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04-1108_FRIESS COMPANY BUILDERS_Compliance with Insurance Requirments
32400 PASEO A€ELANTO i, k' MEMBERS OF THE CITY COUNCIL SAN JUAN CAPISTRANO,CA 92675 i (949)493.1171 SAM ALLEVATO f� } IA[UHP98AiEG DIANE BATHGATE (949)493-1053 F"AX ° fiTSBilslEf6 I �$61 WYATT MART www.s•anjuancapistrano.org 1 76 JOE SOTO • DAVID M.SWERDLIN r • July 25, 2005 Friess Company Builders, Inc. 31658 Rancho Viejo Road, Suite B San Juan Capistrano, CA 92675 RE: Compliance with Insurance Re uirements — Serra Vista Office Building Deferral of Improvements Agreement The following insurance documents are due to expire: General Liability Certificate 07/27/2005 V 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, G Mit i O Deputy City Clerk cc: Kassidy Hill, Administrative Assistant San Juan Capistrano: Preserving the.Past to Enhance the Future �� Printed on recycled paper .te: 7./29/2005 Time; 10; 53 AM To; City of San Juan Capistrano (Or (9 403-1053 Page: 002-r'� 1 R r CERTIFICATE tat LIABILITY INSURANCE � 07/11/2©05 2Rt5nUCER (949)5$2-•5220 FAX (949)582-3512 THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION S P I B Insurance Agency Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE License Number ©719264 HOLDER THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 26441 Crown Valley Parkway Mission View, CA 92691 INSURERS AFFORDtNG COVERAGE MAIC# INSURED Friess Company Builders Inc !NSUPERA. Admiral Insurance Co/c/oStewart ,Smith West 31658 Rancho Viejo Rd, Ste #B =ssuR ---------------------------------------------------------------------------------------------------------•---- S#ate Comp Insurance Fund 210 San Juan Capistrano, CA 92675 iWWRI.RC. QBE Insurance Co/c/o ©Bans 8t Ho r= ----------..-------.._.. -- - - -- _. ti�UR Llayds of Loudon/c/o E.L.M Ins.Brokers [:�VEt�fa�6a' s HE POi.IC!FZ OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAPPED ABOVE FOR THE POLICY PERIOD INDCATED.h 07WITHSTANDING AHY REQUIREMENT.TERM OR C C"DITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CFRTIACATE MAY BE WULD OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AN()CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE 8FEN REDUCED BY PAID CLAIM& I5R' pQECIVE POLICEXP ' Y 4F INSURANCE POLICY NUMBER POLICY EF IRATION LIk1175 • GENERAL LIABILITY ---�-_ -��- CA000000303-04 07/27/2005 07/27/2006 EA.'IICCCURRI NCF 1,©©0,00© 1 X cOrAt,RFRckNL EaEEd thL L IABD?'EY CiArAACE T6 PEN'TEG _..-.._._._ 'SO QQ __ I - -- CLAIMS MADE , f-----� SS excluded xcluded -------- - A PERSONAL 0INJURY 1,000,000 GENERkt AGGREGATE $ 2 r 000,000 i GILITLli( ;i2%=u4TI-I.W:TA'PLIL1`.F'1.:R' PRODUGTO 0OI,1P*,1AGGm '•_____. 2,000,00 I ..".." Pkv -"_- X E'(F_:V JECT LCE AUTOMOBILE LIAB€L}TY __ CGIC9LIN-L;sillGLEc LIMI- S ANY AU?n fin atcicir:3t} _._... �_ _ ...... ............................. ALL hUTCS EOOILv Iv,IUkY �. ..L.I CD.iLL-G fiUF�`a (r�eo per nr1 _ B(X?LY rvJUPI a ENON-01A'NE 1)AUT(is (Pc,amdert)A I PROP[R'Y Df h11AC @ E IPer acr�riMrt} I GARAGE UA91LITY AJTO CYLy-FA ACCITk.N'F HJ�J'l AUTO EA ACCc •..••--..._.–.._–.� 01HLR',HAN _ irXCES51U78REli.A LIA13ILITY FAGH OCC L'"R4E"JCE OCCOR C€.AirJNM"D4c AOC1RIE t AT!- I s I -i-Dt1CT€hl.i ORKeRSCOMPENSATIONAND 1594117-Q5 #37/01/2(305 07/01/2©06 X ° >AT,Y w °T I Eh3PLOYER$'i,IAB�L37Y L: EACH AH 1,000,000 I tipt:'€�i1C'RIcTGf;IPFRITJriRIcX OUTIVE _.__.__.__..__-----------------..__....__. -----------__.._._ m..._ 1I:'IFTECr:rtf+7 i�154f>"r..'7'i=XCL:.IDEC� t _ 'r.. €,!SEASE.-F,A&IOPLOYE S 1,000 0.0..0 =i : �_..--- — --_-- •. � SPS:,Ila-PROVIS€ON beraw F NSCASE.POLIC'l I IM1 s 1'000,000 ,- _ 2612656 11./03/2004 11/03/2005 SPP:$60,000./special/RC ded. CiHk;+i ss Personal Ctroperty; Contr. $500; Contr Equip $40,181 ACV cluip. I Newly Acquired $25,000. Dc'CRIPTION OF OPERATIONS i LOCATIONS I VEHICLES I EXCLUSIONS ADOEO SY ENCORS3=PENT;SPEC€AL PROVISIONS E. SERRA VISTA - PROJECT #02--270, 30300 CAMINO CAPISTRANO, SAKI JUAN CAPISTRANO, CA 92675, CERTIFICATE HOLDER IS NAME© AS ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY AS PER FORM CG2010 (07/04) ATTACKED. ::EXCEPT 10 DAYS NOTICE OF CANCELLATION FOR NON-PAYMENT OF PREMIUM CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE OCSCRIBEfJ POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSU{NG INSURFR 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 SUGIi NOTICE SHALL IMPOSE NO OBLIGATION OR i 1ABILITY 32400 PASEO ADELANTO OF ANY KIND UPON THE INSURER.ITS AGENTS OR REPRESENTATIVES. SAN JUAN CAPISTRANO, CA 52675 AUTHORIZED REPRESENTATIVE ILarry Hines/SHARON ' �+ ACORD 25(2€011138) FAX; (949)493-1053 OACORD CORPORATION 1988 te: 7/29/2005 Time: 1.0: 53 AM To : City of Saiz Juan Capistrano (Or Q 493-1053 Page: 003-0^ IMPORTANT if the certificate holder is an ADDITIONAL INSURED, the pokcy(ies)roust be endorsed. A statement on this certificate does not confer rights to the certificate rudder fn lieu o:such endorsement(s). If SUBROGATION IS WAWEU, 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 hoider in:reu of such endorsements) DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insufer(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 26(2401148) CERTIFlc,,-r rE OF LIABILITY f 1 Ilr SUS ANNE DATE F6/1/2011 YY) 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(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,cert orltrje an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement s. PRODUCER CONTACT Ha deh Bar�zin �t NAME: SPIE Insurance Agency, Inc. 2011 u �: IALoa. xt NE (949)582-522Cf l..FAX ,wot: (sns)5a2-asiz License Number 0719264 C-MAIL : � �Ha deh@s ib.com ADDRESS 26441 Crown Valley Parkway 200 ,r ) w 3 PRODUCER 000 1459 CUSTOMERIQK Mission Viejo CA 92 JUAN �_t ij���RAN ......._. INSURER(S)AFFORDINGCOVERAGE NAIC� ......V....._. ...._...... ._..._.._ .,.... --__ ... ........ INSURED INSURERAMt. Hawley Insurance Co TSpecial INSURER B:National„_Union Fare. Ins Co Off” P TSpecia_ -- m- I. Friess Construction Inc. INSURERc AIG/Granite State Ins Co. averick 32332 Camino Capistrano Suite 102 INsuREROQBE. Insurance Company eans Ha INSURER E ... _ . San Duan Capistrano CA 92675 INSURER F: D2 COVERAGES CERTIFICATE NUMBER:11-12 GL UMB WC PROP REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT, 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. -.ADOL Sut3R - .. Y EFF LTR TYPE OF INSURANCE y- SR WVD _ POLICY NUMBER t�MfOpIYYYY.... ..MM QDIYYYY LIMITS -._.. GENERAL LIABILITY -_ -.-- 1 EACH OCCURRENCE $ 11000,000 X !COMMERCIAL GENERAL LIABILITY gAPAAGE 70 RENTE€) - _ .PREMISE S.jEa nccurrencel $ 50,000 05/26/2011 /26/2012 A I CLAIMS-MADE X. OCCUR GLfl173425 MEp EXP(AnY one person) $^ 5,000 ._..._ _ PERSONAL&ADV SNJURY $ 1,000,000 ....... __._ GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER. � I I PRODUCTS COMP/OP AGO $ 2,000,000 X POLICY PRO-J ECT LOC $ COMBINED SI AUTOMOBILE LIABILITY SINGLE LIMIT $ i Ilia accident) !ANY AUTO E BODILY INJURY(Per person) $ _.. ALL OWNED AUTOS -- - i BODILY INJURY(Pet accident)i$ SCHEDULED AUTOS ...._..._... __w...___.. PROPERTY DAMAGE $ - HIRED AUTOS (Per accident) NON-OWNED AUTOS i $ XUMBRELLA LIAB X OCCUR _ 4,000,000 -... EACH OCCURRENCE $ 4,000,000 lrXCt"SS UAB CLAIMS-MADE I AGGREGATE $ 4,000,000 DEDUCTIBLE € $ B I X RETENTION $ 0 ED67918779 /26/2011 /26/2012 t c WORKERSCOMPENSAT$0N C0.01_90_15191 _ /1/2010 ./1/2911 � VVC STALL J- i 07H I ..—_ AND EMPLOYERS`LIABILITY X i4(?Y..UMIT�Fi ANY PROPRIETDRIPARTNERIFXE.CUTIVE i I j E L EACH"ACC#DENT $ _ 1,00.0,000 OFFICER/MEMBER EXCLUDED? � NIA -. - ........ _.. ....... ._.._.__....... (Mandatory in NH) E L.DISEASE-EA E:MPI OYE $ 1,000,000 .._.. ._ ......._ ... I yes.describe un er E L.DISEASE-POLICY LIMIT , $ 1 000 000 DESCRIPTION OF OPERATIONS beEow D �Bus.Personal Prop. ;In a,nd 1 750456 11/3/2010 1/3/2011 Lease/Burr Equipment Total $50,000 Marine;Rent/Lease Special € eplacement Cost 0,!d $500 PP Limit:$60,900 Scheduled Equip on ACV $28,381 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 107,Additional Remarks Schedule,If more space Is required) RE: BOYS AND GIRLS CLUB-'PEEN CENTER, 1 VIA POSITIVA, SAN JUAN CAPISTRANO, CA 92675. BOYS AND GIRLS CLUBS OF CAPISTRANO VALLEY AND THE CITY OF SAN JUAN CAPISTRANO ARE NAMED AS ADDITIONAL INSUREDS WITH RESPECT TO GENERAL LIABILITY AS PER COMPANY FORM CGL216 04/98 AS REQUIRED BY WRITTEN CONTRACT, CERTIFICATE FOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF SAN JUAN CAPISTRANO ACCORDANCE WITH THE POLICY PROVISIONS. 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA 92675 AUTHORIZED REPRESENTATIVE L Hines, CPCU ARM CLU ACORD 25(2009109) ©1988-2009 ACORD CORPORATION. All rights resetved. INS025(20asos) The ACORD name and logo are registered marks of ACORD LI-1, NOTICE: I. THE INSURANCE POLICY THAT YOU HAVE PURCHASED IS BEING ISSUED BY AN INSURER THAT IS NOT LICENSED BY THE STATE OF CALIFORNIA. THESE COMPANIES ARE CALLED "NONADMITTED" OR "SURPLUS LINE" INSURERS. 2. THE INSURER IS NOT SUBJECT TO THE FINANCIAL SOLVENCY REGULATION AND ENFORCEMENT THAT APPLY TO CALIFORNIA LICENSED INSURERS. 3. THE INSURER DOES NOT PARTICIPATE IN ANY OF THE INSURANCE GUARANTEE FUNDS CREATED BY CALIFORNIA LAW. "THEREFORE, THESE FUNDS WILL NEIN PAY YOUR CLAIMS OR PROTECT YOUR !ASSETS IF THE INSURER BECOMES INSOLVENT AND IS UNABLE TO MAKE PAYMENTS AS PROMISED. 4. CALIFORNIA MAIN'T'AINS A LISTOF ELIGIBLE SURPLUS LINE INSURERS APPROVED BY THE INSURANCE COMMISSIONER. ASK YOUR .AGENT OR BROKER IF THE INSURER IS ON THAT LIST, OR VIEW THAT LIST AT THE INTERNET WEB SITE OF THE CALIFORNIA DEPARTMENT OF INSURANCE: www.insurance.ca.gov. 5. FOR ADDITIONAL INFORMATION ABOUT THE INSURER YOU SHOULD ASK QUESTIONS OF YOUR INSURANCE AGENT, BROKER, OR "SURPLUS LINE" BROKER OR CONTACT THE CALIFORNIA DEPARTMENT OF INSURANCE, AT THE FOLLOW ING TOLL-FREE 'TELEPHONE NUMBER: 1.-500-927-4357. 