me on the basis of satisfactory evidence to be the person(p) whose name(s) is/gre
subscribed to the within instrument and acknowledged to me that be/she/tttieq executed the same in
Ws/her/j1*r authorized capacity{ies),and that by It/her/ttir signature(g)on the instrument the personK,
or the entity upon behalf of which the personnXacted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph
NERISSA S.BARTOLOME
is true and correct.
s F Notary Public California WITNESS my hand and official seal.
San Francisco County
Commission#2290576
r` •"
My Comm.Expires Jun 24,2023 LCSignature s
Signature of Notary Public
Place Notary Seal Above
OPTIONAL
Though this section is optional, completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document: Document Date:
Number of Pages: __ Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name: Nancy L. Hamilton ----------------------- e' 's Nrame:
El Corporate Officer — Title(s): _ Cor to Officer — Title(s):
Partner — El Limited General Partner — imited <Gn
Individual Attorney in Fact Individual ttt
Trustee Guardian or Conservator Trustee nservator
Other: Other:
Signer Is Representing: Signer epresenting:
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02014 National Notary Association •www.NationalNotary.org - 1-800-US NOTARY(1-800-876-6827) Item#5907
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CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT 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 truthfulness,accuracy,or validity of that document. j
i
State of California
County of SANTA CLARA
On
8/12/19
before me,
RHONDA L. O'NEAL-FULTZ
Date Here Insert Name and Title of the Officer
personally appeared -- BUSTER SEGURA AND NO OTHERS ---------------------------------
Name(s)of Signer(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
RHONDA L.O'NEAL-FULTZ paragraph is true and correct.
Notary Public—California
Santa Clara County WITNESS my hand and o eal.
Commission M 21217118
My Comm.Expires Oct 7,2021
Signature
Place Notary Seal and/or Stamp Above Signa f Notary Public
OPTIONAL
Completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document: --Performance Bond 30079836-City of Cupertino-- p
Document Date: 08-Aug-2019 NumberofPages: 2
Signer(s) Other Than Named Above: --- Nancy Hamilton ---
Capacity(ies) Claimed by Signer(s)
Signer's Name: Buster Segura Signer's Name: Nancy Hamilton
0 Corporate Officer— Title(s): Piic Corporate Officer—Title(s):
Partner— Limited General Partner— Limited General
Individual Attorney in Fact Individual E] Attorney in Fact
Trustee Guardian of Conservator Trustee Guardian of Conservator
Other: Other:
Signer is Representing: Signer is Representing:
02017 National Notary Association
California All-Purpose Acknowledgment
The so-called"all-purpose"acknowledgment wording,as prescribed in Still,however,any acknowledged document notarized and filed or
California Civil Code Section 1189(a),is mandatory for all acknowledgments recorded in California must bear only an all-purpose certificate.
taken in the state,whether the acknowledger is signing as an individual or
a representative(partner,corporate officer,attorney in fact,trustee,etc.).State law requires the"all-purpose"certificate wording to be used exactly
as it appears in statute.
Law permits California Notaries to use an out-of-state acknowledgment
form on a document that will be filed in that other state or U.S.jurisdiction, The optional section at the bottom can deter alteration of the document
but only if"the form does not require the Notary to determine or certify or fraudulent reattachment of this form to an unintended document.The
that the signer holds a particular representative capacity or to make other insertions in this section are not required by law.Failure to fill out this
determinations and certifications not allowed by California law"(Civil Code section will not affect the validity of the certificate.
Section 1189[c]).
