CONTRACT 3983 Public Works Contract CLOSED3983. :I
ORIGINAL
PUBLIC WORKS CONTRACT
BETWEEN
THE CITY OF EL SEGUNDO AND
PAVEMENT COATINGS COMPANY
This CONTRACT is entered into this 1st day of September, 2009, by and
between the CITY OF EL SEGUNDO, a general law city and municipal corporation ( "the
City ") and Pavement Coatings Company ( "the Contractor ").
1. WORK.
A. The Contractor will provide all work required by the Contract Documents
(the "Work "). The Contractor agrees to do additional work arising from
changes ordered by the City in accordance with the Contract Documents.
B. The Contractor and the City agree to abide by the terms and conditions
contained in the Contract Documents;
C. The Contractor will furnish all of the labor; supplies and materials;
equipment; printing; vehicles; transportation; office space and facilities; all
tests, testing and analyses; and all matters whatsoever .(except as
otherwise expressly specified to be furnished by the City) needed to
perform and complete the Work and provide the services required of the
Contractor by the Contract Documents.
D. "Contract Documents" means the Notice Inviting Bids; Instructions to
Bidders; Supplementary Instructions to Bidders; Proposal; this Contract;
Standard Specifications; Supplementary Conditions; Exhibits; Technical
Specifications; List of Drawings; Drawings; Addenda; Notice to Proceed;
Change Orders; Notice of Completion; and all other documents identified
in the Contract Documents which together form the contract between the
City and the Contractor for the Work. The Contract Documents constitute
the complete agreement between the City and the Contractor and
supersede any previous agreements or understandings.
2. CONTRACT SUM. The City agrees to pay the Contractor a sum not to exceed ONE
HUNDRED NINETY NINE THOUSAND, NINE HUNDRED EIGHTY SEVEN DOLLARS
AND ZERO CENTS ($199,987.00) for the Work in the manner set forth in the Contract
Documents. The City may adjust this amount as set forth in the Contract Documents.
3. TIME FOR PERFORMANCE.
A. The Contractor will fully complete the Work within FORTY FIVE (45)
calendar days (the "Contract Time. ")
am
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B. The Contract Time will commence when the City issues a notice to
proceed. The Contract Documents will supersede any conflicting
provisions included on the notice to proceed issued pursuant to this
Contract.
C. The Contractor may not perform any Work until:
i. The Contractor furnishes proof of insurance as required by the
Contract Documents; and
ii. The City gives the Contractor a written, signed, and numbered
purchase order and notice to proceed.
D. By signing this Contract, the Contractor represents to the City that the
Contract Time is reasonable for completion of the Work and that the
Contractor will complete the Work within the Contract Time.
E. Should the Contractor begin the Work before receiving written
authorization to proceed, any such Work is at the Contractor's own cost
and risk.
4. DISPUTES. Disputes arising from this contract will be determined in accordance
with the Contract Documents and Public Contracts Code §§ 10240 - 10240.13.
5. THIRD PARTY CLAIMS. In accordance with Public Contracts Code § 9201, the
City will promptly inform the Contractor regarding third -party claims against the
Contractor, but in no event later than ten (10) business days after the City receives such
claims. Such notification will be in writing and forwarded in accordance with the "Notice"
section of the Contract Documents. As more specifically detailed in the Contract
Documents, the Contractor agrees to indemnify and defend the City against any third -
party claim.
6. TAXPAYER IDENTIFICATION NUMBER. The Contractor will provide the City with
a Taxpayer Identification Number.
7. PERMITS AND LICENSES. Unless otherwise provided, the Contractor, at its sole
expense, will obtain and maintain during the Contract Time, all necessary permits,
licenses, and certificates that may be required in connection with the Work.
8. OWNERSHIP OF DOCUMENTS. All documents, data, studies, drawings, maps,
models, photographs and reports prepared by the Contractor under the Contract
Documents are the City's property. The Contractor may retain copies of said
documents and materials as desired, but will deliver all original materials to the City
upon the City's written notice.
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9. INDEMNIFICATION. The Contractor agrees to indemnify, defend, and hold the City
harmless as set forth in the Contract Documents. The requirements as to the types and
limits of insurance coverage to be maintained by the Contractor as required by the
Contract Documents, and any approval of such insurance by the City, are not intended
to and will not in any manner limit or qualify the liabilities and obligations otherwise
assumed by the Contractor pursuant to the Contract Documents, including, without
limitation, to the provisions concerning indemnification.
10.INDEPENDENT CONTRACTOR. The City and the Contractor agree that the
Contractor will act as an independent contractor and will have control of all work and the
manner in which is it performed. The Contractor will be free to contract for similar
service to be performed for other employers while under contract with the City. The
Contractor is not an agent or employee of the City and is not entitled to participate in
any pension plan, insurance, bonus or similar benefits the City provides for its
employees. Any provision in this Contract that may appear to give the City the right to
direct the Contractor as to the details of doing the work or to exercise a measure of
control over the work means that the Contractor will follow the direction of the City as to
end results of the work only.
11. AUDIT OF RECORDS. The Contractor will maintain full and accurate records with
respect to all services and matters covered under this Contract. The City will have free
access at all reasonable times to such records, and the right to examine and audit the
same and to make transcript therefrom, and to inspect all program data, documents,
proceedings and activities. The Contractor will retain such financial and program
service records for at least three (3) years after termination or final payment under the
Contract Documents.
12. NOTICES. All communications to either party by the other party will be deemed
made when received by such party at its respective name and address as follows:
The City
Maryam M. Jonas
Principal Engineer
City of El Segundo
350 Main St.,
El Segundo, CA 9024
(310) 524 -2361
The Contractor
Doug Ford
President
Pavement Coatings Company
10240 San Sevaine Way
Mira Loma, CA 91752
(714) 826 -3011
Any such written communications by mail will be conclusively deemed to have been
received by the addressee three (3) days after deposit thereof in the United States Mail,
postage prepaid and properly addressed as noted above. In all other instances, notices
will be deemed given at the time of actual delivery. Changes may be made in the
names or addresses of persons to whom notices are to be given by giving notice in the
manner prescribed in this paragraph.
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13. NO THIRD PARTY BENEFICIARY. This Contract and every provision herein is for
the exclusive benefit of the Contractor and the City and not for the benefit of any other
party. There will be no incidental or other beneficiaries of any of the Contractor's or the
City's obligations under this Contract.
14. INTERPRETATION. This Contract was drafted in, and will be construed in
accordance with the laws of the State of California, and exclusive venue for any action
involving this Contract will be in Los Angeles County.
15. EFFECT OF CONFLICT. In the event of any conflict, inconsistency, or incongruity
between any provision of the Contract Documents, precedence will be as follows:
A. This Contract;
B. The Standard Specifications; and
C. Precedence of documents as determined in the Standard Specifications.
16. SEVERABILITY. If any portion of the Contract Documents are declared by a court
of competent jurisdiction to be invalid or unenforceable, then such portion will be
deemed modified to the extent necessary in the opinion of the court to render such
portion enforceable and, as so modified, such portion and the balance of this Contract
will continue in full force and effect.
17.AUTHORITY /MODIFICATION. The Parties represent and warrant that all necessary
action has been taken by the Parties to authorize the undersigned to execute this
Contract and to engage in the actions described herein. This Contract may be modified
by written amendment. The City's city manager, or designee, may execute any such
amendment on the City's behalf.
18.ACCEPTANCE OF FACSIMILE SIGNATURES. The Parties agree that this
Contract, agreements ancillary to this Contract, and related documents to be entered
into in connection with this Contract will be considered signed when the signature of a
party is delivered by facsimile transmission. Such facsimile signature will be treated in
all respects as having the same effect as an original signature.
19. COVENANTS AND CONDITIONS. The parties agree that all of the provisions
hereof will be construed as both covenants and conditions, the same as if the words
importing such covenants and conditions had been used in each separate paragraph.
20. CAPTIONS. The captions of the paragraphs of this Contract are for convenience of
reference only and will not affect the interpretation of this Contract.
21. TIME IS OF ESSENCE. Time is of the essence for each and every provision of the
Contract Documents.
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IN WITNESS WHEREOF the parties hereto have executed this contract the day
and year first hereinabove written.
ATTEST:
Uta Lb-),-A� �� —
Cindy Mort sen,
City Clerk
APPRfflHS
MARK
By:
Karl H. Berger,
Assistant City
I -D -5
PAVEMENT COATINGS CO.
—� �
President
Taxpayer ID No. 15'- 29 ILdo *70
Business License No.:. �8Z0
1
39 83 - J
LABOR AND MATERIALS BOND
Bond No. 6663968
Bond Fee: Included in Performance Bond
PAVEMENT COATINGS COMPANY , as principal
( "PRINCIPAL ") and First National Insurance Company of America , a corporation
incorporated under the laws of the State of Washington and licensed by the State of
California to execute bonds and undertakings as sole surety, as surety ( "SURETY "), are held and
firmly bound unto the CITY OF EL SEGUNDO ( "CITY ") in the sum of ONE HUNDRED NINETY
NINE THOUSAND, NINE HUNDRED EIGHTY SEVEN DOLLARS AND ZERO CENTS
($199,987.00) dollars, which is a minimum one hundred percent (100 %) of the contract, lawful
money of the United States, which may be increased or decreased by a rider hereto executed in the
same manner as this bond, for the payment of which sum PRINCIPAL and SURETY bind
themselves, their successors, and assigns, jointly and severally, by this instrument.
This bond is conditioned upon and guarantees payment by PRINCIPAL to contractors,
subcontractors, and persons renting equipment; payment by PRINCIPAL and all PRINCIPAL'S
subcontractors for all materials, provisions, provender, or other supplies, and equipment used in,
upon, for or about the performance of the work contemplated in 2008 -2009 FURNISHING AND
APPLICATION OF SLURRY SEAL ON VARIOUS STREETS, SPECIFICATIONS NO. PW 09 -10
( "Public Project "), the public works contract executed for such Public Project, and for all work or
labor of any kind performed for the Public Project. In the case of any default in the performance of
the conditions and stipulations of this undertaking, it is agreed that PRINCIPAL or SURETY will
apply the bond or any portion thereof, to the satisfaction of any damages, reclamation,
assessments, penalties, or deficiencies arising by reason of such default.
