2100 - Terra Pave - Stratmore and Virginia St. Roadway Rehab Project No. 21851A
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015284406
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RECORDING REQUESTED BY
CITY OF ROSEMEAD
AND WHEN RECORDED MAIL TO:
Name
City of Rosemead
Street Address
8838 E. Valley Blvd.
City & state
Rosemead, CA 91770
ATTN: CITY CLERK
Notice is hereby given that:
25452816
111111 (IIII VIII VIII VIII Illli VIII VIII IIII IIII
Batch Number: 15284406
VIII! VIII VIII illi VIII (IIII VIII VIII IIII IIII
SPACE ABOVE THIS LINE FOR RECORDER'S USE
Notice of Completion
1. The undersigned is owner of the interest or estate stated below in the property hereinafter described.
2. The full name of the undersigned is:
3. The full address of the undersigned is:
of Rosemead
8838 E. Valley Blvd., Rosemead, CA 91770
4. The nature of the title of the undersigned is: In fee
(If other than fee, strike "In fee" and insert, for example, "purchaser under contract of purchase", or 'lessee")"
5. The full names and full addresses of all persons, if any, who hold title with the undersigned are:
Names Addresses
N/A N/A
6. The names of the predecessors in interest of the undersigned, if the property was transferred subsequent to
the commencement of the work of improvement herein referred to:
Names Addresses
N/A N/A
no transter made, insert, "none".
7. A work of improvement on the property hereinafter described was completed on: February 28, 2025
8. The name of the contractor, if any for such work of improvement was: Terra Pave, Inc.
9. The property on which said work of improvement was completed is in the City of Rosemead
County of Los Angeles , State of California, and is described as follows: Strathmore Avenue
and Virginia Street Roadway Rehabilitation Project No. 21851
10. The street address of said property is: Strathmore Avenue and Virginia Street, Rosemead CA 91770
no street address has been officially assigne , insert "none"
Signatl
owner
Dated: �i p (]ZS in para
By: City of Rosemead
I certify (or declare) under penalty of perjury that the foregoing is true and correct.
Date —rte
Rosemead, CA
Place of Execution
City of Rosemead, California
CALIFORNIA ACKNOWLEDGMENT CIVIL CODE § 1189
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A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document
to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
�(��
County of
On AnA —`� ��Z.S before me, -A
Date (� Here Insert Name and Title of the fficer
personally appeared `\Ikftkj1 Gu"Ojiio
Namel of Signerl
who proved to me on the basis of satisfactory evidence to be the person whose names/eM subscribed
to the within instrument and acknowledged to me that hefeheflMe7 executed the same in hisATEIyTITelf
authorized capacity;009), and that by his0signature/-Cn the instrument the personfpror the entity
upon behalf of which the persony)eacted, executed the instrument.
NATALIE HAW0wrH
Notary Public - California
c Los Angeles County
Commission; 2427955 it
Nmy Comm. Expires Dec 20, 2026 11,
Place Notary Seal and/or Stamp Above
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 WO_
Signature AAotary Public
OPTIONAL
Completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended docume t.
Description of Attached Do ument(�, "�`"�'�`���1`;• "��^•N `'•
Title or Type of Document:, Wit-"
Document Date: 41 Number of Pages:
Signer(s) Other Than Named Above:
Capacity(les) Claimed by Signer(s)
Signer's Name:
❑ Corporate Officer - Title(s):
❑ Partner- ❑ Limited ❑ General
❑ Individual ❑ Attorney in Fact
❑ Trustee ❑ Guardian or Conservator
❑ Other:
Signer is Representing:
02019 National Notary
Signer's Name:
❑ Corporate Officer - Title(s):
❑ Partner- ❑ Limited ❑ General
❑ Individual ❑ Attorney in Fact
❑ Trustee ❑ Guardian or Conservator
❑ Other:
Signer is Representing:
CONSTRUCTION CONTRACT
STRATHMORE AVENUE AND VIRGINIA STREET — ROADWAY
REHABILITATION PROJECT NO. 21851
(TERRA PAVE, INC.)
7\ii1=F�Ll� �
This Contract is made and entered into this to day of 2 2014
(Effective Date) by and between the City of Rosemead, a municipa corporation of the State
of California, located at 8838 E. Valley Blvd., Rosemead, California 91770, ("City') and
TERRA PAVE, INC. with its principal place of business at 12115 Rivera Rd. Whittier, CA
90606 (hereinafter referred to as "Contractor"). City and Contractor are sometimes
individually referred to as "Party" and collectively as "Parties" in this Contract.
2. RECITALS
2.1 Contractor
Contractor desires to perform and assume responsibility for the STRATHMORE
AVENUE AND VIRGINIA STREET — ROADWAY REHABILITATION PROJECT NO. 21851
by the City on the terms and conditions set forth in this Contract. Contractor represents that
it is experienced in providing such work services to public clients, that it and its employees or
subcontractors have all necessary licenses and permits to perform the Services in the State
of California, and that is familiar with the plans of City.
2.2 Project
City desires to engage Contractor to render such services described herein as Project
('Project') as set forth in this Contract.
3. TERMS
3.1 Scope of Services and Term
3.1.1 General Scope of Services. Contractor promises and agrees to furnish
to the City all labor, materials, tools, equipment, services, and incidental and customary work
necessary to fully and adequately supply the professional construction services necessary
for the Project ("Services"). The Services are more particularly described in Exhibit "A"
attached hereto and incorporated herein by reference. All Services shall be subject to, and
Terra Pave, Inc.
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performed in accordance with, this Contract, the exhibits attached hereto and incorporated
herein by reference, and all applicable local, state and federal laws, rules and regulations.
3.1.2 Term. The term of this Contract shall be from Effective Date shown
above to December 10th, 2025 unless earlier terminated as provided herein. Contractor
shall complete the Services within the term of this Contract, and shall meet any other
established schedules and deadlines. The Parties may, by mutual, written consent, extend
the term of this Contract if necessary to complete the Services.
3.2 Responsibilities of Contractor.
3.2.1 Control and Payment of Subordinates; Independent Contractor. The
Services shall be performed by Contractor or under its supervision. Contractor will
determine the means, methods and details of performing the Services subject to the
requirements of this Contract. City retains Contractor on an independent contractor basis
and not as an employee. Contractor retains the right to perform similar or different services
for others during the term of this Contract. Any additional personnel performing the Services
under this Contract on behalf of Contractor shall also not be employees of City and shall at
all times be under Contractor's exclusive direction and control. Contractor shall pay all
wages, salaries, and other amounts due such personnel in connection with their performance
of Services under this Contract and as required by law. Contractor shall be responsible for
all reports and obligations respecting such additional personnel, including, but not limited to:
social security taxes, income tax withholding, unemployment insurance, disability insurance,
and workers' compensation insurance.
3.2.2 Schedule of Services: Contractor shall perform the Services
expeditiously, within the term of this Contract, and within the schedules timeline. Contractor
represents that it has the professional and technical personnel required to perform the
Services in conformance with such conditions. In order to facilitate Contractor's
conformance with the Schedule, City shall respond to Contractor's submittals in a timely
manner. Upon request of City, Contractor shall provide a more detailed schedule of
anticipated performance to meet the Schedule of Services.
3.2.3 Conformance to Applicable Requirements. All work prepared by
Contractor shall be subject to the approval of City.
3.2.4 City's Representative. The City hereby designates the City Manager,
Gloria Molleda, or her designee, to act as its representative for the performance of this
Contract ("City's Representative"). City's Representative shall have the power to act on
behalf of the City for all purposes under this Contract. Contractor shall not accept direction
or orders from any person other than the City's Representative or his or her designee.
3.2.5 Contractor's Representative. Contractor hereby designates Aaron
Terry, or his designee, to act as its representative for the performance of this Contract
("Contractor's Representative"). Contractor's Representative shall have full authority to
represent and act on behalf of the Contractor for all purposes under this Contract. The
Contractor's Representative shall supervise and direct the Services, using his/her best skill
and attention, and shall be responsible for all means, methods, techniques, sequences and
Terra Pave, Inc.
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procedures and for the satisfactory coordination of all portions of the Services under this
Contract.
3.2.6 Coordination of Services. Contractor agrees to work closely with City
staff in the performance of Services and shall be available to City's staff, consultants and
other staff at all reasonable times.
3.2.7 Standard of Care; Performance of Employees. Contractor shall perform
all Services under this Contract in a skillful and competent manner, consistent with the
standards generally recognized as being employed by professionals in the same discipline in
the State of California. Contractor represents and maintains that it is skilled in the
professional calling necessary to perform the Services. Contractor warrants that all
employees and subcontractors shall have sufficient skill and experience to perform the
Services assigned to them. Finally, Contractor represents that it, its employees and
subcontractors have all licenses, permits, qualifications and approvals of whatever nature
that are legally required to perform the Services, including a City Business License if
applicable, and that such licenses and approvals shall be maintained throughout the term of
this Contract. As provided for in the indemnification provisions of this Contract, Contractor
shall perform, at its own cost and expense and without reimbursement from the City, any
services necessary to correct errors or omissions which are caused by the Contractor's
failure to comply with the standard of care provided for herein. Any employee of the
Contractor or its sub -contractors who is determined by the City to be uncooperative,
incompetent, a threat to the adequate or timely completion of the Project, a threat to the
safety of persons or property, or any employee who fails or refuses to perform the Services
in a manner acceptable to the City, shall be promptly removed from the Project by the
Contractor and shall not be re-employed to perform any of the Services or to work on the
Project.
3.2.8 Laws and Regulations. Contractor shall keep itself fully informed of and
in compliance with all local, state aind federal laws, rules and regulations in any manner
affecting the performance of the Project or the Services, including all Cal/OSHA, AQMD
requirements, and shall give all notices required by law. Contractor shall be liable for all
violations of such laws and regulations in connection with Services. If the Contractor
performs any work knowing it to be contrary to such laws, rules and regulations and without
giving written notice to the City, Contractor shall be solely responsible for all costs arising
therefrom. Contractor shall defend, indemnify and hold City, its officials, directors, officers,
employees and agents free and harmless, pursuant to the indemnification provisions of this
Contract, from any claim or liability arising out of any failure or alleged failure to comply with
such laws, rules or regulations.
3.2.9 Insurance: Contractor shall maintain, prior to the beginning of and for
the duration of this Contract, insurance coverage as specified in Exhibit B attached to and
part of this Contract.
3.2.10 Safety. Contractor shall execute and maintain its work so as to avoid
injury or damage to any person or property. In carrying out its Services, the Contractor shall
at all times be in compliance with all applicable local, state and federal laws, rules and
regulations, and shall exercise all necessary precautions for the safety of employees
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appropriate to the nature of the work and the conditions under which the work is to be
performed. Safety precautions as applicable shall include, but shall not be limited to: (A)
adequate life protection and life saving equipment and procedures; (B) instructions in
accident prevention for all employees and subcontractors, such as safe walkways, scaffolds,
fall protection ladders, bridges, gang planks, confined space procedures, trenching and
shoring, equipment and other safety devices, equipment and wearing apparel as are
necessary or lawfully required to prevent accidents or injuries; and (C) adequate facilities for
the proper inspection and maintenance of all safety measures.
3.2.11 Prevailing Wages. Contractor is aware of the requirements of California
Labor Code Section 1720, et seq., and 1770, et seq., as well as California Code of
Regulations, Title 8, Section 1600, et seq., ("Prevailing Wage Laws"), which require the
payment of prevailing wage rates and the performance of other requirements on "public
works" and "maintenance" projects. If the Services are being performed as part of an
applicable "public works' or "maintenance" project, as defined by the Prevailing Wage Laws,
and if the total compensation is $1,000 or more, Contractor agrees to fully comply with such
Prevailing Wage Laws. City shall provide Contractor with a copy of the prevailing rates of
per diem wages in effect at the commencement of this Contract. Contractor shall make
copies of the prevailing rates of per diem wages for each craft, classification or type of
worker needed to execute the Services available to interested parties upon request, and
shall post copies at the Contractor's principal place of business and at the project site.
Contractor shall defend, indemnify and hold the City, its elected officials, officers, employees
and agents free and harmless from any claim or liability arising out of any failure or alleged
failure to comply with the Prevailing Wage Laws.
3.2.12 Bonds.
3.2.12.1 Performance Bond: If specifically requested by City,
Contractor shall execute and provide to City concurrently with this Contract a Performance
Bond in the amount of the total, not -to -exceed compensation indicated in this Contract, and
in a form provided or approved by the City. If such bond is required, no payment will be
made to Contractor until it has been received and approved by the City.
3.2.12.2 Payment Bond. If required by law or otherwise specifically
requested by City, Contractor shall execute and provide to City concurrently with this
Contract a Payment Bond in the amount of the total, not -to -exceed compensation indicated
in this Contract, and in a form provided or approved by the City. If such bond is required, no
payment will be made to Contractor until it has been received and approved by the City.
