05-030, Union City Construction - Pavement Restoration
CONTRACT FOR PUBLIC WORKS
This CONTRACT made on 28th day of March, 2005 by the CITY OF CUPERTINO, a
municipal corporation of the State of California, hereinafter called CITY, and
Union City Construction, 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 incorporated 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 Pavement Restoration, Project No. 2005-02
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's Compensation Insurance and Notice of Policy
Cancellation Endorsement.
All of the above documents are incorporated into 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 pavement restoration, 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, Pavement Restoration,
Project No. 2005-02 and which Plans and Specifications are identified by the signatures of the
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
CONTRACTOR, 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.
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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 Sixty Two Thousand, Five
Hundred Dollars and No Cents ($62,500.00) 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 preservation 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, approval, 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 alterations, 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 Contract 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 authorized, 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.
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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
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 the 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 MATERIALS. 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 arrange 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 CONTRACTOR'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 be 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 CONTRACTOR'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 prosecute the same to completion by contract, or by
any other method it may deem advisable, for the account 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 may be on the site of the work and necessary therefore.
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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 CONTRACTOR 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 amounts 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
CITY shall be considered as a payment made under the Contract by CITY to CONTRACTOR,
and CITY shall not be liable to CONTRACTOR 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; CUPERTINO, 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, , 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 sealed 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 there under, shall be assigned by CONTRACTOR without the
prior written approval of CITY.
16. COMPLIANCE WITH SPECIFICATIONS 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.
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17. WORKER'S COMPENSATION INSURANCE AND EMPLOYER'S LIABILITY
INSURANCE. CONTRACTOR shall take out 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 site of the project. In case any work is sublet,
CONTRACTOR shall require any and all subcontractors 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 liability for worker's compensation or to undertake
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, if 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 following 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 damage that may happen to said building, work, or
equipment or any part thereof, or in, on, or about 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 guarantees such lesser quality; and that the work as
performed by CONTRACTOR will conform with the Plans and Specifications or any written
authorized deviations there from. In case of any defect in the work, materials, apparatus or
equipment, whether latent or patent, revealed to 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.
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P.O. No.
21. DEFERRED AL TERNA TE SELECTION. The City reserves the right for the term of
the Contract, the deferred selection of none, any or 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 executed this Contract, in duplicate, the day and
year first hereinabove written.
CITY OF CUPERTINO:
CONTRACTOR: Union City Construction
By:j)..,J~
David Knapp
City Manager
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By:
Edward Dillon, Partner
Attest:
Date:
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CIty Clerk
,2005
Notary acknowledgment is required. If a
corporation, corporate seal and corporate
notary acknowledgment and Federal Tax
I.D. are required. Ifnot a corporation a
Social Security No. is required.
Social Security #
Federal Tax I.D. #
Contractor's License No. 812791
Project Name & Number: Pavement Restoration, Project No. 2005-02 and
Contractor's Name & Address:
Union City Construction
1147 Atlantic Street
Union City, CA 94587
Contract Amount: $ 62,500.00
Account Number: 270-9450-9300
File No: 98,493.76
6
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
County of
Alameda
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State of California
on__Jl~jSXjjSl?______._________ before me ,__A!1lYJ/@j:J~.go-:i,~LJiQ.1: a ry-J?u b.l.ic__..____,
Daln NiHM and Tille of Officer (O,g_, "Jano 000, Notary Public"}
personally appeared____J;:g~~ d12JJ.J_()t:l.__
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Nam8(S) 01 Si9f10r(5)
, Xpersonally known to me
proved to me on the basis of satisfactory
evidence
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to be the person(s) whose name(s) is/are
subscribed to the within instrument and
aclmowledged 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.
OPTIONAL
Though the information below is not required lJY law, it may prove valuable to persons relying on the documenf and could prevent
fraudulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document:T.!fg__gj.!X_.9f _S;_l!E~!"!=JnQ..!._~Q.J:l.~!:il:~t:_<;t9_~9______.________
Document Date:
Number of Pages:__________
Signer(s) Other Than Named Above:..______
Capacity(ies) Claimed by Signer
Signer's Name:__._..____..__
.
Tn.p of thumb here
Individual
Corporate Officer - Title(s): ______
Partner - Limited General
Attorney-in-Fact
Trustee
Guardian or Conservator
Other:
Signer Is Representing:.__
Ij,') 1999 National Notary Associat:on . 9350 Do Solo Ave., PO Box 2402 . Chalsworth, CA 9131],.2402 . www,nalionalr,olaryOlQ
PHXi. No. 5907
Reordef" Call Toll.Fme '.800-876-6827
,EXHIBIT A
BID PROPOSAL
PAVEMENT RESTORATION
PROJECT 2005-02
TO: THE DIRECTOR OF PUBLIC WORKS, CITY OF CUPERTINO, STATE OF CALIFORNIA
Dear Sir:
In compliance with the plans and specifications furnished for the work of the PAVEMENT
RESTORATION PROJECT in the City of Cupertino, PROJECT NO. 2005-02, the
undersigned, hereby declare that I have read the proposal requirement, visited the sites, and
examined the specifications. I, the undersigned, hereby propose to do all work required to
complete the work in accordance with the plans and specifications for the prices set forth in the
following schedule. I further understand that said prices include all costs including, but not
limited to, local, state and federal taxes, and transportation costs.
