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21-003 Amendment #1 07-01-20211 FIRST AMENDMENT TO AGREEMENT 21-003 BETWEEN THE CITY OF CUPERTINO AND ABODE SERVICES; ALLIED HOUSING, INC. FOR PROVIDING TEMPORARY HOUSING, SUPPORT AND FINANCIAL SERVICES FOR WOLFE RD ENCAMPEMENT E This First Amendment to Agreement 21-003 between the City of Cupertino and Abode Services, Allied Housing, Inc., or reference dated June 28, 2021, is by and between the City of Cupertino, a municipal corporation (hereinafter "City") and Abode Services Allied Housing Inc., a corporation (“Contractor”) whose address is 40849 Fremont Blvd, Fremont, CA 94538, and is made with reference to the following: RECITALS: A. On January 4, 2021, Agreement 21-003 (“Agreement”) was entered into by and between City and Contractor for Providing temporary housing, support and financial services for Wolfe Rd Encampment E. B. City and Contractor desire to modify the Agreement on the terms and conditions set forth herein. NOW, THEREFORE, it is mutually agreed by and between and undersigned parties as follows: 1. Paragraph 3 of the Agreement is modified to read as follows: TIME OF PERFORMANCE 3.1 This Agreement begins on the Effective Date and ends on June 30, 2022 (“Contract Time”), unless terminated earlier as provided herein. Contractor’s Services shall begin on effective date and shall be completed by June 30, 2022. The City’s appropriate department head or the City Manager may extend the Contract Time through a written amendment to this Agreement, provided such extension does not include additional contract funds. Extensions requiring additional contract funds are subject to the City’s purchasing policy. 3.2 Schedule of Performance. Contractor must deliver the Services in accordance with the Schedule of Performance, attached and incorporated here Exhibits B and B-1. 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. 2. Paragraph 4 of the Agreement is modified to read as follows: 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 2 $234,672.03 (“Contract Price”), based upon the scope of services in Exhibits B and B-1 and the budget and rates included in Exhibits C and C-1, 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. 3. Exhibits B-1 and C-1, attached hereto, are added to the Agreement. 4. Except as expressly modified herein, all other terms and covenants set forth in the Agreement shall remain the same and shall be in full force and effect. SIGNATURES CONTINUE ON THE FOLLOWING PAGE 3 IN WITNESS WHEREOF, the parties hereto have caused this modification of Agreement to be executed. CITY OF CUPERTINO By Title Date APPROVED AS TO FORM City Attorney ATTEST: City Clerk Date ABODE SERVICES; ALLIED HOUSING, INC. By Title Date CEO Jul 1, 2021 Heather M. Minner Jul 1, 2021 Interim City Manager Jul 1, 2021 Exhibit A: Scope of Services Overview Abode Services, (Contractor) will perform the following work for the City of Cupertino (the City) related to providing temporary housing, as well as supportive services, and the ability to provide other financial services to support participants’ needs for up to 10 individuals living or previously occupying in the Wolfe Road Encampment. Term of Contract The term of this Agreement shall commence on July 1, 2021 and, unless terminated earlier as provided herein, end on the earlier of (i) June 30, 2022 and (ii) such time as all funds under this Agreement have been exhausted. Contract Services/ Eligible Costs The Contractor shall run support the individuals through a combination of the following activities, depending on the need of each individual.  Outreach and Engagement of Wolfe Road encampment residents;  Pay hotel costs/ fees associated with the placement of up to 10 encampment residents  Support participants in storing their belongings.  Provide guest orientation to indoor city-sponsored outdoor location.  