3.2.12.3 Bond Provisions. Should, in City's sole opinion, any bond
become insufficient or any surety be found to be unsatisfactory, Contractor shall renew or
replace the affected bond within 10 days of receiving notice from City. In the event the
surety or Contractor intends to reduce or cancel any required bond, at least thirty (30) days
prior written notice shall be given to the City, and Contractor shall post acceptable
replacement bonds at least ten (10) days prior to expiration of the original bonds. No further
payments shall be deemed due or will be made under this Contract until any replacement
bonds required by this Section are accepted by the City. To the extent, if any, that the total
compensation is increased in accordance with the Contract, the Contractor shall, upon
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request of the City, cause the amount of the bonds to be increased accordingly and shall
promptly deliver satisfactory evidence of such increase to the City. To the extent available,
the bonds shall further provide that no change or alteration of the Contract (including, without
limitation, an increase in the total compensation, as referred to above), extensions of time, or
modifications of the time, terms, or conditions of payment to the Contractor, will release the
surety. If the Contractor fails to furnish any required bond, the City may terminate this
Contract for cause.
3.2.12.4 Surety Qualifications. Only bonds executed by an
admitted surety insurer, as defined in Code of Civil Procedure Section 995.120, shall be
accepted. The surety must be a California -admitted surety with a current A.M. Best's rating
no less than A:VIII and satisfactory to the City. If a California -admitted surety insurer issuing
bonds does not meet these requirements, the insurer will be considered qualified if it is in
conformance with Section 995.660 of the California Code of Civil Procedure, and proof of
such is provided to the City.
3.3 Fees and Payments.
3.3.1 Compensation. The total compensation shall not exceed Two Hundred
Twenty -Seven Thousand Nine Hundred ($227,900.00) without advance written approval of.
City's project manager. Extra Work may be authorized, as described below, and if
authorized, will be compensated at the rates and manner set forth in this Contract.
3.3.2 Payment of Compensation. Contractor shall submit to City a monthly
itemized statement that indicates work completed and hours of Services rendered by
Contractor. The statement shall describe the amount of Services and supplies provided
since the initial commencement date, or since the start of the subsequent billing periods, as
appropriate, through the date of the statement. City shall, within 45 days after receiving
such statement, review the statement and pay all approved charges. The payments will be
subject to a 5% retention amount, which would be released and paid after all work under the
Contract has been satisfactorily completed, and 35 days after a Notice of Completion is filed
with the County of Los Angeles.
3.3.3 Reimbursement for Expenses. Contractor shall not be reimbursed for
any expenses unless authorized in writing by City.
3.3.4 Extra Work. At any time during the term of this Contract, City may
request that Contractor perform Extra Work. As used herein, "Extra Work" means any work
that is determined by City to be necessary for the proper completion of the Project, but which
the parties did not reasonably anticipate would be necessary at the execution of this
Contract. Contractor shall not perform, nor be compensated for, Extra Work without written
authorization from City's Representative.
3.4 Accounting Records.
3.4.1 Maintenance and Inspection. Contractor shall maintain complete and
accurate records with respect to all costs and expenses incurred under this Contract. All
such records shall be clearly identifiable. Contractor shall allow a representative of City
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during normal business hours to examine, audit, and make transcripts or copies of such
records and any other documents created pursuant to this Contract. Contractor shall allow
inspection of all work, data, documents, proceedings, and activities related to the Contract
for a period of three (3) years from the date of final payment under this Contract.
3.5 General Provisions.
3.5.1 Termination of Contract.
3.5.1.1 Grounds for Termination. City may, by written notice to
Contractor, terminate the whole or any part of this Contract at any time and without cause by
giving written notice to Contractor of such termination, and specifying the effective date
thereof, at least seven (7) days before the effective date of such termination. Upon
termination, Contractor shall be compensated only for those services that have been
adequately rendered to City, and Contractor shall be entitled to no further compensation.
Contractor may not terminate this Contract except for cause.
3.5.1.2 Effect of Termination. If this Contract is terminated as
provided herein, City may require Contractorto provide all finished or unfinished Documents
and Data and other information of any kind prepared by Contractor in connection with the
performance of Services under this Contract. Contractor shall be required to provide such
document and other information within fifteen (15) days of the request.
3.5.1.3 Additional Services. In the event this Contract is
terminated in whole or in part as provided herein, City may procure, upon such terms and in
such manner as it may determine appropriate, services similar to those terminated.
3.5.2 Delivery of Notices. All notices permitted or required under this Contract
shall be given to the respective parties at the following address, or at such other address as
the respective parties may provide in writing for this purpose:
CONTRACTOR:
Terra Pave, Inc.
12115 Rivera Rd.
Whittier, CA, 90606
Attn: Aaron Terry
Tel: (562) 693-7283
CITY:
City of Rosemead
8838 E. Valley Boulevard
Rosemead, CA 91770
Attn: Ben Kim, City Manager
Such notice shall be deemed made when personally delivered or when mailed, forty-eight
(48) hours after deposit in the U.S. Mail, first class postage prepaid and addressed to the
party at its applicable address. Actual notice shall be deemed adequate notice on the date
actual notice occurred, regardless of the method of service.
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3.5.3 Cooperation; Further Acts. The Parties shall fully cooperate with one
another, and shall take any additional acts or sign any additional documents as may be
necessary, appropriate or convenient to attain the purposes of this Contract.
3.5.4 Attorney's Fees. If either party commences an action against the other
party, either legal, administrative or otherwise, arising out of or in connection with this
Contract, the prevailing party in such litigation shall be entitled to have and recover from the
losing party reasonable attorney's fees and all other costs of such action.
3.5.5 Indemnification. Contractor shall defend, indemnify and hold the City, its
officials, officers, employees, volunteers and agents free and harmless from any and all
claims, demands, causes of action, costs, expenses, liability, loss, damage or injury, in law
or equity, to property or persons, including wrongful death, in any manner arising out of or
incident to any alleged acts, omissions or willful misconduct of Contractor, its officials,
officers, employees, agents, consultants and contractors arising out of or in connection with
the performance of the Services, the Project or this Contract, including without limitation the
payment of all consequential damages and attorneys fees and other related costs and
expenses. Contractor shall defend, at Contractor's own cost, expense and risk, any and all
such aforesaid suits, actions or other legal proceedings of every kind that may be brought or
instituted against City, its directors, officials, officers, employees, agents or volunteers.
Contractor shall pay and satisfy any judgment, award or decree that may be rendered
against City or its directors, officials, officers, employees, agents or volunteers, in any such
suit, action or other legal proceeding. Contractor shall reimburse City and its directors,
officials, officers, employees, agents and/or volunteers, for any and all legal expenses and
costs incurred by each of them in connection therewith or in enforcing the indemnity herein
provided. Contractor's obligation to indemnify shall not be restricted to insurance proceeds,
if any, received by the City, its directors, officials, officers, employees, agents or volunteers.
3.5.6 Entire Contract. This Contract contains the entire Contract of the parties
with respect to the subject matter hereof, and supersedes all prior negotiations and
understandings. This Contract may only be modified by a writing signed by both parties.
3.5.7 Governing Law. This Contract shall be governed by the laws of the
State of California. Venue shall be in Los Angeles County.
3.5.8 Time of Essence. Time is of the essence for each and every provision
of this Contract.
3.5.9 City's Right to Employ Other Contractors. City reserves right to employ
other contractors in connection with this Project.
3.5.10 Successors and Assigns. This Contract shall be binding on the
successors and assigns of the parties.
3.5.11 Assignment or Transfer. Contractor shall not assign, hypothecate, or
transfer, either directly or by operation of law, this Contract or any interest herein without the
prior written consent of the City. Any attempt to do so shall be null and void, and any
assignees, hypothecates or transferees shall acquire no right or interest by reason of such
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attempted assignment, hypothecation or transfer.
3.5.12 Construction; References; Captions. Since the Parties or their agents
have participated fully in the preparation of this Contract, the language of this Contract shall
be construed simply, according to its fair meaning, and not strictly for or against any Party.
Any term referencing time, days or period for performance shall be deemed calendar days
and not workdays. All references to Contractor include all personnel, employees, agents,
and subcontractors of Contractor, except as otherwise specified in this Contract. All
references to City include its elected officials, officers, employees, agents, and volunteers
except as otherwise specified in this Contract. The captions of the various articles and
paragraphs are for convenience and ease of reference only, and do not define, limit,
augment, or describe the scope, content, or intent of this Contract.
3.5.13 Amendment; Modification. No supplement, modification, or amendment
of this Contract shall be binding unless executed in writing and signed by both Parties.
3.5.14 Waiver. No waiver of any default shall constitute a waiver of any other
default or breach, whether of the same or other covenant or condition. No waiver, benefit,
privilege, or service voluntarily given or performed by a Party shall give the other Party any
contractual rights by custom, estoppels, or otherwise.
3.5.15 No Third Party Beneficiaries. There are no intended third party
beneficiaries of any right or obligation assumed by the Parties.
3.5.16 Invalidity; Severability. If any portion of this Contract is declared invalid,
illegal, or otherwise unenforceable by a court of competent jurisdiction, the remaining
provisions shall continue in full force and effect.
3.5.17 Prohibited Interests. Contractor maintains and warrants that it has not
employed nor retained any company or person, other than a bona fide employee working
solely for Contractor, to solicit or secure this Contract. Further, Contractor warrants that it
has not paid nor has it agreed to pay any company or person, other than a bona fide
employee working solely for Contractor, any fee, commission, percentage, brokerage fee, gift
or other consideration contingent upon or resulting from the award or making of this
Contract. For breach or violation of this warranty, City shall have the right to rescind this
Contract without liability. For the term of this Contract, no member, officer or employee of
City, during the term of his or her service with City, shall have any direct interest in this
Contract, or obtain any present or anticipated material benefit arising therefrom.
3.5.18 Equal Opportunity Employment. Contractor represents that it is an
equal opportunity employerand it shall not discriminate against any subcontractor, employee
or applicant for employment because of race, religion, color, national origin, handicap,
ancestry, sex or age. Such non-discrimination shall include, but not be limited to, all
activities related to initial employment, upgrading, demotion, transfer, recruitment or
recruitment advertising, layoff or termination. Contractor shall also comply with all relevant
provisions of City's Minority Business Enterprise program, Affirmative Action Plan or other
related programs or guidelines currently in effect or hereinafter enacted.
3.5.19 Labor Certification. By its signature hereunder, Contractor certifies that
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it is aware of the provisions of Section 3700 of the California Labor Code that require every
employer to be insured against liability for Worker's Compensation or to undertake self-
insurance in accordance with the provisions of that Code, and agrees to comply with such
provisions before commencing the performance of the Services.
3.5.20 Authority to Enter Contract. Contractor has all requisite power and
authority to conduct its business and to execute, deliver, and perform the Contract. Each
Party warrants that the individuals who have signed this Contract have the legal power, right,
and authority to make this Contract and bind each respective Party.
3.5.21 Counterparts. This Contract may be signed in counterparts, each of
which shall constitute an original.
3.6 Subcontracting.
3.6.1 Prior Approval Required. Contractor shall not subcontract any portion of
the work required by this Contract, except as expressly stated herein, without prior written
approval of City. Subcontracts, if any, shall contain a provision making them subject to all
provisions stipulated in this Contract.
[SIGNATURES ON NEXT PAGE]
Terra Pave, Inc.
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CITY OF ROSEMEAD
l�
Ben Kinjoeity Manager Date
Attest:
12116461
Ericka Hernandez, City Clerk bate
Approved as to Form:
awIlIvI 1�lwj v
ache) Richman, ity Attorney Date
TERRA PAVE, INC.
By: 1 Z 1* 7
Signature Date
Name:
nt
President
[If Corporation, TWO SIGNATURES, President 09
Vice President AND Secretary, AND CORPORATE
SEAL OF CONTRACTOR REQUIRED] - - --
By:
Name: chrlafIna Santos
Title:
Corporate Secretary
Terra Pave, Inc.
EXHIBIT A
SCOPE OF CONTRACT SERVICES
SEE ATTACHED BID SCHEDULE/PROPOSAL
CITY OF ROSEMEAD
STRATHMORE AVENUE AND VIRGINIA STREET - ROADWAY
REHABILITATION PROJECT NO. 21851
SECTION I - BID SCHEDULE
CONTRACT BID FORMS
CBF -1
BIDDER: € . r:, 'ave_, Inc.
BID SCHEDULE
SCHEDULE OF PRICES FOR
STRATHMORE AVENUE AND VIRGINIA STREET —ROADWAY REHABILITATION
NO.
ITEM DESCRIPTION
UNIT
EST.
QTY.