I, the undersigned, also understand that the quantities shown below are estimates only, being
given as a basis for comparison of bids. The City of Cupertino does not state that the actual
amount of work will correspond but reserves the right to increase or decrease the amount of any
class or portion of the work or to omit items or portions of work deemed unnecessary by the
Engineer.
The City of Cupertino reserves the right to unilaterally determine and award the contract to any
qualified bidder based on the most advantageous proposal, to reject any or all bids, or to waive
any irregularities in the procedures.
The work to be done consists of furnishing all labor, methods of process, tools, machinery and
material required to complete the PA VEMENT RESTORATION, PROJECT NO. 2005-02 as
described in the Special Provisions.
I, the undersigned, shall diligently prosecute the work to completion as scheduled. I further
understand that I shall pay to the City of Cupertino the sum of One Hundred Fifty Dollars
($150.00) per day, for each and every day services are not completed as scheduled and/or
specified.
In the event of discrepancies between the written unit price and the numerical unit price, the
written price shall govern.
Bid Proposal Page 1 of 8
I, the undersigned, agree that if this proposal is accepted, I will enter into a contract with the City
of Cupertino to provide all necessary machinery, tools, apparatus, and other means of
construction and to do all the work specified in the contract in the manner and time specified.
I, the undersigned, declare that this bid is made without connection with any person, firm, or
corporation making a bid for the same work, and is in all respects fair, and without collusion or
fraud.
I, the undersigned, recognize that the Director of Public Works of the City of Cupertino will
reserve the right to establish the priority of one job over another and each starting date where
conflict of construction schedules occur.
Attached hereto is the required certified check or bid bond in the amount of $ /0 t: {1"/ ~'/, as
I
required by law and the Notice to Bidders. (10% of bid amount)
Bid Proposal Page 3 of 8
NON COLLUSION AFFIDAVIT TO BE EXECUTED BY
BIDDER AND SUBMITTED WITH BID
I, the undersigned, being first duly sworn, depose and say that I am
Partner
(Business Title)
of Union City Construction
(Business Name)
the party making the foregoing bid, that the bid is not made in the interest of, or on behalf of, any
undisclosed person, partnership, company, association, organization, or corporation. The bid is
genuine and not collusive or sham. The bidder has not directly or indirectly induced or solicited
any other bidder to put in a false or sham bid, and has not directly or indirectly colluded,
conspired, connived, or agreed with any bidder or anyone else to put in a sham bid, or that
anyone shall refrain from bidding. The bidder has not in any manner, directly or indirectly,
sought by agreement, communication, or conference with anyone to fix the bid price of the
bidder or any other bidder, or to fix any overhead, profit, or cost element of the bid price, or of
that of any other bidder, or to secure any advantage against the public body awarding the contract
of anyone interested in the proposed contract. All statements contained in the bid are true and,
further, the bidder has not, directly or indirectly, submitted the bid price or any breakdown
thereof, or contents thereof, or divulged information or data relative thereto, or paid, and will not
pay, any fee to any corporation, partnership, company, association, organization, bid depository,
or to any member or agent thereof to effectuate a collusive or sham bid.
Bid Proposal Page 4 of 8
BIDDER QUALIFICATION FORM
In further compliance with the specifications furnished, I, the undersigned, submit the following
statements as to my experience and qualifications to perform this work as a part of this proposal.
We have been in business under the present name for 1(;() (2.) years.
Our experience in work comparable with that required by the proposal contract is 10
years operating under the following different name(s).
VlI!A/
I
My California Contractor's License Number is 812791
The classification of my Contractor's License is II A"
The expiration date for my Contractor's License is 09/30/06
******************************************************************************
*
(This Section for City use only)
flu/rlMt- Ly~aaqrl
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*
The above information has been verified by
on ,3/2. ~/~5
*
Contractors State License Board (800) 321-2752 or (408) 277-1244.
******************************************************************************
Where federal funds are involved, no bid submitted shall be invalidated by the failure of the
bidder to be licensed in accordance with the laws of the State of California, however, at the time
the contract is awarded the contractor shall be properly licensed.
Bid Proposal Page 5 of 8
Union City Construction
P.O. Box 3277
Fremont, CA 94539
Ph: (510) 441-1262 Fax: (510) 441-1263
Contractor's License No. 812791
PROJECT REFERENCES:
CITY OF LAFAYETTE
P.O. Box 1968
Lafayette, CA 94549
COUNTY OF SACRAMENTO
827 ih Street
Sacramento, CA 95814
2002 Pavement Manaqement Project
City Project 099001160
Matt Luttropp Phone No: (925) 299-3247
Completed: June 2002
Amount of Contract: $162,000.00
Rubberized Chip Seal Project
Proiect No. 3502
Ali Chehade Phone No: (916) 875-2722
Completed: November 2002
Amount of Contract: $117,000.00
COUNTY OF ALAMEDA
951 Turner Court, Room 100
Hayward, CA 94545
VALLEY TRANSPORTATION AUTHORITY
3990 lanker Road
San Jose, CA 95134
Spec No. 1946
Slurry Seal Surfacinq of approx. 3.2 km
of Various Roadways in Unincorporated
Areas of Alameda County California
Ed Herholdt Phone No: (510) 670-5450
Completed: October 2002
Amount of Contract: $ 73,500.00
Cerone Complex
Greg Beattie Phone No: (408) 321-5555
Completed: December 2002
Amount of Contract: $67,000.00
MOUNTAIN VIEW-LOS ALTOS UNION
HIGH SCHOOL DIST.
