03-106 Reconstruction curbs & gutters
~'1
CITY OF
CUPEI~TINO
City Hall
10300 Torre Avenue
Cupertino, CA 95014-3255
(408) 777-3354
PUBLIC WORKS DEPARTMENT
CERTIFICATE OF' COMPLETION
AND
NOTICE OF ACCEPTANCE OF COMPLETION
RECONSTRUCTION OF CURBS, GUTTIL;RS & SIDEWALKS, PROJECT 2003-O1
NOTICE IS HEREBY GNEN THAT I, Ralph A. Qualls, Jr., Director of Public Works and
City Engineer of the City of Cupertino, California, dc- hereby certify that the work and improvements in
hereinafter described in the contract which was entert~d into, by, and between the City of Cupertino and
JJR Construction, Inc. on November 4, 2003, in accordance with the plans and specifications for said
work, have been completed to my satisfaction and ac~~eptance of completion was ordered on August 16,
2004.
That said work and improvements consisted of famishing all labor, materials, tools, and equipment
required to complete said project, all as more particularly described in the plans and specifications for
said project.
~ ~
Director of 1'~ ~blic Works and
(~ity Engineer of the City of Cupertino
Date: August 17, 2004
Printed on Rec_icled Paper
o ~- r~~
CONTRACT FOR PUBLIC WORKS
This CONTRACT made on November 4, 2003 by the CITY OF CUPERTINO, a
municipal corporation of the State of California, hereinafter called CITY, and J.J.R.
Construction, Inc. hereinafter called CONTRACTOR.
IT IS HEREBY AGREED by CITY and CONTRACTOR as follows:
1. THE CONTRACT DOCUMENTS. The complete contract consists of this contract and
the following contract documents incorportated herein by reference:
a. Notice to Contractors, Proposal, Time of Completion, Estimated Quantities, Noncollusion
Affidavit, Bidder Qualification Form, Subcontractors Form and Signature Form.
b. Standard Specifications, General Provisions and Special Provisions.
c. Plans and Specifications for Reconstruction ~~f Curbs, Gutters and Sidewalks. Project No.
2003-01
d. Faithful Performance Bond and Payment Bond.
e. Insurance Agreement, Certificate of Insurance, Endorsement of Primary Insurance,
Additional Insured Endorsement, Endorsement of Aggregate Limits of Insurance per Project,
Waiver of Subrogation Endorsement Worker';~ Compensation Insurance and Notice of Policy
Cancellation Endorsement.
All of the above documents are incorporated intro this contract by reference so that any work
called for in one and not mentioned in another, is to be executed the same as if mentioned in all
of said documents. -The documents comprising the complete contract are sometimes hereinafter
referred to as the Contract Documents. In case of conflict between the Plans and the
Specifications on the one hand, and this Contract on the other, the Plans and Specifications shall
prevail.
2. THE WORK. CONTRACTOR agrees to furnish all of the tools, equipment, apparatus,
facilities, labor, transportation and materials necessary to perform and complete in a good and
working order, the work of reconstructing curbs, gutters and sidewalks, as called for, and in the
manner designated in, and in strict conformity with, the Plans and Specifications prepared by the
Engineer and adopted by CITY, which Plans and Specifications are entitled, respectively,
Recoizstructio~a of Curbs, Gutters and Sidewalks, Project No. 2003-O1 and which Plans and
Specifications are identified by the signatures of t:he parties to this Contract. It is understood and
agreed that said tools, equipment, apparatus, facilities, labor, transportation and materials shall be
furnished, and that said work shall be performed and completed as required in said Plans and
Specifications under the sole direction of CON"CRACTOR, but subject to the inspection and
approval of CITY, or its representative.
CITY hereby designates as its representative for the purpose of this Contract the Engineer, Mr.
Ralph A. Qualls, Jr.
3. CONTRACT PRICE. CITY agrees to pay, and CONTRACTOR agrees to accept, in full
payment for the work above agreed to be done, the sum of $ 397,400.00 (Three Hundred
Ninety Seven Thousand and Four Hundred ]Dollars and No Cents), subject to additions
and/or deductions as provided in the Contract Documents, per Exhibit A attached hereto.