UNIT
PRICE
ITEM
COST
1
TRAFFIC CONTROL AND MOBILIZATION
1
LS
$2.1 Too --$
21---Fgoo
TRENCH REPAIR ALONG STRATH MORE AVENUE
AND VIRGINIA STREET. WORK LIMITS SHOWN
ON APPENDIX B: PROJECT PLANS. WORK SHALL
BE AS DETAILED IN APPENDIX A:
GEOTECHNICAL EVALUATION - PAVEMENT
2
SETTLEMENT REPORT DATED AUGUST 26TH,
2024. WORK SHALL INCLUDE REMOVAL AND
4,500
SF
$ 1 50
$ b� 2So
RE -COMPACTION OF BACKFILL MATERIALS TO
A DEPTH OF 48" AND REPLACEMENT OF THE
PAVEMENT, IN ACCORDANCE WITH APPENDIX
A AND PER TS -4-111 THROUGH TS -5: CITY OF
ROSEMEAD PAVING STANDARDS (SEESHEET4
OF APPENDIX B).
COLD -MILL 2" EXISTING ASPHALT CONCRETE
AND CONSTRUCT 2" AC (WEARING COURSE
3
SHALL BE C2 PG 64-10). WORK LIMITS AS
32,000
SF
$ 3. b 0
$ I I_ -2,00
SHOWN ON SHEET 3 OF APPENDIX B - PROJECT
PLANS. WORK SHALL INCLUDE CRACK SEALING.
ADJUST MANHOLE COVERS TO GRADE,
4
COMPLETE AND IN PLACE. MANHOLES SHOWN
7
EA
$1-115,0
$ IZt_ S—=
ON SHEET 3 OF APPENDIX B.
ADJUST WATER/GAS VALVES TO GRADE,
5
COMPLETE AND IN PLACE. VALVES SHOWN ON
8
EA
$ $oo —
$ b oo —
SHEET 3 OF APPENDIX B.
ADJUST IN -ROAD VAULTTO GRADE, COMPLETE
6
AND IN PLACE. VAULT LOCATION SHOWN ON
1
EA
$ Z o00 _
$ Z coo —
SHEET 3 OF APPENDIX B.
FURNISH AND INSTALL TRAFFIC STRIPING &
PAVEMENT MARKINGS. WORK SHALL
7
INCLUDE INSTALLATION OF BLUE
1
LS$Ste-
$ SS o
RETROFLECTIVE RPMs. SEE SHEET 3 OF
APPENDIX B: PROJECT PLANS FOR DETAILS.
TOTAL BID AMOUNT IN NUMBERS
$ Z2 i 00
TOTAL BID AMOUNT IN WORDS: Trio )4.apW£2 Tv4V,dT`(—SSVZ-J
j41'o.�S 4.1� til�� 1=��DfLEY) qy o �°yt..42rj
The award of Contract shall be based on the TOTAL BASE BID AMOUNT.
CBF -2
BIDDER: ,-
In the case of discrepancies in the amount of bid, unit prices shall govern over extended
amounts, and words shall govern over figures.
Full compensation for the items listed to the
Demebilizatien
right as Items A, $, C, D and E are considered
C. NPDES, WECP, and Best Management
inclusive each Bid Item listed above in
Practices (BMPs), Public Convenience and
the Bid Schedule as applicable, and no
th
Safe ty
additional and/or separate compensation will
D. Construction Staking by Land Surveyor
be allowed.
E. Clearing and Grubbing
The bid prices shall include any and all costs, including labor, materials, appurtenant expenses,
taxes, royalties and any and all other incidental costs to complete the project, in compliance
with the Bid and Contract Documents and all applicable codes and standards.
The City reserves the right to add, delete, increase or decrease the amount of any quantity
shown and to delete any item from the contract and pay the contractor at the bid unit prices so
long as the total amount of change does not exceed 25% (plus or minus) of the total bid
amount for the entire project. If the change exceeds 25%, a change order may be negotiated to
adjust unit bid prices.
All other work items not specifically listed in the bid schedule, but necessary to complete the
work per bid and contract documents and all applicable codes and standards are assumed to be
included in the bid prices.
A bid is required for the entire work, that the quantities set forth in the Bid Schedule are to
calculate total bid amount, and that final compensation under the contract will be based upon
the actual quantities of work satisfactorily completed.
Note: The City of Rosemead reserves the right to reduce or increase the quantities of any items in the
schedule of bid items above, within the limits define in Section 3-2.2.1 of the Standard
Specifications, to stay within the budgeted amount of this project.
The award of Contract shall be based on the TOTAL BASE BID AMOUNT only. If the Bid lists any
Additive Alternate bids, the ADDITIVE ALTERNATE BID ITEMS shown per the ADDITIVE
ALTERNATE BID SCHEDULE above will not be taken into account in determining the lowest
responsible bidder. City may add bid items from the ADDITIVE ALTERNATE BID SCHEDULE at
the sole and complete discretion of the City as part of the performance of the contract.
The undersigned agrees that these Contract Bid Forms constitute a firm offer to the Owner which
cannot be withdrawn for the number of Working Days indicated in the Notice Inviting Bids from and
after the bid opening date, or until a Contract for the Work is fully executed by the Owner and a third
party, whichever is earlier. The undersigned also agrees that if there is a discrepancy between the
written amount of the Bid Price and the numerical amount of the Bid Price, the written amount shall
govern.
Attached hereto is a certified check, a cashier's check or a bid bond the amount of
-r'Ji �tY --Twa -r%4 9J so. j>
tt+L..+ N+Apwcp N.1£ t Y %r_ Dollars ($ 2L� 7 ej o — ) said amount emg not less than ten percent
(10%) of the Total Bid Price. The undersigned agrees that said amount shall be retained by the
Owner if, upon award, we fail or refuse to execute the Contract and furnish the required bonds,
certificates and endorsements of insurance and other certifications within the time provided.
CBF -3
019
If awarded a Contract, the undersigned agrees to execute the formal Contract, which will be prepared
by the Owner for execution, within five (5) Calendar Days following the Letter of Award for the
Contract, and will deliver to the Owner within that same period the necessary original Certificates of
Insurance, Endorsements of Insurance, Performance Bond, Payment Bond and all other
documentation and certification required by the Contract.
The undersigned offers and agrees that if this bid is accepted, it will assign to the purchasing body all
rights, title, and interest in and to all causes of action it may have under Section 4 of the Clayton Act
(15 U.S.C. Section 15) or under the Cartwright Act (Chapter 2 of Part 2 of Division 7 of the
Business and Professional Code), arising from purchases of goods, materials or services by the
Bidder for sale to the purchasing body pursuant to the bid. Such assignment shall be made and
become effective at the time the purchasing body tenders final payment to he Contractor.
Bidder understands and agrees that, when requested by Owner, he shall provide: (1) evidence
satisfactory to the Owner of Bidder's California contractor's license(s) in good standing; (2)
evidence that the person signing this Bid is authorized to bind Bidder to this Bid and to a contract
resulting therefrom; and (3) any other information and documentation, financial or otherwise, needed
by Owner to award a Contract to the lowest responsible and responsive bidder.
Bidder understands and agrees that liquidated damages shall apply to this Contract in the amounts of
five hundred dollars ($500.00)per calendar day if pro iect is not completed within the working days
Contract Form and the Contract Documents.
Bidder acknowledges that data submitted with its Contract Bid Forms which it requires to be
incorporated into a Contract arising out of this Submittal has been so identified by Bidder. Bidder
further acknowledges that the Owner may, at its discretion, incorporate any of the remaining data
submitted herewith into a contract arising out of this Bid.
The undersigned acknowledges receipt, understanding and full consideration of the following
addenda to the Contract Documents.
Addenda Nos. Q � A- * -�- _ 4 4 Ar '-L
The Bidder understands and agrees that the Total Bid Price is inclusive of all labor, materials, and
equipment or supplies necessary to complete the Work as described in the Bid Documents. If this
bid is accepted, the undersigned Bidder agrees to enter into and execute the Contract with the
necessary bonds and accept the Total Bid Price as compensation in full for all Work under the
contract.
CBF -4
BIDDER:
EXAMINATION OF SPECIFICATIONS AND SITE OF WORK
The Bidder declares that he/she has carefully read and examined the project plans, specifications, bid
documents, and he/she has made a personal examination of the site (indicate name of the person,
representing the bidder, who inspected the site and date below) and that he/she understands the exact
scope of the Project.
Name of Person who inspected the site:
Date of Inspection:
Al -e -1 I` -F—
V211312QL4
ADDENDA ACKNOWLEDGMENT
The Bidder acknowledges receipt of the following Addenda and has included their provisions in this
Proposal:
Addendum No. ° Dated
Addendum
Dated
Addendum No. Dated
Addendum No. Dated
CBF -5
BIDDER:
PUBLIC CONTRACT CODE STATEMENT AND QUESTIONAIRE
PUBLIC CONTRACT CODE SECTION 10285.1 STATEMENT
In conformance with Public Contract Code Section 10285.1 (Chapter 376, Stats. 1985), the bidder hereby
declares under penalty of perjury under the laws of the State of California that
the bidder has _ , has not ✓ been convicted
within the preceding three years of any offenses referred to in that section, including any charge of fraud,
bribery, collusion, conspiracy, or any other act in violation of any state or Federal antitrust law in connection
with the bidding upon, award of, or performance of, any public works contract, as defined in Public Contract
Code Section 1101, with any public entity, as defined in Public Contract Code Section 1100, including the
Regents of the University of California or the Trustees of the California State University. The term "bidder"
is understood to include any partner, member, officer, director, responsible managing officer, or
responsible managing employee thereof, as referred to in Section 10285.1.
Note: The bidder must place a checkmark after "has" or "has not' in one of the blank spaces provided.
The above Statement is part of the Proposal. Signing this Proposal on the signature portion
thereof shall also constitute signature of this Statement. Bidders are cautioned that making a false
certification may subject the certifier to criminal prosecution.
PUBLIC CONTRACT CODE SECTION 10162 QUESTIONNAIRE
In conformance with Public Contract Code Section 10162, the Bidder shall complete, under penalty of
perjury, the following questionnaire:
Has the bidder, any officer of the bidder, or any employee of the bidder who has a proprietary interest in the
bidder, ever been disqualified, removed, or otherwise prevented from bidding on, or completing a federal,
state, or local government project because of a violation of law or a safety regulation?
Yes No V
If the answer is yes, explain the circumstances in the following space.
CBF -6
BIDDER:
PUBLIC CONTRACT CODE 10232 STATEMENT
In conformance with Public Contract Code Section 10232, the Contractor, hereby states under penalty of
perjury, that no more than one final unappealable finding of contempt of court by a federal court has been
issued against the Contractor within the immediately preceding two-year period because of the Contractor's
failure to comply with an order of a federal court which orders the Contractor to comply with an order of the
National Labor Relations Board
Note: The above Statement and Questionnaire are part of the Proposal. Signing this Proposal
on the signature portion thereof shall also constitute signature of this Statement and
Questionnaire.
Bidders are cautioned that making a false certification may subject the certifier to criminal
prosecution.
CBF -7
By: _
Signature
a hvis - a ;antics
Type or Print Name
001-P. JCwt.}Ar
Title
BIDDER:
12115 Rivera Road
Business Street Address
Whittier, CA 90606
City, State and Zip Code
(662) 693 - 7283
Telephone Number
Bidder's/Contractor's State of Incorporation: C44rKi A
Partners or Joint Venturers:
Bidder's License Number(s):
Department Industrial Relations
Registered No.
NOTES:
Lic. It 456836, A 8. C-12
DIR #1000000807
1) By its signature on this Bid, the Bidder certifies under penalty of perjury the accuracy of the
representations made on the Contract Bid Forms.
2) If Bidder is a corporation, enter State of Incorporation in addition to Business Address
3) If Bidder is a partnership or joint venture, give full names of all partners or joint
venturers.
As further discussed in the Instructions to Bidders, Bidder will be
required to provide evidence that the person signing on behalf of the
corporation, partnership or joint venture has the authority to do so.
CBF -8
MINUTES OF REGULAR MEETING OF
DIRECTORS
OF
TERRA PAVE, INC.
a California corporation
BY UNANIMOUS CONSENT
The Board of Directors of TERRA PAVE, INC., a California corporation, having
unanimously consent in writing to, (in accord with Section 307 ofthe California Corporations Code),
the following actions of this corporation, which unanimous written consent is evidenced by the
signatures of all of the directors of this corporation at the end of these Minutes, have adopted on this
date the following resolution(s):
The President briefly reviewed the activities of the corporation for the past year.
Uponmotion duly made, seconded andunanimously adopted, the following resolutions were
adopted by the Board of Directors:
RESOLVED, that this Board of Directors hereby approves all of the contracts entered into
by any officer of this corporation for the past year, and ratifies said contracts.
RESOLVED FURTHER, that all salaries and loans made to any employees, officers or
directors of the corporation are hereby ratified and approved, and the salaries of the managing
officers of the corporation were also reviewed and approved.
RESOLVED FURTHER, All contracts and all documents may be executed by any officer
of the corporation.
