19-129 (1)Placeworks, Inc., for Loc-N-Store Self Storage ProjectCITY OF
a PROFESSIONAL/CONSULTING SERVICES AGREEMENT
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CUPERTINO
1. PARTIES
a
This Agreement is made and entered into as of June 28, 2019
Effective Date") by and between the City of Cupertino, a municipal corporation ("City"), and
PLACEWORKS, INC Contractor"),
a corporation
for the preparation of notice of exemption for the Loc-N-Store Self Storage project
2. SERVICES
Contractor agrees to provide the services and perform the tasks ("Services") set forth in detail in
Scope of Services, attached here and incorporated as Exhibit A.
3. TIME OF PERFORMANCE
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3.1 This Agreement begins on the Effective Date and ends on June 30, 2020
Contract Time"), unless terminated earlier as provided herein. Contractor's Services shall begin
on July 16, 2019 and shall be completed by June 30, 2020
3.2 Schedule of Performance. Contractor must deliver the Services in accordance with the
Schedule of Performance, attached and incorporated here Exhibit B.
3.3 Time is of the essence for the performance of all the Services. Contractor must have
sufficient time, resources, and qualified staff to deliver the Services on time.
4. COMPENSATION
4.1 Maximum Compensation. City will pay Contractor for satisfactory performance of the
Services an amount that will based on actual costs but that will be capped so as not to exceed
9,454.20 Contract Price"), based upon the scope of services in Exhibit A and
the budget and rates included in Exhibit C, Compensation attached and incorporated here. The
maximum compensation includes all expenses and reimbursements and will remain in place even
if Contractor's actual costs exceed the capped amount. No extra work or payment is permitted
without prior written approval of City.
4.2 Invoices and Payments. Monthly invoices must state a description of the deliverable
completed and the amount due for the preceding month. Within thirty (30) days of completion of
Services,Contractor must submit a requisition for final and complete payment of costs and pending
claims for City approval. Failure to timely submit a complete and accurate payment requisition
relieves City of any further payment or other obligations under the Agreement.
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5. INDEPENDENT CONTRACTOR
5.1 Status. Contractor is an independent contractor and not an employee, partner, or joint
venture of City. Contractor is solely responsible for the means and methods of performing the
Services and for the persons hired to work under this Agreement. Contractor is not entitled to
health benefits, worker's compensation or other benefits from the City.
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5.2 Contractor's Qualifications.Contractor warrants on behalf of itself and its subcontractors
that they have the qualifications and skills to perform the Services in a competent and professional
manner and according to the highest standards and best practices in the industry.
5.3 Permits and Licenses. Contractor warrants on behalf of itself and its subcontractors that
they are properly licensed, registered, and/or certified to perform the Services as required by law
and have procured a City Business License.
5.4 Subcontractors. Only Contractor's employees are authorized to work under this
Agreement. Prior written approval from City is required for any subcontractor, and the terms and
conditions of this Agreement will apply to any approved subcontractor.
5.5 Tools, Materials and Equipment. Contractor will supply all tools, materials and
equipment required to perform the Services under this Agreement.
5.6 Payment of Taxes. Contractor must pay income taxes on the money earned under this
Agreement. Upon City's request, Contractor will provide proof of payment and will indemnify
City for violations pursuant to the indemnification provision of this Agreement.
6. PROPRIETARY/CONFIDENTIAL INFORMATION
In performing this Agreement, Contractor may have access to private or confidential information
owned or controlled by the City, which may contain proprietary or confidential details the
disclosure of which to third parties may be damaging to City. Contractor shall hold in confidence
all City information provided by City to Contractor and use it only to perform this Agreement.
Contractor shall exercise the same standard of care to protect City information as a reasonably
prudent contractor would use to protect its own proprietary data.
7. OWNERSHIP OF MATERIALS
7.1 Property Rights. Any interest (including copyright interests) of Contractor in any
product, memoranda, study, report, map, plan, drawing, specification, data, record, document or
other information or work, in any medium(collectively, "Work Product"),prepared by Contractor j
in connection with this Agreement will be the exclusive property of the City and shall not be shown
to any third-party without prior written approval of City.
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7.2 Copyright. To the extent permitted by Title 17 of U.S. Code,all Work Product arising out
of this Agreement is considered "works for hire" and all copyrights to the Work Product will be
the property of City. Alternatively, Contractor assigns to City all Work Product copyrights.
Contractor may use copies of the Work Product for promotion only with City's written approval.
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7.3 Patents and Licenses. Contractor must pay royalties or license fees required for
authorized use of any third party intellectual property, including but not limited to patented,
trademarked,or copyrighted intellectual property if incorporated into the Services or Work Product
of this Agreement.
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7.4 Re-Use of Work Product. Unless prohibited by law and without waiving any rights, City
may use or modify the Work Product of Contractor or its sub-contractors prepared or created under
this Agreement,to execute or implement any of the following:
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a) The original Services for which Contractor was hired;
b) Completion of the original Services by others;
c) Subsequent additions to the original Services; and/or
d) Other City projects.
7.5 Deliverables and Format. Contractor must provide electronic and hard copies of the
Work Product, on recycled paper and copied on both sides, except for one single-sided original.
8. RECORDS
Contractor must maintain complete and accurate accounting records relating to its performance in
accordance with generally accepted accounting principles. The records must include detailed
information of Contractor's performance, benchmarks and deliverables, which must be available
to City for review and audit. The records and supporting documents must be kept separate from
other records and must be maintained for four years from the date of City's final payment.
9. ASSIGNMENT
Contractor shall not assign, sublease, hypothecate, or transfer this Agreement, or any interest
therein, directly or indirectly, by operation of law or otherwise, without prior written consent of
City. Any attempt to do so will be null and void. Any changes related to the financial control or
business nature of Contractor as a legal entity is considered an assignment of the Agreement and
subject to City approval, which shall not be unreasonably withheld. Control means fifty percent
50%) or more of the voting power of the business entity.
10. PUBLICITY/SIGNS
Any publicity generated by Contractor for the project under this Agreement, during the term of
this Agreement and for one year thereafter, will reference the City's contributions in making the
project possible. The words "City of Cupertino" will be displayed in all pieces of publicity,
including flyers,press releases,posters, brochures,public service announcements, interviews and
newspaper articles. No signs may be posted, exhibited or displayed on or about City property,
except signage required by law or this Contract, without prior written approval from the City.
