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American Asphalt Repair and Resurfacing 2023-10-13
COU No. 23 z — )Of CITY OF UKIAH Mendocino County, California AGREEMENT FOR Slurry Seal of Local Streets Specification No. 23-12 ;Ir l� THIS AGREEMENT,made this day of 'C �J ems'' ,20A3,by and between the City of Ukiah, Mendocino County,California,hereinafter called the City and American Asphalt Repair a Resurfacing co "hereinafter called the Contractor, WITNESSETH: WHEREAS, the City has caused to be prepared in accordance with law, specifications, drawings and other contract documents for the work herein described and shown and has approved and adopted these contract documents,specifications and drawings and has caused to be published in the manner and for the time required by law a notice to bidders inviting sealed proposals for doing the work in accordance with the terms of this contract and WHEREAS, the Contractor, in response to the notice to bidders, has submitted to the City a sealed proposal accompanied by a proposal guaranty in an amount of not less than 10 percent of the bid price for the construction of the proposed work in accordance with the terms of this contract and WHEREAS, the City, in the manner prescribed by law, has publicly opened, examined and canvassed the proposals submitted and as a result has determined and declared the Contractor to be the lowest and best regular responsible bidder for the work and for the sums named in the proposal, NOW, THEREFORE, THIS AGREEMENT WITNESSETH: Article 1. Work to be Done and Contract Days Allowed. That the Contractor shall provide all necessary machinery,tools,apparatus and other means of construction;shall furnish all materials,superintendence,overhead,expenses,all labor and expenses of whatever nature necessary for completion of the work in conformity with the Special Provisions and other contract documents hereto attached and according to such instructions as may be given by the Engineer.The Contractor shall complete the work within fifteen(15)calendar days. Contract days shall be counted starting with the 10th day following receipt of notice that the contract has been executed by the City. Contractor, at his or her option, may begin work prior to start of counting contract days, however. in no event shall the Contractor start work without giving notification to the Engineer at least 72 hours prior to the start of work,without obtaining an encroachment permit from the City, or without having submitted certificates of insurance that have been accepted and approved by the Engineer Slurry Seal of Local Streets 51 Spec.No.23-12 Article II. Contract Prices. That the City shall pay the Contractor the prices stated in the proposal submitted by the Contractor,for complete performance of the contract by the Contractor. The Contractor hereby agrees to accept the prices as full compensation for all material and appliances necessary to the work, for all labor and use of tools and other implements necessary to execute the work contemplated in this contract;for all loss or damage arising out of the nature of the work or from the action of the elements,or from any unforeseen obstructions or difficulties which may be encountered in the prosecution of the work; for all risks of every description connected therewith; for all expenses of the work,as herein specified;for all liability and other insurance,for all overhead and other expenses incident to the work; all according to the Contract Drawings, the Special Provisions,the Details, the instructions and the requirements of the City. Article III. tabor Discrimination. Attention is directed to Section 1735 of the Labor Code,which reads as follows: "No discrimination shall be made in the employment of persons upon public works because of the race, color,national origin or ancestry,or religion of such persons and every contractor for public works violating this section is subject to all the penalties imposed for a violation of this chapter." In connection with the performance of work under this contract,the Contractor agrees as follows: (a) The Contractor will not willfully discriminate against any employee or an applicant for employment because of race, color, religion, ancestry, or national origin. The Contractor will take affirmative action to ensure that applicants are employed and that employees are treated during employment without regard to their race,color,religion,ancestry,or national origin.Such action shall include,but not be limited to, the following: employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training,including apprenticeship.The Contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the awarding authority setting forth the provisions of this Fair Employment Practice section. (b) The Contractor will send to each labor union or representative of workers with which he or she has a collective bargaining agreement or other contract or understanding, a notice,to be provided by the awarding authority, advising the said labor union or worker's representative of the Contractor's commitments under this section, to employees and applicants for employment. (c) The Contractor will permit access to his or her records of employment,employment advertisements, application forms and other pertinent data and records by the Fair Employment Practices Commission,City of Ukiah or any other appropriate agency of the State of California designated by the awarding authority, for the purposes of investigation to ascertain compliance with the Fair Employment Practices section of this contract. (d) A finding of willful violation of the Fair Employment Practices section of this Contract or of the Fair Employment Practices Act shall be regarded by the awarding authority as a basis for determining the Contractor to be not a "responsible bidder' as to future contracts for which such Contractor may submit bids,for revoking the Contractor's pre-qualification rating,if any and for refusing to establish, reestablish or renew a pre-qualification rating for the Contractor. The City of Ukiah shall deem a finding of willful receipt of written notice from the Fair Employment Practices Act to have occurred upon that it has investigated and determined that the Contractor has Slurry Seal of Local Streets 62 Spec.No,23-12 violated the Fair Employment Practices Act and has issued an order under Labor Code Section 1426 or obtained an injunction under Labor Code Section 1429. Upon receipt of such written notice From the Fair Employment Practices Commission,the City shall notify the Contractor that unless he or she demonstrates to the satisfaction of the awarding authority within a stated period that the violation has been corrected, his or her pre-qualification rating will be revoked at the expiration of such period. (e) The Contractor agrees that should the City determine that the Contractor has not complied with the Fair Employment Practices section of this Contract,then pursuant to