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04-1108_FRESS COMPANY BUILDERS, INC._Agreement for Deferral of ImprovementsrI RECORDING REQUESTED BY: City of San Juan Capistrano 32400 Paseo Adelanto San Juan Capistrano, CA 92675 AND WHEN RECORDED, MAIL TO: Margaret R. Monahan, City Clerk City of San Juan Capistrano 32400 Paseo Adelanto San Juan Capistrano, CA 92675 Exempt from Recording Fees: Gov Code 27383 & 6103 City of San Juan Capistrano Title of Document: 0 Recorded in Official Records, Orange County Tom Daly, Clerk -Recorder 111111111111111111111111111111111111111111111111!IIIii1IIIIIIIIIIIIIIIIi1IINO FEE 200400105176211:42am 11124104 117 92 Al2 7 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 This Space for Recorder's Use Only / AGREEMENT FOR DEFERRAL OF IMPROVEMENTS Architectural Control (AC) 00-06: Serra Vista Office Building between THE CITY OF SAN JUAN CAPISTRANO a California municipal corporation and Friess Company Builders, Inc. Prepared on: November 9, 2004 Agreement for Deferral of Improvements mi Ag reement for Deferral 011provements Friess Company November 9, 2004 Page 2 of 5 I. PARTIES AND DATE. This Agreement for the Deferral of Improvements ("Agreement") is entered into as of this 8th day of November, 2004, by and between the City of San Juan Capistrano, a California municipal corporation ("City") and, Friess Company Builders, Inc. (a corporation) with its principal office located at 31658 Rancho Viejo Road, Suite 8 ("Developer"). City and Developer are hereinafter individually referred to as "Party' and hereinafter collectively referred to as the "Parties." RECITALS. 1. On October 24, 2000 the City of San Juan Capistrano Planning Commission adopted PC Resolution No. 00-10-24-1 approving Architectural Control (AC) 00-06, Zone Variance 00-05, and Rezone 00-03. This project approval became effective on November 7, 2000 and includes the property located at 31658 Rancho Viejo Road, Suite B comprised of .9 acres and precisely referred to as APN 649-361-07. 2. The application has been approved for construction of a 10,328 square foot commercial office building. 3. Developer has constructed certain improvements on the Project Site in accordance with the approval granted by PC Resolution 00-10-24-1, 4. Developer desires to obtain a Temporary Conditional Certificate of Occupancy for a 10,328 square foot Commercial Office Building on the Project Site in order to allow utility connections and occupancy of the building. 5. Developer desires to defer the installation of shrubs and groundcover along the parking lot edge at Camino Capistrano, and the installation of the Historic Depiction program, and City agrees to such deferment in accordance with the terms contained herein as agreed to by developer. III. EXPIRATION OF AGREEMENT. 1. EXPIRATION. This agreement shall expire upon the completion of all the project improvements required by Resolution PC 00-10-24-1 and issuance of a Final Certificate of Occupancy, or May 9, 2005, whichever occurs first. IV. TERMS. 1. AGREEMENT BINDING ON SUCCESSOR IN INTEREST. This agreement is an instrument affecting the title to or possession of the real property described in Section 11.1 above. Upon sale or division of the property described in Exhibit 1, the terms of this Agreement shall apply separately to each parcel, and the owner of each parcel shall succeed to the obligations imposed on Developer by this Agreement. Agreement for Deferral oflprovements • Friess Company November 9, 2004 Page 3 of 5 2. INCOMPLETE IMPROVEMENTS TO BE DEFERED. Prior to issuance of a FINAL Certificate of Occupancy for the Project Site, but no later than May 9, 2005, whichever occurs first, the following improvements shown on the approved site plan and established by PC Resolution 00-10-24-1 shall be completed subject to approval of City: 2.1 Installation of shrubs and groundcover along the parking lot edge at Camino Capistrano which consists of 1 gallon (42) and 5 gallon (145) shrubs and groundcover from flats and a Historic Depiction Program. In the event said improvements have not been completed by the expiration date of this agreement, developer shall be in default of this agreement and shall be subject to code enforcement action to ensure completion of the improvements. 3. CASH DEPOSIT. The Cash Deposit for faithful performance, labor, and materials for improvements submitted by Developer to City in the amount of $7,275.00 shall be deemed by City as adequate surety to ensure completion of improvements as specified in this Agreement. Upon the completion of all improvements cited in Section 2 of this agreement by Developer, and on demand of "Developer" shall process and refund deposited monies provided herein. The refunded amount shall be equal to the original deposit amount less the cost of any City completed improvements. 4. INSURANCE. Insurance required herein shall be provided by Admitted Insurers in good standing with the State of California and having a minimum Best's Guide Rating of A- Class VII or better. 4.1 Comprehensive General Liability. Throughout the term of this Agreement, Developer shall maintain in full force and effect Comprehensive General Liability coverage in the following minimum amounts: $500,000 property damage; $500,000 injury to one person/any one occurrence/not limited to contractual period; $1,000,000 injury to more than one person/any one occurrence/not limited to contractual period. 4.2 Comprehensive Automobile Liability. Throughout the term of this Agreement, Developer shall maintain in full force and effect Comprehensive Automobile Liability coverage, including owned, hired and non -owned vehicles in the following minimum amounts: 41 .Agreement for Deferral ofoprovements Friess Company November 9, 2004 Page 4 of 5 $500,000 property damage; $500,000 injury to one person/any one occurrence/not limited to contractual period; $1,000,000 injury to more than one person/any one occurrence/not limited to contractual period 4.3 Worker's Compensation. If Developer intends to employ employees to perform services under this Agreement, Developer shall obtain and maintain, during the term of this Agreement, Worker's Compensation Employer's Liability Insurance in the statutory amount as required by state law. 4.4 Proof of Insurance Requirements/Endorsement. Prior to beginning any work under this Agreement, Developer shall submit the insurance certificates, including the deductible or self -retention amount, and an additional insured endorsement to the Consultant's general liability and umbrella liability policies using ISO form CG 20 10 11 85 (in no event with an edition date later than 1990) to the City's General Counsel for certification that the insurance requirements of this Agreement have been satisfied. 4.5 Notice of Cancellation/Termination of Insurance. The above policy/policies shall not terminate, nor shall they be cancelled, nor the coverage reduced, until after thirty (30) days' written notice is given to City, except that ten (10) days' notice shall be given if there is a cancellation due to failure to pay a premium. Notice shall be provided, by hand -delivery or first-class mail (return receipt requested), to: Molly Bogh, Planning Director 32400 Paseo Adelanto San Juan Capistrano, CA 92675 5. INDEMNIFICATION. Developer agrees to protect, defend and hold harmless City, its elected and appointed officials and employees from any and all claims, liabilities, expenses or damages of any nature, including attorneys' fees, for injury or death of any person or damage to property or interference with use of property and for errors and omissions committed by Developer arising out of or in connection with the work, operation or activities of Developer, its agents, employees and subcontractors in carrying out its obligations under this Agreement. -Agreement for Deferral ofoprovements • Friess Company November 9, 2004 Page 5 of 5 6. QUALITY OF WORK. All improvements as described in the Agreement shall be constructed and installed pursuant to City review and approval. The construction plans and specifications for the improvements shall be prepared in accordance with all applicable federal, state and local laws, ordinances, regulations and other requirements. In addition, the improvements shall be completed in accordance with all maps, plans and specifications on file with City, as well as all applicable federal, state and local laws, ordinances, regulations and other requirements. It is understood and agreed that all work and improvements done pursuant to this Agreement shall conform to the standards applicable at the time work is actually commenced. V. DEMAND TO PERFORM. 