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PROOF OF INSURANCE (2018 - 2019) CLOSED ALPIN-2 OP ID: BF DD/YYYY) (MMI CERTIFICATE OF LIABILITY INSURANCE DATE MMI2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). ME: North County Insurane North Count PI Insurance II'ONI CT FAX 6 P.O. Box 907 No 760-745-9157 Escondido CA 92033-0907 Rosalie Delaney A�Y05RESS.� bfak 7459 1 0count cnsurance.Com(,. „ INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:U. S.Specialty Ins CO 29599 INSURED Alpino Building INSURER B: 14422 Pauma Vista Drive Valley Center,CA 92082 INSURER c: INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE ------ AND '5MUBDR POLICPOLICYNUMBER IM IDDIIYYNYI rhP1(,�MORIY YYL LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMA TO RENTED CLAIMS-MADE X OCCUR X X U18AC105760-00 06/08/2018 06/08/2019 MISES,(Ea,occurrence) $ 100,000 MED ERCP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 N POLICY FRO- 1 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 P JECT O7"'11F;It AUTOMOBILE LIABILITY COMBINED SI'NGC.0 LIMI'T' (Ea accide nk) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS .. ... . NON-OWNED GC"CYN"Cn'Fi'IfY'DVIINIP4rI;` ..$ HIRED AUTOS AUTOS (l or accodrrntl MBRELLA UAB- X lOCCUR CLAIMS-MADE UlEAC105760-00 06/08/2018 06/08/2019 AGGREGATE RRENCE .$ , ,m 1000 ,000 000,000 A X XCESSLAB DEDI I RETENTION$ $ WORKERS COMPENSATION _IN _A STATUTEPER __ _ ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y E L EACH ACCIDENT $ OFFICEPIMEMBER EXCLUDED? NIA (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ If yes,de�xribe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more space is required) RE:DOWNTOWN EL SEGUNDO PARKLETTE DESIGN&CONSTRUCTION, PROJECT NO. PW 18-23 City of El Segundo,its off lc'ers,offic'ials,em ploees,ag ents and Volunteers are additional Insured per attached CG2010 0704,CG2037 0704.Primary non- contributory and waiver of subrogation per attached HCS04061013. CERTIFICATE HOLDEN. CANCELLATION CITYELS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of EI Segundo, its ACCORDANCE WITH THE POLICY PROVISIONS. officers,officials,employees agents and volunteers AUTHORIZED REPRESENTATIVE 350 Main Street EI Segundo,CA 90245 I ©1988-2014 ACORD CORPORATION. All rights reserved, ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: U18AC105750-00 COMMERCIAL GENERAL LIABILITY CG 2010 07 04 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 SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location(s) Of Covered Operations Any person or organization for whom you are performing operations during the policy period 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. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", "property This insurance does nota I to "bodilyinjury" or damage" or "personal and advertising injury" ,.property damage occurring after: apply caused, in whole or in part, by: 1. All work, including materials, parts or 1. Your acts or omissions; or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. 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. CG 20 10 07 04 ©ISO Properties, Inc.,2004 Page 1 of 1 C0 POLICY NUMBER: U1SAC105750-00 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location And Description Of Completed Or Organization(s): Operations Any person or organization,when you and such parties have agreed in writing in a contract or agreement pertaining to"your work" performed during the policy period. This additional insured coverage does not apply to"excluded residential construction". "Excluded residential construction"means: a) the ground-up construction of any building whose units will be individually owned and titled; and, b) "your work" performed on the conversion of any building into a condominium or townhome. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products- completed operations hazard". CG 20 37 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 D POLICY NUMBER: U18AC105750-00 COMMERCIAL GENERAL LIABILITY HCS 040 06 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY Y AMID BLANKET WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. PRIMARY AND NON-CONTRIBUTORY TO B. WAIVER OF SUBGROGRATION— BLANKET OTHER INSURANCE Under SECTION IV — COMMERCIAL GENERAL With respect to any person or organization that is LIABILITY CONDITIONS, The Transfer Of an additional insured under this Coverage Part, Rights Of Recovery Against Others To Us the following is added to paragraph 4. of Condition is amended by the addition of the SECTION IV — COMMERCIAL GENERAL following: LIABILITY CONDITIONS: We waive any right of recovery we may have If you have agreed in writing in a contract or against any person or organization because of agreement that this insurance is primary and non- payments we make for injury or damage arising contributory relative to an additional insured's own out of: insurance, then this insurance is primary and we a. Your ongoing operations; or will not seek contribution from that other insurance. For the purpose of this endorsement, b. "Your work" included in the "products- the additional insured's own insurance means completed operations hazard". insurance on which the additional insured is a However, this waiver applies only when you have Named Insured. agreed in writing to waive such rights of recovery When this endorsement is attached to the policy it in a contract or agreement, and only if the contract supersedes all other insurance conditions within. or agreement: a. Is in effect or becomes effective during the term of this policy; and b. Was executed prior to loss. HCS 040 06 10 13 Page 1 of 1 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. 