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HomeMy WebLinkAboutPRR24255 McKiernan 764 Woodbridge StUpdated 05/2023 Cityof SanLuisObispo Request forPublic Records TheCaliforniaPublic Records Act (Government Code .etset.) was enactedto ensure public records are available for inspection by members of the public. Completion ofthis form will assist staff inidentifyingrelatedrecordsto accurately complete your request. Requested recordswill be distributed tothe email addressthat is listed onthis form,unless directed otherwiseby City staff. Requestsfor printed recordswill require payment su Comprehensive FeeSchedule.Payment mustbe rendered prior to production ofprinted materials. McKiernan08/23/2024Name:_______________________________________________ Date:______________________ James LastFirst _______________________ Release Forms Requests for certain public records legally require release forms tobe submitted for records to be distributed to the requestor. To help expedite your request, please read below and ensure additional information is submitted along with this public records request form. Personal healthinformation Records containing personal health information require a HIPAA Release Form. Examples o HIPAA Release Form Printed residential and/orcommercial building plans The Public Records Act does not allow the release of printed copies of this material withoutthe permission ofthe architect/engineer copyright owner.Thepublicrecords requestor is responsiblefor obtaining saidauthorization bycompleting allthree releaseformslisted below. You may call the Community Development Department at (805) 781-7170 to find out the name of the copyright owner. In-person viewing of plans do not require release forms. o Copies of Plans Affidavit o Plan Request Architect/Engineer Authorization o Plan Request Owner Authorization Continued Record Information: List the records you are requesting. Specify relevantinformation such as: subject, title, incident number, location/address, person(s) involved, project name, etc. Any document mentionning the name oftheengineer ofrecords responsible foraligning the curb inlet infront of764 Woodbridge Street inSan Luis Obispo, CA 93401; Any document mentionning the name ofthe concrete contractor who was incharge ofpouring concrete toconnect the curb/street infront 764 Woodbridge Street inSan Luis Obispo, CA 93401 toaFilterra Unit \[see attached picture\]. Dateand Time:Specify theincidentdate or date and time range of the requested records 05/06/2014 -05/06/2024. Questionsmaybedirectedto theCity -7100. Submit Completed Forms To: cityclerk@slocity.org OR 990Palm Street San LuisObispo, CA93401 YOUR REQUEST WILL BE PROCESSED IN COMPLIANCE WITH THE PUBLIC RECORDS ACT (PRA). California Government Code Section 7921.An Agency shall notify the requestor within 10 days from receipt of request with a Determination which states if the Agency is in possession, in whole or in part, of the requested documents, and possible legal exemptions which prohibit the release of non-disclosable documents, as outlined per the PRA. In some instances, an Agency may require an extensionofup to 14 days to provide a Determination, as authorized by the PRA. A notice will be provided to the requestor setting forth the reasons for the extension and the date onwhich a Determination is expected to be supplied. City ofSan Luis Obispo, Community Development, 919 Palm Street, San Luis Obispo, CA, 93401-3218, 805.781.7170, slocity.org Copies of Plans Affidavit I hereby request the authority to duplicate the official copy of the building plans for: address) And agree: 1. That the copy of the plans shall only be used for the maintenance, operation, and use of the building. 2. That drawings are instruments of professional service and are incomplete without the interpretation of the certified, licensed, or registered professional of record. 3. That subdivision (a) of Section 5536.25 of the Business and Professions Code states that a licensed architect who signs plans, specifications, reports, or documents shall not be responsible for damage caused by subsequent changes to, or uses of those plans, specifications, reports, or documents, where the subsequent changes or uses, including changes or uses made by state or local governmental agencies, are not authorized or approved in writing by the licensed architect who originally signed the plans, specifications, reports, or documents, provided that the written authorization or approval was not unreasonably withheld by the architect and the architectural service rendered by the architect who signed and stamped the plans, specifications, reports, or documents was not also a proximate cause of the damage. 