The meeting then proceeded to the election of officers for the next ensuing year,
Upon motion duly made, seconded and unanimously carried, the following resolution was
adopted:
RESOLVED, the following persons shall be elected to the following offices, to wit:
President:
Vice President for Production:
Vice President:
Agent Designated
for Service of Process:
Secretary:
Treasurer:
Chief Financial Officer:
Aaron Terry
William Allan Allred
John Terry
Aaron Terry
Christine Santos
Aaron Terry
Aaron Terry
IN WITNESS WHEREOF, we have adopted the said resolution(s) and caused our
signatures to be affixed hereto this 15" day of April, 2
Aaron Terry, President
ATTEST:
Chris ' Santos, Secretary
D' ctor: .--
Aaron Terry
Z: OKU NNUAL MLEI INGMINU'I EStAprdVI'ma Pare auaN_NLwpd
BIDDER:
SECTION 2
BID DATA FORMS
BOND NO. BB2024466
BIDDER: TERRA PAVE, INC.
Bidder shall submit its Bid data in accordance with the format shown on each of the following Bid
Data Forms. Bidders shall prepare and use as many sheets as are necessary to adequately provide
the information required. Bidder shall ensure that every page of its Bid Data Forms are properly
identified with the Bidder's name and page number.
2.A BID BOND
KNOW ALL MEN BY THESE PRESENTS:
THAT TERRA PAVE, INC. as
Principal, and U.S. SPECIALTY INSURANCE COMPANY
'as Surety, are held firmly bound unto the
CITY OF ROSEMEAD (hereinafter called the OWNER) in the sum of
TEN PERCENT OF AMOUNT BID
DOLLARS
($ 10% OF AMOUNT BID ), being not less than ten percent (10%) of the Total Bid
Price; for the payment of which sum will and truly to be made, we bind ourselves,
our heirs, executors, administrators, successors, and assigns, jointly and severally,
firmly by these presents.
WHEREAS, said Principal has submitted a bid to the OWNER to perform all Work
required for the STRATHMORE AVENUE AND VIRGINIA STREET —
ROADWAY REHABILITATION PROJECT NO. 21851—as set forth in the
Notice Inviting Bids and accompanying Bid Documents, dated
12/4/2024
NOW, THEREFORE, if said Principal is awarded a Contract for the Work by the
OWNER and, within the time and in the manner required by the above- referenced
Bid Documents, enters into the written form of Contract bound with said Bid
Documents, furnishes the required bonds (one to guarantee faithful performance and
the other to guarantee payment for labor and materials) furnishes the required
insurance certificates and endorsements, and furnishes any other certifications as
may be required by the Contract, then this obligation shall be null and void;
otherwise it shall remain in full force and effect. In the event suit is brought upon
this bond by the OWNER andjudgment is recovered, said Surety shall pay all costs
incurred by the OWNER in such suit, including reasonable attomeys' fees to be fixed
by the court.
SIGNED AND SEALED, this 26th day of NOVEMBER , 2024
U.S. SPECIALTY
TERRA PAVE, INC. (SEAL) INSURA NY
Principal
By: rtstlno Santos y:
Signaturtlxkpor2te Secretary Signature
CBF -10
LNN
TOKIOMARINE
HCC
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS:
That, U.S. SPECIALTY INSURANCE COMPANY (the "Company"), a corporation duly organized and existing under the laws of the State
of Texas, and having its principal office in Houston, Harris County, Texas, does by these presents make, constitute and appoint,
MICHAEL ALLAN QUIGLEY
its true and lawful Attorney-in-fact with full power and authority hereby conferred In its name, place and stead, to execute, acknowledge
and deliver bond number B6204466 issued in the course of its business and to bind the Com an thereby,
y
in an amount not to exceed wenminion and 00/100 (_$20.008.300.00).
Said appointment is made under and by authority of the following resolutions of the Board of Directors of U. S. Specialty Insurance
Company:
"Be it Resolved, that the President, any Vice -President, any Assistant Vice -President, any Secretary or any Assistant Secretary shall be
and Is hereby vested with full power and authority to appoint any one or more suitable persons as Attorney(s)-in-Fact to represent and
act for and on behalf of the Company subject to the following provisions:
Attorney -in -Fact may be given full power and authority for and in the name of and on behalf of the Company, to execute, acknowledge
and deliver, any and all bonds, recognizances, contracts, agreements or indemnity and other conditional or obligatory undertakings,
Including any and all consents for the release of retained percentages and/or final estimates on engineering and construction contracts,
and any and all notices and documents canceling orterminating the Company's liability thereunder, and any such instruments so executed
by any such Attorney -in -Fact shall be binding upon the Company as if signed by the President and sealed and effected by the Corporate
Secretary.
Be it Resolved, that the signature of any authorized officer and seal of the Company heretofore or hereafter affixed to any power of
attorney or any certificate relating thereto by facsimile, and any power of attorney or certificate bearing facsimile signature or facsimile
seal shall be valid and binding upon the Company with respect to any bond or undertaking to which it Is attached." Adopted by unanimous
written consent in lieu of meeting on September 151, 2011.
The Attorney -In -Fact named above may be an agent or a broker of the Company. The granting of this Power of Attorney is specific to this
bond and does not indicate whether the Attomey-in-Fact is or is not an appointed agent of the Company.
IN WITNESS WHEREOF, U.S. Specialty Insurance Company hp,pmpsed Its seal to be affixed hereto and executed by Its Senior Vice
President on this 181i day of April, 2022.
°' °aa1 mama �o„
"o?- U.S. SPECIALTY I ISURANCE COMPANY
_,4 13 eBy.
Adam S. Pessih, Senior Vice Prosldent
or
or
State of California
County of Los Angeles
to
On this 18th day of April, 2022, before me, Sonia O. Carrejo, a notary public, personally appeared Adam S. Pessin, Senior Vice President
of U.S. Specialty Insurance Company, who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed
to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature on the
Instrument the person, or the 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. SONIA 0. CAARIDO
NMtry Pub5c • Cellfornk,
1M An,"CwMy I?
Signature Cantu nl"n ri3Vpi0
g (seal) my ow EYPirnmApr 33. 3036
I, Kio Lo, Assistant Secretary of .S. Specialty Insurance Company, do hereby certify that the Power of Attorney and the resolution
adopted by the Board of Directors of said Company as set forth above, are true and correct transcripts thereof and that neither the said
Power of Attorney nor the resolution have been revoked and they are now In full force and effect.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed the seals of said Companies at Los Angeles, California this
26th day of November 2024"""""°
Bond No. 662024466 Za` 01
Agency No. 19895 �( r a !$ � Klo Lo, AAss t Secretary
�,f_
Visit tmhcc.com/surety for more Information""n,,,,,no"°A\ acc50zzronuss1co77zo23
_ Surety Group
y� TOKIdMARINE eoi S. Figueroa so-eaf, sone 700
W HCC Los Angeles, CA 8D017 USA
Tel: 310.849-0800
SURETY BOND SEAL ADDENDUM
AMERICAN CONTRACTORS INDEMNITY COMPANY TEXAS BONDING COMPANY
UNITED STATES SURETY COMPANY U.S. SPECIALTY INSURANCE COMPANY
Due to logistical issues associated with the use of traditional seals during this COVID-19
pandemic, American Contractors Indemnity Company, Texas Bonding Company, United States
Surety Company and U.S. Specialty Insurance Company, (individually, the "Company" and
collectively, the "Companies") have authorized its Attorneys -in -Fact to affix the Companies'
corporate seal to any bond executed on behalf of the Companies by any such Attomey-in-Fact by
attaching this Addendum to said bond.
In addition, the Companies accept digital or digitized signatures as original wet signatures for
bond execution. All bonds that are properly executed via digital or digitized signature are valid as
if they were executed via physical signature.
To the extent this Addendum is attached to a bond that is executed on behalf of any of the
Companies by its Attorney -in -Fact, each Company hereby agrees that the seal below shall be
deemed affixed to said bond to the same extent as if its raised corporate seal was physically
affixed to the face of the bond. Additionally, each Company hereby agrees that electronic
signatures are accepted and given the same validity as physically wet signatures.
Dated this 1 s' day of April 2020.
American Contractors Indemnity Company, Texas Bonding Company,
United States Surety Company and U.S. Specialty Insurance Company
A01,CT0#S `a eeouwnur aaonmuuq ,ummuw
,�pACTGgs Oy ;: pN01NG Ce4y4 �o.`K`�g 8V/iF?.ra .`oOY lMurap4
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06
1) aenmm`
Frank Master, Vice President
Reference Inftlrrridtion
Principal Name: TERRA PAVE, INC.
Bond/Bid Number: BB2024466
Agency Name: QUIGLEY INSURANCE SERVICES, INC.
Attorney -in -Fact: MICHAEL ALLAN QUIGLEY
Date: November 26, 2024
HC -?RNPERFMC23
CLEAR
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL .r
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
countyof ORANGE
on 11/26/2024
Date
before me, JEFFREY MICHAEL QUIGLEY, NOTARY PUBLIC
Personally appeared MICHAEL A. QUIGLEY
Here Insert Name and Title of the Officer
Nome(s) of Signer(s)
who proved to me on the basis of satisfactory evidence to be the person(s) whose names) is/are subscribed to
the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized
capacity(ies), and that by his/her/their signature(s) on the instrumentthe person(s), orthe entity upon behalf of
which the person(s) acted, executed the instrument.
JEFFREY MICHAEL QUIGLEY
Coia l 2388467
NOTARY PUBLIC -CALIFORNIA UI
4 ORANGE COUNTY
gY Comm. EXP. DEC. 29.2025
Place Notary Seal Above
I certify under PENALTY OF PERJURY under the laws of the
State of California that the foregoing paragraph is true and
correct.
WITNESS my handand official s
Signature �
Signature of Not ry
,.----'—"'-_—__-----_- OPTIONAL---����-_----_-----------'
Though this section is optional, completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document
Document Date
Number of Pages Signer(s)OtherThanNamed Above
Capac"Ies) Claimed by Signer(s)
Signer's Name
❑ Corporate Officer—Title(s)
❑ Partner ❑ Limited ❑ General
❑ Individual ❑ Attorney In Fact
❑ Trustee ❑ Guardian or Conservator
❑ Other
Signer Is Representing
Signer's Name
❑ corporate Officer—Title(s)
❑Partner ❑Limited []General
❑ Individual ❑ Attorney in Fact
El Trustee ❑Guardian ofConservator
❑ Other
Signer Is Representing
m2014National NotaryAssociation • www.NationalNutary.org • 1 -800 -US NOTARY (1-800-876-6827) Item #5907
BIDDER: . i .. on -6 Favi, fnc.
2.11 LIST OF PROPOSED SUBCONTRACTORS
In compliance with the "Subletting and Subcontracting Fair Practices Act," Sections 4100
through 4114 of the California Public Contract Code, and any amendments thereto, each
Bidder shall provide the information requested below for each subcontractor who will
perform work, labor or render service to Bidder in or about the construction of the Work in
an amount in excess of one-half of one percent (greater than 0.5 %) of the Bidder's Total Bid
Price, or, in the case of bids or offers for the construction of streets or highways, including
bridges, in excess of one-half of 1 percent of the Contractor's total bid or ten thousand dollars
($10,000), whichever is greater, and shall further set forth the portion of the Work which will
be done by each subcontractor. Bidder shall list only one subcontractor for any one portion
of the Work.
Pursuant to Public Contract Code Section 4104, the Owner has determined that it will allow
Bidders twenty-four (24) additional hours after the deadline for submission of bids to submit
the information requested by the Owner about each subcontractor, other than the name and
location of each subcontractor.
If the Bidder fails to specify a subcontractor for any portion of the Work to be performed
under the Contract, it shall be deemed to have agreed to perform such portion itself, and shall
not be permitted to subcontract that portion of the Work except under the conditions
hereinafter set forth below.
Subletting or subcontracting of any portion of the Work in excess of one half of one percent
(greater than 0.5%) of the Total Bid Price or, in the case of bids or offers for the construction
of streets or highways, including bridges, in excess of one-half of l percent of the
Contractor's total bid or ten thousand dollars ($10,000), whichever is greater, for which no
subcontractor was designated in the original bid shall only be permitted in cases of public
emergency or necessity, and then only after Owner approval.
CBF -11
BIDDER: 1'=11 1=' vc:, fnc,
2.11 LIST OF PROPOSED SUBCONTRACTORS (continued)
[**Duplicate Next 2 Pages if needed for listing additional subcontractors.**]
Name and Location
of Subcontractor
Description of Work
to be Subcontracted
Name: S j P w P i o rim P 44C -AS ' T rt e
Address: 5417, t<ti s s sT vests �, a, g o k 3
License No.: "17 b
Departm ustrial Relation Registration No. I o 0 0 0 c i A -1 b
Name and Location
of Subcontractor
Description of Work
to be Subcontracted
9,J(�
Name: 345 fTQ1yrVAt1
Address: 15-44 S. 4t a c g ti ry' A- v o tJ r 40-0 q. ST V-,
License No.: 9-327-11 q 1-1 b
Department of Industrial Relation Registration No. 10 000 o k9
and Location
of Subcontractor
Name:
Address:
License No.:
Department of Industrial Relation Registration No.