Coordinate with motel and storage sites to safely store guest belongings  Respond to the crisis using de-escalation techniques;  Provide referral and linkage to housing and supportive services;  Maintain administrative and financial records;  Provide administrative oversite, support, and reporting. Publicity A. Except as otherwise required by law, the City of Cupertino shall not use the name of Abode Services its related entities, officers, directors, employees, or agents, in advertising, publicity releases, or other similar external communications without securing the prior written consent of Abode Services in each instance. B. Notwithstanding anything in this Section, City of Cupertino may describe the project in advertising, publicity releases, or other similar external communications, including a website, provided that the external communication references that Abode is a Service Partner in the project. Exhibit B-1: Schedule of Performance July 1, 2021 – June 30, 2022  Placement of up to 10 Wolf Road encampment residents into a hotel setting.  Service Coordination for 10 Wolf Road encampment residents who have been moved into hotel settings.  Ongoing coordination with the city and county to assess participants’ eligibility for county housing programs. Performance Target The goal of the Program is to provide motel site coordination, support for up to 10 people previously residing in the Wolfe Road encampment. Services include a combination of:  Service Coordination  Placement/ rental of hotel rooms  Support in storing for belongings  General outreach and engagement Program Deliverables and Evaluation The Contractor shall provide a Monthly Progress Report of program capacity, demographics, and a narrative of services provided. Progress reports are due within 15 calendar days after the end of the reporting month. Exhibit C-1: Payment Schedule A. The maximum compensation paid to the Contractor under this Agreement shall not exceed the maximum financial obligation of this Agreement. As a result of these services the not to exceed the amount of Two hundred Thirty-Four thousand, Six hundred Seventy-Two dollars and Three cents ($234,672.03). B. The Contractor shall be paid by the City Cupertino for its actual, reasonable, necessary, and allowable costs incurred up to the maximum compensation, for the performances of services. C. The Contractor must submit for invoice for the full Two hundred Thirty-Four thousand, Six hundred Seventy-Two dollars and Three cents ($234,672.03) at the start of the contract and provide verification of eligible costs incurred with the quarterly performance reports. Any unspent dollars spent at the end of the contract needs to be return to the City of Cupertino. Estimated Costs (Funds can be moved between line items as needed with authorization by the City.) Expense Category Description of Eligible Expenses Not to Exceed Direct Client Expenses Motel, Storage, Transportation, Moving Costs $199,872.03 Staffing Costs Service Coordination, Outreach, Admin Costs $34,800.00 FY 2021 – 2022 Budget Expense City of Cupertino CDBG-CARES Hotel/Motel Casa De Novo $145,000.00 $34,672.03 Other Hotel $ - Repair/Flex Fund Contingency $10,000.00 Total Hotel/Motel $155,000.00 $34,672.03 Storage $10,200.00 Total Storage $10,200.00 Staffing (Outside of Casa De Novo) $6,000.00 Admin @ 13% $28,800.00 TOTALS $200,000.00 $34,672.03 Exh. D-Insurance Requirements for Design Professionals & Consultants Contracts 1 Form Updated Sept. 2019 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 MINIMUMS 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 10 (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 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.  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: EXHIBIT D Insurance Requirements Design Professionals & Consultants Contracts Exh. D-Insurance Requirements for Design Professionals & Consultants Contracts 2 Form Updated Sept. 2019 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 and automobile liability policies. 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. 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 of premiums. 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, or better. 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 during the 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 by Consultant. 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. ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH- STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 3/29/2021 (626) 799-7000 (626) 441-3233 Abode Services; Allied Housing, Inc. 40849 Fremont Blvd. Fremont, CA 94538 10855 A 1,000,000 X X 202003766 11/15/2020 11/15/2021 500,000 20,000 1,000,000 2,000,000 1,000,000 SOCIAL PROFESSI 1,000,000 1,000,000A 202003766 11/15/2020 11/15/2021 10,000,000A 202003766UMB 11/15/2020 11/15/2021 10,000,000 0 B X ABWC240794 4/1/2021 4/1/2022 1,000,000 1,000,000 1,000,000 Re: 15 individuals who used to live at the Wolfe Road Encampment - Per written Agreement The City of Cupertino, its City Council, officers, officials, employees, agents, servants and volunteers are named as additional insureds per form CG2010 and CG2037 attached. Waiver and Primary & Non-Contributory forms attached. WC Blanket Waiver endorsement attached. City of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 ALLIHOU-C1 MSUN Bolton & Company 3475 E. Foothill Blvd., Suite 100 Pasadena, CA 91107 propcasualty@boltonco.com Nonprofits' Ins. Alliance Cypress Insurance Co. X X X X X X X X POLICY NUMBER:COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – SCHEDULED PERSON OR ORGANIZATION CG 20 10 04 13 2020-03766 Named Insured:Allied Housing, Inc.; Abode Services* The City of Cupertino, its City Council, officers, officials, employees, agents, servants and volunteers All insured premises and operations. Location(s) Of Covered Operations Name Of Additional Insured Person(s) Or Organization(s) SCHEDULE COMMERCIAL GENERAL LIABILITY COVERAGE PART This endorsement modifies insurance provided under the following: Wolfe Road Encampment Contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1.Your acts or omissions; or 2.The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1.The insurance afforded to such additional insured only applies to the extent permitted by law; and A. B.With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1.All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2.If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. © Insurance Services Office, Inc., 2012 Page 1 of 2CG 20 10 04 13 2.That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C.With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1.Required by the contract or agreement; or 2.Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. © Insurance Services Office, Inc., 2012 Page 2 of 2CG 20 10 04 13 POLICY NUMBER:COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – COMPLETED OPERATIONS CG 20 37 04 13 2020-03766 Named Insured:Allied Housing, Inc.; Abode Services* The City of Cupertino, its City Council, officers, officials, employees, agents, servants and volunteers All insured premises and operations. Location And Description Of Completed Operations Name Of Additional Insured Person(s) Or Organization(s) SCHEDULE COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART This endorsement modifies insurance provided under the following: Wolfe Road Encampment Contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only 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". However: 1.The insurance afforded to such additional insured only applies to the extent permitted by law; and A.B.With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 2.If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. 1.Required by the contract or agreement; or 2.Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. © Insurance Services Office, Inc., 2012 Page 1 of 1CG 20 37 04 13 Allied Housing, Inc.; Abode Services*NAMED INSURED: FORM: NIAC-E26 11 17 POLICY NUMBER: 2020-03766 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS (WAIVER OF SUBROGATION) COMMERCIAL GENERAL LIABILITY COVERAGE PART SOCIAL SERVICE PROFESSIONAL LIABILITY COVERAGE FORM This endorsement modifies insurance provided under the following: Name of Person or Organization: SCHEDULE The City of Cupertino, its City Council, officers, officials, employees, agents, servants and volunteers Wolfe Road Encampment Contract Where you are so required in a written contract or agreement currently in effect or becoming effective during the term of this policy, we waive any right of recovery we may have against that person or organization, who may be named in the schedule above, because of payments we make for injury or damage. 