HomeMy WebLinkAboutALLIANCE ENVIRONMENTAL GROUP, INC.City of Santa A ^a
Clerk of the Coin.. it
AGREEMENT TERMINATION FORM
Please complete this form in its entirety when the attached agreement anr� III
amendments (if any) are no longer in effect. LL''NN
Note: If your agreement is grant related, please ensure that all grant retention requirements CITY
have been satisfied prior to signing the termination form. rI N
Is the agreement(s) a permanent record? Yes _ No
Return form to the Clerk of the Council Office (M-30).
Call 647-1520 if you have any questions.
The agreement with
No N-2017-213 was completed on
(List all amendments. Use space below if needed.)
'b Pit 3..39
1=.JiA ANA
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a3 and final payment has been made.
Department: i f>A
Phone/Ext.: y{q
Signature: pr!✓����%z—
Date:
Revised: 10-I8-16
N-2017-213
vWRA MAY PROCEED
UNTIL INSURANCE EXPIRES
vjc -, I -A,? -10,
99OWest TentfM%at, Azusa, CA91702 Ph: 626-633-3500 rx:
Uc, # 716538 - DLO.S.H. #630
Project: City of Santo Ana - City Hall Bio Hazard
1. Propertv" Address: 20 Civic Center Plaza
Qltv; Santa Ana State: CA Zip: 92701-4058
Contact. Rol) Ono
Work No,: 714-647-5400
Mobile No,: Home No.:
Claim Number:
Customer nx Billing Party 0
City of Santa Ana
Work Authorization
www.alllance-enviro.com
Info@aIIIanoe-env1ro,00m
Address: 20 Civic Center Plaza
City: Santa Ana Siate:CA Z102701.4058
Contact: Ron Ono
Phone No,: 714-647-5400
Fax No.:
Scheduled Start Date: 10/17117 Scheduled Completion Date: 12/31)17
Total Bid Amount $4,869.73 Deposit Required: $0.00 Salance Due on Completion: $4869.73
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Project as AEG understands it is to provide a pressure washing and disinfectIon serviretapplication to an area West of the Santa Ana city hall
known as 60 flags. Area is currently being used to house the homeless. Area is approximately 50,000 elf and will have the service performed to
approximately 25.000 elf at a time on the let Tuesday of the month and returning the 3rd Tuesday of the month to perform the same service on
the other half of the property, It Is understood that the costs of subsequent pressure washing assignment shall be mutually agreed upon by the
parties.
It is understood thatwater will be available end AEG will collect waste water and properly dispose of It. City will have the homeless and
personal belongings moved off each half by 9 am the morning of.
1. Provide a crew of blood home certified technicians to properly remove any human waste and needles from said areas,
2. Technicians will be wearing proper PPE as needed.
3, Any trash left with In the service area will be removed and disposed Of.
4, A hospital grade EPA registered disinfectant will be applied to the area before pressure washing begins to allow for proper dwell time.
5. A diking system will be set up In order not to allow any run off water into storm drains or personal belongings stored on the other half of
property.
6. All needles found will be properly removed and disposed of,
7. Run off water will be collected and properly disposed of,
8. Once disinfection application and pressure washing is complete a deodorizer will be, applied to the area to help mitigate the human waste
odor and could last Lip to several weeks,
NOTE: AEG is not responsible for any personal belonging possibly getting wet or damaged due to pressure washing.
NOTE: Price shown reflects prevailing wage,
NOTE: Price shown Is per service visit or half of the 50 flags area,
NOTE: Total amount for service shall not exceed $25,000
C-17-151956-1 Page 1 of 5 Please Initial: 0-1-
Notes:
1. UNLESS OTHERWISE NOTED IN THIS CONTRACT, Homeowner or tenant is ultimately responsible to ensure
that all personal Items are removed from the work area priorto the arrival of Alliance. In the event that a third
party company Is contracted to remove the contents from that area, and not all necessary items are removed
prior to Alliance's arrival, a cancellation fee or content manipulation charge to the homeowner or tenant may
apply as outlined in the following paragraph. In order to prevent these charges, homeowner is responsible to
ensure all necessary content manipulation has been completed or to notify Alliance of any changes prior to
Alliance's arrival.