Name and Location
of Subcontractor
Name:
Address:
License No.:
Department of Industrial Relation Registration No.
Name and Location
of Subcontractor
Address:
License No.:
Description of Work
to be Subcontracted
Description of Work
to be Subcontracted
Description of Work
to be Subcontracted
Department of Industrial Relation Registration
CBF -12
BIDDER:
2.0 REFERENCES
The following are the names, addresses and telephone numbers for three public agencies for which
BIDDER has performed similar work within the past two (2) years:
1.Ib4uo LoliolZ&po
G I T i o i- d-rL1,.-4 „ T D,4 TL -A -A 1T
Name and Address of Owner
2.
91
JA-SotA 131120a4,1 (Sb2� 90$—IO2oc�
Name and telephone number of person familiar with project
3; 3-I D 07,
Contract Amount
Type of Work
G I -I'-( o f of t-{- , -t-'-r- I e- R --
Name and Address of Owner
Date
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Name and telephone number of person familiar with project
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Contract amount Type of Work
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Name and Address of Owner
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Contract amount Type of Work Date Completed
CBF -13
BIDDER:
4. 100 c 1 J fi G'(v a Tei, �+-- W M �. �•
LI Ti oF- %.4p to I+AOIa L4 , gZ2o1
Name and Address of Owner
J4g..1 PC,(zEycul c, A- (°ISI ) $9-:�- OK 7,6
Name and telephone number of person familiar witli project
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Cont act amount
Type of Work Date Completed
CBF -14
BIDDER:
SECTION 3
NON- COLLUSIONAFFIDAVIT
CBF -15
BIDDER: err . ne, lit',.
NON -COLLUSION AFFIDAVIT
In accordance with Public Contract Code Section 7106, the undersigned, being first duly
swom, deposes and says that he or she holds the position listed below with the bidder, 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.
�
Signatu
ChriS4ihG Santos
Typed or Printed Name
Corpor'%h -f&"e{-Rq
Title
Terra Owe, ivtc•
Bidder
Subscribed and sworn before me
This 22no1 day of (7 umbtl- 20 21(
Notary Public in and for
the State of California
My Commission Expires: Jpn, 2, 2016
CBF -16
Set c.+4c cc d OmkA%tA-k
(Seal)
CALIFORNIA JURAT WITH AFFIANT STATEMENT GOVERNMENT CODE § 8202
——
$See Attached Document (Notary to cross out lines 1-6 below)
❑ See Statement Below (Lines 1-6 to be completed only by document signer[s], not Notary)
Signature of Document Signer No. 1
Signature of Document Signer No. 2 (if any)
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
County of ORANGE
NA)EN SA Erol
Notary Publlc • Ca8lornla
-+ Orange Canty
Commission 7 2478467
My Comm, Expires Jan 2, 2028 r
Seal
Place Notary Seal Above
Subscribed and swom to (or affirmed) before me
on this 2ND day of DECEMBER 2024—
by
024.by Date Month Year
(and
CHRISTINE SANTOS
Names) of Signers)
proved to me on the basis of satisfactory evidence
to be the person(s) who appeared before me.
Signature 04;��
Signature of Notary Public
OPTIONAL
Though this section is optional, completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document: NON -001 1 11SION AFFIDAVIT Document Date:DECEMBER 2, 2024
Number of Pages: 16 Signer(s) Other Than Named Above: NIA
02014 National Notary Association • www.NationaiNotary.org • 1 -800 -US NOTARY (1-800-876-6827) Item #5910
Terra Pave, Inc.
EXHIBIT B
INSURANCE REQUIREMENTS
Prior to the beginning of and throughout the duration of the Work, Contractor will maintain
insurance in conformance with the requirements set forth below. Contractor will use existing
coverage to comply with these requirements. If that existing coverage does not meet the
requirements set forth here, Contractor agrees to amend, supplement or endorse the
existing coverage to do so. Contractor acknowledges that the insurance coverage and
policy limits set forth in this section constitute the minimum amount of coverage required.
Any insurance proceeds available to City in excess of the limits and coverage required in
this Contract and which is applicable to a given loss, will be available to City.
Contractor shall provide the following types and amounts of insurance:
Commercial General Liability Insurance. Contractor shall maintain commercial general
liability insurance with coverage at least as broad as Insurance Services Office form CG 00
01, in an amount not less than $1,000,000 per occurrence, $2,000,000 general aggregate,
for bodily injury, personal injury, and property damage, and a $2,000,000 completed
operations aggregate. The policy must include contractual liability that has not been
amended. Any endorsement restricting standard ISO "insured contract" language will not
be accepted.
Automobile liability insurance. Contractor shall maintain automobile insurance at least
as broad as Insurance Services Office form CA 00 01 covering bodily injury and
property damage for all activities of the Contractor arising out of or in connection with
Work to be performed under this Agreement, including coverage for any owned, hired,
non -owned or rented vehicles, in an amount not less than $1,000,000 combined single
limit for each accident.
Workers' compensation insurance. Contractor shall maintain Workers' Compensation
Insurance (Statutory Limits) and Employer's Liability Insurance (with limits of at least
$1,000,000) for Contractor 's employees in accordance with the laws of the State of
California, Section 3700 of the Labor Code In addition, Contractor shall require each
subcontractor to similarly maintain Workers' Compensation Insurance and Employer's
Liability Insurance in accordance with the laws of the State of California, Section 3700 for
all of the subcontractor's employees.
Excess or Umbrella Liability Insurance. (Over Primary) Contractorshall obtain and maintain
an umbrella or excess liability insurance policy that will provide bodily injury, personal injury
and property damage liability coverage at least as broad as the primary coverages setforth
above, including commercial general liability, automobile liability, and employer's liability.
Such policy or policies shall include the following terms and conditions: Contractor shall
obtain and maintain an umbrella or excess liability insurance policy that will provide bodily
injury, personal injury and property damage liability coverage at least as broad as the
primary coverages set forth above, including commercial general liability, automobile
liability, and employer's liability. Such policy or policies shall include the following terms and
conditions:
Terra Pave, Inc.
• A drop down feature requiring the policy to respond in the event that any
primary insurance that would otherwise have applied proves to be uncollectable in
whole or in part for any reason;
• Pay on behalf of wording as opposed to reimbursement;
• Concurrency of effective dates with primary policies; and
• Policies shall "follow form" to the underlying primary policies.
• Insureds under primary policies shall also be insureds under the umbrella or
excess policies.
Builder's risk insurance. Upon commencement of construction and with approval of Agency,
Contractor shall obtain and maintain builder's risk insurance for the entire duration of the
Project until only the Agency has an insurable interest. The Builder's Risk coverage shall
include the coverages as specified below.
The named insureds shall be Contractor and Agency, including its officers, officials,
employees, and agents. All Subcontractors (excluding those solely responsible for design
Work) of any tier and suppliers shall be included as additional insureds as their interests
may appear. Contractor shall not be required to maintain property insurance for any portion
of the Project following transfer of control thereof to Agency. The policy shall contain a
provision that all proceeds from the builder's risk policy shall be made payable to the
Agency. The Agency will act as a fiduciary for all other interests in the Project.
Policy shall be provided for replacement value on an "all risk" basis for the completed value
of the project. There shall be no coinsurance penalty or provisional limit provision in any
such policy. Policy must include: (1) coverage for any ensuing loss from faulty
workmanship, Nonconforming Work, omission or deficiency in design or specifications; (2)
coverage against machinery accidents and operational testing; (3) coverage for removal of
debris, and insuring the buildings, structures, machinery, equipment, materials, facilities,
fixtures and all other properties constituting a part of the Project; (4) Ordinance or law
coverage for contingent rebuilding, demolition, and increased costs of construction; (5)
transit coverage (unless insured by the supplier or receiving contractor), with sub -limits
sufficient to insure the full replacement value of any key equipment item; (6) Ocean marine
cargo coverage insuring any Project materials or supplies, if applicable; (7) coverage with
sub -limits sufficient to insure the full replacement value of any property or equipment stored
either on or off the Site or any staging area. Such insurance shall be on a form acceptable
to Agency to ensure adequacy of terms and sublimits and shall be submitted to the Agency
prior to commencement of construction.
Insurance procured pursuant to these requirements shall be written by insurers that are
admitted carriers in the state of California and with an A. M. Bests rating of A- or better and
a minimum financial size VII.
General conditions pertaining to provision of insurance coverage by Contractor.
Contractor and City agree to the following with respect to insurance provided by
Contractor:
1. Contractor agrees to have its insurer endorse the third party General liability policies
shall provide or be endorsed to provide that Agency and its officers, officials,
employees, agents, and volunteers shall be additional insurer under such policies
Terra Pave, Inc.
using standard ISO endorsement No. CG 2010.. Contractor also agrees to require
all contractors, and subcontractors to do likewise.
2. No liability insurance coverage provided to comply with this Contract shall prohibit
Contractor, or Contractor's employees, or agents, from waiving the right of
subrogation prior to a loss. Contractor agrees to waive subrogation rights against
City regardless of the applicability of any insurance proceeds, and to require all
contractors and subcontractors to do likewise.
3. All insurance coverage and limits provided by Contractor and available or applicable
to this Contract are intended to apply to the full extent of the policies. Nothing
contained in this Contract or any other Contract relating to the City or its operations
limits the application of such insurance coverage.
4. None of the coverage required herein will be in compliance with these requirements
if they include any limiting endorsement of any kind that has not been first submitted
to City and approved of in writing.
5. No liability policy shall contain any provision or definition that would serve to
eliminate so-called "third party action over" claims, including any exclusion for bodily
injury to an employee of the insured or of any contractor or subcontractor.
6. All coverage types and limits required are subject to approval, modification and
additional requirements by the City, as the need arises. Contractor shall not make
any reductions in scope of coverage (e.g. elimination of contractual liability or
reduction of discovery period) that may affect City's protection without City's prior
written consent.
7. Proof of compliance with these insurance requirements, consisting of certificates of
insurance evidencing all of the coverage required and an additional insured
endorsement to Contractor's general liability policy, shall be delivered to City at or
prior to the execution of this Contract. In the event such proof of any insurance is
not delivered as required, or in the event such insurance is canceled at any time and
no replacement coverage is provided, City has the right, but not the duty, to obtain
any insurance it deems necessary to protect its interests under this or any other
Contract and to pay the premium. Any premium so paid by City shall be charged to
and promptly paid by Contractor or deducted from sums due Contractor, at City
option.
8. Certificate(s) are to reflect that the insurer will provide 30 days notice to City of any
cancellation of coverage. Contractor agrees to require its insurer to modify such
certificates to delete any exculpatory wording stating that failure of the insurer to
mail written notice of cancellation imposes no obligation, or that any party will
"endeavor' (as opposed to being required) to comply with the requirements of the
certificate.
Terra Pave, Inc.
9. It is acknowledged by the parties of this Contract that all insurance coverage
required to be provided by Contractor or any subcontractor, is intended to apply first
and on a primary, noncontributing basis in relation to any other insurance or self
insurance available to City.
10. Contractor agrees to ensure that subcontractors, and any other party involved with
the project who is brought onto or involved in the project by Contractor, provide the
same minimum insurance coverage required of Contractor. Contractor agrees to
monitor and review all such coverage and assumes all responsibility for ensuring
that such coverage is provided in conformity with the requirements of this section.
Contractor agrees that upon request, all Contracts with subcontractors and others
engaged in the project will be submitted to City for review.
11.Contractor agrees not to self -insure or to use any self-insured retentions or
deductibles on any portion of the insurance required herein and further agrees that it
will not allow any contractor, subcontractor, Architect, Engineer or other entity or
person in any way involved in the performance of work on the project contemplated
by this Contract to self -insure its obligations to City. If Contractor's existing
coverage includes a deductible or self-insured retention, the deductible or self-
insured retention must be declared to the City. At that time the City shall review
options with the Contractor, which may include reduction or elimination of the
deductible or self-insured retention, substitution of other coverage, or other
solutions.
12. The City reserves the right at any time during the term of the contract to change the
amounts and types of insurance required by giving the Contractor ninety (90) days
advance written notice of such change. If such change results in substantial
additional cost to the Contractor, the City will negotiate additional compensation
proportional to the increased benefit to City.
13. For purposes of applying insurance coverage only, this Contract will be deemed to
have been executed immediately upon any party hereto taking any steps that can be
deemed to be in furtherance of or towards performance of this Contract.
14. Contractor acknowledges and agrees that any actual or alleged failure on the part of
City to inform Contractor of non-compliance with any insurance requirement in no
way imposes any additional obligations on City nor does it waive any rights
hereunder in this or any other regard.
15.Contractor will renew the required coverage annually as long as City, or its
employees or agents face an exposure from operations of any type pursuant to this
Contract. This obligation applies whether or not the Contract is canceled or
terminated for any reason. Termination of this obligation is not effective until City
executes a written statement to that effect.