BOND CONDITIONS
1. PRINCIPAL will construct the public improvements identified in SPECIFICATIONS
NO. PW 09- 10,and the public works contract executed for such Specifications, copies of which is on
file with CITY's Engineering Division ( "Public Project "). Such performance will be in accordance with
CITY's plans and profiles (CITY DRAWING FILE NO. ), which are made a part of this
bond when said plans and profiles are approved by the City Council and filed with CITY's
Engineering Division.
PRINCIPAL will pay all contractors, subcontractors, and persons renting equipment.
3. PRINCIPAL will pay for all materials and other supplies, for equipment used in, on,
for or about the performance of the Public Project, and will pay for all work and labor thereon.
4. This bond is conditioned upon and guarantees due compliance with all applicable law
including, without limitation, the El Segundo Municipal Code ( "ESMC ").
5. SURETY, for value received, agrees that no changes, extensions of time, alteration
or modification of SPECIFICATIONS NO. PW 09 -10, or of the obligation to be performed will in any
way affect its obligation on this bond, and it waives notice of any such change, extension of time,
alteration or modification of the contract documents or of the obligation to be performed.
SpeWcOws— Pro,.ch1PW Labor Malai.le Bond ( 1103) I —F -1
3983 ,
6. This bond consists of this instrument; the plans and specifications identified above;
and the following TWO (2) attached exhibits all of which are incorporated herein by reference:
A. A certified copy of the appointment, power of attorney, bylaws or other instrument
entitling or authorizing the persons executing this bond to do so; and
B. A certificate issued by the county clerk for the county in which SURETY's
representative is located conforming with California Code of Civil Procedure §
995.640 and stating that SURETY's certificate of authority has not been
surrendered, revoked, cancelled, annulled, or suspended, or in the event that it
has, that renewed authority has been granted.
7. Should PRINCIPAL perform its obligations within the time allowed, PRINCIPAL's
obligation will be void upon the acceptance of the performance by CITY; otherwise this obligation will
remain in full force and effect.
SIGNED AN SEALED this 8th day of September . 2009
"JI/ vll)�,Iry
T
PRIN L's PRESIDE SURETY'S PRESIDEN
PRINCIP C TAR
PRINCIPAL's MAILING ADDRESS:
10240 San Sevaine Way
Mira Loma, CA 9 752
Richard L. Wells, Attorney;In -Fact
SURETY's SECRETARY
SURETY's MAILING ADDRESS:
120 Vantis, 1st Floor
Aliso Viejo, CA 92656
NOTE: (1) ALL signatures must be acknowledged by a notary public.
Return two (2) originals to City Clerk's Office.
(2) Bond shall be effective for one (1) year after acceptance of the job.
LABOR AND MATERIALS BOND I•F•2 (0687102) I_F-2
POWER
.e OF ATTORNEY
KNOW ALL BY THESE PRESENTS: No. 10053
3983
First National Insurance Company of America
1001 4th Avenue
Suite 1700
Seattle, WA 98154
That FIRST NATIONAL INSURANCE COMPANY OF AMERICA, a Washington corporation, does hereby appoint
* * * * * * * * * * * * *SUZANNE ADAMS; TED ADAMSON; LYNN A. BEIMER; RICHARD L. WELLS; Brea, CA * * * * * * * * * * * * * * **
its true and lawful attorney(s) -in -fact, with full authority to execute on behalf of the company fidelity and surety bonds or
undertakings and other documents of a similar character issued by the company in the course of its business, and to bind FIRST
NATIONAL INSURANCE COMPANY OF AMERICA thereby as fully as if such instruments had been duly executed by its regularly
elected officers at its home office.
IN WITNESS WHEREOF, FIRST NATIONAL INSURANCE COMPANY OF AMERICA has executed and attested these presents
this 15th day of January 2009
Dexter R. Legg, Secretary Timothy A. Mikolajewski, Vice President
CERTIFICATE
Extract from the By -Laws of FIRST NATIONAL INSURANCE COMPANY OF AMERICA:
"Article V, Section 13. - FIDELITY AND SURETY BONDS ... the President, any Vice President, the Secretary, and any Assistant
Vice President appointed for that purpose by the officer in charge of surety operations, shall each have authority to appoint
individuals as attorneys -in -Fact or under other appropriate titles with authority to execute on behalf of the company fidelity and surety
bonds and other documents of similar character issued by the company in the course of its business... On any instrument making or
evidencing such appointment, the signatures may be affixed by facsimile. On any instrument conferring such authority or on any bond or
undertaking of the company, the seal, or a facsimile thereof, may be impressed or affixed or in any other manner reproduced;
provided, however, that the seal shall not be necessary to the validity of any such instrument or undertaking."
Extract from a Resolution of the Board of Directors of
FIRST NATIONAL INSURANCE COMPANY OF AMERICA adopted July 28,1970.
"On any certificate executed by the Secretary or an assistant secretary of the Company setting out,
(i) The provisions of Article V, Section 13 of the By -Laws, and
(ii) A copy of the power -of- attorney appointment, executed pursuant thereto, and
(iii) Certifying that said power -of- attomey appointment is in full force and effect,
the signature of the certifying officer may be by facsimile, and the seal of the Company may be a facsimile thereof."
I, Dexter R. Legg , Secretary of FIRST NATIONAL INSURANCE COMPANY OF AMERICA, do hereby certify that the
foregoing extracts of the By -Laws and of a Resolution of the Board of Directors of this corporation, and of a Power of Attorney
issued pursuant thereto, are true and correct, and that both the By -Laws, the Resolution and the Power of Attorney are still in full force
and effect.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed the facsimile seal of said corporation
this 8th
SEAL
1928 .ter
f Of WASO
S- 1049/13F 1/09
day of September , 2009
�X* Rr kj j
Dexter R. Legg, Secretary
Safeco® and the Safeco logo are registered trademarks of Safeco Corporation.
WEB PDF
s .
CALIFORNIA ALL - PURPOSE ACKNOWLEDGEMENT
State of California
County of Orange
On 9/8/09 before me, Lynn A. Beimer, Notary Public
Date Here Insert Name and Title of the Officer
personally appeared Richard L. Wells
Name(s) of Signers)
LYNN A. BEIMER
Commission # 1781026
Notary Public - California
Orange County
�.�.�
my Orange
Dec 16,2 11
Place Notary Seal Above
3983•,.,
who proved to me on the basis of Aptisfactory evidence to
be the person* whose name i ;are subscribed to the
within instrument and acknowledged to me that(gAhe /they
executed the ame in is/ er /their authorized capacity0eaj;
and that by is/ er / their signature on the instrument the
person , personX or a entity upon behalf of which the person
acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of
the State of California that the foregoing paragraph is true
and correct.
WITNESS my hand and official seal.
A
Signature XAll11)711,n �;, &10
Signature of Notary Public
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document:
Document Date:
Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name:
❑
Individual
❑
Corporate Officer — Title(s):
❑
Partner
• Limited
• General
❑
Attorney in Fact
Top of thumb her
❑
Trustee
❑
Guardian or Conservator
❑
Other:
Signer is Representing:
Number of Pages:
Signer's Name:
❑
Individual
❑
Corporate Officer — Title(s):
❑
Partner
❑ Limited
❑ General
❑
Attorney in Fact
Top of thumb her
❑
Trustee
L3
Guardian or Conservator
❑
Other:
Signer is Representing:
3983 .
FAITHFUL PERFORMANCE BOND
Bond No. 6663968
Bond Fee: $1224.00
PAVEMENT COATINGS COMPANY ( "PRINCIPAL ")
and First National Insurance Company of America , a corporation
incorporated under the laws of the State of Washington and licensed by the State of
California to execute bonds and undertakings as sole surety, as surety ( "SURETY "), are held and
firmly bound unto the CITY OF EL SEGUNDO ( "CITY ") in the sum of ONE HUNDRED NINETY
NINE THOUSAND, NINE HUNDRED EIGHTY SEVEN DOLLARS AND ZERO CENTS
($199,987.00) dollars, which is a minimum one hundred percent (100 %) of the contract amount,
lawful money of the United States, which may be increased or decreased by a rider hereto executed
in the same manner as this bond, for the payment of which sum PRINCIPAL and SURETY bind
themselves, their successors, and assigns, jointly and severally, by this instrument.
PRINCIPAL or SURETY will apply this bond for the faithful performance of any and all of the
conditions and stipulations set forth in this bond, SPECIFICATIONS NO. PW 09 -10, and the public
works contract executed with such Specifications. In the case of any default in the performance of
the conditions and stipulations of this undertaking, it is agreed that PRINCIPAL or SURETY will
apply the bond or any portion thereof, to the satisfaction of any damages, reclamation,
assessments, penalties, or deficiencies arising by reason of such default.
BOND CONDITIONS
1. PRINCIPAL will construct the public improvements identified in SPECIFICATIONS
NO. PW 09 -10, a copy of which is on file with CITY's Engineering Division ( "Public Project "). Such
performance will be in accordance with CITY's plans and profiles (CITY DRAWING FILE NO.
) which are made a part of this bond when said plans and profiles are approved by the City
Council and filed with CITY's Engineering Division.
2. PRINCIPAL's work on the Public Project will be done in accordance with CITY's
plans and specifications and with any permit issued by CITY. Should PRINCIPAL fail to complete all
required work within the time allowed, CITY may, at its sole discretion, cause all required work to be
done and the parties executing the bond will be firmly bound for the payment of all necessary costs
therefor.
3. PRINCIPAL will guarantee its work against any defective work, labor, or materials on
the Public Project for a period of one (1) year following the Public Project's completion and
acceptance by CITY.
4. This bond is conditioned upon and guarantees due compliance with all applicable law
including, without limitation, the El Segundo Municipal Code ( "ESMC ").
5. SURETY, for value received, agrees that no changes, extensions of time, alteration
or modification of SPECIFICATIONS NO. PW 09 -10 or of the obligation to be performed will in any
Sp,oloetlon,- Projous%PW FMhlul Pvtormenoe Bond (1103)
-E -1
3983 .
way affect its obligation on this bond, and it waives notice of any such change, extension of time,
alteration or modification of the contract documents or of the obligation to be performed.
