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PROOF OF INSURANCE (2017) CLOSEDIRMAJ 14 � ��I� , DAiE(MMIDD'NYYYj.........-- CERTIFICATE OF LIABILITY INSURANCE 6/2/2016 11.11 ........ mm ...�._ -- _. _ .m.- �.,,.������� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUB ........ .......... ..... - -- -- - - - - -- ROGATION 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). ....._... .. ......... ......... .,., .,.... .... .. ... ............. ....� .... .... N ACT —' : ...... —__ ........... . ......... ................ ............................... ...... PRODUCER License # 0252636 NAME_ Christine Crilley, CISR P,O,� BOX 488 .%I Al United A(encies Pwlurt sbk La Verne CA 91750 -7488 Aoo ExtP °7919 R,AAd!1.t. f909) 593 -5477 Ess. ccrilley(�hardylrm.com COVERAGES CERTIFICATE NUMBER: REVISION NUMBER_: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTOTHE INSURED NAMEDABOVE FOR EPOLIC THE Y PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. fL TYPE OF INSURANCE INSD WVD POLICY NUMBER IMMIDDIYYYY) (MMIDDIYYYYI LIMIT S ....... . . A. COM M. ..,,,,,......... . ............................... .. ................................................ -------- ERCIAL GENERAL LIABILITY ...-. _...___� ._._..�..� EACH OCCURRENCE $ 1,000,000 ®occuR X X NA105107003 0311312016 0311312017 PARMMAG�TiiE ElSiur,� " " " "" .... 100,000 CLAIMS -MADE � e nnce) $ ......, MED EXP (Anyone person) $ 5,000 PERSONA,.., .... ............................ $ ...... ......................2,000,000 1,000,000 GEN'LAGGREGATELIMITAPPLIESPER GENERAL AGGREGATE$ _ k "H(b POLICY D J( °.t; T T5 COMPA)P AGO $ „�.... 2, , ........0.....0 „ „ 000..0.... O €11th $ AUTOMOBILE LIABILITY iLalaclra Rd e $IGR E: f..... $ µeu1,)...... .. 1,000000 B ANY AUTO 12001934 0112012016 0112012017 BODILY INJURY (Per person) $ ALL O ED " SCHEDULED AUTOS AUTOS BODILY INJURY (Pe _ .. r accident) $ NON-0 ED PRdJgadN(iYCWf41s6PE HIRED AUTOS AUTOS ... ..... .. .....1111........... ..1111 UMBRELLA LIAB X ... ,,,,,,,,,, ,,,,,,,,, OCCUR .,,,,,,...... ,.............. ........ - -.,.,.,....... $ 4,000,000 .. C X EXCESS LIAB CLAIMS -MADE „_ AGGREGATE GATE $ 4,000,000 . ...,1111 ........... ........ 11...11,, ........, QED RETE NTION $ .. '.. $ WORKERS COMPENSATION ..... ---- - __....._, 1111,,,....... PEit U rH ................. BILITf D EMPLOYERS' LIABILITY Y / N TATUTE ER At R IVE;. E L EACH ACCIDENT OWE @�Mtfi'r IR) k4,. "k.U()WEXI�:�:.CtW I It NIA , ^ _$ ....... ,. (Mandatory In NH) .. E L DISEASE - EA EMPLOYEE $ If has doscrrlyr gpider ....____....__ tkW 4t NC fn)N4I 4Wrx4'a4°RA'NWI'W, R91:tIov - I - - - - ------------ EL DISEASE - POLICY LIMIT $ ................................. DESCRIPTION OF OPERATIONS l LOCATIONS I VEHICLES ...,. ... ............................ ............ ...... ........................ ..................---- ------..... ___.......�.._.. - -. - -- --------- (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) ...................... ............................... Re: Engineering Plan Check Service, City of El Segundo. Certificate holder and its officials, officers, agents and employees are included as additional insured per 49 -0116 (07111) endorsement including primary wording & waiver of subrogation. Via email: jhegvold @elsegundo.org _ Ff ..... . ................... CERTIFICATE HOLDS ... ........... CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo 350 City Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 _......... ............ .. .m......_ _.................. ..m. ......... .......... .. .......... ....,.,.............................. ..................... ......._��Y. AUTHORIZED REPRESENTATIVE L................ � .......................... @...1988 -2014 ACORD CORPORATION. All rights re ... served. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY SCHEDULED ADDITIONAL INSURED ENDORSEMENT (EXCLUDING RESIDENTIAL) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (FORM B) CG 20 10 11 85 Policy Number: NA105107003 Endorsement Effective: 03/13/16 12:01am Named _ �_ �....� ......... ............................ _ Insured: Countersigned By. SCOTT MICHAEL WEAVER SCOTT WEAVER t . ____.........._.�, ,— .