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HomeMy WebLinkAboutVIDO SAMARZICH, INC. (4) Recording Requested By, lkd ` And When Recorded Mail To: City of Santa Ana,Public Works Agency M22 Recorded in Official Records, Orange County 20 Civic Center Plaza,P.O.Box 1988 Hugh Nguyen, Clerk-Recorder Santa Ana,CA 92702 Ill l 111111 111H11 U11 Il 111111111 II 1 1U 11 11N11 NO F E E $ R 0 0 1 2 4 8 4 1 2 7 * 202100006933210:48 am 02/01/21 363 RW11A N12 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000.000.00 0.00 NOTICE OF COMPLETION NOTICE IS HEREBY GIVEN that the undersigned City of Santa Ana, California, a municipal corporation, with the address of City Hall, 20 Civic Center Plaza, Santa Ana, California, 92701, is the owner of the property hereinafter described, that said owner has caused o construction of RESIDENTIAL STREET REPAIR PROGRAM FY 2018-19 under contract U go entered into on NOVEMBER 19 2019 with VIDO SAMARZICH, INC., on which contract aFIDELITY & DEPOSIT COMPANY OF MARYLAND is surety. The property on which such W o work improvement was placed is in the City of Santa Ana, County of Orange, State of go o z California, and described as Project No. 19-7528 located at: HENINGER PARK Ag NEIGHBORHOOD. The work improvement on said property was accepted as completed on o MAY 8, 2020. � o � v CITY OF SANTA ANA,A UNICIPAL CORPORATION z a by Oa Dated: lAk Princi al Civil E eer Jason Gabriel w TITLE a ------------------------------------------------------------------------------------------- VERIFICATION I, the undersigned, say: I am the City Engineer — Edwin "William" Galvez of the City of Santa Ana, California; I executed the foregoing Notice of Completion acting on behalf of the owner of the property therein described; I make this verification on behalf of said corporation by authorization of the City Council of the City of Santa Ana; I have read said notice and know the contents thereof; and I declare under penalty of perjury that the facts therein stated are true. Executed one 1 20�I , at Santa Ana, C fornia �1 r (Signature of indi dual swearing that the contents of Notice of Completion are true.) THIS NOTICE OF COMPLETION MUST BE RECORDED WITHIN TEN(10)DAYS AFTER COMPLETION Bond Ni 08712174 In Duplicate THL -ANAL PREMIUM IS ** ** CITY OF SANTA ANA PREDICATED ON THE BONDS FINAL CONTRACT PRICE PROJECT NO.; 19-7528 RESIDENTIAL, STREET REPAID. PROGRAM FY 18/19 HENINGER PARK NEIGHBORHOOD FAITHFUL, PERFORMANCE BOND KNOW ALL MEN BY THESE PRESENTS that Vido Samarzich, Inc. as CONTRACTOR, andEidiality and Deposit Comigany of Maryland a corporation, organized and existing under the laws of the State, and duly authorized to transact business under the laws of the State of California, as SURETY, are held and firmly bound unto the City of Santa Ana, as AGENCY, in the penal sum of Eight Hundred Seventy -Six Thousand One Hundred Eighty -Three and 00/100 Dollars ($ 876 183.00 ), which is 100 percent of the total contract amount for the above stated project, for the payment of which sum, CONTRACTOR and SURETY agree to be bound, jointly and severally, firmly by these presents. of Illinois THE CONDITIONS OF THIS OBLIGATION ARE SUCH that, whereas CONTRACTOR has been awarded and is about to enter into the annexed Contract Agreement with AGENCY dated for Project No 19-7528 Residential Street Repair Program FY 18119 *; if CONTRACTOR faithfully performs and fulfills all obligations in the performance of the Work of Improvement to be done under said Contract Agreement in the planner and time specified therein, then this obligation shall be null and void, otherwise it shall remain in frill force and effect in favor of AGENCY; provided that any alterations in the obligations or time for completion made pursuant to the terms of the contract documents shall not in any way release either CONTRACTOR or SURETY, and notice of such alterations is hereby waived by SURETY. ** Hettinger Park Neighborhood IN WITNESS WHEREOF the parties hereto have set their names, tittles, hands, and seal this 5th ,y q December 20119. Vido Samarzich, Inc. 6829 Billings Place SURETY* Matthew R. Dobyns , Attorney -in -Fact, 163 Subscribed and sworn to before me, _ 20_ Signature: Notary Public in and for the County of Fourth 777 S. Figueroa Street, Suite 3900 Suite 228, Santa Ana, CA 92701, Tel: 