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AGENCY CUSTOMER ID: ONYXPAV-01 <br /> LOC#: <br /> AC" ADDITIONAL REMARKS SCHEDULE Page 1 of 1 <br /> AGENCY NAMED INSURED <br /> The Baldwin Group West,LLC Onyx Paving Company, Inc. <br /> 22707 La Palma Ave. <br /> POLICYNUMBEFt Ycrba Linda CA92887 <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 <br /> GL Waiver of Subrogation Form#CG 24 04 12 19 <br /> GL Per Project Form#GLS-332s 01 12 <br /> Auto Additional insured,Primary&Non-Contributory,and Waiver of Subrogation Form#U-CA-424-F CW 04 14 <br /> WC Waiver of Subrogation Form#WC 04 03 06 <br /> POLL Additional Insured Form#MEEI 0007 01 23 <br /> POLL Primary and Non-Contributory Form#MEEI 0007 01 23 <br /> POLL Waiver of Subrogation Form#MEEI 0007 0123 <br /> RE:Job#26-004.Willits St,Elder Ave and Center St Traffic Calming. <br /> Additional Insured Vesting: <br /> City of Santa Ana <br /> ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. <br /> The ACORD name and logo are registered marks of ACORD <br />