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45/%606-C%-@0;96%65-6%-CC%8;=5%065/<%798;<-9=/%E0;CF%?-A%10<%65/%C088%79%65/%->8/9=/%01% 6578%798;<-9=/G%-9F% 2>3% 45/%606-C%01%-CC%F/F;=67>C/%-9F%8/C1I798;</F%-@0;968%;9F/<%-CC%65-6%065/<%798;<-9=/B% 2+3% M/%E7CC%85-</%65/%</@-7979.%C088D%71%-9AD%E765%-9A%065/<%798;<-9=/%65-6%78%906%F/8=<7>/F%79%6578% %&!'(($)*(+,-*!'%?<0H78709%-9F%E-8%906%>0;.56%8?/=717=-CCA%60%-??CA%79%/J=/88%01%65/%N7@768% 01%"98;<-9=/%850E9%79%65/%O/=C-<-67098%01%6578%$0H/<-./%,-<6B% !"$ @'ABCD($CE$/B-,F*.$ "1%-CC%01%65/%065/<%798;<-9=/%-H-7C->C/%60%65/%-FF76709-C%798;</F283%?/<@768%=096<7>;6709%>A%/P;-C% 85-</8D% E/% E7CC% 10CC0E% 6578% @/650F% -C80B% %Q9F/<%6578% -??<0-=5% /-=5%798;</<% =096<7>;6/8% /P;-C% -@0;968%;967C%76%5-8%?-7F%768%-??C7=->C/%C7@76%01%798;<-9=/%0<%909/%01%65/%C088%</@-798D%E57=5/H/<% =0@/8%17<86B% "1%-9A%065/<%65/%065/<%798;<-9=/%-H-7C->C/%60%65/%-FF76709-C%798;</F283%F0/8%906%?/<@76%=096<7>;6709% 65/%<-670%01%768%-??C7=->C/%C7@76%01%798;<-9=/%60%65/%606-C%-??C7=->C/%C7@768%01%798;<-9=/%01%-CC%798;</<8B% Endorsement Effective: Policy No.: Insured: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 04 10 C (Ed. 01-19) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA BLANKET BASIS We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform wor k under a written contract that requires you to obtain this agreement from us.) The additional premium for this endorsement shall be calculated by applying a factor of 2% to the total manual premium, with a minimum initial charge of $350, then applying all other pricing factors for the policy to this calculated charge to derive the final cost of this endorsement. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Blanket Waiver Person/Organization Blanket W aiver – Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. Waiver Premium (prior to adjustments) 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 No.: Premium $ Insurance Company: WC 99 04 10 C Countersigned by ______________________________________ (Ed. 01-19) Job Description All CA Operations Cypress Insurance Company ABWC240794 20500.00 04/01/2021 Wolfe Rd Encapment Final Audit Report 2021-07-01 Created:2021-06-30 By:City of Cupertino (webmaster@cupertino.org) Status:Signed Transaction ID:CBJCHBCAABAAZMbUnTXU9Db4X84n9VMImgzFV3dKZw1G "Wolfe Rd Encapment" History Document created by City of Cupertino (webmaster@cupertino.org) 2021-06-30 - 11:21:34 PM GMT- IP address: 35.229.54.2 Document emailed to Araceli Alejandre (aracelia@cupertino.org) for approval 2021-06-30 - 11:22:54 PM GMT Document approved by Araceli Alejandre (aracelia@cupertino.org) Approval Date: 2021-06-30 - 11:28:50 PM GMT - Time Source: server- IP address: 73.170.27.253 Document emailed to Louis Chicoine (lchicoine@abodeservices.org) for signature 2021-06-30 - 11:28:51 PM GMT Email viewed by Louis Chicoine (lchicoine@abodeservices.org) 2021-07-01 - 0:08:42 AM GMT- IP address: 96.90.247.201 Document e-signed by Louis Chicoine (lchicoine@abodeservices.org) Signature Date: 2021-07-01 - 5:03:22 PM GMT - Time Source: server- IP address: 76.103.228.147 Document emailed to Heather M. Minner (heatherm@cupertino.org) for signature 2021-07-01 - 5:03:23 PM GMT Email viewed by Heather M. Minner (heatherm@cupertino.org) 2021-07-01 - 7:42:56 PM GMT- IP address: 45.41.142.28 Document e-signed by Heather M. Minner (heatherm@cupertino.org) Signature Date: 2021-07-01 - 7:43:13 PM GMT - Time Source: server- IP address: 52.39.49.65 Document emailed to Dianne Thompson (diannet@cupertino.org) for signature 2021-07-01 - 7:43:15 PM GMT Email viewed by Dianne Thompson (diannet@cupertino.org) 2021-07-01 - 9:15:25 PM GMT- IP address: 99.179.16.200 Document e-signed by Dianne Thompson (diannet@cupertino.org) Signature Date: 2021-07-01 - 10:17:58 PM GMT - Time Source: server- IP address: 99.179.16.200 Document emailed to Kirsten Squarcia (kirstens@cupertino.org) for signature 2021-07-01 - 10:18:00 PM GMT Email viewed by Kirsten Squarcia (kirstens@cupertino.org) 2021-07-01 - 10:19:35 PM GMT- IP address: 104.47.74.126 Document e-signed by Kirsten Squarcia (kirstens@cupertino.org) Signature Date: 2021-07-01 - 10:20:00 PM GMT - Time Source: server- IP address: 69.110.137.176 Agreement completed. 2021-07-01 - 10:20:00 PM GMT