1299 Bryant Avenue
Mountain View, CA 94040
Fire Lane Repair & Pavinq
Brenda Visas Phone No: (650) 691-2410
Completed: August 2003
Amount of Contract $23,495.80
SUBCONTRACTOR'S FORM
The subcontractor(s), as defined in the General Provisions and in Section 7026 of the California
Business and Professions Code, that I propose to hire to perform any of the work for this project
in an amount in excess of one-half of one percent (0.5%) of the total bid are listed below. Only
those listed below shall perform work on this project and each of them has been provided with a
full and complete set of plans and specifications for this project by the bidder.
1. Name "1l~ i
Address & phone no.
Wark to be Performed
2. Name
Address & phone no.
Work to be performed
3. Name
Address & phone no.
Work to be performed
4. Name
Address & phone no.
Work to be performed
5. Name
Address & phone no.
Work to be performed
6. Name
Address & phone no.
Wark to be performed
Contractor's License No.
Contractor's License No.
Contractor's License No.
Contractor's License No.
Contractor's License No.
Contractor's License No.
Bid Proposal Page 7 of 8
BIDDER'S SIGNATURE FORM
IF YOU ARE AN INDNIDUAL, SO STATE. IF YOU ARE A COMPANY OR A CO-
PARTNERSHIP, STATE THE COMPANY NAME AND LIST THE NAMES OF ALL
INDNIDUAL CO-PARTNERS COMPOSING THE. COMPANY. IF YOU ARE A
CORPORATION, STATE THE LEGAL NAME OF THE CORPORATION AND THE NAMES
OF THE PRESIDENT, SECRETARY-TREASURER, AND MANAGER. THE CORPORATE
SEAL MUST BE AFFIXED TO THIS FORM. ENTER THE NAME OF YOUR BUSINESS
ON THE LINE OPPOSITE THE APPROPRIATE BUSINESS TYPE.
TYPE OF
BUSINESS Partnership
NAME OF
BUSINESS Union City Construction
CORPORATION:
CO-PARTNERSHIP: Edward Dillon, Craig Johnson, Javier Godinez
INDNIDUAL:
JOINT VENTURE:
OTHER:
(Describe)
Name and Signature of Bidder:
&JVltlAL1 &--
(Print or type name)
Edward Dillon, Partner
Date:
03/08/05
Address (mailing & location):
P.O. Box 3277, Fremont, CA 94539 (mailing)
1147 Atlantic Street, Union City CA 94587 (street)
Telephone Number:
(510 ) 441-1262
(510 ) 441-1263
Fax Number:
Acknowledgment of all addenda received is required by circling each addendum number.
(Q (0 3 4 5 6 7 8 9 10
Bid Proposal Page 8 of 8
CITY
CUPEIQ"INO
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 for 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 operations 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 be 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 of 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 be 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 respect 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 Guide Rating of A, Class VII or better or that is
otherwise acceptable to the City.
Worker's Compensation
& Employers' Liability
LIMITS
In accordance with the Worker's Compensation
Act of 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;
including provisions for contractual liability,
personal injury, independent contractors and
products - completed operations hazard.
Automobile Liability - comprehensive covering
owned, non-owned and hired automobiles.
Consultants only: Errors and Omissions liability.
Combined single limit of $1.0 million per
occurrence; $2.0 million in the aggregate.
Combined single limit of$1.0 million per
occurrence.
$1.0 million per occurrence.
Union City Construction
(Contractor's Name)
By: f:rL ,n-J ~
Dated: April 13, 2005
2005
Insurance Agreement Page 2 of 2
CITY OF
CUPERJINO CERTIFICATE OF INSURANCE TO THE CITY OF CUPERTINO
This certifies to the City of Cupertino that the following described policies have been issued to the
insured named below and are in force at this time.
Insured:
Address:
Union City Construction..
P. o. Box'~3277
Fremont, CA 94539
Description of operations/locations/products insured (show contract name and/or number, if any):
City of Cupertino Pavement Restoration Project # 2005-02
----------------------------------------
----------------------------------------------
Zenith Insurance
* Statutory~ Min.
* Employer's
Liability
WORKER'S COMPENSATION
(name of insurer)
$ 1,000,000
$1,000,000
$ 1, 000,000
Insurance Company's State License No.