Labor Code Section 1735 and 1775 the Contractor shall,as a penalty to the City,forfeit for each calendar day or portion thereof,for each person who was denied employment as a result of such non-compliance,the penalties provided in the Labor Code for violation of prevailing wage rates. Such monies may be recovered from the Contractor. The City may deduct any such damages from any monies due the Contractor. {f) Nothing contained in this Fair Employment Practices section shall be construed in any manner of fashion so as to prevent the City or the State of California from pursuing any other remedies that may be available at law. (g) Prior to awarding the Contract,the Contractor shall certify to the awarding authority that he or she has or will meet the following standards for affirmative compliance,which shall be evaluated in each case by the awarding authority: (1) The Contractor shall provide evidence, as required by the City that he or she has notified all supervisors,foremen and other personnel officers in writing of the content of the anti-discrimination clause and their responsibilities under it. (2) The Contractor shall provide evidence, as required by the City, that he or she has notified all sources of employees' referrals (including unions, employment agencies, advertisements, Department of Employment)of the content of the anti-discrimination clause. (3) The Contractor shall file a basic compliance report, as required by the City. Willfully false statements made in such reports shall be punishable as provided by law.The compliance report shall also spell out the sources of the work force and who has the responsibility for determining whom to hire, or whether or not to hire. (4) Personally,or through his or her representatives,the Contractor shall,through negotiations with the unions with whom he or she has agreements, attempt to develop an agreement which will: a. Spell out responsibilities for nondiscrimination in hiring, referral, upgrading and training. b. Otherwise implement an affirmative anti-discrimination program in terms of the unions' specific areas of skill and geography to the end that qualified minority workers will be available and given and equal opportunity for employment. (5) The Contractor shall notify the City of opposition to the anti-discrimination clause by individuals, firms or organizations during the period of its pre-qualification. (h) The Contractor will include the provisions of the foregoing paragraphs 1 through 5 in every first tier subcontract so that such provisions will be binding upon each such subcontractor. (i) The "Fair Employment Practices Certification" must be completed and signed prior to the time of submitting the bid. Slurry Seal of Local Streets 53 Spec.No.23-12 Article IV. Parts of the Contract. That the complete contract consists of the following documents, all of which shall be considered a part of this agreement. 1. Notice to Bidders 2. Wage Rates 3. General Conditions 4. Technical Specifications 5. Proposal 6. Fair Employment Practices Certification 7. Agreement 8. Contract Bonds 9. Contract Drawings and Construction Details 10. Standard Drawings 11. Indemnification Agreement IN WITNESS WHEREOF,this contract being executed in duplicate and the parties having caused their names to be signed by authority of their duly authorized office this Is day of 0 c /V b X r , 20 a3. CITY OF UKIAH, MENDOCINO COUNTY, CALIFORNIA By: - <. - TP AN I UKIAH ,t Attest: �Y - -, CITY CLERK, CITY OF UKIAH By: 3AV C06M.- CONTRAWOR Attest: Title: Secretary The foregoing contract is a proved as to for d legality this /xday of �� . 20 L 3- .r. CITY A ITY KI H Slurry Seal of Local Streets 54 Spec.No.23-12 INDEMNIFICATION AGREEMENT This Indemnification Agreement is made and entered in Ukiah, California, on , 20 by and between the City of Ukiah(Ukiah)and American Asphalt Repair&Resurfacing Co., Inc. (Contractor). Contractor is American Asphalt Repair& Resurfacing Co., Inc. for Ukiah. As a condition of issuing the work order, attached hereto, Ukiah requires assurance that Contractor will protect Ukiah from damage or damage claims which arise from its performance of the work. Accordingly, Contractor agrees as follows: 1. Indemnification. Contractor shall indemnify and hold harmless Ukiah and its officers,agents,and employees from and against any claim, loss,or damage, including the legal and other costs of defending against any claim of damage or loss which arises out of the Contractor's negligent or wrongful performance under the work order attached hereto, except for claims, losses,or damages resulting from the sole and exclusive negligence or other wrongful conduct of Ukiah or its officers, agents and employees. CONTRACTOR BY: TITLE: Secretary Slurry Seal of Local Streets 55 Spec.No.23-12 Issued in Duplicate Original CITY OF UKIAH Mendocino County, California PERFORMANCE BOND BOND No. ES00015856 KNOW ALL PERSONS BY THESE PREESNTS: THAT WHEREAS,the City of Ukiah.organized and operating under the laws of the State of Califomia,(hereinafter referred to as the City") has awarded to American Asphalt Repair and Resurfacing Company Inc. (hereinafter referred to as the "Contractor')an agreement for Contract No. 23-12 (hereinafter referred to as the"Project"). WHEREAS,the work to be performed by the Contractor is more particularly set forth in the Contract for the Project dated ,(hereinafter referred to,together with all attachments and exhibits thereto,as "Contract Documents"), the terms and conditions of which are expressly incorporated herein by reference; and WHEREAS, the Contractor is required by the Contract Documents to perform the terms thereof and to furnish a bond for the faithful performance of said Contract Documents. NOW, THEREFORE, we, nrr>edamAV1altaWPa"bdVGwM.kr- the undersigned Contractor and Everest Natrona Insurance 1:-jmpany ,as Surety,a corporation organized-and duly authorized to transact business under the laws of the State of California. are held firmly bound until the City in the sum of se,+s Rndww* - mThc a we[v&and24nooD&s($ 797,096.24 ), for which amount well and truly to be made,we bind ourselves, our heirs executors and administrators, successors and assigns,jointly and severally, firmly by these presents, THE CONDITION OF THIS OBLIGATION IS SUCH that, if the Contractor, his or its heirs, executors, administrators,successors or assigns,shall in all things stand to and abide by,and well and truly keep and perform the covenants,conditions and agreements in the Contract Documents and any alteration thereof made as therein provided,on its part,to be kept and performed at the time and in the manner therein specified, and in all respects according to their intent and meaning; and shall faithfully fulfill all obligations, and shall indemnify and save harmless the City, its officials, officers, employees, and authorized volunteers, as stipulated in said Contract Documents,then this obligation shall become null and