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Item No. 03 Amend No. 2 - Ext of Agreement All American Asphalt No. Z10002
Text File City of Lake Elsinore 130 South Main Street Lake Elsinore, CA 92530 www.lake-elsinore.org File Number: ID# 17-217 Agenda Date: 6/13/2017 Status: Consent AgendaVersion: 1 File Type: ReportIn Control: City Council Agenda Number: 3) Page 1 City of Lake Elsinore Printed on 6/8/2017 Page 1 of 2 REPORT TO CITY COUNCIL To:Honorable Mayor and Members of the City Council From:Grant Yates, City Manager Approved by: Jason Simpson, Assistant City Manager Prepared by: Catherine Eakins – PW Administrative Assistant Date:June 13, 2017 Subject:Amendment No. 2 – Extension of Agreement for Contract Services (On- Call) for All American Asphalt and NPG, Inc. – Project No. Z10002 Recommendation Approve and authorize the City Manager to execute Amendment No. 2 to the On-Call Contract Services Agreement with All American Asphalt and NPG, Inc., to allow for a one (1) year renewal term in the not to exceed amount of $55,000 each in substantially the form attached and in such final form as approved by the City Attorney. Background The City contracts for street repairs through solicitation of bids. The scope of work consists of furnishing all labor, materials, tools, equipment, and incidentals required to do street work. Locations for crack seal & pothole repairs are developed through staff inspections and resident requests. Work orders are used to complete street repairs. On October 13, 2015, City Council approved the award to both NPG and All American Asphalt for On-Call Contract Services for the Annual Crack Seal & Pothole Repair Program. Discussion The asphalt maintenance program tracks the repair of streets throughout the City. All work orders specify the type and quantity of work. Because each work order is unique, the billing will vary depending on the individual requests. Each contractor will be paid based on the bid schedule and unit prices received. Total payment to each contractor will not exceed $55,000 based on budgeted funding. Fiscal Impact Funds in the amount of $110,000 have been allocated for the Annual Crack Seal Pothole Repair CIP Project No. Z10002 in FY2017/2018 CIP Budget Amendment No. 2 Annual Crack Seal & Pothole Repairs June 13, 2017 Page 2 Page 2 of 2 Exhibits All American Asphalt – Exhibit A Agreement All American Asphalt – Exhibit B Amendment 1 & Original NPG Inc. – Exhibit A Agreement NPG Inc. – Exhibit B Amendment 1 & Original Exhibit A Page 1 of 2 AMENDMENT NO.2 TO AGREEMENT FOR CONTRACTOR SERVICES (ON-CALL) All American Asphalt FY 17/18 Annual Crack Seal & pothole Repairs, Project No. Z10002 This Amendment No. 2 to Agreement for Contractor Services (On-Call) ("Amendment No.2")is made and entered into as of July 1, 2017 by and between the City of Lake Elsinore, a municipal corporation ("City), and All American Asphalt ("Contractor"). RECITALS A. The City and Contractor have entered into that certain Agreement for Contractor Services dated as of October 13, 2015 (the "Original Agreement''). Except as otherwise defined herein, all capitalized terms used herein shall have the meanings set forth for such terms inthe OriginalAgreement. B.The Original Agreement provided for compensation to Contractor in an amount not to exceed Fifty-Five Thousand dollars ($55,000). C.The term of the Original Agreement was for eight (8) months and allows the City to extend the term on an annual basis, for a total of two (2) years. D.Amendment No. 1 dated July 1, 2016, extended the contract a further 12- months through FY 2016/17. E.The parties now desire to extend the term for such services as set forth in this Amendment No 2. NOW, THEREFORE, in consideration of the mutual covenants and conditions set forth herein, City and Contractor agree as follows: 1.Section 2, c. Term and Compliance with Task/Work Order System. of the Original Agreement is hereby amended to add the following: Unless earlier terminated as provided elsewhere in the Original Agreement., this Amendment No. 2 shall continue infull force and effect until June 30, 2018. Except for the changes specifically set forth herein, all other terms and conditions of the Original Agreement shall remain in full force and effect. Page 2 of 2 City of Lake Elsinore Page 2 of 2 All American Asphalt July 1, 2017 INWITNESS WHEREOF, the parties have caused this Amendment No. 2 to be executed on the respective dates set forth below. "CITY" CITY OF LAKE ELSINORE, a municipal corporation Grant Yates,City Manager Date: _________________________ ATT EST: City Clerk APPROVED AS TO FORM: City Attorney Attachment: Amendment No.1-07.01.2016 Original Agreement –10.13.2015 "CONTRACTOR" All American Asphalt, a California corporation ___________________________________ Edward J. Carson, Owner Date: _________________________ AMENDMENT NO. 1 TO AGREEMENT FOR CONTRACTOR SERVICES (ON -CALL) ALL AMERICAN ASPHALT FY 16/17 Annual Crack Seal & Pothole Repairs, Project No. Z10002 This Amendment No. 1 to Agreement for Contractor Services (On -Call) ( "Amendment No. 1 ") is made and entered into as of July 1, 2016 by and between the City of Lake Elsinore, a municipal corporation ( "City), and All American Asphalt ( "Contractor "). RECITALS A. The City and Contractor have entered into that certain Agreement for Contractor Services dated as of October 13, 2015 (the "Original Agreement'). Except as otherwise defined herein, all capitalized terms used herein shall have the meanings set forth for such terms in the Original Agreement. B. The Original Agreement provided for compensation to Contractor in an amount not to exceed Fifty -Five Thousand dollars ($55,000). C. The term of the Original Agreement was for eight (S) months and allows the City to extend the term on an annual basis, for a total of two (2) years. D. The parties now desire to extend the term for such services as set forth in this Amendment No 1. NOW, THEREFORE, in consideration of the mutual covenants and conditions set forth herein, City and Contractor agree as follows: 1. Section 2, Time of Performance, of the Original Agreement is hereby amended to add the following: Unless earlier terminated as provided elsewhere in the Original Agreement, this Amendment No. 1 shall continue in full force and effect until June 30, 2017. The City may, at its sole discretion, extend the term of this Agreement on an annual basis not to exceed one (1) additional renewal term, such notice to be exercised by the City Manager. 2. Except for the changes specifically set forth herein, all other terms and conditions of the Original Agreement shall remain in full force and effect. IN WITNESS WHEREOF, the parties have caused this Amendment No. 1 to be executed on the respective dates set forth below. CITY" CITY OF LAKE ELSINORE, a municipal corporation Gtanf`Y;9X,d. City Manager Date: ATTEST: Attachments: Exhibit B — Original Agreement CONTRACTOR" All American Asphalt, a California corporation Edward J. Carson, *ma , Date: CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 07/12/2016 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 IIELOW. 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 be endorsed. If SUBROGATION IS WAIVED, subject to the terns and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CA LIC OB29370 1 -925- 244 -7700 1 COTACT Certificates Department Edgewood Partners Insurance Centers (EPIC) PHONE Alt Inland Empire - Branch ID 145421 NQ. EX• (925) 244 -7700 AIC Na (92' -5) 901 -0671 E -MAIL EPICcerte0e icbrokere.comP.O. Box 5003 ADAR r=6$ P INSURERS AFFORDING COVERAGE NAI San Ramon, CA 94583 INSURERA:ARCH SPECIALTY INS CO 21199 INSURED INSURERB ZURICH AMER INS CO 16535 All American Asphalt INSURERC:AMERICAN GUAR & LIAB INS 26247 P.O. Box 2229 INSURER Corona, CA 92878 -2229 1 INSURER F: - COVERAGES r..FPTIFIrATF KIII1Ur4F12- 47177AA A loelaeIAKI unucoo. 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 INTS'R TYPE OF INSURANCE AGD AM BR. WVD POLICY NUMBER DPCIO0585600 POLICY EFF 08101116 POL Y EXP MM/D 08/01/17 LIMITS EACH OCCURRENCE 1,000,000AXCOMMERCIALGENERALLIABILITY CLAIMS -MADE OCCUR PA S 100,000 MED EXP Any one person) S PERSONAL dADVINJURY S 1,000,000 GEWL AGGREGATE LIMIT APPLIES PER POLICY JEGT D LOC GENERALAGGREGATE S 2,000, 000 PRODUCTS - COMPIOP AGG 2,000, 000 OTHER AUTOMOBILE LIABILITY BAPS57108804 08/01/ 16 08/01/17 COM81NED SINGLE LI IT e amdenil 2,000,000 X SANYAUTOBODILYINJURY (Per pe(son) ALL OWNED SCHEDULED AUTOS _., AUTOS BODILY INJURY (Per acodent) HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per a dent 5 C UMBRELLALIA13 OCCUR SXS019797000 08/ 01/16 08/01/17 EACH OCCURRENCE 10,000,000 X a 10,000,000EXCESSLIARCLAIMS -MADE AGGREGATE DED TX I RETENTIONS 10,000 Following -Form B WORKERS COMPENSATIONANDEMPLOYERS' LIABILrIY Y i N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED NIA WC593205703 08/ 01/16 08/01/ 17 X PER OETRH- LITE S 1,000,000ELEACHACCIDENT EL DISEASE - EA EMPLOYE 1,000,000MandatorylnNH) If yyes, descnbe under E L OISFE - POLICY LIMIT 2,000,000DESCRIPTIONOFOPERATIONSbelcw I d DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Project NZ10002 / RE: FY 15/16 Annual Crack Seal & Pothole Repairs Certificate Holder is Additional Insured if Required by Written Contract Excluding Workers Compensation [2] v. n, I c nVILUMIN IrANL,CLLA I IL I I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Lake Elsinore THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. South Main Street AUTHORIZED REPRESENTATIVE Lake Elsinore, CA 92531 — I USA 1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD DCannon -is 47377043 MEMO To: Whom it may concern From: Edgewood Partners Insurance Centers (EPIC) Named Insured: All American Asphalt et al Policy Number(s): DPC100585600, BAP557108804, WC593205703, SXS019797000 RE: Notice of Cancellation Should the above described policy be cancelled before the expiration date thereof, we will mail 30 days written notice to the Certificate Holder; except, 10 days notice for non - payment of premium. Sincerely, -k Account Manager tel: 925.244.7700 3000 executive parkway, suite 325, san ramon, ca 94583 ca license OB29370 epicbrokers.com THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED ENDORSEMENT This endorsement modifies Insuranoe provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY SELF- INSURED RETENTION COVERAGE FORM SECTION II — WHO IS AN INSURED is amended to include as an additional Insured those persons or organlzelions who are required under a written contract with you to be named as an addhional Insured, but only with respect to liability for'bodlly Injury', 'property dameW, or "personal and advertising Injury' caused, in whole or In park by your ads or omissions or the ads or omissions of your suboontractors: A. In the performance of your ongoing operatlons or "your work", including 'your work" that has been completed; or B. In connection with your premises owned by or rented to you. As used in this endorsement. the words Wand 'your' refer to the Named Insured. All other terms and conditions of this Policy remain unchanged. Schedule Project City of Lake Elsinore, its elected or appointed officers, officials, Project #Z10002 / RE: FY 15/16 Annual Crack Seal employees, agents and volunteers & Pothole Repairs Endorsement Number: This endorsement is effective on the inception date of this policy unless otherwise slated herein. The Information below Is required only when this endorsement Is Issued subsequent to preparation of the pol Icy) Pdlcy Number DPC100585600 Named Insured: All American Asphah et all Endorsemerd Effective Date: August 1, 2016 4063 00 CGL0006 DO 05 07 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OTHER INSURANCE - BROAD FORM, CGL POLICY ENDORSEMENT This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Under SECTION IV — COMMERCIAL GENERAL LIASILIITY CONDITIONS, the following paragraph Is added to Condition 4. Other Insurance: Where the Named Insured Is required by a written contract to provide insurance that Is primary and norwontributory, and the written contract so requiring Is executed by the Named Insured before any 'occurrence" or offianse, this Insurance will be primary, but only If and to the extent required by that written contract All other terms and conditions of this Policy remain unchanged. Schedule Project City of Lake Elsinore, its elected or appointed officers, officials, Project #Z10002 /RE: FY 15/16 Annual Crack Seal employees, agents and volunteers & Pothole Repairs Endorsement Number This endorsement Is effective on the inception date of this policy unless otherwise slated herein. The information below Is required only when this endorsement Is Issued subsequent to preparation of the policy.) Policy Number: DPC100585600 Named Insured: All American Asphalt at al Endorsement EffedlveDale August 1, 2016 00 CGL0130 00 09 08 Page 1 of 1 4063 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF SUBROGATION ENDORSEMENT This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY SELF - INSURED RETENTION COVERAGE FORM SCHEDULE Name of Parson or Organization, Where required by written contract. Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDMONS, Condition & Transfer Of Rights Of Recovery Against Others To Us Is amended by the addition of the following provision: We welve any right of recovery we may have against the person or organization shown In the SCHEDULE above because of payments we make for injury or damage arising out of your operations or your work" done under a written contract with that person or organLz ation. All other terms and conditions of this Policy remain unchanged. Schedule Project City of Lake Elsinore, its elected or appointed officers, officials, Project #Z10002 /RE: FY 15/16 Annual Crack Seal employees, agents and volunteers & Pothole Repairs Endorsement Number: This endorsement is effective on the inception dabs of this policy unless otherwise stated herein. The irtormation below Is required only when this endorsement Is Issued subsequent to preparation of the policy.) Policy Number: DPC100585600 Named Insured: All American Asphalt at all EndorsementEffedlveDate: August 1, 2016 00 CGLO121 00 09 09 Includes copyrighted material of Insurance Services office, Inc., Page 1 of 1 with Its permission. 4063 POLICYNL*AKR BAPS57108804 COW. AUTO CA 20 40 82 00 THIS ENDORSEM ENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This arrdorseTwd modries Insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM Wth respect to coverage provided by this endorsement, the provisions of the Coverage Form 9" unless modried by this endorsernert. This endorserriert Identifies person(s) or orgardzatton(s) who are 'insureds" under the Who Is An Insured Provision of the Coverage Form. This endorsemerd does not alter coverage provided in the Coverage Form. This endorsement changes the policy eRecM on the Inception date of the policy unless axAb x date Is Indicated below. EndorsanwA E fective: 8/1/16 Countersigned By: Authorized esertative Nand Insured: All American Asphalt SCHEDULE Narrw d Person(s) orbs): ANY PERSON OR ORGANIZATION TO WHOM OR WHICH YOU ARE REQUIRED TO PROVIDE ADDITIONAL INSURED STATUS OR ADDITIONAL INSURED STATUS ON A PRIMARY, NON — CONTRIBUTORY BASIS, IN A WRITTEN CONTRACT OR WRITTEN AGREEMENT EXECUTED PRIOR TO LOSS, EXCEPT WHERE SUCH CONTRACT OR AGREEMENT IS PROHIBITED BY LAW. Schedule Project City of Lake Elsinore, its elected or appointed officers, Project #Z10002 / RE: FY 15/16 Annual Crack Seal officials, employees, agents and volunteers & Pothole Repairs If no entry appears above, Wonnatlon required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown In the Schedule Is at 'insured" for LW My Coverage, but only to the indent that person or organization qualifies as an Insured" under the Who Is An Insured Provision contained In Secion 9 of the Coverage Form. CA 20 I81G 90 Copyright, Insurance Services Officce, Inc.. 1996 Page 1 d 1 0 4063 BAP557108804 POLICY MABER CONO EACt& AUTO CAM"0310 THIS ENDCR.AMW ENT CHANGES THE FOUCY PLEASE READ R CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endcxsemarrt modtfaes hmrarw provkled under the *Akm v: MAN e. "• R mh rasped to oaverape provided by this sWorwwt. the provkbms d the Cmewe Form apply unless M& fled by the wdoriwMil. This rrw* charges the policy effsdtm on theinception date of the poky unless another date is indicated below. liarsd 11- IN All American Asphalt Endmanwit Efbcln Dub: 8 / 1 / 16 KmrMs) orpamori(s)OrOrwwCwwx* ALL PERSONS AND /OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY The Trandw Of F"MS Of Rromwy w%dwrrt Otfrsre To Us Condition does not apply to the pwwKs) or mss) shown In the SeWuae, but ordy to Ow ddwrd that subrop Wn as waked prior to the go)- cadent" or the lass under awritred with the person or ogMikabon. Schedule City of Lake Elsinore, its elected or appointed officers, officials, employees, agents and volunteers will be shown In Ow Project Project #Z10002 / RE: Pothole Repairs FY 15/16 Annual Crack Seal 4069 CAM" 4310 0 Irourawe Servloes Office, Inc.. 2M Peps 1 of 1 13 V11OfKERS' COMPENSATION AND EN+PLOYERS' LIABILITY INSURANCE POUCY WC 04 43 06 6d. 484) WAIVER OF OL R RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-- - CAU FOR NIA V* two the right to recover our payments from anyone ltabb for an injury covered by this policy. Va wil not enforce our rigtt ag2krW the person or orgar"lon named In the Schedule. (This agreement applies only to the adent that you perform work under a written contract that requires you to obtain this a0rrawmt from us.) You must maintain payrol records accurately w gregaft the remuneration of your effvkr while engaged In the work described In the Scheduia The addoonal premim for this andwoernant shaN be 0.00 % of the C.alkwnie workers' c sallon pre - mkm athsrwiee due on such remuneration. Parson or OrUwAralon ALL PZRSOKS AND /OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTIN CONTRACT OR AGREMN? VITH THE INSUR19D , il[ WUTED PRIOR TO THE ACCIDP.NT OR LOSS, THAT 1l;AIVXR OF SUBROGATION U PROVIDED UNDER THIS POLICY FOR VIM PZRFORNICD BY YOU FOR THAT PERSON AND /OR ORGANIZATION SChKkAa Job DascrWon ALL CA OPERATION City of Lake Elsinore, its elected or appointed officers, officials, employees, agents and volunteers All American Asphalt Policy #WC593205703 8/1/16 Project #Z10002 / RE: FY 15/16 Annual Crack Seal & Pothole Repairs Zurich American Ins. Co. 252(444) VC 04 03 06 (Ed, 4-0) Ppr 1 of 1 4063 Form W=9 Request for Taxpayer Give Form to the Rev. December 2014) identification Number and Certification requester. Do not Department of the Treasury Send t0 the IRS. Internal Revenue Service 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. ALL AMERICAN ASPHALT N 2 Business name /disregarded entity name, if different from above m9 3 Check appropriate box for federal tax classification; check only one of the following seven boxes: 4 Exemptions (codes apply only to certartz entities, not individuals; see Individual /sole proprietor or C Corporation S Corporation Partnership Trust/estate instructions on page 3): CL e 4.1 single- member LLC Limited liability company. Enter the tax classification (C =C corporation, S =S corporation, P= partnership) Exempt payee code (if any) o 2 Note. For a single- member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for Exemption from FATCA reporting w the tax classification of the single - member owner. code (if any) CL V Other (see Instructions) lo- Applies to accounts maintained outside the U.S.) 5 Address (number, street, and apt. or suite no.) Requester's name and address (optional) a P.O. Box 2229 6 City, state, and ZIP code Y) Corona, Ca 92878 Citv of Lake Elsinore 7 List account numbers) here (optional) W311 ti Will Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid { Social security number i backup withholding. For individuals, this is generally your social security number ( However, for a page - m - resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. or Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for I Employer identification number guidelines on whose number to enter. 9 F51 - 2 1 5 1 9 5 1 0 1 4 1 3 Certification Under penalties of perjury, I certify that: The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3. Sign Signature of Here U.S. person Date General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. Information about developments affecting Form W -9 (such as legislation enacted after we release it) is at www.irs.gov1fw9. Purpose of Form An individual or entity (Form W -9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following: Form 1099 -INT (interest earned or paid) Form 1099 -DIV (dividends, including those from stocks or mutual funds) Form 1099 -MISC (various types of income, prizes, awards, or gross proceeds) Form 1099 -B (stock or mutual fund sales and certain other transactions by brokers) Form 1099 -S (proceeds from real estate transactions) Form 1099 -K (merchant card and third party network transactions) Form 1098 (home mortgage interest), 1098 -E (student loan interest), 1098 -T tuition) Form 1099 -C (canceled debt) Form 1099 -A (acquisition or abandonment of secured property) Use Form W -9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not retum Form W -9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2. By signing the filled -out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding If you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S, person, your allocable share of any partnership Income from a U.S. trade or business Is not subject to the withholding tax on foreign partners' share of effectively connected Income, and 4. Certify that FATCA codes) entered on this form (if any) Indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information. Cat. No. 10231X Form W-9 (Rev. 12 -2014) CITY OF ,. L i C LSIHOR r 130 SOUTH MAIN STREET LAKE ELSINORE, CA 92530 BUSINESS LICENSE CFRTIFIrATiR BUSINESS LICENSE This business license is issued for revenue purposes only and does not grant authorization to operate a business. This business license is issued without verlflCation that the holder is subject to or exempted from licensing by the state, county, federal government, or any other governmental agency. Business Name: ALL AMERICAN ASPHALT Business Location: P O BOX 2229 CORONA, CA 92878 Owner Name(s): MARK LUER ALL AMERICAN ASPHALT P O BOX 2229 CORONA, CA 92878 CITY OF LAKE ELSINORE ADMINISTRATIVE SERVICES- LICENSING 130 South Main Street Lake Elsinore, CA 92530 951.674.3124 TO BE POSTED IN A CONSPICUOUS PLACE BUSINESS LICENSE NO. 001333 Business Type: GENERAL ENGINEERING CONTRACTOR Description: GENERAL ENGINEERING & EARTHWORK/PAVING CONTRACTOR Issue Date: 2/1/2016 Expiration Date: 1/31/2017 THIS IS YOUR LICENSE • NOT TRANSFERABLE EXHIBIT B ORIGINAL AGREEMENT ATTACHED] EXHIBIT B AGREEMENT FOR CONTRACTOR SERVICES (ON -CALL) ALL AMERICAN ASPHALT FY 15116 Annual Crack Seal & Pothole Repairs, Project No. Z10002 This Agreement for Contractor Services (On -Call) (the "Agreement ") is made and entered into as of October 13, 2015, by and between the City of Lake Elsinore, a municipal corporation ( "City ") and All American Asphalt, a California corporation ( "Contractor"). RECITALS A. The City has determined that it requires the following services: Road repair at various locations Citywide. Services to include but not limited to pothole repair, overlay, and crack seal. B. The City has prepared a notice inviting bids and Contractor has submitted to City a proposal, dated September 24, 2015, both of which are attached hereto as Exhibit A collectively, the "Contractor's Proposal ") and incorporated herein, to provide services and related work to the City pursuant to the terms of this Agreement. C. Contractor possesses the skill, experience, ability, background, certification and knowledge to perform the services and related work described in this Agreement on the terms and conditions described herein. D. City desires to retain Contractor to perform the services and related work as provided herein and Contractor desires to provide such services and related work as set forth in this Agreement. AGREEMENT 1. Scope of Services. Contractor shall perform the services and related work described in Contractor's Proposal (Exhibit A). Contractor shall provide such services and related work at the time, place, and in the manner specified in Contractor's Proposal (Exhibit A), subject to the direction of the City through its staff that it may provide from time to time. Contractor acknowledges that the Scope of Services provides for 24 hour -a -day, 7 day -a -week, on -call support on an as needed basis. 2. Time of Performance. a. Time of Essence. Time is of the essence in the performance of this Agreement. The time for completion of the services and related work to be performed by Contractor is an essential condition of this Agreement. Contractor shall prosecute regularly and diligently the services and related work contemplated pursuant to this Agreement consistent with Contractor's Proposal (Exhibit A) and shall provide, furnish and pay all labor, materials, necessary tools, expendable equipment, and all taxes, utility and transportation services required to perform such the services and related work. b. Performance Schedule. Contractor shall commence the services and related work pursuant to this Agreement upon receipt of a written notice to proceed and shall On -Call Contract All American Asphalt Project Z10002 Page 1 perform all services and related work within the time period(s) established in the Contractor's Proposal (Exhibit A). When requested by Contractor, extensions to the time period(s) specified may be approved in writing by the City Manager. C. Terra and Compliance with Task/Work Order System. Unless earlier terminated as provided elsewhere in this Agreement, this Agreement shall continue in full force and effect for a period of eight (8) months, commencing on October 13, 2015 and ending on June 30, 2016. The City may, at its sole discretion, extend the term of this Agreement on a 12 -month basis not to exceed two (2) additional twelve (12) month renewal terms by giving written notice thereof to Contractor not less than thirty (30) days before the end of the contract term, such notice to be exercised by the City Manager. Contractor hereby agrees and acknowledges that any and all work or services performed pursuant to this Agreement shall be based upon the issuance of a Task/Work Order by the City. Contractor acknowledges that it is not guaranteed any minimum or specific amount of work or services as all work or services shall be authorized through a Task/Work Order issued by the City. 3. Compensation and Cost of Living Adjustment. Compensation to be paid to Contractor shall be in accordance with the fees set forth in Contractor's Proposal (Exhibit A), which is attached hereto and incorporated herein by reference. In no event shall Contractor's compensation exceed FIFTY FIVE THOUSAND DOLLARS ($55,000) without additional written authorization from the City. Notwithstanding any provision of Contractor's Proposal to the contrary, out of pocket expenses set forth in Exhibit A shall be reimbursed at cost without an inflator or administrative charge. Payment by City under this Agreement shall not be deemed a waiver of defects, even if such defects were known to the City at the time of payment. The compensation paid to Contractor may be adjusted on each July 1 following the first anniversary of the commencement of the term of this Agreement, provided that The request for cost of living adjustment shall be presented to the City no later than June 1 st of a particular year and, if approved by the City, will become effective on July 1st of that year. Any adjustment will be based on the Los Angeles- Riverside - Orange County Consumer Price Index (CPI) but in no event shall the price adjustment exceed five percent (5 %). 