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Home My WebLink AboutDMR Builders 2025-09-1825 25 October October Darcy Vaughn (Oct 1, 2025 15:35:45 PDT) Darcy Vaughn 3rd 3rd ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: FAXPHONE A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICYEXPTYPEOFINSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TORENTEDCLAIMS-MADE OCCUR $ PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OPAGGJECT OTHER:$ COMBINED SINGLE LIMIT Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH- STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICYLIMITDESCRIPTIONOFOPERATIONSbelow INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) The ACORD name and logo are registered marks of ACORD 9/18/2025 License # 0603247 707) 462-8615 (707) 468-9541 DMR Builders 2725 Guerneville Rd Santa Rosa, CA 95401 11770 35378S 42376 A 1,000,000 X X CSCU01-00053-02 10/22/2024 10/22/2025 50,000 5,000 1,000,000 2,000,000 2,000,000 POLLUTION LIABI 2,000,000 1,000,000B X X 988427232 4/22/2025 10/22/2025 5,000,000C MKLV5EUL105898 10/22/2024 10/22/2025 5,000,000 0 D X SWC1565542 7/1/2025 7/1/2026 1,000,000 1,000,000 1,000,000 A Pollution CSCU01-00053-02 10/22/2024 Per Aggregate 2,000,000 RE: Remodel of 501 South State Street City of Ukiah its officials, officers, employees and volunteers are named as additional insured with respects to General Liability per CG 20 10 04 13 & CG 20 37 04 13. Primary Wording applies per CSGL 00233 00 08 16. Waiver of Subrogation applies per CG 24 04 05 09. Automobile Additional Insured applies per 2366 including Primary Wording. Waiver of Subrogation applies per 2367. Workers' Compensation Waiver of Subrogation applies per WC 04 03 06. All forms attached. City of Ukiah 300 Seminary Avenue Ukiah, CA 95482 DMRBUIL-01 GMORGAN George Petersen Insurance Agency, Inc. P.O. Box 1180 Santa Rosa, CA 95402 info@gpins.com CUMIS Specialty Insurance Company, Inc. United Financial Casualty Company Evanston Insurance Company Technology Insurance Company X 10/22/2025 X X X X X X X THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 POLICY NUMBER: CSCU01-00053-02 Insurance Services Office, Inc., 2012 Page 1 of2CG20100413 ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", property damage" or "personal and advertising injury" caused, in whole or in part, by: 1.Your acts or omissions; or 2.The acts or omissions of those acting onyourbehalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1.The insurance afforded to such additional insured only applies to the extent permitted by law; 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. 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, parts or equipment furnished in connection with such work, on the project (other than 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 Location(s) Of Covered Operations Where specified by fully executed written contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Any person or organization to whom the Named Insured has agreed by a fully executed written contract that such person or organization be added as an Additional Insured, but only with respect to operations performed by or on behalf of the Named Insured and only with respect to occurrences subsequent to the making of such fully executed written contract otherwise covered by this insurance. Name Of Additional Insured Person(s) Or Organization(s) POLICY NUMBER: CSCU01-00053-02 Insurance Services Office, Inc., 2012 Page 2 of2CG20100413 2.That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. 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 2.Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 POLICY NUMBER: CSCU01-00053-02 Insurance Services Office, Inc., 2012 Page 1 of1CG20370413 ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or property damage" caused, in whole or in part, by your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". However: 1.The insurance afforded to such additional insured only applies to the extent permitted by law; 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. B.With respect to the insurance afforded totheseadditionalinsureds, 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 2.Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Location And Description Of Completed Operations Where specified by fully executed written contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Any person or organization to whom the Named Insured has agreed by a fully executed written contract that such person or organization be added as an Additional Insured for Completed Operations Coverage, but only with respect to operations performed by or on behalf of the Named Insured and only with respect to occurrences subsequent to the making of such fully executed written contract otherwise covered by this insurance. Name Of Additional Insured Person(s) Or Organization(s) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement, effective: 10/22/2024 at 12:01 A.M. standard time at the address of the Named Insured as showing in the Declarations) forms a part of Policy No: CSCU01-00053-02 Issued to: DMR Builders By: CUMIS Specialty Insurance Company Includes copyrighted material of Insurance Services Offices, Inc., used with its permission Page1of1CSGL00233000816 PRIMARY / NON-CONTRIBUTORY INSURANCE ENDORSEMENT (BLANKET) It is agreed that this policy is amended as follows: Notwithstanding any other provision of this policy to the contrary, the insurance afforded to the person or organization named in the above Schedule shall be primary to, and non-contributory with, any other insurance available to such person or organization, but only as respects liability resulting from “your work” performed by the Named Insured at the project designated in the Schedule above for the person or organization named in the Schedule above. This endorsement applies only to “bodily injury” or “property damage” caused by an “occurrence” under Coverage A and not otherwise excluded in the policy. All other terms, conditions and exclusions under the policy are applicable to this endorsement and remain unchanged. Name of Project Where specified by fully executed written contract that was fully executed prior to an "occurrence". Effective Date: 10/22/2024 Any person or organization to whom the Named Insured has agreed by a written contract that was fully executed prior to an "occurrence" that such person or organization be added as an additional insured under this policy on a primary and noncontributory basis, but only with respect to operations performed by or on behalf of the Named Insured and only with respect to "occurrences" subsequent to the making of such fully executed written contract otherwise covered by this policy. Name of Person or Organization COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 POLICY NUMBER: CSCU01-00053-02 Insurance Services Office, Inc., 2008 Page 1 of1CG24040509 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 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. Any person or organization against whom you have agreed to waive your right of recovery in a written contract or written agreement, provided such contract or agreement was executed prior to the date of loss, injury or damage. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Name Of Person Or Organization: Form 2366 (02/11) Blanket Additional Insured Endorsement This endorsement modifies insurance provided by the Commercial Auto Policy, Motor Truck Cargo Legal Liability Coverage Endorsement, and/or Commercial General Liability Coverage Endorsement, as appears on the declarations page. All terms and conditions of the policy apply unless modified by this endorsement. If you pay the fee for this Blanket Additional Insured Endorsement, we agree with you that any person or organization with whom you have executed a written agreement prior to any loss is added as an additional insured with respect to such liability coverage as is afforded by the policy, but this insurance applies to such additional insured only as a person or organization liable for your operations and then only to the extent of that liability. This endorsement does not apply to acts, omissions, products, work, or operations of the additional insured. Regardless of the provisions of paragraph a. and b. of the “Other Insurance” clause of this policy, if the person or organization with whom you have executed a written agreement has other insurance under which it is the first named insured and that insurance also applies, then this insurance is primary to and non-contributory with that other insurance when the written contract or agreement between you and that person or organization, signed and executed by you before the bodily injury or property damage occurs and in effect during the policy period, requires this insurance to be primary and non- contributory. In no way does this endorsement waive the “Other Insurance” clause of the policy, nor make this policy primary to third parties hired by the insured to perform work for the insured or on the insured’s behalf. ALL OTHER TERMS, LIMITS, AND PROVISIONS OF THE POLICY REMAIN UNCHANGED. M_CL Form 2367 (06/10) Blanket Waiver of Subrogation Endorsement This endorsement modifies insurance provided by the Commercial Auto Policy, Motor Truck Cargo Legal Liability Coverage Endorsement, and/or Commercial General Liability Coverage Endorsement, as appears on the declarations page. All terms and conditions of the policy apply unless modified by this endorsement. If you pay the fee for this Blanket Waiver of Subrogation Endorsement, we agree to waive any and all subrogation claims against any person or organization with whom a written waiver agreement has been executed by the named insured, as required by written contract, prior to the occurrence of any loss. ALL OTHER TERMS, LIMITS AND PROVISIONS OF THE POLICY REMAIN UNCHANGED. M_CL CONTRACTOR/SUBCONTRACTOR WORKER CLASSIFICATION The California 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. Project No. Project Title Prime Contractor (All fields must be completed) Name of Prime Contractor Prime Contractor’s License Number Prime Contractor’s DIR Registration # Mailing Address (Street Number or P.O. Box) City State Zip Code Prime Contractor’s Telephone Number Prime Contractor’s Email Address Project Manager (Name) Project Manager’s Email Address Project Manager’s Phone Number Prime 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 TILE WORKERS 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 Mailing Address (Street Number or P.O. Box) City State Zip Code Subcontractor’s Telephone Number Subcontractor’s Email Address Work to Be Performed 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 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 Subcontractor’s License Number Subcontractor’s DIR Registration Number Mailing Address (Street Number or P.O. Box) City State 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 TILE WORKERS Subcontractor 3: (All fields must be completed) Name of Subcontractor Subcontractor’s License Number Subcontractor’s DIR Registration Number Mailing Address (Street Number or P.O. Box) City State 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 TILE WORKERS Subcontractor 4: (All fields must be completed) Name of Subcontractor Subcontractor’s License Number Subcontractor’s DIR Registration Number Mailing Address (Street Number or P.O. Box) City State 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 TILE WORKERS Subcontractor 5: (All fields must be completed) Name of Subcontractor Subcontractor’s License Number Subcontractor’s DIR Registration Number Mailing Address (Street Number or P.O. Box) City State 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 TILE WORKERS Subcontractor 6: (All fields must be completed) Name of Subcontractor Subcontractor’s License Number Subcontractor’s DIR Registration Number Mailing Address (Street Number or P.O. Box) City State 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 TILE WORKERS Subcontractor 7: (All fields must be completed) Name of Subcontractor Subcontractor’s License Number Subcontractor’s DIR Registration Number Mailing Address (Street Number or P.O. Box) City State 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 TILE WORKERS Subcontractor 8: (All fields must be completed) Name of Subcontractor Subcontractor’s License Number Subcontractor’s DIR Registration Number Mailing Address (Street Number or P.O. Box) City State 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 TILE WORKERS Subcontractor 9: (All fields must be completed) Name of Subcontractor Subcontractor’s License Number Subcontractor’s DIR Registration Number Mailing Address (Street Number or P.O. Box) City State 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 TILE WORKERS Subcontractor 10: (All fields must be completed) Name of Subcontractor Subcontractor’s License Number Subcontractor’s DIR Registration Number Mailing Address (Street Number or P.O. Box) City State 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 TILE WORKERS Subcontractor 11: (All fields must be completed) Name of Subcontractor Subcontractor’s License Number Subcontractor’s DIR Registration Number Mailing Address (Street Number or P.O. Box) City State 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 TILE WORKERS Subcontractor 12: (All fields must be completed) Name of Subcontractor Subcontractor’s License Number Subcontractor’s DIR Registration Number Mailing Address (Street Number or P.O. Box) City State 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 TILE WORKERS Subcontractor (All fields must be completed) Name of Subcontractor Subcontractor’s License Number Subcontractor’s DIR Registration Number Mailing Address (Street Number or P.O. Box) City State 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 TILE WORKERS Subcontractor (All fields must be completed) Name of Subcontractor Subcontractor’s License Number Subcontractor’s DIR Registration Number Mailing Address (Street Number or P.O. Box) City State 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 TILE WORKERS Subcontractor (All fields must be completed) Name of Subcontractor Subcontractor’s License Number Subcontractor’s DIR Registration Number Mailing Address (Street Number or P.O. Box) City State 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 TILE WORKERS