void;otherwise it shall be and remain in full force and effect. As part of the obligation secured hereby and in addition to the face amount specified therefore, there shall be included costs and reasonable expenses and fees including reasonable attorneys'fees, incurred by the City in enforcing such obligation. As a condition precedent to the satisfactory completion of the Contract Documents,unless otherwise provided for in the Contract Documents,the above obligation shall hold good for a period of one(1)year after the acceptance of the work by the City,during which time if Contractor shall fail to make full,complete,and satisfactory repair and replacements and totally protect the City from loss or damage resulting from or caused by defective materials or faulty workmanship. The obligations of Surety hereunder shall continue so long as any obligation of Contractor remains. Nothing herein shall limit the City's rights or the Contractor or Surety's obligations under the Contract Documents, law or equity, including, but not limited to, California Code of Civil Procedure Section 337.15. Whenever Contractor shall be, and is declared by the City to be, in default under the Contract Documents, the Surety shall remedy the default pursuant to the Contract Documents, or shall promptly, at the City's option: i. Take over and complete the Project in accordance with all terms and conditions in the Contract Documents; or ii. Obtain a bid or bids for completing the Project in accordance with all terms and conditions in the Contract Documents and upon determination by Surety of the lowest responsive and responsible bidder, arrange for a contract between such bidder, the Surety and the City, and make available as work progresses sufficient funds to pay the cost of completion of the Project, less the balance of the contract "Delaware Slung Seal of Local Streets 56 Spec.No 23-12 price, including other costs and damages for which Surety may be liable.The term"balance of the contract price"as used in this paragraph shall mean the total amount payable to Contractor by the City under the Contract and any modification thereto: less any amount previously paid by the City to the Contractor and any other set offs pursuant to the Contract Documents. iii Permit the City to complete the Project in any manner consistent with California law and make available as work progresses sufficient funds to pay the cost of completion of the Project,less the balance of the contract price including other costs and damages for which Surety may be liable.The term"balance of the contract price'as used in this paragraph shall mean the total amount payable to Contractor by the City under the Contract and any modification thereto, less any amount previously paid by the City to the Contractor and any other set offs by the City pursuant to the Contract Documents. Surety expressly agrees that the City may reject any contractor or subcontractor which may be proposed by Surety in fulfillment of its obligations in the event of default by the Contractor. Surety shall not utilize Contractor in completing the Project nor shall Surety accept a bid from Contractor for completion of the Project if the City when declaring the Contractor in default, notifies Surety of the City's objection to Contractor's further participation in the completion of the Project. The Surety, for value received, hereby stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Contract Documents or to the Project to be performed thereunder shall in any way affect its obligation on this bond,and it does hereby waive notice of any such change,extension of time,alteration or addition to the terms of the Contract Documents or to the Project. [REMAINDER OF PAGE LEFT INTENTIONALLY BLANK] Slurry Seal of Local Streets 57 Spec,No.23-12 IN WITNESS WHEREOF we have hereunto set our hands and seals this 25th day of__ September 2022.3 (Corporate Seal) Amer can Asphalt Repair and Resurfacing Company, Inc. Contractor/Principal By A Title (Corporate Seal) Everest National insurance Company Surety By W�Vn Attorney-in-Fact (Attach Attorney-in Fact Certificate) Title Shamn Rmrth Attnmay In Fart The rate of premium on this bond is $7 001$7.001$5.00 per thousand.The total amount of premium charges is $ $4,985.00 Premium is for contract term and is subject to adjustments based on final contract price (The above must be filled in by corporate attorney.) THIS IS A REQUIRED FORM. Any claims under this bond may be addressed to: (Name and Address of Surety) Everest National Insurance Company 100 Everest Way,Warren Corporate Center Warren, NJ 07059 (Name and Address of Agent or Melissa DeKoven Representative for service of process in 2710 Gateway Oaks Drive, Suite 150N California. if different from above) Sacramento. CA 95833-3505 (Telephone number of Surety and Agent Surety 908-604-3000 Agent:800-881-5669 or Representative for service of process in California) Slurry Seal of Local Streets 58 Spec,No 23-12 ACKNOWLEDGMENT 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 Sacramento } On September 25, 2023 before me, Kathleen Le, Notary Public, (insert name and title of the officer) personally appeared Sharon Smith who proved to me on the basis of satisfactory evidence to be the person(&)whose name(s) isfwz subscribed to the within instrument and acknowledged to me that tee/she/ executed the same in Ahislherl authorized capacity(ko, and that by MalherAbWsignatures) on the instrument the person(s), 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. KATHLEEN LE COMM.#2380925 D WITNESS my hand and official seal. NOTARY PUBLIC CALIFORNIA N 0.1 COUNTY OF SACRAMENTO Comm.Expires OCT 31.2025 ------------------- Signature Seat) everest POWER OF ATTORNEY EVEREST NATIONAL INSURANCE COMPANY KNOW ALL PERSONS BY THESE PRESENTS That Everest National Insurance Company.a corporation of the Slate of Delaware(-Company,having its principal office located at Warren Corporate Center 100 Everest Way.Warren.New Jersey.07059.do hereby nominate,constitute and appoint Elizabeth Collodl,John Hopkins,John J.Weber,Joseph H.Weber,Renee Ramsey,Sara Walliser,Mindy Whitehouse, Jennifer Lakmann,Deanna Quintero,Bill Rapp,Jason March,Matthew Foster,Tony Clark,Krisde Phillips,Claudine Gordon,Michael K.Feeney, Samantha Watkins,Phil Watkins,Brad Espinosa,Paula Senna,Pam Say,Breanna Boatrigh4 Kathleen Le,Sharon Smith its true and lawful Attorneys)in-fad to make,execute.attest seal and deliver for and on Its behalf as surety,and as its ad and deed.where required.any and all bonds and undertakings in the nature thereof,for the penal sum of no one of which is in any event to exceed UNLIMITED,reserving for Itself the full power of substitution and revocation Such bonds and undertakings,when duly executed by the aforesaid Attomey(s)-in-fad shall be binding upon the Company as fully and to the same extent as if such bonds and undertakings were signed by the President and Secretary of the Company and sealed with its corporate