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HomeMy WebLinkAboutNorth Counties Development Corp. 2010-06-08Earth Moving & Transportation GEN ENGR. LIC. 769225 June 7, 2010 Mr. Guy Mills City of Ukiah 300 Seminary Ukiah, CA 95482 Dear Guy: 425 Talmage Road Ukiah, CA 95482 tel: (707) 462-7166 fax: (707) 462-5681 ncd@pacific.net North Counties Development proposes to donate the clearing and grubbing for the Low Gap Skate Park project per the following Scope of Work. SCOPE OF WORK: 1. Remove and dispose of all trees, stumps and shrubs within the project boundary. 2. Remove and dispose of obstructions and debris within the project boundary, specifically the volleyball court sand and uprights, metal table frame, and rotary sign. 3. Strip all grass and vegetation approximately five to ten feet beyond the project boundary to allow for future grading operations. All strippings will be off- hauled. Note: The parking lot, horizontal utility pole barrier, and existing utility pole inside the project boundary will remain intact, and any alterations of same are not part of the Scope of Work referenced above. CONSTRUCTION DURATION: 2 days If you have any questions, please do not hesitate to contact us. Sinc/erely, Berndt Akerstrom Kjell Akerstrom BA/KA:ks CITY OF UKIAH NOTICE TO PROCEED WITH WORK By: Signature Title: , I Date: / CONTRACT APPROVAL/AUTHOIZATION TO PROCEED Instruction: When requesting City Manager approval/signature on a contract, submit the attached checklist confirming proper review/approvals have been obtained, insurance documents have been received and funding/expenditure authorizations approved. To: CITY MANAGER Submitted By: u7 lul 1/5 Date: Apprv'I Apprv'1 Apprv'I Not Recv'd Recv'd Description Required' Yes No 1. Use of City's Professional Services Contract Template (pre-approved by City Attorney) SACity ManagerlRisk Management\Contract Template Use of Vendors Contract (requires City Attorney review) Modified City Contract 6 Z' em. t 7~ (requires City Attorney review) 2. Insurance Documents Received & Approved by Risk Manager 3. Confirmed Sufficient Funding Available and expenditure approved. Attach documentation as V necessary. 4. City ouncil Approved & Date 5. Ot er Documentation/Approvals: 6/8/2010 3:16 PM CITY OF UKIA INDEMNITY AGREEMENT This Indemnification Agreement is made and entered in Ukiah, California, on June 8, 2010, by and between the City of Ukiah and North Counties Development Corp. (Volunteer Contractor). Volunteer Contractor has agreed to perform volunteer construction work for the City on the Ukiah Skate Park project ("the Project"), using workers who have offered freely and without pressure and coercion, direct or implied, to perform work on the Project. Although working as volunteers, Volunteer Contractor has designated these workers as employees covered by Volunteer Contractor's workers compensation insurance. Prior to performing any volunteer work for the City, Volunteer Contractor agrees to: 1. furnish the City with certificates of insurance and policy endorsements demonstrating that it satisfies the insurance requirements set forth in the attached Exhibit A; 2. indemnify, defend, and hold harmless the City of Ukiah and its officers, officials, and employees from and against any and all liability, loss, damage, expense, costs (including without limitation costs and fees of litigation) of every nature caused by the Volunteer Contractor's negligent or willfully wrongful performance of work on the Project, except to the extent that the liability, loss, damage, expense, or costs are caused by the negligence or wrongful conduct of the City, its officials or employees, its contractors performing work on the Project or other volunteers performing work on the Project. / Vice President Signature Title Kjell Akerstrom Print Name June 8, 2010 Date Agency Lic#: OD80851 INSURED INSURER A: Indian Harbor Insurance Com NORTH COUNTIES DEVELOPMENT CORP. INSURER B: _ 425 TALMAGE RD INSURER C: UKIAH CA 95482 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I POLICY EFFECTIVE POLICY EXPIRATION LIMITS ITYPE OF INSURANCE POLICY NUMBER DATE MM/DD DATE MM/DD/YY GENERAL LIABILITY 0005118453 10/30/09 10/30110 EACH OCCURRENCE Is 1,,000,000 COMMERCIAL GENERAL LIABILITI CLAIMS MADEr X OCCUR 1A GEN'L AGGREGATE LIMIT APPLIES PER: X I POLICY n PRO El LOC e AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS GARAGE LIABILITY ANYAUTO EXCESS / UMBRELLA LIABILITY OCCUR ❑ CLAIMS MADE NOV 2009 DAMAGE TO RENTED PREMISES (Ea occurence) $ 100,000 MED. EXP (Any one person) $ 6,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OP AGG. $ 2,000,000 COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) AUTO ONLY - EA ACCIDEP OTHER THAN EA AUTO ONLY: EACH OCCURRENCE AGGREGATE DEDUCTIBLE Zb RETENTION $ $ WORKERS COMPENSATION AND WC STATU- TORY LIMITS OTHER EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ ANY PRDPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE-EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS CITY OF UKIAH IS HEREBY NAMED ADDITIONAL INSURED WITH RESPECT TO THE ABOVE NAMED INSUREDS POLICY ONLY. CERTIFICATE HOLDER CANCELLATION CITY OF UKIAH 30 SEMINARY AVENUE UKIAH CA 95482 Attention: KATRINA ACORD 25 (2001/08) Certificate # 64681 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. 