4. To pay all costs incurred with the reproduction of the plans Iam requesting. I declare, under penalty of perjury pursuant to the laws of the State of California, that the foregoing is true and correct. August23 24ProvidedbytheCityofSanLuisObispo, California on the ____ day of _________, 20_____ James McKiernan, Esq. Print Name Signature crowe@mckiernanlaw.com Telephone Number or E-mail City ofSan Luis Obispo, Community Development, 919 Palm Street, San Luis Obispo, CA, 93401-3218, 805.781.7170, slocity.org Plan Request Architect Authorization I, _______________________________________, the architect of record for the Curb inlet and Filterra unit installation located infront of764 Woodbridge Street, San Luis Obipo, CA 93401. address), authorize the City of San JamesMcKiernanLawyersObispotoreleasecopiesofplanstotherequestor _______________________________. Print Name Signature Date Architect of Record Apply Seal Here City ofSan Luis Obispo, Community Development, 919 Palm Street, San Luis Obispo, CA, 93401-3218, 805.781.7170, slocity.org Plan Request Owner Authorization I, _____________________________________________________, the property owner of curbinlet infrontof764 Woodbrige Street, San Luis Obispo, CA93401 address), authorize the City of San Luis Obispo to release copies of plans for this address. Print Name Signature Date ENCROACHMENT PERMIT Right of Way ENCR-1847-2017Public Works Department • 919 Palm Street • San Luis Obispo, CA 93401-3218 Location:2450 Victoria Ave USA #: N/A X-streets: Project Name: Other permits required: The Yard ; Install public improvements for The Yard Contractor:Wilson Excavating & Grading Doug Wilson 805-801-1773 (Fax: 805-474-9212) Engineer:Ashley & Vance Engineering, Inc. Ken Brown 805-545-0119 (Fax: 805-474-9212) Description of Work: <On 8/30/2018, permit extended to 8/30/2019 with minimum encroachment fee and updated insurance documents>. Install public improvements for The Yard. All work to be done per the approved plans and to City Standard Specifications & Engineering Standards. A traffic and pedestrian control plan must be submitted and approved prior to each phase of construction. Scheduling information must be updated, submitted, and approved each month. Traffic and pedestrian controls must be per an approved plan and City Appendix G & MUTCD Standards. Contact City Public Works inspector Ron Faria at 805-431-5467 two working days prior to the start of work and one working day prior to each subsequent inspection. Permittee is responsible for calling for final inspection so the permit can be closed. *A pre-construction meeting is required prior to the start of work. Frontage Improvements Complete/Upgraded Curb Ramp Complete/Upgraded City Fiber Bus Route Sewer Wye All work performed within the right-of-way shall conform to the City of San Luis Obispo Engineering Standard Details and Standard Specifications. You are responsible for liability for personal injury and / or property damage caused by this work or your failure to do what you are obligated to do. If a claim of such liability is made against the City or any of its departments, officers, or employees, you shall, and hereby agree to, defend and indemnify the City and hold the City harmless from any claims, including costs of defense and attorney fees. All work shall be completed and the right-of-way restored by: August 30, 2019 AGREEMENT: I have read this permit and acknowledge receipt of the City of San Luis Obispo Encroachment Permit General Provisions and ___ pages of attached special conditions which I have read, agree to, and acknowledge as a part of this permit. The City of San Luis Obispo is committed to include the disabled in all of its services, programs and activities. Telecommunications Device for the Deaf (805) 781-7410. 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 08/28/2018 License # 0E02096 1409 (805) 593-1401 31453 Wilson Excavating & Grading 1307 22nd Street Oceano, CA 93445 24082 10120 A 1,000,000 X X 08/31/2018 Rent/Lease/Borrow 100,000 WHEN REQUIRED BY WRITTEN CONTACT THE FOLLOWING FORM(S) ARE APPLICABLE: GENERAL LIABILITY Blanket Additional Insured, Waiver of Subrogation & Primary-Non Contributory Form #CG2010R (12-11), Per Project Aggregate Form #CG2503 (05 09)///AUTOMOBILE Blanket Additional Insured & Waiver of Subrogation Form #CA8810 (01/13), Primary Form #CA0001 (03/06), Pg 10 of 13, 5. Other Insurance///WORKERS COMPENSATION Blanket Waiver of Subrogation form #WC040306 are attached When this Certificate is being provided for a "WRAP/OCIP" Project, it is for Off-Site Operations Only in regards to the General Liability Policy, as coverage is secured under the WRAP/OCIP Policy as insured is an "enrolled contractor", per wording included on the General Liability Blanket Additional Insured Form CG2010R (12/11) attached. City of San Luis Obispo 919 Palm St San Luis Obispo, CA 93401 WILSEXC-01 LWOOLPERT DiBuduo & DeFendis Insurance Brokers, LLC 100 Cross Street, Suite 203 San Luis Obispo, CA 93401 Leonore Woolpert, CPCU lwoolpert@dibu.com Financial Pacific Insurance Company Ohio Security Insurance Company Everest National Insurance Company X 08/31/2019 X X X X POLICY NUMBER:COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. CG 25 03 05 09 ©Insurance Services Office,Inc.,2008 Page 1 of 2 DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE A.For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences"under Section I –Coverage A,and for all medical expenses caused by accidents under Section I –Coverage C,which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1.A separate Designated Construction Project General Aggregate Limit applies to each designated construction project,and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2.The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A,except damages because of "bodily injury "or "property damage"included in the "products-completed operations hazard",and for medical expenses under Coverage C regardless of the number of: a.Insureds; b.Claims made or "suits"brought;or c.Persons or organizations making claims or bringing "suits". 