---------------------------------------------
-------------------------------------------------------
Check Policy Type:
COMPREHENSIVE GENERAL
LIABILITY
[x] Premises/Operations
Each Occurrence
$1,000,000
General Aggregate
(if applicable)
$ 2,000,000
[x] Owners & Contractors
Protective Aggregate $ 2,000,000
[ ] Contractual for Specific
Contract Personal Injury'
$
[x] Products Liability
[x] XCV Hazards
[x] Broad Form P.D. Fire Damage (anyone fire) $ 300,000
[ ] Severability of Interest
Clause
[ ] Personal Injury with Medical Expense $ 5,000
Employee Exclusion Removed (anyone person)
or Self- Insured
COMMERCIAL GENERAL LIABILITY Retention $ 2,000
Transcontinental Insurance Company
(name of insurer)
Policy No. TCP2077702038
Expiration Date 05/06/05
Certificate of Insurance Agreement Page 1 of 2
AUTOMOTIVE/VEHICLE LIABILITY
Commercial Form
Liability Coverage
BODILY INJURY
Each Person
PROPERTY DAMAGE
Each Accident
$
$
Each Accident
American Casualty Co. of Rending
(name of insurer)
$ or
Combined Single Limit $ 1,000,000
Policy No. BUA2077702041
Expiration Date 05/06/05
TRB 1()).,J\?
(agent's initial)
A copy of all Endorsements to the policy(ies) which in any way
limit the above-listed types of coverage are attached to this
Certificate of Insurance.
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 any 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.
IT IS HEREBY CERTIFIED that the above policy(ies) provide liability insurance as required by
the Agreement between the City and the insured.
.~Iu ~~.
By: "{,Thom:R~ ~iShOP "p Dated: April 12
Attach Certificate of Insurance and Additional Insured Endorsement on company forms.
20 05
Certificate of Insurance Agreement Page 2 of 2
CITY F
CUPEI\TINO
ADDITIONAL INSURED ENDORSEMENT
and
ENDORSEMENT OF PRIMARY INSURANCE
and
NOTICE OF POLICY
CANCELLATION ENDORSEMENT
Project Title and Number: Pavement Restorat.ion project- #:WO"i-O?
In consideration of the po~icy premium and notwithstanding any inconsistent statement in the policy
to which this Endorsement is attached or any other Endorsement attached thereto, it is agreed as
follows:
The City of Cupertino ("City") and its directors, officers, engineers, agents and employees,
and all public agencies from whom permits will be obtained and their directors, officers, engineers,
agents and employees are hereby declared to be additional insureds under the terms of this policy,
but only with respect to the operations of the Contractor at or upon any of the premises of the City
in connection with the Contract with the City, or acts or omissions of the additional insureds in
connection with, but limited to its general supervision or inspection of said operations.
The insurance afforded by this policy is primary insurance, and no additional insurance held
or owned by the designated additional insured(s) shall be called upon to cover a loss under said
additional policy.
Cancellation Notice. The insurance afforded by this policy shall not be suspended, voided,
canceled, reduced in coverage or in limits, or materially altered, except after thirty (30) days' prior
written notice by certified mail, return receipt requested, has been given to the City of Cupertino
("City"). Such notice shall be addressed to the City as indicated below.
* la-day notice for non-payment
POLICY INFORMATION
1. Insurance Company:
Transcontinental Insurance Compnany
2. Insurance Policy Number:
TCP2077702038
3. Effective Date of this Endorsement:
April 12
20-'05
4. Insured:
Union City Construction
Additional Insured and Primary Insurance and Notice of Cancellation Endorsement Page 1 of 2
All notices herein provided to be given by the Insurance Company to the City in connection
with this policy and these Endorsements, shall be mailed to or delivered to the City at 10300 Torre
Avenue; Cupertino, California 95014.
I, Thomas R. Bishop (print/type name)
warrant that I have authority to bind the below listed Insurance Company and by my signature
hereon do so bind this Company.
Signature of Authorized Representative:
(Original signature required on all Endorsements furnished to th
Names of
Agent! Agency:
AaD Insrance and Financial
:>ervl.ces, Inc.
Title: Account Executive
Address: 820 Bay Ave., Ste 111
Telephone: 831-476-0900
Capitola, CA 95010
Facsimile:
831-476-7493
Additional Insured and Primary Insurance and Notice of Cancellation Endorsement Page 2 of 2
F
CUPEI\TINO
COMPREHENSIVE GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
ENDORSEMENT OF AGGREGATE LIMITS OF
INSURANCE PER PROJECT
Project Title and Number:
Pavement Restoration Project #2005-02
In consideration of the policy premium and notwithstanding any inconsistent statement in the
policy to which this Endorsement is attached or any other Endorsement attached thereto, it is as
follows:
This Endorsement modifies the insurance provided under the General Liability Coverage part of
the below-referenced policy of insurance.
The general aggregate limit under LIMITS OF INSURANCE applies separately to the project
described as Pavement Restoration Project #" 2005-02
POLICY INFORMATION
1. Insurance Company: Transcontinental Insurance Company
2. Insurance Policy Number:
TCP2077702038
3. Effective Date of this Endorsement:
April 12
20 05
4. Insured:
Union City Construction
5. Additional Insured: City of Cupertino, its directors, officers, agents and employees.
All notices herein provided to be given by the Insurance Company to the City in connection
with this policy and this Endorsement, shall be mailed to or delivered to the City at 10300 Torre
Avenue; Cupertino, California 95014.