____ --_ SCHEDULE Name o f Person or Organization: CITY OF EL SEGUNDO 350 MAIN STREET EL SEGUNDO CA 90245 VARIOUS LOCATIONS THROUGHOUT EL SEGUNDO, CA 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. The following additional provisions apply to any entity that is an insured by the terms of this endorsement: 1. Primary Wording If required by written 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 insureds) shall be excess of the insurance afforded to the named insured and shall not contribute to it. 2. Waiver of Subrogatilon, If required by written contract or agreement: We waive any right of recovery we may have against an entity that 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. 3. Neither the coverages provided by this insurance policy nor the provisions of this endorsement shall apply to any claim arising out of the sole negligence of any additional insured or any of their agents /employees. 4. This endorsement does not apply to any work involving or related to properties intended for permanent residential or habitational occupancy (other than apartments). The words "you" and "your" refer to the Named Insured shown in the Declarations. '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. 49 -0116 0711 May Include Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 1 Used with permission Check A License - License Detail - Contractors State License Board Contractor's License Detail for License # 739029 Page 1 of 1 DISCLAIMER: A license status check provides information taken from the CSLB license database. Before relying on this information, you should be aware of the following limitations. CSLB complaint disclosure is restricted bylaw (B &P 7124 6) If this entity is subject to public complaint disclosure, a link for complaint disclosure will appear below. Click on the link or button to obtain complaint and /or legal action information. Per B &P 7071 17 , only construction related civil judgments reported to the CSLB are disclosed. Arbitrations are not listed unless the contractor fails to comply with the terms of the arbitration. Due to workload, there may be relevant information that has not yet been entered onto the Board's license database. Business Information SCOTT WEAVER 1114 ST GEORGE DR SAN DIMAS, CA 91773 Business Phone Number:(909) 239 -4894 Entity Sole Ownership Issue Date 08/07/1997 Expire Date 08/31/2017 License Status This license is current and active. All information below should be reviewed. Classifications 6� / I)28, D0 0F','&,,, GAI1.S AIJD CIIIVAL U,,G II"II!L'OCIII -S Bonding Information Contractor's Bond license filed a Contractor's Bond with AMERICAN CONTRACTORS INDEMNITY COMPANY. nd Number: SC6028481 nd Amount: $15,000 ective Date: 01/01/2016 IIlti::nd II Illstor'v� license is exempt from having workers compensation insurance; they certified that they have no employees at this time. Aive Date: 07/31/2015 re Date: None :ers' Compensation History https: / /www2. cslb. ca. gov/ OnlineServices/ CheckLicenseII /LicenseDetail.aspx ?LicNum= 739029 6/1/2016 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($1010,000)w IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: (_) I have and will maintain a certificate of consent of self- insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement with the City of El Segundo. Policy No. (� I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone # I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those provisions or the agreement will automatically become void. Signature of Applicant Date r �, �. „�.._,�. Date Agreement for: SCOTT WEAVER T.I. - DOORS Dated„ Reviewed by: _ „°�” NSURAIl CE & IRS SK MANAGIf::NII::NT In aIf iIi( �ti(,rm with Unik,rl A Inc, June 1, 2016 Re: Scot Weaver Worker's Compensation Insurance To Whom It May Concern: Hardy Insurance Service is the insurance agent for Scott Weaver. We currently handle his General Liability & Excess Liability policies. In regards to Worker's Compensation, Scott Weaver is a sole proprietor with no employee's; therefore he is not required to have Worker's Compensation in the State of California. I have attached a copy of the CSLB print out for Mr. Weaver's contractor's license showing he is exempt from having to carry Workers Compensation. If you have any questions please give me a call. Thank you C rCst& er C v'i,L' ley, CIS2 Christine Crilley, CSIR Account Manager