11. INDEMNIFICATION
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11.1 To the fullest extent allowed by law, and except for losses caused by the sole and active
negligence or willful misconduct of City personnel, Contractor shall indemnify, defend and hold
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harmless City, its City Council, boards and commissions, officers, officials, employees, agents,
servants, volunteers and consultants ("Indemnitees"), through legal counsel acceptable to City,
from and against any and all liability, damages, claims, actions, causes of action, demands,i
charges, losses, costs and expenses (including attorney fees, legal costs and expenses related to
litigation and dispute resolution proceedings) of every nature, arising directly or indirectly from
this Agreement or in any manner relating to any of the following:
a) Breach of contract, obligations, representations or warranties;
b) Negligent or willful acts or omissions committed during performance of the Services;
c) Personal injury,property damage,or economic loss resulting from the work or performance
of Contractor or its subcontractors or sub-subcontractors;
d) Unauthorized use or disclosure of City's confidential and proprietary Information;
e) Claim of infringement or violation of a U.S. patent or copyright, trade secret, trademark,
or service mark dr other proprietary or intellectual property rights of any third party.
11.2 Contractor must pay the costs City incurs in enforcing this provision. Contractor must
accept a tender of defense upon receiving notice from City of a third-party claim, in accordance
with California Public Contract Code Section 9201. At City's request, Contractor will assist City
in the defense of a claim, dispute or lawsuit arising out of this Agreement.
11.3 Contractor's duties under this section are not limited to the Contract Price, workers'
compensation payments, or the insurance or bond amounts required in the Agreement.Nothing in
the Agreement shall be construed to give rise to an implied right of indemnity in favor of
Contractor against City or any Indemnitee.
11.4. Contractor's payments may be deducted or offset to cover any money the City lost due to
a claim or counterclaim arising out of this Agreement, a purchase order, or other transaction.
12. INSURANCE
Contractor shall comply with the Insurance Requirements, attached and incorporated here as
Exhibit D, and must maintain the insurance for the duration of the Agreement, or longer as
required by City. City will not execute the Agreement until City approves receipt of satisfactory
certificates of insurance and endorsements evidencing the type, amount, class of operations
covered, and the effective and expiration dates of coverage. Failure to comply with this provision
may result in City, at its sole discretion and without notice, purchasing insurance for Contractor
and deducting the costs from Contractor's compensation or terminating the Agreement.
13. COMPLIANCE WITH LAWS
13.1 General Laws. Contractor shall comply with all local, state and federal laws and
regulations applicable to this Agreement. Contractor will promptly notify City of changes in the
law or other conditions that may affect the Project or Contractor's ability to perform. Contractor
is responsible for verifying the employment authorization of employees performing the Services,
as required by the Immigration Reform and Control Act.
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13.2 Labor Laws. Contractor shall comply with all labor laws applicable to this Agreement. If
the Scope of Services includes a"public works"component,Contractor is required to comply with
prevailing wage laws under Labor Code Section 1720 and other labor laws.
13.3 Discrimination Laws. Contractor shall not discriminate on the basis of race, religious
creed, color, ancestry, national origin, ethnicity, handicap, disability, marital status, pregnancy,
age, sex, gender, sexual orientation, gender identity, Acquired-Immune Deficiency Syndrome
AIDS) or any other protected classification. Contractor shall comply with all anti-discrimination
laws, including Government Code Sections 12900 and 11135, and Labor Code Sections 1735,
1777 and 3077.5. Consistent with City policy prohibiting harassment and discrimination,
Contractor understands that harassment and discrimination directed toward a job applicant, an
employee,a City employee,or any other person,by Contractor or its employees or sub-contractors
will not be tolerated.
13.4 Conflicts of Interest. Contractor shall comply with all conflict of interest laws applicable
to this Agreement and must avoid any conflict of interest. Contractor warrants that no public
official, employee, or member of a City board or commission who might have been involved in
the making of this Agreement, has or will receive a direct or indirect financial interest in this
Agreement, in violation of California Government Code Section 1090 et seq. Contractor may be
required to file a conflict of interest form if Contractor makes certain governmental decisions or
serves in a staff capacity, as defined in Section 18700 of the California Code of Regulations.
Contractor agrees to abide by the City's rules governing gifts to public officials and employees.
13.5 Remedies.Any violation of Section 13 constitutes a material breach and may result in City
suspending payments, requiring reimbursements or terminating this Agreement. City reserves all
other rights and remedies available under the law and this Agreement, including the right to seek
indemnification under Section 11 of this Agreement.
14. PROJECT COORDINATION
City Project Manager.The City assigns Erick Serreno as
the City's representative for all purposes under this Agreement, with authority to oversee the
progress and performance of the Scope of Services. City reserves the right to substitute another
Project manager at any time, and without prior notice to Contractor.
Contractor Project Manager. Subject to City approval, Contractor assigns Terri McCracken
as its single Representative for all purposes under this Agreement, with authority
to oversee the progress and performance of the Scope of Services. Contractor's Project manager
is responsible for coordinating and scheduling the Services in accordance with the Scope of
Services and the Schedule of Performance. Contractor must regularly update the City's Project
Manager about the progress with the work or any delays, as required under the Scope of Services.
City written approval is required prior to substituting a new Representative.
15. ABANDONMENT OF PROJECT
City may abandon or postpone the Project or parts therefor at any time. Contractor will be
compensated for satisfactory Services performed through the date of abandonment, and will be
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given reasonable time to assemble the work and close out the Services. With City's pre-approval
in writing,the time spent in closing out the Services will be compensated up to a maximum of ten
percent(10%) of the total time expended to date in the performance of the Services.
16. TERMINATION
City may terminate this Agreement for cause or without cause at any time. Contractor will be paid
for satisfactory Services rendered through the date of termination, but final payment will not be
made until Contractor closes out the Services and delivers the Work Product.
17. GOVERNING LAW, VENUE AND DISPUTE RESOLUTION
This Agreement is governed by the laws of the State of California. Any lawsuits filed related to
this Agreement must be filed with the Superior Court for the County of Santa Clara, State of
California. Contractor must comply with the claims filing requirements under the Government
Code prior to filing a civil action in court. If a dispute arises, Contractor must continue to provide
the Services pending resolution of the dispute.If the Parties elect arbitration,the arbitrator's award
must be supported by law and substantial evidence and include detailed written findings of law
and fact.