6. IF YOU, AS THE APPLICANT, REQUIRED THAT THE INSURANCE POLICY YOU HAVE PURCHASED BE BOUND IMMEDIATELY, EITHER BECAUSE EXISTING COVERAGE WAS GOING- TO LAPSE WITHIN TWO BUSINESS DAYS OR BECAUSE YOU WERE REQUIRED TO HAVE COVERAGE WITHIN TWO BUSINESSDAYS, AND YOU DID NOT RECEIVE THIS DISCLOSURE FORM AND A REQUEST FOR YOUR. SIGNATURE UNTIL AFTER COVERAGE BECAME EFFECTIVE, YOU HAVE THE RIGHT TO CANCEL THIS POLICY WITHIN FIVE DAYS OF RECEIVING THIS DISCLOSURE. IF YOU CANCEL COVERAGE, THE PREMit.)M WII,I, BE PRORATED AND ANY BROKER'S FEF. CHARGED FOR THIS INSURANCE WILL HE RETURNED TO YOU. SF 199222.2 73670 00741 D-2 (.Effective January 1, 2009) Policy Number: MGLO173425 Mt, Hawley Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURE® - OWNERS, LESSEES OR CONTRACTORS (FORM C) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART (if no entry appears below, information required to complete this endorsement will be shown in the Declarations as appli- cable to this endorsement.) WHO IS AN INSURED (Section li) is amended to include as an insured the person or organization shown in the Sched- ule, but only with respect to liability arising out of"your work"for that insured by or for you. To the extent required under contract, this policy will apply as primary Insurance to additional insureds scheduled below and other insurance which may be available to such additional insureds will be non-contributory. Section Iii., Condition 4.,of this policy is amended accordingly. SCHEDULE Name of Person or Organization: All persons or organizations where required by written contract. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. CGL 216(04198) Page 1 of 1 Insured DATE(MMIDDr YYY)CRTIFIC ,-%TE OF LIABILITY INSUK NCE 7/1/2011 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 Eqg C &2=1 TE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AlD THE C IMPORTANT: If the Certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain olicies may reqa en Qrsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement( up I PRODUCER CONTACT Haydeh Barzin __ SPIB Insurance Agency, Inc. _ ,I T E PHONE .ExzL (949)582-5220 (.arc,Npy(949)5152-ssz2 License Number 0719264 ` '' SAN J N, .J r. :7 . z ri ss.Haydeh@spib.com PRonuc r=R 26441 Crown Valley Parkway#200 PRODUCER ID#00011459 .. .................. . Mission Viejo CA 92691 INSURER(S)AFFORDINGCOVERAGE "IC - --- - -_ INSURED INSURER-A.Mt. . Hawley Insurance Co. TSpeci.al .... _,, INSURER B National Union Fare Ins Co o£ -TSpecial _.. _ ..._ Friess Construction Inc. INSURERCState Camp Insurance Fund, 32332 Camino Capistrano Suite 102 INsuRERD:QBE Insurance Co. eans&Ho INSURER E: San Juan Capistrano CA 92675 1NSURERF 2 COVERAGES CERTIFICATE NUMBER:11-12WC/G1,/M48/PROP REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE !NSURED NAMED A30`JE 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, EXCWSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, Ih15R TYPE OF INSURANCE - .--..-LADBL SUER ... POLICY EFF [ POLIGY EXP _-._. LIMITS- ___-. T LTR INSR WVD POLICY NUMBER MMIDDIYYYY E MMIDDNYYY - GENERAL LIABILITY ' EACH OCCURRENCE $ 1,000,000 .-IJAMAGETO RENTELS _.._ .__ .... X COMMERCIAL GENERAL LIABSLITY _PREMISES EEa occurrence) 50,000 000 ��� 5/26/2011 /26/2012 ` A CLAIMS-MADE y�OCCUR GLp173425 MED EXP(Any one person) $ 5,000 I I PERSONAL&ADV INJURY E $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 .. GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS COMPIOP AGG $ 2,000,000 X POLICY I G LOGI _ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ � (Ea accident) ANY AUTO 3 BODILY INJURY(Per person) $ ALL OWNED AUTOS i BODILY INJURY(Per accEdent)I $ SCHEDULED AUTOS ..__ ....... -- PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ f ............... X UMBRELLA I.IAB OCCUR E I EACH OCCURRENCE _ $ 4,000,000 EXCESSLrAB CLAIMS-MAOI AGGREGATE $ 4,000,000 DEDUCTIBLE $ B x RETENTION $ 0 E067918775 5/26/2011 /26/2012 $ C WORKERS COMPENSATION 96531,2-2011 7/1/2011 /1/2012 INCSTATU 10TH- AND EMPLOYERS`LIAF3ILITY Y!N 3 -x TQRY.QMJS t ._._ J=R.._ _... .,,,. ANY PROPRIETORIPARTNERIEXCCUTIVE I EL EACH ACCIDENT $ j,,1QOQ1..QQO OFFICERIMEMBER EXCLUDED? N 1 A —_ -.-. (Mandatory in NH) E L DISEASE EAMP ELOYE $ 1'0_00'.000 If yes,describe and - -- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMff 1$ 1 1 00 0 0_000 D �Bus.Pers.Prop.Inland]Aarin 750456 1/3/2010 .1/3/2011 Leased/Borrow Equip$50,000 BPP$60,000 Ret/Lease;Spec/RC $50ODed �_ € SchEq€lip$28,381 ACV Iled.$x300 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: SERRA VISTA OFFICE BUILDING, CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY AS PER COMPANY FORM CGL216 0498 AS REQUIRED BY WRITTEN CONTRACT, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF SAN JUAN CAPI STRANO ACCORDANCE WITH THE POLICY PROVISIONS. ATTN: CITY CLERK'S OFFICE 32400 PASEO ADELANTO AUTHORIZED REPRESENTATIVE SAN JUAN CAPISTRANO, CA 92675 L Hines, CPCU ARM CLU ��� ACORD 25(2009109) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(nowg) The ACORD name and logo are registered marks of ACORD L,,,m 1` A CERTIFIGA E OF LIABILITY INSUKP NCE DATA{�rtn�rDt2� 7/1/207.11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO FLIGHTS 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 DOE F)I t f 1 CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIF R IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain poli c�.' !!m equ' a ndfrs ent. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsers t(s). Ltll l t' PRODUCER CONTACTONHaydeh Barzin y _ ....... PHONE (949)562-5220SPIE Insurance Agency, Inc. (949)592-_3 512 License Number 0719264 SAN Jur-13H CA�"is r�tHydeh@sgib.com ... - - - _- ..... .._......... PRODUCER 26441 Crown Valley Parkway#200 cusTS I9:9IDg0001145.. ........ -_ Mission Viejo CA 92691 INSURER{S)AFFORDINGCOVERAGE NAIL# _... ......... ......... — ._ .._ _ _ INSURED INSURER A-Mt Hawley Insurance Co. TSpecia_ INSURER B NationalUnion Fire Ins Co of TSpecial Friess Construction Inc. INSURERC:State Comp, Insurance Fund 32332 Camino Capistrano Suite 102 INSURERD:QBE Insurance Co eans&Ho INSURER E: San Juan Capistrano CA 92675 INSURER F Q2 COVERAGES CERTIFICATE NUMBER:11-12WC/GL/UMB/PROP REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE .NSURED NAMED A13OVE FOR THE POLICY PFRion 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 CONDITI. _._.._ -_ ..... _.... INSR -..AODL SUB- - -......—.. ......... ... POLICY EFF.... ..POLICY EXP LTR _ -TYPE OF INSURANCE -IINSR,WVD POLICY NUMBER _(MMIDDfYYYY1 IMME1= LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 OAMAE TO RENTEp x COMFlIERCIAL GENERAL LSAHILITYPREMISES.(Ea occurrence 50,000 A CLAIMS-MADE 26 OCCUR / /2011 5/26/2012 MED EXP(A y one pe son) $ 5,000 PI=RSONAt_&ADV INJURY $ 1,000,000 IGENERAI_AGGRFGATE _ $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMPIOP AGG $ 2 C II x000,000 PRO- �._.__. ------ j X POI ICY PR.0 i LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT�� $ - _...i (Ea accident) ANY AUTO -... BODILY INJURY{Per person) $ ALL OWNED AUTOS 1 BODILY INJURY(Per acadent) $ SCHEDULED AUTOS PROPERTY DAMAGE $ e HIRED AUTOS (Per accident) NON-OWNED AUTOS $ X UMBRELLA LIAB _...__� _ OCCUR EACH OCCURRENCE $ 4,000,000 ..................... ......... - .... _.. EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000 01-DUCTIRI.F E X RETENTION $ 0 I E067915775 /25/2011 ' /26/2012 $ _ c WORKERS COMPENSATION 955312-2011 /1/2011 /1/2012 I x WCSTATU OTH- AND EMPLOYERS'LIABILITY Y 1 N __ 1..T.O_RX-LHM11$ ,,_....._ ANY PROPRIETORIPARTNERIE:XECUTIVE OFFICERIMEMBER EXCLUDED? � NIA E L EACH ACCIDENT _ $ ,,0001000 (Mandatory in NH) E L DISEASE EA EMPLOYE $ 1 000 000 If(es,describe under _. ..._...... _...�. 1......._..._. DESCRIPTION OF OPERATIONS below — i E.L.DISEASE-POLICY LIMIT $ 1,000,0000 D Bus.Pers.Prop.InlandMarin 2750456312010 1/3/2011 LeasedlBorrow Equip$50,000 BPP$60,000 �.____L�`�.t/Lease;Spec/RC $50RDed 7SchEquip$28,3R1 ACV Ded.$500 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) RE: HOYS AND GIRLS CLUB-TEEN CENTER, 1 VIA POSITIVA, SAN JUAN CAPISTRANO, CA 92675. BOYS AND GIRLS CLUBS OF CAPISTRANO VALLEY AND THE CITY OF SAN JUAN CAPISTRANO ARE NAMED AS ADDITIONAL INSUREDS WITH RESPECT TO GENERAL LIABILITY AS PER COMPANY FORM CGL216 04/98 AS REQUIRED BY WRITTEN CONTRACT, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF SAN JUAN CAPISTRANO ACCORDANCE WITH THE POLICY PROVISIONS. 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA 92675 AUTHORIZED REPRESENTATIVE L Hines, CPCU ARM CLU �� lent ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(2ooso9) The ACORD name and logo are registered marks of ACORN Ac" CERTIFIG,► TE OF LIABILITY 1 Ili SUKANCE DATE(MMn)DNYYY) .-� 7/1/2011 THIS CERTIFICATE 1S 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(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFI T IMPORTANT: If the certificate holder is an ADDITION I ,t (les)must be endorsed. 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). pnt PRODUCER N Elbjia.ydeh Barzin __.. . .... .. _ _ ONE SPIB Insurance Agency, Inc. RA1 oEx� (949)582--5220 _ I.I_AX (9491582-3512 License Number 0719264 ' MAIL Ha deh@s ib. — _ ..... 26441 Crown Valley Parkway#200 SAS JUAN CAPISIM , 4?�RI0MPO000$1f} Mission V].ej_0 CA 92691 INSURER(5}AFE91RDINGCOVERAGE NAIC9 _. .. ..— _ _ _......... INSURED INSURER A Navigators Insurance Co W.BROWN Friess Company Builders Inc. , INSURER B;State Comp Insurance Fund DBA: Friess Electric INSURERC:QBE Insurance Co. EANS&HO 32332 Camino Capistrano, Suite 102 INSURER D. - l INSURER E San Juan Capistrano CA 92675 INSURER F2 COVERAGES CERTIFICATE NU MBERNASTERII-12WC/GL/UMB/PROP REVISION NUMBER: THIS IS TO CERTIFY THAT 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,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ]A�DDL UBR — P0UJCY EFF ...