4tAA_e-~_ fpPr-1h, ol~._ Tamara Epping © ACORD CORPORATION 1988 CG 20101185 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS LESSEES OR CONTRACTORS (FORM 13) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organisation: AUTOMATIC STATUS WHEN AN ADDITIONAL INSURED IS REQUIRED BY CONTRACT. (If no entry appears above, Information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section 11) Is amended to include as an Insured the person or organization shown in the Schedule, but only with respect to Ilability arising out of "your work" for that Insured by or for you. CG 20 10 11 85 Copyright, Insurance Services office, Inc., 1984 A „ CG 24 04 10 83 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name of Person or Organization: - SCHEDULE AUTOMATIC STATUS WHEN AN ADDITIONAL INSURED IS REQUIRED BY CONTRACT. (if no entry appears above, Information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV - COMMERCIAL GENERAL LIABILITY CONDITIONS) Is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown In the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or'your work" done under a contract with that person or organization and included in the "products-completed operations hazard" This waiver applies only to the person or organization shown In the Schedule above. CG 24 0410 93 Copyright, Insurance Services Office, Inc., 1992 x s04/30/2010 14:18 70746^03211 JAY EPSTEIN AGENCY PAGE 02/03 CERTIFICATE % LIABILITY INSURANCE DATE (MM/D/ Oaisoi2o10 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 SY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain polirip5a may squire an ondorsoment. A statement on this certificate does not oollrer rights to the certificate holder in lieu of such endorsement(s). PRODUCER _ tires r Jay Epstein, State Farm Office 488 North State St, Ukiah, CA 95482 r A INSURED North Counties Developmont Corp. 425 Talmage Rd. Ukiah, CA 95482 Ext)f 707-458-0179 I iaiC~ Nol; 707468-3811 jay.epstein.mIr@statefarm,com INSURER(S) AFFORDING COVERAGE NAIC k A : State Farm Mutual Automobile Insurance Company 25178 e: INSURER D : OVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HFRPIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDI I IUNS UI-SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. R TYPE OP INSURANCE ADDL POLICY NUM9ER POLICY EFF PO Li Y EXP MMIDDrrYYY MM! DrfYYY LIMITS GENERAL LIABILITY - EACH OCCURRENCE I $ COMMERCIAL GENERAL LIABILITY ❑ ❑ UAMA UILA Kc -N I? :U PREMISES (Ea occurrenc@ S - CLAIMS-MADE OCCUR MED EXP An on - f An a parnonl S GENT AGGREGATE LIMIT APPLIES PER PDLICY PRO LOC AUTOMOBILE LIAMUT ( 086 2817-825-058 _ ANY Al.n•O ~ ~ U86 -1878-845-05B ALL OWNF-0 AUTOS 086 2820.525-05E X SCHEDULED AUTOS HIRED AUTOS 086 2822-e25-05D NON-OWNED AUTOS UMBRELLA LIAB OCCUR EXCESS LIAR CLAIMS DEDUCTIBLE WORKERS COMPENSATION ANIN GA4PLOY8RS'LIACILITv ANY PROPRIETORIPARTNERrmXECUTIVE YIN OFFICERIMEMBER EXCLUDED? N/A ((Mandatory In NH) I(yee, dewibn under 0212512010 08/25/2010 02/25/2010 0812512010 02/2512010 0812512010 02/25/2010 as/2513010 DESCRIPTION DF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Addltlonai Remarks SGhadula, I(p,ore apace Is raqulrq~ PERSONAL & ADV INJURY S FG-ri-NERAL AGGREGATE S PRODUCTS - COMPIOP AGA 1 .1 I's SINGLE LIMIT is BODILYINJURY(Perpereon) S 1,000,000 SODILYINJURY (Per sccidenl) $ 1,000,000 PROPERTY DAMAGE (Perseaidont) S 750,000 R EACH OCCURRENCE S AGGREGATE L S S . F E.L EACH ACCIDENT S E.L. DISEASE - EA EMPLOYEE S E.L, DISEASE -POLICY LIMIT S City or Ukiah 300 Seminary Dr. Uklah, CA 95482 TIO N SHOULD ANY OF THE AaOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE Pn1 If:Y PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988- 2009 ACORD CORPORATION. All rights reserved. ACORL) 25 (2009109) The ACORD name and logo are registered marks of ACORD 1001486 132849.4 02-11-2010 10 CERTHOLDER COPY INC P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 05-03-2010 GROUP: 000541 POLICY NUMBER: 0001248-2009 CERTIFICATE ID: 8 CERTIFICATE EXPIRES: 01-01-2011 01-01-2010/01-01-2011 CITY OF UKIAH NC JOB:LOW GAP SKATEPARK LOW GAP ROAD 300 SEMINARY AVE UKIAH UKIAH CA 95482-5400 CA This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and condit'ioons, of such policy. t Representative Interim President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01-01-2006 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2010-05-03 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF UKIAH EMPLOYER NORTH COUNTIES DEVELOPMENT CORP 425 TALMAGE RD UKIAH CA 95482 NC [JHL,CNj (REV.1-2010) PRINTED : 05-03-2010