18. ATTORNEY FEES
If City initiates legal action,files a complaint or cross-complaint, or pursues arbitration,appeal,or
other proceedings to enforce its rights or a judgment in connection with this Agreement, the
prevailing party will be entitled to reasonable attorney fees and costs.
19. THIRD PARTY BENEFICIARIES
There are no intended third party beneficiaries of this Agreement.
20. WAIVER
Neither acceptance of the Services nor payment thereof shall constitute a waiver of any contract
provision. City's waiver of a breach shall not constitute waiver of another provision or breach.
21. ENTIRE AGREEMENT
This Agreement represents the full and complete understanding of every kind or nature between
the Parties, and supersedes any other agreement(s) and understanding(s), either oral or written,
between the Parties. Any modification of this Agreement will be effective only if in writing and
signed by each Party's authorized representative. No verbal agreement or implied covenant will
be valid to amend or abridge this Agreement. If there is any inconsistency between the main
Agreement and the attachments or exhibits thereto,the text of the main Agreement shall prevail.
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22. INSERTED PROVISIONS
Each provision and clause required by law for this Agreement is deemed to be included and will
be inferred herein. Either party may request an amendment to cure mistaken insertions or
omissions of required provisions. The Parties will collaborate to implement this Section, as
appropriate.
23. HEADINGS
The headings in this Agreement are for convenience only, are not a part of the Agreement and in
no way affect, limit or amplify the terms or provisions of this Agreement.
24. SEVERABILITY/PARTIAL INVALIDITY
If any term or provision of this Agreement, or their application to a particular situation, is found
by the court to be void, invalid, illegal or unenforceable, such term or provision shall remain in
force and effect to the extent allowed by such ruling. All other terms and provisions of this
Agreement or their application to specific situations shall remain in full force and effect. The
Parties agree to work in good faith to amend this Agreement to carry out its intent.
25. SURVIVAL
All provisions which by their nature must continue after the Agreement expires or is terminated,
including the Indemnification, Ownership of Materials/Work Product, Records, Governing Law
and Attorney Fees, shall survive the Agreement and remain in full force and effect.
26. NOTICES
All notices, requests and approvals must be sent in writing to the persons below, which will be
considered effective on the date of personal delivery or the date confirmed by a reputable overnight
delivery service, on the fifth calendar day after deposit in the United States Mail,postage prepaid,
registered.or certified, or the next business day following electronic submission:
To City of Cupertino To Contractor: PLACEWORKS,INC
10300 Torre Ave.,Cupertino CA 95014 3 Macarther Pl,Ste 1100
Santa Ana,CA 92707
Attention:Erick Serrano Attention: Terri McCracken
Email: ericks@cupertino.org Email:tmccracken@placeworks.com
27. VALIDITY OF CONTRACT
This Agreement is valid and enforceable only if(a) it complies with the purchasing and contract
provisions of Cupertino Municipal Code Chapters 3.22 and 3.23, as amended from time to time,
b) is signed by the City Manager or an authorized designee, and (c) is approved for form by the
City Attorney's Office.
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28. EXECUTION
The person executing this Agreement on behalf of Contractor represents and warrants that
Contractor has full right,power, and authority to enter into and carry out all actions contemplated
by this Agreement and that he or she is authorized to execute this Agreement,which constitutes a
legally binding obligation of Contractor. This Agreement may be executed in counterparts, each
one of which is deemed an original and all of which, taken together, constitute a single binding
instrument.
IN WITNESS WHEREOF,the parties have caused the Agreement to be executed.
CONTRACTOR CITY OF CUPERTINO
A Municipal Corporation
y 6 L'
Name Terri McCracken Name Ben Fu
Title Associate Principal Title Community Development Director
Date July 15,2019 Date 6
Tax I.D. No.: 95-2975827
APPROVED AS TO FORM:
HEATHER M. MINNER
Cupertino City Attorney
ATTEST:
GRACE SCHMIDT
City Clerk
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PLACEWORKS
June 28, 2019
Erick Serrano,Associate Planner
City of Cupertino
Planning Department
10300 Torre Avenue
Cupertino,CA 95014
Re:Proposal to Prepare a Notice of Exemption for the Loc-N-Store Self Storage
Project
Dear Mr. Serrano:
Please accept the attached submittal as PlaceWorks proposal to prepare a Notice of
Exemption (NOE) for the Loc-N-Store Self Storage Project for the City of Cupertino. This
proposal was prepared in response to your e-mail request for proposal (RFP) on February 6,
2019 and June 25, 2019.
PROJECT UNDERSTANDING
The City received an application from Bass Cupertino, LLC for the expansion of the Loc-N-
Store Self Storage Facility located at 10655 Mary Avenue. The project site is approximately
4.03 acres and is assigned Assessor Parcel Number (APN) 326-06-050. The project is located
within the Industrial/Residential (I/R) General Plan Land Use Designation, and the Planned
Development Quasi-Public Building Mini-Storage P(BBQ, MINI-STOR) Zoning District. The i
project site is surrounded by the State Route 85/Interstate 280 interchange to the north and
west, Mary Avenue Bridge and a residential neighborhood to the east, and the Cupertino
Public Works maintenance yard to the south.i
According to the Phase 1 ESA prepared for the project site, the existing site consists of
multiple one-story and wood-framed storage buildings that total approximately 60,000
square feet of building space associated with 463 units of self-storage space.The existing site
also includes oversize parking stalls for recreational vehicles (RV) and three transmission cell
phone towers within the PG&E easement on the site.The proposed project would redevelop
the project site southeast of the on-site PG&E easement, with three buildings that would be
two to three stories in height. According to the preliminary site plans, the proposed storage
expansion would provide 168,316 square feet of self-storage space, 1,870 square feet of
office space, and a 1,455 square-foot manager's residence for a total of 171,641 square feet
of building space. The existing storage building northeast of the PG&E easement would
remain as it is under existing conditions.This results in an increase of approximately 111,000
square feet of building space on the project site (61,692 square feet of existing storage
facilities compared to 171,641 square feet). The project would also provide approximately
23,930 square feet of landscaped area and 13 parking spaces for self-storage use. j
June 28,2019 1 Page 1
PLACEWORKS
Exhibit A Scope of Work
Task A, Project Kick-off & Description
PlaceWorks will participate in a kick-off meeting with the City to review the scope of work,
available information, schedule, and work products.This scope of work assumes this meeting
will be conducted as a conference call. Following the kick-off meeting, PlaceWorks will Y
prepare a detailed, yet brief, project description of the proposed expansion of the self- 1
storage facility.