1. DEMAND TO PERFORM. Upon default of any obligation hereunder, and at any time after any such default, City may make written demand upon Developer or its surety, or both, to immediately remedy the default or complete the improvements. If the required work is not substantially commenced within ten (10) days of such demand, or if it is not thereafter diligently prosecuted to a completion acceptable to City within the time frame contained in the demand, City may then complete all remaining work, manage for the completion of all remaining work, and/or conduct such remedial activity as in its sole and absolute discretion it believes is required. All such work or remedial activity shall be at the sole and absolute expense and obligation of Developer and its surety, without the necessity of giving any further notice to Developer or surety. City's right to take such actions shall in no way be limited by the fact that Developer or its surety may have constructed any of the required improvements at the time of City's demand for performance. In the event City elects to complete or arrange for completion of the remaining work and improvements, City may require all work by Developer or its surety to cease in order to permit adequate coordination by City. In addition, City may revoke the Temporary Conditional Certificate of Occupancy for the model building, and/or withhold issuance of any future certificate of occupancy, until the default is remedied to the satisfaction of City. THE CITY OF SAN JUAN CAPISTRANO By: Planning Director FRIESSCOMP NY BUILDERS INC. By: Daniel L. Friess 20 Approved as to form: Date: November 9, 2004 Date: November 9, lista ATTEST: 4* me t-Defertal of John Waw, City Attorney Marg ret . Monahan, City Clerk • 0 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT State of California County of Or0.r, ss. On I I 1 / (o /0 � before me, J t,�'i.C>rhM\C, QLke udcA Date Name ane rale of O6Mar le.a . -Jane Ooe. Notary Publ¢9 personally appeared Ip.personally known to me �j proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their 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 person(s) acted, executed the instrument. WITNESS my hand and official seal. 2 GL ,Yl_LIA . L Signature of Notary Publicboo OPTIONAL Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document Description of Attached Document Title or Type of Document: _!! a 'KJ fb 't- ty*0. o'C f'Ol�N eQ K Document Date: It I slo Number of Pages: S Signer(s) Other Than Named Above: Capacity(les) Claimed by Signer Signer's Name: WERM ❑ Individual Top or thumb here ❑ Corporate Officer — Title(s): • Partner — ❑ Limited ❑ General ❑ Attorney -in -Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: ®1999 National Notary Association • 9350 Oe Soto Ave., P.O. Box 2402 • Chatsworth, CA 91313-2402 • m rortion.notary.or9 Prof. No 5907 PeorEec Cell TOILFr. 1800-6]6-682] �.... '}vn4�nl. JiNti�kn"Ji} jt ' • PUBLIC, AGENCY FORM OF ACKNOWLEDGEMENT State of California County of Orange ) ss. City of San Juan Capistrano ) (Gov't Code 40814 & Civil Code 1181) 0 On October 6, 2004 before me, Margaret R. Monahan, City Clerk personally appeared Molly Bogh, Planning Director, personally known to me to be the persons whose names are subscribed to the within instrument and acknowledged to me that they executed the same in their authorized capacity, and that by their signatures on the instrument the persons, or the entity upon behalf of which the persons acted, executed the instrument. Capacity Claimed by Signers Planning Director Title Signers are Representing City of San Juan Capistrano WITNESS my hand and official seal. 4-1 . G R. Monahan, City Clerk OPTIONAL Description of Attached Document Agreement for deferral of improvements AC 00-06 — Sena Vista Office Building Title or Type of Document November 9, 2004 Date of Document �� p`I i �' " � `! i :+b .a, ! . \ qe� ;�, 4�a.. n..�/ ���. � s'; �'�,:A ate: 7,/29/2005 Time: 10:53 AM TO: City of San Juan Capistrano (Or @ 493-1053 Vage: 002—Q&A AMM,, CERTIFICATE LIABILITY INSURANCE DATE 11/2005 PRODUCER (949) 582-5220 FAX (949) 582-3512 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION S P I B Insurance Agency Inc. License Number 0719264 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 26441 Crown Valley Parkway POLICY NUMBER Mission Viejo, CA 92691 INSURERS AFFORDING COVERAGE NAICC INSURED Friess Company Builders Inc :NSIRERA Admiral Insurance Co/c/oStewart Smith West 31658 Rancho Viejo Rd, Ste NB .................___......................._....._..._._.._. ..._ .._.......------------._._._._ INSURER e. State Comp Insurance Fund 210 San Juan Capistrano, CA 92675 INSJREec .. QSE Insurance Co/c/o Deans & Honer 07/27/2006 !NSURERC Lloyds of London/c/o E.L.M. Ins.Brokers INSJREft E rnvcoer_cc THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I TR INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION UM17S GENERAL LIABILITY CA000000303-04 07/27/2005 07/27/2006 E.ACH000URRENCF $ 1,000,00 X COPAMERCIAI.GENERAL LIABIL" DAMAGE TO RENTED $ 50,00 Wit. _.._ V V CLAIMSM.ADE [X]OCCUR MEDFXP(A,.,e w.) $ excluded A _---_--_-_.1 _ _. ...__ _....._._.___--__..._.. PERSONAL B ADV INJURY $ 1.000, 00 _ GENERAL AGGREGATE $ 2,0 0,00 GEN'L RJPREGATE LIMB APPLIES PER: PRODUCTS-COMWOPAGG $ 2,000,00 X POLICYPRO LOC ECT AUTOMOBILE LIABILITY CCMBNED SINGLE LIMIT $ ANY AUTO (Ea d.,t) ALL OWNED AUTOS BODILVIW URv S SCHEDULED AUTGS (Per persm) BODILY INJURY c HIREDAUTCS NON OWNED AUTOS (Pei .cadent} PROPERTY DAMAGE (Ppramdentj GARAGE LIABILITY AUTO ONLY -EA ACCIDENT $ OTIIERTHAN EA ACC $ ANY AUTO 0.UTOONLY AGG $ EXCEBBIUMBRELLA LIABILITY EPCHOCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE S $ $ DEDUCTIBLE 8 RETENTION 8 WORKERS COMPENSATION AND 1594117-05 07/01/2005 07/01/2006 X WC 9iATU- EMPLOYERS'LIABILITY E L. EACH ACCIDENT 8 1,000,000 B ANY PROPR, ETOWPARTNERIEXECUTIVE Ei DISEASE EAEMPLOYEF S 1,000,000 OFFICERIMEMSER EXCLUDED? It ym.. descnbe under SPECIAL PROVISIONS below EL DISEASE POLICY LIMIT $ 1,000,00 Fft 2612656 11/03/2004 11/03/2005 BPP:S60,000./special/RC ded. Personal Cperts perty; Contr. tiv. $500; Contr Equip 540,181/ACV Newly Acquired $25,000. DES CRIPTIONOFOPERATIONSILOCATION$IVEMICLESIEXCLUBKINSADOEOSYENDORSEMENTlSPECU PROVISIONS E: SERRA VISTA - PROJECT M02-270, 30300 CAMINO CAPISTRANO, SAN JUAN CAPISTRANO. CA 92675. ERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY AS PER FORM CG2010 07/04) ATTACHED. EXCEPT 10 DAYS NOTICE OF CANCELLATION FOR NON-PAYMENT OF PREMIUM CITY OF SAN JUAN CAPISTRANO 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA 92675 ACORD 25(2901ma1 FAX: (949)493-1053 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. THE ISSUING INSURER MILL ENDEAVOR TO MAIL 30•` DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIARLQY AUTHORCED REPRESENTATIVE \ �(/ A larry Hina,/GHARnN I�rQ 4roft ©ACORD CORPORATION 1988 ate: 7/29/2005 Time: 10:53 AM To: City of San Juan Capistrano (Or R 493-1053 �-I IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed_ A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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 treu of such endorsement0). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORO 26 (2001106) ate 7/29/2005 Time: 10:53 AM To: City of San Juan Capistrano (Or @ 493-1053 Page: 004-6 046 • Policy Number: CA000000303-04 CG 20 10 07 04 Effective Date: 07/2712005 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or O anization s Location(s) Of Covered Operations City of San Juan Capistrano Job #02.270 - Serra Vista 32400 Paseo Adelanto 30300 Camino Capistrano San Juan Capistrano, CA 92675 San Juan Capistrano, CA 92675 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended 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. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: CG 20 10 07 04 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 to its 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. ® ISO Properties, Inc., 2004 Page 1 of 1 13 ate: 7,/29/2005 Time: 10:53 AM To: City of San Juan Capistrano (Or @ 493-1053 Page: 001 W 014 • S P I B Insurance Agency, Inc. Sun Pacific Insurance Brokers, Inc. 19491503 5220 License: 0719264 To: City of San Juan Date: Friday, July 29, 2005 From: Esther Muller Pages: 4 Subject: Revised Certificate of Insurance Message 26441 Crown Valley Parkway P.O. Box 9055 Mission Viejo, CA 92690 Tel: (949) 582-5120 Fax: (949) 582-3512 California License Number: 0719264 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA 92675 (949) 493.1171 (949) 493-1053 FAX www.sanjuancapistrano.org July 25, 2005 IA[RIIAABRI � FSIAIBSRFI I 1961 1776 Friess Company Builders, Inc. 31658 Rancho Viejo Road, Suite B San Juan Capistrano, CA 92675 MEMBERS OF THE CITY COUNCIL SAM ALLEVATO DIANE SATHGATE WYATT HART JOE SOTO DAVID M. SWERDLIN RE: Compliance with Insurance Requirements — Serra Vista Office Building Deferral of Improvements Agreement The following insurance documents are due to expire: I ✓ General Liability Certificate 07/27/2005 ✓ General Liability Endorsement naming the City of San Juan Capistrano as additional insured. Please submit updated documentation to the City of San Juan Capistrano, attention City Clerk's office, 32400 Paseo Adelanto, San Juan Capistrano, CA 92675. If you have any questions, please contact me at (949) 443-6310. Sincerely, Mitzi Deputy City Clerk cc: Kassidy Hill, Administrative Assistant San Juan Capistrano: Preserving the Past to Enhance the Future Irl Pnnted on recycled paper . STHOLDER COPY STATE P.O. BOX 807, SAN FRANCISCO,CA 94142-0807 COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 07-01-2005 GROUP: POLICY NUMBER: 1594117-2005 CERTIFICATE ID: 3 CERTIFICATE EXPIRES: 07-01-2006 07-01-2005/07-01-2006 CITY OF SAN JUAN CAPISTRANO SG JOB: PROFESSIONAL LIABB 32400 PASEO ADELANTO MG -804048 W MARKEL SAN JUAN CAPISTRANO CA 92675 AMERICAN INS. CO. 6 15 99-6 15 00 This is to certify that we have issued a valid Workers' 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 policies 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 may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions and conditions of such policies. AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-01-2005 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER FRIESS COMPANY BUILDERS,INC. 31658 RANCHO VIEJO RD STE B SAN JUAN CAPO CA 92675 (REV.3-03) LEGAL NAME FRIESS COMPANY BUILDERS,INC. / FRIESS CONSTRUCTION, INC. J oo,wire�. 06/17/2005 , SG • SG CERTHOLDER COPY STATE P -O. BOX 420807, SAN FRANCISCO,CA 94142-0807 COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 07-11-2005 GROUP: POLICY NUMBER: 1594117-2005 CERTIFICATE ID: 129 CERTIFICATE EXPIRES: 07-01-2008 07-01-2005/07-01-2008 CITY OF SAN JUAN CAPISTRANO 32400 PASEO ADELANTO SAN JUAN CAPISTRANO CA 92875 SG This is to certify that we have issued a valid Workers' 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 upon30 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. e. 64 AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 41,000,000 PER OCCURRENCE. ENDORSEMENT #1800 - KENNETH E. FRIESS SEC TRES - EXCLUDED. ENDORSEMENT #1800 - DANIEL FRIESS PRESIDENT - EXCLUDED. ENDORSEMENT #2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-01-2001 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER FRIESS COMPANY BUILDERS,INC. 31858 RANCHO VIEJO RD STE B SAN JUAN CAPO CA 92575 SG [CJ2,CNj IREV.2-M PRINTED : 07-11-2005 QCERTIFICATE OF INSURA E SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE CANCELED OR OTHERWISE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN SD DAYS FROM THE DATE WRITTEN. THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED BELOW. This certifies that: ESTATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois ❑ STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois ❑ STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas, Texas, or ❑ STATE FARM INDEMNITY COMPANY of Bloomington, Illinois has coverage in force for the following Named Insured as shown below: NAMED INSURED: FRIESS AND ASSOCIATES, INC. 31658 RANCHO VIEJO RD STE B ADDRESSOF NAMED INSURED: SAN JUAN CAPISTRANO, CA 92675 POLICY NUMBER R55 8128-F15-75 L36 4593-904-75H 75 -V5 -4007 -SG 75-QD3486-8G EFFECTIVE DATE OF POLICY 12/15/04-06/15/05 04/04/05-10/04/05 02/12/05-02/12/06 02/18/05-02/18/06 DESCRIPTION OF VEHICLE(Including VIN) 2001 FORD F150 PU 2110 GMC YUKON SW UMBRELLA UMBRELLA LIABILITY COVERAGE ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO LIMITS OF LIABILITY a. Bodily Injury 100,000 250,000 Each Person 300,000 500,000 Each Accident 25,000 100,000 b. Property Damage Each Accident c. Bodily Injury & Property Damage Single Limit Each Accident 2,000,000 1,000,000 PHYSICAL DAMAGE COVERAGES ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO a. Comprehensive $ Deductible $ Deductible $ Deductible $ Deductible ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO b. Collision $ Deductible $ Deductible $ Deductible $ Deductible EMPLOYERS CAR LIABILITY COVERAGE OVERAGE ❑ YES NO ElI-]El❑ YES NO YES I--] NO NO YES NO HIRED CAR LIABILITY ❑ YES NO E]❑ES ❑ YES ❑ NO Y ❑ NO [I YES ❑ NO COVERAGE FLEET - COVERAGE FOR ALL OWNED AND LICENSED MOTOR VEHICLES ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO AGENT 75-8323 05 Title NArlte and Address of Certificate Holder Name and Address of Agent CITY OF SAN JUAN CAPISTRANO JOHN R. MCMAHAN LIC 0576973 ATTN: CITY CLERK'S OFFICE 32221 CAMINO CAPISTRANO, B-105 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA SAN JUAN CAPISTRANO, CA 92675 INTERNAL STATE FARM USE ONLY: 0 Request permanent Certirioate of Insurance for liability coverage • CERTIFICATE OF INSURASE SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE CANCELED OR OTHERWISE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM THE DATE WRITTEN. THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED BELOW. This certifies that: ® STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois ❑ STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois ❑ STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas, Texas, or ❑ STATE FARM INDEMNITY COMPANY of Bloomington, Illinois has coverage in force for the following Named Insured as shown below: NAMED INSURED: FM ELECTRIC 31658 RANCHO VIEJO RD STE B ADDRESS OF NAMED INSURED: SAN JUAN CAPISTRANO, CA 92675 POLICY NUMBER P47 3958 -F19 -73E 074 6746-B04-75 068 9916-DO7-75 R51 5568 -CIS -75F EFFECTIVE DATE OF POLICY 12/19/04-06/19/05 02/04/05-08/04/05 04/07/05-10/07/05 03/15/05-09/15/05 DESCRIPTION OF VEHICLE (Including VIN) 1998 GMC STAKE 2003 FORD F250 2002 VOLKSWAGON EMPLOYERS NON - BED SUPER DUTY PU JETTA WAGON OWNED AUTO LIABILITY COVERAGE ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO E YES ❑ NO LIMITS OF LIABILITY a. Bodily Injury Each Person Each Accident b. Property Damage Each Accident c. Bodily Injury & Property Damage Single Limit Each Accident 1,000,000 1,000,000 1,000,000 1,000,000 PHYSICAL DAMAGE COVERAGES ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO a. Comprehensive $ Deductible $ Deductible $ Deductible $ Deductible ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO b. Collision $ Deductible $ Deductible $ Deductible $ Deductible EMPLOYERS NON -OWNED CAR LIABILITY COVERAGE ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO HIRED CAR COVERAGE LIABILITY ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO FLEET -COVERAGE FOR ALLO✓RVEH ES NEDAND LICENSED MOTOR MO [:]YES ❑ NO El YES E] NO El YES El NO El YES ❑ NO CITY OF SAN JUAN CAPISTRANO ATTN: CITY CLERK'S OFFICE 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA 92675 AGENT Name and Address of 75-8 JOHN R. MCMAHAN LIC 0576973 32221 CAMINO CAPISTRANO, B-105 SAN JUAN CAPISTRANO, CA FARM USE ONLY: L] Request permanent Certificate of Insurance for liability coverage. 