4. Method of Payment. Contractor shall promptly submit billings to the City describing the services and related work performed during the preceding month to the extent that such services and related work were performed. Contractor's bills shall be segregated by project task, if applicable, such that the City receives a separate accounting for work done on each individual task for which Contractor provides services. Contractor's bills shall include a brief description of the services performed, the date the services were performed, the number of hours spent and by whom, and a description of any reimbursable expenditures. City shall pay Contractor no later than forty -five (45) days after receipt of the monthly invoice by City staff. 5. Suspension or Termination. a. The City may at any time, for any reason, with or without cause, suspend or terminate this Agreement, or any portion hereof, by serving upon the Contractor at least ten 10) days prior written notice. Upon receipt of such notice, the Contractor shall immediately cease all work under this Agreement, unless the notice provides otherwise. If the City suspends Page 2 or terminates a portion of this Agreement such suspension or termination shall not make void or invalidate the remainder of this Agreement. b. In the event this Agreement is terminated pursuant to this Section, the City shall pay to Contractor the actual value of the work performed up to the time of termination, provided that the work performed is of value to the City. Upon termination of the Agreement pursuant to this Section, the Contractor will submit an invoice to the City, pursuant to Section entitled "Method of Payment" herein. 6. Ownership of Documents. All plans, studies, documents and other writings prepared by and for Contractor, its officers, employees and agents and subcontractors in the course of implementing this Agreement, except working notepad internal documents, shall become the property of the City upon payment to Contractor for such work, and the City shall have the sole right to use such materials in its discretion without further compensation to Contractor or to any other party. Contractor shall, at Contractor's expense, provide such reports, plans, studies, documents and other writings to City upon written request. City acknowledges that any use of such materials in a manner beyond the intended purpose as set forth herein shall be at the sole risk of the City. City further agrees to defend, indemnify and hold harmless Contractor, its officers, officials, agents, employees and volunteers from any claims, demands, actions, losses, damages, injuries, and liability, direct or indirect (including any and all costs and expenses in connection therein), arising orIt of the City's use of such materials in a manner beyond the intended purpose as set forth herein. a. Licensing of Intellectual Property. This Agreement creates a nonexclusive and perpetual license for City to copy, use, modify, reuse, or sublicense any and all copyrights, designs, and other intellectual property embodied in plans, specifications, studies. drawings, estimates, and other documents or works of authorship fixed in any tangible medium of expression, including but not limited to, physical drawings or data magnetically or otherwise recorded on computer diskettes, which are prepared or caused to be prepared by Contractor under this Agreement ( "Documents & Data "). Contractor shall require that all subcontractors agree in writing that City is granted a nonexclusive and perpetual license for any Documents & Data the subcontractor prepares under this Agreement. Contractor represents and warrants that Contractor has the legal right to license any and all Documents & Data. Contractor makes no such representation and warranty in regard to Documents & Data which were prepared by design professionals other than Contractor or provided to Contractor by the City. City shall not be limited in any way in its use of the Documents & Data at any time, provided that any such use not within the purposes intended by this Agreement shall be at City's sole risk. b. Confidentiality. All ideas, memoranda, specifications, plans, procedures, drawings, descriptions, computer program data, input record data, written information, and other Documents & Data either created by or provided to Contractor in connection with the performance of this Agreement shall be held confidential by Contractor. Such materials shall not, without the prior written consent of City, be used by Contractor for any purposes other than the performance of the services under this Agreement. Nor shall such materials be disclosed to any person or entity not connected with the performance of the services under this Agreement. Nothing furnished to Contractor which is otherwise known to Contractor or is generally known, or has become known, to the related industry shall be deemed confidential. Contractor shall not use City's name or insignia, photographs relating to project for which Contractor's services are rendered, or any publicity pertaining to the Contractor's services under this Agreement in any magazine, trade paper, newspaper, television or radio production or other similar medium without the prior written consent of City. Page 3 7. Contractor's Books and Records. a. Contractor shall maintain any and all ledgers, books of account, invoices, vouchers, canceled checks, and other records or documents evidencing or relating to charges for services, or expenditures and disbursements charged to City for a minimum period of three 3) years, or for any longer period required by law, from the date of final payment to Contractor to this Agreement. b. Contractor shall maintain all documents and records which demonstrate performance under this Agreement for a minimum period of three (3) years, or for any longer period required by law, from the date of termination or completion of this Agreement. C. Any records or documents required to be maintained pursuant to this Agreement shall be made available for inspection or audit, at any time during regular business hours, upon written request by the City Manager, City Attorney, City Auditor or a designated representative of these officers. Copies of such documents shall be provided to the City for inspection at City Hall when it is practical to do so. Otherwise, unless an alternative is mutually agreed upon, the records shall be available at Contractor's address indicated for receipt of notices in this Agreement. d. Where City has reason to believe that such records or documents may be lost or discarded due to dissolution, disbandment or termination of Contractor's business, City may, by written request by any of the above -named officers, require that custody of the records be given to the City and that the records and documents be maintained in City Hall. Access to such records and documents shall be granted to any party authorized by Contractor, Contractor's representatives, or Contractor's successor -in- interest. 8. Inde endent. Contractor. It is understood that Contractor, in the performance of the work and services agreed to be performed, shall act as and be an independent contractor and shall not act as an agent or employee of the City. 9. PERS Eligibility Indemnification. In the event that Contractor or any employee, agent, or subcontractor of Contractor providing services under this Agreement claims or is determined by a court of competent jurisdiction or the California Public Employees Retirement System (PERS) to be eligible for enrollment in PERS as an employee of the City, Contractor shall indemnify, defend, and hold harmless City for the payment of any employee and /or employer contributions for PERS benefits on behalf of Contractor or its employees, agents, or subcontractors, as well as for the payment of any penalties and interest on such contributions, which would otherwise be the responsibility of City. Notwithstanding any other federal, state and local laws, codes, ordinances and regulations to the contrary, Contractor and any of its employees, agents, and subcontractors providing service under this Agreement shall not qualify for or become entitled to, and hereby agree to waive any claims to, any compensation, benefit, or any incident of employment by City, including but not limited to eligibility to enroll in PERS as an employee of City and entitlement to any contribution to be paid by City for employer contribution and/or employee contributions for PERS benefits. 10. Interests of Contractor. Contractor (including principals, associates and management employees) covenants and represents that it does not now have any investment or interest in real property and shall not acquire any interest, direct or indirect, in the area Page 4 covered by this Agreement or any other source of income, interest in real property or investment which would be affected in any manner or degree by the performance of Contractor's services hereunder. Contractor further covenants and represents that in the performance of its duties hereunder no person having any such interest shall perfomn any services under this Agreement. Contractor is not a designated employee within the meaning of the Political Reform Act because Contractor: a. will conduct research and arrive at conclusions with respect to his /her rendition of information, advice, recommendation or counsel independent of the control and direction of the City or of any City official, other than normal agreement monitoring; and b. possesses no authority with respect to any City decision beyond rendition of information, advice, recommendation or counsel. (FPPC Reg. 18700(a)(2).) 11. Ability of Contractor. City has relied upon the training and ability of Contractor to perform the services hereunder as a material inducement to enter into this Agreement. Contractor shall therefore provide properly skilled personnel to perform all services under this Agreement. All work performed by Contractor under this Agreement shall be in accordance with applicable legal requirements and shall meet the standard of quality ordinarily to be expected of competent contractors in Contractor's field of expertise. 12. Compliance with Laws. Contractor shall use the standard of care in its profession to comply with all applicable federal, state and local laws, codes, ordinances and regulations. 13. Licenses. Contractor represents and warrants to City that it has the licenses, permits, qualifications, insurance and approvals of whatsoever nature which are legally required of Contractor to practice its profession. Contractor represents and warrants to City that Contractor shall, at its sole cost and expense, keep in effect or obtain at all times during the term of this Agreement, any licenses, permits, insurance and approvals which are legally required of Contractor to practice its profession. Contractor shall maintain a City of Lake Elsinore business license. 