2, in the event that the work area is not ready for abatement, the homeowner or tenant will be responsible for
payment of either $70.00 per man per hour to manipulate contents (contents exclusions in subsection 3, titled
exclusions, apply) or a $250 cancellation fee. In the event of a cancellation, the job will be rescheduled for the
soonest opening once the work areas are prepared for abatement.
Customer Initial
Payment notice:
i. In the event that the homeowner is paying Alliance directly, payment is due and payable immediately upon
completion of the job.
2. in the event that an insurance company issues a check to the owner for payment for services performed by
Alliance, the homeowner is responsible to issue payment to Alliance for full contract amount,
s. In the event that an insurance company denies all or part of the claim, the homeowner is ultimately responsible
for payment for the full contract amount.
Customer Initial: '
DEPOSIT may not exceed $1,000 or 10 percent of Contract Amount, whichever is less. Customer shall pay Alliance the Deposit prior to
Alliance scheduling work. In the event of failure to pay any of the amount due In this invoice, all collection costs and/or attorney fees in the
collection of any such amount will be paid by the Customer. Interest at the rate of 1.6% per month, or the maximum rate allowed by law
whichever is less, will be charged on accounts past due more than 30 days. In the event of failure to pay any of the amount due, all collection
costs and/or attorney fees in the collection of any such amount will be paid by the Customer. In the event that an Insurance company issues a
check to the owner for payment for services performed by Alliance, please endorse the check and forward It to Alliance upon the completion of
the job.
Some of the services performed by Alliance require the use of EPA approved chemicals. It is the Customer's responsibility to notify Alliance of any
potential health concerns or known sensitivity to chemicals. I have read and understand that if I have concerns I am to notify Robert McKeever.
and all hazardous waste fees are to be paid by the Customer acknowledges and authorizes Alliance to sign the
wator, not Alliance Environmental Group, Inc. This is Hazardous Waste Manifest "on behalf of the generator.
iding but not limited to ALL generator fees from the
a Board of Equalization and Department of Toxic Customer Inftial: �
'he stale Board of Eaualizatlon will assess a fee for each venerator that produces live tons or more of hazardous waste. This assessed fee is not
Included In liras contract amount. Please be aware that if you generate more than five tons of hazardous waste, the BOE will bill you the required fee.
Current fees are as follows:
Generator Size: Fee: Generator Size: Fee:
Less than 5 tons/year $0.00 25 but less than 50 tons/year $1,594,00
5 but less than 25 tons/vear $199,00 50 but less than 250 tonslyear $3.986.00
Contact your AEG Project MonngedEstimator (Robert McKeever) for assistance in approximating your Generator Fee, Notice:
Recent lead laws require that any pre 1978 structure where lead paint will be disturbed must have the paint tested or it will be presumed
positive. Alliance Environmental Group, Inc. strongly recommends that these painted surfaces be tested for lead content prior to performing
work. If Alliance Environmental Group, Inc. has not been provided lead testing results, it will be assumed that all surfaces contain lead. Alliance
Environmental Group, Inc. will profile and characterize these materials for the proper handling and disposal. Pending results of the lead profile
characterization, additional disposal cost may be charged at a price to be determined by Alliance Environmental Group, Inc.
C•17-151958-1 Page 2 of 6 Please Initial: 0 .c
Alllance Environmental Group, Inc. (hereinafter referred to as "Alliance"), and the undersigned homeowner or tenant (hereinafter referred to as
"Customer") agree as follows: The previous page and above portion of this page are incorporated herein as part of the Contract between the
parties.
1. SCOPE OF WORK: In consideration of the payment specified above, Alliance is hereby authorized to furnish all labor, materials, and
equipment necessary to perform removal and disposal of asbestos, lead, mold, and/or other materials and/or to perform hazardous remediatlon
of hazardous materials, all as specified In the above agreed Scope of Work, in material compliance with applicable laws and regulations.