3.Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the Designated Construction Project General Aggregate Limit for that designated construction project.Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Designated Construction Project General Aggregate Limit for any other designated construction project shown in the Schedule above. 4.The limits shown in the Declarations for Each Occurrence,Damage To Premises Rented To You and Medical Expense continue to apply. However,instead of being subject to the General Aggregate Limit shown in the Declarations,such limits will be subject to the applicable Designated Construction Project General Aggregate Limit. Information required to complete this Schedule,if not shown above,will be shown in the Declarations. Designated Construction Project(s): CG 25 03 05 09 CG 25 03 05 09 ©Insurance Services Office,Inc.,2008 Page 2 of 2 B.For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences"under Section I –Coverage A,and for all medical expenses caused by accidents under Section I –Coverage C,which cannot be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1.Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products-completed Operations Aggregate Limit,whichever is applicable;and 2.Such payments shall not reduce any Designated Construction Project General Aggregate Limit. C.When coverage for liability arising out of the "products-completed operations hazard"is provided, any payments for damages because of "bodily injury"or "property damage"included in the "products-completed operations hazard"will reduce the Products-completed Operations Aggregate Limit,and not reduce the General Aggregate Limit nor the Designated Construction Project General Aggregate Limit. D.If the applicable designated construction project has been abandoned,delayed,or abandoned and then restarted,or if the authorized contracting parties deviate from plans,blueprints,designs, specifications or timetables,the project will still be deemed to be the same construction project. E.The provisions of Section III –Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. 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 LWOOLPERT Leonore Woolpert, CPCU 08/26/2019 WILSEXC-01 A 1,000,000 1,000,000 1,000,000 2,000,000 1,000,000 2,000,000 5,000 100,000 1,000,000 1,000,000 X X X X X License # 0E02096 08/31/2019 08/31/2020 08/31/2019 08/31/2020 08/31/2019 08/31/2020 08/31/2019 08/31/2020 WHEN REQUIRED BY WRITTEN CONTACT THE FOLLOWING FORM(S) ARE APPLICABLE: GENERAL LIABILITY Blanket Additional Insured, Waiver of Subrogation & Primary-Non Contributory Form #CG2010R (12-11), Per Project Aggregate Form #CG2503 (05 09)///AUTOMOBILE Blanket Additional Insured & Waiver of Subrogation Form #CA7109 (01/17), Primary-Non Contributory Form #CA0449 (11/16) ///WORKERS COMPENSATION Blanket Waiver of Subrogation form #WC040306 attached When this Certificate is being provided for a "WRAP/OCIP" Project, it is for Off-Site Operations Only in regards to the General Liability Policy, as coverage is secured under the WRAP/OCIP Policy as insured is an "enrolled contractor", per wording included on the General Liability Blanket Additional Insured Form CG2010R (12/11) attached. DiBuduo & DeFendis Insurance Brokers, LLC 100 Cross Street, Suite 203 San Luis Obispo, CA 93401 (805) 593-14011409 City of San Luis Obispo 919 Palm St San Luis Obispo, CA 93401 Wilson Excavating & Grading 1307 22nd Street Oceano, CA 93445 Financial Pacific Insurance Company Everest Premier Insurance Company 31453 16045 X X Leonore.Woolpert@dibu.com Y X X X Rent/Lease/Borrow 100,000Equipment Floater POLICY NUMBER:COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. CG 25 03 05 09 ©Insurance Services Office,Inc.,2008 Page 1 of 2 DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE A.For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences"under Section I –Coverage A,and for all medical expenses caused by accidents under Section I –Coverage C,which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1.A separate Designated Construction Project General Aggregate Limit applies to each designated construction project,and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2.The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A,except damages because of "bodily injury "or "property damage"included in the "products-completed operations hazard",and for medical expenses under Coverage C regardless of the number of: a.Insureds; b.Claims made or "suits"brought;or c.Persons or organizations making claims or bringing "suits". 3.Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the Designated Construction Project General Aggregate Limit for that designated construction project.Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Designated Construction Project General Aggregate Limit for any other designated construction project shown in the Schedule above. 4.The limits shown in the Declarations for Each Occurrence,Damage To Premises Rented To You and Medical Expense continue to apply. However,instead of being subject to the General Aggregate Limit shown in the Declarations,such limits will be subject to the applicable Designated Construction Project General Aggregate Limit. Information required to complete this Schedule,if not shown above,will be shown in the Declarations. Designated Construction Project(s): CG 25 03 05 09 CG 25 03 05 09 ©Insurance Services Office,Inc.,2008 Page 2 of 2 B.For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences"under Section I –Coverage A,and for all medical expenses caused by accidents under Section I –Coverage C,which cannot be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1.Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products-completed Operations Aggregate Limit,whichever is applicable;and 2.Such payments shall not reduce any Designated Construction Project General Aggregate Limit. C.When coverage for liability arising out of the "products-completed operations hazard"is provided, any payments for damages because of "bodily injury"or "property damage"included in the "products-completed operations hazard"will reduce the Products-completed Operations Aggregate Limit,and not reduce the General Aggregate Limit nor the Designated Construction Project General Aggregate Limit. D.If the applicable designated construction project has been abandoned,delayed,or abandoned and then restarted,or if the authorized contracting parties deviate from plans,blueprints,designs, specifications or timetables,the project will still be deemed to be the same construction project. E.The provisions of Section III –Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2% of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER BLANKET WAIVER OF SUBROGATION This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective:08/31/2019 Policy No. Endorsement No.001 Insured:Wilson, Doug; Wilson, Deborah; Wilson Excavating Premium $ INCL. Insurance Company:Everest Premier Insurance Company Countersigned By: - 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual - 1999. 5 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 LWOOLPERT Leonore Woolpert, CPCU 08/28/2020 WILSEXC-01 A 1,000,000 1,000,000 1,000,000 2,000,000 1,000,000 2,000,000 $1,000. PD Ded/Occ 5,000 100,000 1,000,000 1,000,000 X X X X X X License # 0E02096 08/31/2020 08/31/2021 08/31/2020 08/31/2021 08/31/2020 08/31/2021 08/31/2020 08/31/2021 WHEN REQUIRED BY WRITTEN CONTACT THE FOLLOWING FORM(S) ARE APPLICABLE: GENERAL LIABILITY Blanket Additional Insured, Waiver of Subrogation & Primary-Non Contributory Form #CG2010R (12-11), Per Project Aggregate Form #CG2503 (05 09)///AUTOMOBILE Blanket Additional Insured & Waiver of Subrogation Form #CA7109 (01/17), Primary-Non Contributory Form #CA0449 (11/16) ///WORKERS COMPENSATION Blanket Waiver of Subrogation form #WC040306 attached When this Certificate is being provided for a "WRAP/OCIP" Project, it is for Off-Site Operations Only in regards to the General Liability Policy, as coverage is secured under the WRAP/OCIP Policy as insured is an "enrolled contractor", per wording included on the General Liability Blanket Additional Insured Form CG2010R (12/11) attached. DiBuduo & DeFendis Insurance Brokers, LLC 100 Cross Street, Suite 203 San Luis Obispo, CA 93401 (805) 593-14011409 City of San Luis Obispo 919 Palm St San Luis Obispo, CA 93401 Wilson Excavating & Grading 1307 22nd Street Oceano, CA 93445 Financial Pacific Insurance Company Everest Premier Insurance Company 31453 16045 X X Leonore.Woolpert@dibu.com Y X X X Rent/Lease/Borrow 100,000Equipment Floater From: Leonore Woolpert Sent: 28 Aug 2020 15:56:55 +0000 To: Leonore Woolpert Subject: Emailing: Wilson Ex CERR 20-21 GLIA Blkt AI, Ltd Co Op's, WOS, PNC, Agg- Project Attachments: Wilson Ex CERR 20-21 GLIA Blkt AI, Ltd Co Op's, WOS, PNC, Agg-Project.pdf Your message is ready to be sent with the following file or link attachments: Wilson Ex CERR 20-21 GLIA Blkt AI, Ltd Co Op's, WOS, PNC, Agg-Project Note: To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. COMMERCIAL AUTO CA 71 09 01 17 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CA 71 09 01 17 Includes copyrighted material of Insurance Services Office, Inc., with its permission.Page 1 of 7 BUSINESS AUTO ULTRA ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM COMMON POLICY CONDITIONS COVERAGE INDEX DESCRIPTION PAGE Temporary Substitute Auto Physical Damage 2 Broad Form Insured 2 Employee as Insureds 2 Additional Insured Status by Contract, Agreement or Permit 2 Bail Bond Coverage 3 Loss of Earnings Coverage 3 Amended Fellow Employee Coverage 3 Towing and Labor 3 Physical Damage Additional Transportation Expense Coverage 3 Extra Expense - Theft 3 Rental Reimbursement and Additional Transportation Expense 4 Personal Effects Coverage 4 Personal Property of Others 4 Locksmith Coverage 4 Vehicle Wrap Coverage 5 Airbag Accidental