6. This bond consists of this instrument; the plans and specifications identified above;
and the following two (2) attached exhibits all of which are incorporated herein by reference:
A. A certified copy of the appointment, power of attorney, bylaws or
other instrument entitling or authorizing the persons executing this
bond to do so;
B. A certificate issued by the county clerk for the county in which
SURETY's representative is located conforming with California Code
of Civil Procedure § 995.640 and stating that SURETY's certificate of
authority has not been surrendered, revoked, cancelled, annulled, or
suspended, or in the event that it has, that renewed authority has
been granted; and
7. Should PRINCIPAL perform its obligations within the time allowed, PRINCIPAL's
obligation will be void upon the acceptance of the performance by CITY; otherwise this obligation will
remain in full force and effect.
SIGNED, O EALED this 8th day of September 00
t
PRIN AL's PRESIDENT SURETY's PRESIDENT v -
Richard L. Wells, Attorney -In -Fact
PRINCI L's SEC TAR SURETY's SECRETARY
PRINCIPAL's MAILING ADDRESS:
10240 San Sevaine Way
Mira Loma CA 91252
SURETY's MAILING ADDRESS:
120 Vantis, 1st Floor
Aliso Viejo, CA 92656
NOTE: (1) ALL signatures must be acknowledged by a notary public.
Return two (2) originals to City Clerk's Office.
(2) Bond shall be effective for one (1) year after acceptance of the job.
Spectlketlone - PfoJocU%PW FeHA1ul Pedormence SOnO ( / 103)
I -E -2
KNOW ALL BY THESE PRESENTS:
POWER
OF ATTORNEY
No. 10053
3983
First National Insurance Company of America
1001 4th Avenue
Suite 1700
Seattle, WA 98154
That FIRST NATIONAL INSURANCE COMPANY OF AMERICA, a Washington corporation, does hereby appoint
* * * * * * * * * * * * *SUZANNE ADAMS; TED ADAMSON; LYNN A. BEIMER; RICHARD L. WELLS; Brea, CA * * * * * * * * * * * * * * **
its true and lawful attorney(s) -in -fact, with full authority to execute on behalf of the company fidelity and surety bonds or
undertakings and other documents of a similar character issued by the company in the course of its business, and to bind FIRST
NATIONAL INSURANCE COMPANY OF AMERICA thereby as fully as if such instruments had been duly executed by its regularly
elected officers at its home office.
IN WITNESS WHEREOF, FIRST NATIONAL INSURANCE COMPANY OF AMERICA has executed and attested these presents
this 15th
�X* R'kjj
day of January
Dexter R. Legg, Secretary Timothy A. Mikolajewski, Vice President
CERTIFICATE
Extract from the By -Laws of FIRST NATIONAL INSURANCE COMPANY OF AMERICA:
2009
"Article V, Section 13. - FIDELITY AND SURETY BONDS ... the President, any Vice President, the Secretary, and any Assistant
Vice President appointed for that purpose by the officer in charge of surety operations, shall each have authority to appoint
individuals as attorneys -in -Fact or under other appropriate titles with authority to execute on behalf of the company fidelity and surety
bonds and other documents of similar character issued by the company in the course of its business... On any instrument making or
evidencing such appointment, the signatures may be affixed by facsimile. On any instrument conferring such authority or on any bond or
undertaking of the company, the seal, or a facsimile thereof, may be impressed or affixed or in any other manner reproduced;
provided, however, that the seal shall not be necessary to the validity of any such instrument or undertaking."
Extract from a Resolution of the Board of Directors of
FIRST NATIONAL INSURANCE COMPANY OF AMERICA adopted July 28,1970.
"On any certificate executed by the Secretary or an assistant secretary of the Company setting out,
(i) The provisions of Article V, Section 13 of the By -Laws, and
(ii) A copy of the power -of- attorney appointment, executed pursuant thereto, and
(iii) Certifying that said power -of- attorney appointment is in full force and effect,
the signature of the certifying officer may be by facsimile, and the seal of the Company may be a facsimile thereof."
I, Dexter R. Legg , Secretary of FIRST NATIONAL INSURANCE COMPANY OF AMERICA, do hereby certify that the
foregoing extracts of the By -Laws and of a Resolution of the Board of Directors of this corporation, and of a Power of Attorney
issued pursuant thereto, are true and correct, and that both the By -Laws, the Resolution and the Power of Attorney are still in full force
and effect.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed the facsimile seal of said corporation
this 8th
a SEAL
Y Y� i9Z84
fdj� ! Cf WAS�'�•.
S- 1049/0F 1/09 •�
dayof September , 2009
�X* Prk, I
Dexter R. Legg, Secretary
Safeco® and the Safeco logo are registered trademarks of Safeco Corporation.
WEB PDF
CALIFORNIA ALL - PURPOSE ACKNOWLEDGEMENT
State of California
County of Orange
On 9/8/09 before me, Lynn A. Beimer, Notary Public
Date Here Insert Name and Title of the Officer
personally appeared Richard L. Wells
Name(s) of Signer(s)
LYNN A. BEIMER
commission # 1781026
Notary Public - California z
Z Orange County
Comm. =Z41.6 2011
Place Notary Seal Above
3983
who proved to me on the basis of satisfactory evidence to
be the personfdwhose name(,*Oare subscribed to the
within instrument and acknowledge to me that�shhe/they
executed the same in Is/ er /their authorized capacity(k*,
and that by " is signature* on the instrument the
person; ' or he entity upon behalf of which the persol�w
acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of
the State of California that the foregoing paragraph is true
and correct.
WITNESS my hand and official seal.
Signature L�
Signature of Notary Public
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document:
Document Date:
Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name:
❑
Individual
❑
Corporate Officer — Title(s):
❑
Partner
❑ Limited
❑ General
❑
Attorney in Fact
❑
Trustee
❑
Guardian or Conservator
❑
Other:
Signer is Representing:
Number of Pages:
Signer's Name:
❑
Individual
❑
Corporate Officer — Title(s):
❑
Partner
❑ Limited
❑ General
❑
Attorney in Fact
❑
Trustee
•
Guardian or Conservator
•
Other:
Signer is Representing:
TOM DALY
CLERK - RECORDER
3983 • .':
PROPERTY RECORDS
BIRTH AND DEATH RECORDS
MARRIAGE LICENSES /RECORDS
PASSPORTS
FICTITIOUS BUSINESS NAMES
NOTARY REGISTRATION
ORANGE COUNTY ARCHIVES
CERTIFICATION OF NO RECORD SURRENDERED REVOKED, CANCELLED,
ANNULLED OR SUSPENDEDOF ADMITTED SURETY INSURER
I, Tom Daly, County Clerk- Recorder in and for said County, do hereby certify that based on the
statewide database that First National Insurance Company of America has been issued a
Certificate of Authority as an Admitted Surety by the Insurance Commissioner who authorized
the Insurer to transact Surety Insurance in the State of California, OR, that authority has not been
surrendered revoked cancelled annulled or suspended.
In Witness Whereof, I have hereunto set my hand and affixed the seal of said County this 27th
day of October, 2009.
Tom Daly, Orange County Clerk- Recorder (Seal)
,tea
By: puty Cl
EBE IN C 9
NORTH COUNTY BRANCH OFFICE ORANGE COUNTY SOUTH COUNTY BRANCH OFFICE
HISTORIC DOWNTOWN FULLERTON HALL OF FINANCE AND RECORDS LAGUNA HILLS CIVIC CENTER
201 N. HARBOR BOULEVARD 12 CIVIC CENTER PLAZA, ROOM 101 24031 EL TORO ROAD
FULLERTON, CALIFORNIA 92832 SANTA ANA, CALIFORNIA 92701 LAGUNA HILLS, CALIFORNIA 92653
(714) 834.2500 ♦ FAX (714) 834.2675 • WWW.00RECORDER.COM ♦ WWW.00ARCHIVES.COM
10/30/2009 18:39 Remote ID Imprint ID
3983
0 2/6
ACORDrN CERTIFICATE OF LIABILITY INSURANCE
D roDIYYYVI
100 /30/30 /09
PRODUCER LIC #OD10299 1 -949- 297 -4900
Venture Pacific Insurance Services, Inc.
26487 Rancho Parkway South
Lake Forest, CA 92630
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
NAIL #
INSURED
Pavement Coatings Company
10240 San Sevaine In
Mira Loma, CA 91752
INSURERA:INTERSTATE FIRE & CAS CO
22829
INSURERB:EMPLOYSRS NUT CAB CO
21415
INSURERC
INSURERD:
SGL1002053
I NSURER E:
10 /01 /10
1r%JVII VGI
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
R
DD'L
TYPEOFINSURANCE
POLICY NUMBER
POLICYEFFECTIVE
POLICY EXPIRATION
LIMITS
A
GENERAL LIABILITY
SGL1002053
10/01/09
10 /01 /10
EACH OCCURRENCE
$1,000,000
PREMISES aoccurence
$50,000
X COMMERCIAL GENERAL LAB ILITY
MED EXP (Anyone person)
$
CLAIMS MADE 7 OCCUR
PERSONAL BADVINJURY
$ 1,000,000
GENERAL AGGREGATE
$2,000,000
GEN'L AGGREGATE L IMIT APPLI ES P ER:
PRODUCTS - COMPIOPAGG
$2,000,000
POLICY PRO LOC JECT
6
AUTOMOBILE
LIABILITY
OX81588
10/01/09
10 /01 /10
COMBINED SINGLE LIMIT
$1,000,000
(Eaacddenl)
ANY AUTO
ALL OWNED AUTOS
BODILY INJURY
$
(Par person)
X
SCHEDULEDAUTOS
BODILY INJURY
$
X
HIREDAUTOS
X
(Per accident)
NON -OWNED AUTOS
PROPERTY DAMAGE
$
(Par accident)
GARAGE LIABILITY
AUTO ONLY - EAACCIDENT
$
OTHER THAN EA ACC
$
ANY AUTO
$
AUTO ONLY: AGG
EXCESSIUMBKELLA LIABILITY
EACH OCCURRENCE
$
AGGREGATE
$
OCCUR FI CLAIMSMADE
$
DEDUCTIBLE
$
RETENTION $
WC STATU- OTH-
WORKERS COMPENSATION AND
TORY LIMITS ER
E.L. EACH ACCIDENT
$
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERMIEMBEREXCLUDED?
E.L. DISEASE - EA EMPLOYEE
$
E.L. DISEASE - POLICY LIMIT
$
Ifyes, describe under
SPECIAL PROVISIONS below
B
OTHER
Equipment Floater
OX81588
10/01/09
10 /01 /10
Contractors Equip 1,180,017
Leased/Rented 250,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
10 Day Notice of Cancellation for Non Payment of Premium.
Project: 2008 -2009 Furnishing and Application of Slurry Seal on Various Streets Project # PW09 -10
The City,its officers ,officials,employees,agents, and volunteers will be named as Additional Insureds as required
by written contract as per attached endorsement.
L,nR t IrIl-At n nvi wcm
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of El Segundo DATE THEREOF, THE ISSUING INSURER WILL 0081YA Y5 MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, ffJA4& xf bXM*X
Maryam Jonas88pgpy77MgK�plpg�lliW (i{IfX
350 Main Street
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
E1 Segundo, CA 902 AUTHORIZED REPRESENTATIVE
USA
ACORD 25120011081 cmckinley 0 ACORD CORPORATION 1988
13511142
OCT -30 -2009 14:26 94% P.02
10/30/2009 18:39 Remote ID Imprint ID
IMPORTANT
6983 , D 3/6
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
25 (2001108)
OCT -30 -2009 14:26 94% P.03
10/30/2009 18:39 Remote ID Imprint ID
❑ 4/6
,
3983..,E
POLICY NUMBER: SGL1002053 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS E
(FORM )
This endorsement modifies insurance provided under the follow g.
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person or organization: Any person or organization for whom you are
performing operations when you and such person or organization have agreed
in writing in a contract or agreement that such person or organization be added
as an additional insured on your policy.
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the
Schedule, but only with respect to liability arising out of "your work" for that Insured by or for you.
CG 20 10 11 86
OCT -30 -2009 14:26
Copyright, Insurance Services Office, Inc., 1964
Page 1 of 1 0
94% P.04
10/30/2009 16:39 Remote ID Imprint ID
POLICY NUMBER: SGL1002053
D 5/6
3983
COMMERCIAL GENERAL LIABILITY
CG 24 0410 93
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 under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization; Any person or organization for whom you are performing
operations when you and such person or organization have agreed in writing in a contract or
agreement that such person or organization be added as an additional insured on your policy.
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement,)
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV - COMMER-
CIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following:
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 0410 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 ❑
OCT -30 -2009 14:27 94% P.05
10/30/2009 18:39 Remote ID Imprint ID
D 6/6
3983. ,
AMENDMENT OF OTHER INSURANCE CONDITION - PRIMARY
INSURANCE FOR AUTOMATIC STATUS ADDITIONAL INSURED
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
if required under a written "insured contract" with you, paragraph a. Primary Insurance in SECTION IV -
COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance Is amended by adding the following
paragraph:
Not withstanding the foregoing, the insurance afforded to any person or organization who has been
added to this policy by an Automatic Status Additional Insured Endorsement is primary and non-
contributory insurance, but only as respects "bodily injury" or "property damage" liability arising out of
your sole negligence in performance of "your work" after the effective date of this policy under a written
contract between you and such person or organization that requires you to maintain primary and non-
contributory insurance and to include such person or organization as an additional insured thereunder.
All other terms and conditions of this policy remain unchanged,
ICB -8016 06 -05
OCT -30 -2009 14:27 94% P.06
70% ..
ACORO�
CERTIFICATE OF LIABILITY INSURANCE Date (qm /d / /yy�
10/5/2009
Producer
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.
Bolton & Company
)245 S. Los Robles Ave., Suite 105
Pasadena, CA 91102
THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE
COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
INSURER Arch Insurance Company
(626) 799 -7000 0008309
www.boltonco.com
INSURER
Insured
INSURER
Pavement Coatings Company
10240 San Sevaine Way
Mira Loma CA 91752
INSURER
INSURER
E
.>
Ct S/E1 A E$
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY
EFFECTIVE
DATE
POLICY
EXPIRATION
DATE
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$
COMMERCIAL GENERAL LIAB
CLAIMS MADE DOCCUR
FIRE DAMAGE (Any one fire)
$
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$
GEN'L AGG LIMIT APPLIES PER
PRODUCTS- COMP /OP AGG
$
POLICY FlPROJECT Loc
$
AUTOMOBILE LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
$
ALL OWNED AUTOS
BODILY INJURY
SCHEDULED AUTOS
(Per person)
$
.`
�`
HIRED AUTOS
a
BODILY INJURY
NON -OWNED AUTOS
(Per accident)
$
PROPERTY DAMAGE
ri
(Per accident)
$
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
ANY AUTO
OTHER THAN EA ACC
AUTO ONLY: AGG
$
$
EXCESS LIABILITY
OCCUR F� CLAIMS MADE
EACH OCCURRENCE
$
AGGREGATE
_
$
DEDUCTIBLE
$
RETENTION $
$
A
WORKERS' COMPENSATION &
EMPLOYERS' LIABILITY
ZAWC19174900
10/1/2009
10/1/2010
STATUTORY LIMIT I lOTHER,�'.1,1",'�1-1—
EL EACH ACCIDENT
$ 1000 000
EL DISEASE - EA EMPLOYEE
$ 1,000,00
EL DISEASE - POLICY LIMIT
$
IDES
'RIPTION OF OP E RATIO A I E H I C LES/EXCLUSIO N ALP N
Job: Project #PW 09 -10, 2008 -2009 Furnishing and Application of Slurry Seal on Various Streets.
*10 Days notice of cancellation for non - payment of premium by registered or certified mail.
CERTIFICATE HOLDER CANCELLATION
Project #PW 09 -10
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL KU *)M)% MAIL
30* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
City of El Segundo
350 Main Street
LEFT,c�►xii�rx#a
El Segundo, CA 9024
b?f1(x ' 10 Days for Non - Payment of Premium.
AUTHORIZED
REPRESENTATIVE
William A. Lewis
ACORD 25 -S (7/97) O ACORD CORPORATION 1988
CERT NO.: 5940977 CLIENT CODE: PAVEM -1 Bolton Certificate Processing 10/5/2009 5:37:21 AM Page 1 of 2
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 -S (7/97) created at www.e CertsONLINE.com
CERT NO.: 5940977 CLIENT CODE: PAVEM -1 Bolton Certificate Processing 10/5/2009 5:37:21 AM Page 2 of 2
10/30/2009 16:29 FAX 310 543 9175 ABD CONSTRUCTION
PAVESYSTE
398 3 002
ACORD.M CERTIFICATE OF LIABILITY INSURANCE
• ,
THE POLICIES OF INSURAM';E L.STED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY RROUIREMENT, TERM' )R; CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TA WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN. THE INSURA.4CE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL Tr.IE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE L14 TN. SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
DATE 0129/2" "TY'
10/29/2009
PRODUCER Commercial Line,.; ;"10) 533 -9995
Wells Fargo of 0 lifarnis Insurance Services Inc.
21250 Hawthorn: Bowleverd, Suite 600
Torrance, CA 901 ~034519
THIS C R IFICA �E 1S ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORIOING COVERAGE
NAIC
INSURED Pavement Recyr: ins Systems, Inc,
II
10240 San Sevai•le I
Mira Loma, CA 617:32
jNSVARA A; Insurance Company of the State of Pennsylvania
19426
INSURER BI
GENERA. LIABILITY
COMMERCIAL OIPNEF.AL LINBII.ITY
INSURER C:
AUTHORIZED RePRE6BWN ATM ^,
`�•
INSURER D:
EACH OCCURRENCE
INSURER E;
RENTED
DAMAGE TO IPA wMrftI
• ,
THE POLICIES OF INSURAM';E L.STED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY RROUIREMENT, TERM' )R; CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TA WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN. THE INSURA.4CE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL Tr.IE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE L14 TN. SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TR
TTPE Of IIA111411 �E
POLICY NUMBER
DATE THEREOF, THE ISSWNO INSURER WILL BI IN)VC MAIL 70 DAYS WRRTBN
TiON
LIMBS
1100 E, Ore ngethorpe Avi., Swe. 200
lmmoso m
GENERA. LIABILITY
COMMERCIAL OIPNEF.AL LINBII.ITY
ABPRBYRMVRt117(
AUTHORIZED RePRE6BWN ATM ^,
`�•
EACH OCCURRENCE
f
RENTED
DAMAGE TO IPA wMrftI
6
MED E:XP (MY dna Mnm
CLAIMS MAVE 0 OCCUR
PERSONAL 6 ADV INJURY
6
GENERAL AWIGAT6
S
GEN'L AGGREGATE L: AIT .APPLIES PER;
PRODUCTS - comPIOP AGG
6
POLICY A (�• LOC
AUTOMOBILE UABILF T
COMBINED SINOLE LIMIT
(Ea "cant)
6
ANY AUTO
ALL OWNED AUTO$
POOILY INJURY
(Par Parson)
S
ACHEOULECnu' :15
HIRED AUTOS
BODILY INJURY
(Par wddant)
6
NON.OWNED AUt 09
PROPERTY DAMAGE
(Per sadden)
_
GARAGE LIABILITY —
AUTO ONLY - EA ACCIDENT
OTHER THAN EA ACC
AUTO ONLY: AGO
6
ANY AUTO
S
A
EXCE&MMARP.LLAIY,ABMLRY
X OCCUR C. J CLAIMS MADE
7518522
10101/2009
110/0142010
EACH OCCURRENCE
s 1.000.000
AGGREGATE
6 1.000.000
S
_
DEDUCTIBLE
WC STATU• O
6
RETENTION J
—
WORKERS COMPENSATNONANP
E.L. EACH ACCIDENT
6
EMPLOYERS' LIABILITY
E.L. DISEASE - EA EMPLOYEE
6
ANY pROPNt1ETORIPARTNE6aEft�CUTIVE
OFFICER/MEMBER EXCLUD:: D7
E.L. DISEASE - POLICY LIMIT
6
M. . d611CM6 under
OTHER
DESCRIPTION OF OPERATIONS 16 )CM,TIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Job Number. 29858U Job )daMia: Carson Street
FOR EVIDENCE OF COVI :RAGE
CERTIFIGAIh MVLUtK
SHOULD ANY OF TYRE ABOVE mCR19ED POUC1 W BE CANCELLED BEFORE TNB EXMRATION
DATE THEREOF, THE ISSWNO INSURER WILL BI IN)VC MAIL 70 DAYS WRRTBN
Sully Miller Contracting
NOTICE TO THE CIRTIFICiTE HOLDER NAMED TO THE LEFT, K
1100 E, Ore ngethorpe Avi., Swe. 200
lmmoso m
Anaheim, CA 82801 -1146•
ABPRBYRMVRt117(
AUTHORIZED RePRE6BWN ATM ^,
`�•
RD CORPORATr ^u ,oaa
ACORD 25 (2001108) 1 of 1 925805
(This 3srUcate replaces cartHlcate# 925582 Issued on 10/29/2009)
OCT -30 -2009 15:28 310 543 9175 96%
® M.