1(714) 441-4700 this day of State of Rate of premium on this bond is $15.31 1st $500K & $9.25 Balance per thousand. Total amount of premium charge is $ 11 135.00 To be ,Tlled in by Surety *Provide CONTRACTOR /ADMITTED SURETY name, address, and telephone number cuxrl the name, title, address, and telephone marr;ber oJ'authorized representative. I of 3 EXTRACT FROM BY-LAWS OF THE COMPANIES "Article V, Section 8, Attornevs-in-Pact. The Chief Executive Officer, the President, or any Executive Vice President or Vice President may, by written instrument under the attested corporate seal, appoint attorneys -in -tact with authority to Meade bonds, policies, recognizances, stipulations, undertakings, or other lilts' instruments on behalf of the Company, and only authorize any officer or any such attorney -in -tact to affix the corporate seal thereto; and may with or without cause modify of revolve any such appointment or authority at any tine." CERTIFICATE 1, the undersigned, Vice President of the ZURICH AMERICAN INSURANCE COMPANY, the COLONIAL, AMERICAN CASUALTY AND SURETY COMPANY, and the FIDELITY AND DEPOSIT COMPANY OF MARYLAND, do hereby certify that the foregoing Power of Attorney is still in full force and effect on the date of this certificate; and I do further certify that Article V, Section 8, of the By -Laws of the Companies is still in force. This Power of Attmmey and Certificate may be signed by facsimile under and by authority of the following resolution orthe Board of Directors of t'he ZURICH AMERICAN INSURANCE COMPANY at a meeting duly called and held on the 15th day of December 1998. RESOLVED: "That the signature orthe Presidentor a Vice President and the attesting signature of a Secretary or an Assistant Secretary and the Seal of [Ile Company may be affixed by facsimile on any Power of Attorney...Any such Power or any certificate thereof hearing such facsimile signature and seal shall be valid and binding on the Company." This Power of Attorney and Certificate may be signed by facsimile wader and by authority orthe following resolution of the Board of Directors of the COLONIAL AMERICAN CASUALTY, AND SURETY COMPANY at a locating duly called and held on the 5th day or May, 1994, and the following resolution of the Board of Directors of the FIDELITY AND DEPOSIT COMPANY OF MARYLAND at a meeting duly called and held or the 1 011, day of May, 199Q, RESOLVED: "That the facsimile or mechanically reproduced seal of the company and facsimile or mechanically reproduced signature of any Vice-Prosidents Secretary, or Assistant Secretary of the Company, whether made heretofore or. herealter, wherever appearing upon a certified copy of any power ofaltorney issued by the Company, shall be valid and binding upon the Company with the same force and effect as though manually arlixed. 1N 1 ESTIMONY WHEREOF, 1 have hereunto subscribed my rame and affixed the corporate seals of the said Companies, (his 5th_ day of December , 2019. ,xs w sqs �aI QAI. ,R. R 1a9B Brian M. Hodges, Vice President TO RLPORT A CLAIM WITH REGARD TO A SURETY BOND, PLEASE SUBMIT A COMPLETE DESCRIPTION OF THE CLAIM INCLUDING THE PRINCIPAL ON THE BOND, THE BOND NUMBER, AND YOUR CONTACT INFORMATION TO: Zurich Surety Claims 1299 Zurich Way - Schaumburg,IL 60196-1056 YKww,re ro tsfclaims(rr)zurichua tom 800-626-4577 CALIFORNIA ALL-PURPOSE 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 Coun of ORANGE On before me, ERIKA GUIDO. NOTARY PUBLIC, personally appeared MATTHEW R. DOBYNS ® who proved to me on the basis of satisfactory evidence to be the persons) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his'"e� ,4 authorized capacity (ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the persons) acted, executed the instrument. ERIKAGUIDO N COMM. # 2190052 [ NOTARY PUBLIC CALIFORNIA o 3 ORANGECOUNTY I My comm expires May 5, 2021 It 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. Though the data below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent reattachment of this form. CAPACITY CLAIMED BY SIGNER ❑ INDIVIDUAL ❑ CORPORATE OFFICER ❑ PARTNER(S) ❑ LIMITED ® ATTORNEY -IN -FACT ❑ TRUSTEE(S) ❑ GUARDIAN/CONSERVATOR ❑ OTHER: SIGNER IS REPRESENTING: NAME OF PERSON(S) OR ENTITY(IES) DESCRIPTION OF ATTACHED DOCUMENT 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 LOS