14. Indemnity. Contractor shall indemnify, defend, and hold harmless the City and its officials, officers, employees, agents, and volunteers from and against any and all losses, liability, claims, suits, actions, damages, and causes of action arising out of any personal injury, bodily injury, loss of life, or damage to property, or any violation of any federal, state, or municipal law or ordinance, to the extent caused, in whole or in part, by the willful misconduct or negligent acts or omissions of Contractor or its employees, subcontractors, or agents, by acts for which they could be held strictly liable, or by the quality or character of their work. The foregoing obligation of Contractor shall not apply when (1) the injury, loss of life, damage to property, or violation of law arises from the sole negligence or willful misconduct of the City or its officers, employees, agents, or volunteers and (2) the actions of Contractor or its employees, subcontractor, or agents have contributed in no part to the injury, loss of life, damage to property, or violation of law. It is understood that the duty of Contractor to indemnify and hold harmless includes the duty to defend as set forth in Section 2778 of the California Civil Code. Acceptance by City of insurance certificates and endorsements required under this Agreement does not relieve Contractor from liability under this indemnification and hold harmless clause. This indemnification and hold harmless clause shall apply to any damages or claims for damages whether or not such insurance policies shall have been determined to apply. By Page 5 execution of this Agreement, Contractor acknowledges and agrees to the provisions of this Section and that it is a material element of consideration. 15. Insurance Requirements. a. Insurance. Contractor, at Contractor's own cost and expense, shall procure and maintain, for the duration of the contract, unless modified by the City's Risk Manager, the following insurance policies. i. Workers' Compgnsation Coverage. Contractor shall maintain Workers' Compensation Insurance and Employer's Liability Insurance for his /her employees in accordance with the laws of the State of California. In addition, Contractor shall require each subcontractor to similarly maintain Workers' Compensation Insurance and Employer's Liability Insurance in accordance with the laws of the State of California for all of the subcontractor's employees. Any notice of cancellation or non - renewal of all Workers' Compensation policies must be received by the City at least thirty (30) days prior to such change. The insurer shall agree to waive all rights of subrogation against City, its officers, agents, employees and volunteers for losses arising from work performed by Contractor for City. In the event that Contractor is exempt from Worker's Compensation Insurance and Employer's Liability Insurance for his /her employees in accordance with the laws of the State of California, Contractor shall submit to the City a Certificate of Exemption from Workers Compensation Insurance in a form approved by the City Attorney. ii. General Liability Coverage. Contractor shall maintain commercial general liability insurance in an amount not less than one million dollars ($1,000,000) per occurrence for bodily injury, personal injury and property damage. If a commercial general liability insurance form or other form with a general aggregate limit is used, either the general aggregate limit shall apply separately to the work to be performed under this Agreement or the general aggregate limit shall be at least twice the required occurrence limit. Required commercial general liability coverage shall be at least as broad as Insurance Services Office Commercial General Liability occurrence form CG 0001 (ed. 11188) or Insurance Services Office form number GL 0002 (ed. 1/73) covering comprehensive General Liability and Insurance Services Office form number GL 0404 covering Broad Form Comprehensive General Liability. No endorsement may be attached limiting the coverage. iii. Automobile Liability Coverage. Contractor shall maintain automobile liability insurance covering bodily injury and property damage for all activities of the Contractor arising out of or in connection with the work to be performed under this Agreement, including coverage for owned, hired and non -owned vehicles, in an amount of not less than one million dollars ($1,000,000) combined single limit for each occurrence. Automobile liability coverage must be at least as broad as Insurance Services Office Automobile Liability form CA 0001 (ed, 12/90) Code 1 ( "any auto "). No endorsement may be attached limiting the coverage. b. Endorsements. Each general liability and automobile liability insurance policy shall be with insurers possessing a Best's rating of no less than A:VII and shall be endorsed with the following specific language: Page 6 i. The City, its elected or appointed officers, officials, employees, agents and volunteers are to be covered as additional insured with respect to liability arising out of work performed by or on behalf of the Contractor, including materials, parts or equipment furnished in connection with such work or operations. ii. This policy shall be considered primary insurance as respects the City, its elected or appointed officers, officials, employees, agents and volunteers. Any insurance maintained by the City, including any self- insured retention the City may have, shall be considered excess insurance only and shall not contribute with it. iii. This insurance shall act for each insured and additional insured as though a separate policy had been written for each, except with respect to the limits of liability of the insuring company. iv. The insurer waives all rights of subrogation against the City, its elected or appointed officers, officials, employees or agents. V. Any failure to comply with reporting provisions of the policies shall not affect coverage provided to the City, its elected or appointed officers, officials, employees, agents or volunteers. vi. The insurance provided by this Policy shall not be suspended, voided, canceled, or reduced in coverage or in limits except after thirty (30) days written notice has been received by the City. C. deductibles and Self - Insured Retentions. Any deductibles or self- insured retentions must be declared to and approved by the City. At the City's option, Contractor shall demonstrate financial capability for payment of such deductibles or self - insured retentions. d. Certificates of Insurance. Contractor shall provide certificates of insurance with original endorsements to City as evidence of the insurance coverage required herein. Certificates of such insurance shall be filed with the City on or before commencement of performance of this Agreement. Current certification of insurance shall be kept on file with the City at all times during the term of this Agreement. 16. Notices. Any notice required to be given under this Agreement shall be in writing and either served personally or sent prepaid, first class mail. Any such notice shall be addressed to the other party at the address set forth below. Notice shall be deemed communicated within 48 hours from the time of mailing if mailed as provided in this section. If to City: City of Lake Elsinore Attn: City Manager 130 South Main Street Lake Elsinore, CA 92530 With a copy to: City of Lake Elsinore Attn: City Clerk 130 South Main Street Lake Elsinore, CA 92530 Page 7 If to Contractor: All American Asphalt Attn: Edward J. Carson 400 East Sixth Street Corona, CA 92879 17. Entire Agreement. This Agreement constitutes the complete and exclusive statement of Agreement between the City and Contractor. All prior written and oral communications, including correspondence, drafts, memoranda, and representations, are superseded in total by this Agreement. 18. Amendments. This Agreement may be modified or amended only by a written document executed by both Contractor and City and approved as to form by the City Attorney. 19. Assignment and Subcontracting. The parties recognize that a substantial inducement to City for entering into this Agreement is the reputation, experience and competence of Contractor. Contractor shall be fully responsible to City for all acts or omissions of any subcontractors. Assignments of any or all rights, duties or obligations of the Contractor under this Agreement will be permitted only with the express consent of the City. Contractor shall not subcontract any portion of the work to be performed under this Agreement without the written authorization of the City. If City consents to such subcontract, Contractor shall be fully responsible to City for all acts or omissions of those subcontractors. Nothing in this Agreement shall create any contractual relationship between City and any subcontractor nor shall it create any obligation on the part of the City to pay or to see to the payment of any monies due to any such subcontractor other than as otherwise is required by law. 20. Waiver. Waiver of a breach or default under this Agreement shall not constitute a continuing waiver of a subsequent breach of the same or any other provision under this Agreement. 21. Severability. If any term or portion of this Agreement is held to be invalid, illegal, or otherwise unenforceable by a court of competent jurisdiction, the remaining provisions of this Agreement shall continue in full force and effect. 22. Controlling Law Venue. This Agreement and all matters relating to it shall be governed by the laws of the State of California and any action brought relating to this Agreement shall be held exclusively in a state court in the County of Riverside. 23. Litigation Expenses and Attorneys' Fees. If either party to this Agreement commences any legal action against the other party arising out of this Agreement, the prevailing parry shall be entitled to recover its reasonable litigation expenses, including court costs, expert witness fees, discovery expenses, and attorneys' fees. 24. Mediation. The parties agree to make a good faith attempt to resolve any disputes arising out of this Agreement through mediation prior to commencing litigation. The parties shall mutually agree upon the mediator and share the costs of mediation equally. If the parties are unable to agree upon a mediator, the dispute shall be submitted to JAMS or its successor in interest. JAMS shall provide the parties with the names of five qualified mediators. Each party shall have the option to strike two of the five mediators selected by JAMS and thereafter the mediator remaining shall hear the dispute. If the dispute remains unresolved after mediation, either party may commence litigation. Page 8 25. Authority to Enter Agreement. Contractor has all requisite power and authority to conduct its business and to execute, deliver, and perform the Agreement. Each party warrants that the individuals who have signed this Agreement have the legal power, right, and authority to make this Agreement and to bind each respective party. The City Manager is authorized to enter into an amendment or otherwise take action on behalf of the City to make the following modifications to the Agreement: (a) a name change; (b) grant extensions of time; (c) non - monetary changes in the scope of services; and/or (d) suspend or terminate the Agreement. 26. Prohibited Interests. Contractor maintains and warrants that it has not employed nor retained any company or person, other than a bona fide employee working solely for Contractor, to solicit or secure this Agreement. Further, Contractor warrants that it has not paid nor has it agreed to pay any company or person, other than a bona fide employee working solely for Contractor, any fee, commission, percentage, brokerage fee, gift or other consideration contingent upon or resulting from the award or making of this Agreement. For breach or violation of this warranty, City shall have the right to rescind this Agreement without liability. For the term of this Agreement, no member, officer or employee of City, during the term of his or her service with City, shall have any direct interest in this Agreement, or obtain any present or anticipated material benefit arising therefrom. 27. Equal Opportunity Employment. Contractor represents that it is an equal opportunity employer and it shall not discriminate against any subcontractor, employee or applicant for employment because of race, religion, color, national origin, handicap, ancestry, sex or age. Such non - discrimination shall include, but not be limited to, all activities related to initial employment, upgrading, demotion, transfer, recruitment or recruitment advertising, layoff or termination. 28. Prevailing Wages. Contractor is aware of the requirements of California Labor Code Section 1720, et seq., and 1770, et seq., as well as California Code of Regulations, Title 8, Section 16000, et seq., ( "Prevailing Wage Laws "), which require the payment of prevailing wage rates and the performance of other requirements on "public works" and "maintenance" projects. Contractor agrees to fully comply with all applicable federal and state labor laws including, without limitation, if applicable, the Prevailing Wage Laws). It is agreed by the parties that, in connection with the work or services provided pursuant to this Agreement, Contractor shall bear all risks of payment or non - payment of prevailing wages under California law, and Contractor hereby agrees to defend, indemnify, and hold the City, and its officials, officers, employees, agents, and volunteers, free and harmless from any claim or liability arising out of any failure or alleged failure to comply with the Prevailing Wage Laws. The foregoing indemnity shall survive termination of this Agreement. 