4. DISPUTES PERTAINING TO PAYMENT FOR WORK. Should any dispute arise
respecting the true value of the work done, or any work omitted, or any extra work which
CONTRACTOR may be required to do, or respecting the size of any payment to
CONTRACTOR during the performance of this Contract, said dispute shall be determined either
by reference to the Unit Prices bid, if applicable, or in accordance with agreement of prices, if
applicable, or in accordance with the agreement of the parties, or in accordance with Section 6,
paragraph "f' of the General Provisions.
5. PERMITS, COMPLIANCE WITH LAW. CONTRACTOR shall obtain and bear all
expense for all necessary permits, licenses and easements for the construction of the project, give
all necessary notices, pay all fees required by law, and comply with the laws, ordinances and
regulations relating to the work and to the preserv~ition of the public health and safety.
6. INSPECTION BY THE CITY. CONTRACTOR shall at all times maintain proper
facilities and provide safe access for inspection by CITY to all parts of the work, and to the shops
wherein the work is in preparation. Where the Specifications require work to be specially tested
or approved, it shall not be tested or covered up without timely notice to CITY of its readiness
for inspection and without the approval thereof or consent thereto by CITY. Should any such
work be covered up without such notice, approv~il, or consent, it must, if required by CITY, be
uncovered for examination at CONTRACTOR'S expense.
7. EXTRA OR ADDITIONAL WORK AND CHANGES. Should CITY at any time
during the progress of the work require any alter;~tions, deviations, additions or omissions from
the Plans and Specifications or the Contract Documents, CITY shall have the right to do so, and
the same shall in no way affect or make void the Contract, but the cost or value thereof will be
added to, or deducted from, the amount of the C~~ntract price, as the case may be, by a fair and
reasonable valuation, which shall be determined either by reference to the Unit Prices bid, if
applicable, the Standard Specifications, or in accordance with the agreement of the parties. No
extra work shall be performed or change be made except by a written order from CITY, duly
authorized by resolution of the City Council, and by all agencies whose approval is required by
law, stating that the extra work or change is al~thorized, and no claim for an addition to the
Contract sum shall be valid unless so ordered.
8. CHANGES TO MEET ENVIRONMENTAL REQUIREMENTS. CITY shall have the
right to make changes in this Contract during the; course of construction to bring the completed
improvements into compliance with environmental requirements or standards established by
State and Federal statutes and regulations after the Contract has been awarded or entered into.
CONTRACTOR shall be paid for such changes either by reference to the Unit Prices bid, if
applicable, or in accordance with the agreement of the parties.
9. TERMINATION, AMENDMENT OR MODIFICATION. This Contract may be
terminated, amended or modified, with the mutual consent of the parties. The compensation
payable, if any, for such termination, amendment. or modification, shall be determined either by
2
reference to the Unit Price bid, if applicable, the Standard Specifications, or in accordance with
the agreement of the parties.
10. TIME FOR COMPLETION. All work under this Contract shall be completed in
accordance with the Time for Completion section in the Proposal and the Specifications of this
project. If CONTRACTOR shall be delayed in t]ze work by the acts or neglect of CITY, or its
employees, or those under it by contract or otherwise, or by changes ordered in the work, or by
strikes, lockouts by others, fire, unusual delay in transportation, unavoidable casualties or any
causes beyond CONTRACTOR'S control, or by delay authorized by CITY, or by any cause
which CITY shall determine justifies the delay, then the time of completion shall be extended
accordingly. This paragraph does not exclude the- recovery of damages for delay by either party
under other provisions in the Contract Documents.
11. INSPECTION AND TESTING OF MATEI[ZIALS. CONTRACTOR shall notify CITY
a sufficient time in advance of the manufacture, production or testing of materials to be supplied
under this Contract, in order that CITY may arran;~e for mill, factory or laboratory inspection and
testing of same.