ANGELES On DECEMBER 12, 2019 before me, DESMOND G. WARREN, NOTARY PUBLIC (insert name and title of the officer) personally appeared VIDO L. SAMARZICH who proved to me on the basis of satisfactory evidence to be the personjowhose nameLsrris/ pw subscribed to the within instrument and acknowledged to me that he/peftVey executed the same in hislDw/lheirauthorized capacity0s), and that by his/�� signaturep)-on the instrument the person, 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. ymnnnm nnnnnIsIDES nnnND G. nnARREnnnnc DESMOND G. WARREN, _ COMM. 92190534 :� Notary Public- California o WITNESS my hand and official seal. Riverside County My Comm. Expires Apr. 9, 2021 3 nnnnme iemennnm0mnnNunn nn0nnnnnnennnnmc Signature (Seal) Bond No.:08712174 ** In Duplicate ** CITY OF SANTA ANA BONDS PROJECT NO.: 19-7528 RESIDENTIAL STREET REPAIR PROGRAM FY 18119 HENINGER PARK NEIGHBORHOOD PAYMENT BOND KNOW ALL MEN BY THESE PRESENTS that Vido Samarzich, Inc. as CONTRACTOR, and Fidelity and Deposit Company of Maryland a corporation, organized and existing under the laws of the State, and duly authorized to transact business under the laws of the State of California, as SURETY, are held and firmly bound unto the City of Santa Ana, as AGENCY, in the penal sum ofF-jght Hundred v my -Six T__ hn aannd, One Hundred Eighty -Three and 00/100 Dollars ($876,183.00 ), which is 100 percent of the total contract amount for the above stated project, Ior the payment of which sum, CONTRACTOR and SURETY agree to be bound, jointly and severally, firmly by these presents. of Illinois THE CONDITIONS OF THIS OBLIGATION ARE SUCH that, whereas CONTRACTOR has been awarded and is about to enter into the annexed Contract Agreement with AGENCY dated for Project No.: 19-7528 Residential Street Repair Program FY 18/19 ** if CONTRACTOR or any subcontractor fails to pay for any labor or material of any kind used in the performance of the Work of Improvement to be done under said Contract Agreement, or fails to submit amounts due under the State Unemployment Insurance Act with respect to said labor, SURETY will pay for the same in an amount not exceeding the Stan set forth above, which amount shall insure to the benefit of all persons entitled to file claims under the State Code of Civil Procedures; provided that any alterations in the work to be done, materials to be furnished, or time for completion made pursuant to the terms of the contract documents shall not in any way release either CONTRACTOR or SURETY, and notice of said alterations is hereby waived by SURETY. Heninger Park Neighborhood IN WITNESS WHEREOF the parties hereto have set their names, titles, hands, and seal this 5th /day of December , 2019 . CON�do SamarzichInc Billings Place Rancho (ir^mnnJ,�/0GA 91701By •An_ • Cd,__a.�.�a _.•._r .. _ r .------- SURETY* [Aattheev R. Dobyns , Attorney -in -Fact, 1633 E. Fourth Subscribed and sworn to before me, Signature: 777 S. Figueroa Street, Suite 3900 19) 235-1388 Suite 228, Santa Ana, CA 92701, Tel: 1(714) 541-4700 _ this _ day of Notary Public in and for the County of State of Rate of premium on this bond is $ Included on the Performance Bond perthousand. Total amount of premium charge is $ Included on the Performance Bond. To befilled in /ry Surety "Provide CONTRACTOR /ADA11ITTED SURETY name, address, and telephone n1unber and the name, title, address, and telephone number ofauthorized representative. 2of3 ZURICH AMERICAN INSURANCE COMPANY COLONIAL AMERICAN CASUALTY AND SURETY COMPANY FIDELITY AND DEPOSIT COMPANY OF MARYLAND POWER OF ATTORNEY KNOW ALL MEN BY TI-]ESE PRESENTS: That the ZURICH AMERICAN INSURANCE COMPANY, a corporation of the State of New . York, the COLONIAL AMERICAN. CASUALTY AND SURETY COMPANY, a corporation of the State of Illinois, and the FIDELITY AND DEPOSIT COMPANY OF MARYLAND a corporation of the Slate Of Illinois (herein collectively called the "Companies"), by Robert D. Murray, Vice President, in pursuance of antho ily granted by Article V, Section 8, of the By -Laws of snicl Companies, which are setfov.'h on the reverse side hereof and are hereby certified to be in full force and effect on the date hereof, do hereby nominatc, constitute, and appoint Randy SPOHN, Ashley M. SPOHN, Matthew R. DORYNS and Hamilton KENNEY, all of Santa Ana, California, EACH, its