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2016/09/12 L.C. Paving & Sealing, Inc. Certificate of Liability InsuranceAC40 CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDDIYYYY) �� 8/30/2017 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 CONTACT NAME: JANA CLARK HARTLEY CYLKE PACIFIC-#0574253 PHONE tAICo E:t): (619) 295-5155 No): (619) 291-0912 INSURANCE SERVICES, INC. E-MAIL ADDRESS: 2747 UNIVERSITY AVENUE INSURER(S) AFFORDING COVERAGE NAIC0 SAN DIEGO CA 92104-4068 INSUR_ERA:_JAMES RIVER INSURANCE COMPANY 12203 INSURED INSURER B -Nationwide Insurance CO. 23787 L.C. Paving 6 Sealing, Inc. INSURERC:TOPA INSURANCE COMPANY 18031 330 Rancheros Dr, #208 INSURERDMDWEST EMPLOYERS CASUALTY CO, 23612 INSURER E : San Marcos CA 92069 I INSURER F : COVERAGES CFRTIFICATF NI IMRFR-CL1722245233 RFVlglnPd NI IMRFR- 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. INSR ADDGSUBR. - POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMIDD YYY MMIDDM% I LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE ., $ 1,000,000 DAMAGE -To E RENTED A CLAIMS -MADE X OCCUR - - PREMISESS ( (Ea occurrence) , $ 50,000 X Y 000760470 2/18/2017 2/18/2018 MEDEXP(Anyone person) S 5,000 PERSONAL BADVINJURY !$ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 X i POLICY ! EC LOC PRODUCTS - COMPIOP AGG :. $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LI $ 1,000,000 (Ea accident) - -- B X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED ACP7883877894 ;AUTOS AUTOS 2/iB/2017 2/18/2018 BODILY INJURY (Per accident) $ NON -OWNED C� DED: $250 HIRED AUTOS AUTOS PROPERTY DAMAGE $ (Per —idern) COLL DED: $500 I Medical payments $ 5,000 UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 4,000,000 C X ' EXCESS UAB CLAIMS -MADE AGGREGATE $ 4,000,000 .DED ' RETENTION XL660837201 2/18/2017 2/18/2018 ♦$ WORKERS COMPENSATION X OTH- AND EMPLOYERS' LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE - NIA EI EACH ACCIDENT $ 1,000,000 - D OFFICER/MEMBER EXCLUDED? BNUWC0138038 9/12/2016 9/12/2017 IMandatory in NH) y E L DISEASE - EA EMPLOYEE $ 1,000,000 If yes, descnbe under' I DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY LIMIT $ 1,000,000 B COMMERCIAL PROPERTY ACP7883877894 2/18/2017 2/18/2018 BPP $15,200 DED: $500 INLAND MARINE LEASEDIRENTEDEQUIP $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) City of Menifee and its elected officials, officers, employees, agents, representatives, consultants, contract employees and volunteers are hearby added as additional insured but only as respects work done by, for, or on behalf of the named insured. *10 day notice of cancellation for non-payment of premium shall apply. RE: Quail Valley Goetz Road Pedestrian Sidewalk Improvements Project CIP 16-10 City of Menifee 29714 Haun Rd. Menifee, CA 92586 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE CHAEL HARTLEY/JANA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) POLICY NUMBER' 00076047-0 COMMERCIAL GENERAL LIABIL.IT`! CG 2010 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This erdomement rrodifres insurance: provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organizatlonl(s)_ I Where required by written contract or written agreement I All operations of the Nwried Insureds. Information required to complete this Schedule A. Section It - Who Is An Insured is amended to include as an additional insured the person(s) or organ,zatior,(s) shown in the Schedule, but only with respect to liability for "bodily injur,'% "property damage" or "personal and advertising injury" caused, in whole or in part, by 1. Your acts or omissions: or 2. The acts or omissions of those acting on your behalf, in the pertorm,arce of your ongoing operations for the additional insured(s) at the location(s) desig- nated apove. will be shown in B. lrvith respect to the insurance afforded to these additional insureds, the following additional oxclu- slons apply: This insurance does not apply to "bodily injury" or "property damage" occurring after 1. All work, including materials, part:: or equip- ment turnished 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 beer, put to its in- tended use by any person or organization oth- er than another contractor or subcontractor ergaged in performing operations for a princi- pal as a part of the scare project. CG 20 10 07 04 c ISO Properties Inc . 