Instructions:
Q NAME OF COUNTY where m SIGNER(S)OTHER THAN
Notary performs notarization. NAMED IN SPACE 4.Since all
signers might not be named on the
Q DATE OF NOTARIZATION. same notarial certificate,insert name(s)
Actual month,day and year in which CALIFORNIA ALL-PURPOSEACIWOWLED—ENT CIVIL CODE41189 of signer(s)here that appear(s)or will
signer(s)appear(s)before Notary. rypue„° m r ry „,w appear on other certificates—as many as
mw„mbum..u, namea.alm ma euawwme>:.a,:v.°,°"muv u lli=a°cm
NAME AND TITLE OF
o°° space allows.If there are a large number
sm!e Ar cam°min
NOTARIZING OFFICER.In the case c.—ye tos Angeles of signers,a notation such as"Mary Smith
of a Notary,"Notary Public"would be on 'TUN 19,Z011haei
I-
insert
vat a Bones rlotary"lic 8noother signers"
er
will suffice.If none,
t4ic
the title.
p Hm^Inur!Namc ntl Tln ,
personalty appeared
Q NAME(S)OF SIGNER(S) A°pr°comma°nNebasis°r au na°yMtle e!°beNeprsolslwM1°enam zli aesuhnlb0 Q NAME(S)OF SIGNER(S)from
the witnln i,utwnent and actor I.O,,etlIemeNezM1e/sne/IM1ey usccartetl!M1e sameIn hkmerlmelr
appearing before Notary.Initials and
auawazeticapad QesLand!M1atbyM1l merRMlrsignaWclz)onNUln n m nlNep °Msl,orm° ary space 4 whose capacity and representednp°n henerc°rwnlen Ina person):I anew.e.ec°lee me InsTrumenL
spelling of name(s)should agree with entity follow.
I cemty antler PENALTY. PERJURY antler IM1e
names signed on document and ID card. w.°`ne9'°I°a °`°m'°'h°""°r°'eg°'^g
9 par .pl,lslmeanaenn n Q„(;<#P.ACITY qLA AR.BY
Line through any remaining space. W NP99myM1anaananmdalaeaL SIGNER.Check a,ppmpriatetbox toµrue sr.mn iID
Q SIGNATURE OF NOTARY Pat R. ,& Q indicate whether signer is sighing as
Signelure
exactly as name appears on commissioning
individual(on his or her din'behalf),or
OPTIONAL
papers,in space 3 and in seal.
mAknngw='^'=,m°!m^°°^'e!e,°"er°°°^nr!"°'°`nmenlw as corporate officer{Indl 2teorporate
b°°amen,rem!°rnmem°Wino r°,m m°n°^m!e^Bea a°c°menr
i
D.s<rmuAn Ar-nea DAcumem Ai"a,.y,-.... .tlt e),1.1]ArWq(,(i11,..U..%tPVI.Wo f"limited„
Q NOTARY SEAL IMPRINT, nae....arDnmmenL rTrant Deed O
DncnmemDale: surd.Via,eon N°mhe L 9e,: rn'e or"general"partner),attorney in fact,
clearly and legibly affixed. gne a,OM1n na"Nam°tlwo e:no°der s'cers f
a
trustee,guardian/conservator,or in
Gpaciry asl filelmedb 5I
SPACES 7-14 ARE OPTIONAL. o'er°`°'""mC1 ruX a@ff' n o "ame: another capacity.
P..r uOmur-n9e151: cAry°mle Omcer-TRIe
qPaMe-_Llmlletl°General O Pmmer-O Llmitetl o G.General
Omission of information here will 01na6atlaal DAn.-1.F- OInd.—I OAn°meyI"F.. DESCRIPTION OF OTHER
Trustee °Gualalmi vl C°nsnwlw O Tms Gemolan°I Cunsrva!m
not affect the document's validity. Sig—I, CAPACITY(IES).A single capacity,9lgner.is Represen3n9: Slgner is Represem!ng:
However,completing these spaces can a>.=_>u »,:.,a such as"executor,"may be indicated
deter alteration of the document or here;or a multiple capacity,such as
fraudulent reattachment of this form corporate officer signing for partnership
to on unintended document. in which corporation is partner."
Q TITLE OR TYPE OF m NAME OF PERSON OR LEGAL
DOCUMENT notarized,such as ENTITY that signer is representing.