true and lawful agent' and Attorney -in -Fact, to make, execute, seal and deliver, fell and on its behalf as surety, and its its act and deed: any and all fonds and undertakings, and the execution of such bolds or undertakings in pursuance of these presents, shall be as binding upon. said Companies, as fully and amply, to all intents and purposes, as if they had been duly executed and acknowledged by the regularly elected officers of the ZURICH AMERICAN INSURANCE COMPANY at its office in New York, New York., the regularly elected officers of the COLONIAL AMERICAN CASUALTY AND SURETY COMPANY at its office in Owings Mills, Maryland., and the regularly elected officers of the FIDELITY AND DEPOSIT COMPANY OF MARYLAND at its office in Owings Mills, Maryland., in their own proper -. persons. The said Vice President does hereby certify, that the extract set forth on the reverse side hereof is a true copy of Article V, Section 8, of the By -Laws of said Companies, call is now in fore. - IN WITNESS WHEREOF, the said Vice -President has hereunto subscribed his/her names and affixed the Corporate Seals of the'said ZURICH AMERICAN INSURANCE COMPANY, COLONIAL AMERICAN CASUALTY AND SURETY COMPANY, and FIDELITY AND DEPOSIT COMPANY OF MARYLAND, this 20th day of September, A.D. 2019. Nu crab"" F }9' ,h h.l,e�MaMY!a,l. - l - ATTEST; ZURICH AMERICAN INSURANCE COMPANY COLONIAL AMERICAN CASUALTY AND SURETY COMPANY FIDELITY AND DEPOSIT COMPANY OF MARYLAND 73y: Rober4D. Murray Vice President fay: Dawn E. Brawn Secretary State of Maryland - County of Baltimore On this 20th day of September, A.D, 2019, before the subscriber, a Notary Public cif the State of Maryland, duly commissioned and qulified, Robert 1). Murray, Vice President and Dawn E. Brown, Secretary of the Companies, to me personally known to be the individuals and officers described in and who executed the preceding instrument, and acknowledged the execution of same, and being by me duly sworn, depose(l) and saith, it)at he/she is the said officer of the Company aforesaid, and that the seals affixed to the preceding instrument are the Corporate Seals of said Companies, and that the said Corporate Seals and the signature as such officer were duly affixed and subscribed to the said instrument by the authority and direction attic said Corporations. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed my Official Seal the day and year first above written. .: ............. col. I r 'y "' "' 'r'•wy�.v)wp,;i x iyy2,At j z u+ •; Constance A. Doan, Notary Public s ;u' AJAV,4 <`' �. My Commission Expires. July 9, 2023 illir31111�5- I I I EXTRACT FROM BY-LAWS OF THE COMPANIES "Article V, Section 8, Attorneys -in -Pact. 'fire Chief Executive Officer, the President, or any Executive Vice ]'resident or Vice President may, by written instrument under the attested corporate seal, appoint etlorneys-in-fact with allthofity to execute bonds, policies, rccognizances, stipulations, undertakings, or other like instruments on behalf of the Company, and may authorize ray officer or any such attorney -in -fact to affix the corporate seal thereto; and may with or without cause modify of revoke any such appointment or authority at any time." CERTIFICATE 1, the undersigned, Vice President of the ZURICH AMERICAN INSURANCE COMPANY, the. COLONIAL AMERICAN CASUALTY AND SURETY COMPANY, and the FIDELITY AND DEPOSIT COMPANY OF MARYLAND, do hereby certify that the foregoing Power of Attorney is still in full force and effect on the date of this certificate; and I do further certify that Article V, Section 8, of the By -Laws of the Companies is stilt in force.. This Power of Attorney and Certificate may be signed by facsimile under and by authority of the following resolution of the Board of Directors of the ZURICH AMERICAN INSURANCE COMPANY at a meeting duly called and held on the 15th day of December 1998. RESOLVED: "That the signature of the President or a Vice President and the attesting signature of a Semebuy or an Assistant Secrctary and the Seal of die Company may he affixed by facsimile oil any Power of Attorney... Any such Power on any certificate thereof hearing such - facsimile signature and seal shall be valid and binding on the Company." This Power of Attorney and Certificate may be signed by fincsinrile under and by authority of