Alliance agrees to use reasonable best efforts to complete the Scope of Work. However, Customer acknowledges and agrees that this
Agreement Is for Alliance's effort and not for any particular results, ALLIANCE MAKES NO REPRESENTATION OR WARRANTY THAT THE
WORK DESCRIBED IN THE SCOPE OF WORK WILL RESULT IN THE ELIMINATION OF ASBESTOS, LEAD, MOLD, AND/OR OTHER
HAZARDOUS MATERIALS CONTAMINATION ("HAZARDS CONTAMINATION°) FROM THE AREAS DESCRIBED IN THE SCOPE OF WORK
OR THAT SUCH HAZARDS CONTAMINATION WILL NOT REAPPEAR IN SUCH AREAS OR OTHER AREAS OF THE PROPERTY.
ALLIANCE MAKES NO REPRESENTATION OR WARRANTY REGARDING HAZARDS CONTAMINATION IN AREAS, INCLUDING ADJOINING
AREAS, NOT SPECIFIED IN THE SCOPE OF WORK, NOR THAT SUCH HAZARDS CONTAMINATION WILL NOT MIGRATE TO AREAS
DESCRIBED IN THE SCOPE OF WORK FOLLOWING COMPLETION OF OR DURING THE SCOPE OF WORK Without limiting the
foregoing, Customer specifically waives and releases Alliance from any claim for damages on account of work recommended by Alliance but not
accepted by Customer or Insurer, and for any consequential, incidental or punitive damages, or for loss of use, property or profits of whatever
kind arising out of or in connection with performance of Scope of Work
2. START DATE AND COMPLETION DATE: California Law requires that Contractor start this project within (20) days of execution of this
Contract subject to AI liance's ability to obtain permits and Customers ability to obtain financing if Customer is buying the property in question,
subject to delay caused by any processing and obtaining permits may required which may extend Start Date and correspondingly delay the
Completion Date,
3. EXCLUSIONS: Any work that is not specifically included in Scope of Work shall not be any part of this Contract. Removal of inaccessible
asbestos, mold, or lead -containing materials is not covered in the Contract amount and additional charges will apply If materials must be
removed to uncover same. Doors, lights, ceiling fans, curtains and other Items may need to be removed by Alliance to perform work and
Alliance does NOT rebuild or reinstall these items.Plumbing supply Imes may be faulty and may need to be replaced. This cost is not covered
in the Contract Amount. Contents and appliances need to be removed from work area prior to abatement Additional costs will be applied if
contents need to be removed, unless otherwise stated In the Scope of Work. Unless otherwise stated in the Scope of Work, the cost of third
party clearance testing is not part of the Contract Amount,
4. DAMAGE: Incidental damage to doers, door casings, windows, window sills, baseboards, walls, wallpaper, wood, paneling, painted
surfaces, and to contents or Customer personal items left in work area may occur as a result of work performed, including but not limited to
taping plastic barriers to walls and other surfaces. Every reasonable attempt will be made to minimize such occurrences. Alliance shall not
pay/reimburse for, nor does !too any, repairs, repainting, rebuilding or replacement of such "incidental damages, and such Is not included in the
Scope of Work.
Due to odors caused by chemicals used for mastic removal, the work areas will be razor scraped to remove the majority of mastic but residual
mastic may be left after scraping and will be sealed with an E.P.A. approved encapsulant.
S. SITE ACCESS. Customer agrees to ensure that prior to any work undertaken by Alliance, the site of the work, the area from which the work
is controlled, and any storage area used by Alliance in connection with the work (collectively referred to hereinafter as the "Site"), shall be
vacated and remain closed to all persons (other than ALLIANCE employees) for the duration of the project. In the event that any individual other
than ALLIANCE employees enters the Site, Customer agrees that ALLIANCE shall not be held liable for any claims, including, without
limitation, any claims relative to asbestos, lead, mold and/or hazardous remediation exposure arising there from,
6. DIFFERING SITE CONDITIONS: If ALLIANCE encounters subsurface, latent, unusual or unknown physical conditions in the work area
differing materially from those indicated In Its initial inspection or the Scope of Work, ALLIANCE will promptly notify Customer or Insurer. If
such conditions cause an increase in the cast of, or the time required for, performance of the Scope of Work, appropriate equitable adjustments
in Scope of Work, price and completion date shall be made.