Task B. Notice of Exemption j
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Based on our understanding of the project to date,the CEQA Guidelines section 15332, Class
32 (In-Fill Development Projects), is appropriate. As required by CEQA Guidelines Section l
15332, the NOE will demonstrate how the proposed project would not result in any
significant effects relating to traffic, noise,air quality,or water quality.
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While the proposed self-storage facility expansion would not result in a change in the land
use, additional storage capacity could, however, increase vehicular trips traveling to and from
the project site, which would occur approximately 150 feet from sensitive residential land
uses to the east. Although it is not likely that new or "different" trips generated from the
increase in storage capacity would result in significant traffic during peak traffic periods in
Cupertino, PlaceWorks will prepare a brief traffic memo to provide the substantial evidence
required to demonstrate the proposed changes would not trigger any impacts per City
standards.The traffic memo will be prepared by a California certified transportation engineer.
Additionally, according to the BAAQMD screening tables, construction activities occurring
within 328 feet (0.06 miles) of sensitive receptors would result in potential health risks and
warrant a health risk analysis. As the nearest sensitive receptors fall inside the screening
distance, it is anticipated that project-related construction activities could result in potential
health risks impacts to the receptors at this location.Therefore, the project could potentially
expose sensitive receptors to substantial concentrations of air pollutant emissions during
construction and PlaceWorks will prepare a construction health risk assessment.
Using the results of the traffic memo and health risk assessment, PlaceWorks will prepare an
NOE pursuant to CEQA Guidelines Section 15062 (Notice of Exemption) that identifies the
applicable exemption(s) and describes why the "exceptions" to the categorical exemptions
analysis per CEQA Guidelines Section 15300.2 (Exceptions) do not apply. The NOE will be
submitted to the City for review, as follows:
One (1) electronic copy of an Administrative Draft NOE to the City for review. Staff will
provide PlaceWorks with comments on the Administrative Draft NOE.
One (1) electronic copy of a revised, second draft as an electronic "Screencheck".
PlaceWorks assumes that a minimal level of effort, not exceeding four hours, would be
required to respond to any comments from the City on the Screencheck Draft NOE.
Following approval of the Screencheck, PlaceWorks will provide the City with one (1)
electronic copy of the Final NOE.
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LACEWORKS
If it is determined that potential impacts from construction or operation of the proposed
project require changes to the project or mitigation measures to reduce impacts to a less-
than-significant level, PlaceWorks will inform the City staff to discuss next steps, which could
include the preparation of a Mitigated Negative Declaration.
Task C, Approval
Our scope of work allows for PlaceWorks to attend up to three (3) hearings on the NOE as
requested by the City. Our scope of work assumes that City staff will be responsible for
overseeing the filing of the NOE with the County Clerk following the approval of the proposed
project.
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Schedule
Exhibit B We anticipate that the project can be completed within six (6) weeks of receiving Notice to
Proceed from the City.Our proposed schedule includes a one-week review period for the City
at each submittal phase. We believe this schedule is in keeping with your needs, but we are
happy to revise this schedule if necessary.
COST ESTIMATE
As shown in Table 1, the estimated cost to complete the scope of work described in this
Exhibit C proposal is $9,004. The PlaceWorks team will complete this scope of work for a fixed fee not
to exceed this amount. PlaceWorks bills for its work on a time-and-materials basis with
monthly invoices.We recommend planning for a 5 percent to 10 percent contingency fund to
cover any unforeseen,out-of-scope work that might be necessary for the project.
TABLE 1 COST TABLE
PLAt.EWC1kKS
MCCRACKEN WILSON SOTELO BUSH Garcia
CLERICAL
Associate Project Traffic Project PlaceWorks
Principal Planner Engineer Senior Engineer Scientist PlaceWorks 2%Office Total Task
Hourly Rater $190 $115 $180 $165 $115 $120 Hours Expenses Budget
A 1 K¢k-Off Meeting&Project Description 4 1 5 $18 $893
Task A 5ubtota1 4 1 0 0 0 0 5 $18 $893
B1 Administrative Dralt NOE 1 4 1 6 20 0.5 32.5 $84 $4,264
B.2 Screencheck Oraft NOE 1 2 1 0 0 0.5; 4.5 $13 $673
B.3 Final NOE 1 1 0 o O 5 _ 2.5 $7 $372
f T
TaskBSuhtotalT......_._.......__. .3r.. ._ 7...... ......_ Q. .. 15_ ------._.99.5...__._......$104 $...
wnsaa.
C.1 Hearing 12 3 15 $53 $2,678
T_.._...___.__
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TaskCBuhtotalj —_—12 3.... .. _O O O__--o._ ss...___._... $53 $2,678
Labor Hours Total 19 11 2 6 20 1.5 59.5
Labor Dollars Total $3,610 $1,265 $360 $990 $2,300 $180 174 $8,879
Travel costs 125
EXPENSES TOTAL 125
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June 28,2019 Page 3
PLACEWORKS
Assumptions
This scope of work and cost estimate assumes that:
Our cost estimate includes the project kick-off meeting. Additional meetings would be
billed on a time-and-materials basis. Terri McCracken will participate in all project
meetings, and will attend up to three (1) public hearings. We anticipate that the public
hearing meeting will last up to two(2) hours.
All products will be submitted as electronic files in Word and PDF formats. No printing
assumptions are included in this scope. Printing costs, if requested, will be billed at
PlaceWorks' actual cost.
Please do not hesitate to contact me if you need more information. PlaceWorks looks forward
to working with you on this proposed project for the Loc-N-Store Self Storage Facility in
Cupertino.