P.02
10/30/2009 16:29 FAX 310 549 9175 ABD CONSTRUCTION
IMPORTANT
�
39 003
�� .
If the <- ertiticate holder is an ADDITIONAL INSURED, the policy(ies) Fnust be endorsed. A statement
on this, certificate does not confer rights to the certificate holder In Ilet, of such andorsement(a).
If SUBRCGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require, ar+ endorsement. A statement on this certificate does not confer rights to the certificate
holder n weu of such endorsement(s).
DISCLAIMER
The Ce 0c. to of Insurance on the reverse side of this form does nol constitute a contract between
the Issi Inli Insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmaiiveiy or negatively amend, extend or alter the coverage afforlled by the policies listed thereon.
ACORO 25.5 (2001108) +, �f 2
#S9152601101915043
OCT -30 -2009 15:28 310 643 9175 96%
P.03
3983. ,
PROPOSAL
FOR THE
2008 -2009 FURNISHING AND APPLICATION
OF SLURRY SEAL ON VARIOUS STREETS
IN THE CITY OF EL SEGUNDO
SPECIFICATIONS NO.: PW 09 -10
TO THE CITY OF EL SEGUNDO:
In accordance with the City of El Segundo's Notice Inviting Sealed Bids, the undersigned BIDDER
hereby proposes to furnish all materials, equipment, tools, labor, and incidentals required for the
above stated project as set forth in the Plans, Specifications, and contract documents therefor, and
to perform all work in the manner and time prescribed therein.
BIDDER declares that this proposal is based upon careful examination of the work site, Plans,
Specifications, Instructions to Bidders, and all other contract documents. Submittal of this bid shall
be considered evidence that the BIDDER has satisfied himself regarding the contract documents,
access and any other field conditions which may effect bid prices. If this proposal is accepted for
award, BIDDER agrees to enter into a contract with the City of El Segundo at the unit and /or lump
sum prices set forth in the following Bid Schedule. BIDDER understands that failure to enter into a
contract in the manner and time prescribed will result in forfeiture to the City of El Segundo of the
proposal guarantee accompanying this proposal.
BIDDER understands that a bid is required for the entire work, that the estimated quantities set forth
in the Bid Schedule are solely for the purpose of comparing bids, and that final compensation under
the contract will be based upon the actual quantities of work satisfactorily completed. THE CITY OF
EL SEGUNDO RESERVES THE RIGHT TO INCREASE OR DECREASE THE AMOUNT OF ANY
QUANTITY SHOWN AND TO DELETE ANY ITEM FROM THE CONTRACT. It is agreed that the
unit and /or lump sum prices bid include all apparent expenses, taxes, royalties, and fees. In the
case of discrepancies in the amounts bid, unit prices shall govern over extended amounts, and
words shall govern over figures.
If awarded the Contract, the undersigned further agrees that in the event of the BIDDER'S default in
executing the required contract and filing the necessary bonds and insurance certificates within ten
working days after the date of the City of El Segundo's notice of award of contract to the BIDDER,
including sending by U.S. Mail a Public Works Contract for signature by the Awardee, the proceeds
of the security accompanying this bid shall become the property of the City of El Segundo and this
bid and the acceptance hereof may, at the City of El Segundo's option, be considered null and void.
I -C -1
39 8 3
EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE
BIDDER certifies that in all previous contracts or subcontracts, all reports which may have been due
under the requirements of any agency, State, or Federal equal employment opportunity orders have
been satisfactorily filed, and that no such reports are currently outstanding.
AFFIRMATIVE ACTION CERTIFICATION
BIDDER certifies that affirmative action has been taken to seek out and consider minority business
enterprises for those portions of the work to be subcontracted, and that such affirmative actions have
been fully documented, that said documentation is open to inspection, and that said affirmative action
will remain in effect for the life of any contract awarded hereunder. Furthermore, BIDDER certifies that
affirmative action will be taken to meet all equal employment opportunity requirements of the contract
documents.
NONCOLLUSION AFFIDAVIT
BIDDER declares that the only persons or parties interested in this proposal as principals are those
named herein; that no officer, agent, or employee of the City of El Segundo is personally interested,
directly or indirectly, in this proposal; that this proposal is made without connection to any other
individual, firm, or corporation making a bid for the same work and that this proposal is in all respects
fair and without collusion or fraud.
I -C -2
CITY OF EL SEGUNDO - BID SHEET 3 9 8 3 - fl 04
2008 -2009 FURNISHING AND APPLICATION OF
SLURRY SEAL ON VARIOUS STREETS
PROJECT NO. PW 09 -10
ITEM
NO.
ESTIMATED
QUANTITIES
UNIT PRICE
WRITTEN IN WORDS
UNIT PRICE
IN FIGURES
AMOUNT
Furnish and apply slurry seal, CATIONIC
1
665
Type I, complete and in place as shown
on accompanying map, for Monday
$ -7
$ I N AOS,7
Extra Long
Tons
through Friday work @
61)eA jerd S Vat Pic urJo l«s
�-
Q VIA. '75- ce4 +s per ton
Furnish and apply slurry seal, CATIONIC
2
187
Extra Long
Type I, complete and in place as shown
on accompanying map, for Saturday and
Sunday work @
$ L7 7
$ -79
'
Tons
�hda )y4nL e-A Sevee& ty Fa(A r &pia
per ton
3
LS
Street stripping per specifications for
Ne t v On e p o.; S;g hd 6 4 e )-1,4j✓�ed
_
$ S J l
o 1)4 V/ s lump sum
ALL WORK ON STREETS ADJACENT TO SCHOOL PROPERTIES SHALL BE DONE
ON SATURDAYS OR SUNDAYS
TOTAL BID = $ % 9 q % p D
TOTAL BID WRITTEN IN WORDS ah e A r ej /V,`, z `i- ,, Alto
'- CJ E 1,, -E'/ 5c VeeL dd lla/'S a70A 7ev"d C
I -C -3 (page 1 of 1)
39 83 . ,} , J
BIDDER'S INFORMATION
BIDDER certifies that the following information is true and correct:
Bidder's Name Pavement Coatings Co.
Form of Legal Entity (i.e., individual, partnership, corporation, etc.)
Corporation
If corporation, State of Incorporation (i.e., California) California
Business Pavement Coatings CO.
Address 10240 San Sevaine Way
Mira Loma, CA 91752
Telephone No.
714/826 -3011
Facsimile No. 714/826 -3129
State Contractor's License No. and Class 303609 A C -32
Original Date Issued 03 -03 -1975 Expiration Date 09 -30 -10
The following are the names, titles, addresses, and phone numbers of all individuals, firm members,
partners, joint venturers, and /or corporate officers having principal interest in this proposal:
Doug Ford, President, 10240 San Sevaine Way, Mira Loma, CA 91752 , 714/713 -7978
Richard Gove, Secretary, 10240 San Sevaine Way, Mira Loma, CA 91752 951/682 -1091
The date of any voluntary or involuntary bankruptcy judgments against any principal having an interest
in this proposal is as follows:
None
All current and prior DBA's, aliases, and /or fictitious business names for any principal having an
interest in this proposal are as follows:
None
I -C -4
39 8 3 . ,
IN WITNESS WHEREOF, BIDDER executes and submits this proposal with the names, titles,
hands, and seals of all aforenamed principals this 17th day of August -220 09.
BIDDER
Pavement Coatings Co. / Doug Ford
10240 San Sevaine Way
Subscribed and sworn to this I '-? day of AufruST, 2005
NOTARY PUBLIC
L
t 4411*## oeeollooeeemeeoeeeeee ♦eeee44eee4eee
•�� VAN P. DUNCAN o
COMM. #1689434
NOTARY PUBLIC - CALIFORNIA 0
' ORANGE COUNTY —►
�oe0000 0000eiioiMMIioie oiiooiioieoioiie�
I -C -5
3983. , ,w
PROPOSAL GUARANTEE
810 BOND
2008 -2009 FURNISHING AND APPLICATION
OF SLURRY SEAL ON VARIOUS STREETS
IN THE CITY OF EL SEGUNDO
SPECIFICATIONS NO.: PW 09.10
KNOW ALL MEN BY THESE PRESENTS that, Pavement Coatings Co,
, as BIDDER, and First National Insurance Company
of America , as SURETY, are held and firmly bound unto the City of El Segundo,
In the penal sum of Ten Per�ccent o idDOLLARS ($ 10% of), which is ten (10%) percent of the
total amount bid by BipDER'Co`} ierCi y of El Segundo fd419§'kbA'6ated project, for the payment
of which sum, BIDDER and SURETY agree to be bound, jointly and severally, firmly by these
presents.