Discharge 5 Audio, Visual and Data Electronic Equipment Coverage 5 Auto Loan/Lease Total Loss Protection 5 Glass Repair – Deductible Amendment 5 Amended Duties in the Event of Accident, Claim, Suit or Loss 6 Waiver of Subrogation Required by Contract 6 Unintentional Failure to Disclose 6 Hired, Leased, Rented or Borrowed Auto Physical Damage 6 Mental Anguish 7 Extended Cancellation Condition 7 The COVERAGE INDEX set forth above is informational only and grants no coverage. Terms set forth in are likewise for information only and by themselves shall be deemed to grant no coverage. Page 2 of 7 Includes copyrighted material of Insurance Services Office, Inc., with its permission.CA 71 09 01 17 A. TEMPORARY SUBSTITUTE AUTO PHYSICAL DAMAGE SECTION I – COVERED AUTOS, paragraph C. Certain Trailers, Mobile Equipment and Temporary Substitute Autos is amended by adding the following at the end of the existing language: If Physical Damage Coverage is provided under this Coverage form for an "auto" you own, the Physical Damage coverages provided for that owned "auto" are extended to any "auto" you do not own while used with the permission of its owner as a temporary substitute for the covered "auto" you own that is out of service because of its breakdown, repair, servicing, "loss", or destruction B. BROADENED LIABILITY COVERAGES SECTION II – LIABILITY COVERAGE in Paragraph A. Coverage at 1. Who Is An Insured is amended to include the following: d.Any legally incorporated subsidiary in which you own more than 50% of the voting stock on the effective date of the Coverage Form. However, the Named Insured does not include any subsidiary that is an "insured" under any other automobile policy or would be an "insured" under such a policy but for its termination or the exhaustion of its Limit of Insurance. e.Any organization that is acquired or formed by you, during the term of this policy and over which you maintain majority ownership. However, the Named Insured does not include any newly formed or acquired organization: (1)That is a joint venture or partnership, (2)That is an "insured" under any other policy, (3)That has exhausted its Limits of Insurance under any other policy, or (4)180 days or more after its acquisition or formation by you, unless you have given us notice of the acquisition or formation Coverage does not apply to "bodily injury" or "property damage" that results from an accident that occurred before you formed or acquired the organization. f.Any employee of yours while acting in the course of your business or your personal affairs while using a covered "auto" you do not own, hire or borrow. g.Any person or organization whom you are required to add as an additional insured on this policy under a written contract or agreement; but the written contract or agreement must be: (1)Currently in effect or becoming effective during the term of this policy; and (2)Executed prior to the "bodily injury" or "property damage." The additional insured status will apply only with respect to your liability for "bodily injury" or "property damage" which may be imputed to that person(s) or organization(s) directly arising out of the ownership, maintenance or use of the covered "autos" at the location(s) designated, if any. Coverage provided by this endorsement will not exceed the limits of liability required by the written contract or written agreement even if the limits of liability stated in the policy exceed those limits. This endorsement shall not increase the limits stated in Section II. C. Limits of Insurance. For any covered "auto" you own this Coverage Form provides primary coverage. CA 71 09 01 17 Includes copyrighted material of Insurance Services Office, Inc., with its permission.Page 3 of 7 C. BROADENED SUPPLEMENTARY PAYMENTS SECTION II. LIABILITY A. Coverage 2. Coverage Extensions a. Supplementary Payments (2)and (4)are replaced by the following: (2)Up to $5,000 for cost of bail bonds (including bonds for related traffic violations) required because of an "accident" we cover. We do not have to furnish these bonds. (4)All reasonable expenses incurred by the "insured" at our request, including actual loss of earning up to $500 a day because of time off from work. D. AMENDED FELLOW EMPLOYEE EXCLUSION Only with respect to your "employees" who occupy positions which are supervisory in nature,SECTION II. LIABILITY B. Exclusion 5. Fellow Employee is replaced by: 5. Fellow Employee "Bodily Injury": a.To you, or your partners or members (if you are a partnership or joint venture), or to your members (if you are a limited liability company); b.To your "executive officers" and directors (if you are an organization other than a partnership, joint venture, or limited liability company) but only with respect to performance of their duties as your officers or directors; c.For which there is an obligation to share damages with or repay someone else who must pay damages because of the injury described in paragraph a and b above; or d.Arising out of his or her providing or failing to provide professional health care services. For purposes of this endorsement, a position is deemed to be supervisory in nature if that person performs principle work which is substantially different from that of his or her subordinates and has authority to hire, transfer, direct, discipline or discharge. E. BROADENED PHYSICAL DAMAGE COVERAGES SECTION III – PHYSICAL DAMAGE COVERAGE A. Coverage is amended as follows: 2. Towing is deleted and replaced with the following: 2. Towing and Labor We will pay towing and labor costs incurred, up to the limits shown below, each time a covered "auto" is disabled: a.For private passenger type vehicles we will pay up to $100 per disablement. b.For all other covered "auto's" we will pay up to $500 per disablement However, the labor must be performed at the place of disablement. 