5/5/2005 O• CERTIFICATE OF INSURSE SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE CANCELED OR OTHERWISE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM THE DATE WRITTEN. THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED BELOW. This Certifies that: ® STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois ❑ STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois ❑ STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas, Texas, or ❑ STATE FARM INDEMNITY COMPANY of Bloomington, Illinois has coverage in force for the following Named Insured as shown below: NAMED INSURED: FM ELECTRIC 31658 RANCHO VIEJO RD STE B ADDRESS OF NAMED INSURED: SAN JUAN CAPISTRANO, CA 92675 POLICY NUMBER C99 7185 -C25 -75C D12 8435 -D29 -75C L36 7525 -A15 -75G P43 8807 -D14 -75E EFFECTIVE DATE OF POLICY 03/25/05-09/25/05 04/29/05-10/29/05 1/15/05-1/15/06 04/14/05-10/14/05 DESCRIPTION OF 1994 FORD F350 VEHICLE (Including VIN) 1998 GMC SAVANA 1999 DODGE RAM PU STAKE BED 1989 FORD F250 PU LIABILITY COVERAGE ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO LIMITS OF LIABILITY a. Bodily Injury Each Person Each Accident b. Property Damage Each Accident c. Bodily Injury & Property Damage Single Limit Each Accident 1,000,000 1,000,000 1,000,000 1,000,000 PHYSICAL DAMAGE COVERAGES ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO a. Comprehensive $ Deductible $ Deductible $ Deductible $ Deductible ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO b. Collision $ Deductible $ Deductible $ Deductible $ Deductible EMPLOYERS NON -OWNED CAR LIABILITY COVERAGE ❑ YES [:1 NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO HIRED CAR LIABILITY ElYES E:1 NO YES NO YES NO ❑ YES ❑ NO COVERAGE FLEET -COVERAGE FOR ALLED LASED El YES El NO ❑ YES NO ❑ YES NO ❑ YES NO MOTOR OR VEICLES ICLES CITY OF SAN JUAN CAPISTRANO ATTN: CITY CLERK'S OFFICE 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA 92675 NTERNAL AGENT 75-8323 5/5/05 Tide Agent's Code Number Date 32221 CAMINO CAPISTRANO, B-105 SAN JUAN CAPISTRANO, CA of Insurance for liability coverage. O • CERTIFICATE OF INSURANCE E t SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE CANCELED OR OTHERWISE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM THE DATE WRITTEN. THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED BELOW. This certifies that: ® STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois ❑ STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois ❑ STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas, Texas, or ❑ STATE FARM INDEMNITY COMPANY of Bloomington, Illinois has coverage in force for the following Named Insured as shown below: NAMED INSURED: FRIESS COMPANY BUILDERS, INC. 31658 RANCHO VIEJO RD STE B ADDRESS OF NAMED INSURED: SAN JUAN CAPISTRANO, CA 92675 POLICY NUMBER P47 3958 -F19 -73E 074 6747-1304-75 068 9916-D07-75 R51 5568 -C15 -75F EFFECTIVE DATE OF POLICY 12/19/04-06/19/05 02/04/05-08/04/05 04/07/05-10/07/05 04/14/05-10/14/05 DESCRIPTION OF VEHICLE (Including VIN) 1998 GMC STAKE 2003 FORD F250 2002 VOLKSWAGON EMPLOYERS NON - BED SUPER DUTY PU JETTA WAGON OWNED AUTO LIABILITY COVERAGE ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO LIMITS OF LIABILITY a. Bodily Injury Each Person Each Accident b. Property Damage Each Accident c. Bodily Injury & Property Damage Single Limit Each Accident $1,000,000 $1,000,000 $1,000,000 $1,000,000 PHYSICAL DAMAGE COVERAGES ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO a. Comprehensive $ Deductible $ Deductible $ Deductible $ Deductible ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO b. Collision $ Deductible $ Deductible $ Deductible $ Deductible EMPLOYERS NON -OWNED CAR LIABILITY COVERAGE ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO HIRED CAR LIABILITY ❑ YES ❑ NO ❑YES ❑ NO ❑YES ❑ NO ❑ YES ❑ NO COVERAGE FLEET -COVERAGE FOR ALL OWNED AND LICENSED ElYESNO YES ❑ NO ❑ YES ElNO ❑YES ❑ NO MOTOR VEHI LES 75-8323 05/05/05 bgt re or Autnonzea Kepresentauve + Title Agent's code Number Date Na;e and Address of Certificate Holder Name and Address of Aoent CITY OF SAN JUAN CAPISTRANO JOHN R. MCMAHAN LIC 0576973 ATTN: CITY CLERK'S OFFICE 32221 CAMINO CAPISTRANO, B-105 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA SAN JUAN CAPISTRANO, CA 92675 INTERNAL STATE FARM USE ONLY: I] Request permanent Certificate of Insurance for liability coverage A0 CERTIFICATE OF INSURA• E SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE CANCELED OR OTHERWISE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM THE DATE WRITTEN. THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED BELOW. This certifies that: ® STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois ❑ STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois ❑ STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas, Texas, or ❑ STATE FARM INDEMNITY COMPANY of Bloomington, Illinois has coverage in force for the following Named Insured as shown below: NAMED INSURED: FRIESS COMPANY BUILDERS, INC. 31658 RANCHO VIEJO RD STE B ADDRESS OF NAMED INSURED: SAN JUAN CAPISTRANO, CA 92675 POLICY NUMBER C99 7185 -C25 -75C D12 8435 -D29 -75C L36 7525 -A15 -75G P43 8807 -D14 -75E EFFECTIVE DATE OF POLICY 03/25/05-09/25/05 04/29/05-10/29/05 1/15/05-1/15/06 04/14/05-10/14/05 DESCRIPTION OF 1994 FORD F350 VEHICLE (Including VIN) 1998 GMC SAVANA 1999 DODGE RAM PU STAKE BED 1989 FORD F250 PU LIABILITY COVERAGE ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO LIMITS OF LIABILITY a. Bodily Injury Each Person Each Accident b. Property Damage Each Accident c. Bodily Injury & Property Damage Single Limit Each Accident $1,000,000 $1,000,000 $1,000,000 $1,000,000 PHYSICAL DAMAGE COVERAGES ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO a. Comprehensive $ Deductible $ Deductible $ Deductible $ Deductible ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO b. Collision $ Deductible $ Deductible $ Deductible $ Deductible EMPLOYERS NON -OWNED ❑ YES ❑ NO ❑ YES [:1 NO ❑ YES ❑ NO ❑ YES ❑ NO CAR LIABILITY COVERAGE HIRED CAR LIABILITY E]YES ElNO ❑ ❑ NO YES E][:1YES ❑ NO ❑ YES NO COVERAGE FLEET -COVERAGE ER ALLAGE ED AND LICENSED ❑ YES [:]El❑ YES NO El YES NO ❑ YES NO MO MOTORR VEH LES AGENT 75-8323 05/05/05 Title Name and Address of Certificate Holder Name and Address of Agent CITY OF SAN JUAN CAPISTRANO JOHN R. MCMAHAN LIC 0576973 ATTN: CITY CLERK'S OFFICE 32221 CAMINO CAPISTRANO, B-105 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA SAN JUAN CAPISTRANO, CA 92675 INTERNAL STATE FARM USE ONLY: 0 Request permanent Certificate of Insurance fa liability coverage A • CERTIFICATE OF INSURANCE 3 SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE CANCELED OR OTHERWISE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM THE DATE WRITTEN. THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED BELOW. This certifies that: ESTATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois ❑ STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois ❑ STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas, Texas, or ❑ STATE FARM INDEMNITY COMPANY of Bloomington, 10inois has coverage in force for the following Named Insured as shown below: NAMED INSURED: FRIESS CONSTRUCTION, INC. 31658 RANCHO VIEJO RD STE B ADDRESS OF NAMED INSURED: SAN JUAN CAPISTRANO, CA 92675 POLICY NUMBER C99 7185 -C25 -75C D12 8435 -D29 -75C L36 7525 -A15 -75G P43 8807 -D14 -75E EFFECTIVE DATE OF POLICY 03/25/05-09/25/05 04/29/05-10/29/05 1/15/05-1/15/06 04/14/05-10/14/05 DESCRIPTION OF 1994 FORD F350 VEHICLE (Including VIN) 1998 GMC SAVANA 1999 DODGE RAM PU STAKE BED 1989 FORD F250 PU LIABILITY COVERAGE ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO LIMITS OP LIABILITY a. Bodily Injury Each Person Each Accident b. Property Damage Each Accident c. Bodily Injury & Property Damage Single Limit Each Accident 1,000,000 1,000,000 1,000,000 1,000,000 PHYSICAL DAMAGE COVERAGES ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO a. Comprehensive $ Deductible $ Deductible $ Deductible $ Deductible ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO b. Collision $ Deductible $ Deductible $ Deductible $ Deductible EMPLOYERS NON -OWNED CAR LIABILITY COVERAGE ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO HIRED CAR LIABILITY [:1YES E]NO ❑ YES [:3NO [:1YES E]NO [:1YES ElNO COVERAGE FLEET -COVERAGE FOR OWNEDALL o uCENSED MO MOTORVEHICLES ❑ ❑ NO El YES NO YES NO YES NO and Address of Certificate Holder CITY OF SAN JUAN CAPISTRANO ATTN: CITY CLERK'S OFFICE 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA 92675 AGENT 75-8323 05/05/05 Tale JOHN R. MCMAHAN LIC 0576973 32221 CAMINO CAPISTRANO, B-105 SAN JUAN CAPISTRANO, CA FARM USE ONLY: []Request permanent Certificate of Insurance for liability coverage. W• CERTIFICATE OF INSURANCE SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE CANCELED OR OTHERWISE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM THE DATE WRITTEN. THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED BELOW. This certifies that: ® STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois ❑ STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois ❑ STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas, Texas, or ❑ STATE FARM INDEMNITY COMPANY of Bloomington, Illinois has coverage in force for the following Named Insured as shown below: NAMED INSURED: FRIESS CONSTRUCTION, INC. 31658 RANCHO VIEJO RD STE B ADDRESS OF NAMED INSURED: SAN JUAN CAPISTRANO, CA 92675 POLICY NUMBER P47 3958 -F19 -73E 074 6746-B04-75 068 9916-D07-75 R51 5568 -C15 -75F EFFECTIVE DATE OF POLICY 12/19/04-06/19/05 02/04/05-08/04/05 