2022/09/22 Act 1 Construction, Inc. (3)oiQo"CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED A3 A MATTER OF INFOR ATIO'{ ONLY ANO CONFERS NO RIGHTS UPOI{ THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR
'{EGATIVELY
AI{ENO, EXTEI{O OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEI THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, ANO THE CERTIFICATE HOLDER.
IIIIPORTANT: ll ths cortiffcato holder i8 an AOOITIONAL |i{SURED, tho policylie3) muct havo AODITIOi{AL INSUREO provisions or bs endo'sed.
lf SUBROGATION lS WAIVED, subjoct to thg tgrms and condltlons of the policy, cgrtain policie3 may roquire an ondorsemonl. A atatemonl on
this coniticato dos! not confor.ights to tho cortificato holder in lieu ol luch ondorlomgnt(E).
PRoDUCER New{ront Insurance Services
777 Mariners lsland Blvd., Suite 250
San Mateo. CA 94404
www. newfront.com
aONiair Oscar Osorio
650,488-8565
Oscar.Osorio com
INSTJ RER(SI A FFOFOIN G COVERAGE
TNSURER a : Palomar Specialty lnsurance Company 20338
Act 1 Construction. lnc
444 6th St
Norco CA 92860
TNSURERB: AGCS irarine lnsurance Company 22837
INSURER D
INSUFER E
COVERAGES
THIS IS TO CERIIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREO NAMEO ABOVE FOR THE POLICY PERIOD
INDICATED NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUMENT WTH RESPECT TO WI'IICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDEO BY THE POLICIES DESCRIEED HEREIN IS SUBJECT TO ALL THE TERMS
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOW{ MAY HAVE BEEN REDUCED 8Y PAID CLAIMS,
COM MERCIAL GEI.IERAL LIABILITY
OCCUR
GEN'L AGGREGATE LIMITAPPLIES P€R
OTHER
!$t E.*
PACL 2222069 2t612023 216t2024 EACH OCCURFENCE r1.000,000
PREMISES (Ea occudence)s 300 000
MEO EXP (Any ono p6r$n)s5.000
P€RSONAL & AOV INJURY $1,000,000
GENERALAGGREGATE $2,000,000
PRODUCTS COMP/OPAGG s 2,000,000
Proiecls GeneralAaq $5 ooo ooo
AUTOMOBI!ELIABIUIY
OW!EO
AIJTOS ONTY
HIRED
AUTOSONLY
SCHEDIJLEO
NON.OWNED
AUTOSONLY
SINGLE LIMIT 5
BODILY NJURY (P.TPEiSON)s
S
$
s
EXC€SSLIAB
OCCUR 216t2023 2t612024 EACI] OCCURRENCE $5,000,000
AGGFEGATE s5.000,000
DED
WORXERSCO PENSATIOI{
ANOE PLOYERS'UAEIUTY
ANYPROPRIETOR/PARTNER/EXECIJTIVE
OFFICER/MEMBEREXCLUOED?
D€SCRIPTION OF OPERATIONS bd@
oTu,
E L EACHACCIOENT
E L OISEASE. EA EMPLOYEE
€ L OTSeASE, POLTCY UMrr s
B
B
B
Conlraclors Equipment
Business Fersonal Property
Scheduled Equipmenl
sM1S3087999
sM193087999
sM193087999
9t22t2022
9t22t2022
912212022
9t2212023
9122t2023
912212023
Rented/Leasedr $500,000
830,000
$578.321
DESCiIPIION Oa OPERAnONS / LOCATIONS / VEITICLES IACORO I Ol, Adtll0on.l R.n.ri. Sch.dub. n.y t rtt .h.d lr n{.p.c.lt cqul..dl
REi QuailValley Neu Fire Stalion #5, 29745 Goetz Rd., Menibe, CA 92587
Ctty of Meni€e and its elecled offici8ls, offcers, employees, agenls. representatives. consultants. conrad employees and volunleers are included
as addrlional insured on a pdmary and non-conlribulory basis as respeds their rnterests in the project rebrenced abo\re. if required by wrillen
contracl. A waiver of subrogation applies on allcolErade marked as such, if required by written contract.Thirty (30) days prior wrilten nolice of
cancellation and/or reduclion in coverage of any nature.
CERTIFICATE NUMBER: 72 REVISION NUMBER:
CANCELLATION
@ 1988-20'15 ACORD CORPORATION. All rights ressrvod.
