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05-0603_BELAIRE - WEST LANDSCAPE INC._InsuranceCERTHOLDER COPY STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 06-03-2005 GROUP: POLICY NUMBER: 1767393-2005 CERTIFICATE ID: 80 CERTIFICATE EXPIRES: 01-01-2006 01-01-2005/01-01-2006 CITY OF SAN JUAN CAPISTRANO THIS CERTIFICATE SUPERSEDES AND CORRECTS 32400 PASEO ADELANTO CERTIFICATE #79 DATED 06-03-02005 SAN JUAN CAPISTRANO CA 92675 JOB: SJC LIBRARY SITE WORK This is to certify that we have issued a valid Worker's Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. AUTHORIZED REPRESENTATIVE A(, c . oi� PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #1600 - JANICE STRUIKSMA-GROEN PRES SEC - EXCLUDED. ENDORSEMENT #1600 - DUANE GROEN VP TREAS - EXCLUDED. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01-01-2004 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER BELAIRE-WEST LANDSCAPE, INC. PO BOX 6270 BUENA PARK CA 90622 [JSJ,CNI PRINTED: 06-03-2005 SCIF 10262E AccaPUhis certificate only if you sea a faint watermark Ilial made 'OFFICIAL STATE FUND DOCUMENT' PAGE 1 OF 1 06/01/2005 16:53 8054979 STATE FARM INSWCE PAGE 02 srnn (ARA CERTIFICATE OF INSURANCE Thi at ❑ STATE FARM FIRE AND CASUALTY COMPANY, Bloomington, Illinois ® STATE FARM GENERAL INSURANCE COMPANY, Bloomington, Illinois ins g policyholder for the coverages indicated below. Name of policyholder BELAIRE WEST LANDSCAPE, INC. - Address of policyholder 7371 WALNUT AVENUE. BUENA PARK, CAIFORNIA 9U61U-1159 Location of oparations PITY OF SAN JUAN (`APTRTRANO- CALIFORNIA . Description of operations SAN JUAN CAk'1STIJ,81NU L16KAKT S11P wvKn The policies listed below nave been Issued to the pulicylwldei for the policy period* shown. The insurance dcwAbcd in these policies euhiari In nil tha tpmts PvrJuainnc end rAnditinns of these rxfbries. The limits of liability, shown may have been reduced by any Paid claims. ADDITIONAL INSURED: Name and Address of Certificate Holder CITY OF SAN .TTIAN CAPISTRANO 32400 PASEO ADELANTO If any of the described Polides are canceled before its expiration date, State Farm will I" mad a wnnen notice to the certificate holder30days before cancellation. XX R � XIGI(x��3C�X9f Signature of Authalaed Representative SAN ,JUAN CAPISTRANO, CA 92675 AGENT MICHAEL C. GUSIGK, Agent nue 55*-aeaa2�90PnntedinUS.A.A incNtlollsand0*5I'd.Snite101 JUNE 1, 2005 Thousand Oaks, CA 91386 Dete BUS:8051497-9435 pax:pG)497-9437 POLICY PERIOD LIMITS OF LIABILITY POLICY NUMBER TYPE OF INSURANCE EfTecave Data Expiration Date (,a1xFgtnniInq of poricZ period) Comprehensive BODILY INJURY AND Business liability PROPERTY DAMAGE This insurance Includes: ❑ Products - Completed Operations ❑ Contractual Liability ❑ Underground Hazard Coverogo Each Occurrence S ❑ Personal Injury ❑ Advertising Injury General Aggregate $ ❑ Explosion Hazard Coverage Products - Completed ❑ Collapse Hazard Coverage Operations Aggregate $ ❑ General Aggragate Limit applies to each project 0. EXCESS LIABILITY POLICY PERIOD BODILY INJURY AND PROPERTY DAMAGE Effective Date Ex iration Date (Combined Single Limit) ❑ Umbrella Each Occurrence $ ❑ Other Ngrtgate Part 1 STATUTORY Part 2 BODILY INJURY Workers' Compensation and Employers Liability Each Accident $ Disease Each Employee $ Disease - Policy Limit S POLICY NUMBER TYPE OF INSURANCE POLICY PERIOD Effective Date Expiration Date LIMITS—OF LIA BILITY beginningof 0566526-75CAUT LIABILITY06 OS 03 6 06 at Ilc y period) 1 000 000 L 6 6526-75 UTO LIA TY 03 0 3 OG OG W HIRED & 056 6_526-75 AU O LIABILITY 03 06 05 03J06 06 NON -OWNED ADDITIONAL INSURED: Name and