the following resolution of the Board of Directors of the COLONIAL, AMERICAN CASUALTY AND SURI,,TY COMPANY at a meeting duly called and held on the 5th day of Nlay, 1994, and the following resolution of the Board 'of Dhcctors of the FIDELITY AND DEPOSIT COMPANY OF MARYLAND at a meeting duly called and held on the loth day of May, 1990. RESOLVED: "That the facsimile or mechanically reproduced seal of [he company unit facsimile or mechanically reproduced signature - of any Vice-president, Secretary, or Assistant Secretary of the Company, whether made heretofore or hereafter, wherever appearing upon a certified copy of any Power of attorney issued by the Company, shall be valid and binding upon the Company with the same force and effect l as though mauMlly affixed. W 'I ESI'IMQNY WItEREOF, I have hereunto subscribed my name and affixed the corporate seals of the said Companies, this 5th tiny of December 2019. �,�i,�l ta6L Arty r 021-- VN tlh.4P.P Brian M. Hodges, Vice President TO REPORT A CLAIM WITII REGARD TO SURETY BOND, PLEASE SUBMIT A COMPLETE DESCRIPTION OF THE CLAIM INCLUDING THE PRINCIPAL ON THE BOND, THE BOND NUMBER, AND YOUR CONTACT INFORMATION TO: Zurich Surety Claims 1299 Zurich Way Schaumburg, IL 60196-1056 wvvw. re per its fc l ai m mull 800-626-4577 �I CALIFORNIA ALL-PURPOSE ALKNOWLEDGMENT 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 ORANGE r� On before me, ERIKA GUIDO, NOTARY PUBLIC, personally appeared MATTHEW R. DOBYNS ® who proved to me on the basis of satisfactory evidence to be the person(s) whose name(sj is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/thei authorized capacity (ies), and that by his/heF/their signatureN on the instrument the personal, or the entity upon behalf of which the personN acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of ERIKAGUIDO California that the foregoing paragraph is true and correct. COMM. # 2190052 NOTARY PUBLIC CALIFORNIA N WITNESS my hand and official seal. ORANGE COUNTY J My Comm. expires May 5, 2021 t I'. TV Though the data below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent reattachment of this form. CAPACITY CLAIMED BY SIGNER ❑ INDIVIDUAL ❑ CORPORATE OFFICER ❑ PARTNER(S) ❑ LIMITED ® ATTORNEY -IN -FACT ❑ TRUSTEE(S) ❑ GUARDIAN/CONSERVATOR ❑ OTHER: SIGNER IS REPRESENTING: NAME OF PERSON(S) OR ENTITY(IES) DESCRIPTION OF ATTACHED DOCUMENT 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 LOS ANGELES On DECEMBER 12, 2019 before me, DESMOND G. WARREN, NOTARY PUBLIC (insert name and title of the officer) personally appeared VIDO L. SAMARZICH who proved to me on the basis of satisfactory evidence to be the personjowhose nam%eris/p subscribed to the within instrument and acknowledged to me that he/5keifLV-y executed the same in his/lyartpeirauthorized capacity0s), and that by his/perftlaeir signatur%*-on the instrument the person*, 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. :JIWIIlilll111111IIIIIIIIIIIIIIIIInI111111111nN11111IIIIIIIIIIIIIIL• DESMOND G. WARREN = WITNESS my hand and official seal. COMM. 92190634 _-Al' NotaryPublic- California o Riverside County My Comm. Expires Apr. 9, 2021 munnnliilnnnnmm�nmminlmnnnunnnnnnninrnann'c Signature (Seal) IDOSAM-01 CERTIFICATE OF LIABILITY INSURANCE I DATE ( CM D^IYYYY) 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 PRODUCER Southern California Insurance Brokerage 3110 E. Guest! Road Suite 500 Ontario, CA 91761 INSURED Vido Samarzich, Inc. 6829 Billings Place Rancho Cucamonga, CA 91701 484-2456 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAVE BEEN ISSUEDTOTHE INSURED NAMEDABOVE FORTHE POLICYPERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO 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. INSR TYPE OF INSURANCE LTR ADDLiSUBR NSD MD POLICY NUMBER POLICY EFF POLICY E%P MMIODMlVV MMIDDIVYYY LIMITS A X COMMERCWLGENERALUABILITY EACH OCCURRENCE S 1,000,000 _ J CLAIMS -MADE X OCCUR 60456974 12/23/2019 12/23/2020 DAMMGES'E. 105,000 X occun0ence S MED EXP An one person) S $,000 __ PERSONAL&ADV INJURY 5 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER �,,. ! GENERAL AGGREGATE 5 2,000,000 _.. POLICY X JECT LOC '_PRODUCTS-COMP/OP AGO 5 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 5 ANY AUTO BODILY INJURY Per oersonl 5 OVINED SCHEDULED _AUTOS ONLY II AUTOpSS BODILY INJURYIPeraccldent 5 AUTOS AUOTOS ONEDY aced BLAMAGE ONLY j IPeOr 5 5 A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE 5 1,000,000 EXCESS UAB CLAIMS -MADE 60455974 12123/2019 12123/2020 AGGREGATE 5 11000,000 DED RETENTIONS 5 B WORKERS COMPENSATION X PER I OTH- ANDEMPLOYERS'LWBILITY YIN STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE X 7600020438191 $I22@019 $l22/2020 E.L.EACH ACCIDENT 5 1,000,000 OFFICERIMEMBER EXCLUDED? NIA NH) 1,000,000 (Manda[0ryin F_. L. DISEASE -EA EMPLOYEES It,, dasarihe weer 1,000,000 DESCRIPTION OF OPERATIONS below EL.DISEASE -POLICY LIMIT 5 A Rented/Leased Equip. 