29. Execution. This Agreement may be executed in several counterparts, each of which shall constitute one and the same instrument and shall become binding upon the parties when at least one copy hereof shall have been signed by both parties hereto. In approving this Agreement, it shall not be necessary to produce or account for more than one such counterpart. Signatures on next page] Page 9 IN WITNESS WHEREOF, the parties have caused this Agreement to be executed on the date first written above. CITY" CITY OF LAKE ELSINORE, a municipal corporation Grant lyos, City Manager ATTEST: Ac-43 city C APP OVEN AS TO OR : Chf Attorney Attachments: Exhibit A — Contractor's Proposal CONTRACTOR" All American Asphalt, a California corporation By: Edward J. &arrson Its: .,QAt VP Page 10 EXHIBIT A CONTRACTOR'S PROPOSAL ATTACHED] EXHIBIT A EXHIBIT A CITY OF LAKE ELSINORE PROJECT NO. Z10002 FY 15116 ANNUAL CRACK SEAL & POTHOLE REPAIRS PROPOSER:. All American Asphalt Contractor Name) DDnDnQA1 ITC &AC AC rill I (11A/C- ITEM DESCRIPTION OF ITEMS ESTIMATED QUANTITY UNIT PRICE TOTAL COST NO. FIGURES) FIGURES) 1 Remove and Replace 3 Inches (maximum) 5,000 SF Soo sections jb 1 2 1 % Inch edge mill 10,000 SF 1 C r QO17 3 Install 1 Inch AC leveling course 335 TON 114 - 10 4 Install 1 '/2 inch AC Hot Mix Asphalt 500 TON 1 ( Overlay 1000 TOTAL FOR ITEMS Based on estimated quantities of items 1 through 4 SCHEDULE ATotal Bid: _. '_ Igures -) SCHEDULE ATotal Bid: h 1r",1n c 5ev. --, '-w.ec.., In,r± a... r SQ t' • J CLj 2Q r' c t hA t. ( Words *) BID MAY BE REJECTED IF TOTAL IS NOT SHOWN FOR BOTH FIGURES AN2 WORDS. Payment bond required in this amount - no personal checks will be accepted): 9 a i LLI 9 or,•. Er' 1 r F r. Y ly ylv W CO A Q q .r, W o= i ..d. C/) L o O J c W V X b N rn T t G N AO _ L J N C C CL CK W 9r M v Co OZ a a: 3 C v A O d w Q M LW xW OG O O Y O a3dr0 d c m m 0 0 a V C a V CE 0 U a z O U z Cn Wl!J Z Q z W Z < W wC/) z Z UJ W O rnN F- LU N z 6i a m to 0 O Q K W N 0 N a YSY2 N N J Q 2 Q o0 N U N U w X QZ m0 Q 0. u N QLu LU Z J N r 1x I i yF CO A q .r, W i ..d. L o O X b N T t G N AO _ L J N C C CL co 9r M v Co a a: 3 C v Z U N U wWxW1! n O O YAa3dr0 d c m m 0 0 a C a V Ld O JR, N m a h ayON Rz GJ E LIJ A N ~ N H Z Z ro< 0 y ` E H rn o ` m' m o 00 0 to 0 O Q K W N 0 N a YSY2 N N J Q 2 Q o0 N U N U w X QZ m0 Q 0. u N QLu LU Z J N r 1x I i yF CITY OF _^ LAKE LSINOKE DREAM F.xTRI -ME City of Lake Elsinore Attn: Finance Department 130 South Main Street Lake Elsinore, CA 92530 951) 674 -3124 All American Asphalt VENDOR APPLICATION All American Asphalt Individual Name (if sole proprietor): First Business Address: 400 E. Sixth Street Address Corona _ CA City State Principal Contact for Firm: Edward J. Carlson OFFICE USE ONLY VENDOR NUMBER INPUT DATE 951) 736 -7600 E -Mail r publicworks@allamericanasphalt.com Taxpayer ID # or Social Security # 95- 2595043 MI Last Remittance Address (if different) PO Box 2229 Address 92879 Corona Zip City Title1VicePresident CA 92878 -2229 State Zip Phone: 951) 736 -7600 Type of Entity: Sole Proprietor Corporation Partnership Tax Exempt /Non -profit Government or Trust Is business licensed to do business in the City of Lake Elsinore? Q Yes No City of Lake Elsinore Business License is required if conducting business within the City of Lake Elsinore (LEMC 5.08.010) City Business License # 001333 _ Expiration Date: 1/31/16 Check all that apply: Goods only 0 Goods and Services Legal Services Medical Services Brief description of type of supplies and /or services offered (required): Asphalt Paving, Paving Fabric, Slurry, Concrete Rents /Leases paid to you as agent Other: The undersigend hereby certifies that the above and foregoing information is a full, true, and correct statement ofthe facts. Edward J. Carlson, Vice President I Q 12-8 I Signature Title Date 1. Terms: The City of Lake Elsinore is Net 45 days. 2. The City of Lake Elsinore is not tax exempt. 3. Purchase order required for $2,000.00 or more. 4. W -9 form must be completed to be accepted. 1 DATE (MWDD/YYYY) WSJ /J CERTIFICATE OF LIABILITY INSURANCE 10/ 27/2015 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 be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CA LiL` 0829370 1 -925- 244 -7700 Edgewood Partnern Insurance Centers (EPIC) Inland Empire - Branch ID 145421 P.O. Box 5003 San Ramon, CA 94583 NAME: Certificates Department PONS (925) 244 -7700 f925) 901 -0671 MAILDR g• EPICcertadle icbrokers.com INSURE: S AFFORDING COVE RAGE NAIC0 INSUkrgA: ARCH SPECIALTY INS CO 21199 INSURED All American Asphalt P.O. BOX 2229 Corona. CA 92878 -2229 INSURER B: ZURICH AVER INS CO 16535 INSURER C NATIONAL UNION FIRE INS CO OF PITTS 19445 INSURER D: INSURER E INSURER F: r`nVFRAPF-Q r`9:RTIFI1 ATF MIIMRFR- 45324527 REVISION NUMBER: 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. FNSR TYPE OF INSURANCE POLICY NUMBER I DDIYYY K I IMNVDDNYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY AUTHORIZED REPRESENTATIVE OPP002265807 08/01/15 08/01/16 EACHOCCURRENCE S 1,000, 000 CLAIMS -MADE LX OCCUR PREMISES urrenca 100,000 MED EXP (Any one person) 5 PERSONAL 8 ADV INJURY 1,000, 000 GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 PRODUCTS - COMP/OP AGG 2.000, 000POLICY JECT F1 LOC OTHER: B AUTOMOBILE LIABILITY BAPS57108803 08/01/ 15 08/01/ 16 NGLELIMIT y 2,000,000 BODILY INJURY (Per person) X ANY AUTO BODILY INJURY (Per accident) SALLOWNEDSCHEDULED AUTOS _ AUTOS X HIRED AUTOS X NON -OWNEDAUTOS PROPERTY DAMAGE C UMBRELLA LIAB X OCCUR 8311665655 08/01/ 15 08/01/16 EACH OCCURRENCE 10,000,000 AGGREGATE 10,000, 000XEXCESSLIABCLAIMS -MADE DED I X I RETENTION$ 10,000 Following -Form B WORKERS COMPENSATIONANDEMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE [ OFFICER/MEMBER EXCLUDED? Mandatory In NH) NIA WC593205702 08 /01 / 15 08/ 01/ 16 X STTAA7LITE I ER E. L. EACH ACCIDENT S 1,000,000 EL DISEASE - EA EMPLOYE 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000, 000Ifyeadesmbeunder DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached II more space Is required) Project #Z10002 / RE: FY 15/ 16 Annual Crack Seal is Pothole Repairs Certificate Holder is Additional Insured if Required by Written Contract Excluding Workers Compensation [21 r=cnr!Mi AVM Un1 nco rAN17`01 I ATIlnIJ ACORD 25 (2014101) sleles -ont 45324527 W 1V5t$ -ZU14 AL;VKU Uumrwr•cA I RJrY. AN ngnas rnservva. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Lake Elsinore THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 130 South Main Street AUTHORIZED REPRESENTATIVE Lake Elsinore, CA 92531 I USA ACORD 25 (2014101) sleles -ont 45324527 W 1V5t$ -ZU14 AL;VKU Uumrwr•cA I RJrY. AN ngnas rnservva. The ACORD name and logo are registered marks of ACORD MEMO To: Whom it may concern From: Edgewood Partners Insurance Centers (EPIC) Named Insured: All American Asphalt et al Policy Number(s): GPP0022658 -07, BAP5571088 -03, WC5932057 -02, BE11665655 RE: Notice of Cancellation Should the above described policy be cancelled before the expiration date thereof, we will mail 30 days written notice to the Certificate Holder; except, 10 days notice for non - payment of premium. Sincerely, Account Manager tel: 925.244.7700 3000 executive parkway, suite 325, san ramon, ca 94583 ca license OB29370 epicbrokers.com THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED ENDORSEMENT This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY SELF - INSURED RETENTION COVERAGE FORM SECTION II — WHO 18 AN INSURED is amended to include as an additional insured those persons or organizations who are required under a written contract with you to be named as an additional Insured, but only with respect to liability for "bodily injury, 'property damage', or "personal and advertising injury" caused. In whole or In part, by your acts or omissions or the acts or omissions of your subcontractors: A. In the performance of your ongoing operations or "your work', Including 'your work' that has been completed; or B. In connection with your premises owned by or rented to you. As used in this endorsement, the words 'you' and 'your" refer to the Named Insured. All other terms and conditions of this Policy remain unchanged. Schedule Project City of Lake Elsinore, its elected or appointed officers, officials, Project #Z10002 / RE: FY 15116 Annual Crack Seal employees, agents and volunteers & Pothole Repairs Endorsement Number: This endorsement Is effective on the inception date of this policy unless otherwise stated herein. The Information below Is required only when this endorsement Is Issued subsequent to preparation of the policy.) PollcyNumber GPP0022658 -07 Named Insured: All American Asphalt at al Endorsement Effective gate: August 1, 2015 4063 00 CGL0006 00 05 07 Page t of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OTHER INSURANCE - BROAD FORM, CGL POLICY ENDORSEMENT This endorsement modifies Insurance provided under 11he following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, the following paragaph is added to Condition 4. Other Insurance: Where the Named Insured Is required by a wrltlen contract to provide Insurance that Is primary and non-wntrlbAory, and (lie written cordract so requin g Is executed by the Narned insured bef ©re any "acc»rre)ee" or offense, this Insurance will be prmary. but only If and to the extent required by that written contract All other terms and conditions of this Palley remal n unchanged. Schedule City of Lake Elsinore, its elected or appointed officers, officials, employees, agents and volunteers P roject Project #Z10002 / RE: FY 15116 Annual Crack Seal Pothole Repairs Endorsement Number This endorsement is effective on the inception dais of this policy unless otherwise stated herein. The Information below Is required only when this endorsement Is Issued subsequent to preparatlon of the policy.) Policy Number: GPP0022658 -07 Named Insured: All Amerlcen Asphalt et al Endorsement Effecllve Date August 1, 2015 00 CGL0130 00 09 06 Page 1 of 1 4063 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF SUBROGATION ENDORSEMENT This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY SELF - INSURED RETENTION COVERAGE FORM SCHEDULE Noma of Person or Organization: Where required by written contract. Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDMONS, Condition IL Transfer Of Rights Of Recovery Against Others To Us Is amended by the addition of the following provision: We waive any nght of recovery we may have ,agalnsl the W.rson or organization shown In the SCHEDULE above becrausa of payments we make for Injuiy or darluige arising out of your operations or your work" done under a written contract with that person or organization. All other terms and conditions of this Policy remain unchanged. Schedule Project City of Lake Elsinore, its elected or appointed officers, officials, Project #Z10002 /RE: FY 15/16 Annual Crack Seal employees, agents and volunteers & Pothole Repairs Endorsement Number: This endorsement is effective on the inception date of this policy unless otherwise stated herein. The information below Is required only when this endorsement Is Issued subsequent to preparation of the policy) Policy Number, GPP002265 -07 Named Insured: All Amertcan Asphalt at al Endorsement Effecllve late: August 1, 2015 00 CGL0121 DO 09 06 Includes copyrighted material of Insurance Services Office, Inc„ Page 1 of 1 with Its permission. 4063 POLICYNUMBER BAP5571088 -03 COMMERCIAL AUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modMes Insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modifled by this endorsement. This endorsement IdentMee person(s) or orgenizatlon(s) who are Insureds" under the Who Is An Insured Provision of the Coverage Form. This endorsement does not titer coverage provided In the Coverage Forth. This endorsement chanties the poky effective on the inception date of the poky unless another date Is indicated below. Endorsernent Effective: 8 / 1 / 15 Countersigned By: Authorized Re eseritative Named Insured: All American Asphalt SCHEDULE Name of Persons) or Orgaftdian(s): ANY PERSON OR ORGANIZATION TO WHOM OR WHICH YOU ARE REQUIRED TO PROVIDE ADDITIONAL INSURED STATUS OR ADDITIONAL INSURED STATUS ON A PRIMARY, NON- CONTRIBUTORY BASIS, IN A WRITTEN CONTRACT OR WRITTEN AGREEMENT EXECUTED PRIOR TO LOSS, EXCEPT WHERE SUCH CONTRACT OR AGREEMENT IS PROHIBITED BY LAW. Schedule Project City of Lake Elsinore, its elected or appointed officers, Project #Z10002 / RE: FY 15/16 Annual Crack Seal officials, employees, agents and volunteers & Pothole Repairs If no entry appears above. Infomidlon required to complete this endorsement YAN be shown In the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liabliky Coverage, but only to the extent the person or orgenizeibn qualifies as an 'insured' under the fto is An Insured Provision contained in Section II of the Coverage Form. CA 21148 02 99 Copyright, Insurance Services Offiee, Inc., 1969 Page 1 of 1 O 4063 POLICY NUMBER BAP 5 5 710 8 8— 0 3 COMMERCIAL AUTO CA 04 44 091 O THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies Insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modl- fled by the endorsement. This endorsement changes the policy affective on the Inception date of the policy unless another date Is Indicated below. Namadlroumd: All American Asphalt Endorsement Efbduw tom: 8/1/15 SCHEDULE Nams(s) Of Person(s) Or Orp