04/07/05-10/07/05 04/14/05-10/14/05 DESCRIPTION OF 1998 GMC STAKE 2003 FORD F250 2002 VOLKSWAGON EMPLOYERS NON - VEHICLE (Including VIN) BED SUPER DUTY PU JETTA WAGON OWNED AUTO LIABILITY COVERAGE ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO LIMITS OF LIABILITY a. Bodily Injury Each Person Each Accident b. Property Damage Each Accident c. Bodily Injury & Property Damage Single Limit Each Accident 1,000,000 1,000,000 1,000,000 1,000,000 PHYSICAL DAMAGE COVERAGES ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO a. Comprehensive $ Deductible $ Deductible $ Deductible $ Deductible ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO b. Collision $ Deductible $ Deductible $ Deductible $ Deductible EMPLOYERS NON -OWNED ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO CAR LIABILITY COVERAGE HIRED CAR LIABILITY ❑ YES El YES ❑ NO [-IYES [-INO [1 YES E:1 NO COVERAGE COVERAGE FLEET - COVERAGE FOR ALLNE LICENSED [:1 YES ❑ NO YES NO YES NO ❑ YES ❑ NO MOTORORVEHICLES 75-8323 05/05/05 s ure or Aumoraea Nepresernative - Title Agents Code Number Date me and Address of Certificate Holder Name and Address of Aaent CITY OF SAN JUAN CAPISTRANO JOHN R. MCMAHAN LIC 0576973 ATTN: CITY CLERK'S OFFICE 32221 CAMINO CAPISTRANO, B-105 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA SAN JUAN CAPISTRANO, CA 92675 INTERNAL STATE FARM USE ONLY: 0 Request permanent Certificate of Insurance for liability coverage FRIFSS CONSTRUCT/ON GROUP TRANSMITTAL COVER LETTER To: Maria Guevara Company: City of San Juan Capistrano Address: 32400 Paseo Adelanto, CA 92675 Business Phone: (949) 493-1171 From: Monica Stombaugh Business Phone: (949) 487-9700 x104 Fax Number: (949) 248-8433 Date: 05/04/2005 Re: Auto Liability Insurance Comments: Enclosed are the updated auto liability insurance certificates. 31658 Rancho Viejo Road, Suite B San Juan Capistrano, CA 92675 www.friessco.com License 836571 ACOR .M CERTIFIC OF LIABILITY INSUR E i2/13/2 a' PR=DUCER (949) 582-5220 FAX (949) 582-3512 S P I B Insurance Agency Inc. License Number 0719264 26441 Crown Valley Parkway Mission Viejo, CA 92691 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Friess Company Builders Inc; ;dba:FM Electric 31658 Rancho Viejo Rd #B San Juan Capistrano,Ca. 92675 INSURERA: Admiral Insurance Company/Stewart Smith Wes, INSURERS State Comp Insurance Fund 210 INSURERG. QBE Insurance Corporation/c/oDea sHomer WSURERD. Lloyds of London/E.L.M.Ins.Broke s INSURER E. COVFRarFH THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TR KWN rypE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONI LIMITS SAN JUAN CAPISTRANO, CA 92675 GENERAL LIABILITY CA000000303-03 07/27/2004 07/27/2005 EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50,000 CLAIMS MADE � OCCUR MED EXP (Any one person) $ EXCLUDE A X PERSONAL A ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,00 "i LOC X POLICY JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY $ ALL OWNED AUTOS SCHEDULED AUTOS (Per person) BODILY INJURY $ HIRED AUTOS NON -0W NED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLYCAACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIULE $ RETENTION $ WORKERS COMPENSATION AND 1594117-04 07/01/2004 07/01/2005 X WCSTATU- 2 - EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 1,000,00-0 B ANY PROPRIETOWPARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEEI $ 1,000,000 OFFICFRIMEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE- POLICY LIMIT 1 $ 1.000.000 HF�R 2612656 11/03/2004 11/03/2005 BPP:$60,000./special/RC Ded uOTslness Personal C roperty;Contr. Equip $SOO;Contr Equip $36,800/ACV Newly Aquired $25,000. DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS E: SERRA VISTA - PROJECT #02-270, 30300 CAMINO CAPISTRANO, SAN JUAN CAPISTRANO, CA 92675 ERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY AS PER FORM CG2010 07/04) ATTACHED "revised certificate 2/3/05" 'EXCEPT 10 DAYS NOTICE OF CANCELLATION FOR NON-PAYMENT OF PREMIUM CERTIFICATE ER CANCELLATION ACORD 25 (2001108) ©ACORD CORPORAT fl 1988 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, CITY OF SAN JUAN CAPISTRANO BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 32400 PASEO ADELANTO OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE c.� LarryHines/JESSIC o(Ya SAN JUAN CAPISTRANO, CA 92675 ACORD 25 (2001108) ©ACORD CORPORAT fl 1988 o: t Policy Number: CA000000303-03 CC 20 10 07 04 Effective Date: 07/27/2004 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Nance Of Additional Insured Person(s) Or Or anization s : Ltseatio a Of Covered Operations ANY ENTITY FOR WHOM YOU ARE PERFORMING ALL COVERED PROJECTS ONGOING OPERATIONS, BUT ONLY IF REQUIRED BY WRITTEN CONTRACT PRIOR TO AN "OCCURRENCE" OR LOSS. CITY OF SAN JUAN CAPISTRANO,CA. Information required to co tete this Schedule, if not shown above will be shown in the Declarations. A. Section If — Who Is An Insured is amended to include as an additional insured the ptrsmt(s) or organintion(s) shown in the Schedule, but only with respect to liability for "bodily u0ury". "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 imured(s) at the location(s) deaiguated above. B. With respect to the insurance afforded to these additional msureds, the following additional exclusions apply: CG 20 10 07 04 This insurance does not apply to "bodily injury" or "property damage" occurring atter: 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 ar 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 to its intended use by any person or organization oth" than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. 42 ISO Properties, Inc., 2004 Page 1 of 1 O 0 Maria Guevara From: Meg Monahan Sent: Wednesday, March 30, 2005 9:45 AM To: Maria Guevara Subject: RE: Updated Non-Pay/Non-Compliance Lists Yes this is fine. Meg Monahan, City Clerk City of San Juan Capistrano 32400 Paseo Adelanto San Juan Capistrano, CA 92675 (949) 443-6308 (949) 493-1053 - fax -----Original Message ----- From: Maria Guevara Sent: Wednesday, March 30, 2005 9:18 AM To: Meg Monahan Subject: FW: Updated Non-Pay/Non-Compliance Lists Me 7 fC I X55 Co. Is this enough to put in the file & waive the auto insurance? This agreement did not got to Council. -----Original Message ----- From: John Shaw Sent: Wednesday, March 30, 2005 9:16 AM To: Maria Guevara Subject: RE: Updated Non-Pay/Non-Compliance Lists Auto insurance for this is not necessary. -----Original Message ----- From: Maria Guevara Sent: Monday, March 28, 2005 4:14 PM To: Molly Bogh Cc: Meg Monahan; David Contreras; John Shaw; Lynnette Adolphson Subject: RE: Updated Nan-Pay/Non-Compliance Lists Hi Molly, Our office can't formally waive the auto requirement per the agreement. This is something that needs to be waived by John Shaw. Let me know how you want to handle this. Maria -----Original Message ----- From: Molly Bogh Sent: Monday, March 28, 2005 7:57 AM To: Maria Guevara ►S Cc: Ovid Contreras; Lynnette Adolphson • Subject: RE: Updated Non-Pay/Non-Compliance Lists Regarding the item on Non -Compliance list for Friess office building, there is no need for an auto insurance policy on the deferred improvement agreement. This was an agreement to allow them to get a temporary certificate of occupancy provided they promised to finish installing their landscaping by a certain date. By the way — David — what is the status of landscaping with respect to completion date? The last time I drove past they still had the turf. -- Molly -----Original Message ----- From: Maria Guevara Sent: Friday, March 25, 2005 3:48 PM To: Mitzi Ortiz; Dawn Schanderl; Diane Regier; Dottie Crawford; Douglas Dumhart; Joan Ross; Lynnette Adolphson; Meg Monahan; Michelle Perea Cc: Nasser Abbaszadeh; Amy Amirani; Bill Huber; Cindy Russell; Karen Crocker; Lt. Davis; Molly Bogh Subject: Updated Non-Pay/Non-Compliance Lists << File: NON -PAY LIST.doc >> << File: NON-COMPLIANCNCE LIST.doc >> Maria Guevara, Administrative Secretary City of San Juan Capistrano City Clerk Division (949) 443-6309 0 Maria Guevara From: John Shaw Sent: Wednesday, March 30, 2005 9:16 AM To: Maria Guevara Subject: RE: Updated Non-Pay/Non-Compliance Lists Auto insurance for this is not necessary. -----Original Message ----- From: Maria Guevara Sent: Monday, March 28, 2005 4:14 PM To: Molly Bogh Cc: Meg Monahan; David Contreras; John Shaw; Lynnette Adolphson Subject: RE: Updated Non-Pay/Non-Compliance Lists Hi Molly, 0 Our office can't formally waive the auto requirement per the agreement. This is something that needs to be waived