12. TERMINATION FOR BREACH OR INSOLVENCY. If CONTRACTOR should be
adjudged a bankrupt, or should make a general ;assignment for the benefit of creditors, or if a
receiver should be appointed on account of insolvency, or if CONTRACTOR or any
subcontractor should violate any of the provisions of the Contract, CITY may serve written
notice upon CONTRACTOR and CONTRACT~~R'S surety of its intention to terminate the
Contract. Such notice shall contain the reasons for CITY'S intention to terminate the Contract,
and unless within ten (10) days after serving of such notice, such violation shall cease and
satisfactory arrangements for corrections thereof tie made, the Contract shall, upon the expiration
of said ten (10) days, cease and terminate. In the event of any such termination, CITY shall
immediately serve notice thereof upon CONTR~.CTOR'S surety and CONTRACTOR, and the
surety shall have the right to take over and perform the Contract; provided, however, that, if the
surety within fifteen (15) days after the serving upon it of notice of termination does not give
CITY written notice of its intention to take over and perform the Contract, or does not
commence performance thereof within thirty (30) days from the date of the serving of such
notice, CITY may take over the work and prose~;ute the same to completion by contract, or by
any other method it may deem advisable, for the ~~ccount and at the expense of CONTRACTOR,
and CONTRACTOR AND CONTRACTOR'S surety shall be liable to CITY for any excess cost
occasioned by CITY thereby, and in such event CITY may, without liability for so doing, take
possession of, and utilize in completing the work, such materials, appliances, plant and other
property belonging to CONTRACTOR as maybe on the site of the work and necessary therefor.
13. THE CITY'S RIGHT TO WITHHOLD CERTAIN AMOUNTS AND MAKE
APPLICATION THEREOF. In addition to amounts which CITY may retain under other
provisions of the Specifications until final completion and acceptance of all work covered by the
Contract, CITY may withhold from payment to (:ONTRACTOR such an amount or amounts as
in its judgment may be necessary to pay just claims against CONTRACTOR or subcontractors
for labor and services rendered and materials furnished in and about the work.
City may apply such withheld amount or amount:; to the payment of such claims in its discretion.
In doing so, CITY shall be deemed the agent of CONTRACTOR, and any payment so made by
3
CITY shall be considered as a payment made uncier the Contract by CITY to CONTRACTOR,
and CITY shall not be liable to CONTRACTOF: for any payment made in good faith. Such
payment may be made without prior judicial determination of the claim or claims. With respect
to any retention of payment by CITY to ensure performance of the Contract, CONTRACTOR
will be entitled to substitute securities as provided in Section 4590 of the California Government
Code as more fully described in CITY'S Notice to Contractors.
14. NOTICE AND SERVICE THEREOF. Any notice from one party to the other under
this Contract shall be in writing, and shall be dated and signed either by the party giving such
notice, or by a duly authorized representative of such party. Any such notice shall not be
effective for any purpose whatsoever unless served in the following manner: (a) if the notice is
given to CITY, either by personal delivery thereof to the Engineer of CITY, or by depositing
same in the United States mails, enclosed in a sealed envelope, addressed to CITY OF
CUPERTINO; 10300 TORRE AVENUE; CUl'ERTINO, CA 95014; postage prepaid and
certified; (b) if the notice is given to CONTRACTOR, either by personal delivery thereof to
CONTRACTOR, or to CONTRACTOR'S duly authorized representative at the site of the
project, or by depositing same in the United States mails enclosed in a sealed envelope,
addressed to, 1120 Ninth Avenue, San Mateo, CA 94402, postage prepaid and certified; and (c)
if notice is given to CONTRACTOR'S surety or any other person, either by personal delivery
thereof to CONTRACTOR'S surety or other person, or by depositing
same in the United States mails, enclosed in a se;rled envelope, addressed to CONTRACTOR'S
surety or person, as the case may be, at the address of CONTRACTOR'S surety or the address of
the person last communicated by such person to the party giving the notice, postage prepaid and
certified.
15. ASSIGNMENT OF CONTRACT. Neither the Contract, nor any part thereof, nor
moneys due or to become due thereunder, shall be assigned by CONTRACTOR without the prior
written approval of CITY.
16. COMPLIANCE WITH 5PECIFICATh~NS OF MATERIALS. Whenever in the
Specifications, any material or process is indicated or specified by patent or proprietary name, or
by name of manufacturer, such Specifications must be met by CONTRACTOR, unless CITY
agrees in writing to some other material, process or article offered by CONTRACTOR which is
equal in all respects to the one specified. It shall be CONTRACTOR'S responsibility to prove
equality of any such material, process or article offered as a substitution to the one(s) specified.