riftilon(s): ALL PERSONS AND /OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY Information required to complete this Schedule. C not shown above. will be shown In the Declarations. The Transfer Of Rights Of Reoorary Against Others To Us Condition does not apply to the person(s) or organtzation(s) shown In the Schedule, but only to the extent that subrogation is walved prior to the Ise - cldent" or the loss" under a contract with that parson or organization. Schedule City of Lake Elsinore, its elected or appointed officers, officials, employees, agents and volunteers Project Project #Z10002 /RE: FY 15/16 Annual Crack Seal Pothole Repairs 4063 CA 04 44 0310 0 Insurance Servtces Office, Inc., 2009 Page 1 d 1 0 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 04 09 06 Ed. 4aQ WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- CALIFORNIA V* hem 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 eAeent that you perform work under a written contract that requires you to obtain this agreen*nr from us.) You must maintain payroll records accurralsly segregating the remuneration of your employees while engaged In the work described In the Schedule. The addltkmel premlum for this endorsement shall be 0.00 % of the California workers' compensation pre- mium otherwise due on such remuneration. Parson or Orgsnftdon ALL PERSONS AND /OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY FOR WORK PLUORNED BY YOU FOR THAT PERSON AND /OR ORGANISATION Schedule Job Deaxiptlon ALL CA OPERATION City of Lake Elsinore, its elected or appointed officers, officials, employees, agents and volunteers All American Asphalt Policy #WC5932057 -02 8/1/15 wC 252 (4$4) WC 04 03 06 (Ed. 4.64) Project #Z10002 /RE: FY 15/16 Annual Crack Seal & Pothole Repairs Zurich American Ins. Co. Page 1 or 1 4063 Form w'9 Request for Taxpayer Give Form to the Rev. December 2 Identification Number and Certification requester. Do not send to the IRS. re s7.14=1. fre TreasuryService 1 Name (as shown on your income tax return). Name Is required on this line; do not leave this line blank. All American Asphalt r`i 2 Business nameldlsregarded entity name, If different from above drn 4 Exemptions (codes apply only toc3Checkappropriateboxforfederaltaxclassification; check only one of the following seven boxes: certain entitles, not Individuals; see G Indivlduallsole proprietor or C Corporation S Corporation Partnership Trust/estate Instructions on page 3): single - member LLC Exempt payee code (If any) Limited liability company. Enter the tax classification (C =C corporation, S =S corporation, P= partnership) iS Note. For a single- member LLC that Is disregarded, do not check LLC; check the appropriate box In the line above for Exemption from FATCA reporting the tax classification of the single - member owner. code (if any) Other (sea inslruClfons) pppa to. —ft m.FrrrnW ouha• fe. U.S.) 5 Address (number, street, and apt. or suite no.) Requester's name and address (optional) PO Box 2229 City of Lake Elsinore a City, state, and ZIP rode 130 South Main Street Corona, CA 92878 -2229 Lake Elsinore CA 92530 7 List account number(s) here (optlonaf) Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number backup withholding. For individuals, this Is generally your social security number ( However, for e disregarded the Part I instructions on 3. For otherpageresidentalien, sole proprietor, or entity, see page titles It is our em to er identification number (EIN) If you do not have a number see How to get aenIypy TIN on page 3. or Note. If the account is In more than one name, see the instructions for line 1 and the chart on page 4 for _Employer identification number guidelines on whose number to enter. 9 5- 2 5 9 5 0 4 3 Ill:Frallill Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends. or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3. Sign Signature of Here I U.S. person Date 10 ke, - General Instructions mt(h "i 1 [;I$ ka5, <_e(- `e t Section references are to the Internal Revenue Code unless otherwise noted. Future developments Information about developments affecting Form W -9 (such as legislation onacU d after we release it) is at www.irs.govlfw9. Purpose of Form An Individual or entity (Form W -9 requester) who Is required to file an Information return with the IRS must obtain your correct taxpayer idenllficatlon number (TIN) which may be your social security number (SSN), IMNIdual taxpayer Identification number (ITIN), adoption taxpayer Identlftcation number (ATIN), or employer Identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an Information return, Examples of Information retwma mclude, but are not limited to, the following: Form 1099 -INT (interest earned or paid) Form 1099 -DIV (dividends, including those from stocks or mutual funds) Form 1099 -MISC (various types of income, prizes, awards, or gross proceeds) Form 1099 -8 (stock or mutual fund sales and certain other transactions by brokers) Form 1099 -S (proceeds from real estate transactions) Form 1099 -K (merchant card and third party network transactions) Form 1098 (home mortgage interest), 1098 -E (student loan Interest), 1098 -T tuition) Form 1099 -C (canceled debt) Form 1099 -A (acquisition or abandonment of secured property) Use Form W -9 only if you are a U.S. person (Including a resident alien), to provide your correct TIN. If you do nor relurn Form W -9 to the requester with a TIN, you might be subject to backup, vithholding. Sea What is backup wlrhholding? on page 2. By signing the filled -out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from 'backup withholding If you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership Income from a U.S. trade or business Is not subject to the withholding tax on foreign partners' share of offecilvely connected Income, and 4. Certify that FATCA code(s) entered on this form Of any) indicating that you are exempt from the FATCA reporting, Is correct. See What is FATCA raporftng? on page 2 for further information. Cat. No 10231X Form W -9 (Rev. 12 -2014) Page 1 City of Lake Elsinore NPG. Inc July 1, 2017 AMENDMENT NO.2 TO AGREEMENT FOR CONTRACTOR SERVICES (ON-CALL) NPG, Inc. FY 17/18 Annual Crack Seal & pothole Repairs, Project No. Z10002 This Amendment No. 2 to Agreement for Contractor Services (On-Call) ("Amendment No.2")is made and entered into as of July 1, 2017 by and between the City of Lake Elsinore, a municipal corporation ("City), and All American Asphalt ("Contractor"). RECITALS A.The City and Contractor have entered into that certain Agreement for Contractor Services dated as of October 13, 2015 (the "Original Agreement''). Except as otherwise defined herein, all capitalized terms used herein shall have the meanings set forth for such terms inthe OriginalAgreement. B.The Original Agreement provided for compensation to Contractor in an amount not to exceed Fifty-Five Thousand dollars ($55,000). C.The term of the Original Agreement was for eight (8) months and allows the City to extend the term on an annual basis, for a total of two (2) years. D.Amendment No. 1 dated July 1, 2016, extended the contract a further 12- months through FY 2016/17. E.The parties now desire to extend the term for such services as set forth in this Amendment No 2. NOW, THEREFORE, in consideration of the mutual covenants and conditions set forth herein, City and Contractor agree as follows: 1.Section 2, c. Term and Compliance with Task/Work Order System. of the Original Agreement is hereby amended to add the following: Unless earlier terminated as provided elsewhere in the Original Agreement., this Amendment No. 2 shall continue infull force and effect until June 30, 2018. Except for the changes specifically set forth herein, all other terms and conditions of the OriginalAgreement shall remain in full force and effect. Page 2 City of Lake Elsinore NPG. Inc July 1, 2017 INWITNESS WHEREOF, the parties have caused this Amendment No. 2 to be executed on the respective dates set forth below. “CITY” CITY OF LAKE ELSINORE, a municipal corporation Grant Yates, City Manager Date: ATTEST: City Clerk APPROVED AS TO FORM: City Attorney “CONTRACTOR” NPG, Inc., a California corporation Date: Attachment: Amendment No. 1 – 07.01.2016 Original Agreement – 10.13.2015 CITY OF LADE LSIf10R E DREAM EXTREME August 29, 2016 NPG, Inc. Attn: Mimi Stone, Public Works Admin. 1354 Jet Way Perris, CA 92571 RE: ON -CALL CONTRACTOR SERVICES AGREEMENT AMENDMENT NO. 1 Dear Ms. Stone: Enclosed for your files, please find your fully executed copy of the On -Call Contractor Services Agreement Amendment No. 1 for the Fiscal Year 2016 -2017 Annual Crack Seal & Pothole Repairs, Project No. Z10002. Please do not hesitate to give this office a call, should you have any questions. Sincerely, Susan M. Domen, MMC City Clerk Enclosure 951.674.3124 130 S. MAIN STREET LAKE ELSINORE, CA 92530 WWW.LAKE- ELSINORE ORG AMENDMENT NO. 1 TO AGREEMENT FOR CONTRACTOR SERVICES (ON -CALL) NPG, Inc. FY 16117 Annual Crack Seal & Pothole Repairs, Project No. Z10002 This Amendment No. 1 to Agreement for Contractor Services (On -Call) ( "Amendment No. 1 ") is made and entered into as of July 1, 2016 by and between the City of Lake Elsinore, a municipal corporation ( "City), and NPG, Inc., a California corporation ( "Contractor"). RECITALS A. The City and Contractor have entered into that certain Agreement for Contractor Services dated as of October 13, 2015 (the "Original Agreement"). Except as otherwise defined herein, all capitalized terms used herein shall have the meanings set forth for such terms in the Original Agreement. B. The Original Agreement provided for compensation to Contractor in an amount not to exceed Fifty -Five Thousand dollars ($55,000). C. The term of the Original Agreement was for eight (8) months and allows the City to extend the term on an annual basis, for a total of two (2) years. D. The parties now desire to extend the term for such services as set forth in this Amendment No 1. NOW, THEREFORE, in consideration of the mutual covenants and conditions set forth herein, City and Contractor agree as follows: 1. Section 2, Time of Performance, of the Original Agreement is hereby amended to add the following: Unless earlier terminated as provided elsewhere in the Original Agreement, this Amendment No. 1 shall continue in full force and effect until June 30, 2017. The City may, at its sole discretion, extend the term of this Agreement on an annual basis not to exceed one (1) additional renewal term, such notice to be exercised by the City Manager. 2. Except for the changes specifically set forth herein, all other terms and conditions of the Original Agreement shall remain in full force and effect. IN WITNESS WHEREOF, the parties have caused this Amendment No. 1 to be executed on the respective dates set forth below. CITY" CITY OF LAKE ELSINORE, a municipal rnia corporation corporation Grant Yate City Manager L7:]ts i Wit ATTEST: erk Attachments: Exhibit B - Original Agreement er q'inliu EXHIBIT A CITY OF LAKE ELSINORE PROJECT NO. Z10002 FY 15116 ANNUAL CRACK SEAL & POTHOLE REPAIRS PROPOSER: NPG, Inc. Contractor Name) PROPOSAL ITEMS AS FOLLOWS: ITEM DESCRIPTION OF ITEMS ESTIMATED UNIT PRICE 1 TOTAL COST NO. QUANTITY FIGURES) FIGURES) 1 Remove and Replace 3 inches (maximum) 5,000 SF 3.75 18,750.0 sections 2 1 % Inch edge mill 10,000 SF 0.76 7,600.00 3 Install 1 Inch AC leveling course 335 TO 165.00 55,275.0 4 Install 1 % Inch AC Hot Mix Asphalt Overlay 500 TON 160.00 80,000.0 TOTAL FOR ITEMS Based on estimated quantities of Items 1 through 4 161,625.00 SCHEDULE A Total Bid: SCHEDULE A Total Bid: 161,625.00 Figures*) One hundred sixty one thousand six hundred twenty five dollars and zero Words *) BID MAY BE REJECTED IF TOTAL IS NOT SHOWN FOR BOTH FIGURES AND WORDS. Payment bond required in this amount — no personal checks will be accepted): U11 CONTRACTORS STATE LICENSE BOARD `' " M. Contractor's License Detail for License # 664779 DISCLAIMER: A license status check provides information taken from the CSLB license database. Before relying on this information, you should be aware of the following limitations. CSLB complaint disclosure is restricted by law (B &P 7124.6) If this entity is subject to public complaint disclosure, a link for complaint disclosure will appear below. Click on the link or button to obtain complaint and /or legal action information. Per B &P 7071.17 , only construction related civil judgments reported to the CSLB are disclosed. Arbitrations are not listed unless the contractor fails to comply with the terms of the arbitration. Due to workload, there may be relevant information that has not yet been entered onto the Board's license database. Business Information NPG INC P O BOX 1515 PERRIS, CA 92572 Business Phone Number:(951) 940 -0200 This license is current and active. All information below should be reviewed. C12 - EARTHWORK AND PAVING B -GENERAL BUILDING CONTRACTOR A - GENERAL ENGINEERING CONTRACTOR Entity Corporation Issue Date 02/17/1993 Expire Date 02/28/2017 License Status Data current as of 8/17/2016 2:32:29 PM Classifications Bonding Information) Contractor's Bond This license filed a Contractor's Bond with AMERICAN CONTRACTORS INDEMNITY COMPANY. Bond Number: 151812 Bond Amount: $15,000 Effective Date: 01/01/2016 Contractor's Bond History Bond of Qualifying Individual The qualifying individual JEFFREY SCOTT NELSON certified that he /she owns 10 percent or more of the voting stock /membership interest of this company; therefore, the Bond of Qualifying Individual is not required. iEffective Date: 08/19/1997 IBQI's Bond History Workers' Compensation This license has workers compensation insurance with the INSURANCE COMPANY OF THE WEST Policy Number:WVE5028828 Effective Date: 01/01/2015 Expire Date: 01/01/2017 orkers' Comp(,msatjon Histoi y n +Mer OP ID: DB CERTIFICATE OF LIABILITY INSURANCE DATE ( THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER _ H°'EA °T John Sheffield Crosby Insurance, Inc PHONE 714- 221 -5255 aiC.N.,. 