60455974 12/2312019 12123/2020 ICORO Limit 100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 101, Additional Remarks Schedule, may be attached if mare space is required) RE: PROJECT NO. 19-7528; RESIDENTIAL STREET REPAIR PROGRAM. THE CITY OF SANTA ANA, ITS OFFICERS, EMPLOYEES, AGENTS AND REPRESENTATIVES ARE NAMED AS ADDITIONAL INSURED ON THIS POLICY PURSUANT TO WRITTEN CONTRACT, AGREEMENT, OR MEMORANDUM OF UNDERSTANDING. -All (ON -GOING 8 COMP. OPS), PRIMARY WORDING AND W.C. WAIVER ATTACHED. 30-DAY NOC TO FOLLOW. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF SANTA ANA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLAZA Santa Ana, CA 92702 AUTHORIZED REPRESENT THE a�A ACORD 25 (2016/03) © 198 5 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered markV6f ACORD POLICY NUMBER: COMMERCIAL GENERAL LIABILITY JCG 20 1 OP 41 85 THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (FORM 8) This endorsement modifies insurance provided under the fdlowing COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Pervqrvot begahlizatIO0,; -(If no entry, appears above information required to completethis endorsement will be shown in the Declaiat!Orja as applicable to this endorsement.) WHO IS AN, IKSIJRJED (SeCtion 11j is amended to include kis an insured the person or Q(48fizatign shown in the Schedule, hot only to the extent 'that, person or organization s, held liable for "Your wo rk" for that, p#(5,qn Of arganizaffion by, or For you, When - this endOrwoent applies and, when required by Written contract, such insurance as isOff9rced by the. general -liability policy is pflMar insurance :and Other insurance shall be excess and shall not contribute to the Insurance afforded by this endorsement. This qhdorsenrqnt 9p -pites to the following work., Descriptipp of'Jolb; .Lacation of Job. .Al only efto6iva fKqm: Effective Date,, Expiration Date: CG 20 lop 11 851 page 1 of 1 Inciud6s copryngtited material of Insurahco SOrvjcQs Qffi(,e,, lnrp., with its Refmissrpn, POLICY NUMBER: CG 20 101112 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED —OWNERS, LESSEES OR CONTRACTORS .(WITH LIMITED COMPLETED OPERATIONS COVERAGE) This endorsement,modifles Insurance provided under the followings COMMERCIAL GENERAL LIABILITY COVERAGE PART' BVSINESSOWNERS COVERAF,FOIRM�, SCHEDULE 4E OF PERSON -bRORGANIZATIO j1hp quAlHylog language 4bovp because of Any person brarganization'to whqM or towhlGh payme­nN we snake foflnjury: the nalmed insured is obligated by A virtue of A written contract, to provide, in%jqrAjjpe that, is LOCATION 6F JQB , afforded. by this. pofloy. Where required by The job iqqgtion Must be within the State, Of contract, the Officers, officials envOy0s, Any d withinornici of the riannedinsured, or w , directors, sulpl$rdiarjesi partners; SUCCOSSO'Ka. bonfiguous State -therefor pafqrrm, divldom4 archltepts, su-rVeyofs, and - I Arioineers are imoludecf, a s addigo na! ins ureds. tYESQRIF;vT.IQN, OF VvbRk ig but 60 All other entities iricludir f limited to, The rtyp a of work Performed rnv,5t be that As agents, volunteers,,servants, Members, And desoritTed under clas�sifiq0ti6tis in the CGL partnerships are inducted as additional insurods, Goverdge Part Declarations. 