Tho ACORD nams and logo ars roqistorod marks of ACORD
Crtv of Menifee
29844 Haun Rd.
Menibe CA 925E0
SHOULD ANY OF THE ABOVE OESCRISEO POLICIES BE CANCELLED BEFORE
THE EXPIRATION OATE I}IEREOF, NOTICE WILL BE OELIVERED IIt
ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZEO REPRESENTATIVE
Rod Sockolov
CERTIFICATE HOLDER
ACORD 2s (2016/03)
T
.1, XSr Hc L..sed Equrp, BP!, sch.d Equ,p r o3c.r ororro | 2/6.:0:l r1:05r5.r Au ,PsT, P.ge I o! 3cdncels and supersecles ArL p!evlouSIy issued cer.ilrcates.
INSUREO
.Z
SODILY TNJURY lP.' .@d€.0
PALXS 2222070
tr
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
SCHEOULE
Act 'l Conslruction. lnc
POLICY NUIVBER: PAGL 2222069
A. Section ll - Who ls An lnsurod 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
haza(d".
However:
'1. The insurance afforded to such additional
insured only applies to the extent permitted
by law; and
2. lf 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.
B. Vvith respect to the insurance afforded to these
additional insureds, the followjng is added to
Section lll - Limits Of lnsurancer
lf coverage provided to the additional insured is
required by a contracl or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1. Required by the contract or agreementi or
2. Available under the applicable Limits of
lnsurance shown in the Declarations,
whichever is less.
This endorsement shall not increase the applicable
Limits of lnsurance shown in the Declarations.
7
@ lnsurance Services Office, lnc., 2012
CG 20 37 0'l 13
]:3""/0L.i-.l,cl,xsrdcI..s.dEqJIp'BPP'sch.dE9ulpcdncers and supelsedes AII previousty rs3ued ce.rifrcates.
Name Of Additional lnsured Person(s)
Or Organization(s)Location And Description Of Completed Operations
Citv of Menibe
29844 Heun Rd
l4eni€e CA 92586
REi OuailValley New Fire Statlon #5, 29745 Goelz Rd., Menifee, CA I
lnformation required to complete this Schedule, if not shown above, will be shown in the Declarations
Page 1 of 1
COMMERCIAL GENE RAL LIABILITY
cG 20 37 04 13
Act I Comtructron.lnc
POLICY NUMBER : PA.GL 2222Me COMMERCIAL GENERAL LIABILITY
cG 20 t0 04 t3
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifes insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Namo Of Additional lnsured Person(s)
Or Organization(s)Location(s) Of Covered Operations
Cit\ ofMcnifee
?98.1,.1 tlaun Rd
t!,lcnrfee CA 92586
RFI: QuarlValley New Frre Slation d5,29745 Coetz Rd. N4en,fcc. CA 925i
lnformation required to complete this Schedule. if not shown above, will be shown in the Declarations
A. Section ll - Who ls An lnsured is amended to
include as an additional insured the person(s) or
organization(s) shown in the Schedule, but only
with respect to liability for "bodily injury", "property
damage" or "personal and advertising injury"
caused, in whole or in part, by:
1. Your acts or omissionsi 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 lo the extent permitted by
law; and
2. lf 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 ansured.
B. Wth 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. Wth respect to the insurance afforded to these
additional insureds, the following is added to
Section lll - Limits of lnsurance:
lf 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 conlract or agreementi or
@ lnsurance Services Office, lnc., 2012
cG 20 10 04 13
." ,:. -i L€atrd Equrp, 3PP, Sch.d Equrp l/5/:0:t 1t:05:51 Ax (psTr I parJ€ 3 or 3'tit. "t t'- ',r, 'J1,pl. dnd >uperspd"s ALL prFvroLaty rssueo .ar,r!rcdrps.
Page I of 2
2. Available under the applicable Limits of
lnsurance shown in the Declarations,
whichever is less.
This endorsement shall not increase the
applicable Limits of lnsurance shown in the
Declarations.
@ lnsurance Services Office, lnc., 2012
cG 20 10 04 't3
_13)q]-0 r. - rJ- Gt, xs, llc L€.s.d Equip, BPP, S.h.d EouiD ro!.rr ororio r216/202l tr:05:5ll}l rDsT) rr.9.aoteThrs :ertirrcate cancels a^d super'seiles r.iL prevr6uily rssued certifrcares.
Page 2 ol 2
Policy NumberPAGL 2222069
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY AND NONCONTRIBUTORY -
OTHER INSURANCE CONDITION
This endorsement modifies insurance provided under the following
COMMERCIAT GENERAL LIABILIry COVERAGE PART
PRODUCTS/COMPLETED OPERANONS LIABILIry COVERAGE PART
CG 20 01 (x '13 O lnsurance Services Offce, lnc., 2012
_-.3.'-o. Equrp, Bpp, och.o EoLrp I or(a! osor'o ' 2.6/202i l-r05:51 Al', ,psT, p!96 5 o, s.dnfers ond sJpersedes ArL prevtously rssued cerLilicate!.