seal This Power of Attorney is granted and is signed by facsimile under and by the authority of the following Resolutions adopted by the Board of Directors of Company('Board')on April 21.2016: RESOLVED,that the President,any Executive Vice President and any Senior Vice President are hereby appointed by the Board as authorized to make,execute,seat and deliver for and on behalf of the Company,any and all bonds,undertakings,contracts or obligations in surety orco-surefy with others and that the Secretary orany Assistant Secretary of the Company be and that each of them hereby is authorized to attest to the execution of any such bonds, undertakings,contracts or obligations in surety or co-surety and attach thereto the corporate seal of the Company. RESOLVED,FURTHER.that the President,any Executive Vice President and any Senior Vice President are hereby authorized to execute powers of attorney qualifying the attorney named in the given power of attorney to execute-on behalf of the Company bonds and undertakings in surety or co-surefy with others.and that the Secretary or any Assistant Secretary of the Company be,and that each of them is hereby authorized to attest the execution of any such power of attorney.and to attach thereto the corporate seat of the Company RESOLVED,FURTHER.that the signature of such officers named in the preceding resolutions and the corporate seat of the Company may be affixed to such powers of attorney or to any certificate relating thereto by facsimile, and any such power of attorney or certificate bearing such facsimile signatures or facsimile seal shall be thereafter valid and binding upon the Company with respect to any bond,undertaking,contract or obligation in surety or co-surety with others to which it is attached. IN WITNESS WHEREOF.Everest National Insurance Company has caused their corporate seals to be affixed hereto,and these presents to be signed by their duly authorized officers this 151 day of February 2023. 0 03 LflSurdo Everest Reinsurance Company `olyat".' r� z SEAL c 1965 7 � -- By:Anthony Romano,Senior Vice President On this 1Sth day of February 2023,before me personally came Anthony Romano,known to me.who,being duly sworn,did execute the above instrument; that he knows the seal of said Company;that the seal affixed to the aforesaid instrument is such corporate seal and was affixed thereto;and that he executed said instrument by like order LINDA ROBINS Notary Public,State of New York `✓/ j NoCIR06239736X�(4 1,Jaco.r--- qualifled In Queens County r Tenn Expire■April 2S,2027 Linda Robins,Notary Public I,Sylvia Semerdjisn,Secretary of Everest National Insurance Company do hereby certify that I have compared the foregoing copy of the Power of Attorney and affidavit,and the copy of the Section of the bylaws and resolutions of said Corporation as set forth in said Power of Attorney,with the ORIGINALS ON FILE IN THE HOME OFFICE OF SAID CORPORATION,and that the same are correct transcripts thereof,and of the whole of the said originals,and that the said Power of Attorney has not been revoked and is now in full force and effect. IN WITNESS WHEREOF,I have hereunto set my hand and affixed the seal of said Company,this 25th day of September 2023 - Z� LM4r, rP {�J SEAT r91s m * !o By:Sylvia Semerd)ian,Secretary ES 00 01 04 16 Premium is inc uded in the Performance bond and is subject to adjustments based on final contract price Issued in Dup irate Original CITY OF UKIAH Mendocino County, California PAYMENT BOND BOND No. ES00015856 KNOW ALL PERSONS BY THESE PRESENTS American.Asphalt Repair and Resurfacing Corn any.Inc WHEREAS, the City of Ukiah ("City") has awarded to F'Contractor/Principal") a contract (City Agreement No. 23X' dated referred to as the "Agreement") for the work described as slum Seal Proiect2023 The Agreement is incorporated by this reference into this Payment Bond("Bond"); and WHEREAS, Contractor/Principal is required to furnish a bond in connection with the Agreement and pursuant to California Civil Code section 9550; NOW, THEREFORE, we American Asphalt Repair and Resurfacim Company,Inc. the undersigned Contractor/Principal: and EverestNatlana Insurance Company ("Surety"). a corporation organized and existing under the laws of the State of Delaware , and duly authorized to transact business under the laws of the State of California, as Surety, are held firmly bound until the City, and to any and all persons, companies or corporations entitled by law to file stop payment notices under California Civil Code Section 9100,or any person, company,or corporation entitled to make a claim on this bond,in the sum of$ for which payment will and truly be made,we bind ourselves,our heirs,executors and administrators,successors and assigns,jointly and severally, firmly by these presents. THE CONDITION OF THIS OBLIGATION IS SUCH that if Contractor/Principal,its heirs,executors,administrators, successors,or assigns,or subcontractor,shall fail to pay any person or persons named in Civil Code section 9100; or fail to pay for any materials, provisions, or other supplies, used in, upon,for, or about the performance of the work contracted to be done, or for any work or labor thereon of any kind, or for amounts due under the Unemployment Insurance Code,with respect to work or labor thereon of any kind;or shall fail to deduct,withhold, and pay over to the Employment Development Department,any amounts required to be deducted,withheld,and paid over by Unemployment Insurance Code Section 13020 with respect to work and labor thereon of any kind, then Surety will pay for the same,in an amount not exceeding the amount herein above set forth,and in the event suit is brought upon this bond,also will pay such reasonable attomeys'fees as shall be fixed by the oou(t,awarded and taxed as provided in California Civil Code Section 9550, et seq. It is further stipulated and agreed that the Surety of this bond shall not be exonerated or released from the obligation of the bond by any change,extension of time for performance,addition,alteration or modification in,to, or of any contract, plans, or specifications, or agreement pertaining or relating to any scheme or work of improvement herein above described;or pertaining or relating to the furnishing of labor, materials, or equipment therefor; nor by any change or modification of any terms of payment or extension of time for payment pertaining or relating to any scheme or work of improvement herein above described; nor by any rescissions or attempted rescission of the contract, agreement or bond; nor by any conditions precedent or subsequent in the bond attempting to limit the right of recovery of claimants otherwise entitled to recover under any such contract or agreement or under the bond;nor by any fraud practiced by any person other than the claimant seeking to recover on the bond;and that this bond be construed most strongly against the Surety and in favor of all persons for whose benefit such bond