Grant Deed." It could,for example,be the name
Q DATE OF DOCUMENT notarized.
of an absent person represented by
Most but not all documents will have a
attorney in fact.It could be the name
date,usually at the top or following the
of a condominium association,such
signature.If none,insert"No Date."
as"Blue Lagoon Condo Assn."Or it
could be multiple entities,such as"XYZ
Q NUMBER OF PAGES in the Corp.,partner in Mutual Enterprises,a
notarized document.This may point out partnership."
fraudulent addition or removal of pages.
Do not count the certificate as a page.
However,the certificate will be regarded as
a page by recording officials in assessing NATIONAL
recording fees. NOTARY
A330CIATIO N® ASSOCIATION
9350 De Soto Ave., Chatsworth, CA 91311-4926 1 1-800-876-6827 1 NationalNotary.org
02017 National Notary Association
Item N05907
Western Surety Company
POWER OF ATTORNEY APPOINTING INDIVIDUAL ATTORNEY-IN-FACT
Know All Men By These Presents,That 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 State of South Dakota,and that it does by virtue of the signature and seal herein affixed hereby
make,constitute and appoint
Charles R Shoemaker, Nancy L Hamilton, Roger C Dickinson, Stanley D Loar, Mark
M Munekawa, Joan DeLuca, Kelly Holtemann, Nerissa S Bartolome, Alicia Dass, Patrick
R Diebel,Yvonne Roncagliolo, Thomas E Hughes, Valerie Garcia, Sara Ridge, Individually
of Novato and San Francisco,CA,its true and lawful Attomey(s)-in-Fact with full power and authority hereby conferred to sign,seal and execute for and on
its behalf bonds,undertakings and other obligatory instruments of similar nature
In Unlimited Amounts -
and to bind it thereby as fully and to the same extent as if such instruments were signed by a duly authorized officer of the corporation and all the acts of said
Attorney,pursuant to the authority hereby given,are hereby ratified and confirmed.
This Power of Attorney is made and executed pursuant to and by authority of the By-Law printed on the reverse hereof,duly adopted,as indicated,by
the shareholders of the corporation.
In Witness Whereof, WESTERN SURETY COMPANY has caused these presents to be signed by its Vice President and its corporate seal to be
hereto affixed on this 2nd day of May,2019.
WESTERN SURETY COMPANY
I°i;oY,PORq j 3e;
Ws4 may== I
Paul T.Bruflat,Vice President
State of South Dakota 1
JjCountyofMinnehaha
ss
On this 2nd day of May,2019,before me personally came Paul T.Bruflat,to me known,who,being by 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 the seal of said corporation;that the seal affixed to the said instrument is such corporate seal;that it was so affixed
pursuant to authority given by the Board of Directors of said corporation and that he signed his name thereto pursuant to like authority,and acknowledges
same to be the act and deed of said corporation.
My commission expires J.MOHR
NOTARY PUBLIC
June 23,2021 BBAL SOUTH s
J.Mohr,Notary Public
CERTIFICATE
I,L. Nelson,Assistant Secretary of WESTERN SURETY COMPANY do hereby certify that the Power of Attorney heremabove set forth is still in
force,and further certify that the By-Law of the corporation printed on the reverse hereof is still in force. In testimony whereof I have hereunto subscribed
my name and affixed the seal of the said corporation this 8th day of August,2019.
aS RET}c, WESTERN SURETY COMPANY
H 4 l^i9
s P6'VrH DPµ,p`,:
zun w..CY 2",,/
L.Nelson,Assistant Secretary
Form F4280-7-2012
Go to www.cnasurety.com >Owner/Obligee Services>Validate Bond Coverage, if you want to verify bond authenticity.
Authorizing By-Law
r
ADOPTED BY THE SHAREHOLDERS OF WESTERN SURETY COMPANY
This Power of Attorney is made and executed pursuant to and by authority of the following By-Law duly adopted by the shareholders
of the Company.
Section 7. All bonds, policies, undertakings, Powers of Attorney, or other obligations of the corporation shall be executed in the
corporate name of the Company by the President, Secretary, and Assistant Secretary, Treasurer, or any Vice President, or by such other
officers as the Board of 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 of the
corporation. The signature of any such officer and the corporate seal may be printed by facsimile.