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PROOF OF INSURANCE (2010) CLOSEDACffRD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 05/09Z2009 PRODUCER (818) 225 -7025 rSu Insurance Services - Meridian Brokerage 22801 Ventura Blvd. Suite 203 woodland Hills CA 91364- THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY HOLDER. NTHIS OCERT CERTIFICATE DOES NOT AMEND EXTEND R ALTER THE COVERAGE AFFORDED BY THE POLICIkS BELOW. INSURERS AFFORDING COVERAGE NAICII INSURED Bandmaster, Inc.,dba Sandmaster Sandblasting 18140 San Fernando Mission Blv INorthridge CA 91326- INSURERA:Colony Insurance Co LIMITS INSURERS: X INSURER C: OL3411955 INSURER 02/25/2010 INSURER E: $ 11000,000 1914171 1:1-TO :$-9 THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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. sISR OD' TYPE OF INSURANCE POLICY NUMBER Mj L1tWDWYY) pp qq��pp DATE WNDWYY LIMITS A X GENERAL LIABILITY OL3411955 02/25/2009 02/25/2010 EA HOCCURR CE $ 11000,000 3. COMMERCIALt SHEeRALLIABILITY CLAIMS MADE a] OCCUR / / / % P MI E re $ 30,000 MEDEXP (Anyone arson S 3,000 RSONAL DV INJURY $ 11000,000 GENERAL AGGREGATE S 2,000,000 GENLAGGREGATELIMITAPPLIESPER: X POLCY JEA- LOC PR DUCT - MP P S 2,000,000 / / / / Deductible 11000 AUTOMOBILE LIABILITY ANY AUTO / / % % COMBINED SINGLE LIMIT (Ea socident) : ALL OWNED AUTOS SCHEDULED AUTOS / / / / BODILY INJURY (Per Person) S HIRED AUTOS NON-OWNEOAUTOS / / / / BODILY INJURY (Peracddenf) : PROPERTY DAMAGE (Per socident) S GARAGE LIABILITY AUTO ONLY - EA ACCIDENT i ANY AUTO / / / / OTHER THAN EA ACC S AUTOONLY: A S EXCESSIUMBRELUA LIABILITY / / / EACH 0 C4URRENCE S AGGREGATE S OCCUR F CLAIMS MADE s DEDUCTIBLE S RETENTION S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY / % / / TgwLws E.L.EACHACCIDENT S ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? If yes, desmb* under DISEASE • EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT $ SPECIAL PROVISIONS b0 OTHER DESCRIPTION OF OPi[ RATIONWLOCATIONSAIEHICLEWEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS Waterproofing By Pressure Apparatus. Job Loc: Acacia Perk & Pool - 600 Block Of W. Acacia, El Segundo, CA 90245 & Hilltop Park i Pool - N/W Corner Of Maryland St a Grand Ave., E1 Segundo, CA 90245. City of 21 Segundo, Its Officers, Officials, &Vloyees, Agents & Volunteers Are Named As Additional Insured Per Attached Endorsement. Coverage On This Policy Is Primary & Non- Contributory. CERTIFICATE HIOL13ER caNrFl 1 ATInu #% ,Vl%W ca (wuuUa) * „A I08025ioloe).os ELECTROI.6SER FORMS, INC. - (800)327 -0545 0 ACORD CORPORATION 1988 Peg* 1 of 2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE UPIRAMON DATE THEREOF. THE ISSUING INSURER WILL a]fOUVANX= MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, WK City of El Segundo ) bIIJIXA4) SIHf) 616IfAiKIXirN�1fI< iQ( dI�WEIIiI I' i( 968�fIIYpfafKltlR )OitaOas><X1f16)U4141ilfE City Hall X 350 lain Street AUTH:EDREPRESENTATIVE 81 Seaundo CA 90245 - ° #% ,Vl%W ca (wuuUa) * „A I08025ioloe).os ELECTROI.6SER FORMS, INC. - (800)327 -0545 0 ACORD CORPORATION 1988 Peg* 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 Ilsted thereon. ACORD 25 (2001108) 4_ INS025tojoeyos Pop 2or2 GENERAL CHANGE ENDORSEMENT This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below: Name of Insurance Company(ies) Cclony Insurance Company Colony Ins Company 100.01 GenLiab Endorsement Effective 5/11/2009 Inception Date Expiration Date 2!2512009 2/25/2010 Policy Number Endorsement 4 GL3411755 I Named Insured 2,D, Burnett Sandmaster, Inc Countersigned By (Authorized Representative) IN CONSIDERATION OF THE ADDITIONAL PREMIUM SHOWN BELOW, IT IS HEREBY UNDERSTOOD AND AGREED THAT THE POLICY IS AMENDED AS FOLLOWS: THE FORM U156 (08107) ADDITONAL INSURED- OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION IS HEREBY ADDED TO THE POLICY AS PER THE ATTACHED FORM FOR THE FOLLOWING: CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS & VOLUNTEERS 350 Main Street El Segundo, CA 90245 All other terms and conditions remain unchanged FRXICUM ..... : $ 250.00 (FLILLY EARNED) Tax.......... $ 7.50 STMMING FEE: $ .56 TOTAL........ $ 258.06 vegoldsmith 5!2612009 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name of Additional Insured Person(s) or Organization(s) of Covered City of El Segundo, Its Officers, Officials, Employees, Agents, & tca4:1a rarer W. ruu, Volunteers 600 Block of W. Acacia, El Segundo, CA 90245 350 §IrIFI, l Se�tndo, CA 90245 estop Park & Pool N.W. Corner of Maryland St. & Grand Ave $250.00 - Fully Earned El Segundo, CA 90245 A. SECTION II - WHO IS AN INSURED is amended to incivae as an additional insured the perso(s) or organization(s) shown in the Schedule 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. Such person or organization is an additional insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" casued, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: Additional Insured Contractual Liability "Bodily injury" or "property damage" for which the "additional insured(s)" are obligated to pay damages by reason of the assumption of liability in a contract or agreement. Finished Operations or Work "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. Negligence of Additional insured "Bodily injury" or "property damage" directly caused by or resulting from the negligence of the "additional insured(s)". ALL OTHER TERMS AND CONDITIONS OFTHE POLICY REMAIN UNCHANGED. U156 -0807 Includes copyrighted material of ISO Properties, Inc., Page 1 of 1 with its permission. BLANKET ADDITIONAL INSUREDS - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: City of El Segundo Any person or organization that the named insured is obligated by virtue of a written contract or agreement to provide insurance such as is afforded by this. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) A Section II —Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions 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 site 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. The words 'you" and 'your" refer to the Named Insured shown in the Declarations. D. 'Your work" means work or operations performed by you or on your behalf; and materials, parts or equipment furnished in connection with such work or operations. Primary Wording if required by writlen contract or agreement: Such insurance as is afforded by this policy shall be primary insurance, and any insurance or self- insurance maintained by the above additional insured(s) shall be excess of the insurance afforded to the named insured and shall not contribute to it. Waiver of Subrogation_ If required by written contract or agreement: We waive any right of recovery we may have against an entity treat is an additional insured per the terms of this endorsement because of payments we make for injury or damage arising out of 'your work" done under a contract with that person or organization. ANF- ES 043 (5! 2006) Insured Copy ',n- ...•cam _46i acoRV CERTIFICATE OF LIABILITY INSURANCE OP ID PR SAN= -1 DATE(MM/DDIYYYY) 1 05/07/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Modern Insurance, Inc. 333 W. 5th St., P.O. Sox 1031 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.. f San Pedro CA 90733 -1031 Phone: 310 - 832 -1131 ._INSURERS AFFORDING COVERAGE NAIC # u v� INSURED j1 INSURER A. Mercury Casualty 011908 _ INSURER B: Sandmaster Inc. DBA: SandmasterSandblq,st *ng 18410 San Fernando Mission Bvd Porter Ranch CA 91326 INSURER C: INSURER D: INSURER E: re%V=DersFC 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. LTR INSIRE TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YY DATE LIMITS El Segundo CA 90245 JIMIM GENERAL UABILITY EACH OCCURRENCE $ UANTAUI: I HEN EAJ PREMISES (Ea occurence) $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE C] OCCUR MED EXP (Any one person) 5 {(�GENERAL PERSONAL & ADV INJURY $ AGGREGATE II _ $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- LOC JEC7 PRODUCTS - COMPIOP AGG i S A X AUTOMOBILE LIABILITY ANY AUTO AC11044679 12/08/08 12/08/09 COMBINED SINGLE LIMIT (Ea accident) I 51,000,000 � � - --- - - -_ -� ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per person) $ X HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per acutident) $ j _ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGG EXCESSIUMBRELLA LIABILITY OCCUR CLAIMS MADE i EACH OCCURRENCE AGGREGATE $ $ $ DEDUCTIBLE $ $ RETENTION $ WORKERS COMPENSATION AND TORY EMPLOYERS' LIABILITY ANY PROPRIETORMARTNEWEXECUTIVE El EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE S OFFICERIMEMBER EXCLUDED? f Yes, describe under SPECIAL PROVISIONS below , El. DISEASE- POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS *Except 10 days for nonpayment of premium. Certificate Holder City of E1 Segundo, its officers, officials, employees, agents, and volounteers are Additional Insured, but only as respects to the operations of the insured as covered by this policy. rPOT'IFIrATF Hnl nFa CANCELLATION C.ITZZS3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL EMAIL 30* DAYS WRITTEN City of El Segundo NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Recreation & Parks ymeD�meao�agDi<ooxa�o>x�3CX 350 Main Street El Segundo CA 90245 JIMIM AUTHORIZED , v Paulett Redlew CI R ACORD 25 (2001108) V AGUKU GUKPUMAI IVN IV00 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) IQ pA GATE IMMIDDM —M ACOR . CERTIFICATE OF LIABILITY INSURANCE _1 0512810 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE modern insurance, Inc. mode 333 r 5th St . , P.O. Box 1031 San Pedro CA 90733 -1031 phones 310 -832 -1131 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC N INSURED INSURER A: G elaea ca Lion iaa FW A OA INSURER B: LIMITS $.. UMANUE IV KEN I PREMISES (En aavrence INSURER C: MED EXP (Any one person) $andmaater Inc. DBlls�andmasterSandbl�1st ng 1841 Sass i4 Ills$ on Bvd porter Aanob CA 9326 INSURER D: 1uR11RFR F COVERAGE$ THE POLICIES OF INSURANCE LISTED BELOW NAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE 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 18 SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCEO BY PAID CLAIMS. LTR R TYPE OF INSURANCE 09NERAL LIABILITY COMMERCIAL GENERAL LIABILITY POLICY NUMBER OA Recreation & Parks LIMITS $.. UMANUE IV KEN I PREMISES (En aavrence S MED EXP (Any one person) i CLAIMS MADE � OCCUR PERSONAL S ADV INJURY i GENERAL AGGREGATE S PRODUCTS • COMP/0P AGG - -... — .. ---- ---- �.._. _. GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea ecodeni) S ANY AUTO ALL OWNED AUTOS BODILY INJURY (Per person) S SCHEDULED AUTOS HIREDAUTOS NON-OWNED AUTOS v((i,V� BODILY INJURY (Per ewdent) S J) PROPERTY DAMAGE (Per eccidere) i GARAGE LIABILITY ANY AUTO AUTO ONLY ACCIDENT S __EA OTHER THAN EA ACC AUTO ONLY: AGO S S EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE S AGGREGATE + $ OCCUR CLAIMS MADE S S DEDUCTIBLE RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS'UABILITY ANY PROP$KTORIPARTNE'LEXECUTIVE OFFICERIMEMBER EXCLUDED? 163546009 09/17/09 09/17/10 x 17ORP LIhjT3 E EL EACH ACCIDENT $1,000,000 E.L. DISEASE •EAEMPLOYE 1 i1, 000, 000 E.L. DISEASE • POLICY LIMIT S 1, 000 000 I describe under SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS *Except 10 days for nonpayment of Premium. Ur.K I Irewt 1 C nVwYGR - -- - - -- - SHOULD ANY OF THE ABOVE DESCRIBED POUC1E3 BE CANCELLED BEFORE THE EXPIRATION CITSES3 DATE THEREOF, THE ISSUING INSURER WILL 9W2[AQDa WAWL 30* DAYS WRITTEN City of El Segundo NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BaF Recreation & Parks �p$'p smSXOti�14X 350 Blain Street �ia6 81 Segundo CA 90245 A a P. xi ins ,w wr•non PAO�AD�71Ae1 SAAR ACORD 25 (2001108) /