Address of Certificate Holder CITY OF SAN .TTIAN CAPISTRANO 32400 PASEO ADELANTO If any of the described Polides are canceled before its expiration date, State Farm will I" mad a wnnen notice to the certificate holder30days before cancellation. XX R � XIGI(x��3C�X9f Signature of Authalaed Representative SAN ,JUAN CAPISTRANO, CA 92675 AGENT MICHAEL C. GUSIGK, Agent nue 55*-aeaa2�90PnntedinUS.A.A incNtlollsand0*5I'd.Snite101 JUNE 1, 2005 Thousand Oaks, CA 91386 Dete BUS:8051497-9435 pax:pG)497-9437 06/01/2005 16:53 80549796 it�i! MSM ' INLYI1IiMCi ' STATE FARM INSIWCE PAGE 01 Michael C. Guslck, Agent tic 0465577 199 E Thousand Oaks Blvd. Suite 101 Thousand Oaks, CA 91360 (805) 497.,-9435 Fax (805) 4,97-9437 qfY csS ?&. lwlYlSril%ttd ?W -A -N TO: 1� Fax: a/V1 45 ' I V ✓ �/ Attn: From: Amanda Hanson O Data: 6/1/2005 For Mike Gusick Re:��/Y kmt t� W Poges:�—lncludingcover sheet 0 Urgent XX For Review O Please Comment ❑ Pknse Reply ❑ Please Recycle AUTO'- LIFE -. HEALTH - NOME - BUSINESS ..... . ..... ..... .... . L7 10 CALIFORNIA PRELIMINARY NOTICE IN ACCORDANCE WITH Sf O MEDCALIFORNIA CIVIL CODE'" THIS IS NOT A N. "' THIS IS NOT A REFLECTION ON THE INTEGRITY OFANY CONTRACTOR OR SUBCQJ�TRACTOR. �1115AUG-3 P 1. 3 lL NOTICE IS HEREBY GIVEN that CITY CLERK AVER OR REPUIED OWNER OR PUBLIC AGENCY SAN JUAN CAPISTR ROBERTSON'S CITY SAN JUAN CAPISTRANO 200 S MAIN ST, SUITE 200 32400 PASEO ADELANTO CORONA CA 92878 SAN JUAN CAPISTCAN92675 (909)685-2200 Has or will Furnish labor, services, equipment, or materials, generally described as: READY MIX CONCRETE, ROCK & SAND To be furnished or furnished for the building, structure or the work of improvement described as follows: 31495 EL CAMINO REAL SAN JUAN CAPISTRANO J.C.N. # 449 Tract No. Lot No. Cert Num: 21206241 Name of Person or Firm who contracted for purchase of the labor, services, equipment, or materials is: BELAIRE-WEST LANDSCAPE IN 7371 WALNUT AVE BUENA PARK CA 90620 An estimate of the total price of said labor, services, equipment or materials is: 3,904.20 BELAIRE-WEST LANDSCAPE TRUST FUNDS TO WHICH SUPPLEMENTAL FRINGE BENEFITS ARE PAYABLE DATL+D' ED: 08/01/2005 BY: LORI LANNI BY * PLEASE ISSUE JOI�J�`CHECKS***** ROBERTSON'S i;i j O�QtES POgTgGF _ P.O. BOX 3600 I CORONA, CA 92878-3600 02 1A $02-670 7108 1176 8853 1206 L416 °„ " MAILED FROM' ZIP CODE IMPORTANT: CALIFORNIA PRELIMINARY NOTICE CITY SAID ,J UAN :. J= -STRP. VO 3290( Pf; ,O AT),PIJ`I'O SAN JUAN CP,PL:; I CA 92675 SS 46"1 8+36Z'9 -S3 c,�nci Ill. .1,1111111t I I i I Ii n I II a II a I I I II n I i I nI I i nI n 61 92002 449 THIS IS NOT A LIEN. THIS IS NOT A REFLECTION ON THE INTEGRITY OF ANY CONTRACTOR OR SUBCONTRACTOR. YOU ARE HEREBY NOTIFIED: DATE: July 15, 2005 THE NAME AND ADDRESS OF THE PERSON OR FIRM WHO HAS FURNISHED OR WILL FURNISH LABOR, SERVICES, EQUIPMENT OR MATERIAL OF THE FOLLOWING DESCRIPTION IS: DESCRIPTION OF LABOR, SERVICES, EQUIPMENT OR MATERIAL: F WEST COAST DEMOLITION & I & CONSTRUCTION, INC. R 1384 HUNDLEY STREET M ANAHEIM, CA 92806 BY: VANNESA BUCK Hard & Soft Demolition Sawcut Break & Remove JOB NAME AND LOCATIOICAMI NO CAPISTRANO & LAZAN A CAMINO CAPISTRANO & LAZANJA THE NAME AND ADDRESS OF THE PERSON WHO CONTRACTED FOR THE PURCHASE OF (PRIVATE WORKS) OR WHO WILL BE FURNISHED (PUBLIC WORKS) SUCH LABOR, SERVICES, EQUIPMENT OR MATERIAL IS: ORION CONTRACTING INC 806 E AVENUE PICO SUITE 1-337 SAN CLEMENTE, CA 92672 TO: OWNER, REPUTEDCITY OF SAN IUAN CAPISTRANO OWNER OR 32400 PASEO ADELANTO PUBLIC ENTITY SAN JUAN CAPISTRANO CA 92675 TO:ORIGINAL ORION CONTRACTING INC CONTRACTOR OK806E AVENUE PICO REPUTED CONTRACTOR SUITE 1-337 