I, Thomas R. Bishop (print!type name)
warrant that I have authority to bind the below listed Insurance Company and by my signature
hereon do so bind this Company.; f) /
Signature of Authorized Representative:f I1t"-Y.fl R ~
(Original signature required on all Endorsements furnished to. e Dlstnct)
Names of
Agent!Agency: ABO Insurance & Financial Services Title: Account Executive
Address: 820 Bay Ave., Ste 111 Telephone:l:S.H-476-0900
Facsimile: 831-476-7493
Cqpitola. CA 95010
Aggregate Limits Endorsement Page 1 of 1
.
CUPERJINO
~;e cll!ar he(t
----
(
....-'----
VER OF SUBROGATION ENDORSEMENT
RKER'S COMPENSATION INSURANCE
Project Title and NumbeA
"
\
In consideration of the polic~\premium and notwithstanding any inconsistent statement in the
policy to which this Endorsement i~attached or any other Endorsement attached thereto, it is agreed
as follows: '\,
\
\
It is agreed that with respect to su~h insurance as is afforded by the policy, the Insurance
Company waives any right of subrogatio~ against the City of Cupertino, and each of its directors,
officers, agents, consultants and employee~\ by reason of any payment made on account of injury,
including death resulting therefrom, sustained by any employee of the insured, arising out of the
\
performance of the above-referenced Contract:,
\
".
'\
/\.
POLICY INFORMATION
1. Insurance Company:
,
'.
,
\
\,
'~
\
20
2. Insurance Policy Number:
3. Effective Date of this Endorsement:
4. Insured:
,
All notices herein provided to be given by the Insuran~f( omp y to the City in connection
with this policy and this Endorsement, shall be mailed to or \ livered to the City at 10300 Torre
Avenue; Cupertino, California 95014.
I, .., (print/type name)
warrant that I have authority to bind the below listed Insurance\Company and by my signature
hereon do so bind this Company. .,
Signature of Authorized Representative:
(Original signature required on all Endorsements furnished to the District)
Names of
Agent! Agency:
Title:
Address:
Telephone:
Facsimile:
'\
\
\
t--
Subrogation Endorsement Page 1 of 1
Amy Matteis
From:
Sent:
To:
Cc:
Subject:
Thomas Bishop [trb@abdLcom]
Tuesday, April 12, 2005 12:10 PM
Amy Matteis
Debbie Dillon
Union City Construction Policy Z067174501 Eft Date 04/17/2005 Coverage Workers
Compensation - Certificate of Insurance City of Cupertino
Amy,
We are in the process of issuing the certificate and required forms for
the
City of Cupertino with the exception of the workers compensation wavier
of
subrogation endorsement for workers compensation. The Department of
Insurance requires ONLY filed forms be used on workers compensation
policies. Since the City of Cupertino form is not filed or authorized
by
the Department of Insurance, we will request that your insurance carrier
provide the specific endorsement. Please note there is a charge of 5%
of
the premium for the job for the waiver. Please make sure you maintain
separate payroll records for this project. Should you have any further
questions please contact me directly. Thank you.
Regards,
Tom Bishop
Account Executive
Commercial Lines Services
ABD Insurance Services & Financial Services
820 Bay Avenue Suite 111
Capitola, CA 95010
Phone: (831)477-7411
Fax: (831)476-7493
email: trb@abdi.com
The information in the e-mail and in any attachments is confidential,
privileged, and the property of ABD Insurance and Financial Services.
If
you received this message in error, please destroy this message, delete
any
copies and attachments stored on your systems and notify the sender
immediately. Any further distribution or copying of this message is
strictly prohibited.
1
FILE No.619 04/20 '05 09:52
ID:ABD INS.& FIN.
FAX:8314767493
PAGE 2/ 2
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY COpy ONLY
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 organi~ation llamed 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 5 % of the California workers compensation premium
otherwise due on such remuneration.
Minimum Premium: $50
Schedule
Person or Organization-Job Description
CITY OF CUPERTINO, 10300 TORRE AVENUE, CUPERTINO,CA 95014
RE: PROJECf #2005-02, PA VEMENT RESTORATION
This endorsement Changes the policy to whiCh it is aUached and is effective on the date issued unless otherwise stated.
Endorsement Effective 04/17/05
Insured UNION CI7Y CONSYR UCTION
Policy No. 2067174501
Policy Period 04/17/05 To 04/17/06
Issued On 04/19/05
ZENITH INSURANCE COMPANY
At PLeastl.lllon, CA
SECRETARY
W C-04"()3-06
(Ed. 04-84)
Endorsement No. 16
FAITHFUL PERFORMANCE BOND
BOND 114392028
Premium: $588.00
KNOW ALL MEN BY THESE PRESENT:
THAT WE, Union City Construction as
Principal, (contractor's name)
and Great American Insurance Company as
Surety, (bonding company's name)
are held and firmly bound unto the City of Cupertino, State of California, in the sum of
Sixty Two Thousand Five Hundred Dollars---($62, 'j00 .00) lawful
money of the United States, for the payment of which will and truly to be made, we bind ourselves,
our heirs, executors, successors and assigns, jointly and severally, firmly by these presents.