7 required by, ooritrao, only when acting within the course and scope of their'dotlea, controlled and supervised bythe Primary (first) Additional Insured. If An Owner Controlled fnsurarioe Program is Myolved, the aovonage applies to Off- PRIMARY CLAUSE; site operations only. If the purpose of this Whqn this, endorsement applies and when endoosemerjt is for bid purp0qgs only, therl:r)Q teci uIr., I Ad by, written contract, suph insurance as; coverage applies; is afford'ed , by the QooQrqt jiablljty policy Is, primary insuranoe and OthOrins3prarjoe shall, be HO IS AN INSURED{Section II") excess and shelf fiat contribute to the insurance� This s gtion is pMerpftcl to jo an 4$ afforted by this endorsement_. Insuredthe pqrs-on of orqarilzallonw[Ittiln,tile- scopeoftho,qualifying language ,above, but tiny EXCL(Atd I to the extent that the person of OTgalf7-ptian is This insurance provided to the additional insured. hold llabt,Q, for your an� or omissions In the i , "bodily does not Apply, iQ QOIIY inivry" mpody, c%rrsa, of "your -WOTO for that person or damage` qr 1porsoij-pi wd, acNerdsing Inj1jr/_ Organization by or fot you. The "pro4u9ts- prisng, out of 00 prohitAct' J S, f0glnOpOs or ... c Ohl' hazard" portion of. the PlAtold 0106fatkong d" surveyor's rendering or failure to render any IIQY coverage as respects ih�., ireldW041 sp to -d.ing , professional sefvii�qs,iolufr rwaq,tlqes not Apply to Any work involving of I 711P Prel)Pffng, 9-PPrOviV, or fAkiT4 to related to propprfas intended fqr rasiI _ dontlal or prepare or approve, reaps, d6siqn8, h4itatioal Occupar(py0fier $6ri Apartments), shop drawings, ovinioiu_�, reports, - his clause.: ause, does not affeot he -"prOd14_ls_ t - sWveYs, field orders,, change Orders, or , bb rriojetejoperations" :Ca rage provided _0 to Itip, drawings and old nam los od wp.doj, 2 Qotfmrl�,, qMh(ta0tpTaI or _qporyisory, insp engineering gq,(Ivfties'� WAIVER bF $LjBk`,Q WOvkivo syright fecp�M When rear Endarsemertt EFF50TIVED4JE:_ SEE DEC by ., written oonttact- that may wq, -rlAt have against; fire ­w1firin the scope of Endorsement EXPIRATION pAit- -,SEE DEC Co 20 AP 111 Page 1 OT h6ludes 0pytighted mzteri6l of I n8tiranc6 S&Niteaoffde, Inc , with rtfii p8!rmMi6h 1308 00455974 VIDD SAMARZICH INC NOTIFICATION ENDORSEMENT FOR CANCELLATION/NON-RENEWAL or MATERIAL CHANGE IN COVERAGE UW 17 30 0211 44-0302 SOUTHERN CAL INS nROKERAQE THIS ENDORSEMENT SUPPLEMENTS THE TERMS OF THE POLICY. PLEASE READ IT CAREFULLY. GENERAL LIABILITY 1. If the Schedule below indicates "Cancellation/Non-Renewal Notification". we agree to provide written notice to the person(s) or organization($) shown in the Schedule due to a cancellation or non -renewal of the policy to which this form is endorsed. The number of days' notice we will provide is indicated in the Schedule. 2. If the Schedule below indicates "Material Change in Coverage Notification", we agree to provide written notice to the person(s) or organization(s) shown in the Schedule due to a material change in the policy to which this form is endorsed. For purposes of this endorsement a material change Is a change: a. that is initiated by us; and b. in which the First Named Insured is provided written notification by us. The number of days' notice we will provide is indicated in the Schedule. SCHEDULE Name of Person($) or Organization(s) and Mailing Address : CITY OF SANTA ANA fM-F&.;A V 1 20 CIVIC CENTER PLZ SANTA ANA CA 92701-4058 UL 2 9 2019 Cancellation/Non-renewal Notification. Number of Days: 30 (if no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) UW 17 30 02 11 /tiQM WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 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 2 %e of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR BLANKET WAIVER OF SUBROGATION WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER 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 Effective05-22-19 Policy No.7600020438191 Endorsement No. 001 Insured VIDO SAMARZICH INC Premium $ INCL. Insurance Company EVEREST PREMIER INSURANCE COMPANY Countersigned By, 1999.by the Workers' Compensation. insurance. Rating Bureau of California.. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual -1999. NWREO COPY ADDITIONAL INSURED ENDORSEMENT Insurance Company F-64mr n N�o�j�.�+iC kid- ce-6 r This endorsem nt modifies such insurance as is afforded by the provisions of Policy # D 3S T relating to the following: 1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; it officers, employees, agents and representative are named as additional insureds ("additional insureds") with regard to liability and defense of suits arising from the operations and uses performed by or on behalf of the named insured. 