Sincerely,
PLACEWORKS
Terri McCracken
Associate Principal
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June 28,2019 l Page 4
EXHIBIT D
Insurance Requirements
Design Professionals & Consultants Contracts
Consultant shall procure prior to commencement of Services and maintain for the duration of the contract, at
its own cost and expense, the following insurance policies and coverage with companies doing business in
California and acceptable to City.
INSURANCE POLICIES AND MR41 MUMS REQUIRED
1. Commercial General Liability (CGL) for bodily injury, property damage, personal injury liability for
premises operations, products and completed operations, contractual liability, and personal and
advertising injury with limits no less than $2,000,000 per occurrence (ISO Form CG 00 01). If a
general aggregate limit applies, either the general aggregate limit shall apply separately to this
project/location(ISO Form CG 25 03 or 25 04)or it shall be twice the required occurrence limit.
a. It shall be a requirement that any available insurance proceeds broader than or in excess of the
specified minimum insurance coverage requirements and/or limits shall be made available to the
Additional Insured and shall be (i)the minimum coverage/limits specified in this agreement; or(ii)the
broader coverage and maximum limits of coverage of any insurance policy,whichever is greater.
b. Additional Insured coverage under Consultant's policy shall be "primary and non-contributory,"
will not seek contribution from City's insurance/self-insurance, and shall be at least as broad as ISO
Form CG 20 01 (04/13).
c. The limits of insurance required may be satisfied by a combination of primary and umbrella or
excess insurance,provided each policy complies with the requirements set forth in this Contract. Any
umbrella or excess insurance shall contain or be endorsed to contain a provision that such coverage
shall also apply on a primary and non-contributory basis for the benefit of City before the City's own
insurance or self-insurance shall be called upon to protect City as a named insured.
2. Automobile Liability:ISO CA 00 01 covering any auto (including owned,hired, and non-owned
autos)with limits no less than$1,000,000 per accident for bodily injury and property damage.
3. Workers' Compensation: As required by the State of California,with Statutory Limits and
Employer's Liability Insurance of no less than$1,000,000 per occurrence for bodily injury or disease.
O Not required. Consultant has provided written verification of no employees.
4. Professional Liability for professional acts, errors and omissions, as appropriate to Consultant's
profession, with limits no less than $2,000,000 per occurrence or $2,000,000 aggregate. If written on a
claims made form:
a. The Retroactive Date must be shown and must be before the Effective Date of the Contract.
b. Insurance must be maintained for at least five(5)years after completion of the Services.
c. If coverage is canceled or non-renewed,and not replaced with another claims-made policy form with
a Retroactive Date prior to the Contract Effective Date,the Consultant must purchase"extended
reporting"coverage for a minimum of five (5)years after completion of the Services.
OTHER INSURANCE PROVISIONS
The aforementioned insurance shall be endorsed and have all the following conditions and provisions:
Exh. D-Insurance Requirements for Design Professionals&Consultants Contracts Form Updated Feb. 2018
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Additional Insured Status
The City of Cupertino, its City Council,officers,officials, employees,agents, servants and volunteers
Additional Insureds")are to be covered as additional insureds on Consultant's CGL policy. General
Liability coverage can be provided in the form of an endorsement to Consultant's insurance(at least as broad
as ISO Form CG 20 10(11/85)or both CG 20 10 and CG 20 37 forms, if later editions are used).
Primary Coverage
Coverage afforded to City/Additional Insureds shall be primary insurance. Any insurance or self-insurance
maintained by City, its officers, officials, employees, or volunteers shall be excess of Consultant's insurance
and shall not contribute to it.
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Notice of Cancellation
Each insurance policy shall state that coverage shall not be canceled or allowed to expire, except with written
notice to City 30 days in advance or 10 days in advance if due to non-payment ofpremiums.
Waiver of Subrogation
Consultant waives any right to subrogation against City/Additional Insureds for recovery of damages to the
extent said losses are covered by the insurance policies required herein. Specifically, the Workers'
Compensation policy shall be endorsed with a waiver of subrogation in favor of City for all work performed
by Consultant, its employees, agents and subconsultants. This provision applies regardless of whether or not
the City has received a waiver of subrogation endorsement from the insurer.
Deductibles and Self-Insured Retentions
Any deductible or self-insured retention must be declared to and approved by the City. At City's option,
either: the insurer must reduce or eliminate the deductible or self-insured retentions as respects the
City/Additional Insureds; or Consultant must show proof of ability to pay losses and costs related
investigations, claim administration and defense expenses. The policy shall provide, or be endorsed to
provide,that the self-insured retention may be satisfied by either the insured or the City.
Acceptability of Insurers
Insurers must be licensed to do business in California with an A.M. Best Rating of A-VII, orbetter.
Verification of Coverage
Consultant must furnish acceptable insurance certificates and mandatory endorsements(or copies of the policies
effecting the coverage required by this Contract), and a copy of the Declarations and Endorsement Page of
the CGL policy listing all policy endorsements prior to commencement of the Contract. City retains the right
to demand verification of compliance at any time duringthe Contract term.
Subconsultants
Consultant shall require and verify that all subconsultants maintain insurance that meet the requirements of
this Contract, including naming the City as an additional insured on subconsultant's insurance policies.
Higher Insurance Limits
If Consultant maintains broader coverage and/or higher limits than the minimums shown above,City shall be
entitled to coverage for the higher insurance limits maintained byConsultant.
Adequacy of Coverage
City reserves the right to modify these insurance requirements/coverage based on the nature of the risk, prior
experience, insurer or other special circumstances,with not less than ninety(90)days prior written notice.
Fxh. D-Insurance Requirements for Design Professionals&Consultants Contracts Form Updated Feb. 2018
2
ACo® CERTIFICATE OF LIABILITY INSURANCE
DATE /YYYY)
os/ze/2019zols
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
Marsh Risk&Insurance Services NAME:
17901 Von Karman Avenue,Suite 1100 PHONECN o E t AA/C No):
949)399-5800;License#0437153 E-MAIL
Irvine,CA 92614
ADDRESS:
Attn:NewpodBeach.CedRequest@marsh.com/F:212-948-4323 INSURERS AFFORDING COVERAGE NAIC#
CN115158923-01-01-19-20 INSURER A:Crum&Forster Specialty Insurance Co 44520
INSURED
PlaceWorks,Inc INSURER B:Travelers Property Casualty Company Of America 25674
Dba:The Planning Center INSURER C:
Design Community&Enviomment INSURER D:
3 MacArthur Place,Suite 1100
Santa Ana,CA 92707 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: LOS-002212059-20 REVISION NUMBER: 3
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTVVITHSTAN DING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VVITH 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.