THE CONDITIONS OF THIS OBLIGATION ARE S UCH that, whereas BIDDER is about to submit a
-laid to the City of El Segundo for the above stated project, If said bid is rejected, or if said bid is
accepted and a contract is awarded and entered into by BIDDER In the manner and time specified,
then this obligation shall be null and void, otherwise it shall remain In full force and effect in favor of
the City of EI Segundo,
IN WITNESS WHEREOF the parties hereto have set their names, titles, hands, and seals this
7th day of August 2009
BIDDER" Pavement Coatings Co.
DOUG FORD
President
SURETY* First National Insurance Company of America
Ted A amson, Attorney -in- act
Subscribed and swom to this day of 20
NOTARY PUBLIC
Provide BIDOERISURETY name, address and telephone number and the name, title,
address and telephone number for authorized representative.
I -C -6
3983 -
CALIFORNIA -• ACKNOWLEDGMENT
State of California
County of l2l VC- ✓15f ✓l+5--
On Val tr ics,— i'Z�tevo .7 before me, V fit-1 iP ' 0 O
,
Dae Here Insert me Te 2tl /fH
�° personally appeared w
2 �Name(s) of Signer(s)
who proved to me on the basis of satisfactory evidence to
be the person(s) whose name(s) is /are subscribed to the
within instrument and acknowledged to me that
he /she /they executed the same in his /her /their authorized
♦+++++++ e+ +++++ +e+ee+a + + +++e++ ++�+ +++ ++ +� capacity(ies), and that by his /her /their signature(s) on the
"u instrument VAN P. DUNCAN instrument the person(s), or the entity upon behalf of
p COMM. #1689434 g which the person(s) acted, executed the instrument.
NOTARY PUBLIC - CALIFORNIA p
O ORANGE COUNTY
+ MyComm4sionExpiraa SEPTEMBER 21 ,nio + 1 certify under PENALTY OF PERJURY under the laws
i�+ ++++♦ ♦ +++ ++o++ +ei+++++ai of the State of California that the foregoing paragraph is
true and correct.
WITNESS my hand and official seal.
Place Notary Seal Above Signature ��` Signature of Notary Public
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document: P21 t9 66N12 f)
Document Date: 4 u: & u -7 i -7, 2 m o
Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name:
❑ Individual
❑ Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑ General
❑ Attorney in Fact - •
❑ Trustee Top of thumb here
• Guardian or Conservator
• Other:
Signer Is Representing:
Number of Pages:
Signer's Name:
❑ Individual
❑ Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑ General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing
RIGHTTHUMBPRINT
OF SIGNER
of thumb here
02007 National Notary Association- 9350 De Soto Ave., P.O. Box 2402 - Chatsworth, CA 91313 -2402- www.NationalNotary.org Item #5907 Reorder: Call Toll -Free 1.800. 876 -6827
POWER
OF ATTORNEY
KNOW ALL BY THESE PRESENTS: No. 10053
39 83
First National Insurance Company of America
1001 4th Avenue
Suite 1700
Seattle, WA 98154
That FIRST NATIONAL INSURANCE COMPANY OF AMERICA, a Washington corporation, does hereby appoint
* * * * * * * * * * * * *SUZANNE ADAMS; TED ADAMSON; LYNN A. BEIMER; RICHARD L. WELLS; Brea, CA * * * * * * * * * * * * * * **
its true and lawful attorney(s) -in -fact, with full authority to execute on behalf of the company fidelity and surety bonds or
undertakings and other documents of a similar character issued by the company in the course of its business, and to bind FIRST
NATIONAL INSURANCE COMPANY OF AMERICA thereby as fully as if such instruments had been duly executed by its regularly
elected officers at its home office.
IN WITNESS WHEREOF, FIRST NATIONAL INSURANCE COMPANY OF AMERICA has executed and attested these presents
this 15th day of January , 2009
Dexter R. Legg, Secretary Timothy A. Mikolajewski, Vice President
CERTIFICATE
Extract from the By -Laws of FIRST NATIONAL INSURANCE COMPANY OF AMERICA:
"Article V, Section 13. - FIDELITY AND SURETY BONDS ... the President, any Vice President, the Secretary, and any Assistant
Vice President appointed for that purpose by the officer in charge of surety operations, shall each have authority to appoint
individuals as attorneys -in -fact or under other appropriate titles with authority to execute on behalf of the company fidelity and surety
bonds and other documents of similar character issued by the company in the course of its business... On any instrument making or
evidencing such appointment, the signatures may be affixed by facsimile. On any instrument conferring such authority or on any bond or
undertaking of the company, the seal, or a facsimile thereof, may be impressed or affixed or in any other manner reproduced;
provided, however, that the seal shall not be necessary to the validity of any such instrument or undertaking."
Extract from a Resolution of the Board of Directors of
FIRST NATIONAL INSURANCE COMPANY OF AMERICA adopted July 28,1970.
"On any certificate executed by the Secretary or an assistant secretary of the Company setting out,
(i) The provisions of Article V, Section 13 of the By -Laws, and
(ii) A copy of the power -of- attorney appointment, executed pursuant thereto, and
(iii) Certifying that said power -of- attorney appointment is in full force and effect,
the signature of the certifying officer may be by facsimile, and the seal of the Company may be a facsimile thereof."
I, Dexter R. Legg , Secretary of FIRST NATIONAL INSURANCE COMPANY OF AMERICA, do hereby certify that the
foregoing extracts of the By -Laws and of a Resolution of the Board of Directors of this corporation, and of a Power of Attorney
issued pursuant thereto, are true and correct, and that both the By -Laws, the Resolution and the Power of Attorney are still in full force
and effect.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed the facsimile seal of said corporation
this 7th day of August 2009
\�S�RANCF,,^0
=P� `Op P o g"4 f�>
a SEAL
N %1928 `os3
e1P wAS� ��b� Dexter R. Legg, Secretary
S- 1049/13F 1/09 • • r SafecoO and the Safeco logo are registered trademarks of Safeco Corporation.
WEe POF
CALIFORNIA ALL ACKNOWLEDGEMENT 3983 , e ..
State of California
County of Orange
On August 7, 2009 betore me, Lynn A. Beimer, Notary Public
Date Here Insert Name and Ttle of the Officer
personally appeared Ted Adamson
Name(s) of Signers)
who proved to me on the basis of satisfactory evidence to
be the persono�' whose named I /are subscribed to the
within instrument and ac owledge to me that(gshe /they
executed the same in Is/ r /their authorized capacity(-ieo,
LYNN A. BEIMER and that by " is signatures on the instrument the
Commission # 1781026 person or a entity upon behalf of which the personK
Notary Public - California z acted, executed the instrument.
' Orange County
comet. esoec16,2o11 I certify under PENALTY OF PERJURY under the laws of
the State of California that the foregoing paragraph is true
and correct.
WITNESS my hand and official seal.
Signatureo
Place Notary Seal Above Signature of Notary Public
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document:
Document Date:
Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name:
❑ Individual
❑ Corporate Officer — Title(s):
❑ Partner
Signer is Representing:
Number of Pages:
Signer's Name:
• Individual
• Corporate Officer — Title(s):
❑ Partner
❑ Limited
❑ General
• Attorney in Fact Top of thumb here
• Trustee
• Guardian or Conservator
• Other:
Signer is Representing:
❑ Limited
❑ General
❑
Attorney in Fact
❑
Trustee
•
Guardian or Conservator
•
Other:
Signer is Representing:
Number of Pages:
Signer's Name:
• Individual
• Corporate Officer — Title(s):
❑ Partner
❑ Limited
❑ General
• Attorney in Fact Top of thumb here
• Trustee
• Guardian or Conservator
• Other:
Signer is Representing:
CONTRACTOR'S LICENSE DECLARATION
Business and Professions Code Section 7028 15)
BIDDER'S Contractor's License Number is:
303609 Class No.: A ; C -32
2. The expiration date of BIDDER'S Contractor License is:
09 -30
2009
3983•.._
3. BIDDER'S acknowledges that Section 7028.15(e) of the Business and Professions
Code provides as follows:
"A licensed contractor shall not submit a bid to a public agency unless his or her
contractor's license number appears clearly on the bid, the license expiration date is
stated, and the bid contains a statement that representations herein are made under
penalty of perjury. Any bid not containing this information, or a bid containing
information which is subsequently proven false, shall be considered non - responsive
and shall be rejected by the..public agency."
The undersigned declares, under penalty of perjury, that the representations made
by the undersigned in this bid proposal are true and correct.
Executed on 08 -17 , 20 09 , at
Mira Loma, CA (insert City and State where Declaration is signed).
_1� 7�
Signature
Doug Ford
Typed Name:
President
Title:
Pavement Coatings Co.
Name of Bidder:
I -C -7
State of California
ss.
County of Ri vers i de
Doug Ford
3983,..
NON - COLLUSION AFFIDAVIT TO BE EXECUTED
BY BIDDER AND SUBMITTED WITH BID
being first duly sworn, deposes and say tha he r she is
President of Pavement Coatings Co.
the party making the foregoing bid that the bid is not made in the interest of, or on behalf of, any
undisclosed person, partnership, company, association, organization, or corporation; that the bid is
genuine and not collusive or sham; that the BIDDER has not directly or indirectly induced or solicited
any other BIDDER to put in a false or sham bid, and has not directly or indirectly colluded,
conspired, connived, or agreed with any BIDDER or anyone else to put in a sham bid, or that
anyone shall refrain from bidding; that the BIDDER has not in any manner, directly or indirectly,
sought by agreement, communication, or conference with anyone to fix the bid price of the BIDDER
or any other BIDDER, or to fix any overhead, profit, or cost element of the bid price, or of that of any
other BIDDER, or to secure any advantage against the public body awarding the contract of anyone
interested in the proposed contract; that all statements contained in the bid are true; and further, that
the bidder has not, directly or indirectly, submitted his or her bid price or any breakdown thereof, or
the contents thereof, or divulged information or data relative thereto, or paid, and will not pay,, any
fee to any corporation, partnership, company association, organization, bid depository, or to any
member or agent thereof to effectuate a collusive or sham bid.
Signature
Doua Ford
Typed Name
President
Title
I -C -8
Pavement Coatings Co.
Name of Bidder
Date
3983•...