4. Coverage Extensions a. Transportation Expenses is amended to provide the following limits: We will pay up to $60 per day to a maximum of $1,800. All other terms and provisions of this section remain applicable. The following language is added to 4. Coverage Extensions: c. Theft Recovery Expense If you have purchased Comprehensive Coverage on an "auto" that is stolen, we will pay the expense of returning that stolen auto to you. The limit for this coverage extension is $5,000. Page 4 of 7 Includes copyrighted material of Insurance Services Office, Inc., with its permission.CA 71 09 01 17 d. Rental Reimbursement We will provide Rental Reimbursement and Additional Expense coverage only for those Physical Damage coverages for which a premium is shown in the Declarations or schedule pages. Coverage applies only to a covered "auto". (1)We will pay for auto rental expense and the expense incurred by you because of "loss" to remove and transfer your materials and equipment from a covered "auto" to a covered "auto." Payment applies in addition to the otherwise applicable coverage you have on a covered "auto." No deductible applies to this coverage. (2)We will pay only for expenses incurred during the policy period and beginning 24 hours after the "loss" and ending, regardless of the policy's expiration, with the lesser of the following number of days: (a)The number of days reasonably required to repair or replace the covered "auto." If "loss" is caused by theft, this number of days is added to the number of days it takes to locate the covered "auto" and return it to you, or (b)30 days. (3)Our payment is limited to the lesser of the following amounts: (a)Necessary and actual expenses incurred; or (b)$75 per day. (c)This coverage does not apply while there are spare or reserve "autos" available to you for your operations. (d)If "loss" results from the total theft of a covered "auto" of the private passenger or light truck type, we will pay under this coverage only that amount of your rental reimbursement expense which is not already provided for under the SECTION III – PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions, a. Transportation Expenses. e. Personal Effects If you have purchased Comprehensive Coverage on this policy for an "auto" you own and that "auto" is stolen, we will pay, without application of a deductible, up to $500 for Personal Effects stolen with the "auto". The insurance provided under this provision is excess over any other collectible insurance. For this coverage extension, Personal Effects means tangible property that is worn or carried by an "insured". f. Personal Property of Others We will pay up to $500 for loss to personal property of others in or on your covered "auto." This coverage applies only in the event of "loss" to your covered "auto" caused by fire, lightning, explosion, theft, mischief or vandalism, the covered "auto's" collision with another object, or the covered "auto's" overturn. No deductibles apply to this coverage. g. Locksmith Coverage We will pay up to $250 per occurrence for necessary locksmith services for keys locked inside a covered private passenger "auto". The deductible is waived for these services. CA 71 09 01 17 Includes copyrighted material of Insurance Services Office, Inc., with its permission.Page 5 of 7 h. Vehicle Wrap Coverage If you have Comprehensive or Collision coverage on an "auto" that is a total loss, in addition to the actual cash value of the "auto", we will pay up to $1,000 for vinyl vehicle wraps which are displayed on the covered "auto" at the time of total loss. Regardless of the number of autos deemed a total loss, the most we will pay under this Vehicle Wrap Coverage for any one "loss" is $5,000. For purposes of this coverage provision, signs or other graphics painted or magnetically affixed to the vehicle are not considered vehicle wraps. F. SECTION III – PHYSICAL DAMAGE COVERAGE, B. Exclusions is amended at 3.to include the following language: If you have purchased Comprehensive or Collision Coverage under this policy, this exclusion does not apply to mechanical breakdown relating to the accidental discharge of an air bag. This coverage applies only to a covered auto you own and is excess of any other collectible insurance or warranty. No deductible applies to this coverage. G. BROADENED LIMITS OF INSURANCE SECTION III – PHYSICAL DAMAGE COVERAGE – C. Limit of Insurance at 1.b.is amended to provide the following limits: b.Limits of $1,000 per "loss" is