by John Shaw. Let me know how you want to handle this. Maria -----Original Message ----- From: Molly Bogh Sent: Monday, March 28, 2005 7:57 AM To: Maria Guevara Cc: David Contreras; Lynnette Adolphson Subject: RE: Updated Non-Pay/Non-Compliance Lists Regarding the item on Non -Compliance list for Friess office building, there is no need for an auto insurance policy on the deferred improvement agreement. This was an agreement to allow them to get a temporary certificate of occupancy provided they promised to finish installing their landscaping by a certain date. By the way — David — what is the status of landscaping with respect to completion date? The last time I drove past they still had the turf. -- Molly ----Original Message ----- From: Maria Guevara Sent: Friday, March 25, 2005 3:48 PM To: Mitzi Ortiz; Dawn Schanderl; Diane Regier; Dottie Crawford; Douglas Dumhart; Joan Ross; Lynnette Adolphson; Meg Monahan; Michelle Perea Cc: Nasser Abbaszadeh; Amy Amirani; Bill Huber; Cindy Russell; Karen Crocker; Lt. Davis; Molly Bogh Subject: Updated Non-Pay/Non-Compliance Lists << File: NON -PAY LIST.doc >> « File: NON-COMPLIANCNCE LIST.doc >> Maria Guevara, Administrative Secretary City of San Juan Capistrano City Clerk Division (949)443-6309 0 CALIFORNIA PRELIMINARY NOTICE IN ACCORDANCE WI'�i�.¢Iq,7098, CALIFORNIA CIVIL CODE *** THIS IS N�a I N. *** THIS IS NOT A REFLECTION ON THE INTEGRITY OFANY CONTRACTOR OR SUBCONTRACTOR. 2005 JUL 1 1 P I. 19 ' NOTICE IS HEREBY GIVEN that: CITY CLERK OWNER OR REPUTED OWNER OR PUBLIC AGENCY SAN JUAN CAPISTRANO ROBERTSON'S CTY OF SAN JUAN CAPISTRNO 200 S MAIN ST, SUITE 200 32400 PASEO ADELANTO CORONA CA 92878 SAN JUAN CAPISTCAN92692 (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: DEL, OBISPO,PASEO AOELANTO SAN JUAN CAPISTRANO J.C.N. n 050615 Tract No. Lot_ No. Cert Num: 2120241$ Name of Person or Firm who contracted for purchase of the labor, services, equipment, or materials is: ECONOLI'I'E 'T'RAFF'IC ENG & M 3360 E. LA PALMA AVE ANAHFTM CA 92806 An estimate of the total price of said labor, services, equipment or materials is: 1,573.12 LIEN. DAY61 ED: 07/07/2005 BY: MARY PERRON FRIESS CONSTRUCTION 31658 RANCHO VIEJO RD STE B SAN JUAN CARTS CA 92675 x D4v� TRUST FUNDS TO WHICH SUPPLEMENTAL FRINGE BENEFITS ARE PAYABLE BY *****PLEASE ISSUE JOINT CHECKS***** ROBERTSON'S cF CORONA, CA 92 PO. BOX 3600 02 ti rva✓.a 878-3600QQxmivx w�+n 669C JL,) ! + d i • MAILED FROM ZIP CODEl9'S- 71. 8 1 6r6 8852 120 ? C>> IMPORTPNIT: CALIFORNIA PRELIMINARY NOTICE Cl" OF SAN C ):J ('.> 'NO i310O 'BSL70 ? )J,E.� SAI+ ,fUAN CAF I 3T 92692 22950 050615 CALIFORNIA PRELIMINARY NOTICE�� (California Civil CZ3e, Section 3097 as amended by Senate Bill 1379 [Chapter 3961 effective January /, 1978) t - Notice to Property Owner -If bills are not paid if full for the labor, services, equipment or materials furnished or to be furnished, a mechanic's Gen leading to the loss, through court foreclosure proceedings, of all or pan of your property being so improved may be placed against the property even though you have paid your contraaor in full. You may wish to protect yourself against this consequence by (1) Requiting your contractor to furnish a singed release by the person or firm giving you this notice before making payment to your contractor, or (2) Any method or device that is appropriate under the circumstances. Other than residential homeowners of dwellings containing fewer than five units, TO: CITY OF SAN JUAN C4PISIRAND OWNER nePuaEDOWNER 32400 PASDO ADELANTO OR PUBLICAGENCY i For the building, structure or other work of improvement U9 at�� MAR 15 U9 f sS1F THE THE PURQ OFSUCH LAN ERIAL - ECONOLITE Dated MARCH 14, 2005 OCSS JOB NUMBER 43-5002 YOU ARE HEREBY NOTIFIED That the undersigned has famished or will furnish labor, services, equipment or materials of the following description. OBISPO STREET AND PASEO ADELANTO SAN JUAN CAPISTRANO WHO CONTRACTED VICES, EQUIPMENT OR 3360 EAST LA PALMA AVENUE I1b/�1.1' aYlur�O tY.7TiL'Qrl iCT FRIESS CONSTRUCTION GROUP TO: m� 31658 RANCHO VIEJO ROAD SUITE B tR SAN JUAN CAPISTRANO, CA 92675 S E N D E R Trust funds to which supplemental fringe benefits are payable NAME AEURISS NNE Name of wits equipment or rnmaterial ORANGE COUNTY STRIPING SERVICE, INC. — LIC. #346095 labor, service Address 783 NORTH PIXLEY STREET — ORANGE, CA 92868 By TO: oazqu uimt OR msmm x UNDER 'Phis aclatowledges receipt on Data Title AUTHORIZED AGENT Date MARCH 14, 2005 NOTICE TO CONSTRUCTION LENDER ONLY Estimated total price of the labor, services, equipment or materials described hereon. ACKNOWLEDGMENT OF RECEIPT OF PRELIMINARY 20 -DAY NOTICE (Section 3097. 1, Calif. Civil Code) of copy ofthis preliminary 20A, notice at (Address where Nonce received) (Date this acknowledgment is executed) (Signature of arson acknowledging receipt, with title ofacknowledgment is made on behalf ofm ather person) or description ofjob site) r 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA 92675 (949) 493-1171 (949) 493-1053 FAx WN'W. smyuancapistrano. org November 19, 2004 Clerk -Recorder's Office County of Orange P.O. Box 238 Santa Ana, California 92701 • -i �� 11IIOIRRPoAAR MEMBERS OF THE CITY COUNCIL t� SAM L AT • DIANEEL.. BATHGATE WYATT HART JOE SOTO DAVID M. SWERDUN Re: Aqreement for Deferral of Improvements AC 00-06/Serra Vista Office Guilding SENT VIA CERTIFIED MAIL The noted document is enclosed for recording: When placed of record, please return the recorded document to this office. Thank you for your assistance. Very truly /yours / M rga t R. Monahan C ty C rk Cc: David Contreras, Associate Planner Molly Bogh, Planning Director ru In r`- ry r -q U.S. postal Servicers 0 0 ReWM RecieP?Fee Req"" )EndCeSeWent CERTIFIED Delrva uFX) Req A MAIL,. RECEIPT Covera9 .provided) M T�ral Paetege 6 Fee: Mail Only; No Insurance (DomesNe e1'a'aW'oaPa'oom® _ ._,�-.e.., Information visit our Website ru In r`- ry r -q Cedllied Fee 0 0 0 ReWM RecieP?Fee Req"" )EndCeSeWent ORestricted Delrva uFX) Req A (Endmeement r3 M T�ral Paetege 6 Fee: m 0 0 1` San Juan Capistrano: Preserving the Past to Enhance the Future I / 0 • u DC - City of San Juan Capistrano Planning Department 32400 Paseo Adelanto San Juan Capistrano, California 92675 FEE AND DEVELOPER DEPOSIT COMPUTATION FORM GENE 14 PERMIT FEES - _ OO NT NO. Research: hours $2&hour Land Use Adjustment $300 Sign Permit $100 Grand Opening 6 Promotional Banner $25 Sign Monument not part of AC application) $300 Special Event Permit Application varies see fee resolution Street Banner $80. Temporary Sign Permit $25 Temporary Use Permit $150 Zone Variance $750 Site Plan Review $500 Exception to RadkA sh Antenna Regulations $100 Exception to Title 9 Regulation $750 Pr"pplication Consultation/Preliminary Review $150 Other /V/se-- o s T— $ 7,2 7 • oo p7,2 7.5r, 00 MAPS • ACG011NT NO.01.4531 General Plan Ma $5.00 each Zodnq Ma $5.00 each Los Rios Specific Plan Ma $5.00 each PU CATIO -A.. NTNO.914=1 General Plan or General Plan EIR $32 each General Plan Appendices $46 each Title 9 Land Use Code sold in CityGerk's Office Demooraphic Statistics $3.50 each Los Rios Specific Plan $9.00 each Architectural Deskin Guidelines $13.50 each Planning Commission minutes (copies of tapes) $20.00/1st + $5.()W2 or 3m Copies: pages $0.20/page CONSULTANT CONTRACT FEES -ACCOUNT NO. 18 - Project Name: Log. No. DEVELOPER DEPOSIT - ACCOUNT NO. IS - Project Name: Log No: Prepared W. y� / �a Date: /f — 9 —D Check No: ODX5-0pO5D� Total f 7, 975. 