16.Contractor shall provide proof that policies of insurance required herein expiring
during the term of this Contract have been renewed or replaced with other policies
providing at least the same coverage. Proof that such coverage has been ordered
Terra Pave, Inc.
shall be submitted prior to expiration. A coverage binder or letter from Contractor's
insurance agent to this effect is acceptable. A certificate of insurance and/or
additional insured endorsement as required in these specifications applicable to the
renewing or new coverage must be provided to City within five days of the expiration
of the coverage.
17.The provisions of any workers' compensation or similar act will not limit the
obligations of Contractor under this Contract. Contractor expressly agrees not to
use any statutory immunity defenses under such laws with respect to City, its
employees, officials and agents.
18. Requirements of specific coverage features or limits contained in this section are not
intended as limitations on coverage, limits or other requirements nor as a waiver of
any coverage normally provided by any given policy. Specific reference to a given
coverage feature is for purposes of clarification only as it pertains to a given issue,
and is not intended by any party or insured to be limiting or all-inclusive.
19.These insurance requirements are intended to be separate and distinct from any
other provision in this Contract and are intended by the parties here to be
interpreted as such.
20. The requirements in this Section supersede all other sections and provisions of this
Contract to the extent that any other section or provision conflicts with or impairs the
provisions of this Section.
21. Contractor agrees to be responsible for ensuring that no contract used by any party
involved in any way with the project reserves the right to charge City or Contractor
for the cost of additional insurance coverage required by this Contract. Any such
provisions are to be deleted with reference to City. It is not the intent of City to
reimburse any third party for the cost of complying with these requirements. There
shall be no recourse against City for payment of premiums or other amounts with
respect thereto.
Contractor agrees to provide immediate notice to City of any claim or loss against
Contractor arising out of the work performed under this Contract. City assumes no
obligation or liability by such notice, but has the right (but not the duty) to monitor the
handling of any such claim or claims if they are likely to involve City.
ALS o" CERTIFICATE OF LIABILITY INSURANCE
W,"" no2"4"'
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 poitcy(les) 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 Halt of auch endorasment s .
PRODUCER
Acrisure Southwest Partners Insurance Services, LLC
18952 MacArthur Blvd., Suite #300
Irvine, CA 92612
Lauren Bierman
PNONE 949A86-7900 FAX
Eooa lblermanapatrisk.com
INSURER(S)AFFORDING COVERAGE NAZCA
✓
INsuaeRA: XL Insurance America Inc. A+XV 24554
wwwpaMsk.00m OK07568
INSURED
Terra Pave, Inc.
12115 Rivera Road
INSURERS: Greenwich Insurance Company A+XV 22322
INOURERc: Insurance Company of the West AXII 27847
INSURER D: Westchester Surplus Lines Insurance Cc 10172
Whittier CA 90606
INSURER E:
INSURERF:
COVERAGES CERTIFICATE NUMBER' A9G13A1A RFVIRION NIIMRFR-
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.
/LTR NSR
TYPE OF INSURANCEMUEDRI
INSO
POLICY NUYBER
PO ICOYEFF
MLOILLIIC EXP
LIMBS
A
✓ COMMERCWLGENERALUASIUTY
✓
✓
NPC -1000484-05
4/1,12024
4/1/2025
EACHOCCURRENCE $1000000
CLVMS-MADE M OCCUR
PREMISES Ea oraxll $100000
MED EXP AA one person $6,000
✓ Deductible $1,000
PERSONAL S ADV INJURY $1,000,000
GENL AGGREGATE LIMIT APPLIES PER
GENERAL AGGREGATE $2,000,000
POLICY LOC
PRODUCTS-COMPXJPAGG 32000000
$
OTHER
A
AU70MOBRELUeItITY✓
✓
NBA -1000488.05
4/1/2024
4/112025
EOMe�IrRmDSINGLE LIMB $1000000
BODILY INJURY(Perperscn) $
✓
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INAMY(Peraaidanl) $
PROPERTY Yill $
✓
ATOS ONLY ✓ ED AUTOS ONLY ED
B
,i
UMSRELLALUB
✓
OCCUR
NEC -6006547-03
4/1/2024
4/1/2026
E,CH000uRREHCE $5000000
AGGREGATE $5000000
EXCESB IIAe
CINMS4
DEC RETENTION$
$
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
OFFICER ME ERE LVOEo CVTNE YIN
NIA
✓
WSD 504706505
4/1/2024
4/1/2026
✓TAT E
I
E.LEACHACCIOENT $1000000
E.L. DISEASE - EAEMPLOYE $1,000,000
(Lb4Watoryln NN)
N yec daunbe Order
DE SCRIPTXNI OF OPERATIONS bebv
EL DISEASE -POLICY LIMB $f00D000
D
Pollution
G74438143002
2/24/2024
4/1/2025
2,0D 0000Ccurtence
$2,000,000 Aggregate
DESCRIPTION OF OPERATIONS/LOCATIONS /VEHICLES (ACORD 101, AddlVonal Remarks Seh.&I% mey W elleehad N mors spaes Ia,equlrsdt
Re: Strathmore Avenue and Virginia Street— Roadway Rehabilitation Project No. 21851
The City of Rosemead, Its officials, officers, employees, Volunteers, and agents are included as additional Insured per the terms of the attached
Genera( LWbflity and Auto Liability endorsements. Waiver of subroga8on applies per the terms of the attached endorsements.
Primary wording applies per the terms of the attached endorsements.
'30 -Day notice of cancellation / 10 -Days for non-payment of premium.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Rosemead THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Department of Public Works ACCORDANCE WITH THE POLICY PROVISIONS.
8838 E. Valley Blvd.
Rosemead CA 91770 AUTHORIZED REPRESENTATIVE
Dave Jacobson v
I0TVa4-YU1OAt;VKu6UKPUKAIIUN. Anngnisreservea.
ACORD 25 (2018103) The ACORD name and logo are registered marks of ACORD
82933810 1 24/25 - GL/AU/V /W/POLL I Lauren eiernan 1 12/6/2024 11:48:31 N4 (PST) I Page I of 19
Terra Pave, Inc.
POLICY NUMBER: NPC -1000484-05
COMMERCIAL GENERAL LIABILITY
CG 20 10 12 19
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 O anization s
Locations Of Covered Operations
Blanket as required by written contract.
Blanket as required by written
contract.
Information required to complete this Schedule N not shown above will be shown In the Oedaretiona.
A. Section II — Who Is An Insured Is amended to
Include as an additional Insured the person(s) or
orgenlzatian(s) shown In the Schedule, but only
with respect to liability for 'bodily Injury', "property
damage or 'personal and advertising Injury"
caused, In whole or In part, by:
1. Your acts or omissions; or
B. With respect to the Insurance afforded to these
additional insureds, the following additional
exclusions apply:
This Insurance does not apply to "bodily Injury' or
'property damage" occurring after.
1. All work, Including materials, parte 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.
2.
However.
1. The Insurance afforded to such additional
Insured only applies to the extent permitted by
low; and
2. If coverage provided to the addlUonal Insured Is
required by a contract or agreement, the
Insurance afforded to such additional Insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional Insured.
CG 20 10 12 19
equipment furnished in connection with such
work, on the project (other then 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
That portion of your work' out of which the
Injury or damage arises has been put to Re
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
® Insurance Services Office, Ino., 2018
82933810 1 24125 - GL/AV/N®/FC/POLL I Lauren Siet n 1 12/6/2024 1L'98:31 A4 (P32) I Paye 2 of 19
Page 1 of 2
C. With respect to the Insurance afforded to these
additional Insureds, the following Is added to
Section III —Limits Of Insurance:
If coverage provided to the additional Insured is
required by a contract or agreement, the most we
will pay on behalf of the additional Insured Is the
amount of insurance:
1. Required by the contract or agreement; or
Page 2 of 2
2. Available under the applicable limits of
Insurance;
whichever Is lose.
This endorsement shall
applicable Omits of Insurance.
® Insurance Services Office, Inc., 2019
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not increase the
CO 20 10 12 19
Terra Pave, Inc.
POLICY NUMBER: NPC -1000484-05
COMMERCIAL GENERAL LIABILITY
CG 20 37 12 19
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
PRODUCTSICOMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s)
Location And Description Of Completed Operations
Blanket as required by written contract.
Blanket as required by written contract.
Information required to complete this Schedule if not shown above will be shown in the Dectaretions.
A. Section 11 — 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 daage' caused, in whole or In part, by
"your work"mat the location designated and
described In the Schedule of this endorsement
performed for that additional Insured and Included
In the'productscompleted operations hazard'.
However.
1. The Insurance afforded to such additional
Insured only applies to the extent permitted by
low; and
2. If coverage provided to the additional Insured Is
required by a contract or agreement, the
Insurance afforded to such additional Insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional Insured,
CO 20 371219
B, W respect to the i su%ye 8tlo ed t these
aJ&Ional Insureds, the following A to
Section III — Limits Of Insurance:
If coverage provided to the additional Insured is
required by a contract or agreement, the most we
will pay on behalf of the additional Insured Is the
amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable limits of
Insurance;
whichever is less.
This endorsement shall not Increase the
applicable limits of insurance.
® Insurance Services Office. Inc., 2018
62933610 124/25 - GL/AOI JPIK</POLL I Laa[en 0leman 1 12/6/2024 11:4801 AM (PST) I Page 4 of 15
Page 1 of 1
ENDORSEMENT#
This endorsement; effective 12:01 a.m.04101/2024 forms a part of Policy No.
—Tr—'
NPC•t000484-OS Issued
avep 8ued t0 by XL insurance Amerip, inc. AtXV
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
XLPlus Endorsement
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
GENERAL DESCRIPTION OF COVERAGE - This endorsement broadens coverage. The
following listing Is a general coverage description only. Limitations and exclusions may apply
to these coverages. Read this endorsement carefully to determine rights, duties, and what Is
and is not covered.
A. Reasonable Fora — Bodily Injury or Property Damage
B. Damage To Premises Rented To You Extension
• Perils of fire, lightning, explosion, smoke, aircraft or vehicles, riot or civil commotion,
vandalism, leakage from fire extinguishing equipment or water damage
• Limit Increased to $300,000
C. Aircraft Chartered with Crew
D. Non -Owned Watercraft
E. Personal and Advertising Injury —Assumed by Insured Contract
F. Increased Supplementary Payments
• Cost for ball bonds Increased to $5,000
• Loss of earnings Increased to $1,000 per day
G. Broadened Named Insured
H. Blanket Additional Insured — Managers or Lessors of Premises
I. BlanketAddrdonalInsured— LessorofLeasedEquipment
J. Injury to Co-Employeas and Co Volunteer Workers
K. Knowledge and Notice of Occurrence or Offense
L. Unintentional Omission
M. Liberalization
N. Blanket Waiver of Subrogation
O. Incidental Medial Malpractice Injury
P. Extension of Coverage — Bodily Injury
O. Coverage Territory
Form XIL 4381208 ® 2008, XL America, Ina Page 1 of 8
Includes copyrighted materiel of Ir•unnce Services 080, In, with IIs pemAskn.
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A. REASONABLE FORCE —BODILY INJURY OR PROPERTY DAMAGE
Exclusion a. Expected Or Intended Injury of Part 2., Exclusions of Coverage A. Bodily injury
And Property Damage Liability of Section 1— Coverages Is deleted In its entirety and replaced
by the following:
[This insurance does not apply to:)
Expected or Intended Injury or Damage
'Bodily Injury' or'property damage' expected or intended from the standpoint of the Insured.
This exclusion does not apply to 'bodily Injury' or 'property damage resulting from the use of
reasonable force to protect persons or property.
B. DAMAGE TO PREMISES RENTED TO YOU EXTENSION
1. The last paragraph of 2. Exclusions of Coverage A. Bodily Injury And Property Damage
Liability of Section I - Coverages Is deleted in Its entirety and replaced by the following:
Exclusions c. through a, do not apply to damages to premises while rented to you, or
temporarily occupied by you with permission of the owner, caused by fire, lightning,
explosion, smoke, aircraft or vehicles, dot or civil commotion, vandalism, leakage from
Ire extinguishing equipment or water damage. A separate limit of insurance applies to
this coverage as described in Section III- Limits of Insurance.
2. This Insurance does not apply to damage to premises while rented to you, or temporarily
occupied by you with permission of the owner, caused by:
a. Rupture, bursting, or operation of pressure relief devices;
b. Rupture or bursting due to expansion or swelling of the contents of any building or
structure, caused by or reeuHing from water, or
c. Explosion of steam boilers, steam pipes, steam engines, or steam turbines.