00 DATE(MMIDDIYYYY) AC-"RI)i CERTIFICATE OF LIABILITY INSURANCE kw�. 6/14/2018 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 policyQes)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Jennifer Rhodes Auto Insurance Specialists PHONEa.Iat).' ) 800-498 AMC: 866-570-7335 ,vice No -3293 DES, I@aisinsurance.com 17785 enter Court rive E-MAIL commercial@aisinsurance.com 500 INSURER(S)AFFORDING COVERAGE NAIC# Cerritos CA 90703 INSURER A:California Automobile Insurance Company 38342 INSURED INSURER B: Vincent Alpino INSURERC: DBA Alpino Building INSURER D ................................................... 14422 Pauma Vista Dr INSURER E .......................................................................................... Valley Center CA 92082 INSURER F; COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADedSaR -- POLICY EFF - PO'LI'CY E'XP LTR TYPE OFINSURANCE POLICY NUMBER (MMlDDIYYYY) NM1ODfYYYY J .. ._._LIMITS COMMERCIAL GEN LIABILITY � EACH OCCURRENCE $ TACCREN TLO CLAIMS-MADE DOCCUR $ ........... MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 0 PRO.YRi,CT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ A AUTOMOBILE LIABILITY CC_a�x,cINED SINGLE LIMIT 000,000 COMBINED SINGLE BA040000046197 06/14/2018 06/14/2019 ) $ 1 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS ® HIRED NON-OWNED PI4,l'APEIfi'6"Y'DAMAGE AUTOS ONLY AUTOS ONLY _C€>srr apr;,aur)rapal)� $ .____,........... OCCUR OCCURRENCE ................................................................. EXCESS LlAB.UMBRELLALIA.B............. ...o..........M.S-MADE AGGREGATE........ DED F-1 1 RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN STATUTE, ERH $ OF ICd R MEBE EXCLUDED? ED?ECUTIVE ❑ N/A E.L.DISEASE-EA EMPLOYEE $ ..... If (Mandatory ry ) DESCRIPTION OF OPERATIONS below r E�L,DISEASE POLICY LIMIT describe under $ Q Q DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate holder is listed as additional insured. CERTIFICATE HOLDER CANCELLATION City of EI Segundo, it?s officers,officials,employees,agents and SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE volunteers THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo, CA 90245-3813 AUTHORIZEDRCPRC$ENTAnV I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Produced using Forms Boss Web Software.www.FormsBoss.com(c)Impressive Publishing 800-208-1977 Policy Number: BA040000046197 ' CUR INSURANCE Effective Date: 06/14/2018 New Declarations BUSINESS AUTO DECLARATIONS For resolving issues or other information you can contact your agent or Mercury using the below phone numbers: .............. Issued By: Agent: California Automobile Insurance Company Auto Ins Specialists-CA P.O. Box 10730 PO BOX 6507 Santa Ana,CA 92711-0730 ARTESIA,CA 90702 Billing:(888)637-2176 Agent Number:044034 Claims: (800)503-3724 Agent Phone: (800)493-7879 ITEM ONE GENERAL INFORMATION Named Insured: VINCENT ALPINO DBA ALPINO BUILDING Mailing Address: 14422 Pauma Vista Dr, Valley Center,CA 92082-4505 Policy Period: From 06/14/2018 to 06/14/2019 at 12:01 AM Standard Time at your mailing address Business Type: Carpenter Business Category: Construction Form of Business: Individual/Sole Proprietorship Total Policy Premium: $1,939.76 This policy may be subject to final audit. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. ENDORSEMENTS ATTACHED TO THIS POLICY _ IL 00 17 1198-Common Policy Conditions MCANONFAC0516-Permanently Attached Non-Factory IL 00 2109 08-Nuclear Energy Liability Exclusion CA 2154 10 13-California Uninsured Motorists Coverage- IL 00 03 09 08-Calculation of Premium CA 2155 10 13-California Uninsured Motorists Coverage- CA 00 0110 13-Business Auto Coverage Form CA 03 05 10 13-California Changes-Waiver of Collision CA 01 21 10 13-Limited Mexico Coverage CA 0143 05 17-California Changes IL 02 70 09 12-California Changes-Cancellation and CA 23 94 10 13-Silica or Silica Related Dust Exclusion IL N 119 10 15-California Auto Body Repair Consumer Bill of CA 20 48 10 13-Designated Insured MCA650CW1215-Transportation Network and Livery CA 04 25 10 13-California Individual Named Insured MCADS030817-CA Page 1 of 4 06/14/2018 08:31 AM PT MERCURY Policy Number: BA040000046197 4/ INSURANCE Effective Date: 06/14/2018 ITEM TWO SCHEDULE OF COVERAGES AND COVERED AUTOS This policy provides only those coverages where a charge is shown in the premium column below. Each of these coverages will apply only to those "autos" shown as covered "autos". "Autos" are shown as covered "autos" for a particular coverage