17. WORKER'S COMPENSATION INSURANCE AND EMPLOYER'S LIABILITY
INSURANCE. CONTRACTOR shall take o~xt and maintain during the life of this Contract
Worker's Compensation Insurance and Employer's Liability Insurance for all of
CONTRACTOR'S employees employed at the rite of the project. In case any work is sublet,
CONTRACTOR shall require any and all s~zbcontractors similarly to provide Worker's
Compensation and Employer's Liability Insurance for all of the latter's employees unless such
employees are covered by the protection afforded to the CONTRACTOR.
In signing this Contract CONTRACTOR makes the following certification, required by Section
1861 of the Labor Code: "I am aware of the provisions of Section 3700 of the Labor Code which
requires every employer to be insured against liat~ility for worker's compensation or to undertake
4
self insurance in accordance with the provisions of the Labor Code, and I will comply with such
provisions before commencing the performance of the work of this Contract."
18. ACCIDENT PREVENTION. Precaution shall be exercised at all times for the
protection of persons (including employees) and property. The safety provisions of applicable
laws, building codes and construction codes shall be observed. Machinery, equipment and other
hazards shall be guarded or eliminated in accordance with the safety provisions of the
Construction and Safety Orders issued by the Industrial Accident Commission of the State of
California.
19. CONTRACTOR'S RESPONSIBILITY FOR THE WORK. CONTRACTOR shall
not be responsible for the cost of repairing or restoring damage to the work caused by Acts of
God. NEVERTHELESS, CONTRACTOR shall, :.f the insurance premium is a separate bid item,
obtain the insurance to indemnify CITY for any damage to the work caused by Acts of God.
"Acts of God" shall include only the follov~~ing occurrences or conditions and effects:
earthquakes and tidal waves, when such occurrences or conditions and effects have been
proclaimed a disaster or state of emergency by the President of the United States or by the
Governor of the State of California, or were of a magnitude at the site of the work sufficient to
have caused a proclamation of disaster or state of Emergency having occurred in a populated area.
Subject to the foregoing, CITY shall not, in any way or manner, be answerable or suffer loss,
damage, expense or liability for any loss or dam~~ge that may happen to said building, work, or
equipment or any part thereof, or in, on, or abo~it the same during its construction and before
acceptance.
20. CONTRACTOR'S GUARANTEE. CONTRACTOR unqualifiedly guarantees the
first-class quality of all work and of all materials, apparatus and equipment used or installed by
CONTRACTOR or by any subcontractor or supplier in the project which is the subject of this
Contract, unless a lesser quality is expressly authorized in the Plans and Specifications, in which
event CONTRACTOR unqualifiedly guarantee:; such lesser quality; and that the work as
performed by CONTRACTOR will conform wi1:h the Plans and Specifications or any written
authorized deviations therefrom. In case of any defect in the work, materials, apparatus or
equipment, whether latent or patent, revealed ~:o CITY within one (1) year of the date of
acceptance of completion of this Contract by CITY, CONTRACTOR will forthwith remedy such
defects without cost to CITY.
5
P.O. No.
21. DEFERRED ALTERNATE SELECTIO]v. The City reserves the right for the term of
the Contract, the deferred selection of none, any ~~r all alternate bid items at the bid price. The
alternates chosen would be for any sites currently under construction or to be constructed in the
future.
IN WITNESS WHEREOF, the parties have e~:ecuted this Contract, in duplicate, the day and
year first hereinabove written.
CITY OF CUPERTINO:
By:
Mayor
Attest:
City Cl
Date: ~~ f ~ , 20~
City Clerk
APPROVED AS TO FORM:
City Attorney
CONTRACTOR:
JJR CONSTSUC~'ION, INC.
CI.ABS A LICENSE ~
(ssol ~~o~
By:
Notary acknowledgment is required. If a
corporation, corporate seal and corporate
notary acknowledgment and Federal Tax
I.D. are required. If not a corporation a
Social Security No. is required.
Social Security #
g y-3~~iiy_a
Federal Tax I.D. #
Contractor's License No. ~~ ~~~~
Project Name & Number: Reconstruction of C~irbs, Gutters and Sidewalks, Project No.