7. EXTRA WORK AND CHANGE ORDERS: Customer and Alliance, or Insurer (defined below) and Alliance, may change the Scope of Work at
any time and from time to time, including changes in scope, methods, scheduling or performance requirement, but no such change shall be
effective unless and until an agreed written Change Order Is made and executed, including appropriate adjustments to the overall price and
completion date of the Scope of Work. Subject to the following, if Alliance undertakes additional or different work notwithstanding the absence of
a Change Order, it will not operate as a waiver of this provision, and Alliance will nevertheless be entitled to appropriate equitable adjustments to
the price and completion date terms of the Scope of Work. All phone quotes are subject to field verification, Extra work and Change Orders
become part of the Contract once the order is prepared in writing and signed by the parties. The Change Order must describe the scope of the
extra or change, the cost to be added or subtracted from the contract, and the effect the order will have on the schedule of progress payments, if
any. Change Orders required by the building department at the jobsite shall be considered incorporated Into the contract without being signed
by both parties.
8. ELIMINATION OF CONDITIONS: Customer acknowledges that it, and not Alliance, Is responsible for the elimination of any and all
conditions from the Property that may cause or contribute to re -contamination by Mold or other Irritants, including but not limited to standing
water, faulty plumbing, leaks, dampness from condensation, damaged wood, roof leaks, direct wood to soil contact, improperly protected
exterior wood surfaces, landscaping above foundation grade line, and improperly installed irrigation.
C-17-151966-1 Page 3 of 6 nC
Please Initial: Uv'
9, UTILITIES; STORAGE: Customer agrees to provide to Alliance, free of charge, reasonable use of electrical power, light, water, and storage
space necessary for the proper undertaking and completion of the Services at the Property.
10. FORCE MAJEURE: Alliance shall not be deemed to default nor be liable for damages for any failure or delay in performance of its work
which arise out of causes beyond its reasonable control. Such causes may Include, without limitation, acts of God, acts of terrorists or terrorist
organizations, the public enemy, acts of government In either its sovereign or contractual capacity, fires, Floods, earthquakes, epidemics,
quarantine restrictions, strikes, freight embargoes, material shortages, or unusual severe weather. In the event work by Alliance is delayed by
such causes, the completion date will be extended accordingly.
11. MECHANICS LIEN WARNING: Anyone who helps improve your property, but who is not paid, may record what is called a mechanics' lien
on your property. A mechanics' lien is a claim, like a mortgage or home equity loan, made against your property and recorded with the county
recorder.
Even If you pay your contractor in full, unpaid subcontractors, suppliers, and laborers who helped to improve your property may record
mechanics' liens and sue you in court to foreclose the lien. If a court finds the lien is valid, you could be forced to pay twice or have a court
officer sell your home to pay the lien. Liens can also affect your credit.
To preserve their right to record a lien, each subcontractor and material supplier must provide you with a document called a "20-day Preliminary
Notice." This notice is not a lien. The purpose of the notice is to let you know what the person who sends you the notice has the right to
record a lien on your property If he or she is not paid.
BE CAREFUL. The Preliminary Notice can be sent up to 20 days after the subcontractor starts work or the supplier provides material. This can
be a big problem if you pay your contractor before you have received the Preliminary Notices. You will not get Preliminary Notices from your
prime contractor or from laborers who work on your project. The law assumes that you already know they are improving your property.
PROTECT YOURSELF FROM LIENS. You can protect yourself from liens by getting a list from your contractor of all the subcontractors and
material suppliers that work on your project. Find out from your contractor when these subcontractors started work and when these suppliers
delivered goods or materials. Then wait 20 days, paying attention to the Preliminary Notices you receive.
PAY WITH JOINT CHECKS. One way to protect yourself is to pay with a joint check. When your contractor tells you it is time to pay for the
work of a subcontractor or supplier who has provided you with a Preliminary Notice, write a joint check payable to both the contractor and the
subcontractor or material supplier.
For otherways to prevent liens, visit CSLB's website at www.cslb.ca.gov <hftpr//www.cslb.ca.00v> or call CSLB at 1-800-321-CSLB (2752),
Remember, if you do nothing, you risk having a lien placed on your home. This can mean that you may have to pay twice, or face the
forced sale of your home to pay what you owe.
12. COMMERCIAL GENERAL LIABILITY INSURANCE (CGL): Alliance carries CGL insurance written by Starr Surplus Lines Insurance
Company. You may call the insurance company at (646) 227-6300 to check Alliance's coverage.