is give;and under no circumstances shall the Surety be released from liability to those for whose benefit such bond has been given, by reason of any breach of contract between the Owner and Contractor/Principal or on the part of any oblige named in such bond;that the sole condition of recovery shall be that the claimant is a person described in California Civil Code section 9100, and who has not been paid the full amount of his or her claim; and that the Surety does hereby waive notice of any such change, extension of time, addition,alteration or modification herein mentioned,including but not limited tothe provisions of section 2819 and 2845 of the California Civil Code. %ei Rnded Nr*S%W Roan fnEty*and 24PI00 OukS WW,09524) Slurry Seal of Local Streets 59 Spec.No.23-12 Any notice to Surety may be given in the manner specified in the Agreement and delivered or transmitted to Surety as follows Attn:Claims Address:100 Everest Way.Warren Corporate Center City/State/Zip:Warren, Ni 07059 Phone 908-604-3000 Fax:441-295-4a28 Email:-Kevin.Chambers@everes!global.com IN WITNESS WHEREO,two identical counterparts of this Bond,each of which shall for all purposes be deemed an original thereof, have been duly executed by Contractor/Principal and Surety above named, on the 25thday of September , 2023 - American Asphalt Repair and Resurfacing-vompany inc. (SEAL) Contractor/Principal By ContradcIfs Representative 24200 Clawiter Road Contractor/Principal's Address Hayward. CA 94545 City,State,Zip Everest National Insurance Coma (SEAL) Surety By Surety's Representative Sharon ith,Attomey-In-Fact 100 Everest Way,Warren Corporate Center Surety's Address Warren, NJ 07059 City,State,Zip 908-604-3000 Telephone Number NOTE:Signatures of those executing for Surety must be properly acknowledged,The bond must be accompanied by a properly acknowledged Power of Attorney from the Surety authorizing its agent to bind it to this bond.A copy of such Power of Attorney must be in file with the City. Slurry Seal of Local Streets 60 Spec.No 23 12 ACKNOWLEDGMENT 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 Sacramento ) On September 25, 2023 before me, Kathleen Le, Notary Public, (insert name and title of the officer) personally appeared Sharon Smith who proved to me on the basis of satisfactory evidence to be the person(&)whose name(s) isl1z subscribed to the within instrument and acknowledged to me that ke/she/#W executed the same in tislherltbeixauthorized capacity(j*, and that by i691herltt signature(s)on the instrument the person(s), or the entity upon behalf of which the person(s) 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. KATHLEEN LE COMM.#2380925 A o� NOTARY PUBLIC CALIFORNIA 5� a COUNTY OF SACRAMENTO w Comm.Expket OCT 31 2025 Signature (Seal) everest POWER OF ATTORNEY EVEREST NATIONAL INSURANCE COMPANY KNOW ALL PERSONS BY THESE PRESENTS That Everest National Insurance Company.a corporation of the State of Delaware('Company')having its principal office located at Warren Corporate Center 100 Everest Way,Warren New Jersey 07059,do hereby nominate,constitute,and appoint: Elizabeth Collodi,John Hopkins,John J.Weber Joseph H.Weber,Renee Ramsey,Sara Waliiser,Mindy Whitehouse, Jennifer Lakmann,Deanna Quintero,Bill Rapp,Jason March,Matthew Foster,Tony Clark,KNsffe Phillips,Claudine Gordon,Michael K.Feeney, Samantha Watkins,Phil Watkins,Brad Espinosa,Paula Senna,Pam Soy,Breanne Boatright,Kathleen Le,Sharon Smith its true and lawful Altorney(s)-m-fact to make.execute attest.seal and deliver for and on its behalf as surety,and as its ad and deed,where required,any and all bonds and undertakings in the nature thereof for the penal sum of no one of which is in any event to exceed UNLIMITED,reserving for itself the full power of substitution and revocation Such bonds and undertakings,when du y executed by the aforesaid Attorneys)-in-fad shall be binding upon the Company as fully and to the same extent as if such bonds and undertakings were signed by the President and Secretary of the Company and sealed with its corporate seal. This Power of Attorney is granted and is signed by facsimile under and by the authority of the following Resolutions adopted by the Board at Directors of Company(-Board')on April 21 2016: RESOLVED.that the President,any Executive Vice President,and any Senior vice President are hereby appointed by the Board as authorized to make,execute.seal and deliver for and on behalf of the Company.any and all bonds,underfaknrgs.contracts orobligations in surety or co-surety with others and that the Secretary or any Assistant Secretary of the Company be and that each of them hereby is authorized to attest to the execution of arty such bonds, undertakings,contracts or obligations in surely or co-surety and attach thereto the corporate seat of the Company. RESOLVED,FURTHER that the President,any Executive vice President,and any Senior Vice President are hereby authorized to execute powers of attorney qualifying the attorney named in the given power ofattomey to execute.on behalf of the Company,bonds and undertakings in surety or co-surety with others,and that the Secretary or any Assistant Secretary of the Company be.and that each of them is hereby authorized to attest the executon of any such power of attorney.and to attach thereto the corporate seal of the Company RESOLVED,FURTHER.that the signature of such officers named in the preceding resolutions and the corporate seal of the Company may be affixed to such powers of attorney or to any certificate relating thereto by facsimile.and any such power of attorney or certificate bearing such facsimile signatures or facsimile seal shall be thereafter valid and binding upon the Company with respect to any bond,undertaking,contract or obligation in surety or co-surety with others to which it is attached IN WITNESS WHEREOF,Everest National Insurance Company has caused their corporate seals to be affixed hereto,and these presents to be signed by their duly authorized Officers this 15P day of February 2023. opa tnsf�6' Everest Reinsurance Company 4o9y"4r1 f`0 SEAL c o ' � f415 7 -- By-Anthony Romano,Senior Vice President On this 15th day of February 2023,before me personally came Anthony Romano known to me.who,being duly swum.did execute the above instrument that he knows the seal of said Company,that the seal affixed to the aforesaid instrument s such corporate seal and was affixed thereto;and that he executed said instrument by like order LINDA ROBINS Notary public,State of New York ti No OIRe6239736 rr!