�' POLICY EXP LTR TYPE OF INSURANCE^ SR WVD POLICY NUMBER MMIDWYYYY MMA)DIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE € � ©AMAGE TU RENTkI� $ 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES (Ea occu encu $ 50 000 A -^ CLAIMS-MADE FXI OCCUR CIOCGLO1648500 /27/2010 7/27/2011 MED EXP(Any one person) $ 5,000 X PERSONAL.&ADV INJURY $ 1,000,000 ..._..... .PRO- _ GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER 3 PRODUCTS COMPIOP ACG $ _ 2,000,000 X 1 POLICY i ,FC El LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ - (Ea accident) ANY AUTO _...- ------ BODILY INJURY(Per person) $ ALL OWNED AUTOS _._ ._ __.__..._._ .._....... ._., BODILY INJURY(Per acadent) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per acddwt) €$ NON-OWNED AUTOS $ $ X UMBRELLA LIAR _ OCCUR I EACH OCCURRENCE $ 1,000,000 EXCESS.LIAB.. CLAIMS-MADE AGGREGATE $ 1,000,000 ......... .. .....W...-___.. DEDJCTiB(E $ A I X RETENTION $ 10,000 ClIUMB017151—___J/10/203.1 /27/2011 $ B WORKERS COMPE=NSATIONi WC STAT"U-�II IIU)H- AND EMPLOYERS'LIABILITY Y/N )-X LTORY-.LIMLTS..1..._ 1 ER__ ANY PROPRIE.TORIPARTNERIEXECUTNE E L EACH ACCIDENT $ _1,000,000 OFFICERIMEMBER EXCLUDER? N f A - - . ... (Mandatory in NH) 1965312-2011 /1/2011 /1/2012 E L DISEASE EA EMPLOYE $ 1.,000 000 _ _c - Ifyes,describe under __ .... DESCRIPTION OF OPERATIONS below __ E.L-DISEASE-POLICY LIMIT $ 1 000_,_000 C �Bus.Rer.PropinlandMarine 2750456 3./3/2010 .1/3/2011 LeasedlBorrow.Equip$50,000 BPP $60,000 Rent/Lease;Spec/RC$50ODed I LS Equip$28.389 m ACV Ded.$500 DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES (Attach ACORD 901,Additional Remarks Schedule,If more space is required) PROOF OF INSURANCE ONLY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF SAN JUAN CAPISTRANO ACCORDANCE WITH THE POLICY PROVISIONS. ENGINEERING DEPT 32400 PASEO ADELANTO AUTHORIZED REPRESENTATIVE SAN JUAN CAPISTRANO, CA 92675 L Hines, CPCU ARM CLU ACORD 25(2009/09) ©'19$5-2009 ACORD CORPORATION. All rights reserved. INS025(2D09t39) The ACORD name and logo are registered marks of ACORD u 201 4: 34F� F r I e 5 C'151ruo io C.roup Nc- 9923 P. I ��Q® \� �I�� r LATE(MMM0teYYY) E LIABILITY TY INSURAI CE 7/1/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT'S 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(S). AUTHORIZED `EPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLM .PORTANT' ff the certlticata holder Is an ADDITIONAL. INSUR i ) 9 be endorsed. It SUBROGATION IS WAIVED, subject to the forms and conditions of the policy,certain pollctes may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Ileu of such andorearrienl s. PRODUCER LUI I JU -5 QN�,I y lezin 9PIB Insurance Agency, Inc, aHO (949)582-5220 FAX (paassa� dsT2 License Number 0719264 E I doh@ap�b.cam 2641 Grown Valley Parkway#200 N JL I ot, ` , 59 mission vi e o CA 92691 INauRERS ArcORDINCCOVERAGE NAICp IN9uftEO INGURER A Mt. Hawlay Insurance Co. RTSpecial mayRfRa.National Union Fire Trio Co o£ & eaiat E"rx®es Construction Inc, IN9uriERC State Cam Insurance Fuad ?2332 Camino Capistrano Suite 102 INuaeaD; 8E 1rta rance Co, eans&Ho INSURER E; San Juan Capistrano CA92675 INSUMRF 2 COVERAGES CERTIFICATE NUMBER,11.-12WC/GL/u'M!3/PRO P REVISION NUMBER- THIS IS TO CERTFFY THAT 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 ISSUE=D OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIE9.L[MITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR V i1 POLICY EFF POLI YN LTR YYPE OF INSURANCE ANCE POLICY NUMBER MMIDD W MMUB IY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X CUMIAERCIAL GENERAL LIABILITY PREA4F3E5 RE Cg g 50,000 A CLA1hISMAO) lil OCCUR CdLfl173825 /25/2011 /26/ 012 MEDE)lf' An ono green g 5,000 PERSONAL d ACV INJURY S 1,000,000 GENERAL AGOREGATE E 2,000,000 qGENT AGGREGATE LIMIT APPLIES PER, PRODUCTS-COMPIOP AGG $ 2 000,000 POLICY PL 0- LUG 5 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUJT{1 (Ea at7T.lflaffi) -•—••---- BOOILY I1,3URY(Pcr personl 5 ALL OWNED AUTOS BODILY INJURY(PerscadeM) I SCr�EDULEQ AUTOS PROPERTY DAMAGE HIRED AUTOS (Per occident) g NON-OWNED At/TOS g S 7C UMBReLLA LIAR OCCuR EACI{OCCURRENCE S 4,000,000 EXCESS LIAR CIAiMSMAOE AGGREGATE.�W — 5 �8MM•OOO1000 DEDUCTIBLE 3 $ X RETENTION S p BE061910775 /26/201! /16/2032 $ JANDNERSCOMPENSATION 965312-2011 13/2011 /1/zOx2 wCsrArel- pTy. MPLOYERS'L.IABILITY YIN ROPRIETORIPARYr4ERIEXECUTrVE EAlA[Eltat»R ExCiUOEn3 NIAatory In NH)aeatnne� derRtPriONOFOPE----. b.'- D Bue.Pers.Prop.InlandMarin 730856 3/3/2010 1/3/2011 Lameare7rovEgwp$W.000 BIPP660,000 Dart/Leaee,Spec/RC $6000ed achEaolp428.391 ACV 0641 6500 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(AINICh ACORD 101,Additional Remir"&ohednie,If mora apace to raq.rlrsd) RE: SERRA VISTA =FICE BUILDING. CERTIIFICATE HOLDER 18 NA1d>ED AS AN ADDITIONAL xNSURED WITH RESPZCT TO GENEWLL LIABILTPY AS PER COHPAZrY 61ORm cr1L216 04ge A9 Axgurpi:tD BY WRITTEN CONTRACT. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF SAN JUAN CAPI STRANO ACCOROANCIE WITH THE POLICY PROVISIONS A'TTN: CITY CLERK'S O� ICE 32400 PASEO ADELANTO AUTH OR1240 REPRESPNTATIVE SAN JUAN CAPISTRANO, CA 92675 L Hina9, C?CU ARM CLU ACORD 25(2009109) 0 1980-2009 ACORD CORPORATION. All rights reserved. INS025(moaos) The ACORD name and logo are registered marks of ACORn • ' LIABILITY DAI ,IIIM- CERTIFICATE ®F IN������� 7/28/2010 PRODUCER (949)582-5220 FAX: (949)582-3512 THIS CERTIFICATE IS ISSUED A5 A MATTER OF INFORMATION SPIN Insurance Agency, Inc. � `, ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE a� HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR License Number 07 9264 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 26441 Crown Valley Parkway#2013 Mission Viejn CA 92699 y -� k �,N�. ERS AFFORDING COVERAGE . .. _ M. AIC# INSUREDNSURERANaVi�a✓O_r.8_ 7n$Lr�_n_d3_ Co.-Cd ..R Brown 6 As.s..oc Erssss Company Builders Inc. ,D3A:F1E9ectra , �lnvorick znNAIG/Granite State Ins Go. Friess Electric E`' INSURRC_QBE Insurance Co [Deana s Horner 32332 Camino Capistrano, Suite 112 !€ [INWRER 0 [ Sari warp Capistrano CA 92675 INSURER E ._ _ COVERAGES THE POLICIES OF INSURANCE LISTER BELOW HAVE SEEN ISSUED TO THE WSURED 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. INBR D _---- OF INSURANCE POLICY NUMBER POUCYMFF£CTIVE POLICY£nPIRATION UMiTS _GENERAL LIABILITY EACH OCCURRENCES 1,000DAMAGE TO RR4TED 000 X CAMiAEF2CIALGENERAL LIA&LI7Y PRFISES_ — rr2ne8 S 50,000 A CLAIMS MADE ®OCCUR 10CGL01648500 7/27/2010 7/27/2011 MEDExP.(rrmepersonJ $ 5000 X Deductible $2,500 P ._PERSONAL —S It0001000 X Per Occurrence GENERAL AGGREGATE $ _ ...2.,000,.000 GEMLAGGREGATE LIMIT APPUESPER: PRODUCTS-COMP/OP AGG $ 2 000,000 X POLICY 0 PRO- LOC IF AUTOMOOILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea ac4denl) ALL OWNED AUTOS BODILY INJURY SCHEnt"OAUTOS (Perperson) $ "RED AUTOS BODILY INJURY $ NON-OWNEO AUTOS (Per arced") PROPERTY DAMAGE $ (Par acla4a+M) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS i UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ _ _S DEDUCTIBLEF1 5 ReErENTION WORKERS COMPENSATI NINC 11A1 AND EMPLOVERS'L IARJUTY YIN — .TARY..LIA�IS _._..ER_ANY PROPRIETORIPARTNEME7(ECUTIVE❑ E.L.EACH ACCIDENT _$___1 000 f D 0 0 OFFICER)MEMBER EXCLUDED? (MandatmInNH) COOL-90-6791 7/1/2010 7/1/2011 E.LDISEASE-EAEMPL $ 1 000,000 If yes.describe under - SPECIAL PROVISIONS baav_. E.E.DISEASE-POLICY UMR S 1,000,000 C OTNeRBusiness Personal 736441 11/3/2009 11/3/2010 i sPP:560,000/special RC/Ded.$500 Property:Ynla:nd leased Borrowed Eq $50,000 t,4arine-Rented/Leased IA28,381 DESCRIPTION OF OPERATIONS I LOCATIONS)VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT ISPECLAL PROVISIONS PROOF OF INSURANCE ONLY *CANCELLATICN CLAUSE AKWDETi TO INCLUDE: 10 BAYS NOTICE OF CANCELLATION MR NON PAYMENT OF PREMIUM. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITY OF SAN JUAN CAPI ST1ZANO DATE THEREOP.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN ENGINEERING DEPT NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO SO SHALL 32400 PASEO ADELANTO SAN JUAN CAPI STRANO, CA 92 675 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,TTS AGENTS 09 REPRESENTATIVES. AUTHORIZED REPAMNTATIVE L Hines, CPCU ARM CLU •�� ACORD 25(2009101) ®1988-2009 ACORD CORPORATION. All rights reserved. INS025(awi) The ACORD rums and logo are registered marks of ACORD 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 This Certificate of Insurance 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(2008101) INS025 pDo9oi� NOTICE: L THE INSURANCE POLICY THAT YOU HAVE PURCHASED IS BEING ISSUED BY AN INSURER THAT IS NOT LICENSED BY THE STATE OF CALIFORNIA. THESE COMPANIES ARE CALLED "NONADMITTED" OR "SURPLUS LINE" INSURERS. 2. THE INSURER IS NOT SUBJECT TO THE .FINANCIAL SOLVENCY REGULATION AND ENFORCEMENT THAT APPLY TO CALIFORNIA LICENSED INSURERS. 3. THE INSURER DOES NOT PARTICIPATE .IN ANY OF THE INSURANCE GUARANTEE FUNDS CREATED BY CALIFORNIA LAW. THEREFORE, THESE FUNDS WILL NOT PAY YOUR CLAIMS OR PROTECT YOUR ASSETS IF THE INSURER BECOMES INSOLVENT AND IS UNABLE TO MAKE PAYMENTS AS PROMISED. 4. CALIFORNIA MAINTAINS A LIST OF ELIGIBLE SURPLUS LINE INSURERS APPROVED BY THE INSURANCE COMMISSIONER. ASK YOUR AGENT OR BROKER IF THE INSURER IS ON THAT LIST, OR VIEW THAT LIST AT THE INTERNET WEB SITE OF THE CALIFORNIA DEPARTMENT OF INSURANCE: www.insurance.ca.gov. 5. FOR ADDITIONAL, INFORMATION .ABOUT THE INSURER YOU SHOULD ASK. QUESTIONS �7OF YOUR INSURANCE AGENT, BROKER, OR "SURPLUS S LIl,I E" BROKERS (�yOR CONTACT THE CALIFORNIA DEPARTMENT OF INSURANCE, AT THE FOLLOWING TOLL-FREE TELEPHONE NUMBER: 1-800-927®4357. 