THE CONDITION of the foregoing obligation is such that,
WHEREAS, the Principal has entered into a contract with the City dated
March 28 20~ with the obligee to do and perform the following work to-wit:
Pavement Restoration, Project 2005-02
NOW, THEREFORE, if the said principal shall well and truly perform the work contracted
to be performed under said contract, then this obligation shall be void; otherwise to remain in full
force and effect.
IN WITNESS WHEREOF, this instrument has been duly executed by Principal and Surety
this 1st day of April ,2005 .
(To be signed by Principal and Surety, Notary acknowledgment required)
CONTRACTOR Union City Construction
~~
~~or
Principal
Great American Insurance Company
Surety
Street Address: 1350 Treat Blvd., 11300
City, State, Zip Walnut Creek, CA 94596
/~,
//
By: ~./
JOdYJhn
The above bond is accepted and approved this _day of
,20_.
Faithful Performance Bond Page I of 1
CALIFORNIA ALL.PURPOSE ACKNOWLEDGMENT
::::~fO~al'fO':~~m_e}a _______ _..... }"
On_.__Q.~_LS22.ISl.5_________.__.._.__ before me ,__6!llY.M!Jj;..t~_tQ.L.N 0 t a ry-J?u bJ i c _._______,
Dnl() NamB and Title of Officor \o,g.. "Jan/) 000, Notary PubliC")
personally ap pea red.____r.:g~<:l:.:;:<!.12ilJ.QPc___
Namo(s) of Signor(s)
Xpersonally known to me
proved to me on the basis of satisfactory
evidence
r;-----
--..-.--..---.-
i. Com.:,,~:3145 1
t Notary PubIc . CaIfomla J
1 Santa Claro County !
~ - - ~~:~~~~
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.
OPTIONAL
Though the informatIOn below is not requimd by law, it may prove valuable to persons relying on the document and could prevent
fraudulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Docu ment :!:!~_g__.gi!]---9_f__G..l!P~!:.!=_Ln..~.L_~.Q.!:l_~ r a.~.Ld_~L~.e_____________
Document Date:
. ____._____.....____.. Number of Pages:_________
Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer
Signer's Name:
.
T0P of lhurnb here
Individual
Corporate Officer - Title(s): ._______
Partner - Limited General
Attorney.in-Fact
Trustee
Guardian or Conservator
Otl"ler:
l_..___________
Signer Is Representing:....._._._...__.__.__.......
~ 1999 National Notary ASSOCIilt:on . 9:350 De Solo Al,'fJ.. PO Box 2402. Chalsworlh. CA 91313-2402. wwwn.-.liona(nolnryofQ
Prod. No. 5907
Reorder: Call TolI-Fr(~e 1-800-876-6027
California All Purpose
Acknovvledgment
State of
California
County of
San Mateo
On April 1 , 2005
Date
, before me, Jean L. Neu, Notary Public
Name ft Title of Officer/Notary
personally appeared
Jody A. Johnson
Names(s) of Signers(s)
personally known to me to be the person whose name is subscribed to the within instrument
and acknowledged to me that she executed the same in her authorized capacity, and that by
her signature on the instrument the person, or the entity upon behalf of which the person
acted, executed the instrument.
.,...~_~~_""",-'.....~,,,c~'_"""".-~_",j",~'~
X'" JE....N L. NEUna r
') - Comrnist,icn 1$ 133~20~ ~
:< . . NolaN puolic .. CalifornIa ~
~ -. S~n Mnteo cou~ty
M-i C'lrr:m. Ext>ires Doc 21,2005
,j ..-,--''- ":"> ~:"~....,~~ '
~--- """"",, '""~""",." , .- .
WITNESS my hand and official seal.
,. 'l
? ~l 1//...,
~/\~-
~) Notary Public OPTIONAL
(The information below is not required by law)
Description of Attached Document
Title/type of Document
Date of Document
No. of Pages
Other Signer(s)
h:\docs\surety\forms\notary .doc
PAYMENT BOND
BOND 114392028
KNOW ALL MEN BY THESE PRESENT:
WHEREAS, the City of Cupertino, State of California, and
Union City Construction
hereinafter designated as "Principal" have entered into or are about to enter into a contract
providing for the installation, construction, and erection by Principal of
Pavement Restoration, Project No. 2005-02
more particularly described in said contract; and incorporated herein by reference.