` Qualffled In Queens County Term Expires April 25,2027 Linda Robins,Notary Public I,Sylvia Semerdjian,Secretary of Everest National Insurance Company do hereby certify that I have compared the foregoing copy of the Paver of Attorney and affidavit,and the copy of the Section of the bylaws and resolutions of said Corporation as set forth in said Power of Attorney with the ORIGINALS ON FILE IN THE HOME OFF CE OF SAID CORPORATION,and that the same are correct transcripts thereof,and of the whole of the said originals.and that the said Power of Attorney has not been revoked and is now in full force and effect. IN WITNESS WHEREOF,I have hereunto set my hand and affixed the seal of said Company,this 25th day of September 2023 . Sa tnsua �p et,�011+rf'^� SEAL U dson 3 a ; r By:Sylvia Semerdjian,Secretary ES 00 01 04 16 Bond No ES00015856 Issued in Duplicate Orginal CITY OF UKIAH Mendocino County, California DEFECTIVE MATERIAL AND WORKMANSHIP(MAINTENANCEI BOND KNOW ALL MEN BY THESE PRESENTS, That we, American Asphalt Repair and Resurfacing Company Inc. as PRINCIPAL and Everest National Insurance Company as SURETY, are held and firmly bound unto the City of Ukiah as Obligee, in the penal sum of Thirty-Nine Thousand Eight Hundred Fifty-Four and 8V100 Dollars ($ 39.854 81 ) (5 PERCENT OF THE FINAL CONTRACT AMOUNT) to which payment well and truly to be made we do bind ourselves, our and each of our heirs, executors, administrators successors and assigns jointly and severally, firmly by these presents. WHEREAS,the said Principal entered into a Contract with the City of Ukiah dated for Slurry Seal Project 2023 Contract No. 23-12 WHEREAS, said Contract has been completed, and was approved on the day of NOW,THEREFORE,THE CONDITION OF THIS OBLIGATION IS SUCH,that if the Principal shall guarantee that the work will be free of any defective materials or workmanship which become apparent during the period of one (1)year following completion of the Contract,then this obligation shall be void,otherwise to remain in full force and effect, provided however, any additional warranty or guarantee whether expressed or implied is extended by the Principal or Manufacturer only, and the surety assumes no liability for such a guarantee. Signed, sealed, and dated this 25th day of September , 202023 American Asphalt Repair and Resurfacing Company, Inc. (Seal) BY: A JJ C. (Seal) k (Seal) Principal Everest WiRnal Insurance Coma (Seal) BY: (Seal) Sharon Smith,Attomey-In-Fact (Seal) Surety Slurry Seal of Local Streets 62 Spec No.23-12 ACKNOWLEDGMENT 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 Sacramento ) On September 25, 2023 before me, Kathleen Le, Notary Public, (insert name and title of the officer) personally appeared Sharon Smith who proved to me on the basis of satisfactory evidence to be the person(&)whose name(s) is/ma subscribed to the within instrument and acknowledged to me that ke/she/VW executed the same in "slheditiixauthorized capacity(jaii), and that by taiadher/Mmixsignature(&)on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. 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. ••• KATHLEEN LE It COMM.#23130925 D p NOTARY PUBLIC CALIFORNIA 'Coo Q COUNTY OF SACRAMENTO w k Comm Expkes OC7 31 2025 Signature _ Seal i everest POWER OF ATTORNEY EVEREST NATIONAL INSURANCE COMPANY KNOW ALL PERSONS BY THESE PRESENTS That Everest National Insurance Company.a corporation of the State of Delaware("Company')having its principal office located at Warren Corporate Center 100 Everest Way,Warren.New Jersey 07059,do hereby nominate,constitute,and appoint: Elizabeth Collodl,John Hopkins,John J.Weber,Joseph H.Weber,Renee Ramsey,Sara Walliser,Mindy Whitehouse, Jennifer Lakmann,Deanna Quintero,Bill Rapp,Jason March,Matthew Foster,Tony Clark,Kriade Phillips,Claudine Gordon,Michael K.Feeney, Samantha Watkins,Phil Watkins,Brad Espinosa,Paula Senna,Pam Soy,Breanna Boafrfght,Kathleen Le,Sharon Smith its true and awful Attomey(s)-in-fact to make,execute.attest.seal and deliver for and on Is behalf.as surety and as its act and deed.where required.any and all bonds and undertakings in the nature thereof for the penal sum of no one of which s in any event to exceed UNLI MITED,reserving for itself the full power of substitution and revocat on. Such bonds and undertakings,when duly executed by the aforesaid Attomey(s)-in-fad shall be binding upon the Company as fully and to the same extent as if such bonds and undertakings were signed by the President and Secretary of the Company and sealed with its corporate seal. This Power of Attorney is granted and is signed by facsimile under and by the authority of the fallowing Resolutions adopted by the Board of Directors of Company;-Boa,-d'l on April 21,2016: RESOLVED,that the President,any Executive Vice President and any Senior vice President are hereby appointed by the Board as authorized to make.execute,seal and deliver for and on behalf of the Company,any and all bonds,undertakings,contracts orobligations in surety orco-surely with others and that the Secretary or any Assistant Secretary of the Company be and that each of them hereby is authorized to attest to the execution of any such bonds, undertakings,contracts or obligations in surety or co-surety and attach thereto the corporate seat of the Company. RESOLVED,FURTHER,that the President,any Executive Vice President and any Senior vice President are hereby authorized to execute powers of attorney quaklying the attorney named in the given power of attorney to execute on behalf of the Company bonds and undertakings in surety or co-surety wrth others.and that the 5`aeretary or any Assistant Secretary of the Company be.and that each of them is hereby authorized to attest the execution of any such power of attorney,and to attach thereto the corporate seal of the Company RESOLVED,FURTHER,that the signature of such officers named in the preceding resolutions and the corporate sea.!of the Company may be affixed to such powers of attorney or to any certificate relating thereto by facsimile.and any such power of attorney or certificate bearing such facsimile signatures ar facsimile s eai shall be thereafter valid and binding upon the Company with respect to any bond,undertaking contract or obligation in surety or co-surety with ethers to w lL ch it is attached. IN WITNESS WHEREOF,Everest National Insurance Company has caused their corporate seals to be affixed hereto and these presents to be signed by their duly authorized officers this 151i day of February 2023 QC3 Snstard, Everest Reinsurance Company 2 SEAL ` t9as 0 �d AQAviA0 By:Anthony Romano,Senior Vice President On this 15th day of February 2023,before me personally came Anthony Romano,known to me,who,being duly sworn.did execute the above nstrumenl. that he knows the seal of said Company;that the seal affixed to the aforesaid instrument is such corporate seal and was affixed thereto,and that he executed said instrument by like order LINDA ROBINS Notary Public,State of New York No01R06230738 Qualified In Queens County Tenn Expires April 26,2027 Linda Robins.Notary Pub is I,Sylvia Semerdjian,Secretary of Everest National Insurance Company do hereby certify that I have compared the foregoing copy of the Power of Attorney and affidavit,and the copy of the Section of the bylaws and resolutions of said Corporation as set forth iv.said Power of Attorney with the ORIG NAI S CN FILE