2003-01
Contractor's Name & Address:
Contract Amount: $ 397,400.00
Account Number: 270-8403-7014
File No: 50,340
J.J.R. Construction, Inc.
1120 Ninth .Avenue
San Mateo, CA 94402
6
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personally appeared . ~~ ~ -~
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Name(sl or Signed;)
^ personally known to me - OR - r roved to me on the basis of satisfactory evidence to be the person(s)
whose name(s) ts~re subscribed to the within instrument
and-ac~:nowledged to me that he/she/they executed the
same in hislher/their authorized capacity(ies), and that by
his/her/:heir signature(s) on the instrument the person(s),
TNAtiERA. SNEHADEH or the entity upon behalf of. which the person(s) acted,
S COMM. ~f1412311 -~ executed the instrument.__: -
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Though the information below is not required by law, it may prove va/gable to persons relying on the document and could prevent
fraudulent removal and reattachment of Ibis form to another document.
Cescrip#i®r~ ®fi At#ac~ie~ C®c~ar~es~t
Title or Type of Document:
Document Date:
Signer(s) Other Than Named Above:
Cap~acit~(ies) Csaita~e~! by Sigraes~(s)
Signer's Name:
^ Individual
^ Corporate Officer
Title(s):
Partner - ^ Limited ^ General
Attorney-in-Fact
Trustee
Guardian or Conservator
Other:
Signer Is Representing
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Si~~ner's Name:
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Number of Pages:
Individual
Corporate Officer
Title(s):
Partner - ^ Limited ^ General
Attorney-in-Fact
Trustee
Guardian or Conservator
Other:
Siclner Is Representing
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m 1995 National Notary association • 823'o Remmet Ave., P.O. Sox 718~i • Canoga Park, CA 91;09-7181 Prod. No. 5907 Reorder. Call To11-rree 1-800-876-0827
INSURANCE FORMS INSTRUCTIONS
FOR ITEMS 3, 4 AND 5, THE FORMS PROVIDED BY THE CITY OF CUPERTINO
MUST BE USED. FORMS OTHER THAN THESE WILL NOT BE ACCEPTED.
ALL DOCUMENTS MUST BE ORIGINALS -SUBMIT IN TRIPLICATE
1. Insurance Agreement -Must be signed by Contractor.
2. Certificate of Insurance to the City of Cupertino -must be completed by the insurance
agent or must provide a certificate on the corzpany's form. They must contain the same
information.
3. Endorsement of Additional Insured and Primary Insurance and Notice of Cancellation -must be
signed by the insurance agent for general liability acid automobile liability only.
4. Comprehensive general liability/commercial ge~ieral liability endorsement of aggregate limits of
insurance per project - must be signed by the insur~mce agent for general liability only.
5. Waiver of subrogation endorsement worker's compensation insurance -must be signed by the
insurance agent for worker's compensation only.
Insurance Inshuctions
~(~G.
CITY OF
CUPEI~TINO INSURANCE AGREEMENT
A. Contractor is aware of the provisions of Section 3700 of the Labor Code, which requires
every employer to be insured against liability i.or worker's compensation or undertake self-
insurance in accordance with the provisions of that Code, and will comply with such provisions
before commencing the performance of the work of this Contract.
B. Contractor and all subcontractors will carry worker's compensation insurance for the
protection of its employees during the progress of the work. The insurer shall waive its rights of
subrogation against the City, the City's officers, agents and employees and shall issue an
endorsement to the policy evidencing same.
C. Contractor shall carry at all times, on all of~erations hereunder, commercial general liability
insurance, automobile liability insurance and builder's all risk insurance. All insurance coverage
shall be in amounts required by the City and shall lie evidenced by the issuance of a certificate in a
form prescribed by the City and shall be underwritten by insurance companies satisfactory to the
City for all operations, sub-contract work, contractual obligations, product or completed operations,
all owned vehicles and non-owned vehicles. Said insurance coverage obtained by the Contractor,
excepting worker's compensation coverage, shall- name the City, its engineer, and each of its
directors, officers, agents and employees, as determined by the City, as additional insureds on said
policies. Insurers must be licensed to do business in the State of California. The Insurers must also
have an "A" policyholder's rating and a financial rating of at least Class VII in accordance with the
current Best's Guide Rating or that is otherwise acceptable to the City.