WHEREAS, said principal is required to furnish a bond in connection with said contract,
providing that if said Principal, or any of his or its subcontractors, shall fail to pay for materials,
provisions, provender or other supplies or teams used in, upon, for or about the performance of
work contracted to be done, or for any work or labor done thereon of any kind, the Surety on said
bond shall pay the same to the extent hereinafter set forth;
NOW, THEREFORE, WE, Union City Construction as Principal,
(contractor's name)
and Great American Insurance Company as Surety,
(bonding company' s name)
firmly bind ourselves, our executors, administrators, successors and assigns, jointly and severally,
unto the City of Cupertino, and any and all materialmen, persons, companies, or corporations
furnishing materials, provisions, provender or other supplies used in, upon, for or about the
performance of the aforesaid work contracted to be executed or performed under the contract
hereinabove mentioned, and incorporated herein by reference, and all persons, companies or
corporations lending or hiring teams, implements or machinery, for or contributing to said work to
be done, and all persons who perform work or labor upon the same, and all persons who supply
both work and materials, whose claim has not been paid by Principal or by any other person, in the
just and full sum of Sixty Two Thousand Five Hundred Dollars---:($62,500.00)
THE CONDITION OF THIS OBLIGATION IS SUCH THAT if said principal, his or its
subcontractors, heirs, executors, administrators, successors or assigns, shall fail to pay for any
materials, provisions, provender or other supplies or teams used in, upon, .for or about the
performance of the work contracted to be done, or for any work or labor thereon of any kind, or for
amounts due under the Unemployment Insurance Act with respect to such work or labor, or any and
all damages arising under the original contract, then said Surety will pay the same and also will pay
in case suit is brought upon this bond, such reasonable attorney's fee as shall be fixed by the court.
This bond shall insure to the benefit of any and all persons, companies, and corporations
entitled to file claims under Section 1184.1 of the Code of Civil Procedure, so as to give a right of
action to them or their assigns in any suit brought upon this bond.
Payment Bond Page 1 of 2
And the said Surety, for value received, hereby stipulates, and agrees that no change,
extension of time, alteration or addition to the terms of the contract or to the work to be performed
thereunder or the specifications accompanying the same shall in any wise affect its obligations on
this bond, and it does hereby waive notice of any such change, extension of time, alteration or
addition to the terms of the contract or to the work or to the specifications.
IN WITNESS WHEREOF, this instrument has been duly executed by Principal and Surety
this 1st day of April ,20 05.
(To be signed by Principal and Surety. Notary acknowledgments required.)
CONTRACTOR
Union City Construction
By: Sill Y1 \ctCOt-
(AwavvL t)l\t(fY\.1~vY
Principal /
Great American Insurance Company
Surety
Street Address: 1350 Treat Blvd., Suite 300
City, State, Zip Walnut Creek, CA 94596
.~./~
The above bond is accepted and approved this _day of
,20_
Payment Bond Page 2 of 2
CALIFORNIA ALL.PURPOSE ACKNOWLEDGMENT
::::I:IO~'''IO'::ame_~a__~_~_ ... }"
On___!l~_LSJ..2.LQ':>______ _.___.___. before me,_.A.!!lY.M9:.U~_i..;?._ Notary Publli._______.._,
Dnto NanlH and TillH 01 Ollicor (O,g.. "Jano 000. Notary Public")
personally ap pea red_____J:':<:l~~::;:<!.~illQ!l.__._____.______.._____.____._...._------.----------.----,
N<lmll{s) of Signor(s)
: Xpersonally known to me
proved to me on the basis of satisfactory
evidence
r;------
@ AMV~'; -,
f -,,; ,;ommlsalon # 1443 J 45
C faty Public - CaIItomIa J
Santa Clara Cowltv !
- - ~~,":~~~2~
to be the person(s) w~lose name(s) is/are
subscribed to the within instrument and
acknowledged to me tllat he/st18/they executed
tile 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 ltle instrument.
OPTIONAL
Though the II1formation below is not required by law. it may prove valuable to persons relying on the document and could prevent
fraudulrmt removal and reattachment of this form to another document.
Description of Attached Document
Title 0 I' Type of Docu ment:y,gg_.gl!jT_...9_L.fl!.E~!!_!!!Q.L .f:Q.1}_~ r C!~t__d_g_c:;.1i..._._________._
Document Date: . ..m______._____..__.__._______.._____.__._._.__.._._.._.._.___.m Number of Pages :_.__.______
Signer(s) Other Than Named Above:.____..__.
Capacity(ies) Claimed by Signer
Signer's Name:
Individual
Corporate Officer - Tille(s): __...____._
Partner - i Limited General
Attorney-in-Fact
Trustee
Guardian or Conservator
011"181':
.
Top of lhurnb here
S igne I' Is Representi I1g :m._._.__._........._._.__._..____..._.._...___.__._
'];) 1999 Nallonal Notary AssociCll:on . 9350 Do Solo Ave., P,O Box 2402 . Chalswor111, CA 9\313,.2t1m). www,rlalionalnolnryorg
Pr<xl No, 5907
Reorder: Call Toll-Fme '.BOO~87G-6827
California All Purpose
Acknovvledgment
State of
California
County of
San Mateo
On April 1, 2005
Date
, before me, Jean L. Neu, Notary Public
Name & Title of Officer/Notary
personally appeared
Jody A. Johnson
Names(s) of Signers(s)
personally known to me to be the person whose name is subscribed to the within instrument
and acknowledged to me that she executed the same in her authorized capacity, and that by
her signature on the instrument the person, or the entity upon behalf of which the person
acted, executed the instrument.
iJ~
WITNESS my hand and official seal.