ILTR TYPE OF INSURANCE
ADDL SUBR
POLICY NUMBER MMIDDfYYYY MMIDD//YYYY LIMITS
1
A X COMMERCIALGENERALLIABILITY X X EPK127413 07/01/2019 07/01/2020 EACH OCCURRENCE 5,000,000DAMAGETORENTE—DCLAIMS-MADE FxI OCCUR PREMISES(Ea occurrence) $ 50,000
X BI&PD Ded.$5,000 MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $5,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $5,000,000
X PRO-
POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 5,000,000
OTHER:Contractors Pollution 5,000,000
B AUTOMOBILE LIABILITY X X BA1N96406A19CAG 07/01/2019 07/01/2020 COMBINED SINGLE LIMIT $ 1,000,000Eaaccident
X ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY(Per accident) $
HIRED NON-OWNED
AUTOS ONLY AUTOS ONLY Pear ac IcdenDAMAGE
Comp/Coll Deductibles $ 1,000
UMBRELLA LIAB X OCCUR EX6J3287561943 07/01/2019 07/01/2020 EACH OCCURRENCE 4,000,000
X EXCESS LIAR CLAIMS-MADE AGGREGATE 4,000,000 i
DED I I RETENTION$
B WORKERS COMPENSATION UB7K7286761943G 7 07/01/2 220 X PER OTH-
AND EMPLOYERS'LIABILITY STATUTE ER
Y/N
ANYPROPRIETORtPARTNER/EXECUTIVE 1,000,000
OF ICER/MEM E EXC U ED F jN/A E.L.EACH ACCIDENT
Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under 1,000,000DESCRIPTIONOFOPERATIONSbelowE.L.DISEASE-POLICY LIMIT $
A Errors&Omissions-Claims Made EPK127413 07/01/2019 07/01/2020 Each Claim/Aggregate 5,000,000
Retro Dates:See 2nd Page
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space Is required)
Re:IS/MND Cupertino CA
The City of Cupertino,its city council,boards and commissioners,officers,employees,and volunteers are included as additional insured where required by written contract with respect to General and Auto Liability.
This insurance is primary and non-contributory over any existing insurance and limited to liability arising out of the operations of the named insured and where required by written contract with respect to General
Liability.Waiver of subrogation is applicable where required by written contract with respect to General and Auto Liability.
CERTIFICATE HOLDER CANCELLATION
City of Cupertino SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
10300 Toree Ave. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Cupertino,CA 95014 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh Risk&Insurance Services
Rosalynda Martinez
@ 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
BAIN95406A19CAG Effective 07/01/2019
COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE REAP? IT CAREFULLY.
BUSINESS AUTO EXTENSION ENDORSEMENT
This endorsement modifies insurance provided under the following;
BUSINESS AUTO COVERAGE FORM
GENERAL DESCRIPTION OF COVERAGE—This endorsement broadens coverage. However; coverage for any
injury, daimage or medical expenses described in any of the provisions of this endorsement may be excluded or
limited by another endorsement to the Coverage Part, and these coverage:broadening provisions do. not apply to
the extent that coverage is excluded or linnited by such an endorsement. The following listing is a`-general cover-
age description only.,Limitations and exclusions may apply to these coverages: Read all the provisions.of this en-
dorsernent and the rest of your policy carefully to determine rights, dutles, and what Is and is not covered.
A. BROAD FORM NAMED INSURED H. HIRED;AUTO PHYSICAL DAMAGE Loss OF
B. BLANKE'r ADDITIONAL INSURED USE—INCREASED LIMIT
I. PHYSICAL DAMAGE -- TRANSPORTATION
C. EMPLOYEE HIRED AUTO`EXPENSES—INCREASED`L:iMIT
D: `EMPLOYEES INSURED.'J.. PERSONAL PROPERTY
E. SUPPLEMENTARY PAYMENTS — INCREASED K. ;AIRBAGS
LIMITS L:: NOTICE AND KNOWLEDGE OF ACCIDENT OR
F. HIRED.. AUTO LIMITED WOR0WI0E COV- LOSS
ERAGE INDEMNITY BASIS M. BLANKET tVAIVER OF SUBROGATION.
G. WAIVER:OF DEDUCTIBLE—GLASS N. UNINTENTIONAL ERRORS.OR OMI.S81QNS
PROVISIONS
A. BROAD FORM NAMED INSURED this insurance applies and only to the extent that
The following is added to Paragraph A.'I., Who Is person or organization qualifies as an "insured"
An Insured, of SECTION 11—COVERED AUTOSunder the Who Is An Insured provision contained
LIABILITY COVERAGE: in Section 11,
Any organization You;newly acquire or forrn dur- C. EMPLOYEE HIRED AUTO
4 ing the policy period over which you maintain 1. The following is added to Paragraph A.1.,
50% or more ownership interest and that is not Who Is An Insured, of SECTION II -- COV-
separately insured for Business Auto Coverage,. ERE AUTOS LIABILITY COVERAGE: j
Coverage under this provision is afforded only un-An "employee" of yours is an"insured" while.
til the 180th day after you acquire or form the:or operating an "auto" hired or rented under a
ganization or the end of the policy period, which-contract or agreement: in an "employee's
ever is earlier. name, with your permission, while:performing
duties related to the. conduct Of your bus!-
B. BLANKET ADDITIONAL INSURED ness.
The following is added to Paragraph c. in. AA... 2 The following replaces Paragraph b. in B.S.,
Who Is An Insured, of SECTION II —COVERED Other Insurance, of SECTION IV W BUS1-
AUTOS LIABILITY COVERAGE: NESS AUTO CONDITIONS:
Any person or organization who Is required under b. For Hired Auto Physical Damage Cover-
a written contract or agreement between you and age, the following are deemed to be cov-
that person or organization, that is signed and ered "autos"you own:
executed by you before the "bodily injury" or 1) Any covered "auto you lease, hire,l
property damage" occurs and that is in effect rent ar borrow; and
during the policy period, to be named as an addi 2) Any covi?red''auto" hired or rented by
tional insured is an."insured" for Covered Autos your "errtployee" under a contract in
Liability Coverage, but only for damages to which an "employee's" name; with your
CA T3 53 0215 Q tots The Travelers indemnity.oompeny.All rights reserved. Page I of 4
Includes copyrighted material d Insurance services office;Ino_with.its permission.
