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CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDlYYYY) <br /> 3/1312025 <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. <br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the polley(ies)must have ADDITIONAL INSURED provisions or be endorsed. <br /> If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on <br /> this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br /> PRODUCER GUIMIAUr <br /> NAME: <br /> Liberty Mutual Insurance Co.Nat'l Ins Northeast PHONE FAX <br /> 500 IV 3rd St, Suite 300 EMAIL WC,No): <br /> Wausau,WI 54403 ADDRESS: CMeCertProduction Liber( Mutual,com <br /> INSURERS AFFORDING COVERAGE NAIC# <br /> www.LibertyMutual,cpm INSURER A: LibertyMutual Fire Insurance Cc.m an 23 335 <br /> INSURED INSURER B: LM Insurance Corporation 33600 <br /> SULLY-MILLER CONTRACTING COMPANY <br /> 135 S.State College Blvd. INSURERC: <br /> Suite 400 INSURER D: <br /> Brea CA 92821 INSURER E: <br /> INSURER F <br /> COVERAGES CERTIFICATE NUMBER: 84336107 REVISION NUMBER: <br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, <br /> INSR I TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP <br /> LTR POLICYNUMBER MM1DD MM1DDPffYYI LIMITS <br /> A COMMERCIAL GENERAL LIABILITY �/ ✓ TB2-631-510805-025 4/1/2025 4/1/2026 EACH OCCURRENCE $2000000 <br /> D AGE TO RENTED <br /> CLAIMS-MADE �/ OCCUR PREMISES Ea occurrence $500 000 <br /> / Per Job Aggregate MED EXP(Any one person) $10 000 <br /> IncludesXCU PERSONAL&ADV INJURY $2000000 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 <br /> POLICY[Z]jECOT- LOC PRODUCTS-COMPIOPAGG $3000000 _ <br /> OTHER: $ <br /> A AUTOMOBILELIA01tTY ✓ AS2-631-510805-015 4/1/2025 4/1/2026 EasBcoideDtswGLELIMIT T$2,OOO,000ANY AUTO BODILY INJURY(Per parson)OWNE❑ SCHEDULED BODILY INJURY PeAUTOS ONLY AUTOS ( raccident)HIRED NON-OWNED PROPERT DDAMAGEAUTOS ONLY AUTOS ONLY Per accident <br /> $ <br /> UMBRELLALIAB HOCCUR EACH OCCURRENCE $ - <br /> EXCESS LIAB CLAIMS-MADE <br /> AGGREGATE $ <br /> DED I I RETENTION $ <br /> B WORKERS COMPENSATION WC5-631-5W805-035 4/1/2025 4/1/2026 <br /> AND EMPLOYERS'LIABILITY YIN Covers All States ✓ STATUTE ERH- <br /> ANYPROPRIETORIPARTNERIEXECUTIVE N E.L.EACH ACCIDENT $2 00O 000 <br /> OFF N NIA <br /> (Mandatory In NHI E.L.DISEASE-EA EMPLOYEE $ <br /> 0 <br /> If S lNunder E.L.DISEASE-POLICY LIMIT $2000000 <br /> DESCRIPTION OF OPERATIONS below <br /> A Automobile Physical Damage: AS2-631-514805-015 4/1/2025 4/1/2026 <br /> **All Medium,Heavy,Extra Heavy and Trailer Types Camp&Coll Deds:$1,500 <br /> **All Private Passengers, Pick Lips and Vans Camp&Call Deds:$500 <br /> DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (ACORD 101,Addlllonal Remarks Schedule,maybe attached if more space Is required) <br /> RE:Project NO.11-6741 Bristol Street Improvements from Warner Avenue to Saint Andrew Place and Project No.:19-6499 Bristol Street(Phase 4) <br /> Water Main <br /> '*See Addendum" <br /> Digitally sign <br /> Tu Tra n'9TY Tram APPROVED <br /> N guye'niazs: .g7 sY Nguyen Tu Tran en at 9:24 am,Apr 07,2025 <br /> o4 3 Y <br /> 0424r1n-071aa <br /> CERTIFICATE HOLDER CANCELLATION <br /> Job10340704 <br /> City of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> City Hall- Ross Annex ACCORDANCE WITH THE POLICY PROVISIONS. <br /> 20 Civic Center Plaza <br /> Santa Ana CA 92701 <br /> AUTHORIZED REPRESENTATIVE <br /> Diane Beaudoin <br /> 01988-2015 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <br /> R4336107 1 3-004090 1 4/25-4/26 - Sully Miller I .7Ulie Nelson 1 3/13/2025 9:59:32 Af4 (EDT) I Page 1 of 2 <br />