increased to $5,000 per "loss". All other terms and provisions of this section remain applicable. SECTION III – PHYSICAL DAMAGE COVERAGE – C. Limit of Insurance is amended by adding the following language: 4.In the event of a total "loss" to a covered "auto" shown in the Schedule pages, subject at the time of the "loss" to a loan or lease, we will pay any unpaid amount due including up to a maximum of $500 for early termination fees or penalties on the lease or loan for a covered"auto" less: a.The amount paid under the Physical Damage Coverage Section of the policy; and b.Any: (1)Overdue lease / loan payments at the time of the "loss''; (2)Financial penalties imposed under a lease for excessive use, abnormal wear and tear or high mileage; (3)Security deposits not returned by the lessor; (4)Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance purchased with the loan or lease; and (5)Carry-over balances from previous loans or leases. H. GLASS REPAIR – DEDUCTIBLE SECTION III – PHYSICAL DAMAGE COVERAGE – D. Deductible is amended by adding the following: Any deductible shown in the Declarations as applicable to the covered "auto" will not apply to glass breakage if the damaged glass is repaired, rather than replaced. Page 6 of 7 Includes copyrighted material of Insurance Services Office, Inc., with its permission.CA 71 09 01 17 I. AMENDED DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS Under SECTION IV – BUSINESS AUTO CONDITIONS, A. Loss Conditions , the following is added to paragraph 2. Duties In The Event of Accident, Suit or Loss: d.Knowledge of any "accident", "claim", "suit" or "loss" will be deemed knowledge by you when notice of such "accident", "claim", "suit" or "loss" has been received by: (1)You, if you are an individual; (2)Any partner or insurance manager if you are a partnership; (3)An executive officer or insurance manager, if you are a corporation; (4)Your members, managers or insurance manager, if you are a limited liability company; or (5)Your officials, trustees, board members or insurance manager, if you are a not-for-profit organization. J. WAIVER OF SUBROGATION REQUIRED BY CONTRACT Under SECTION IV ,BUSINESS AUTO CONDITIONS, A. Loss Conditions 5. Transfer of Rights of Recovery Against Others to Us the following language is added: However, we waive any rights of recovery we may have against the person or organization with whom you have agreed in writing in a contract, agreement or permit, to provide insurance such as is afforded under the policy to which this endorsement is attached. This provision does not apply unless the written contract or written agreement has been executed, or permit has been issued, prior to the "bodily injury" or "property damage." K. UNINTENTIONAL FAILURE TO DISCLOSE Under SECTION IV – BUSINESS AUTO CONDITIONS, B. General Conditions , the following is added to 2. Concealment, Misrepresentation Or Fraud : Your unintentional error in disclosing, or failing to disclose, any material fact existing at the effective date of this Coverage Form, or during the policy period in connection with any additional hazards, will not prejudice your rights under this Coverage Form. L. HIRED, LEASED, RENTED OR BORROWED AUTO PHYSICAL DAMAGE Under SECTION IV – BUSINESS AUTO CONDITIONS B. General Conditions 5. Other Insurance Paragraph 5.b.is replaced by the following: b. (1)For "Comprehensive" and "Collision" Auto Physical Damage coverage provided by this endorsement, the following are deemed to be covered "autos" you own: (a)Any Covered "auto" you lease, hire, rent or borrow; and (b)Any Covered "auto" hired or rented by your "employee" under a contract in that individual "employee's" name, with your permission, while performing duties related to the conduct of your business. However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered "auto" (2) Limit of Insurance For This Section The most we will pay for any one "loss" is the lesser of the following: (a)$75,000 per accident, or (b)actual cash value at the time of loss, or (c)cost of repair. CA 71 09 01 17 Includes copyrighted material of Insurance Services Office, Inc., with its permission.Page 7 of 7 Minus a $500 deductible. An adjustment for depreciation and physical condition will be made in determining actual cash value in the event of a total loss. No deductible applies to "loss" caused by fire or lightning. (3)This Hired Auto Physical Damage coverage is excess over any other collectible insurance. (4) Definitions For This Section (a)Comprehensive Coverage: from any cause except the covered "auto's" collision with another object or the covered "auto's" overturn. We will pay glass breakage, "loss" caused by hitting a bird or animal and, "loss" caused by falling objects or missiles. (b)Collision Coverage: caused by the covered "auto's" collision with another object or by the covered "auto's" overturn. M. MENTAL ANGUISH Under SECTION V – DEFINITIONS, C.is replaced by the following: C."Bodily injury" means bodily injury, sickness or disease sustained by a person including mental anguish or death resulting from bodily injury, sickness, or disease. N. EXTENDED CANCELLATION CONDITION Under CANCELLATION,of the COMMON POLICY CONDITIONS form, item 2.b.is replaced by the following: b.60 days before the effective date of cancellation if we cancel for any other reason. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2% of the California workers’ compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER BLANKET WAIVER OF SUBROGATION This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: Policy No. Endorsement No.001 Insured:Wilson, Doug; Wilson, Deborah; Wilson Excavating Premium $ INCL. Insurance Company:Everest Premier Insurance Company Countersigned By: - 1998 by the Workers’ Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB’s California Workers’ Compensation Insurance Forms Manual - 1999. 5 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 08/30/2017 License # 0E02096 1409 (805) 593-1401 31453 Wilson Excavating & Grading 1307 22nd Street Oceano, CA 93445 24074 10120 A 1,000,000 X X 08/31/2017 Rent/Lease/Borrow 100,000 WHEN REQUIRED BY WRITTEN CONTACT THE FOLLOWING FORM(S) ARE APPLICABLE: GENERAL LIABILITY Blanket Additional Insured, Waiver of Subrogation & Primary-Non Contributory Form #CG2010R (12-11), Per Project Aggregate Form #CG2503 (05 09)///AUTOMOBILE Blanket Additional Insured & Waiver of Subrogation Form #CA8810 (01/13), Primary Form #CA0001 (03/06), Pg 10 of 13, 5. Other Insurance///WORKERS COMPENSATION Blanket Waiver of Subrogation form #WC040306 are attached City of San Luis Obispo 919 Palm St San Luis Obispo, CA 93401 WILSEXC-01 LWOOLPERT DiBuduo & DeFendis Insurance Brokers, LLC 100 Cross Street, Suite 203 San Luis Obispo, CA 93401 Leonore Woolpert, CPCU lwoolpert@dibu.com Financial Pacific Insurance Company Ohio Casualty Insurance Company Everest National Insurance Company X 08/31/2018 X X X X X POLICY NUMBER:COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. CG 25 03 05 09 ©Insurance Services Office,Inc.,2008 Page 1 of 2 DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE A.For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences"under Section I –Coverage A,and for all medical expenses caused by accidents under Section I –Coverage C,which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1.A separate Designated Construction Project General Aggregate Limit applies to each designated construction project,and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2.The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A,except damages because of "bodily injury "or "property damage"included in the "products-completed operations hazard",and for medical expenses under Coverage C regardless of the number of: a.Insureds; b.Claims made or "suits"brought;or c.Persons or organizations making claims or bringing "suits". 3.Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the Designated Construction Project General Aggregate Limit for that designated construction project.Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Designated Construction Project General Aggregate Limit for any other designated construction project shown in the Schedule above. 4.The limits shown in the Declarations for Each Occurrence,Damage To Premises Rented To You and Medical Expense continue to apply. However,instead of being subject to the General Aggregate Limit shown in the Declarations,such limits will be subject to the applicable Designated Construction Project General Aggregate Limit. Information required to complete this Schedule,if not shown above,will be shown in the Declarations. Designated Construction Project(s): CG 25 03 05 09 CG 25 03 05 09 ©Insurance Services Office,Inc.,2008 Page 2 of 2 B.For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences"under Section I –Coverage A,and for all medical expenses caused by accidents under Section I –Coverage C,which cannot be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1.Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products-completed Operations Aggregate Limit,whichever is applicable;and 2.Such payments shall not reduce any Designated Construction Project General Aggregate Limit. C.When coverage for liability arising out of the "products-completed operations hazard"is provided, any payments for damages because of "bodily injury"or "property damage"included in the "products-completed operations hazard"will reduce the Products-completed Operations Aggregate Limit,and not reduce the General Aggregate Limit nor the Designated Construction Project General Aggregate Limit. D.If the applicable designated construction project has been abandoned,delayed,or abandoned and then restarted,or if the authorized contracting parties deviate from plans,blueprints,designs, specifications or timetables,the project will still be deemed to be the same construction project. E.The provisions of Section III –Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2% of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER BLANKET WAIVER OF SUBROGATION This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective:08/31/2017 Policy No. Endorsement No.001 Insured:Wilson, Doug; Wilson, Deborah Premium $ INCL. Insurance Company:Everest National Insurance Company Countersigned By: - 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual - 1999. 4