oozosu
BA7E37616719:CAG Effective 07r'01/.2.019
COMMERCIAL AUTO
permission, while performing duties a) With respect to any claim made or "suit"
related to the conduct,of your bus[- brought outside the United States of
ness. America, the territories and possessions
of the United States of America, PuertoHowever; any"auto"that is leased, hired,
Rico and.Canada;rented or borrowed with a driver Is not a
covered "auto". 1) You must arrange to defend the "in-
D. EMPLOYEES AS INSURED; sured" against, and investigate or set-
tle any such claim or"suit" and keepThefollowingisaddedtoParagraphA.1., Who Is us advised of all proceedings and ac-
An Insured, of SECTION 11 -COVERED AUTOS bons.
LIABILITY COVERAGE.,
Any"employee of yours is;an "insured"while us
ii) Neither you nor any other involved"
insured" will make any settlement
ing a covered "auto"you don`t own, hire or borrow without our consent.
in your business or your personal affairs.
iii) We may, at our discretion, participateE. SUPPLEMENTARY PAYMENT'S — INCREASED in defending the "insured. against, or
LIMITS in the settlement of' any claim or
1. The follo4ng replaces Paragraph A.2.a.(2),
of SECTION Il —COVERED AUTOS LIABIL- iv)We will reimburse the "insured" forITYCOVERAGE:
Burns that the "insured" legally must
12) Up to $3,000`for cost of bail bonds (in- pay as damages because of "bodily
cluding bonds for related traffic law viola- injury" or"property damage" to which
tions) required because of.an "accident" this insurance applies, 'that the "in
we cover. We do not have to furnish sured" pays with .our consent, but
these bonds. only up to the limit described in Para-
2. The following replaces Paragraph A.2.a.(4), graph C., Limits Of Insurance, of
of SECTION Ill-- COVERED AUTOS LIABIL- SECTION II -- COVERED AUTOS
ITY COVERAGE: LIABILITY.COVERAGE..
4) All reasonable expenses incurred by the u) We will reimburse the "Insured" for
insured" at our request, including actual the reasonable expenses incurred
Inns of earnings up to $5011 a;day be-
cause of time off from work, tion of such claims and your defense
of the "insured" against any such
F. HIRED .AUTO — LIMITED WORLDWIDE COV suit", but only up to and included
ER4GE-INDEMNITY BASIS within the limit described in Para-
The following replaces Subparagraph (5) in Para- graph G., limits of Insurance, of
graph B.7., Policy.Period, Coverage Territory, SECTION II COVERED AUTOS'
of SECTION 1V -. BUSINESS AUTO. CONDI LIABILITY COVERAGE, and not in
TIONS`. addition to such limit. Our duty to
a) Anywhere in the world, except any country or make such payments ends when we
jurisdiction while any trade sanction, em- have used up the applicable.,limit. of
bargo, or similar regulation imposed by the insurance in payments t•or damages;.
United States of America applies to and pro- settlements ordefense expenses.
habits he transaction of business with or b);`This Insurance is excess over any valid:
within such country or jurisdiction, for Cov- and collectible other insurance available
ered Autos Liability Coverage for any covered to the "insured" whether primary, excess,
auto" that you lease, hire, rent Of borrow contingent or on any other basis.
without a driver for a period of 30 days or less G) This insurance is not a substitute for re-
and that Is not an "auto" you lease, hiire,,rent rjuired or compulsory insurance in anyorborrowfromanyof` your "employees", country outside the United States, its ter-partners (if you are a partnership), members ritories and possessions, Puerto Rico and
if you are a limited liability company) or Canada.
members of their households;
Page 2 of'4.@ 2015 The Travelers Indemnity company,All righte reserved. GA T3 53.02 15
Includes copyrighted mateiial.of insurance Services Offioe,..lno.Wth its permission.:
WE3761671.9CAG.Effective 07/01/2019
COMMERCIAL AUTO
You agree to maintain all required or 2) in or on your covered"auto
compulsory insurance In any such coun- This coverage applies only in the event of a total
try up to the minimum limits required by theft of your covered "auto'.
Focal law. Your failure to comply with No deductibles apply to this Personal PropertycompulsoryInsurancerequirementswillcoverage.
not invalidate the coverage afforded by
this policy, but we will only be liable to the K. AIRBAGS
same extent we would have been liable The following is added to Paragraph 13.3., Exclu-
had you complied with the compulsory in ions,. of SECTION III - PHYSICAL DAMAGE
surance requirements. COVERAGE
d) It is understood that;we are not ail admit- Exclusion 3.0. does not apply to"loss to one or
ted or authorized: insurer outside the more airbags.in a covered"auto"you.own that in-
Urilted States of America, its territories flate due to a cause other than, a cause of"Foss''
and possessions, Puerto Rico,and Can set forth in Paragraphs A.t.b, and A.t.c., but.
ada. We assume no responsibility for the only:
furnishing of certificates of insurance, or a. If that "auto"is a covered "auto" for Compre-
for compliance. in any way with the.laws hensive Coverage under this policy;
of other countries relating to:Iinsurance. b. The airbags are not covered under any war-
G. WAIVER OF DEDUCTIBLE GLASS rarity; and
The following is added to Paragraph D., Deducti- c. The airbags were not intentionally inflated.
ble, of SECTION III -- PHYSICAL DAMAGE We will pay up to a maximum of$t,000 for ariy
COVERAGE:one "lass".