D. Before Contractor performs any work at, or prepares or delivers materials to, the site of
construction, Contractor shall furnish certificates ~~f insurance evidencing the foregoing insurance
coverages and such certificates shall provide the name and policy number of each carrier and policy
and that the insurance is in force and will not bc; canceled or modified without thirty (30) days
written notice to the City. Contractor shall maintain all of the foregoing insurance coverages in
force until the work under this Contract is fully completed. The requirement for carrying the
foregoing insurance shall not derogate from the provisions for indemnification of the City by
Contractor under this Contract and for the duration of the warranty period. Notwithstanding nor
diminishing the obligations of Contractor with resf~ect to the foregoing, Contractor shall maintain in
full force and effect during the life of this Contract.. the following insurance in amounts not less than
the amounts specified and having a Best's Guicie Rating of A, Class VII or better or that is
otherwise acceptable to the City.
LIMITS
Worker's Compensation In accordance with the Worker's Compensation
& Employers' Liability Act oil the State of California -Worker's comp -
"statutory" per CA Law; Employers' Liability -
$1,000,000 per occurrence.
Insurance Agreement Page 1 of 2
General Liability -commercial general liability; Combined single limit of $1.0 million per
including provisions for contractual liability, occurrence; $2.0 million in the aggregate.
personal injury, independent contractors and
products -completed operations hazard.
Automobile Liability -comprehensive covering Combined single limit of $1.0 million per
owned, non-owned and hired automobiles. occurrence.
Consult~~c~~~s~~~siy~~iability. $1.0 million per occurrence.
C1Ji18s A LICENSE ~M885845
11'0 !TH AVE.. SAN YATEO. CA EM02
(030) ~~10! EAX (630) 343.620T
By.~ aV~
Dated: ILIA-f~yh,~.,~ ohs, 200
(Contractor's Name)
Insurance Agreement Page 2 of 2
:...............:::::.~::f::::: ~:::::;: ~:: ;::::::::::::::1::.:::1:::::.::::::::::::~
............
PRODUCER Karen Troy
Talbot Insurance & Fin Services, I
400 Taylor Blvd ##300
Pleasant Hill, CA 94523
925-609-6500 fax925-609-6550
INSURED
JJR Construction, Inc.
1120 9th Avenue
San Mateo, CA 94402
COMPANY
D
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVI. 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 HAVI: BEEN REDUCED BY PAID CLAIMS.
CO
LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE
DATE IMM/DD/YY) POLICY EXPIRATION
DATE IMM/DD/YY) OMITS
A GEN ERALUABIUTY GS307339 07/05/2003 07/05/2004 GENERAL AGGREGATE S 2, OOO, 000
X COMMERCIAL GENERAL LIABILITY PRODUCTS -COMP/OP AGG S 2, 0 0 0, O O O
CLAIMS MADE X^ OCCUR PERSONAL & ADV INJURY S 1 , ~ O O , O O O
X OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE S 1, OOO , OOO
X Per Project Aggregat FIRE DAMAGE IAny one fire) S 5 0 , D 0 0
MED EXP IAnv one cersonl 5 5. 0 0 0
B Aur onnoelLEUABIUrv BPP9742815 07/05/2003 07/05/2004
1
O O O
O O O
COMBINED SINGLE LIMIT S
,
,
X ANY AUTO
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS IPer person) S
X HIRED AUTOS
BODILY INJURY
X
NON-OWNED AUTOS
IPer accident! S
PROPERTY DAMAGE S
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT S
AGGREGATE S
EXCESS LIABILITY EACH OCCURRENCE S
UMBRELLA FORM AGGREGATE S
OTHER THAN UMBRELLA FORM S
C WORKERS COMPENSATION AND 046991603 01/01/2003 01/01/2004 X ORY IM TS DER
EMPLOYERS' LIABILITY
EL EACH ACCIDENT S 1, O O O, O O O
THE PROPRIETOR/ INCL EL DISEASE -POLICY LIMIT S 1, O ~ O, 0 0 0
PARTNERS/EXECUTI V E
OFFICERS ARE: EXCL EL DISEASE - EA EMPLOYEE S 1 , O ~ O , O O O
OTHER
CRIPTION OF OPERATIONS/LOCATIONSNEHICLESlSPECIAL ITEMS
2003-01 RECONSTRUCTION OF CURBS, GUTTERS, SIDEWALKS
ITIONAL INSURED AS REQUIRED BY WRITTEN CONTRACT AND PER FORM .?NF160(12/2002) ATTACHED.