IN THE HOME OFFICE OF SAID CORPORATION,and that the same are correct transcripts thereof.and of the whole of the said originals.and that the said Power of Attorney has not been revoked and is now in full force and effect. IN WITNESS WHEREOF,I have hereunto set my nand and affixed the seal of said Company,this 25th.day of September 2023 . oca nl su'a `aneae4j���, U SEA!, e tea, ah,rrn.'o .' -- By:Sylvia Semerdjian,Secretary FS 00 01 04 1113 A`�U7 CERTIFICATE OF LIABILITY INSURANCE DATE(M AE(M oz3 Y) 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 INSURERIS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(tes)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER InterWest Insurance Services, LLC PHONE Katie Snell Fax P.O. BOX 8110 916-609-8374 n No:916-609-8374 Chico CA 95927-8110 ADDRE • ksnell@iWns.com INSURERS AFFORDING COVERAGE NAIC 0 Licensell.OB01094 INSURER A.Pennsylvania Mfr's Assn Ins Co 12262 INSURED AMERASP.04 INSURER B:Travelers Property&Casualty Co of America 25674 American Asphalt Repair and Resurfacing Company, Inc.24200 Clawiter Rd. INSURER c:Westchester Surplus Lines Ins 10172 Hayward CA 94545 INSURER D:Arch Insurance Company 11150 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1177640228 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I�TR TYPE OF INSURANCE im L X=SIJBR POLICY NUMBER MM1DDIYYY r Y EFF MMIOD1YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y 3022011368497 12/3112022 1213112023 EACHOCCURRE:NCE $1000000 CLAIMS MADE a OCCUR PREMISES Ea occurrence $300000 MED EXP(Any one person) $10000 PERSONAL 8 ADV INJURY $1000000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2000000 POLICY JECT TLOC PRODUCTS-COMPIOPAGG $2000000 X OTHER: $ A AUTOMOBILE LIABILITY Y Y 1522011368497 12/31/2022 12/31/2023 COMBINED SINGLE LIMIT $1000000 Ea accident X ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) S HIRED X NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Per Xaocidenll S B X UMBRELLA LIAB X OCCUR CUPeT98709222 12/31/2022 12/31/2023 EACHOCCURRENCE $6000000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ D WORKERS COMPENSATION Y ZAM19413906 4/112023 411/2024 X STATUTE I I ERµ AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETORfPARTNERIEXECUTIVE ❑ NIA E.L.EACH ACCIDENT $1,000,000 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1.000,000 11 yes,descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1.000.000 C Pollution Liability G70915613004 8127/2022 8/27/2024 LIMIT EA OCC 5,000,000 LIMIT EA AGG 10,000,000 DEDUCTIBLE $10,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more apace is required) Additional Insured status applies to requested entities,if required by written contract,per the attached policy forms/endorsements. Waiver of subrogation applies to requested entities,if required by written contract,per the attached policy forms/endorsements. Primary non-contributory applies to requested entities, if required by written contract,per the attached policy formslendorsements. Re:Project:Slurry Seal Project 2023-Specification No.23-12. City of Ukiah,its officers,officials,employees and volunteers. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CI Of Ukiah ACCORDANCE WITH THE POLICY PROVISIONS. 300 Seminary Avenue Ukiah CA 95482-5400 AUTHQItrLEOREPRESENTATIVE 01988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 1522011368497 COMMERCIAL AUTO CA 20 4810 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement,the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s)or organization(s)who are"insureds"for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: American Asphalt Repair and Resurfacing Company, Inc. Endorsement Effective Date: 12/1/2022 SCHEDULE Name Of Person(s)Or Organization(s): As required by written contract. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. Each person or organization shown in the Schedule is an"insured"for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an"insured"under the Who Is An Insured provision contained in ParagraphA.1.of Section II-Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2.of Section I-Covered Autos Coverages of the Auto Dealers Coverage Form. ®Insurance Services Office,Inc. POLICY NUMBER: 1522011368497 COMMERCIAL AUTO CA 04 49 11 16 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. A. The following is added to the Other Insurance B. The following is added to the Other Insurance Condition in the Business Auto Coverage Form Condition in the Auto Dealers Coverage Form and and the Other Insurance— Primary And Excess supersedes any provision to the contrary: Insurance Provisions in the Motor Carrier This Coverage Form's Covered Autos Liability Coverage Form and supersedes any provision to Coverage and General Liability Coverages are the contrary: primary to and will not seek contribution from any This Coverage Form's Covered Autos Liability other insurance available to an "insured" under Coverage is primary to and will not seek your policy provided that: contribution from any other insurance available to an "insured"under your policy provided that: 1. Such "insured" is a Named Insured under such other insurance; and 1. Such "insured" is a Named Insured under such 2, You have agreed in writing in a contract or other insurance; and agreement that this insurance would be 2. You have agreed in writing in a contract or primary and would not seek contribution from agreement that this insurance would be any other insurance available to such primary and would not seek contribution from "insured". any other insurance available to such "insured". CA 04 49 11 16 ©Insurance Services Office, Inc., 2016 Page 1 of 1 POLICY NUMBER, 1522011368497 COMMERCIAL AUTO CA04441013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: American Asphalt Repair and Resurfacing Company, Inc. Endorsement Effective Date: 12/1/2022 SCHEDULE Name(s)Of Person(s)Or Organization(s): As required by written contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the"loss" under a contract with that person or organization. CA 04 44 10 13 0 Insurance Services Office, Inc., 2011 Page 1 of 1 Policy Number:3022011368497 COMMERCIAL GENERAL LIABILITY CG 20 01 1219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the This insurance is primary to and will not seek additional insured, contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and CG 20 01 12 19 ©Insurance Services Office, Inc., 2018 page 1 of 1 AGENT POLICY NUMBER: 3022011368497 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Where required by written contract or Agreement. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: 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 04 05 09 O Insurance Services Office, Inc.,2008 Page 1 of 1 G WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04 M) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA 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.