6. IF YOU, AS THE APPLICANT, REQUIRED THAT THE INSURANCE POLICY YOU HAVE PURCHASED BE BOUND IMMEDIATELY, EITHER. BECAUSE EXISTING COVERAGE WAS GOING TO LAPSE WITHIN TWO BUSINESS DAY'S OR BECAUSE YOU WERE REQUIRED TO HAVE ('OVERAGE WITHIN TWO BUSINESS DAYS, AND YOU DID NOT RECEIVE THIS DISCLOSURE FORM AND A REQUEST FOR YOUR SIGNATURE UNTIL AFTER COVERAGE BECAME EFFECTIVE, Y'OU HAVE THE RIGHT TO CANCEL THIS POLICY WITHIN FIVE DAYS OF RECEIVING THIS DISCLOSURE. :IF YOU CANCEL COVERAGE, THE PREMII;M 'VVII,I. BE PRORATED AND ANY BROKER'S FEE CHARGED FOR THIS :INSURANCE WILL BE RETURNED TO YOU. SF 199222.2 73670 00741 D-2 (Effective January 1, 2009) Kristen Lewis From: Kristen Lewis Sent: Wednesday, August 18, 2010 3:56 PM To: David Contreras Cc: Christy Jakl; Ayako Rauterkus Subject: Friess Company Builders Insurance Attachments: Scan 100818154915.pdf Hello, Friess Company Builders recently sent in a new insurance certificate from a new insurance company. We have the General Liability and Workers Comp, but we are missing the endorsement forms for General Liability and possibly Umbrella Liability (there is mention of this in the agreement) and Automobile Liability. I have attached the pages that give the requirements for insurance. Thank you! Kristen Lewis Administrative Specialist City Clerk's Office/City Manager's Office City of San Juan Capistrano 32400 Paseo Adelanto San Juan Capistrano, CA 92675 (949) 443-6308 (949) 493-1053 fax 1 Acs CERTIFICATE CSF LIABI I INSURAN E �A D�YYYY, �� 7j/1/2l/2 010 PRODUCER (949)582-,9220 FAX: (949)582-353.2 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION SPIB Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE License Number 0719264 HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 26441 Crown Valley Parkway#200 Mission Viejo CA 92691 INSURERS AFFORDING COVERAGE MAIC# ........ ........ INSURED _ ..... __ _. . w.8rccarm 6 INsuRE�xA.I�1berty Surplus Ins CorpCoz- Assoc Prises Company Builders Inc. , bBA. FTM Electric INSURERBAIG/Granite State Ins Ca Dfaveri.ck Ins S. _._._. 31658 Rancho Viejo Ptd Ste F3 I INSURERC QBE Insurance Co. Deans & Homer ...... ___. -''____ _ .._.......... 1 ................. San Jua Capistrano CA 92675 f INSURER E: R2 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. Type LTR OF I POLICY NUMBER DA LICY EFSEC7NE DATE Y EXPIRATIOBd ._... ...................—LlY{75 GFNFAAI.UAFULITY EACH OCCURRENCE S 1 000 000 X COMMERCIAL GENERAL LUABILTTY A RE ___ - _ P 65E5[�aorcu+sancaL, 5 50,000 1k _ CLAIMS MADE lid OCCUR OLLA20�209037 7/2'7/2009 7/27/2010 MED EXP lwrgo�ep3lsr�nl $ -0- _ m — X PERSONAL&ADV INJURY $ 1 000,000 GENERAL AGGREGATE S 2 000 000 GEN'L AGGRO-GATE LIMIT APPLIES PER- PRODUCTS•COMPVCP AGG S 2,000,000 JECT X POLICY P"'), LOC AUTOMOOMI LIABILITY COMBINED SINGLE LMT ANY AUTO COMBINED acdden4 ALL OWNED AUTOS BODILY IN,fURY S SCHEDULED AUTOS (Pa•oerson) HIRED AUTOS ._._. BODLYIWURY S NON•OWNED AUTOS {Pet acdtlarN} - _- _m---------. PROPERTY DA1.sAGE 5 (Per acdder* GARAGE UAaIUTY AUTD ONLY•EA ACCIDENT S ANY AUTO ACC_ S - OTHERTHAN AUTO ONLY: AGG $ EXCl-SSIUMBRELLA LIAB3ILITY EACH OCCURRENCE 5 OCCUR CLAIMS MADE AGGREGATE $ 5 OEDUCTISL E S I3E7Flr1"fON 5 Yrt RKIERS C£34aPE9dSATsf^At WC STATU- ! DTH- ��,-..,.... AND EMPLOYERS' BI LIALITY YIN S...�_...ANY PROPMETOrRIPARTNEFZVEXECUTIVEE.L.EACH ACCIDENT' S 000 0QO OFFICER(MEMBER EXCLUDED? ❑ - ---r----.-.--T----- (Mandatory In NH) COOI-90-6791 7/112010 7/1/2011 E.L OISEASE-EA EMPLOYEE S.._.__ 1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L DISEASE•POLICY 1UMfT i s 1,000,000 C OTRER>3usiness Personal 11/3/2009 LI/3/2010 aPF:S6o,000/special RC/Ded.$500 property;InlanC1 Leased Borrowed Eq $50,000 Marine-Rented/Leased ACV nadAsn(I $28,381 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL ANOVI61ONS PROOF Or INSURANCE ONLY *CANCEI.Y ATION CLNUSE AMENDED TO INCLUDP— 10 DAYS NOTICE OF CANCELLATION FOR NON PAYMENT OF PREMIUM. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITY OF SAN JUAN CAPI STRANO DATE THEREOF.THE MSUING INSURER WILL ENDEAVOR TO MAIL. 30 RAYS WRITTEN ENGINEERING DEPT NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,Bur FAILURE TO 00 SO SHALL 32400 PASEO ADELANTO SAN JUAN CAPI STRANO, CA 92 675 IMPOSE NO OBLIGATION OR UABIUTY OF ANY KIND UPON THE INSURER.rM AGENTS OR REPRESENTATIVES. AMORIZED REPRESENTATIVE i. Hines, CPCU ARM CLU ACORD 25(2009101) ®'1985-2009 AC ORD CORPORATION. All rights reserved. INS025(xoosw) The ACORD name and logo are registered marks Of ACORD ACC)RV® DATE(MMDDIYYYY) �,,,...- CERTIFICATE F LIABILITY INSURANCE 7,1/2010 PRODUCER (949)582-5220 FAX: (949)582--3512 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION SPIE Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR License Numkaar 0719264 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW- 26441. Crown Valley Parkway##200 - — Mission Viejo CA 92691 E INSURERS AFFORDING COVERAGE NAIL# .. _. _ . .... INSURED INSURERA.Liberty Surplus Ins Corp w crown s Assoc ... Friess Company Builders Inc. , DBA: FM Electric INSURERS ATG/Granite State Ins. Co. Have... k Ing S. 31658 Rancho 'Viejo Rd Ste 18INSURERC QBE insurance Co. i Deans L air INSURER O San Juan Capistrano CA 92675 INSURERS D2 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED}OR MAY nRTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEDHEREIN[S SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONOCTIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY NUMBER POLICYEFFECTIVE POLICY EXPIRATION drabs GENERAL LIABILITY __ �......�. EACH OCCURRENCE S 0 000 DAMAGE TU RENrF15 X COMMERCIAL GENERAL LIABILITY Pf1EMISES Ea ocwrrenoe�--_ a.�..._ 5 0 000 A 71 CLAIMS MADE FXIOCCUR DGLLA207209037 7/27/2009 7/27/2010 MED EXP(Any cneperson} $ -0- x PERSONU A ADV INJURY $ 7, 9-00-1100-0, GENERAL AGGREGATE _ S 2r 000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PROoMts-COMP1pP AGG S 21000,000 X POLICY PRow LAC AUTOMOBILE LIABILITY COMBINED SINGLE WMT $ ANY AUTO (Ea aeddent) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Pe<a�cidenE¢ S -.._.._.-_.......,....._.._. PROPERTY DAMAGE S (Per aMdWr GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO m^EA ACC_ $ OTHEit THAN - AUTO ONLY: AC4, 5 EXCESS I UMBRELLA LIABILITY £PCH OCCURRENCE $ OCCUR FICLAIMS MADE AGGREGATE S DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION � WCSTATU- pp OTFI- ANDEMPLOYERS'I.IABfLITY YIN 1..�__. ..__ ..—.... ANY PROMIETOWPARTNER(EXECUTtVE❑ E.L.EACH ACCIDENT $ 1. 000 000 OFFICERIM8MA EXCLUDED? —....... .._ ._ _. (Mandelory In NH) CD01-90-6791 7/1/2010 7/1/2011 E.LDISEASE-EAEMPLOYE $ 1 OOO 00 I If yes,describe under SPECIAL PROVISIONS below E-L.DISEASE-POLICY LIMIT I s IL,00(),000 D OTHERBusinegg personal 2736441 11/3/2009 11/3/2010 BpP.s60,000/special RC/Ded.$500 Property;Ireland Leased Borrowed Eq $50,000 Marine-Rented/Leased hcu 28 3B1 DESCRIPTION Of OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE: ROBINSON RESIDENCE, 27292 VIEWPOINT CIRCLE, SRN JUAN CRpISTRRNO, CR 92675. CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED WITS RESPECT TO GENERAL LIABILITY AS PER COMPANY FORM CGL1338 0108. *CANCELLATION CLAUSE AMENDED TO INCLUDE: EXCEPT 10 DAYS NOTICE OF CANCELLATICN FOR NON PAYMENT OF PRM4rU'I. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBE.[POLICIES BE CANCELLED BEFORE THE EXPIRATION CITY OF SAN JUAN CAPISTRANO DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 32 400 PASEO ADELANTO NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,OUT FAILURE TO DO SO SHALL SAN JUAN CAPISTRANO, CA 92675 IMPOSE k0 OBLIGATION OR LIABILrTY Of ANY KIND UPON THE INSURER,ITS AGENTS OR REPT ESENTATIVES. AUTHORIZED REPRESENTATIVE IL Hines, CFCU ARM CLU ACORD 25(2009101) ®1988-2009 ACORD CORPORATION. All rights reserved. INS025(moeai) The ACORD name and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(les) 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 This Certificate of Insurance 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. ACOR❑25(2009101) INS025 pzoosoi f fay CERTIFICATE OF LIABILITY IN U AIVCE OA/1/2DDIYYYY) 010 PRODUCER (949)582-S220 FAX: (949)582-3512 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION SPIB Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR License Number 0719264 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 26441 Crown Valley Parkway#200 Mission Viejo CA 92691 INSURERS AFFORDING COVERAGE MAIC # INSURED._. . -__. __. .. .................... _ 1µSURERA,Mt. -Hawley Insurance Co. /Rr Specialty Friess Construction Inc. Scottsdale — INLSLIRER B. .. - aRr sgocsatty 31658 Rancho Viejo Rd. Suite B lINSURERCAIG/Granite State Ins.Co. i/Nsa�a3xcic I-nssV .... INSURER 0 San Juan Capistrano CA 92675 INSURER I- D2 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 HEREEN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE 1_IMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POUCYEFFECTIVE POUCYE�IUNITSXPMRAfi6 Lra IN= TYPE OF INSIM MCE POLICY NUMBER AM-MIMMMI DAM GENERALUA31LITY EACH OCCURRENCE S x ()00 O00 X COMMERCIAL GENERAL UABLUTY PR ASISES{hoc ice 5 5Q,fl00 tBi CLAMS MADE nOCCUR KGLO170304 5/25/2010 5/25/2011 MEDEXP(Ary one Parson) 5 5 000 PERSONAL& %D NJ�RY S 1s_900L000 GENE ATE S 2000,000 GENLAGGREGATE LIMIT APPLIESPER PRODUCTS-COMPIOPAGG 5 2„x,000,000 XPOLICY F PRo- LOC AUTOMOBILE LIABILITY - COMBINED&NGLE LIMIT 5 ANY AUTO (Ea acaden!) ALL OWNED AUTOS #DOILY INJURY 5 SCHEDULED AUTOS (Perpewn) HIRED AUTOS BODILY INJURY S NDN-OWNED AUTOS (Per acodeat) --- PROPERTY DAMAGE $ (Per acddam) GARAGE UARILITY' 'AUTO ONLY-EA ACCIDENT 5 ANY AUTO EA ACC S OTHER THAN AUTO ONLY: AGG 5 EXCESS)U5aeRELLA LIAIRLITY EACH OCCURRENCE $ 00,000 OCCUR EICLAIMS MADE AGGREGATE S 4,000,000, _ S B DEDUCTIBLE KLS0067277 5/25/2010 5/26/2011 s X RETENTION S 5 C WORKERS COUPFNSATTONx NIC STATU- QTFW AMC EMPLOYERS'U kA1LITW Y I NF umiTs ANY PROPRIE70"ARTNEWEXECUTIVEF-1 WC001-90-6791 7/1/2010 7/1/2011 E.L.EACH ACCIDENT S 1000,000 OFFICEWMEMBER EXCLUDEI37 (MandJd(Wy In NNE) —E It ye�s,descabecndar E.E DISEASE•EAEMPLOYEE 5 11000,000 SPECFAL PROVISIONS below E.L_DISEASE-POLICY LIMIT S 11,000'..000 OTHER DESCRIPTION Of OPERATIONS I LOCATIONS/VEHICLES(EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE. SERRA VISTA OFFICE BUILDING, CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY AS PER COpHBAATY FORM CCL216 04 98 AS REQUIRED BY WRITTEN CONTRACT. *CANCELLATION CLAUSE ANPMED TO INCLUAE: EXCEPT 10 DAYS NOTICE OF CANCELLATION FOR NON PAYMWT OF PRETffUM. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIHEO POUCIES BE CANCELLED BEFORE THE EXPIRATION CITY OF SAN JUAN CAPI STRANO DATE THEREOF.THE ISSUING INSURER WELL ENDEAVOR TO MAIL. 313 DAYS WRITTEN ATTN: CITY CLERK'S OFFICE NOTICE TO THE CERTIFICATE HOLDER NAMPO TO THE LEFT.BUT FAILURE TO DO 30 SHALL 32400 PASEQ ADELANTO SAN JUAN CAFI STRF,NO, CA 92 675 IMPOSE NO OBLIGATION OR UABILMTY Of ANY KIND UPON THE INSURER.ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE L Hines, CPCU ARM CLU ACORD 25(2009/01) <D9988-2009 ACORD CORPORATION. All rights reserved. INS025(2X19DI) The ACORD name and logo ars registered marks of ACORD ACC>RGO CERTIFICATE OF LIABILITY INSURANCE 7/172010 PRODUCER (949)582-5220 F`AX: (949)582-3512 THIS CERTIFICATE IS ISSUED AS A SMATTER OF INFORMATION SPIE Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR License Number 0719264 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 26441 Crown Valley Parkway#200 Mission Viejo CA 92691 INSURERS AFFORDING COVERAGE NAIC# INSURED _._.�:NsuREkA.Mt Hawley Insurance Co. _. /RT Spaca,alty F'rioss Construction Inc. INSURERS Scottsdale ?RT Spociaity 31658 Rancho Viejo Rd. Suite B [INWRERC.AIG/Granite State Ins.Co. /mavo itk InsSV _ ..... INSURER a _ . San JLaax: Capistrano CA 92675 INSURER E. ` Dx 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. _......--...._. -.._-....._.........................— INS J.0 POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION UL41TS GENERAL LIABILITY EACH OCCURRENCE L 1,000,000 X COMMERC€AL GENERAL LJABILTTY pR¢ ${ES(>CWnlInCC 5 5O OOO A T �CLAIMSMkOE OCCUR AGL0170304 5/26/2010 5/26/2011 MED EXP A:�I wepasnnl s 5 000 PERSONAL b AoV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEIv-L AGGRZGATE LIAI€T APPLIES PER: PRODUCTS OOLP= P AGG 5 7 O0O O D O X POLICY PRO-JECT El LOC _ __?.000,000 AUTOMOBILE€JAI€LITy COMBINED SINGLE LEIdtT S ANY AUTO (Ea acddae€) ALL OWNED AUTOS BODILY INJURY (Par person) S --. SCHE[hS€.-ED AUTOS _....._._-._...,,._...__ ............._.,_....�_._______ __ HRED AUTOS BODILY INJURY S NOWOWNED AUTOS (Per amdeN) - - .--- --- - PROPERTY DAMAGE i (Per wxxi () GARAGE UMNLITY AU70ONLY-EAACCfOENT S _ ANY AUTO OTHER THAN _�ACC S AUTO ONLY: AGO $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE S �-e 000,Y.00Q x OCCUR FICLAIMS MADE AGGREGATE S 41000 000 21s S DEDUCTIBLE 50067277 5/26/2010 5/26/2011 S X RETENTION E S C WORKERS COMPENSATION � WC STATU OTti AND EYIPLOYEERS,LFAF3 UTY APROPRIETORIPARTNEWEXECUTrIE� NY wCo01-90-G?91 7/1/2010 7/1/2011 E.L.EACH ACCIDENT. s 1,000,_000 OFFICERI MEASI=R EXCLUDED? (Mawatmy in"HI E.L DISEASE-EA EMPLOYEE S 1,000,000 =-= dasaibe ur7dQrx SPECIAL.PROVT510NSbe€ae E.L.DISEASE•POLICYL.IMIT S 1,000 000 OTHER E DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES f EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL.PROVISIONS RE: BOTS AND GIRLS CLUB-TELN CENTER, I VIA POSITIvA, SAN jUAN CAPISTRANO, CA 92675. BOYS AND GIRLS CLUBS OF CAPISTRMO VALLEY AND TRE CITY OF SHAT 7UAN CAPIST14ANO ARE NAMED AS ADDITIONAL INSUREDS WITH RESPECT TO GENERAL LIABILITY AS PER COMPANY FORM CCL216 04/ 98 AS REQUIRED BY WRITTEN CONTRACT.*CANCELLATION CLAUSE AMENDED TO INCLUDE: EXCEPT 10 DAYS NOTICE OF CANCELLATION FOR ?TON PAYMENT OF PREMIUM. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BECANCELLED BEFORE THE EXPIRATION CITY OF SAN JUAN CAPISTRANO DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 32400 PASEO ADELANTO NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,9UT FAILURE.TO DO So SHALL SAN JUAN CAPISTRANO, CA 92675 IMPOSE NO DELIGATION OR LIABILITY OF ANY KING UPON THE INSURER,ITS AGENTS OR RE PRE SE NTATI VES. AUTHORIZED REPRESENTATIVE L Hines, CPCU ARM CLU ACORD 25(2009101) ®1986-2009 ACORD CORPORATION. All rights reserved. INSO25(2008oii The ACORD namo and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL. INSURE©, the policy(ies) must be endorsed. A statement on this certificate noes 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 This Certificate of Insurance 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. ACBRQ 25(2009101) INS025(200901) lte: 7/29/2005 Time: 3.0. 53 AM To: City of Saiz Juan Capistrano (Or e 453-1.053 Page: 004-On4 Policy Number: CA000000303-04 CG 20 10 ill 04 Effective Date:07/27/2005 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) Location(s)Of Covered Operations dr Q anization s City of San Juan Capistrano Job#02-270 Serra Vista 32400 Paseo Adelanto 303€0 Camino Capistrano San Juan Capistrano,CA 92675 San Juan Capistrano,CA 92675 Informatian re uired#q coat le#e#his Schedule, if na#shown above,w`;l be shown in the Declarations. A. Section tl-Who is An Insured is amended to This insurance does not apply to"bodily injury" include as an additional insured the persons)or or"property damage"occurring after: organization(s)shown in the Schedule, but only 1, All work. including materials, parts or with respect to iiability for"bodily injury", equipment furnished in connection with such 'property damage"or"personal and advertising work,an the project(other than service, injury"caused, in whole or in part, by: maintenance or repairs)to be perforated by i- Your acts or omissions; or or on behalf of the additional insured(s)at 2, The acts or omissions of those acting on the location of the covered operations has your behalf; been completed;or in the performance of your ongoing operations 2• That portion of'your work"out of which the for the additional insured(s)at the location(s) injury or damage arises has been put to its designated above:, intended use by any person or organization other than another contractor or B, With respect to the insurance afforded to these subcontractor engaged in performing additional insureds,the following additional operations for a principal as a part of the exclusions apply same project. CG 20 10 07 04 C ISO Properties, lrtc., 2004 Page I of 1 0 te: 7/29/2005 Time: 107 : 53 AM To : City of San Juan Capistrano (©r 2 493-1053 Page: 001-"n4 S P I B Insurance Agency, Inc. Sun Pacific Insurance Brokers, Inc. �sas�ssz-szzo €3es,o�s26e To: City of Sart Juan Date. Friday, July 29, 2005 From: Esther Muller Pages: 4 Subject: Revised Certificate of Insurance Message 26441 Crown Valley Parkway P.D. Bax 9055 Mission Viejo, CA 92690 Tel: (949) 582-5220 .fax: (949) 552-3512 Ca4f ornia License Numher: 0719264 SG " i 3THOLDER COPY TAT P.Q. BOX l,$p7, SAN FRANGSCO,GA 94 9 4 -080.7 C6MPkNSAT1014 1NSUtw A14E � :, :FUND CERTIFICATE OF WORKERS' COMPENSATION .INSURANCE :ISSUE DATE 07-01-2005 GROUP: POLICY.NUMBER 1594t17 2005 CERTI:FICATP €Q. 3 CERTIFICATE EXPIRES'':07-01:-2006 07-01X2005/07-01-2006 CITY' OF SAN JUAN.. CAPISTRANp SG 'JOB: PROFESSIONAL LIAB# . 324.00 PASEO ADELANTO MGk-804048 W MARKEL SAN JUAN CAP I STRANO CA :92675. AMERICAN INS. ice. 6 i5 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 befow for the policy period, indicated. This policy is not subject to cancellation by the Fund except upon 30days' 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 fisted 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. NIL, AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILETY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE. ENDORSEMENT #2055 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 0.7-01-2005 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER LEGAL NAME FR I`£SS COMPANY BUILDERS !NC. : FRIES5 COMPANY BUILDERS,.ZNC; 31658 RANCHO VIEJO Rp STE B FRIESS CONSTRUCTION INC SAN JUAN CAPO CA, 92.675 REV.3-431 PRINTED; 06/17/2005 PQ4fl8 SG CERTHOLDER COPY TATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 COMPENSATION IN S U R A N C E FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 07-11-2005 GROUP: POLICY NUMBER: 1594117-2005 CERTIFICATE ID: 129 CERTIFICATE EXPIRES:07-01-2006 07-01-2005/07-01-2006 CITY OF SAN JUAN CAPISTRANO SG 32400 PASEO ADELANTO SAN JUAN CAPISTRANO CA 92675 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the Califcrn,la Insurance Commissicner to the employer na!ned below for the policy period indicatsd. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We wifi 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 PRESIDENT EMPLOYERS LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #1600 - KENNETH E. FRIESS SEC TRES - EXCLUDED. ENDORSEMENT #1600 - DANIEL FRIESS PRESIDENT - EXCLUDED. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-01-2001 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER FRIESS COMPANY BUILDERS,INC. SG 31658 RANCHO VIEJO RD STE 8 SAN JUAN CAPD CA 92675 [CJ2,CN] (REV.2-05) PRINTED : 07-11-2005 y�YATA FAkM CERT'IFICAT'E 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: FRIFSS AND ASSOCIATES, INC. 31658 RANCHO VIEJO RD STE B ADDRESS OF NAMED INSURED. SAN JUAN CAPISTRANO, CA 92675 POLICY NUMBER R55 83.28-F15-75 L36 4593-904-75H 75--V5-4007-5G 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 Stn? 