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AGENCY CUSTOMER ID: 3-004090 <br /> LOC#: <br /> AC"I?" ADDITIONAL REMARKS SCHEDULE Page of <br /> AGENCY NAMED INSURED <br /> Liberty Mutual Insurance Co.Nat'l Ins Northeast 135 S.State CollLLER ege CONTRACTING COMPANY <br /> POLICYNUM13ER Suite 400 <br /> Brea CA 92821 <br /> CARRIER NAIC CODE <br /> EFFECTIVE DATE: <br /> ADDITIONAL REMARKS <br /> THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br /> FORM NUMBER: 25 FORM TITLE:Certificate of Liability Insurance(03/16) <br /> HOLDER: City of Santa Ana City Hall-Ross Annex <br /> ADDRESS:20 Civic Center Plaza Santa Ana CA 92701 <br /> RE: Project No. : 11-6741 Bristol Street Improvements from Warner Avenue to Saint Andrew <br /> Place / Project No. : 19-6499 Bristol Street (Phase 4) Water Main Improvements <br /> The City of Santa Ana, its City Council, officers, officials, employees, agents and <br /> volunteers is/are additional insured with regards to general liability and automobile <br /> liability, as their interest may appear, where required by written contract with respect <br /> to liability arising out of work or operations performed by or on behalf of the Permittee <br /> including materials, <br /> Coverage is primary and nen-contributory. <br /> Waiver of Subrogation is included in favor of the certificate bolder on general liability, <br /> workers Compensation and automobile liability, and applies only to the specific jobs of <br /> the insured performed under written contract, and where applicable by law. <br /> 30-day Notice of Cancellation, except for 10-day Notice of Cancellation for nonpayment of <br /> premium. <br /> ACORD 101 (2000/01) ©2008 ACORD CORPORATION. All rights reserved. <br /> The ACORD name and logo are registered marks of ACORD ADDENDUM <br /> 04336107 1 3-004090 1 4/25-4/26 - Gully Miller I Julie Nelson 1 3/13/2025 8:5802 AM (=T) I Page 2 of 2 <br />