2. With respect to claims arising out of the operations and uses performed by or on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds. 3. This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or organization as an insured shall not affect any right which such person or organization would have as a claimant if not so included. 4. With respect the additional insureds, this insurance shall not be cancelled, or materially reduced in coverage or limits except after thirty (30) days written notice has been given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701. (Completion of the following, Including countersignature, is required to make this endorsement effective.) Effective 11'_ 5-1 (R this endorsement form as part of Policy# 60C�+S-T Issued to Vt� �? oc tal, V e-- Name Insured Countersigned by Page 20 of 20 CERTIFICATE OF LIABILITY INSURANCE °aTE(MM/DD/ryryi THIS CERTIFICATE IS ISSUED qS q 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 THESPOULICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING ORDERINSURR(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen Policies PRODUCER RICHARD H. VOSSMEYER, AGENT ONTA T LICENSE #: 0532861 NAME: RICHARD H. VOSSMEYER PHONE StateFarlrr 2722 FOOTHILL BLVD EMAIL 816 94s 44 3 F C No : 818 949 427 LA CRESCENTA, CA 91214 aD°REss: RICHARD.VOSSMEYER.BSRZ STATEFARM.COM INSURED VIDO SAMARZICH, INC. 6829 BILLINGS PL RANCHO CUCAMONGA, CA 91701-1260 _.. -� -1-WGAN- - _• _ wrawry NUMBER: THE INSU Y REQUIREMENT, TERM OR CONDITION OF ANY CONTI? CTOOR CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE XCLUSIONS 0 HER DOCUMENTAWITH RESPECT TC AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN TYPE OF INSURANCE D LS B IS SUBJECT TO ALL HAVE BEEN REDUCED BY PgID CLAIMS, GENERAL LIABILITY POLICY NUMBER POLICY EFF POLICY p ❑ MM/DD/YVyy MNIIDDlYYYY COMMERCIAL GENERAL LIABILITY LIMITS CLAIMS -MADE ❑ OCCUR EACH OCCURRENCE $ PREMISES Be occunence $ MED EXP (Any one person) $ GEN'LAGGREGATE LIMIT APPLIES PER PERSONALS ADV INJURY $ POLICY PRO- GENERALAGGREGATE $ LOC AUTOMOBILILELIABILITY PRODUCTS-COMPfOP qGG $ ANY AUTO NED Y ❑ 456 4465-B06-75 $ 04/16/2019 04/12/2020 COMBINED ING E LI IT Ea acGden1 AUTOS X SCHEDULE° AUTOS X HIREDAUTOS X gUT03�E0 $ BODILY INJURY(Perpereon) $ 5164139-EO9-75A 01/17/2019 01/17/2021 BODILY INJURY (Per accdent) $ UMBRELLA LIAB PR PERTY DAMAGE Per accident $ OCCUR EXCESS LIAB YfN EDIWA DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (AUach ACORD 101, Additional Remarks Schedule, Project No, 19-7528 Residential Street Repair Program If more apace Is required) City of Santa Ana, its officers, employees, agents and representatives are Additional Insureds with respect to auto liability per the attached endorsement as required by the written contract. Insurance is Primary and Non -Contributory, p 30 Day Notice of cancellation with 10 days notice for non-payment of premium In accordance with the policy provisions. CERTIFICATE HOLDER City of Santa Ana Risk Management 20 Civic Center Plaza Santa Ana, CA 92701 SHOULD ANY OF THE ABOVE DESCRIBED r*NDTTTHEREOF, NI -a BE CAP WILL BE TERMS, IN ACORD 25 (20101 The ACORD name and logo are registerep marks of 132849.8 01-23-2013 AGENCY CUSTOMER ID: 1500 LOC #: ACC) ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Richard H. Vossmeyer, Agent NAMED INSURED VIDO SAMARZICH, INC. 6829 BILLINGS PL RANCHO CUCAMONGA, CA 91701-4923 POLICY NUMBER See Remarks CARRIER State Farm Mutual Automobile Insurance Company NAIC CODE 25178 EFFECTIVE DATE: 12/05/2019 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER:.. _ _ FORM TITLE: Additional Insured. Policy Numbers: 456 4465-B05-75 516 4139-EO9-75A Additional Insured: The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701, it officers, employees, agents, and volunteers Additional Insured's Notice of Coverage State Farm Mutual Automobile Insurance Company Policy Messages: The policy Includes a loss payable clause protecting the additional Insureds interest in the described car to the extent of the insurance provided and subject to all policy provisions. The additional Insured will be given 30 days notice if the policy is terminated. Until such notice is provided, it shall be presumed that the required renewal premiums have been paid. The additional Insured must notify us within 10 days of any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD 1004362 142991.1 01-21-2013