714 - 221 -5210 8181 E. Kaiser Blvd _iA1G,,h4. Eut): _{ Anaheim Hills, CA 92808 EMAIL ksheffield crosbyinsurance.comADDRES$; John Sheffield PRODUCERe "MTmuvrr w,,NPGCO -J INSURED NPG, Inc. aka: Nelson Paving Grading, Goldstar Asphalt Products P.O. Box 1515 Perris, CA 92572 COVERAGES CERTIFICATE NUMBER: INSURER (S)AFFORDIN.G COVERAGE NAIC # INSUSERA:lronshore S eclalty Ins Co INSURER s: General Ins Co of America INSURER c: Liberty Ins Underwriters INSUReRD,ICW Group INSURER E: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THt F'ULIC:Y rtKIUu 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. INSR – – FiOdL;SUBFt POLICY EFF LSR TYPE OF INSURANCE POLICYNUMBER f IYYYY POLICY XP L1AlIT3YYY Lake Elsinore, CA 92530' I GENERAL LIABILITY EACH OCCURRENCE 11000, A X COMMERCIAL GENERAL LIABILITY AGS0058702 11115/2015 11115/2016 PREMl =Urrsnce SO,O )0 CLAIMS -MADE 1_2X J OCCUR MED EXP (Anyone porsomi 5,0 PERSONAL & ADV INJURY 1,000,00 GENERAL AGGREGATE 2,000,00 HGEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG 2,000,00 POLICY [_X_1 PRRO- LOC _ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,00Eaaccident) B X ANY AUTO 24 -CC- 206754 -9 11/15/2015 11/1512016 BODILY INJURY (Per person) ALL OWNED AUTOS INCL PHYSICAL DAMAGE BODILY INJURY (Per accident) SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS PER ACCIDENT) Comprehensive 1,000 de X NON -OWNED AUTOS Hired Phys Dam 50;000 MAXIMUM LIMIT 1,000 de X Collision UMBRELLA LIAB OCCUR EACH OCCURRENCE 5,000,000 X EXCESS LABLAB CLAIMS -MADE 100002437206 11/15/2015 11/15/20166 AGGREGATE 5,000,00 DEDUCTIBLE RETENTION $ WORKERS COMPENSATION OT _ X AND EMPLOYERS' LIABILITY D ANY PROPRIETOR /PARTNER /EXECUTIVE Y / N WVE5028828 01 01/01/2016 M ERTaRYLATU% 01/ 01/2017 E.L. EACH ACCIDENT 1,000,000 OFFICER /MEMBER EXCLUDED? NIA Mandatory In NH) LL_ DISEASE - EA EMPLOY 0()0,0001000,0001, y describe under DCSC:RIPTION OF OPERATIONS below E. L.d15EASE - POLICY LIMIT 1,000,000 B EQUIPMENT RENTED 24- CC316773 -10 11/1512015 1111512016 Limit 500,000 FROM OTHERS I J 1 Ded 1,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) If cancelled for non - payment of premium, only 10 days notice will be given. SEE ATTACHED nRY.^. T°1 r /ITIPII t IV 1Y86 -f VUV AlilR[N r.Vr%r -WF MI Ivly. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD CITYLEL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Lake Elsinore THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: City Manager AUTHORIZED REPRESENTATIVE130S. Main Street Lake Elsinore, CA 92530' I IV 1Y86 -f VUV AlilR[N r.Vr%r -WF MI Ivly. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD NOTEPAD: HOLDER CODE CITYLEL NPGCO -J INSURED'SNAME NPG, Inc. aka: Nelson Paving OP ID: DB City, its elected or appointed officers, officials, employees, agents volunteers is named Additional Insured as respects General Liability Auto Liability only as per attached endorsements. eral Liability is Primary and Non - Contributing only as per attached orsements. ver of Subro ation applies to General Liability, Auto Liability and lovers Liability only as per attached endorsements. oral Liability losses are subject to a deductible of $5,000 ject: NPG Job 15649 - City of Lake Elsinore, Project #Z10002, FY 15 -16 ual Crack Seal & Pothole Repairs (on -call) PAGE 2 Date 12/31/2015 POLICY NUMBER: AGS0058702 COMMERCIAL GENERAL LIABILITY CG 2010.0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location (s) Of Covered Operations As required by written contract. If required by your Any Location written contract or written agreement with such Additional Insured, this insurance is primary and non - contributory. If anyone, other than the Additional Insured, provides similar insurance for the Additional Insured, then this insurance will apply as outlined in SECTION IV — COMMERICAL LIABILITY CONDITIONS, paragraph 4. Other Insurance, subparagraph c. Method of Sharing. The inclusion of one or more Insured(s) under the terms of this endorsement does not increase our limits of liability. All other terms and conditions remain unchanged Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who IS An Insured is amended to 2. If coverage provided to the additional Insured Is include as an additional insured the person(s) or required by a contract or agreement, the organization(s) shown in the Schedule, but only insurance afforded to such additional insured with respect to liability for "bodily injury", "property will not be broader than that which you are damage" or "personal and advertising injury" required by the contract or agreement to caused, in whole or in part, by: provide for such additional insured. 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 CG 2010 0413 © Insurance Services Office, Inc., 2012 Page 1 of 2 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. 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 Ilf— 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. Page 2 of 2 0 Insurance Services Office, Inc., 2012 CG 2010 0413 POLICY NUMBER: AGS0058702 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations As required by written contract. If required by your The insurance afforded by this policy for the benefit of written contract :or written agreement with such the additional insured does not apply to Additional Insured, this insurance is primary and property damage' to any building, structure or non- contributory. appurtenant structure intended to be occupied as a 'private residence'. The term "private residence" If anyone, other than the Additional Insured, provides includes single family homes or residences, similar insurance for the Additional Insured, then this multi - family homes or residences Apartments are not insurance will apply as outlined in SECTION IV — considered "private residences " COMMERICAL LIABILITY CONDITIONS, paragraph 4. Other Insurance, subparagraph c. Method of Sharing. The inclusion of one or more Insured(s) under the terms of this endorsement does not increase our limits of liability All other terms and conditions remain unchanged Information required to complete this Schedule, if not shown above will be shown in the Declarations. A. 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 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. CG 20 37 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 2 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: 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: Page 2 of 2 0 ISO Properties: 2004 CG 20 37 04 13 POLICY NUMBER: AGS0058702 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided underthe following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: As Required by Written Contract Information required to complete the Schedule, if not shown above, will be shown in the Declarations. J The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the products- completed operations hazard ". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 C Insurance Services Office, Inc., 2008 Page 1 of 1 13 Policy No 24-CC- 206754 -9 COMMERCIAL AUTO CA 71 10 03 07 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AUTO PLUS ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement, EXTENDED CANCELLATION CONDITION Paragraph 2.b, of the CANCELLATION Common Policy Condition is replaced by the following: b. 60 days before the effective date of cancellation if we cancel for any other reason. TEMPORARY SUBSTITUTE AUTO — PHYSICAL DAMAGE COVERAGE Under paragraph C. — CERTAIN TRAILERS, MO- BILE EQUIPMENT AND TEMPORARY SUBSTITUTE AUTOS of SECTION 1 — COVERED AUTOS, the following is added: If Physical Damage coverage is provided by this Cov- erage Form, then you have coverage for: Any "auto" you do not own while used with the per- mission of its owner as a temporary substitute for a covered "auto" you own that is out of service be- cause of its breakdown, repair, servicing, "loss" or destruction. BROAD FORM NAMED INSURED SECTION II — LIABILITY COVERAGE — A.1. WHO IS AN INSURED provision is amended by the addition of the following: d. Any business entity newly acquired or formed by you during the policy period provided you own 50% ur rnure of the business entity and the business entity is not separately insured for Business Auto Coverage. Coverage is extended up to a maximum of 180 days following acquisi- tion or formation of the business entity. Coverage under this provision is afforded only until the end of the policy period. BLANKET ADDITIONAL INSURED SECTION II — LIABILITY COVERAGE — A.1. WHO IS AN INSURED provision is amended by the addition of the following: e. Any person or organization for whom you are re- quired by an "Insured contract" to provide insur- ance is an "insured ", subject to the following additional provisions: 1) The "insured contract" must be in effect during the policy period shown in the Decla- rations, and must have been executed prior to the "bodily injury" or "property damage ". 2) This person or organization is an 'ensured" only to the extent you are liable due to your ongoing operations for that insured, whether the work is performed by you or for you, and only to the extent you are held liable for an accident" occurring while a covered "auto" is being driven by you or one of your em- ployees. 3) There is no coverage provided to this person or organization for "bodily injury" to its em- ployees, nor for "property damage" to its property. 4) Coverage for this person or organization shall be limited to the extent of ynur negli• gence or fault according to the applicable principles of comparative negligence or fault. 5) The defense of any claim or "suit" must be tendered by this person or organization as soon as practicable to all other insurers which potentially provide insurance for such claim or "suit". Includes copyrighted material of Insurance Services Office, Inc., with its permission. Copyright, Insurance Services Office, Inc., 1997 Saleco and the SNIP..^.0 kq3 are reglslared trademarks at Saleco Corporallon CA 71 10 W 07 Page 1 of 6 EP 6) The coverage provided will not exceed the lesser of: a) The coverage and /or limits of this policy; or b) The coverage and /or limits required by the "insured contract ". 7) A person's or organization's status as an insured" under this subparagraph d ends when your operallons for that "insured" are completed. EMPLOYEE AS INSURED Under Paragraph A. of Section II — LIABILITY COV- ERAGE item f. is added as follows: Your "employee" while using his owned "auto ", or an auto" owned by a member of his or her household, in your business or your personal affairs, provided you do not own, hire or borrow that "auto ". This coverage is excess to any other collectible insurance coverage. FELLOW EMPLOYEE COVERAGE Exclusion 5. FELLOW EMPLOYEE of SECTION II -- LIABILITY COVERAGE — B. EXCLUSIONS is amended by the, addition of the following; However, this exclusion does not apply if the "bodily injury" results from the use of a covered "auto" you own or hire, and provided that any coverage under this provision only applies in excess over any other collectible insurance. BLANKET WAIVER OF SUBROGATION We waive the right of recovery we may have for pay- ments made for "bodily injury" or "property damage" on behalf of the persons or organizations added as Insureds" under Section II — LIABILITY COVERAGE A.1,D. BROAD FORM NAMED INSURED and A,1.e. BLANKET ADDITIONAL INSURED. PHYSICAL DAMAGE — ADDITIONAL TRANS- PORTATION EXPENSE COVERAGE The first sentence of paragraph A.4. of SECTION III PHYSICAL DAMAGE COVERAGE is amended as follows: We will pay up to $50 per day to a maximum of 1,500 for temporary transportation expense incurred by you because of the total theft of a covered "auto" of the private passenger type. PERSONAL EFFECTS COVERAGE A, SECTION III — PHYSICAL DAMAGE COVER- AGE, A.4. COVERAGE EXTENSIONS, is amended by adding the following: c. Personal Effects Coverage For any Owned "auto" that is involved in a covered "toss ", we will pay up to $500 for personal effects" that are lost or damaged as a result of the covered "loss ", without applying :a deductible. EXTRA EXPENSE -- BROADENED COVERAGE Paragraph A. -- COVERAGE of SECTION III — PHYSICAL DAMAGE COVERAGE is amended to add: 5. We will pay for the expense of returning a stolen covered "auto" to you. AIRBAG COVERAGE Under paragraph B. — EXCLUSIONS of SECTION III PHYSICAL DAMAGE COVERAGE, the following is added: The exclusion relating to mechanical breakdown does not apply