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CG 2010 1185 <br />DATE: JAN 15 08 <br />POLICY NUMBER: PHPK215316 <br />INSURED NAME: <br />CHOC V. LE <br />d FABRIANO <br />lRVINE CA 92620.2576 <br />HE POLICY. PLEASE READ IT CAREFULLY <br />THIS ENDORSEMENT CHANGES T <br />ADDITIONAL INSURED • OWNERS, LESSEES OR CONTRACTORS (FORM B) <br />This endorsement modifies insurance provided under the following: <br />COMMERCIAL GENERAL LIABILITY COVERAGE PART <br />SCHEDULE <br />Name Of Person or Organization: <br />JobfPrOject: <br />(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as <br />applicable to this endorsement.) <br />rson or <br />d the <br />WHO edule, N INSUREDith (respect totliability arising tout of 'your work' for o include as an that insured by or foayoution shown in the <br />Sch <br />efit Of the <br />ditionai <br />Primary Insurance it is agreed <br />that asuch nd any other nsuran insuranceas is maintainednta ned by the additional rded by this policy for the nnsured(s) shalll be excess <br />shown shall be primary i loss or liability arising out of the operations of the named <br />and non-contributory, but only as respects any claim, loss liability <br />liability is determined to be solely the negligence or <br />insured(s) or its subcontractors, and only if such claim, <br />responsibility of the named insured. <br />the company <br />ll <br />vide <br />e additional insured shown <br />wNotice of Cancellation or ith 0 days notice of cancellation of this l it is agreeln the tevent of cancellationdue to company election only. below <br />WAIVER OF SUBROGATION have <br />It is agreed mat we waive any right of recovery a may r injury or da age arising out ofnst the person or nyourowork' <br />Shown in the schedule because of Pay lies only to the person or <br />done under a contract with that person or organization. The waiver applies Y <br />organization shown in the schedule. <br />SCHEDULE <br />NAME OF PERSON OR ORGANIZATION <br />City of Santa Ana, it's Respective Officers, <br />Employees, Agents, Volunteers and Representatives. <br />20 Civic Center Plaza (M-25) <br />Santa Ana, CA 92701 <br />