by the entry of one or more of the symbols from the Covered Autos Section of the Business Auto Coverage Form next to the name of the coverage. ......................... Coverage Limit Coverages Symbol The Most We Will Pay For Any One Accident Or Loss Premium Liability 7,8,9 $1,000,000 CSL I $1,539 Medical Payments Uninsured Motorists Bodily 7 $75,000 CSL $67 Injury Uninsured Motorists 7 $3,500 V $33 Property Damage Actual Cash Value Or Cost Of Repair,Whichever Is Less, Minus Deductible Shown in ITEM THREE For Each Covered Comprehensive Auto, But No Deductible Applies To Loss Caused By Fire Or Lightning.See ITEM FOUR For Hired Or Borrowed Autos. Actual Cash Value Or Cost Of Repair,Whichever Is Less, Specified Causes of Loss Minus Deductible Shown in ITEM THREE For Each Covered Auto For Loss Caused By Mischief Or Vandalism.See ITEM FOUR For Hired Or Borrowed Autos. ............. Actual Cash Value Or Cost Of Repair,Whichever Is Less, Collision Minus Deductible Shown in ITEM THREE For Each Covered Auto.See ITEM FOUR For Hired Or Borrowed Autos. Premium For ITEM FOUR(Hired Auto Coverage) $100.00 Premium For ITEM FIVE(Non-Ownership Liability) $174.00 Premium For Endorsements $25.00 Miscellaneous Fees and Expense California Consumer Services and Fraud Program Fees $1.76 Total Policy Premium $1,939.76 MCADS030817-CA Page 2 of 4 RY Policy Number: BA0400000461970/ ERCU Effective Date: 06/14/2018 INSURANCE f ITEM THREE SCHEDULE OF COVERED AUTOS YOU OWN Covered Garaging Description Body Type VIN Auto No. _ _ City ST Zip Code 1 2004 FORD F250 SUPER DUTY- Pickup 1FTNW211394EA11521 Valley Center CA 92082 .�. .._.__.............- aCovered Radius (In Miles) Vehicle Use Business Use *Stated Amount ' Non-Factory Loss Payee Auto No. . .., Equipment Limit 1 Up to 100 Miles Personal&Business Service $0 ......... ._____�_ Q Q *Stated Amount coverage lists your vehicle's actual cash value,including the actual cash value of any Non-Factory Equipment permanently attached to the vehicle that you disclose to us,and is the most we will pay for a loss.Non-Factory Equipment coverage is subject to a sub-limit shown on the Declarations.Be sure to check the Stated Amount and Non-Factory Equipment sub-limit at every renewal in order to receive the best value from your Mercury Business Auto policy. COVERAGES,PREMIUMS,LIMITS,AND DEDUCTIBLES (Absence of a deductible or limit entry in any column below means that the limit or deductible entry in the corresponding ITEM TWO column applies instead.) Covered Auto Medical UM Bodily Injury UM Property Comprehensive Auto No. Liability Premium Payments Premium Damage Premium Premium Deductible Premium 1 $1,539 (( $67 $33 qq 4 � R I 1 Covered Specified Causes Of Loss Collision CDW Roadside Assistance Auto No. Deductible Premium Deductible Premium Premium Limit Per Premium Occurrence 1 9 I I o II Covered Rental Reimbursement Audio,Visual,&Data Equipment ....................� Auto Loan/Lease ___ ____ ____,_______............_. _ Total Vehicle Auto No. Maximum Payment Gap Premium Premium Each Covered Auto Premium Limit Premium 1 $1,639.00 R I I a MCADS030817-CA Page 3 of 4 Policy Number: BA040000046197 I SU A ICE MERCURYelm AVAE II" Effective Date: 06/14/2018 TOTAL PREMIUMS Liability $1,539 Medical Payments Uninsured Motorists Bodily Injury $67 Uninsured Motorists Property Damage $33 Collision Deductible Waiver Comprehensive Specified Causes of Loss I Collision Roadside Assistance Rental Reimbursement Loan/Lease Gap Audio,Visual and Data Electronic Equipment ITEM FOUR SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS Cost of hire means the total amount you incur for the hire of"autos"you don't own (not including"autos"you borrow or rent from your partners or"employees" or their family members). Cost of hire does not include charges for services performed by motor carriers of property or passengers. Estimated Liability Coverage Physical Damage Coverage Total ITEM AnnualFOUR Cost Of Hire Premium Limit Of Insurance Premium Premium Actual Cash Value Or Cost Of Repair, If Any $100 Whichever Is Less, Minus$500 Deductible $100 For Each Covered Auto. ITEM FIVE SCHEDULE FOR NON-OWNERSHIP LIABILITY Number Of Employees(Including Volunteers) Total ITEM FIVE Premium 0-10 $174 Y ADDITIONAL INFORMATION Discounts • Auto Pay-EFT Discount • Multi-Line • Personal Auto Policy Driver Information Listed Drivers Excluded Drivers VINCENT ALPINO .........................................� Additional Insureds . .._................ EL SEGUNDO 1234 Street City,California 91942 MCADS030817-CA Page 4 of 4 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 ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. 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 EI Segundo. Policy No. __..._._...__. ._.._._� ( j 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 EI 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 EI 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 complywit those provdupns or„the�a greement will automatically become void. Signature of Applicant Date W f Agreement for: "� v/ V 1 ��02 Dated: Reviewed 1