3. Paragraph S. of Section III- Limits of Insurance Is deleted In its entirety and replaced by
the following:
e.a. Subject to Paragraph S. above, the Damage To Premises Rented To You Limit Is the
most we will pay under Coverage A for damages because of 'property damage' to
any one premises while rented to you, or temporarily occupied by you with
permission of the owner, caused by fire, explosion, lightning, smoke, aircraft or
vehicle, dot or civil commotion, vandalism, leakage from fire extinguishing equipment
or water damage. The Damage To Premises Rented To You Limit will apply to all
damage proximately caused by the same'occurrance, whether such damage results
from fire, explosion, lightning, smoke, aircraft or vehicle or dot or civil commotion,
vandalism, leakage from fire extinguishing equipment or water damage or any
combination of any of these.
b. The Damage to Premises Rented to You Limit will be the higher of.
(1) $300,000; or
(2) The amount shown on the Declarations for Damage to Premises Rented to You
Limit.
Form XIL 4381208 O 2008, XL America, Inc. Page 2 of 8
Indudes copyrighted materiel of trawanoe SeMOee Offte, Inc., with he permission.
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4. Paragraph 9.e. of the definition of 'Insured contract' under Section V- Definitions, Is
deleted In Re entirety and replaced by the following:
(insured contract' means:]
a. A contract for a lease of premises. However, that portion of the contract for a lease of
premises that indemnifies any person or organization for damage by fire, lightning,
explosion, smoke, aircraft or vehicle, dot or civil commotion, vandalism, leakage from
fire extinguishing equipment or water damage to premises while rented to you, or
temporarily occupied by you with the permission of the owner Is not an 'Insured
contract.
6. This Ardde B. does not apply it coverage for Damage to Premises Rented to You of
Coverage A. Bodily Injury And Property Damage Liability of Section 1 — Coverages Is
excluded by endorsement.
C. AIRCRAFT CHARTERED WITH CREW
1. The following Is added to the exceptions contained in Exclusion g., Aircraft, Auto or
Watercraft In Part 2., Exclusions of Coverage A. Bodily Injury And Property Damage of
Section I — Coverages:
(This exclusion does not apply to:)
Alrcraft chartered with crew to any insured.
2. This Article C. does not apply If the chartered aircraft is owned by any insured.
3. The Insurance provided by this Article C. shall be excess over any valid and collecuble
Insurance available to the Insured, whether primary, excess, contingent or on any other
basis, except for Insurance purchased specifically by you to be excess of this policy.
D. NON -OWNED WATERCRAFT
1. The exception contained in Subparagraph (2) of Exclusion g. Aircraft. Auto or Watercraft
In Part 2., Exclusions of Coverage A. Bodily Injury And Property Damage Liability of
Section 1— Coverages Is deleted in Its entirety and replaced by the following:
(2) A watercraft you do not own that Is:
(a) 60 feel long or less; and
(b) Not being used to carry persona or property for a charge;
2. This Article D. applies to any person who, with your expressed or Implied consent, either
uses or Is responsible for the use of the watercraft.
3. This insurance provided by this Article D. shall be excess over any other valid and
collectible Insurance available to the Insured, whether primary, excess, contingent or on
any other basis, except for Insurance purchased specifically by you to be excess of this
policy.
E. PERSONAL AND ADVERTISING INJURY —ASSUMED BY INSURED CONTRACT
1. Exclusion e. Contractual Liability In Part 2., Exclusions of Coverage B. Personal And
Advertising Injury Liability of Section I — Coverages Is deleted In tis entirely and replaced
by the following:
Form XIL 4361208 ® 20D8, XL America, Ina Page 3 of 6
Indudes copyrighted materiel of InsuramLs SeMces OPoce, Inc.. with Its pennsalon.
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[This Insurance does not apply lo:)
e, Contractual Liability
'Personal and Advertising Injury' for which the Insured has assumed liability Ina contract
or agreement. This exclusion does not apply to liability for damages:
1. That the insured would have In the absence of the contractor agreement; or
2. Assumed Ina written contractor agreement that Is an "Insured contract'; provided the
'personal and advertising Injury' Is caused by an olfenee which occurs subsequent to
the execution of the contract or agreement.
2. Subparagraph f. of the definition of 'Insured contract' Section V: Definitions Is deleted In its
entirety and replaced by the following:
f. That part of any other contract or agreement pertaining to your business, including an
Indemnification of a municipality In connection for work performed for a municipality,
under which you assume the tort liability of anther party to pay for *bodily Injury',
'properly damage' or 'personal and advertising Injury' to a third party or organization.
Tort liability means a liability that would be Imposed by law In the absence of any
contract or agreement.
2. This Article E. does not apply if Coverage B. Personal And Advertising Injury Liability is
excluded by endorsement.
F. INCREASED SUPPLEMENTARY PAYMENTS
Subparegraphe 1. b. and d. of Supplementary Payments — Coverages A And B of Section I -
Coverages are amended as follows:
1. In Subparagraph b., the amount we will pay for the coat of ball bonds Is Increased up to
88,000.
2. In Subparagraph d., the amount we will pay for a loss of earnings is Increased up to
81,000 a day.
G. BROADENED NAMED INSURED
1. The Named Insured In Item 1. of the Declarations is as follows:
The person or organizations named In Item 1. of the Declarations and any organization,
other than a partnership or joint venture, over which you maintain ownership or majority
Interest on the effective date of the policy. However, coverage for any such organization
will cease as of the date that you no longer maintain ownership of, or majority Interest In,
such organization.
2. This Article G. does not apply to any person or organization for which coverage is
excluded by endorsement.
Form XIL 4381208 ® 2008, XL America, Inc. Page 4 of 8
Includes copyrighted material of Insurance SerAces OBbe, Inc, with Its pemlMalon.
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H. BLANKET ADDITIONAL INSURED —MANAGERS OR LESSORS OF PREMISES
1. Section II•Who Is An Insured Is amended to Include as an Insured any person or
organization with whom you have agreed In a written contract executed prior to lose (an
'additional Insured'), but only with respect to liability arising out of the ownership,
maintenance or use of that part of any premises leased to you, subject to the following
provisions:
a. Limits of Insurance. The Limbs of Insurance afforded to the 'additional Insured' shall
be the limits you agreed to provide, or the limits shown on the Declarations,
whichever Is lose.
b. The Insurance afforded to the *additional Insured' does not apply to:
(1) Any 'occurrence that takes place after you cease to be a tenant In that
premises;
(2) Any premises for which coverage Is excluded by endorsement: or
(3) Structural alterations, new construction or demolition operations performed by or
on behalf of such 'additional Insured'.
2. The insurance afforded to the oadditional Insured' is excess over any valid and collectible
Insurance available to such 'additional insured', unless you have agreed In a written
contract for this insurance to apply on a primary or contributory basis.
I. BLANKET ADDITIONAL INSURED— LESSOR OF LEASED EQUIPMENT
1. Section II -Who Is An Insured Is amended to Include on'additional Insured' (as defined In
Article H. above), but only with reaped to their liability arising out of maintenance,
operation or use by you of equipment leased to you by such •additional Insured', subject
to the following provisions:
a. Limits of Insurance. The Limits of Insurance afforded to the eadditional Insured' shall
be the limits which you agreed to provide, or the limits shown on the Declarations,
whichever is less.
b. The Insurance afforded to the'addidonal Insured' does not apply to:
(1) Any'oeeurrence'that takes place after the equipment lease expires; or
(2) 'Bodlly injury' or "property damage' arising out of the sole negligence of such
additional insured.
2. The Insurance provided to the additional Insured' is excess over any valid and collectible
Insurance available to such 'additional Insured', unless you have a written contract for
this Insurance to apply on a primary or contributory basis.
J. INJURY TOCO-EMPLOYEES AND CO -VOLUNTEER WORKERS
1. Section It. Who Is An Insured Is amended to Include your'smployses' as Insureds with
respect to'bodily injury'to a oo= employee" in the course of the co= employee's'
employment by you, or to your Ovolunteer workers' while performing duties related to the
conduct of your business, provided that this coverage for your •employees' does not
apply to acts outside the scope of their employment by you or while performing duties
unrelated to the conduct of your business.
Forth XIL 4381248 ® 2088, XL America, Ina Page ti of e
Indudas eopydghted material of Insurance eenkes Olf oo. Ina, r,11h Its pemNeebn.
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2. Section II — Who Is An Inaured Is amended to Include your 'volunteer workers' as
Insureds with reaped to'badlly Injury* to a co volunteer worker" while performing duties
related to the conduct of your business, or to your 'employees" employment by you,
provided that this coverage for your'volunteerworkers" does not apply while performing
duties unrelated to the conduct of your business.
K. KNOWLEDGE AND NOTICE OF OCCURRENCE OR OFFENSE
The following Is added to Paragraph 2., Duties In The Event of Occurrence, Offense, Claim or
Suit of the Section IV - Commercial General Liability Conditions:
Notice of an `occurrence' or of an offense which may result in a claim under this Insurance
shall be given as soon as practicable after knowledge of the'occurrenoe' or offense has
been reported to any insured listed under Paragraph 1. of Section it -Who Is An insured or
any "employee" (such as Insurance, lose control, risk manager or administrator) designated
by you to give such notice.
Knowledge of any other "employee(s)' of an "oocurrenoe' or of an offense does not imply that
you also have such knowledge.
Notice shall be deemed prompt If given in good faith as soon as practicable to your workers
compensation Insurer. This applies only If you subsequently ghre notice to us as exon as
practicable after any Insured listed under Paragraph 1. of Section It — Who Is An Insured or
an'employse' (such as an Insurance, loss control, or risk manager or administrator)
designated by you to give such notice discovers that the'oocurenoe', offense or claim may
Involve this policy.
L. UNINTENTIONAL OMISSION
The following Is added to Paragraph 6., Repreaentallons, of Section IV- Commercial General
Liability Conditions:
The unintentional omlesion of, or unintentional error in, any Information provided by you shall
not prejudice your rights under this insurance. However, this Article L. does not affect our
right to collect additional premium or to exercise our right of cancellation or nonrenewal In
accordance with applicable state Insurance laws or regulations,
M. LIBERALIZATION
The following Is added to Section IV -Commercial General Liability Conditions:
Llberaltration
After the Issuance of this policy, If we adopt a change in our forms or rides which would
broaden the coverage provided by any form that Is a part of this policy without a premium
charge, the broader coverage will apply to this policy. This extenelon Is effective upon the
approval of such broader coverage In your state,
Form XIL 4361206 ® 2008, XL America, Inc Page 6 of 8
Indudes eopydghled materiel of Insurance SeMces Office, Inc., vdlh Its permieelom
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N. BLANKET WAIVER OF SUBROGATION
The following Is added to Section IV-Commercal General Liability Conditions:
Waiver of Subrogation
We waive any right of recovery we may have against any person or organization because of
payments we make for Injury or damage arising out of premises owned or occupied or rented
or loaned to you; ongoing operations performed by you or an your behalf, done under a
contract with that person or organization; 'your work'; or *your products". We waive this right
where you have agreed to do so as part of a written contract, executed by you prior to loss.
O. INCIDENTAL MEDICAL MALPRACTICE INJURY
1. For Insurance applicable to this Article O, the definition ofbodily Injury' in Section V -
Definitions is amended to Include,'Incidental Medical Malpractice Injury'.
2. The following definition Is added to Section V. Definitions:
'Incidental medical malpractice injury' means 'bodily injury', mental anguish, sickness or
disease sustained by a person, including death resulting from any of these at any time,
arising out of the rendering of, or failure to render, the following services:
a. Medical, surgical, dental, laboratory, x-ray or nursing service or treatment, advice or
Instruction, or the related furnishing of food or beverages;
b. The furnishing or dispensing of drugs or medical, dental or surgical supplies or
appliances;
c. First aid; or
d. 'Good Samaritan Services% As used in this Article O., 'Good Samaritan Services'
are those medical services rendered or provided In an emergency and for which no
remuneration is demanded or received.
3. Paragraph 2.a.(1)(d) of Section 11 -Who Is An Insured does not apply to any registered
nurse, licensed practical nurse, emergency medical technician or paramedic employed by
you, but only while performing the services described in Paragraph 2. above and while
acing within the scope of their employment by you. Any'employese rendering'Good
Samaritan Services' will be deemed to be acting within the scope of their employment by
you.
4. The following exclusion is added to Paragraph 2. Exclusions of Coverage A. — Bodily
Injury And Property Damage Liability of Section I — Coverages:
[This Insurance does not apply to:)
Willful Violation of Penal Statute
Liability arising out of the willful violation of a penal statute or ordinance relating to the
safe of pharmaceuticals by or with the knowledge or consent of the Insured.
S. For the purposes of determining the applicable Limits of Insurance, any act or omission,
together with all related acts or omissions In the furnishing of services described In
Paragraph 2.a. through 2.d. above to any one person, will be considered one
'oocurence'.
S. This Article O. does not apply R you are In the business or occupation of providing any of
the services described in Paragraph 2. above.
Form XIL 4381208 ® 2008, XL America, Ina Page 7 of 8
Intrudes copyrighted material of Irrsuranoe aeMeas office, Ira, wfth b permisebn.
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7. The Insurance provided by this Article O. shall be excess over any other valid and
collectible Insurance available to the Insured, whether primary, excess, contingent or on
any other basis, except for Insurance purchased specifically by you to be excess of this
policy.