2004 Page 1 of 1 0 POLICY NUMBER 00076047-0 COMMERCIAL GENERAL 1_IABILI1-r' CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS ,This endorsement modifies insurance provided under the foILDWng. COMMERCIAL GENERAL LIABILfTY COVERkC-E PART SCHEDULE Name Of Additional Insured Person(s) Or t?rganization9Z Location And Description Of Completed Opera - dons Where required by written contract or wntten All cperations of thr9 Named Insureds agreement above, will be shown in the Decl4rations,�� Into(mation required to co!!lMete this Schedule, it not shown Sectlon 11 -- Who Is An Insured it; amenried to include as an aadit+cnat Insured the person(s) or organiza- tions) shown in thu Schedule, but only with respect to liabili,y for 'bodily injury" or "property damage caused, in whut°a or in part, by "your work" at the location desig- nated and described in the schedule of this enaorse- meni performed for that addilional insured and included in the "produrts-completed operations hazard" CG 20 37 07 04 :D ISO Prop�art,es. Inc 2C04 Page t of 1 0 POLICY NUMBER: 0007$047-0 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endor,en;ent modifies insurance provided under the fol'rl-mng COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTSfCOMPLETED OPERATIONS LIABILITY 'COVE RAGE PART SCHEDULE Name Of Pers4on Or Organization: Where required by wriven contract of written agreerTrent. information r equired to Complete this Schedule, if not shown above. will he shown in the Declarations. The lottowing ,s _rddecr to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of SeGUon W — Condition%; We waive any ncghl 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 nut of your ongoing operations or ,.your work" done under a contract with that person or organization an,d included in the "products - completed operations hazard" This waiver applies only to the person or organization sty in the Schedule above. CG 24 04 05 09 r9) Insurance Services Office Inc 2008 Page 1 of 1 0 - ROLICY NUMBER BNUM0128038 WORKERS COMPENSATION AND EMPLOYERS L1rQ.I tTY IN3URANCF POLICY WC 04 03 06 (Ed. 04-94) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSIEWENT CALWORN)A (Blanket) V* hwm ttw rigri to recover out payments from anycne liabl,) for an injury coverart by this poUcy We wdl not enforce our nght aft tlM psrtwn or organization named in the Schedule (This agreement ;rcplius only to the sxtertt that you perform work undW * wtrftn Contract that requires you to obtain this agreement from us ) You mt)if matintarn payroll retards acxvrately segregatfrig the remuneraw)n of yet r ei-p'o;ees Y^ls engags(i in the work deiwr!-•rU in ih,� Schedule. ' .�:c :df i' o^AI prem,um for ttws endorsement shall be p4 '.o of the Cat+tam,a v c*eracompensatK)n pranvurn othtrwtw due nn cuch (wnuneralion. Scheove ytala Descriptlon CA- Any pwly wAh whom the tmsured agrees to wa+va wbrogahon in a wr,tttin wmtatl ihft/timewmatttent tnanrle9 the p06ey to v.n cn a iA el*Che+d an(Jn; pttecuv o, tnr; . sued ur. sas olherw+se s txtod t7M Ia110ttttalt�lNt below is required only when nrio ondorsemant I% laouod aubiuqucnt to proparstlon of the p4DI".) otaaetsat Etllacl-w Caw Pu" NumBer BNUVVC0138038 Endoraemeni 1io ttwwwod Nam" Ir,3uran,_a Cornyxt+y h'idw++it EnPtcyrrs Cusu�s;y Company counfersgneo By