CERTIFICATION
Section 1861 OF THE LABOR CODE
(Workers' Compensation)
Pursuant to Section 1861 of the Labor .Code, the BIDDER, in submitting his /her
PROPOSAL, shall sign the following certification:
"I am aware of the provisions of Section 3700 of the Labor Code which. require every
employer to be insured against liability for workers' compensation or to undertake self - insurance in
accordance with the provisions of that code, and I will comply with such provisions before
commencing the'performance of the work of this contract."
Signature of Bidder:
Title: President
Business Name: Pavement Coatings Co.
Business Address: 10240 San Sevai ne flay
Mira Loma, CA 91752
Telephone Number: ( 714 ) 826 -3011
Dated this 17th day of August , 2009
I-C' -9
3983•.
BIDDER'S CERTIFICATION OF SUBCONTRACTORS
As detailed in Section 2 -3.1 (Page II -B -3) of the City Standard Specifications, Bidder certifies
that he has listed below all subcontractors who will perform work in excess of one -half of one
percent (1/2 %) of the total bid price or certifies that the bidder is fully qualified to perform and
will perform that portion of the work himself.
NAME, ADDRESS AND PHONE
NUMBER OF SUBCONTRACTORS
a� o Sa�.4' i�C �¢v,
o35-6
SUBCONTRACTED WORK
�f r ► a ��;,� ,
(Make copies of this page if additional space is needed)
08 -17 -09
Signature of Bidder Date
DOUG FORD
President
I -C -10
3983 . , ,
REFERENCES
The following are the names, addresses, and telephone numbers for three (3) public agencies
for which BIDDER has performed similar work as the prime contractor or major subcontractor
within the past two (2) years:
1. Project Title: Slurry Seal & Microsurfacing FY 06 -07
Location: Various City Streets in the City of Orange
City of Orange, 300 E. Chapman Ave., Orange, CA 92866
Name and address of owner
Alan Trounq 714/744 -5544
Name and telephone number of person familiar with project
Type of Work: Application of Slurry Seal
Contract amount: $ 151,251. Date completed: 06 -25 -07
Amount of work done by my /our firm under contract $ 129,580.
Did your firm have any financial interest in Project?
No
2. Project Title: 2006 -07 Slurry Seal Project ( #8340)
Location: Various City Streets in the Town of Yucca Valley
Town of Yucca Valley, 57090 Twentynine Palms Hwy, Yucca Valley, CA 92284
Name and address of owner
Duane Gassaway 760/369 -7207
Name and telephone number of person familiar with project
Type of Work: Application of Slurry Seal
Contract amount: $ 223,645. Date completed: 08 -09 -07
Amount of work done by my /our firm under contract $ 216,952.
Did your firm have any financial interest in Project? No
3. Project Title: P1 acement of S1 urry Seal in Zone 4, Cash Contract #2007 -02
Location: Various City Streets in The City of La Mirada
City of La Mirada, 13700 La. Mirada Blvd., La Mirada, CA 90638
Name and address of owner
Steve Froster 562/902 -2385
Name and telephone number of person familiar with project
Type of Work: Application of Slurry Seal
Contract amount: $ 375,842. Date completed: 04 -28 -08
Amount of work done by my /our firm under contract $ 244,570.
Did your firm have any financial interest in Project? No.
I -C -11 (Page 1 of 2)
3983 .
4. Project Title: Slurry Seal & Cape Seal Phase I I I
Location: Various City Streets in the City of Duarte
City of Duarte, 1600 Huntington Dr, Duarte, CA 91010
Name and address of owner
Steve Esbenshade 626/357 -7931
Name and telephone number of person familiar with project
Type of Work: Application of • S1 urry Seal
Contract amount: $ 395,741. Date completed: 05 -22 -08
Amount of work done by my /our firm under contract, 334,905.
Did your firm have any financial interest in Project? no
5. Project Title: 2007 -08 Slurry Seal Project
Location: Various City Streets in the City of Aliso Viejo
City of Aliso Viejo, 12 Journey, Ste. 100, Aliso Viejo, CA 92656
Name and address of owner
Angel P Fuertes 949/425 -2533
Name and telephone number of. person familiar with project
Type of Work: Application of Slurry Seal
Contract amount: $ 490,971. Date completed: 06 -19 -08
Amount of work done by my /our firm under contract $ 361,202.
Did your firm have any financial interest in Project?
Z
The following are the names, addresses, and telephone numbers for all brokers and sureties
from whom BIDDER intends to procure insurance bonds:
First Natt6nal Insurance Company of America, 949/860 -6612
120 Vantis #130, Aliso- Viejo, CA 92650
1800 Lambert Road #215
Smith Newman & Adamson Insurance Agency, Brea, CA 92821 714/257 -9644
Rancho Parkway South
Ventura Pacific Insurance Services, Inc. Lake Forest, CA 92630 949/297 -4900
I -C -11 (Page 2 of 2)
10/30/2009 18:39 Remote ID Imprint ID
'f
J,3 2/6
ACORDI. CERTIFICATE OF LIABILITY INSURANCE
1 DATE 10/ 330/09 0 /09IYVYY)
PRODUCER LIC #OD10299 1- 949- 297 -4900
Venture Pacific Insurance Services, Inc.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
26487 Rancho Parkway South
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
POLICYEFFECTIVE
DATE(MMIDDfYYI
POLICY EXPIRATION
-J-
Lake Forest, CA 92630
INSURERS AFFORDING COVERAGE
NAIC#
INSURED
INSURERA INTERSTATE FIRE & CAS CO
22829
Pavement Coatings Company
INSURERe:EMPL0YER5 MIIT CAS CO
21415
INSURERC:
$ 50,000
10240 San Sevaine Ln
NSURERD: _
X COMMERCIAL GENERAL LLABILITY
Mira Loma, CA 91752
INSURER E:
MED EXP (Any ore person)
rn%iCOAr -Cc
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 CON IRACT 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN R =DJCED BY PAID CLAIMS.
INSR
LTR
DOL
POLICY NUMBER
POLICYEFFECTIVE
DATE(MMIDDfYYI
POLICY EXPIRATION
-J-
LIMITS
A
AUTHORIZED REPRESENTATIVE
GENERAL LIABILITY
SGL1002053
10/01/09
10 /01 /10
EACH OCCURRENCE
$1,000,000
PREMISES Eaoccurence
$ 50,000
X COMMERCIAL GENERAL LLABILITY
MED EXP (Any ore person)
$
CLAIMSMADE Fx-1 OCCUR
PERSONAL& ADV INJURY
$1,000,000
GENERAL AGGREGATE
$2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMPIOPAGO
$2,000,000
POLICY 7 PRO- LOC
B
AUTOMOBILELIABILITY
ANY AUTO
0X81588
10/01/09
10 /01 /10
COMBINED SINGLE LIMIT I $1,000,000
(Ea a or. idenq
X
ALL OWNED AUTOS
SCHEDULEDAUTOS
BODILY INJURY
(Per person) $ _
X
HIREDAUTOS
1 BODILY INJURY
X
NON -OWNED AUTOS
(Par accident) $
--
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EAACCIDENT
$
$
ANY AUTO
OTHER THAN EA ACC
$
AUTO ONLY AGO
EXCESSIUMBRELLA LIABILITY
EACH OCCURRENCE
$
$
OCCUR El CLAIMSMADE
AGGREGATE
$
DEDUCTIBLE
RETENTION $
_
�-
$
WC STATU- OTH-
WORKERS COMPENSATION AND
TORY LIMITS ER
$ --
EMPLOYERS' LIABILITY
' E.L. EACH ACCIDENT
ANY PROPRIETORrPARTNERIEXECUTIVE
--
$
OFFICERIMEMBER EXCLUDED?
E,L. DISEASE - EA EMPLOYEE
Ifyes, describe under
SPECIAL PROVISIONS below
EL. DISEASE - POLICY LIMIT
$
B
OTHER
Equipment Floater
0X81588
10/01/09
10 /01 /10
Contractors Equip 1,180,017
Leased /Rented 250,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
10 Day Notice of Cancellation for Non Payment of Premium.
Project: 2008 -2009 Furnishing and Application of Slurry Seal on Various Streets Project # PW09 -10
The City,its officers ,o£ficials,employees,agents, and volunteers will be named as Additional Insureds as required
by written contract as per attached endorsement.
COWTIFIr ATF un1 IIFR I'ANr Fl I ATInm
ACORD 25 (2001108) cmckinley
13511142
OCT -30 -2009 14:26
UAU,UKUI.UKrUMA1IUIV Iy00
94% P.02
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of El Segundo
DATE THEREOF, THE ISSUING INSURER WILL L XW*9 MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, ffuMyA %FS'oVWdUJMX'X
Maryam Jonas
��pffilypyph} ItNyr7gjp( g�L ItYX1�XA$ 14�IAa> d�i XAbffili7p1087fnX9UpRX�f�SBKi�giOlX
350 Main Street
XXONENKA%kN)V"XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
AUTHORIZED REPRESENTATIVE
El Segundo, CA 902
USA
ACORD 25 (2001108) cmckinley
13511142
OCT -30 -2009 14:26
UAU,UKUI.UKrUMA1IUIV Iy00
94% P.02
10/30/2009 18:39 Remote ID Imprint ID
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 (2001 /08)
D 3/6
OCT -30 -2009 14:26 94% P.03
10/30/2009 18:39 Remote ID Imprint ID
3983 1 D 4/6
t. It
POLICY NUMBER: SGLI002053 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - (FORM B)
This endorsement modifies insurance provided under the follow' g.
COMMERCIAL GENERAL LIABILITY COVERAGE PART...
SCHEDULE
Name of Person or Organization: Any person or organization for whom you are
performing operations when you and such person or organization have agreed
in writing in a contract or agreement that such person or organization be added
as an additional insured on your policy.
(if no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the
Schedule, but only with respect to liability arising out of "your work" for that Insured by or for you.