13. WORKERS' COMPENSATION INSURANCE: Alliance carries workers' compensation insurance for employees.
14. INFORMATION ABOUT CONTRACTORS STATE LICENSE BOARD (CSLB): See Attached Notice .
16. INSURANCE TRANSACTION AND INSURANCE AUTHORIZATION TO RELEASE FUNDS: When Contract for Scope of Work Is between
Alliance and Customer's Insurance company ("Insurer'), Customer shall nevertheless be jointly and severally liable with Insurer to pay Alliance
all amounts due to Alliance. Customer's signature on this Contract grants Alliance the Customers power of attorney to sign/endorse Insurer
checks and/or drafts payable to the Customer, Including as result of Customer's claim to Insurer for property damages, concerning or Intended
to be in payment for Alliance's work. Customer agrees checks from Insurer will be sent directly to Alliance.
NOTICE OF INFORMATION ABOUT CONTRACTORS STATE LICENSE BOARD
CSLB is the state consumer protection agency that licenses and regulates construction contractors. You may contact CSLB for information
about the licensed contractor you are considering, Including information about disclosable complaints, disciplinary actions and civil judgments
that are reported to CSLB. Use only licensed contractors, If you file a complaint against a licensed contractor within the legal deadline (usually
four years), CSLB has authority to investigate the complaint. If you use an unlicensed contractor. CSLB may not be able to help you resolve
your complaint. Your only remedy may be in civil court, and you may be liable for damages arising out of any injuries to the unlicensed
contractor or the unlicensed contractor's employees. For more information: VISIT: CSLB's website at www.calb.ca.gov. CALL: CSLB at
1-600-3321-CSLB (2762). WRITE: CSLB at P.O. Box 26000, Sacramento, CA 95826.
C-17-151956-1 Page 4 of 5
Please Initial: a- .
N-2017-213
* YOU, THE CUSTOMER, ARE ENTITLED TO A COMPLETELY FILLED IN COPY OF THIS CONTRACT,
SIGNED BY BOTH YOU AND ALLIANCE, BEFORE ANY WORK MAY BE STARTED.
* YOU, THE CUSTOMER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO THE THIRD
BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE ATTACHED NOTICE OF
CANCELLATION FORM FOR EXPLANATION OF THIS RIGHT.
Customer signature below Is acknowledgement that Customer has received THREE-DAY RIGHT TO CANCEL form.
THIS CONTRACT WILL NOT BECOME BINDING ON THE PARTIES UNTIL ACCEPTED BY AN AUTHORIZED REPRESENTATIVE OF
ALLIANCE, AT ALLIANCE'S OFFICES,
CUSTOMER: ALLIANCE ENVIRONMENTAL GROUP, INC,:
Dated:
Print Namet,
6Printed Na )
nthi J. Kurtz
Interim City Manager
Approved as to Form Attest
hn M. Funk MMaria D. �Huizar
ssistant City Attorney Clerk of the Council
Corporate Office
C-17.15195&1
990 W. Tenth Street, Azusa, CA 91702
Page 5 of 5
Representative: Robert McKeever
Rgha,,u,ldk .e(0ct 13.2017)
Recommended for Approval
Executive Director,
Parks, Recreation &
Community Services Agency
Ph. 626-633.3500 Fax: 626-633-3599
Please Initial: 0� ,
cc�RJra CERTIFICATE OF LIABILITY INSURANCE DATEtMhLDDY YYi
1 Df1 Sf2o17
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($), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
IMFUNIAN'i: IT the CSThnCate hOKIGr [San ADDITIONAL INSURED, the polft y(les) must have ADDITIONAL INSURED provisions or ha endorsed,
If SUBROGATION IS WAIVED, subtect to the terms and conditions Of the policy, certain policies may requite an endorsement. A statement on pf
this certificate does not confer rihhts to the certificate holder in lieu of such endorsement(st.
PRODUCER
CA DOI License No.
INSURED
Alliance Environmental Group, Inc.
990 West Tenth Street
Azusa CA 91702 N-2017-213
COVERAGES CERTIFICATE NUMRER- aARAnRgo RC'vLclnM MINJRPP,
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION
OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE
BEEN REDUCED BY PAID CLAIMS.