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. Com rehenslve $ Deductible $ Deductible $ Deductible $ Deductible ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO b, Collision $ Deductible $ Deductible $ Deductible $ Deductible EMPCARLOYIwRTN COVERAGE YES ❑ NO ❑ YES ❑ NO [] YES ❑ NO ❑ YES ❑. NO CAR LIABILITY COVERAGE ❑ HIRED CAR LIRBILi7Y YES ❑ NO ❑ YES ❑ NO COVERAGE ❑ ❑ YES ❑ NO [:1 YES ❑ NO FLEET-COVERAGE FOR ALL OWNED AND LICENSED YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO MOTOR VEHICLES ❑ AGENT 75-8323 05/05/05 Si gture of Authorized Representative Title Agent's Code Number Date Nl I e and Address of Certificate Holder Name and Address o€A ent CITY OF SAN JUAN CAPISTRANO JOHN R. MCMkH71N LIC 0576973 ATTN: CITY CLERK'S OFFICE 32221 CAMINO CAPISTRANO, 8-105 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA SAN JUAN CAPTSTRANO, CA 92675 INTERNAL STATE FARM USE ONLY: ❑Request permanent Certificate of Insurance For liability coverage. sinFF rnrM NSURRNCF CERTIFICATE OF INSURANCE SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAKED 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: E 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-C15-75F 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 1998 GIC 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 CAR LIABILITY COVERAGE [:1YES ❑ NO El YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO HIRED CAR COVERAGE LIABILITY ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO FLEET-COVERAGE FOR ALL OWNED HI&L ❑ El MOTORRVEH(k3.LE5 YES ❑ NO YES NO YES NO YES NO Signa re of Au horized Representative " TICIe Agent's Code dumber Date Narrie and Address of Certificate Holder Name and Address of A ent CITY OF SAN JEJAN CAPISTRANO JOHN R. MCMAH711V LTC 0576973 ATTN: CITY CLERK'S OFFICE 32221 CAMINO CAPISTRANO, B--105 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA SRN JUAN CAPISTRANO, CA 92675 INTERNAL STATE FARM USE ONLY: © Request permanent Certificate of Insurance for liability coverage. iTRTR MRM lNSIiRAN[i CERTIFICATE OF INSURANCE R 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 OE 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 I 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 COVERAGE YES ❑ NO ❑ YES ❑ NO ❑ YES - CAR LIABILITY COVERAGE ❑ ❑ NO ❑ YES ❑ NO HIRED CAR COVERAGE LIABILITY ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO FLEET-COVERAGE FOR ALL MOTOROWNED ANDVEHICLES LICENSED YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO MOTOR VE 1cLEs ❑ Si��lature of Authorized Represent five Title Agent's Code Number Date I�me and Address of Certificate Holder Name and Address of A ent CITY OF 5AN JUAN CAPISTRANO JOHpT R. MCNIAH71N LIC ©576973 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: ❑ Request permanent Certificate of Insurance for liability coverage. SYAR[FARM ]]CA T CER ■T FI ■ E 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 COMPANY BUILDERS, INC. 31658 RANCHO VIEJO RD STI; B ADDRESS OF NAMED INSURED: SAN JUAN CAPISTRANO, CA 92575 POLICY NUMBER P47 3958W-F19--73E 074 6797-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) BEA 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 COVERAGE ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO FLEET-COVERAGE FOR ALL OWNED LICENSED MOTORR VEHICLMCLES [I YES NO YES NO YES NO ❑ YES NO g i AGENT 75-8323 05/05/05 Sigrfat re of Authorized kepresenfiue Title Agent's Code Number Date Name and Address of Certificate Holder Name and Address of Ag ent CITY OF SAN JUAN CAPISTRANO JOHN R. MCMAHAN LIC 0576973 ATTN: CITY CLERK'S OFFICE 32221 CAMINO CAPISTRANO, B--105 32400 PASEO ADELANT'O SAN JUAN CAPISTRANO, CA SAN JUAN CAPISTRANO, CA 92675 INTERNAL STATE FARM USE ONLY: 0 Request permanent Certificate of Insurance for liability coverage, Rrp,€lRRM HxupR�,4 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 PROVIDER 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 S ADDRESS OF NAMED INSURED: SAN JUAN CAPISTRANO, CA 92675 1 POLICY NUMBER C99 7185-C25--75C D12 8435-D29-75C L36 7525-A15-75G P43 8807-n14--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 19B9 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 COVERAGE CAR LIABILITY COVERAGE ❑ [:1E] E] ElEl [:1YES NO YES NO ❑ YES NO YES NO HIRED CAR LIABILITY COVERAGE ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO FLEET-COVERAGE FOR ALL OWNED ANDLICENSED MOTOR VEHICLES YES NO YES ❑ NO YES NO [__1 YES NO ❑ El ci AGENT 75-8323 05/05/05 Sign ture of Authorized Representative Title Agent's Code Number Date Name and Address of Certificate Holder Name and Address of Aq ent CITY OF SAN JUAN CAPISTRANO JOHN R. MCMAHAN LSC 0576973 ATTN: CITY CLERK'S OFFICE 32221 CAMINO CAPISTRANO, B-105 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CA SAN JUAN CAPISTRANO, CA 92675 I INTERNAL STATE FARM USE ONLY: ❑Request permanent Certificate of Insurance for liability coverage. .STaT!fR&M 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! FIDE 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 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. Com rehensive $ 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 COVERAGELIABfLITY El YES El NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO FLEET-COVERAGE FOR ALL MOT )INED VEHICND LES LICENSED ❑ YES ❑ NO ❑YES [3 NO ❑ YES ❑ NO ❑ YES ❑ NO MOTOR VEHICLES � � ,E 'T �L' � AGENT 75-8323 ©5/05/05urs of Authorized Re rese 9 p Title Agent's Cade Dumber Date N ' e 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 324003 PASEO ADELANTO SAN JUAN CAPISTRANO, CA SAN JUAN CAPISTRANO, CA 92675 INTERNAL STATE FARM USE ONLY: ❑Request permanent Certificate of Insurance for liability coverage. ,5iak5 a Ra4 i.suRas.cF CERTIFICATE OF INSURANCE Y SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE CANCELED OR OTHERWISE TERMINATED WITHOUT GIVING 90 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORD THAN 30 DAYS ERCT 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 395B--F19-73E 074 6746-B04-75 068 9916-D07-75 R51 5568m-C15-75F EFFECTIVE DATE OF POLICY 12/19/04-06/19/05 02/04/05-08/04/05 034/07/05-10/07/05 04/14/05-10/14/05 DESCRIPTION OF 1998 GMC STAKE 2003 FORD F250 2002 VOLKSW GON EMPLOYERS NON-- VEHICLE(including VIN) BED SUPER DUTY PU JETTA WAGON OWNED AUTO LIABILITY COVERAGE ® YES ❑ NO 0 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 1,000,00() 1,000, 000 1,000, 000 PHYSICAL DAMAGE COVERAGES ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO a. Com rehensive $ 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 FIRED CAR LIABILITY COVERAGE F-1YES ElNO ElYES ❑ NO [:1YES ❑ NO ElYES ❑ NO FLEET-COVERAGE FOR ALLO R VEHICLES E HICLEs ❑ AND E] E] [_1 ❑LICENSED MOTOR YES NO YES NO ❑ YES ❑ NO YES ❑ NO M© , � ,�.„ �r � '. , s [`+1�• °�AG> N T -8323 05/05/05 Signature of Authorized Representative Title Agent's Code Number Date l4zme and Address of Certificate Halder Name and Address of A ent 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. CONSTRUCTION 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) 4879700 x104 Fax Number: (949) 248-8433 Date: 05/04/2005 Re: Auto Liability Insurance Comments. Enclosed are the updated auto liability insurance certificates. ct: (J• p w w.friessco.coni License 836571 ATE(MMIDDNYYY A-CO)RA CERTIFICA '- OF LIABILITY INSURI, CE 12/13/2004 1 2/13/2041 PRraDUCER (949)582-5220 FAX (949)582-3512 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION S P I B Insurance Agency Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE License Number 0719264 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 26441 Crown Valley Parkway Mission Viejo, CA 92691 INSURERS AFFORDING COVERAGE NAIL# INSURED Friess Company Builders Inc; INSURERA, Admiral Insurance tompany/Stewar Smith Wes.: ;dba;FM Electric INSURER State Comp Insurance Fund -- 31658 Rancho Viejo Rd #B INSURER C: QBE Insurance Corporation/c/oDea sHomer San Juan Capistrano,Ca. 92675 INSURER D: Lloyds of London/E.L.M.Ins.Broke s 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. INSR ADD1 TYPE OF INSURANCE — POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONLTR INSR LIMITS GENERAL LIABILI TY CA000000303-03 07/27/2004 07/27/2005 EACH OCCURRENCE $ 11000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $—..�.� S0,000 CLAIMS MADE r�] OCCUR MED EXP(Any one person) $ � EXCLUDE A X PERSONAL&ADV INJURY $ 1,000,000 ... GENERA(_AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY PRO JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) .. ALI.OWNED AUTOS BODILY INJURY SCHEDULED AUTOS Per person} HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS {Per accident) _._._....._... PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT 5 ANY AUTO OTHER THAN EA ACC $ --- AUTO ONLY: AGG S EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE S $ DEDUCTIBLE � $ RETENTION WORKERS COMPENSATION AND 1594117-04 07/01/2004 07/01/2005 X .V'JC STATU- OTH- EMPLOYERS'LIABILITY R ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDFNT $ 1,000,000 B OF9CFR1MEMBFR EXCLUDED? E.L.DISEASE-EA EMPLOYEE $__— 11000,000 If es,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DTHE,R 2612656 11/03/2004 11/03/2005 BPP:$60,000./special/RC Ded Business Personal C roperty;Contr. Equip $500;Contr Equip $36,800/ACV Newly Aquired $25,000. DESCRIPTION OF OPERATIONS f LOCATIONS f VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 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) ATTACHE© 'revised certificate 2/3/05" EXCEPT 10 DAYS NOTICE OF CANCELLATION FOR NON-PAYMENT OF PREMIUM CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 300 _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 ENSURER,ITS AGENTS OR REPRESENTATIVES. SAN JUAN CAPISTRANO, CA 92675 AUTHORIZED REPRESENTATIVE ILarryHines/JESSIC �f ACORD 26(2001/08) aACORD CORPORAT�19111 Policy Number:CA000000303-03 CG 20 10 07 04 Effective Date:07/27/2004 THIS ENDORSEMENT CHANCES THE POLICY. PLEASE READ IT CAREFULLY. ADDITI®NAL INSURED _ DWNERS9 LESSEES DTA CONTRACTORS - SCHEDULED PERSOX OR ORGANIZATION ZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Nanw Of Additional Insured Person(s) Or Organization(s): Locati0 s Of Covered Operations- ANY erationsANY ENTITY FOR WHOM YOU ARE PERFORMING ALL COV'lEPXD PROJECTS T ONGOING OPERATIONS,BUT ONLY IF REQUIRED BY WRITTEN CONTRACT PRIOR TO AN"OCCURRENCE„ OR LOSS. CITY OF SAN JUAN CAPISTRANO,CA. Information required to com fete this Schedule,if not shown above will be shown in the Declarations. A. Section 11—Who Is An Insured is aur aded to This insurance does not apply to"bodily injury"or