CG 20 10 11 85
OCT -30 -2009 14:26
Copyright, Insurance Services Office, Inc., 1984
Page 1 of 1 0
94% P.04
T rint 1D
10/30/2009 18:39 Remote ID mp
COMMERCIAL GENERAL 4IABILITY `10 93
POLICY NUMBER: SGL1002053
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
TRANSFER OF RIGHTS OF RECOVERY
AGAINST
WAIVER OF TRAN OTHERS TO US
s1� &'p-:
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
1 '
person or organization for whom you are performing
Name of Person or Organization; Any p reed in writing m a contract or
operations when y
ou and such person or organization have agreed our policy.
such person or organization be added as an additional own area Declarations as
agreement that P
ears above, information required to complete this endorsement will be
(If no entry app.
applicable to this endorsement.) � S of the following:
F RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMM e
The TRANSFER OF RIGHTS O our work" done
ainst the person or organization shown in the Schedule ' done
CIAL GENERAL LIABILITY CONDITIONS) is
ag mended by the a ongoing operations or ions hazard" This
right of recovery we may arising out of your ong g p Brat
We waive any ig or damage ,products- completed op
because of payments we make for organization and included in the p
under a conttr only ittotihe eon or org
waiv er app
person or organization shown in the Schedule a ove.
CG 24 04 10 93
nrT -q0 -2009 14:27
Copyright, Insurance Services Office, Inc., 1992
Page 1 of 1 13
P.05
94%
10/30/2009 18:39 Remote ID Imprint ID
AMENDMENT OF OTHER INSURANCE CONDITION - PRIMARY
INSURANCE FOR AUTOMATIC STATUS ADDITIONAL INSURED
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
[) 6/6
If required under a written "insured contract" with you, paragraph a. Primary Insurance in SECTION IV —
COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance is amended by adding the following
paragraph:
Not withstanding the foregoing, the insurance afforded to any person or organization who has been
added to this policy by an Automatic Status Additional Insured Endorsement is primary and non-
contributory insurance, but only as respects "bodily injury" or "property damage' liability arising out of
your sole negligence in performance of "your work' after the effective date of this policy under a written
contract between you and such person or organization that requires you to maintain primary and non-
contributory insurance and to include such person or organization as an additional insured thereunder.
All other terms and conditions of this policy remain unchanged.
icB -8016 06 -05
OCT -30 -2009 14:27 94% P.06
Aco or
F
(r�1m /dJ /yy� '
CERTIFICATE OF LIABILITY INSURANCE Date 10/5/2009
Producer
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.
Bolton & Company
245 S. Los Robles Ave., Suite 105
Pasadena, CA 91102
THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE
COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
INSURER Arch Insurance Company
A
INSURER
(626) 799 -7000 0008309
www.boltonco.com
Insured
INSURER
Pavement Coatings Company
C
INSURER
10240 San Sevaine Way
Mira Loma CA 91752
INSURER
E
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
POLICY
POLICY
INSR
LTR
TYPE OF INSURANCE
POLICY NUMBER
EFFECTIVE
M DATE Y
EXPIRATION
M ATE
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$
FIRE DAMAGE (Any one fire)
$
COMMERCIAL GENERAL LIAB
CLAIMS MADE OCCUR
MED EXP (Any one person)
_
$
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$
GEN' L AGG LIMIT APPLIES PER
PRODUCTS- COMP /OP AGG
$
$
POLICY PROJECT F LOC
AUTOMOBILE LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
$
BODILY INJURY
ALL OWNED AUTOS
SCHEDULED AUTOS
(Per person)
$
HIRED AUTOS
NON -OWNED AUTOS
t;
BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
GARAGE LIABILITY
_
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
$
ANY AUTO
AUTO ONLY: AGG
$
EXCESS LIABILITY
EACH OCCURRENCE
$
OCCUR ❑ CLAIMS MADE
AGGREGATE
$
S
$
DEDUCTIBLE
$
RETENTION $
A
WORKERS' COMPENSATION &
EMPLOYERS' LIABILITY
ZAWC19174900
10/1/2009
10/1/2010
STATUTORY LIMIT THE
"
EL EACH ACCIDENT
$ 1,000,000
EL DISEASE - EA EMPLOYEE
$ 1,000,000
EL DISEASE - POLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATIONS /LO ATIONS V HICLES EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS
Job: Project #PW 09 -10, 2008 -2009 Furnishing and Application of Slurry Seal on Various Streets.
'10 Days notice of cancellation for non - payment of premium by registered or certified mail.
CERTIFICATE HOLDER CANCELLATION
Project #PW 09 -10
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL i 0010 2 U MAIL
30* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
City of El Segundo
350 Main Street
El Segundo, CA 90241st
LEFT,Ifo2(fXIL�4i�i?Ob}��(d4Afl
10 Days for Non - Payment of Premium.
AUTHORIZED
REPRESENTATIVE
William A. Lewis ��������Vy� • `�������V �//
ACORD 25 -S (7/97) O ACORD CORPORATION 1988
CERT NO.: 594097'/ CLIENT CODE: PAVEM -1 Bolton 1 -ezt i.ficate Pi ocessi ng 10/5/20119 5.37 21 AM Page 1 of
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 -S (7/97) created at www.e CertsONLINE.com
CEPT NO.: 5940977 CILIENT CODE: PAVEM -I Bolton Certificate Pror_escing 10/5/2009 5 37:7.] AM Page ^ of 7
10/30/2009 16:29 FAX 310 549 9175 ABD CONSTRUCTION
1& 002
J
PAVEBYeTE
ACURD.M CICERTIFICATE OF LIABILITY INSURANCE 1 oar10 2009 T1
LTp
THIS CERTIFICA IS ISSUED AS A MATTER OF INFORMATION
PRODUCER Commercial Line-.: ',: TO) 533 -9995
.E
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
EACH OCCURRENCE
5
HOLDER. THIS COTIFICATE DOES NOT AMEND, EXTEND OR
Wells Fargo of 0ilifornia Insurance Services Inc.
GENERAL LIABILITY
ALTER THE COVEERAGE AFFORDED BY THE POLICIES BELOW.
21250 Hawthorn, Bowleverd, Suite 600
DAMAGE TO RENTED
S
Torrance, CA 90r'034S519
INSURERS AFFOR14ING COVERAGE
NAIC 0
INSURER A: Insurance Company of the State of Pennsylvania
19428
INSURED pavement Recyc: ng w:yslems, Inc,
6
GENERALAOORSQATE
S
10240 San Seva; )e I 0"Iay
INSURER a:
PRODUCTS - COMPIOP AGG
S
INSURER c:
—
INSURER D:
Mira Loma. CA k 1T ?;::
COVERAGES _
THE POLICIES OF INSURAN;E LSTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY RIEOUIREMENT, TERM' )K ONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITM RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURR•4CE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL Tr.IE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE 1-1141 TV$HOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
— Tit UMITS
LTp
TYPE OF INGS RAW9
POLICY NUMBER
EACH OCCURRENCE
5
GENERAL LIABILITY
DAMAGE TO RENTED
S
COMMERCIAL GI: NENAL LIABILITY
CLAIMS MAI'E D OCCUR
MED EXP (MY 0014 Perean )
S
PERSONAL 6 ADV INJURY
6
GENERALAOORSQATE
S
'
PRODUCTS - COMPIOP AGG
S
—
OEN'L AGGREGATE L: AIT .APPLIES PER:
POLICY JIEZ I LOC
AUTOMOBILE UABILF T
COMBINED SINGLE LIMIT
(go ac4l0enl)
5
ANY AUTO
ALL OWNED AUT IS
BODILY INJURY
(Per perc401)
3
eCHEOU6EDAU' 75
HIRED AUTOS
BODILY INJURY
(Per a0deen1)
S
NON -OWNED ALh OS
PROPERTY DAMAGE
(Per B0d0erel
S
—'
AUTO ONLY - EA ACCIDENT
$
GARAGE LIABILITY
ANY AUTO
OTHER EA ACC
AUTO ONLY; A00
$
3
q
ExcESSnIMeReLU N. AeaurY
X OCCUR C CI -AIMS MADE
7518522
10101J2009
10/0'12010
EACH OCCURRENCE
S t,00�,000
AGGREGATE
f t,00n,000
S
S
DEDUCTIBLE
a
RETENTION b -
WC STATU- 0
WORKERS COMPENSATIOWANI"
EMPLOYERS' LIABILITY
ESL, EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE
i
ANY PROPRIETORIPARTNEV9XEr1UTIVE
OFFICEWMEMBER EXCLUDI; D7
If ee, dmWft IMOer
E.L. DISEASE - POLICY LIMIT
3
R V �.
OTHER
DESCRIPTION OF OPERATIONS 16 )CA+TIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS
Job Number: 299580 Job Wawa! Carson Street
FOR EVIDENCE OF COWRAGE
Sully Miller Contracting
1100 E. Orangethorpe &0., She. 200
Anaheim, CA 92801 -1146,
ACOR13 25 12001/0811 of
SHOULD ANY OF THE A9eiVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSk "1140 INSURER WILL 901091MR11111IMMAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIPIC4TE HOLDER NAMED TO THE LEFT, X
AUTHORIZED
(This:ergicate replaces certificate# 925582 lesued on TUwJ19vuu)
OCT -30 -2009 15:28 310 543 9175
® ACORD CORPORATION 199E
96% P.02
10/00/2009 16:29 FAX 310 540 9175 ABD CONSTRUCTION
IMPORTANT
If the s-ertifiaats holder is an ADDITIONAL INSURED, the policy(iss) f'nust be endorsed. A statement
on this. certificate does not confer rights to the certificate holder In IleL of such endorsement(s).
If SUB ICC' ATION IS WAIVED, subject to the terms and conditions or the policy, certain policies may
require arr endorsement. A statement on this certificate" does not confer rights to the certificate
holder n weu of such endorsement(s).
DISCLAIMER
The Ctirtltiaate of Insurance on the reverse side of this form does nol constitute a contract between
the Issi Ini.I Insurer(s), authorized representative or producer, and the certificate holder, nor does it
effirmaNvely or negatively amend, extend or alter the coverage afforlied by the policies listed thereon.
ACORD 25.3 (2001108) if 2
#S91526011iA915043
OCT -30 -2009 15:28 310 643 9176 96%
[A 003
P.03