P. EXTENSION OF COVERAGE— BODILY INJURY
The definition ofbodily Injury' Section V. Definitions is deleted In Its entirely and replaced by
the following:
3. 'Bodily Injury' means bodily Injury, mental anguish, mental Injury, shock, fright, disability,
humiliation, sickness or disease sustained by a person, including death resulting from
any of these at any time.
0. COVERAGE TERRITORY
The definition ofcoverage territory' Section V- Definitions Is deleted in he entirety and
replaced by the following:
4. 'Coverage territory' means anywhere In the world.
This insurance does not apply to:
a. 'bodily Injury' or'property damage' that takes place; or
b. 'personal and advertising Injury' caused by an offense committed
outside the United States of America (including Its possessions and territories),
Canada and Puerto Rico, unless a *suit* on the merits (to determine the Insured's
responsibility to pay damages to which this Insurance applies) Is brought In the
United States of America (Including Its possessions and territories), Canada or
Puerto Rico.
This Insurance does not apply to damage, lona, coat or expense& In connection with any
'sulf brought outside the United States of America (Including Its possessions and
territories), Canada or Puerto Rico.
Form XIL 43612x18 ® 2008, XL America, Inc. Page 8 of 6
Inductee copyrighted materiel of Ineuranw Services Ms. Inc., with Its pennW Ian.
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Terra Pave, Inc.
POLICYNUMBER: NBA -1000486-05
XIC 4211013
THIS ENDORSEMENTCHANGES THE POLICY. PLEASE READ IT CAREFULLY.
XL PLUS BUSINESS AUTO EXTENSION
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
COVERAGE DESCRIPTION
A. Temporary Substitute Auto Physical Damage
B. Who Is An Insured
1. Broad Form Insured
2. Employees As Insureds
3. Additional Insured By Contract, Agreement or Permit
4. Employee Hired Autos
C. Supplementary Payments
D. Amended Fellow Employee Exclusion
E. Physical Damage Coverage
1. Rental Reimbursement
2. Extra Expense— Broadened Coverage
3. Personal Effects Coverage
4. Lease Gap
S. Glass Repair— Waiver Of Deductible
F. Physical Damage Coverage Extensions
1. Additional Transportation Expense
2. Hired Auto Physical Damage
G. Business Auto Conditions
1. Notice Of Occurrence
2. Waiver Of Subrogation
3. Unintentional Failure To Disclose Hazards
4. Primary Insurance
H. Bodily Injury Redefined
I. Extended Cancellation Condition
XIC 421 1013 ® 2013 X.L. America, Inc, All Rights Reserved. Pagel of 0
May not be copied without permission.
Includes copyrighted materiel of Insurance Services Office, Inc., with Na permission.
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A. Temporary Substitute Auto Physical Damage
SECTION I — COVERED AUTOS, C. Certain Trailers, Mobile Equipment And Temporary Substitute
Autos is changed by adding the following:
If Physical Damage coverage, is provided by this Coverage Form, the following types of vehicles are also
covered'autose for Physical Damage coverage:
1. Any'auto' you do not own while used with the permission of Its owner as a temporary substitute for
a covered "auto' you own that is out of service because of Its:
a. Breakdown;
b. Repair,
or Servicing;
d. "Losse; or
a. Destruction.
8. Who Is An Insured
SECTION 11 — COVERED AUTOS LIABILITY COVERAGE, A. Coverage, 1. Who Is An Insured is
changed by adding the following:
1. Broad Form insured
For any covered 'auto', any subsidiary, affiliate or organization, other than a partnership or Joint
venture, as may now exist or hereafter be constituted over which you assume active management
or maintain ownership or majority Interest, provided that you notHy us within ninety (90) days from
the date that any such subsidiary or affiliate is acquired or formed and that there Is no similar
insurance available to that organization. However, coverage does not apply to 'bodily Injury' or
"property damage that occurred before you acquired or formed the organization,
2. Employees As Insureds
Any "employee' of yours is an *insured* while using a covered "auto' you don't own, hire or borrow,
In your business or your personal affairs.
3. Additional Insured By Contract, Agreement Or Permit
Any person or organization with whom you have agreed In writing in a contract, agreement or permit
to provide Insurance such as is provided under this policy, provided that the 'bodily injury" or
"property damage occurs subsequent to the execution of the written contract, agreement orpermlL
4. Employee Hired Autos
An'employse' of yours Is an 'Insured" while operating an *auto' hired or rented under a contract or
agreement in that'employee'se name, with your permission, while performing duties related to the
conduct of your business.
XIC 4211013 ® 2013 X.L. America, Inc. All Rights Reserved. Page 2 of 6
May not be copied without permission.
Includes copyrighted material of insurance Services Office, Inc.. with Its permission.
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SECTION IV — BUSINESS AUTO CONDITIONS, B. General Conditions, 6. Other Insurance, b.
Is replaced with the following:
b. For Hired Auto Physical Damage Coverage, the following are deemed to be covered
'autos' you own:
(1) Any covered auto' you lease, hire, rent or borrow, and
(2) Any covered •auto' hired or rented by your 'employee* under a contract In that
Individual 'employee's' name, with your permission, while perforating duties
related to the conduct of your business.
However, any 'auto' that Is leased, hired, rented or borrowed with a driver is not a covered
•auto'.
C. Supplementary Payments
SECTION II — COVERED AUTOS LIABILITY COVERAGE, A. Coverage, 2. Coverage Extensions, a.
Supplementary Payments is changed as follows:
Item (2) Is deleted and replaced by the following:
(2) Up to $3,500 for cost of ball bonds (including bonds for related traffic law violations) required
because of an'acoldenV we cover. We do not have to fumish these bonds.
Item (4) Is deleted and replaced by the following:
(4) All reasonable expenses Incurred by the'insured' at our request, Including actual loss of earnings
up to $500 a day because of time off from work.
D. Amended Fellow Employee Exclusion
SECTION 11— COVERED AUTOS LIABILITY COVERAGE, B. Exclusions, 6. Fellow Employee does not
apply.
The Insurance provided under this Provision D. Is excess over any other collectible Insurance.
E. Physical Damage Coverage
SECTION III — PHYSICAL DAMAGE COVERAGE, A. Coverage Is changed by adding the following:
1. Rental Reimbursement
a. We will pay for rental reimbursement expenses Incurred by you for the rental of an 'auto'
because of lose to a covered 'auto'. Payment apples in addition to the otherwise
applicable amount of each coverage you have on a covered'auto'. No deductibles apply
to this coverage.
b. We will pay only for those expenses Incurred during the policy period beginning twenty-four
(24) hours after the'Ioss' and ending, regardless of the pollcys expiration, with the leaser
of the following number of days:
XIC 4211013 ® 2013 X.L. America, Inc. All Rights Reserved. Page 3 of 6
May not be copied without permission.
Include® copyrighted material of Insurance Services Office, Ina, with Its permlaslon.
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2.
3.
4.
XIC 421 1013
(1) The number of days reasonably required to repair or replace the covered 'auto'. If
"lose• is caused by theft, this number of days is added to the number of days It takes
to locate the covered "auto* and return it to you.
(2) Thirty (30) days.
C. Our payment Is limited to the lesser of the following amounts:
(1) Necessary and actual expenses Incurred.
(2) $50 any one day per private passenger'autc";
$100 any one day per truck;
$1,500 any one period per private passenger auto';
$3,000 any one period per truck; or
Higher limits If shown elsewhere In this policy.
d. This coverage does not apply while there are spare or reserve lautoe available to you for
your operations.
e. If'loss' results from the total theft of a covered 'auto* of the private passenger type, we will
pay under this coverage only that amount of your rental reimbursement expenses which is
not already provided for under the Physical Damage Coverage Extension.
Extra Expense— Broadened Coverage
We will pay forthe expense of returning a stolen covered "auto" to you.
Personal Effects Coverage
If you have purchased Comprehensive Coverage on this policy for an 'auto* you own and that'auto'
Is stolen, we will pay, without application of a deductible, up to $500 for 'personal effects' stolen
from the "auto".
As used In this endorsement, 'personal effects' means tangible property that is wom or carried by
an'insured% 'Personal effects' does not Include tools, Jewelry, money or securities.
Lease Gap
In the event of a total 'loss' to a covered'auto' shown in the Declarations, we will pay any unpaid
amount due on the lease or loan for a covered'auto', leas:
a. The amount paid underthe Physical Damage Coverage Section of the policy; and
b. Any:
(1) Overdue leaseAoanpsymentsatthe time ofthe 'lose';
(2) Financial penalties Imposed under a lease for excessive use, abnormal wear and
tear or high mlleage;
(3) Security deposits not returned by the lessor;
(4) Costa for extended warranties, Credit Life Insurance, Health, Accident or Disability
Insurance purchases with the loan or lease; and
(5) Carry-over balances from previous loans or leases.
0 2013 X.L. America, Inc. All Rights Reserved. Page 4 of 8
May not be copied without permission.
Includes copyrighted material of Insurance Services Office. Ina, with Its permission.
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6. Glass Repair— Waiver Of Deductible
No deductible applies to glass damage If the glass is repaired rather than replaced.
F. Physical Damage Coverage Extensions
SECTION III — PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions is amended by
the following:
1. Additional Transportation Expense
Sections a. and b. are amended to provide a limit of $50 per day and a maximum limit of $1,000.
2. Hired Auto Physical Damage
The following section Is added:
Any'auto' you lease, hire, rent or borrow is deemed to be a covered 'auto" for physical damage
coverage. The most we will pay for each covered auto' Is the lesser of:
(1) the actual cash value;
(2) the cost for repair or replacement or
(3) $50,000, or higher limit If shown on the Declarations for Hired Auto Physical Damage
Coverage.
For each covered 'auto' a deductible of $100 for Comprehensive Coverage and $1,000 for
Collision Coverage will apply.
0. Business Auto Conditions
SECTION IV— BUSINESS AUTO CONDITIONS, A. Lose Conditions Is changed by the following:
1. Notice Of Occurrence
Section 2. — Duties In The Event Of Accident, Clain, Suit Or, Loss, a. is changed by adding the
following:
If you report an Injury to an 'employee' to your workers' compensation carrier and If it is
subsequently determined that the injury Is one to which this Insurance may apply, any failure to
comply with this condition will be waived if you provide us with the required notice as soon thereafter
as practicable after you know or reasonably should have known that this Insurance may apply.
2. Waiver Of Subrogation
Section 6. Transfer Of Rights Of Recovery Against Others To Us is changed by adding the
following:
However, this Condition does not apply to any person(s) or organlzatton(s) with whom you have a
written contract, but only to the extent that subrogation Is waived prior to the'ecoldenr or the loss,
under such contract with that person or organization.
XIC 4211013 ® 2013 X.L. America, Inc. All Rights Reserved. Page 5 of 6
May not be copied without permission.
Includes copyrighted meterial of Insurance SwWom Office, Inc., with is pemibelom
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SECTION IV —BUSINESS AUTO CONDITIONS, B. General Conditions Is changed by the following:
3. Unintentional Failure To Disclose Hazards
The following condition Is added:
Your unintentional failure to disclose all hazards as of the inception date of the policy shall not
prejudice any insured with respect to the coverage afforded by this policy.
4. Primary Insurance
Condition S. Other Insurance is changed by adding the following:
For any covered 'auto' this Insurance shall apply as primary and not contribute with any other
Insurance where such requirementis agreed In a written contract executed prior to a'loss".
H. Bodily Injury Redefined
SECTION V — DEFINITIONS, C. 'Bodily Injury!' Is replaced by the following:
'Bodily Injury' means bodily Injury, sickness or disease sustained by a person including mental anguish,
mental Injury, shock, fright or death resulting from any of these at any time.
Extended Cancellation Condition
COMMON POLICY CONDITIONS (Form IL 0017), A. Cancellation, 2.b. Is replaced by the following:
The greater of sixty (00) days or the time required by any applicable stale amendatory endorsement before
the effective date of cancellation if we cancel for any other reason.
All other terms and conditions of this policy remain unchanged.
XIC 4211013 ® 2013 X.L. America, Inc. All Rights Reserved. Page S of S
May not be copied without permission.
Includes copyrighted material of insurance Services Office, Inc., with Its permission.
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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 08 34
(Ed. B-00)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - BLANKET
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not
enforce our right against the person or organization named in the Schedule. (This agreement applies only to the
extent that you perform work under a written contract that requires you to obtain this agreement from us).
The additional premium for this endorsement shall be 3% of the total California Workers' Compensation premium
otherwise due.
Schedule
Person or Organization
ANY PERSON I ORG WHEN REQUIRED
BY WRITTEN CONTRACT
Policy Number. WSD 5047055 05
Endorsement Effective:411n024
Issue Date:12i6n024
WC 99 08 34
(Ed. 8-00)
,Job Description
ALL CA OPERATIONS
Insured: Te" Pave, ins.
Coverage Provided by: Ins Cc of the West
Countersigned by:
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