00 Check Payor. Receipt No: P:VnannuVN lan shared0ept Fo slFa FeeComp.wpd j'c CA c / L U� C_..v� C •� f�l \ .. t t•4�`Y� W S / I Ih jytl c - i A \� st L F3?i��e t r � _ W c O 2 ^o Q � H moa: aZo Vwv Za 0 0 i Zaw yooa N U LL"z Q j r1 LJ r1 U • Policy Number: CA000000303-02 Friess Company Builders, Inc. CG 20 10 10 01 Number: Effective Date: 07/27/2003 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: o AS REQUIRED BY WRITTEN CONTRACT (if no entry aooears above. information reouired to complete s endorsement will be shown in the Declaratiom as annlicahle to this endorsement.) A. Section H — Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability aris- ing out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these addi- tional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to "bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment fumished in connection with such work, on the project (other than serv- ice, maintenance or repairs) to be per- formed by or on behalf of the additional in- sured(s) at the site 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 to its intended use by any person or organiza- tion other than another contractor or sub- contractor engaged in performing opera- tions for a principal as a part of the same project. If you are required by a written contract to provide primary insurance, then this policy shall be primary and not contributory with any other insurance available to the additional insured named in the schedule above. Form CG0001 Commercial General Liability Coverage (but only Section IV. Paragraph 4., subparagraph b) is amended accordingly and shall not apply with respect to coverage provided for the Additional Insured named above in the schedule. CG 20 10 10 01 ®ISO Properties, Inc., 2000 Page 1 of I "4� • 0 City of San Juan Capistrano 32400 Paseo Adelanto San Juan Capistrano, CA. 92675 (949) 493-1171 Fax: (949) 493-1053 FAX TRANSMISSION COVER SHEET Date: //al -- To: l �—l ,llc t4 (C� Fax. �/2,(--z -'4 (� S3 Re: -D:�4-3 S u f-CAAkc C Sender: Wave 6 c'zeUa'�-a' YOU SHOULD RECEIVEcZPAGE(S), INCLUDING THIS COVER SHEET. IF YOU DO NOT RECEIVE ALL THE PAGES, PLEASE CALL (949)'KV3 - �0 e.a,vsr.c:;e;rnn= ("NOV", Project Information Project # 04587 Arch. Project # Title Serra Plaza Office Building Address 31910 and 31920 Del Obispo City, State, Zip San Juan Capistrano, CA 92675 Country USA From Maria (City Clerk's Office) Contact Monica Stombaugh Company Friess Construction Group Address 31658 Rancho Viejo Road, Ste. B City, State, Zip San Juan Capistrano, CA 92675 Country USA Phone 949487-9700 Fax 949 248-8433 Transmittal Maria (City Clerk's Office) Transmittal # 00413 Issue Date 12/15/2004 Subject Auto Ins & Workers' Comp Certificates TO Contact Maria (City Clerk's Office) Company City of San Juan Capistrano (General) Address 32400 Paseo Adelanto City, State, Zip San Juan Capistrano, CA 92675 Country Phone (949) 493-1171 Fax (949) 493-1053 Copies and Remarks Submit Copies For Distribution Sender US Mail Resubmit Copies For Approval Remarks Enclosed are the updated Certificates of Insurance for Automobile coverage (4) and Workers' Compensation. Return Corrected Prints Transmittal Items Updated Certificates of Insurance (5) 12115104 Page 1 of 1 FRIE.SS coxsreuerin.m 6ROYIP Project Information Project # 02-270 Arch. Project # Title Serra Vista Address 30300 Camino Capistrano City, State, Zip San Juan Capistrano, CA 92675 Country USA Contact Carlene Myers �(1�'' Company Friess ConsUv on G oup Address 31658 Rancho Viejo d. Subject Suite B Gley, State, Zip San Juan Capistrano, CA 92675 Country USA Phone (949)487-9700 Fax (949) 248-8433 Transmittal Transmittal # 00410 Issue Date 12/14/2004 Subject Certificate of Liability Insurance To Contact Maria (City Clerks Office) Company City of San Juan Capistrano Address 32400 Paseo Adelanto City, State, Zip San Juan Capistrano, CA 92675 Country Phone (949)493-1171 Fax (949) 493-1053 Copies and Remarks Submit Copies For Distribution Sender Hand Resubmit Copies For Approval Remarks Enclosed is our current Certificate of Liability Insurance for the Serra Vista project. Return Corrected Prints Transmittal fterns CerNflsateofLlati ityInsurance w � Qj 12/14(04 Page 1 of 1 ACORD CERTIFICA OF LIABILITY INSURA E °1Zf13f2O 4 PRODUCER (949) 582-5220 FAX (949)582-3S12 S P I B Insurance Agency Inc. License Number 0719264 41 Crown Valley Parkway sion Viejo, CA 92691 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE MAIC # INSURED Friess Company Builders Inc; Friess Construction Inc. 31658 Rancho Viejo Rd #B San Juan Capistrano,Ca. 92675 INSURER& Admiral Insurance Company/Stewar Smith Wes, INSURER State Comp Insurance Fund 210 INSURER QBE Insurance Corporation/c/oDea sHomer INSURER D: INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRDD'NqRg 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS SAN JUAN CAPISTRANO, CA 92675 GENERAL LIABILITY CA000000303-03 07/27/2004 07/27/2005 EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50,00 CLAIMS MADEO OCCUR MED EXP Any one person) $ EXCLUDE A X PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS - COMP/OP AGO $ 2,000,00 PRO- OC X POLICY JECT AUTOMOBILE LIABILITY COMBINEDSINGLE LIMIT $ ANY AUTO (Ea accidendent)U ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per Parson) HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per awident) PROPERTY DAMAGE $ As L (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑ CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND 1594117-04 07/01/2004 07/01/2005 X I WCSTATU- DTH - EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 1,000,000 B ANY PROPRIETOR/PARTNERIEXECUTIVE E. L. DISEASE - EA EMPLOYEE $ 1,000,00 OFFICER/MEMBER EXCLUDED? It yes, describe under SPECIAL PROVISIONS below E. L. DISEASE -POLICY LIMIT $ 1,000,00 OTIuR 2612656 11/03/2004 11/03/2005 BPP:$60,000./special/RC Ded usiness Personal C roperty;Contr. Equip SSOO;Contr Equip $36,800/ACV Newly Aquired $25,000. DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS E: SERRA VISTA - PROJECT #02-270, 30300 CAMINO CAPISTRANO, SAN JUAN CAPISTRANO, CA 92675 ERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY AS PER FORM CG2010 07/04) ATTACHED '°EXCEPT 10 DAYS NOTICE OF CANCELLATION FOR NON-PAYMENT OF PREMIUM CERTIFICATE HOLDER CANCELLATION ACORD 25 (2001)08) ©ACORD CORPORATION 1888 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, CITY OF SAN JUAN CAPISTRANO BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 32400 PASEO ADELANTO OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE SAN JUAN CAPISTRANO, CA 92675 Larry Hines JESSIC ACORD 25 (2001)08) ©ACORD CORPORATION 1888 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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 endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08) 02/03/2005 09:18 FAX 94948933400 7D -g c` c r� to_ Fax: 1� — Phone - 16�s FRIESS • ® 001 FRIESS CONSTRUCTION GROUP 31655 Ran(ho Vl JD Raba, Suite B sa^)"anCapictrRk�a Cf+J2675 relepha"eF,4X._94J1245-543-- / From;"�% Gc-otiC� CLS , � ^ Papel: 3 t-, CrJv'fJl -DS =� S 02/03/2005 09:16 FAX 9494893340 Lte: L/3/2UUS 'Time: 9:15 A01 Page: 002-003 AC -ORD,,, CERTIFICATE OI PRODUCER (949)S82-5220 FAX (949)58; S P 16 Insurance Agency Inc. License Nunber 0119264 26441 Crown Valley Parkway Mission Viejo, CA 92691 wsuuia Friess Company Builders Inc; ;dba:FM Electric 31658 Rancho Viejo Rd 0B San Juan Capistrano.Ca. 92675 COVERAGES THF POL ICIFS OF INSURANCE LISTED BELOW HAVE BEEN 155444 ED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT IDR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES ESCRIBED HEREIN IS SUCUECT TO ALL THE TERMS EXCLUSIONS AND CONDIMNS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED '— BY PAID CLAIMS INSR D TYPE OF wSURANCB POLICY =ER POLICY EFFECTTYE POLICY FXPRATION -_-- LAIIiE GENERAL LIABILITY CAOD00 0303-03 07/27/2004 07/27/2005 EACH OCCURRENCE 3 I,000 QQ X COMHERCHIGFNERALLUBILITT DAMAGE TOREMEO $ 50,00( CLAWS MADE OCCUR MEO EXP IMT one AMM) S EXCLUDE A X PERSONAL A AOV INJURY S 1,000,000 GENERAL AGGREGATE 3 2,000, CEN'L AGGREGATE LRBT APPLIES PER PROODCTS-COMPIOP AGG 3 2,000,00-0 X7 POLICv 7 �i LOC AUTONGBILE UARLITY CGMRwEO SINGLE VAN, S ANY AUTO (Ea xcMenl) BODILY INJURY S ALL OWNED AUTOS SCHEDULED ALMS Fra, Penang BODILY INJURY 3 HRED AUTOS NONOWNED AUTOS IPA uodenl; PROPERTY DAMAGE S Irerscedenl) GAMGE LABILITY AUTO ONLY EA ACCIDENT S OTIIERPAN EAACC S ANY AUTO AUIODNLY AGG S EECESIIUNBREW UWEUTY tAO+OCCUHHLHCM S OCCUR ❑ CLAIMS WOE ACCAECATE 3 3 S DEDUCTIBLE S RETENTION S WORKERS COMPENSATOR AND 1594117-04 07/01/2004 07/01/2005 x I WCsTATU. DTH - B EMPLOYERS' LIABILITY ITY ANv PROPRIETO"ARTNERIEXECUTIVE WFICERINIEMBEH EXCLUDED, E.L. EACH ACCIDENT S 1,000, EL DISEASE - EA EMPLOYE 3 1 OOO II Ye defcnbe ander SPE CIMPROVISIONTeelpv EL DISEASE POLICY LIMIT S 1.000.000 C usISR Personal roperty-Contr. Equip 2612656 11/03/2004 11/03/2005 BPP:S60,000./special/RC Ded SSOO;Contr Equip 536,800/ACV Newly Aquired S2S,000. S I VEHICLES IRACLUSN3 AD DESCRYTNS, OF DPERAHONa/LOCAT�or�HIIODE E: SERRA VISTA - PRC EL,T 002-270, 30300 CA OY ENDORSEMENT I SPECIAL PROVISIONS INO CAPISTRANO, SAN JUAN CAPISTRANO, CA 92675 ERTIFICATE MOLDER IS NAMED AS ADDITIONAL I SIRED WITH RESPECT TO GENERAL LIABILITY AS PER FORM CG2010 07/04) ATTACHED 'revised certificate 2/3/OS" 'EXCEPT 10 DAYS NOTICE OF CANCELLATION FOR -PAYMENT OF PREMIUM CITY OF SAN JUAN CAPISTRANO 32400 PASEO ADELANTO CAW 1114W CADTCTRANA CA 0147C SHOULD ANY OF THE ABOVE DESCRIBED POLICES RE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISAVING MURER WILL ENDEAVOR TO MAR 30 DATE WRrr1EN NOTICE TO THE CERTIFKATE HOLDER NAKED TO TIE LEFT. BUT FAILURE TO MNL SUCH NOTICE SHALL MOOSE NO ORUGATION OR LIABILITY OF ANY M ��RWNI)in On REPRESENTATIVES 02/03/2005 09:17 FAX 9494893340 Lte: Z/3/ZOOb Time: S : I b AWO Page: 003-003 Policy Number CA00000C303-03 TMS ENDORSEMENT FRIESS httll:Sb COMPANY BUILDERO MOniCa Z003 'L4U-8433 CG 20 10 07 as Effixtive Date: 07/27/2004 THE POLICY. PLEASE READ PP CAREFULLY. ADDITIONAL INSVRED - OWNERS, LESSEES OR CONTRACTORS -- SCHEDULED PERSON OR ORGANIZATION This mdorsemem modift insurance prop under the following: OOMMFRCIAL GF.NI3RAL 1IAB COVERAGE PART SCNi.OlrL6 Nam Of Additional ]"owed renu Or O toi.atia • : tike) Of co. rad O one ANY ENITTY FOR WHOM YOU AREPERF G ALL COVERED PROJECTS ONOOING OVE ATIONS, BVI ONLY IF REQUIRED BY WRn M CONTRACT PRIOR TO AN "OCNRRENCE" repaua) to be performed by or on behalf of the OR LOSS. addidoail rnsmcdls) u the Incsdm of the row CITY OF SAN JUAN CAPISTRANO,CA. I. rhar pomon of"your work"our of which the Tnfmmauo t rcqmred to coroplete &x Scheduleif not drawn above will be shown ip Iba Deelacusom A Saedon A - Who L An bund i. amender include as an addruooJ formed the prn*e org7. wadoc(s) MotYO m the Schedub, but a respecl m Wh t6y for "bodily itd0ry". "Drool daroagc" or "pericoW tied advMismg impoy' in whole m in parr, by: L. Pout tea a cotussioru; or 2. The itis a omorwns of those Leong on behstf; in fie peforeaonoe ofyour ongoing openrioi edyrr:onA wsartJ(>) .r J.c toc.lion(s) Jc.:y above. 8. W nth respect to the m%%&nimc aRorded to Ihc additional arsracds, the folluwrint additional exclusions apply: W This iosuraocc docs not apply to "bodily mjwr or OF 'property damage" ocarnog after: ly Mlh 1. All work including naturals, pate m eyuipescm N caowd. larsubcd in mn0ntrion wrm wilt w"X on the pmjcet (other Than veru cc, maintamunre at repaua) to be performed by or on behalf of the addidoail rnsmcdls) u the Incsdm of the row eov=d operatimu ha bean eomplered` or I. rhar pomon of"your work"our of which the r for dee uyury or damSe anter bat born pot to itv 'cJ inteded ace by any person or odic* tban another comactor or mbeomnetor engaged in perfonming op�ftam for a prmupal as a pail - of the mains project. CC Is to 4704 0 ISO Properties. Inc., 2004 Age 1 ar 1 13 tte: 10/4/2004 Time: 12:5M TO: FRIESS COMPANY BURRS lFriess B 248-8433 Page: 0 002 POLICYHOLDER COPY STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 COMP[N$ATIDN I N S U H A N G S FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 10-04-2004 CITY OF MISSION VIEJO 200 CIVIC CENTER MISSION VIEJO CR 92691 GROUP: POLICY NUMBER: 1594117-2004 CERTIFICATE ID: 77 CERTIFICATE EXPIRES: 07-02-2005 07-01-2004/07-01-2003 This is to certify that we hew issued a valid Worker's Compenastion insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is rat 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 prim to its normal expiration This certificate of insurance is not in insurance policy and does not amend, extend or atter the coverage'egordsd by the policy listed herein. Notwithstanding any requirement, tarts or condition of any contract or other document with respect to which this owfificate 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. NIl}IORIffU REP1hE8ENWlVk PRF IDWT l EXPLOYRR'S-LIABILITY LIMIT INCLUDING DEFENSE C09T21 $1,i000,000-PRR-OCCURRENCE. E[mORSEM21T01600 - KENNETH E. FRIESS, SEC, TRES --EXCLUDED. - - -- Z=ORSEMHNT 01600 - DANIEL FRIESS, PRESIDENT - EXCLUDED. ENDORSEIRNT 02065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-01-2001 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. FRIERS COMPANY BUILDERR,INC. FRIESS CONSTRUCTION, INC. 31659 RANCHO VIEJO RD STE B RAN JUAN CAPO CA 92675 r 0111 w OS;Zzpm F. 001 STATE FARM INSURANCE COMPANIES JOHN MCMAHAN, AGENT 32221 CAMINO CAPISTRANO SAN JUAN CAPI>STRANO, CA 92675 FACSIMILE TRANSMITTAL SHEET TO: FROM: COMPANY: ' ' ' DATE: PA% NU TOTAL NO. 01, PtAKS INCLUDING COMB& NUMBER: (%9) 6614985 RE: YOUR REFERENCE NUMBER 0 URGENT ❑ FOR REVIEW 0 PLEASE COMMENT 0 PLEASE REPLY 0 PLEASE RECYCLE • 0111406 05:22pm P. 003 k CERTIFICATE OF INSURANCE SWCHMS RANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE OR OTHERWISE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM THE DATE WRITTEN. THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED BELOW. This certifies that: ® STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois ❑ STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois ❑ STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas, Texas, or ❑ STATE FARM INDEMNITY COMPANY of Bloomington, Illinois has coverage in force for the following Named Insured as shown below: r NAMED INSURED: FRIESS COMPANY BUILDERS, INC. -- 31658 RANCHO VIEJO RD STE B 1 ADDRESS OF NAMED INSURED: SAN JOAN CAPISTRANO, CA 92675 _ _ - POLICY NUMBER C99 7185-025-75C D12 8435-D29 -/SC L36 7525 -A15 -75G P43 8807 -D14 -75R EFFECTIVE DATE 09/25/04_-03/25/05 .:0/29/04_-04/29/05 1/15/05-1/15/06 10/14_/_04.04/14/05 AOFPOLICY SCRIPTION OF _ 1994 FORD F350 �VEHICLE(IncludingVIN) 1998 GMC SAVANA 1999 DODGE RAM PU STAKE SED 1989 FORD FZ50 PU I LIABILITY COVERAGE ® YES ❑ NO ® YES ❑ NO N YES ❑ NO ® YES ❑ NO LIMITS OF LIABILITY a. Bodily Injury Each Person Each Accident b Property Damage Each Accident _ c. Bodily Injury 8 Property Damage Single Limit Each Accident $1,000, 000 $1, Doo, 000 $1,000,000_ $1,000,000 PHYSICAL DAMAGE COVERAGES ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES _ ❑ NO a- Comprehensive $ Deductible $ Deductible $ Deductible $ Deductible ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO b- Collision $ Deductible $ Deductible $ Deductible $ Deductible EMPLOYERS NON -OWNED El YES El El El El ❑ NO ❑ YES ONO CAR LIABILITY COVERAGE HIRED CAR LIABILITY [I YES [I NO El YES El NO ❑ YES ❑ NO ❑YES ❑ NO COVERAGE FLEET -COVERAGE FOR ALL OWNED AND LICENSED MOTOR VEHICLES ❑ ❑ NO ❑ YES ❑ NO YES [:1[_1YES ❑ NO YES ❑ NO REGARDING SERRA VISTA PROJECT 3030C CAMINO CAPISTRANO SAN JUAN CAPISTRANO, CA 92675 AGENT Title 75-8323 _01/14/_05 Agent's Code Number Date JOHN R. MCMAHAN LIC 0576973 32221 CAMINO CAPISTRANO, B-105 SAN JUAN CAPISTRANO, CA j .Y. 0 Request permanent Certificate of Insurance for liability coverage. 01/*S 0G;22pm F. 002 i a S. ,.. �, m CERTIFICATE OF INSURANCE SUCHdRANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE OR OTHERWISE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM THE DATE WRITTEN. THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED BELOW. This certifies that: ® STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois ❑ STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois ❑ STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas, Texas, or ❑ STATE FARM INDEMNITY COMPANY of Bloomington, Illinois has coverage in force for the following Named Insured as shown below: NAMED INSURED_:_ FRIE_SS COMPANY BUILDERS, INC. 31658 RANCHO VTP.JO RD STE A ADDRESS OF NAMED INSURED. SAN JUAN CAPISTRANO, CA 92675 POLICY NUMBER P47 3958 -F19 -73E. 074 6747-B04-75 068 9916-DO7-75 R51 5568 -_C_15 -75F EFFECTIVE DATE OF POLICY 12/19/04-06/19/05 08/04/04-02/04/05 3.0/07/04-04/07/05 10/14/04-04/14/05 DESCRIPTION OF 1996 GMC STAKE 2003 FORD F250 2002 VOLKSWAGON EMPLOYERS NON- VEHICLE(IncludingVIN) BED SUPER DUTY PU JETTA WAGON OWNED AUTO LIABILITY COVERAGE ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO LIMITS OF LIABILITY a. Bodily Injury Each Person Each Accident b. Property Damage Each Accident C. Bodily—injury & Property Damage Single Limit Each Accident $1,000,000 $1,000,000 $1,000,000 $1,000,000 PHYSICAL DAMAGE COVERAGES ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO 2. Comprehensive $ Deductible $ Deductible $ ❑ YES Deductible ❑ NO 4 $ Deductible ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES []NO b. Collision $ Deductible $ Deductible $ Deductible $ EMPLOYERS NON -OWNED AR LIABILITY OVERAGE CCOVERAGE El_ YES ElNO ElYES ElNO [IYES ElNO ElYES _Deductible ❑ NO HIRED CAR LIABILITYYES ❑ ❑ NO ❑YES E] NO ❑ YES El NO YES NO COVERAGE _ _ FLEET -COVERAGE FOR ALL OWNED AND LICENSED El [INO ❑ YES ElNO [IYES ElNO ❑ YES EJNO MOTOR VEHICLES Warne and Address of Certificate Holder_ C.iTY FO SAN JUAN CAPISTRANO REGARDING SERRA VISTA PROJECT 30300 CAMINO CAPISTRANO SAN JUAN CAPISTRANO, CA 92675 STATE FARM USE ONLY. AGENT 75-8323 0114/05 Title of 32221 CAMINO CAPISTRANO, B-105 SAN JUAN CAPISTRANO, CA Request permanent Certificate of Insurance for liability coverage. Date