to the accidental discharge of an airbag. NEW VEHICLE REPLACEMENT COST Under Paragraph C — LIMIT OF INSURANCE of Section III — PHYSICAL DAMAGE COVERAGE sec- tion 2 is amended as follows: 2. An adjustment for depreciation and physical con- dition will be made in determining actual cash value in the event of a total loss. However, in the event of a total loss to your "new vehicle" to which this coverage applies, as shown in the declarations, we will pay at your option: a. The verifiable `new vehicle" purchase price you paid for your darnaged vehicle, not In- cluding any insurance or warranties pur- chased; Page 2 of 6 U. The purchase price, as negotiated by us, of a new vehicle of the same make, model and equipment, not including any furnishings, parts or equipment not installed by the manufacturer or manufacturer's dealership. If the same model is not available pay the purchase price of the most similar model available; c. The market value of your damaged vehicle, not including any furnishings, parts or equip- ment not installed by the manufacturer or manufacturer's dealership. This coverage applies only to a covered "auto" of the private passenger, light truck or medium truck type (20;000 Ibs or less gross vehicle weight) and does not apply to initiation or set up costs associated with loans or leases, TWO OR MORE DEDUCTIBLES Under SECTION III — PHYSICAL DAMAGE COV- ERAGE, if two or more "company" policies or cover- age forms apply to the same accident, the following applies to paragraph D. Deductible: a. If the applicable Business Auto deduct- ible is the smaller (or smallest) deduct- ible it will be waived; or b. If the applicable Business Auto deduct- ible is not the smaller (or smallest) de- ductible it will be reduced by the amount of the smaller (or smallest) deductible; or c. If the loss involves two or more Busi- ness Auto coverage forms or policies the smaller (or smallest) deductible will be waived. For the purpose of this endorsement company" means: a. Safeco Insurance Company of America b. American States Insurance Company c. General Insurance Company of America d. American Economy Insurance Company e. First National Insurance Company of America f. American States Insurance Company of Texas g. American States Preferred Insurance Company h. Safeco Insurance Company of Illinois LOAN/LEASE GAP COVERAGE Under paragraph C — LIMIT OF INSURANCE of SECTION III — PHYSICAL DAMAGE COVERAGE, the following is added: a. Actual cash value of the damaged or stolen property as of the time of the "loss ", less an adjustment for depreciation and physical condition; or b. Balance due under the terms of the loan or lease that the damaged covered "auto" is subject to at the time of the "loss ", less any one or all of the following adjustments: 1) Overdue payment and financial penalties associated with those payments as of the date of the loss ". 2) Financial penalties imposed under a. lease due to high mileage, exces- sive use or abnormal wear and tear. 3) Costs for extended warranties, Cre- dit Life Insurance, Health, Accident or Disability Insurance purchased with the loan or lease. 4) Transfer or rollover balances from previous loans or leases. 5) Final payment due under a "Balloon Loan ". 6) The dollar amount of any un- repaired damage that occurred prior to the "total loss" of a covered auto ". 7) Security deposits not refunded by a lessor. 8) All refunds payable or paid to you as a result of the early termination of a lease agreement or any war- ranty or extended service agree- ment on a covered "auto ". 9) Any amount representing taxes, 10) Loan or lease termination fees GLASS REPAIR — WAIVER OF DEDUCTIBLE Under paragraph D. — DEDUCTIBLE of SECTION III PHYSICAL DAMAGE COVERAGE, the following is added: No deductible applies to glass damage if the glass is repaired rather than replaced. AMENDED DUTIES IN THE EVENT OF ACCII. DENT, CLAIM, SUIT OR LOSS 4. The most we will pay for a total "loss" in any one The requirement in LOSS CONDITION 2.a. — accident" is the greater of the following, subject DUTIES IN THE EVENT OF ACCIDENT, CLAIM, to a $1,500 maximum limit: SUIT OR LOSS — of SECTION IV — BUSINESS AUTO CONDITIONS that you must notify us of an CA 71 10 03 07 Page 3 of 6 EP accident" applies only when the "accident" is known to: 1) You, if you are an individual; 2) A partner, if you are a partnership; or 3) An executive officer or insurance manager, if you are a corporation. UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS SECTION IV — BUSINESS AUTO CONDITIONS --- B.2. is amended by the addition of the following: If you unintentionally tail to disclose any hazards ex- isting at the Inception date of your policy, we will not deny coverage under this Coverage Form because of such failure. However, this provision does not affect our right to collect additional premium or exercise our right of cancellation or non - renewal. HIRED AUTO — LIMITED WORLD WIDE COVER- AGE Under Section IV — Business Conditions, Paragraph 13.7.b.e(1) is replaced by the following: 1) The "accident" or "loss" results from the use of an "auto" hired for 30 days or less. RESULTANT MENTAL ANGUISH COVERAGE SECTION V — DEFINITIONS — C. is replaced by the following: Bodily injury" means bodily injury, sickness or dis- ease sustained by a person including mental anguish or death resulting from any of these. HIRED AUTO PHYSICAL DAMAGE COVERAGE If hired "autos" are covered "autos" for Liability cov- erage and if Comprehensive, Specified Causes of Loss or Collision coverages are provided under this Coverage Form for any "auto" you own, then the Physical Damage Coverages provided are extended to "autos" you hire or borrow. The most we will pay for loss to any hired "auto" is S50,000 or Actual Cash Value or Cost of Repair, whichever is smallest, minus a deductible. The de- ductible will be equal to the largest deductible appli- cable to any owned °auto" of the private passenger or light truck type for that coverage. Hired Auto Phy- sical Damage coverage is excess over any other col- lectible insurance. Subject to the above limit, deductible and excess provisions, we will provide coverage equal to the broadest coverage applicable to any covered "auto" you own. HIRED AUTO PHYSICAL DAMAGE COVERAGE — LOSS OF USE SECTION III — PHYSICAL DAMAGE AA.b. Form does not apply. Subject to a maximum of $1;000 per accident, we will cover loss of use of a hired "auto" if it results from an accident, you are legally liable and the lessor in- curs an actual financial loss. RENTAL REIMBURSEMENT COVERAGE A. We will pay for rental reimbursement expenses incurred by you for the rental of an "auto" be- cause of a covered "loss" to a covered "auto ". Payment applies in addition to the otherwise ap- plicable amount of each coverage you have on a covered "auto ". No deductibles apply to this coverage. B. We will pay only for those expenses incurred during the policy period beginning 24 hours after the "loss" and ending, regardless of the policy's expiration, with the lesser of the following number of days; 1. 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. 2. 30 days. C. Our payment is limited to the lesser of the fol- lowing amounts: 1. Necessary and actual expenses incurred. 2. $50 per day. D. This coverage does not apply while there are spare or reserve "autos" availableto you for your operations. E. If 'loss" results from the total theft of a covered auto" of the private passenger type, we will pay under this coverage only that amount of your rental reimbursement expenses which is not al- ready provided for under the PHYSICAL DAM- AGE COVERAGE Coverage Extension. F. The Rental Reimbursement Coverage described above does not apply to a covered "auto" that is described or designated as a covered "auto" on Page 4 of 6 Rental Reimbursement Coverage Form CA 99 23. AUDIO, VISUAL AND DATA ELECTRONIC EQUIPMENT COVERAGE A. Coverage 1. We will pay with respect to a covered "auto" for losW' to any electronic equipment that receives or transmits audio, visual or data signals and that is not designed solely for the reproduction of sound. This coverage applies only if the equipment is permanently installed in the covered "auto" at the time of the loss" or the equipment is removable from a housing unit which is permanently installed in the covered "auto" at the time of the loss ", and such equipment is designed to be solely operated by use of the power from the "autos" electrical system, in or upon the covered "auto ". 2. We wilt pay with respect to a covered "auto" for "loss" to any accessories used with the electronic equipment described in paragraph A.1. above. However, this does not include tapes, records or discs. 3. If Audio, Visual and Data Electronic Equip- ment Coverage form CA 99 60 or CA 99 94 is attached to this policy, then the Audio, Vi- sual and Data Electronic Equipment Cover- age described above does not apply. B. Exclusions The exclusions that apply to PHYSICAL DAM- AGE COVERAGE, except for the exclusion relat- ing to Audio, Visual and Data Electronic Equipment, also apply to this coverage. In addi- tion, the following exclusions apply: We will not pay for either any electronic equip- ment or accessories used with such electronic equipment that is: 1. Necessary for the normal operation of the covered "auto" for the monitoring of the covered "auto'S" operating system; or 2. Both: a. an integral part of the same unit housing any sound reproducing equipment de- signed solely for the reproduction of sound if the sound reproducing equipment is permanently installed in the covered "auto ": and b. permanently installed in the opening of the dash or console normally used by the manufacturer for the installation of a radio. C. Limit of Insurance With respect to this coverage, the LIMIT OF IN- SURANCE provision of PHYSICAL DAMAGE COVERAGE is replaced by the following; 1. The most we will pay for "loss" to audio, vi- sual or data electronic equipment and any accessories used with this equipment as a result of any one "accident" is the lesser of: a. The actual cash value of the damaged or stolen property as of the time of the loss "; or b. The cost of repairing or replacing the damaged or stolen property with other property of like kind and quality, c. $1,000. 2. An adjustment for depreciation and physical condition will be made in determining actual cash value at the time of the 'loss ". 3. If a repair or replacement results in better than like kind or quality, we will not pay for the amount of the betterment. D. Deductible 1. If "loss" to the audio, visual or data elec- tronic equipment or accessories used with this equipment is the result of a 'loss" to the covered "auto" under the Business Auto Coverage Form's Comprehensive or Colli- sion Coverage, then for each covered "auto" our obligation to pay for, repair, return or re- place damaged or stolen property will be re- duced by the applicable deductible shown in the Declarations. Any Comprehensive Cov- erage deductible shown in the Declarations does not apply to "loss" to audio, visual or data electronic equipment caused by fire or Lightning. 2. If "loss" to the audio, visual or data elec- tronic equipment or accessories used with this equipment is the result of a "loss" to the covered "auto" under the Business Auto Coverage Form's Specified Causes of Loss Coverage, then for each covered "auto" our obligalion to pay for, repair, return or replace tjdrii. +;erl or stolen property will be reduced by a $100 deductible. 3. If "loss" occurs solely to the audio, visual or data electronic equipment or accessories used with this equipment, then for each cov- ered "auto" our obligation to pay for, repair, CA 71 10 03 07 Page 5 01 6 EP return or replace damaged or stolen property SECTION V — DEFINITIONS Is amended by adding will be reduced by a $'100 deductible. the following.- 4. In the event that there :ls more than one ap- Q, "personal effects" means your tangible plicable deductible, only the highest deduct- property that is worn or carried by you, ex- ible will apply. In no event will more than one cept for tools, jewelry, money. or securities. deductible apply, R. "New vehicle" means any "auto" of which you are the original owner and trio "auto" has not been previously titled and is less than 365 days past the purchase elate. Page 6 of 6 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY 'WC 99 06 34 Ed. 8 -00) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - BLANKET 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 .ar• 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). The additional premium for this endorsement shall be otherwise due. Person or Organization ANY PERSON OR ORGANIZATION WHEN REQUIRED BY WRITTEN CONTRACT 3 % of the total California Workers' Compensation premium Schedule Jodi Description ALL CALIFORNIA. OPERATIONS This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. The Inforrrratlon below Is reyulred only when this endorsement Is Issued subsequerd to preparation of Me policy.) Endorsement Effective 01/01/2016 Policy No. WFE 5028828 01 EndorseiTrent Igo. Insured NPO INC Premium $ INCL . Insurance Company INSURANCE COMPANY OF THE WEST Countersigned By_ W WC 99 06 34 Ed. 8.00) INSURED