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DESCRIPTION OF OPERATIDNSd LOCATIONS I VEHICLES (ACORD191,Adam... I RemarksSchasuN,
may he attached if more apace is requlmdG
The City of Santa Ana, its: officers, employees, agents and representatives are named
as additional insureds and primary/non-contribCut
$
clause applies to the general liability policy -see attached endorsement.
The above policies Contain s 30-day notice provision for non -renewal and cancellation, 10=day notice for nonpayment of
�tl.�tt�� `r{,
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City of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Attn: PRCSA ACCORDANCE WITH THE POLICY PROVISIONS,
20 Civic Center Plaza, M-23
Santa Ana CA 92701
AU'mOR12EO REPRESENTATIVE T r�1
aAlnl�n'il Pl,nlnllnm
ACONO 2512015103) The ACORD name and logo are registered marks Of ACORD
36W532 I Alliance 1 29-18 WC, 1948 OL-AL-VAI-CPL-PL 1 Aharry Yonrp 119/16/261'1 006,1&AM (Rw) I Fagg i of 3
POLICY NUMBER; 1000066722171
COMMERCIAL GENERAL LIABILITY
CG 20 10 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED — OWNERS, LESSEES OR
CONTRACTORS SCHEDULE PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
Or Organization(s); I Location(a) Of Covered Operations
M_23 I All operations
A. Section II— Who Is An Insured is amended B.
to include as an additional insured the
person(s) or organization(s) shown in the
Schedule, but only with respect to liability for
'bodily Injury", "property damage", or "personal
and advertising Injury" caused, in whole or in
part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on
your behalf;
in the performance of your ongoing operations
for the additional insured(s) at the location(s)
designated above.
With respect to the insurance afforded to
these additional Insureds, the following
additional exclusions apply:
This insurance does not apply to "bodily
injury" or "property damage" occurring after:
1, All work, including materials, parts or
equipment furnished In connection with
such work, on the project (other than
service, maintenance or repairs) to be
performed by or on behalf of the
additional insured(s) at the location of the
covered operations has been completed;
or
2. That portion of "your work" out of which
the injury or damage arises has been put
toits intended use by any person or
organization other than another
contractor or subcontractor engaged in
performing operations for a principal as a
part of the same project.
CG 20 10 07 04 @ISO Properties, Inc., 2004
Page 1 of 1
a3380532 1 4111.. 1 17-28 Ii 19-la'OL-AL-AM-QPL�P I Sheri, Y,UO, 1 JP1,61,019 9:36:15 RM (POT) I Page 2 of 3
POLICY NO.: 1000066722171
COMMERCIAL GENERAL LIABILITY
CG20370704
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS- COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Additional Insured Person(s)
Or Organizatfori
Location(s) Of Covered Operations
The City of Santa Ana, Its officers, employees, agents
and representatives
All operations
ataa271 M-23SnAnCA 90
Information required to Complete this Schedule if not shown above will be shown in the Declarations.
Section II — Who Is An Insured Is amended to
include as an additional Insured theperson(s) or
organization(s) shown In the Schedule, but only
with respect to liability for "bodily injury", "property
damage" caused, in whole or in part, by "your
work" at the location
designated and described in the schedule of this
endorsement performed for that additional insured
and Included in the "products -completed
operations hazard,"
CG 20 37 07 04 O ISO Properties, Inc., 2004
Page 1 of 1
9818093E I Alliance 11i-18.%a, 1]-ls GL-AI. OM.CPL-PL I sherry Young 1 10/16/2017 9t16:15 Ant (PDT) I Page 3 of 3
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 Orange )
On October 16, 2017 before me, Rosa A. Flores . Notary Public
(insert name and title of the officer)
personally appeared Cynthia J. Kurtz, who proved to me on the basis of satisfactory evidence to
be the personK whose name(y is 4axe subscribed to the within instrument and acknowledged to me
that he/she/they executed the same in his/her/their authorized capacity(Aer), and that by his/her/their
signature(* on the instrument the personW,, or the entity upon behalf of which the persons) 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.
WITNESS my hand and official seal. Rosn A. FtbRr s
Commission # 2057129
Z +`�. Notary Public - California z
IS Orange County
Signature �
��'J�-' , Avw (Seal)