No deductible for a covered "auto" will apply to L. NOTICE AND KNOWLEDGE OF:ACCIDENT OR
glass damage if the glass is repalred`rather than LOSS
replaced. The following is added ta. Paragraph A.2.A., of
H. HIRED AUTO PHYSICAL DAIUTA011- LOSS Or SECTION IV-BUSINESS AUTO:CONDITIONS;
USE—INCREASER LIMIT Your duty to give us or our authorized represents-
The following replaces the last>sentence of Para tive prompt notice of the '`accident" or "loss" ap-
graph AA.b., Loss Of Use Expenses, of SEC- plies only when the "accident" or"loss" is known
TION III- PHYSICAL DAMAGE COVERAGE; to:
However, the most we:will pay for any expenses a) You(if you are an individual);
for loss of use is $65 per day, to a maximum of b) A partner(if you area partnership),
750 for any one"accident% c) A member (if you are a limited liability com-
pany);I. PHYSICAL_ DAMAGE. - TRANSPORTATION
EXPENSES-INCREASED LIMIT d) An executive officer, director or insurance
The following replaces the firstsentence in Para-manager (if you are a corporation or other or-
graph A.4 a., Transportation Expenses, of ganizat on);or
N--- SECTION III - PHYSICAL DAMAGE COVER- e) Any"employee" authorized by you to give;no-
p,AGE: Tice of the "accident" or"loss".
i
We will pay up to $50 per day to a rnaximunn of M. BLANKET WAIVER OF SUBROGATION
1,500 for temporary transportation expense in
curved by you because of the total theft of a coo-
The following replaces Paragraph A.S., Transfer
Cif.Rights Of Recovery Against Others To Us
ered "auto" of the private passenger type. of SECTION IV BUSINESS AUTO CONDI-
o J. PERSONAL PROPERTY TIONS:
The following Is added to Paragraph A A., Covet-- 5. Transfer Of Rights Of `Recovery Against
age Extensions, of SECTION III -- PHYSICAL Others To U5
DAMAGE COVERAGE We waive any right of recovery we may have
Personal Property against any person or organization to.the ex-
tent required of you by a written contract
We will pay up to $400 for "loss" to wearing ap-signed and executed prior to any "accident"
petal and otherpersanat properly which is; or"loss", provided that the "accident"or"loss"
1) Owned by an "insured"; and arises out of operations contemplated by
CA T3 53 02 1,5' 2015 i he Travelers Indemnity company.All rights reserved: Page 3 of 4`
Includes copyrighted material of insurance services Office.Inc,with its permission.
CO2087
I
BA7E37616719CAG Effective 07/01/2019
COMMERCIAL AUTO
I
such contract. The waiver applies only to the The unintentional omission or, or unintentional
person or organization designated in such error In, any Information given. by you shall not
contract. prejudice your rights under this insurance. How-
N. UNINTENTIONAL ERRORS.017 OMISSIONS ever this provision does not affect our right to cql
The following is added to Paragraph B.2., Con- lest additional premium or exercise our right of
cealment, Misrepresentation, Or Fraud, of cancellation or non-renewal.
SECTION IV- BUSINeSS AUTO CONDITIONS.
I
I
Page 4:of 4 r W15 The Travelers Indemnity companj,All rights reserved CA T3 53 02 15
Invludes copyrighted material of insuranoe Services Office,Inc.with its permission.
EPK127413 Effective 07/01/2019
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS -
COMPLETED OPERATIONS
This endorsernent modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Additional Persons}or Organization(s)- Location And Description Of Completed Operations
Where Required By Written Contract. Where Required By Written Contract..
Information required to complete this Schedule,if not shown above,will be shown in the Declarations.
A. Section III — Who is An Insured within the
Common Provisions is amended to include as
an insured the person(s) or organization(s)
shown in the Schedule, but only with respect to
liability for "bodily injury" or "property damage"
caused, in whole or in part, by "your work" at
the location designated and described in the
schedule of this endorsement performed for
that additional insured and Included In the
products-completed operations hazard".
EN0320-0211 Page 1 of 1
EPK127413 Term.7-1-19 to 7-1-20
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY,
PRIMARY AND NON-CONTRIBUTORY ADDITIONAL INSURED
WITH WAIVER OF SUBROGATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
CONTRACTORS POLLUTION LIABILITY COVERAGE PART
ERRORS AND OMISSIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) or Organization(s)
Where Required By Written Contract.
A. SECTION III — WHO IS AN INSURED within the Common Provisions is amended to include as an
additional insured the person(s) or organization(s) indicated in the Schedule shown above, but only with
respect to liability arising out of "your work" for that person or organization performed by you, or by those
acting on your behalf.
B, As respects additional insureds as defined above, this insurance also applies to "bodily injury" or "property
damage" arising out of your negligence when the following written contract requirements are applicable:
1. Coverage available under this coverage part shall apply as primary insurance. Any other insurance
available to these additional insureds shall apply as excess and not contribute as primary to the
insurance afforded by this endorsement.
2. We waive any right of recovery we may have against the person(s) or organization(s) indicated in the
Schedule shown above because of payments we make for injury or damage arising out of"your worle,
performed under a written contract with that person(s) or organization(s).
3. The term "additional insured" is used separately and not collectively, but the inclusion of more than one
additional insured" shall not increase the limits or coverage provided by this insurance_
ThisEndorsement does not reinstate or increase the Limits of Insurance applicable to any "claim"to which the
coverage afforded by this Endorsement applies_
ALLOTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED,
EN0147-1 111 Page 1 of 1
i
i
I
I
TRAVELERS ,
AW. WORKERS COMPENSATIONJAND
Orrin TOWER SQUARE EMPLOYERS LIABILITY POLICY
RXRTVORD CT 06183
ENDORSEMENT WC 99 03 76( A)- 001
I
PQL.ICY NUMBER. UB-7K728676-19-43-G I
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS 1ENDORSEMENT - CALIFORNIA
BLANKET WAIVER)
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.
The additional premium for this endorsement shall be 2.00 °h of the California workers' compensation pre-
en lum,
Schedule
Person or Organization Job Description
A= PERSON OR ORGANIZATIO9 IVOR
WHICH THE INSURED HAS AGREED
BY WRITTBIi CONTRACT EXECUTOD
PRIOR TO LOSS 'TO rUfRNYSH THIS
waxv.
a
o—
I
o
Qw
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise
stated.
The information below is required only when this endorsement is issued subsequent to preparation of
the policy.)
Endorsement Effective 07/01/2019 Policy No. UB7K728676-19-43-C Endorsement No. 1
Insured Premium
Insurance Company Travelers Property Casualty Countersigned by
DATE OF ISSUE: 06-11-18 ST ASSIGN: Page 1 of 1
001746