i[tcludc as an additional insured the pers*s)or "property damage"occurring after: organization(s)shown in the Schedule,but only with I. All work,including materials,parts or equipment respect to liability for"bodily injury"."property A furnished in connection with such work,on the dawage"or"personal and advertising injury"caused, project(other than service,maintenance or in whole or in part,by: repairs)to be perforated by or on behalf of the 1. Your acts or omissions;or additional insured(s)at the location of the 2. The acts or omissions of those acting on your covered operations has been completed;or behalf; 2. That portion of"your work"out of which the in the performance of your ongoing operations for the injury or damage arises has been put to its additional insurcd(s)at the location(s)designawd intended use by any person or organization other above, than another contractor or subcontractor engaged in performing operations for a principal as a part B. With respect to the insurance afforded to these of the same project. additional insureds,the following additional exclusions apply: CG 20 10 07 04 C ISO Properties,Inc.,2004 Page I of 1 i Maria Guevara From: Meg Monahan Sent: Wednesday, March 30, 2005 9:45 AM b° To: Maria Guevara -w 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 Meg, 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 Bog Cc: Meg Monahan; ©avid Contreras; .john Shaw; Lynnette Adolphson Subject: RE: Updated Non-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 Jahn Shaw. Let me know how you want to handle this. Maria -----Original Message----- From: Malty Bogh Sent: Monday, March 28, 2005 7:57 AM To: Maria Guevara 1 Cc: .avid Contreras; Lynnette Ado[phson 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 Durnhart; Joan Ross; Lynnette Adolphson; Meg Monahan; Michelle Perea Cc: Nasser Abbaszadeh; Amy Amirani; Bill Huber; Cindy Russell; !Caren Crocker; Lt. Davis; Molly Bogh Subject: Updated Non-Pay/Non-Compliance Lists << File: NON-PAY LIST.doc >> <<File. NON-COMPLIANCNCE LISTAOC >> Maria Guevara, Administrative Secretary City of San Juan Capistrano City Clerk Division (949) 443-6309 2 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 Mon-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 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 CALIFORNIA PRELIMINARY NOTICE ACC0RDANCEWIS NggJEN.0E—W,THIS&D098,CALIFORNIA CIVIL THIS *** IS NOT A REFLECTION ON CODE * THE INTFGRITY OF ANY CONTRACTOR OR SIJBCONTRACTOR, nos JUL 19 P 1, NOTICE IS HEREBY GIVEN that: G 1-1,y CI P"i"I f2WNER QR REPuTED OWN'R PTIRT 1(- 'k(ZV.NrV SAN JUAN CI'J)ISI` R"o A 01 f N ....,i"I'll".N 2 2()() ",,t)1�.J.J ,2 4, 0 A. S!,Ji JUAN CT,-P c�T'" r) Has or will Furnish Libor,services,equipment,or materials,generally described Rs: LENDER OR REPUTED LENDER i"EADY il I X CONC'FtiET!' , ROCK & `AN1) To be furnished or furnished for the building,structure or the work of improvement described as follows: SAN iUJAH CAP TS'!'RANO i N . # 0-5 0 6 15 ORIGINAL OR REPUTED.ORIGINAL CONTRACTOR Lot No . >°RJLES-S CONSTRUCTION T (- -� cert_ �Nu'.111 21.2()2 4 1,5 31.658 KANCEO V -10 ) I I,) SAN -.)UAN C A P 1S CA 926 5 Name of Person or Firm who contracted for purchase of the labor,services, equipment,or materials is: M 0 o ,N,r"["" "I" 1-'FL,,/�1-',T'T(.' ENG & M SUBCONTRACTOR with whom claimant has contracted CI 11 -1. 1. 3"a 6 0 ' , LA P A'1-IM-A ill Vin: 'N A F I Til CA. 92BOfl An estimate of the total price of said Libor,services,equipment or materials is: ALSO NOTIFIED TENANT OR BONDING. AGENT ***NOTICE TO PROPERTY OWNER*** IF BILLS ARE NOT PAID IN FULL FOR THE LABOR SERVICES, EQUIPMENT, OR MATERIALS FURNISHED OR TO BE FURNISHED A MECHANIC'S LIEN LEADING TO THE LOSS, THROUGH 6OURT FORECLOSURE PROCEEDINGS, OF ALL OR PART OF YOUR PROPERTY BEING SO IMPROVED MAY BE PLACED AGAINST THE PROPERTY EVEN THOUGH YOU HAVE PAID YOUR CONTRACTOR IN FULL. YOU MAY WISH TO PROTECT YOURSELF AGAINST THIS CONSEQUENCE BY ill) REQUIRING YOUR CONTRACTOR TO FURNISH A IGNED RELEASE BY THE PERSON OR FIRM GIVING YOU THIS NOTICE BEFORE MAKING PAYMENT TO YOUR CONTRACTOR OR 024 ANY �0 OTHER METHOD OR DEVICE THAT IS A PRO RATE "Ouk,ot 11" UNDER THE CIRCUMSTANCES. OTHER THAN RESIDENTIAL HOMEOWNERS OF DWELLINGS CONTAINING FEWER THAN FIVE UNITS, PRIVATE PROJECT OWNERS MUST NOTIFY THE ORGINAL CONTRACTOR AN ANY LIEN CLAIMANT WHO HAS PROVIDED THE OWNER WITH A PRELIMINARY 20- DAY LIEN NOTICE IN ACCORDANCE WITH SECTION 3097 OF THE CIVIL CODE THAT A NOTICE OF COMPLETION OR NOTICE OF CESSATION HAS BEEN RECORDED WITHIN 10 DAYS OF ITS RECORDATION. NOTICE SHALL BE BY TRUST FUNDS TO WHICH SUPPLEMENTAL FRINGE BENEFITS ARE PAYABLE REGISTERED MAIL, CERTIFIED MAIL, OR FIRST-CLASS MAIL, EVIDENCE BY CERTIFICATE OF MAILING. FAILURE TO NOTIFY WILL EXTEND THE DEALINES TO RECORD A LIEN. DA44f)I: BY _j CALIFORNIA PRELIMINARY NOTICE (California Civil Code,Section 3047 as amendedHt,Senate Bill 1379[Chapter 396J effective January 1, 1978) 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 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 contractor in full. You may wish to protect yourself against this consequence by(1)Requiring 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_fi_v_e units, Private ra ect owners must notify the original contractor and any lien claimant who has proviided.the owner with a preliminary 2C-day lien notice in accordance with Section 3097 of the Civil code that a notice of completion or notice of cessation has been recorded within 10 days of its recordation. Notice shall be b re istered mail ^�r certi t tify will.extend the deadlines to record a lien. mail,or first class snail,evidenced y a certificate of smiling. Failure to n.o„ TO: CITY OF SP JUt N CAPTS"IRAN7 Dated MARCH 1..4, 2005 1-71 OWNER [ RCPUTEDOWNER 32400 PASEO ADELANTO OCSS JOB NUMBER 43-5402 Olt r1sl.tc�eeNcv SAN JUAN CAPISTRANO, CA 92675 YOU ARE HEREBY tNOTIFIED That the undersigned has furnished or will famish labor,services,equipment or materials of the following -; description. STKIPI�IG,I STENt IT-8'x S16�4S SAisl Bf-,ASTING, N4ARKFRS, THERMOPLASTIC. GUARDRAIL., BARRICADE Fat the building,structure or DEL OBISPO STREET AND PASEO ADELANTO SAN JUAN CAPISTRANO other work of improvement 1pc�t�d at t t;p, 1 THE NANTE-,ANI) „AD„ 9F THE PEl§ -WHO CONTRACTED 'FOR THE PIIRF-0=VgUCH LA862,SERVICES,EQUIPMENT OR Trust funds to which supplemental fringe benefits are payable ;ATERIAL - 5,..,, ...v CONOL,ITE N x,148 3360 EAST LFA PALMA AVENUE atxx t�5 ANAHEIM, CA 92805-2856 FRIESS CONSTRUCTION GROUP t TO: cravrwctx 31658 RANCHO VIR O ROAD SUITE B N�iE tx cr4 R'r SAN JUAN CAPISIPANO, CA 92675 � ('Material men not requured tofurnish the above) S 1Eosrveqor firm ntoraE ice pt lmercal ORANGE COUNTY STRIPING SERVICE, INC.—LIC.#i~346095 N Address 483 NORTH PIXLEY STREET— ORANGE, CA 92868 E By ^�-.-_.5�',�' Title AUTHORIZED AGENT Date MARCH 14, 2005 8 N NE EPO D NOTICE TO: TO CONSTRI.ICTION LENDER ONLY czrvZ-1w tatty tam Estimated total price of the labor,services, OR equipment or materials described hereon. t�nnrn LLtS"II�L71i3v [L�fit ACKNOWLEDGMENT OF RECEIPT OF PRELIMINARY 20-DAY NOTICE (Section 3097.1,Calif C.'.iviI Code This acknowledges receipt oto of copy of this prolindnary 20-day notice at (Daze) (&Tress where Nofxre receive,i) Date: (Dwe this arknowledgmene a ececulM) (Signaiwe ofperson acknowledg ng reeeipi,vtwh title of acknowledgmew is made otr behalfof another person) (Address or description of)oh site) Upon receipt o'f fhis notice,please detach and sign this acknowledgment and return same to sender LIN— �••. City of San Juan Capistrano Planning:Department 32400 Paseo Adeianto San Juan Capistrano,California 92675 FEE AND DEVELOPER DEPOSIT COMPUTATION FORM CA pJA GENEM4&PERMIT PEES-ACCOUNT NO, - � �"" �0 Research: hours $25/hour Land Use Ad'ustment $300 Sign Permit $100 Grand Openin2&Promotional Banner $25 Sign Monument tnot part of AC application) $300 Spedial Event Permit Applicabon varies see fee resolution Street Banner $80 Temporary S' nPermit $25 Temporary Use Permit. $150 Zone Variance $750 Site Plan Review $500 ELcetion to Radio/Dish Antenna Regulations $100 Exce tion to Titie 9 Regulation $750 Pre-aeptication Consultation/Preliminary Review $150 i/ Other 7,5-, U 7 ; or> MAPS-ACCOU.W RQ.01-4521 General Plan Ma $5.00 each Zoning Ma $5.00 each Los Rias Specific Plan Ma $5.00 each PUBLICATIONS-ACCOUNT NO.Gi4521 General Plan or General Plan EIR $32 each General Plan Lpend ices $46 each Title 9 Land Use Code sold in Cfty Clerk's Office Demographic Statistics $3.50 each Los Rios Ppecific Plan $9.00 each Architectural Design Guidelines $13.50 each Planning Commission minutes(copies of to es $20.00/1st+ $5.00/2 4 or 3`d Co ies: pages $0.20/page CONSULTANT CONTRACT FEES.-ACCOUNT NO.18- Project Name: Log.No. DEVELOPER DEPOSIT-ACCOUNT NO.18- Project Name: tog No: ✓ Prepared by: m� Date: Chock No: ® 5 pDp Total: Check Payor: � Receipt No: PAPlanningtPlan shasedkQept.FormsTormFeeComp.wpd .. TMi$IVIUl;TI%TO.NE*"lf#EA OF TF11=.�€30CU1tiAiVjTpGFiANGS 'O:LO'Fi GFi>AGtUlALL1fr,*,4NDYE ErYRd t ElAfii(T�1, FiT`Y(/[T '*f3"AH'IG(rFi REAS.B -T1i T A-'NDaBOT1'OM:`�` - UNION r✓ � <r: f,r�' .�,... �r:"6�"�.r+� ,;r,i°�r.:= .E� .;ter �.r(°��. 9 ;i '"s;�i .� �6 ,r:,.7 j;;�� 3 v -•at�,^� v 9 a: r` 1 ,�y,� { .� 4',.+,,,.. ,r[EDt � i rr ,.t e �.�9 +"r�(� f Ffi",! !9<�".a•� § 11� � I �+ y „�`(�y. 3,°. Y t. #� INpbW^� E3.6� ♦ Y�?�1 S rni �?alfrrdferfSvf�eve ar 11?moths bd�lrs Nnv�m �F- 9 �D�4 _ c : 7k1k' �ir lot r AY TO THE -- 9 ORDER C7F REMiT?E DANIEL LE'M§,FRlFss _ . .' .. ORIZE 51G1°3M 9 nc� s . 