OPTIONAL
(The information below is not required by law)
Description of Attached Document
Title/type of Document
Date of Document
No. of Pages
Other Signer(s)
h:\docs\surety\forms\notary .doc
GREAT AMERICAN INSURANCE COMPANY@
Administrative OffIce: 580 WALNUT STREET. CINCINNATI, OHIO 45202 · 513-369-5000. FAX 513.723.2740
The number of persons authorized by
this power of attorney is not more than FIVE
No.O 14246
POWER OF A ITORNEY
KNOW ALL MEN BY THESE PRESENTS: That the GREAT AMERICAN INSURANCE COMPANY, a corporation organized and existing
under and by virtue of the laws of the State of Ohio, does hereby nominate, constitute and appoint the person or persons named below its true and lawful
attomeyin-fact, for it and in its name, place and stead to execute in behalf of the said Company, as surety, any and all bonds, undertakings and contracts of
suretyship, or other written obligations in the nature thereof; provided that the liability of the said Company on any such bond, undertaking or contract of
suretyship executed under this authority shall not exceed the limit stated below.
Name
Address
Limit of Power
ERIN BAUTlST A
JEAN L. NEU
JODY A. JOHNSON
BRYAN D. MARTIN
B.A. POITEVIN
ALL OF
REDWOOD CITY,
CALIFORNIA
ALL
UNLIMITED
This Power of Attorney revokes all previous powers issued in behalf of the attorney(s)-in-fact named above.
IN WITNESS WHEREOF the GREAT AMERICAN INSURANCE COMPANY has caused these presents to be signed and attested by its
appropriate officers and its corporate seal hereunto affIXed this 21" day of, JANUARY , 2004.
Attest
GREAT AMERICAN INSURANCE COMPANY
STATE OF OHIO, COUNTY OF HAMILTON - ss:
DAVID C. KITCHIN (513-36~11)
On this 21" day of JANUARY ,2004, before me personally appeared DAVID C. KITCHIN, to me known, being duly
sworn, deposes and says that he resides in Cincinnati, Ohio, that he is the Divisional Senior Vice President of the Bond Division of Great American Insurance
Company, the Company described in and which executed the above instrument; that he knows the seal of the said Company; that the seal affixed to the said
instrument is such corporate seal; that it was so affixed by authority of his office under the By-Laws of said Company, and that he signed his name thereto by
like authority.
This Power of Attorney is granted by authority of the following resolutions adopted by the Board of Directors of Great American Insurance
Company by unanimous written consent dated March 1, 1993.
RESOLVED: That the Division President, the several Division Vice Presidents and Assistant Vice Presidents, or any one of them, be and hereby is
authorized,from time to time, to appoint one or more Attorneys-in-Fact to execute on behalf of the Company, as surety, any and all bonds, undertakinf9S and
contracts of suretyship, or other written obligations in the nature thereof; to prescribe their respective duties and the respective limits of their authority; and to
revoke any such appointment at any time.
RESOL VED FURTHER: That the Company seal and the signature of any of the qforesaid officers and any Secretary or Assistant Secretary of the
Company may be qffixed by facsimile to any power of attorney or certificate of either given for the execution of any bond, undertaking, contract or suretyship,
or other written obligation in the nature thereof, such signature and seal when so used being hereby adopted by the Company as the original signature of such
officer and the original seal of the Company, to be valid and binding upon the Company with the same force and effect as though manuallya.ffixed.
CERTIFICATION
I, RONALD C. HAYES, Assistant Secretary of Great American Insurance Company, do hereby certify that the foregoing Power of Attorney and the
Resolutions of the Board of Directors of March 1, 1993 have not been revoked and are now in full force and effect.
Signed and sealed this 1 s t
day of, April
, 200,5
S 1029T (11/01)
TERRORISM COVERAGE RIDER
NOTICE-DISCLOSURE OF TERRORISM COVERAGE AND PREMIUM
The Terrorism Risk Insurance Act of 2002 establishes a program within the Department
of the Treasury, under which the federal government shares, with the insurance industry,
the risk of loss from future terrorist attacks. The Act applies when the Secretary of the
Treasury certifies that an event meets the definition of an Act of Terrorism. The Act
provides that, to be certified, an Act of Terrorism must cause losses of at least five
million dollars and must have been committed by an individual or individuals acting on
behalf of any foreign person or foreign interest to coerce the government or population of
the United States.
To be attached to and form part of Bond No. 4392028, effective April 1 , 2005
In accordance with the Terrorism Risk Insurance Act of 2002, we are providing this
disclosure notice for bonds on which Great American Insurance Company, its affiliates
(including, but not limited to Great American Alliance Insurance Company, Great
American Insurance Company of New York and Great American Assurance Insurance
Company) is the surety.
The United States Government, Department of the Treasury, will pay a share of terrorism
losses insured under the terms of the Act. The federal share equals 90% of that portion of
the amount of such insured losses that exceeds the applicable insurer retention.
This Coverage Part/Policy covers certain losses caused by terrorism. In accordance with
the Federal Terrorism Risk Insurance Act of2002, we are required to provide you with a
notice disclosing the portion of your premium, if any, attributable to the coverage arising
from losses for Terrorist Acts Certified under that Act.
The portion of your annual premium that is attributable to coverage for Terrorist Acts
Certified under the Act is : $:00.
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