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be INCL % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION WHERE ALL JOBS UNDER CONTRACT WAIVER OF OUR RIGHT TO RECOVER IS PERMITTED BY LAW AND IS REQUIRED BY WRITTEN CONTRACT PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO DATE OF LOSS This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 04-01-2023 Policy No. ZAWCI9413906 Endorsement No. Insured AMERICAN ASPHALT REPAIR Premium $ INCL. Insurance Company ARCH INSURANCE COMPANY Countersigned By (D 1998 by the Workers!compensation Insurance Rating Bureau of Callfamla. All rights reserved. From the WCIRB's California Workers'Compensation Insurance Forms Manual©1999. Policy Number:3022011368497 COMMERCIAL GENERAL LIABILITY Effective Date: 9/26/2023 CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organ ization s : Locations Of Covered Operations As required by written contract. If required by your agree- As Required by Written Contract. ment with such Additional Insured,this Insurance shall be primary insurance and non-contributory for that Additional Insured. If anyone, other than the Additional Insured, provides similar insurance for the Additional Insured, then this insur- ance will apply as outlined in SECTION IV-COMMERCIAL GENERAL LIABILITY CONDITIONS, paragraph 4, Other Insurance, subparagraph c., Method of Sharing. The Inclu- sion of one or more Insured under the terms of this endorse- ment does not increase our limits of liability. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or or- additional insureds, the following additional exclu- ganization(s) shown in the Schedule, but only with sions apply: respect to liability for "bodily injury", "property dam- This insurance does not apply to "bodily injury" or age" or "personal and advertising injury caused, in "property damage"occurring after: whole or in part, by: 1. All work, including materials, parts or equipment 1. Your acts or omissions; or furnished in connection with such work, on the 2. The acts or omissions of those acting on your project (other than service, maintenance or ie- behalf; pairs) to be performed by or on behalf of the ad- in the performance of your ongoing operations for ditional insured(s) at the location of the covered the additional insured(s) at the location(s) desig- operations has been completed; or nated above. 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 2010 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 POLICY NUMBER.3022011368497 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organ ization s : Location And Description Of Completed Operations As required by written contract. If required by your As Required by Written Contract agreement with such Additional Insured,this Insurance shall be primary insurance and non-contributory for that Additional Insured. If anyone, other than the Additional Insured, provides similar insurance for the Additional Insured,then this insurance will apply as outlined in SECTION IV-COMMERCIAL GENERAL LIABILITY CONDITIONS, paragraph 4, Other Insurance, subpara- graph c., Method of Sharing. The Inclusion of one or more Insured under the terms of this endorsement does not increase our limits of liability. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or or- ganizations) shown in the Schedule, but only with respect to liability for "bodily injury" or "property dam- age"caused, in whole or in part, by"your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 page 1 of 1 CONTRACTORISUBCONTRACTOR WORKER CLASSIFICATION The Ca`Ifornia Department of Industrial Relations(DIR)requires a registration number for all contractors and subcontractors who perform work on public works projects as defined in Labor Code Section 1720. No contractor or subcontractor may be awarded a contract, on a public works project, unless registered with the Department of Industrial relations pursuant to Labor Code section 1725.5. Additionally, contractor and subcontractor are required to furnish electronic certified payroll record to the Labor Commissioner. Revise and resubmit if changes occur with subcontractors during project. Protect No. Proiet:t7ltle No. 23-12 Slurry Seal Project 2023 Prime Contractor(All fields must be completed) Name,of Prime Contractor Prime contractor's license Number Prime Contractor's DIR Registration# American Asphalt Repair&Resurfacing Co., Inc. 439591� 1000002117 Mailing Address(Street Number or P O.$Oki racy Nate tip 0Q& 24200 Clawiter Road Hayward CA .94545 Prime Contractor's Telephone Number Pnme Contractor's Finad Address I 1510-723-0280 steve@americanasphalt.com Project Manager(Name} Project Manager's Finall Address Project Mariager s Phnne Number_.. She Aguirre steve@americanasphalt.com 510-760-0035 Prime Contractor's Worker Classifications(select classifications that apply) ❑ASBESTOS ❑ BOILERMAKER ❑BRICKLAYERS ❑CARPENTERS ❑ CARPET/LINOLEUM la CEMENT MASONS ❑ DRYWALL FINISHER ❑ DRYWALL/LATHERS ❑ ELECTRICIANS ❑ ELEVATOR MECHANIC ❑GLAZIERS ❑ IRON WORKERS la LABORERS ❑ MILLWRIGHTS 0 OPERATING ENGINEER ❑ PAINTERS ❑ PILE DRIVER ❑ PIPE TRADES ❑ PLASTERERS ❑ ROOFERS ❑SHEET METAL ❑SOUND/COMM ❑SURVEYORS 12 TEAMSTER ❑TILE WORKERS 0 Check this box to indicate there are no other subcontractors and agree to report any subcontractors if used while providing services to City of Ukiah. Prime contractor is to provide a listing of all sub-contractors who have a direct contractual relationship. (Only one subcontractor can be listed per trade). Subcontractor 1: (All fields must be completed) Name of Subcontractor Subcontractor's License Number Subcontractor's DIR Registration Number Specialized Pavement Marking 854894 100086659 Mailing Address(Street Number or P 0.Box) city Statr 7-rove 19652 N. Hirsch Ct. Anderson CA 96007 Subcontractor's Telephone Number Subcontractor's Email Address Work to Be Performed 530-365-4000 jeff.earhart@spmnw.com Striping Sub-Contractor's Worker Classifications(select classifications that apply) ❑ ASBESTOS ❑ BOILERMAKER ❑ BRICKLAYERS ❑CARPENTERS ❑ CARPET/LINOLEUM ❑CEMENT MASONS ❑ DRYWALL FINISHER ❑ DRYWALL/LATHERS ❑ ELECTRICIANS ❑ ELEVATOR MECHANIC ❑GLAZIERS ❑ IRON WORKERS la LABORERS ❑ MILLWRIGHTS ❑OPERATING ENGINEER ® PAINTERS ❑ PILE DRIVER ❑ PIPE TRADES ❑ PLASTERERS ❑ ROOFERS ❑ SHEET METAL ❑ SOUND/COMM ❑ SURVEYORS ❑TEAMSTER ❑TILE WORKERS Subcontractor 2: (All fields must be completed) Name of Subcontracto Subcontractors License Number Subcontractor's DIR Registration Number N/A Mailing Address(Street Number or P.0 Box) City Stale Zip Code Subcontractor's Telephone Number Subcontractor's Email Address Work to Be Performed Sub-Contractor's Contractor's Worker Classifications(select classifications that apply) ❑ASBESTOS ❑ BOILERMAKER ❑ BRICKLAYERS ❑ CARPENTERS ❑ CARPET/LINOLEUM ❑ CEMENT MASONS ❑ DRYWALL FINISHER ❑ DRYWALL/LATHERS ❑ ELECTRICIANS ❑ ELEVATOR MECHANIC ❑ GLAZIERS ❑ IRON WORKERS ❑ LABORERS ❑ MILLWRIGHTS ❑ OPERATING ENGINEER ❑ PAINTERS ❑ PILE DRIVER ❑ PIPE TRADES ❑ PLASTERERS ❑ ROOFERS ❑ SHEET METAL ❑ SOUND/COMM [] SURVEYORS ❑TEAMSTER 11 TILE WORKERS