SAN CLEMENTE, CA 92672 TO: LENDER OR NONE REPUTED LENDER TO: SUBCONTRACTORNONE TO: BONDING CO. MALLONEE & ASS. 35 W. GRAND AVE ESCONDIDO CA 92025 SAN JUAN CAPISTA, CA **********####****#### NOTICE TO PROPERTY OWNER******#*******#*** IF BILLS ARE NOT PAID IN FULL FOR THE LABOR, SERVICES, EQUIPMENT, OR MATERIALS FURNISHED OR TO BE FURNISHED, A MECHANICS' LIEN LEADING TO THE LOSS, THROUGH COURT FORECLOSURE PROCEEDINGS, OF ALL OR PART OF YOUR PROPERTY BEING SO IMPROVED MAY BE PLACED AGAINST THE PROPERTY EVEN THOUGH YOU HAVE PAID YOUR CON- TRACTOR IN FULL. YOU MAY WISH TO PROTECT YOURSELF AGAINST THIS CONSEQUENCE BY (1) REQUIRING YOUR CON- TRACTOR TO FURNISH A SIGNED RELEASE BY THE PERSON OR FIRM GIVING YOU THIS NOTICE BEFORE MAKING PAYMENT TO YOUR CONTRACTOR OR (2) ANY OTHER METHOD OR DEVICE THAT IS APPROPRIATE UNDER THE CIRCUMSTANCES. (THIS STATEMENT IS APPLICABLE TO PRIVATE WORK ONLY.) TRUST FUNDS TO WHICH SUPPLEMENTAL FRINGE BENEFITS ARE PAYABL Operating Engineers Trust Fund (MATERIAL MEN NOT REQUIRED TO F9NISH INE ABOVE) ESTIMATED PRICE OF THE LABOR, SES, M EQUIPMENT OR MATERIAL DESCRIBED 1iE� dF x:'710,00 n� m �rr1 C < -4:,- 70 rn _ cn o � PROOF OF SERVICE AFFIDAVIT - (SECTION 3097. 1, CALIFORNIA CIVIL Vannesa Buck , declare that I served copies of the above PRELIMINARY NOTICE (check appropriate box). (a) [ J By personally delivering copies to (name(s) and title(s) of persons served) at at (b) [ X1 (date) (year) (time) By First Class Certified or Registered Mail service, postage prepaid, addressed to each of the parties at the address shown above on 200S I declare under penalty of perjury that the foregoing is true and correct. --1 Signed at 1384 Hundley Street Anaheim CA 92806 on Signature of person making service:��— DRIVER ALLIANT INS x:909-083-5123 Jun 1 20013:39 P.01 d4"iver*eluant I INSURANCE SERVICES 3270 Inland Empire Blvd., Suite 100, Ontario, CA 91764 Telephone (909) 483-5137 • Facsimile (909) 483-5123 License #OC36861 • www.driveralliant.com Fac To: Brian Perry From: Christina Farnsworth City of San Juan Fax: 949-493-1053 Pages: 3 (including cover) Phone: 949-493-1171 Date: 6/1/05 Re: Belaire West Landscape, Inc. CC: Dan @ Belaire West Fax: 714-523-9201 ❑Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle • Comments: Please see the following certificate as requested by the above captioned Insured. Should you have any questions or require any additional information, please give me a call. Thank you, Christina Farnsworth Account Representative Driver Alliant Insurance Services, Inc. 909 483-5137 Direct 909 483-5123 Fax cfamsworth@driveralliant.com CONFIDENTIALITY STATEMENT. This message is intended only for the use of the individual or entity to which 0 is addressed, and may contain information that is privileged, confidential and exempt from disclosure under the applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering brie message to the intended recipient, you are Hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and return the original message to us at the address above via the U.S. Postal Service, Thank you b 0 W Belaire-West Landscape, Inc. P.O. Bax 6270,BPark, CA 90622-6270 Tuesday, June 07, 2005 City of San Juan Capistrano 32400 Paseo Adelanto San Juan Capistrano, 92675 Attn: Brian Perry Subj: Two Contracts, One Labor & Material Bond and One Performance Bond Dear Mr. Perry: Please find enclosded the mentioned documents Please call me with any questions. Sincer ly, BEL RE- ST LANDSCAPE, INC. Dan a on Chief Estimator CC: File Lic. 448636 P (714) 523-9200 F (714) 523-9201 City of SIC Library Site Work BWL Job No. 449