Page 'l of 1
The following is added to the Other lnsurance
Condition and supersedes any provision to the
contrary:
Primary And Noncontributory lnsurance
This insurance is primary to and will not seek
contribution tom any other insurance available
to an additional insured under your policy
provided that:
(1) The additional insured is a Named lnsured
under su€h other insllrance: and
(2) You have agreed in writing in a contract or
agreemenl that this insurance would be
primary and would not seek contribution
from any other insurance available to the
additional insured.
COMMERCIAL GENERAL LIABILITY
cG 20 01 04 13
ill COMMERCIAL GENERAL LIABILITY
POLICY NUMBER pACt. 22220(e
MARKff
EVANSTON INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modities insurance provided under the following
COMMERCIAL GENERAT LIABILITY COVERAGE FORM
SCHEDULE
Nams Ot Person Or Organization:
Any person(s) or organization(s) with whom the Named lnsured agrees, in a written contract
executed prior to the "occurrence", to waive rights of recovery
Additional Premium:
The following is added to Condition 8. Transfer Of Rights Of Recovery Against Others To Us under Section lV -
Commercial General Liability Conditions:
We waive any right of recovery we may have against any person or organization shown in the Schedule of this
endorsement. This waiver applies only to the person or organization shown in the Schedule of this endorsement.
MEGL 0241-01 05 16 lncludes copyrighted material of lnsurance Services Office, lnc.,
with its permission.
l.-q,-..0.9 -.1.? - ri c!, xsr 8c 1....d EqJlp, I o,c.r orolro t t/bt2a)\ tttortll Ax rpsl, I p.s. 6 of tcancers and sup€rsedes AIL previousty issued cerrificares
Page 1 of I
All other terms and conditions remain unchanged
ill COMMERCIAL GENERAL LIABILITY
POLICY NUM BER: 7AGL 222206s
TIARKEIT
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION BY US AS REQUIRED BY CONTRACT TO
ADDITIONAL INSUREDS
This endorsement modifies insurance provided under the following
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SCHEDULE
Number Of Days: 30 days -
plus 3 days
for mailing.
The following is added to the Cancellation condition:
We will provide written Notice of Cancellation to an additional insured stating when, not less than the number of days
shown in the Schedule above, cancellation will become effective.
This condition only applies if:
'1. The policy is cancelled by us;
2. Cancellation is for reasons other than:
a, Nonpayment of premium; or
b. Non-payment of any deductible reimbursement;
3. You are required by written contract to provide the additional insured with such notice; and
4. You agree to provide us with a list of the applicable additional insureds, including their complete mailing addresses,
within 7 days of our request.
lf notice is mailed, proof of mailing is sufficient proof of such notice.
[ilEGL 1879 07 15 lncludes copyrighted material of lnsurance Services Office, lnc.,
with its permission.
rnrs 'orr rrr.aLe cdncpls and supersedes AIL prev)ously issued certrticares.
Page 1 of 'l
EVANSTON INS URANCE COMPANY
All other terms and conditions remain unchanged.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
( 5lt7etl:
wc 00 03 13
(Ed.4-84)
We have lhe right to recover our paymenls from anyone liable for an injury covered by this policy. We will nol enforce
our right against the person or organization named in the Schedule. (This agreement applies only to the extent that
you perform work under a written conlract that requires you lo obtain this agreemenl lrom us.)
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule
This ondorsement changes the policy to r,vhich it is attached and is €flective on the date issued unless otherwise stated.
(Ths lntotmallon bolow ls roqulred only whon thls andorsoment ls lssusd subsoquonl lo pleparallon ol lhe pollcy.)
Endorsement Eflectivo Dat€: Policy No. Endorsement No.
Policy Etfective Datet t,ot/2022 to Premium $
lnsureqf;l llq]struction.
Inc
NorcoCA 92860
DBA:
Carrier Name / Code:
wc 00 03 13
(Ed.4-84)
O 1983 Nallonrl Councll on Comlanaatlon lnslEncc.
Countersigned by
l?4"o0:o Jj *c Lerted Equrp, spp, schoo Equlp I os.ar ororlo | ?/6/20rr 11:05rsr ap psTj o!9. s or 3rlrs er'1r1:are cdncers and sLpe!s€de3 AIL p!eviously lssJed cerrrrlcores.
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
Page I oI 1