CITY OF CUPERTINO
CITY HALL
10300 TORRE AVENUE
CUPERTINO, CA 95014-3255
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL~c$}~Cg MAIL
3 O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Ste~l~a~ys notice for non- aym~ent
uCi3;_]5a]{I}~'.3"[~}5'noix'su uc"yi js{p'~.IC'E7V;7{nit}Qn~CPlacdSGhi`~g~}~j,S617U7ij9~isl~4$fX
AUTHORIZED REPRESENTATIVE /~}~ ~i/
rnri o~f~G7Zf2dl S7~TFA
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED ENDORSEMENT -
(EXCLUDING RESIDENTIA L AND HABITATIONAL)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS (FORM B)
CG 20 10 11 85
SCHEDULE
Name of Person or Organization:
Any person or organization that the named insured is obligated by virtue of a written
contract or agreement to provide insurance :such as is afforded by this policy,
provided the Company is notified in writnig within 30 days of the inception of
the contract or agreement, or the inception of this policy, whichever is later.
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization
shown in the Schedule, but only with respect to liability arising out of "your work" for that insured
by or for you.
The following additional provisions apply to any entity that is an insured by the terms of this
endorsement:
Primary Wording
If required by written contract or agreement: Such insurance as is afforded by this policy shall
be primary insurance, and any insurance or self-insurance maintained by the above additional
insureds) shall be excess of the insurance; afforded to the named insured and shall not
contribute to it.
2. Waiver of Subrogation
If required by written contract or agreement: We waive any right of recovery we may have
against an entity that is an additional insur~:d per the terms of this endorsement because of
payments we make for injury or damage arising out of "your work" done under a contract with
that person or organization.
Neither the coverages provided by this insurance policy nor the provisions of this endorsement
shall apply to any claim arising out of the s~~le negligence of any additional insured or any of
their agents/employees.
4. This endorsement does not apply to any work involving or related to properties intended for
permanent residential or habitational occupancy.
ANF 160 (12/2002)
Forming a part of
Policy Number: gPP9742815
Coverage Is Provided In
Named Insured: Agent:
JJR CONSTRUCTION, INC,. TALBOT INSURANCE AND FINANCAIL SERVICES INC.
Agent Code: Agent Phone:
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ R CAREFULLY.
ADDITION~-L INSURED
This endorsement modifies Insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
TRUCKERS COVERAGE FORM
The person or organization shown in the Schedule is an insured to the exten~: of their liability for the conduct of an insured under Section II-Liability
Coverage of this policy.
SCHEDULE
AS REQUIRED BY':'WRITTEN CONTRACT
GECA 812 (10196)
POLICYHOLDER COPY
STATE P.O. BOX 420807, SAN FRANCI;iCO, CA 94142-0807
COMPENSATION
I N S U R A N C E
FUN ~ CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
NOVEMBER 19, 2003 GROUP: 000046
POLICY NUMBER: 9916-2003
CERTIFICATE ID: 16s
CERTIFICATE EXPIRES: of-01-2004
01-01-2003/01-01-2004
CITY OF CUPERTINO
10300 TORRE AVE, CITY HALL
CUPERTINO CA 95014-3255
This is to certify that we have issued a valid Worker's Compensation insurance policy in a form approved by the California
Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer
We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the
policies listed herein. Notwithstanding any requirement, term or condition of any contract or other document with
respect to which this certificate of insurance 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.
AUTHORIZED REPRESENTATIVE
,~~~ c . ~
PRESIDENT
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE
JOSE RAPOSO PRES. - EXCLUDED
CARLOS RAPOSO VICE PRESIDENT - EXCLUDED
LAURA RAPOSO SECRETARY TREA. - EXCLUDED
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01-01-2002 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 11-19-2003 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME:
CITY OF CUPERTINO
EMPLOYER
J J R CONSTRUCTION, INC
1120 9TH AVE
SAN MATEO CA 94402
SCIF 10262E fEPF-U1: RRCI