4V:M,btl26, (bofm9063} 2a7 t ��"0045000502w, 1: 123100049 ?1: 056600000611" CF€VE❑ BANK TRANSIT $CHECKS $CASH OATS NAME L}ESC IPTION gy — NO. INVALID 108824 SIGIGNNAATTUT URE oft CITY OF SAN JUAN CAPISTRANO 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CALIFORNIA 92675 ce2iso2s Ir.va7 PolicyNurnb= CA000000303-02 Friess Company Builders, Inc. CG 20 1010 01 Number: Effective Date: 07127/2003 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES, OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorscment modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE:PART SCHEDULE Name of Person or Organization: AS REQUIRED BY WRITTEN CONTRACT (If no entry appears above,inforrriation required to coroplete&s endorsement will be shown in the Declarations as applicable to this endorsement-) A. Section II—Who Is An Insured is amended to (1) All work, including materials,parts or include as an insured the person or organization shown equipment furnished in connection with in the Schedule,but only with respect to liability aris- such work,on the;project(other than serv- ing out of your ongoing operations performed for that ice,maintenance or repairs)to be per- insured. formed by or on behalf a f the additional Ln- D. With respect to the insurance afforded to these addi- cured(s)at the site of the covered tional insureds,the following exclusion is added: operations has been completed;or 2. Exclusions (2) That portion of our work" out of which the injury or damage arises has been put to This insurance does not apply to"bodily injury"or its intended use by any person or organiza- to property damage"occurring after tion other than another contractor or sub- contractor engaged in perforrning 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 CISO Properties,Inc,,2004 Page 1 of 1 CiYY of Say Juan Capistrano 32400 Paseo Adelanto San Juan Capistrano, CA. 92675 (949) 493-1171 Fax: (949) 493-1053 FAX TRANSMISSION COVER SHEET Date: r To: (.Dt4(C Fax: - Re: u f cw c Sender: "Vic._- 6 L�)cC1c J� YO U SHO ULD RECEIVES PAGE(S), INCL UDING THIS COVER SKEET. IF YO U DO NOT RECEIVE ALL THE PAGES, PLEASE CALL (949)VI . 3 FRIESS E.—7Tr r r Project Information Transmittal Project# 04-587 Transmittal# 00413 Arch. Project# Issue Date 12/15/2004 Title Serra Plaza Off=ice Building Subject Auto Ins& Address 31910 and 31920 Del Obispo Workers'Comp Certificates i City,State,Zip San Juan Capistrano, CA 92675 Country USA Igor,^ I To Contact Monica Stornbaugh Contact Maria (City Clerk's Office) Company Friess Construction Group Company City of San Juan Capistrano (General) Address 31658 Rancho Viejo Road, Ste. B Address 32400 Paseo Adelanto City,State,Zip San Juan Capistrano, CA 92675 City,State,Zip San Juan Capistrano, CA 92675 E Country USA Country Phone 949 487-9700 Phone (949)493-1171 Fax 949 248-8433 Fax (949)493-1053 Copies and Remarks Submit Copies For Distribution Sender US Mail I Resubmit Copies For Approval Remarks Enclosed are the updated Certificates of Insurance for Automobile i _ coverage(4)and Workers'Compensation. Return Corrected Prints i i Transmittal Items Updated Certificates of Insurance(5) r ; 14. tb 10 f 12115/04 Page 1 of 1 Project Information Transmittal Project# 02-270 Transmittal# 00410 Arch.Project# issue Date 12/14/2004 Title Serra Vista Subject Certificate of Address 30300 Camino Capistrano Liability Insurance City,State,Zip San Juan Capistrano,CA 92675 Country USA From i n „r To Contact Carlene Myers °(I,✓ Contact Maria(City Clerk's Office) Company Friess Construdtion Goup Company City of San Juan Capistrano Address 31658 Rancho Viejo Rd. Address 32400 Paseo Adelanto Suite B City,State,Zip San Juan Capistrano, CA 92675 City,State,Zip San Juan Capistrano, CA 92675 Country USA Country Phone (949)487-9700 Phone (949)493-1171 Fax (949)248-8433 Fax (949)493-1053 Copies and Remarks Submit Copies For Distribution Sender Land Resubmit Copies For Approval Remarks Enclosed is our current Certificate of Liability Insurance for the Serra Vista project. Return Corrected Prints I Transmittal items Certificate of Liability Insurance 92/14/04 Page 1 of 1 MCD-RD-P. CEI 1 FCA) LLI OF LIABILITY Y INSURAi- rE D 12/11332/f /2000404 ATE fDD PRODUCER (949)582-5220 FAX (949)582-3512 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION S P I B Insurance Agency Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE License Number 0719264 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ""441 Crown Valley Parkway Psion Viejo, CA 92691 INSURERS AFFORDING COVERAGE NAIC# INSURED Frness Company Builders Inc; INSURERAAdmiral Insurance Company/Stewart Smith Wes- Friess Construction Inc. INSURERB: State Comp Insurance Fund 210 31658 Mancha Viejo Rd #B INSURERC QBE Insurance Corporation/c/oDea sHomer San Juan Capistrano,Ca. 92675 INSURERD 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, INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONI TP MRP LIMITS GENERAL LIABILITY CA000000303-03 07/27/2004 07/27/2005 EACH OCCURRENCE 5 11000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50,000 CLAIMS MADE �OCCUR MED EXP(Any one person) $ EXCLUDED A X PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 2,000,000 X POLICY PRO- LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY � SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OVJN ED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY, AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE t AGGREGATE $ J .,,»,,,,,,, DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND 1594117-04 07/01/2004 07/01/2005 X WG STATU- OTH- EMPLOYERS'LIABILITY -I^� T'Sf FIR B ANY PROPRIETORIPARTNERIEXECUTIVE E,L.EACH ACCIDENT S 1,000,000 OFF]CERIMEMBER EXCLUDED? E L DISEASE-EA EMPLOYEE $ 11000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE.-POLICY LIMIT $ 1,000,000 OTHER 2612656 11/03/2004 11/03/2005 BPP:$60,000./special/RC Ded C usTness Personal roperty;Contr. Equip $500;Contr Equip $36,800/ACV Newly Aquired $25,000. DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT f 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 CERTIf ICATE HOLDER CANCELLATION 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 ADE LANTO OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. SAN JUAN CAPISTRANO, CA 92675 AUTHORIZED REPRESENTATIVE ILarry Hines/JESSIC lAftrb ACORD 25(2001108) ©ACORD CORPORATION 1988 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(2007108) 02/03/2005 09: 16 FAX 9494893340 FRIES5 2001 FESS C0NS7RUCr1O1V GROUP 3Y6SE'rzA cho VL1d Rogd, sure B .SG�vtiJuGrv�GG��ic�rl v�.a G/+�.26�5 7D To Fax: j r / Q `S pages= !� Phone: _._.., 02/03/2005 08: 18 PAX 9494893340 FRIESS 1002 Lte: z/;i/zUUS 'rime: 9 : 1b AM 1`0 :1 1-'KI.Et6 COMPANY NU1L,LlER" Monica L Z48- 3433 E Page: 002-003 -TnA AC-ORA, CERTIFICATE OF LIABILITY INSURANCE li/13//2 04 PRODUCtR (949)S82-S220 FAX (949)592-3112 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION S P 1 B Insurance Agency Inc. ONLY AND CONFERS NO RIGHYS UPON THE CEIRT1FiCATE License IWcrrl�er 0719264 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, 26441 Crown Valley Parkway Mission Viejo, CA 92691 INSURERS AFFORDING COVERAGE NAI:C# INsuRtD Friess Company guilders Inc; INSUREnA, Admiral insurance Company/Stewart Smith Wes, ;dba;FlN Electric INsuRERa State Comp Insurance Fund 210 31658 Rancho Viejo Rd #8 NsuuLkc QRE Insurance Corpora tion/c/oDeal sHomer San Juan Capistrano.Ca. 92675 �PLSLIQFRI) Lloyds of Landon/E.L_M.Ins_Broke s INSURER E COVERAGES TIF POLIC€FS OF INSURANCE L€STEO BELOW HAVE BEEN iss ED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTW iTHSTANDINC; ANY REQVIREMENT,TERM OR CONDITION OF ANY CONTRACT IOR OTHER DOCUMENT WI fH RESPECT TO WHICH THIS CERTIFICATE MAY IRE ISSUED OR MAY PERTAIN,THE:INSURANCE APPOROEfl Lav THE POLICIES LIESCRISEO HFRF€N IS SUOJFCT TO ALL TAE'TERNLS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN Rr:DUCED BY PAID CLAIMS 1N 6-15;k aaTYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLKY E%PIRAY70N �— LI/xI75 CEIIERAL LLAIU'rY CA0000 0303-03 07/27/2004 07/27/200S FACHOCCURRENCE s 1.000,00( x COnIM£RCIAL GENE RAL U.8,07 I ONWX TO REED s 51,001 CLAIMS MADE OCCUR MEO EXP IAnTnroPrSWI EXCLUDE A X PSRSONAL A AOV INIURY S 1,000 T 11p GENERAL AGGREGATE S 2,000,000 CFN'L AGGREGATE LIWT APPLIES PER PRODUCTS-COMPIOPAGG is 2,000,000 X PDL€CY. I'TO LpC A00u1081LE LIABILITY CCimalneo SINGLE LIMIT { ANY AUTO IES JCCvdpRif � 9 ALL OWNED AUTOS 6ODILY IWURY (Per Deneni SCHEDULED AUTOS I HIRED AUTO$ BOOILY INJURY (Per 7CACenIj, $ NON-OwNEO AUTOS PROPERTY DAMAGE # EPe�acodenil GARAGE LIABILITY AUTO ONLY EA ACCIDENT S ANY AUTO OTI EER THAN EA ACC S AU 10 ONLY. AG(: 5 EXCESSIUMBRELLA LIABILITY LACHOCCUNHL.I'ICk 3 OCCun CLAIMS MADE _ ACCRECATE 5 I S OEOLJ£riBLE s RETENTION S r1 r! WORKE"COMPENSAnON AND 1594117-0407/01/2004 1 07/01/2005DTH- 5NPLDYERS'L IA8iLITY E.L.EACH ACCIDENT 1 1 000 000 ANY PROPMETORIPARTNER/FXECLirive OFFICtRWEMBfK EXCLUOEU' E L DISEASE-EA£MPLOYE % 1,000,M Ues delcr.be under SPECIAL PROv15IDN5 tolow E L DISEASE-POLICY LIMi7 S 1,000.000 DTWPIR 2612656 11/03/20041 11/03/2005 BPP360,000_/special/RC Ded usyess Personal C ropert5Perso Equip S500;Conty Equip $36,800/ACV Newly Aqu i r•ed S 2 5,600. DESCRIPTION Oi OPERATIONS t LOCATION&.!VbOCUSS r EACL.USIOWS ADDED DY EHOORSEMEkT I SPECIAL PROVISIONS E_ SERRA VISTA - PROJECT ##02-270, 30300 CA INO CAPISTRANO, SAN ]DAN CAPISTRANO, CA 92675 ERTIFICATE HOLDER IS NAMED AS ADDITIONAL I SURED WITH RESPECT" TO GENERAL LIARYLM AS PER FORM CG2010 K07/04) ATTACHED F'reVised certificate 7/3/05" ,EXCEPT 10 DAYS NOTICE OF CANCELLATION FOR ON-PAYMENT OF PREMIUM IFERTIIF'1 D CANCELLATION SHOULD ANY OF TUE ABOVE DEWRAEIE0 POLICES RE CATtCELLED AEFORe THe E%PA^T€ON DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL ;0 DAY6 WNr7YEN NOTICE TO THE CERTIFR:ATE HOLDER NAMED 10 1"f LEFT. CITY OF SAN JUAN CAPISTRANO BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OHLJGATIOM OR LIABILITY 32400 pASEO ADELANTO OF ANY KIND UPON THE INSURER,TTS AGENTS OR REPRESENTATIVES CAU -rllau rAdYc VDA#.In rA 0141< TNL w 02/03/200.5 09: 17 FAX 9494893340 FRIESS 1 003 te: Z/3/200t) 'rime: 9: 1b AN '1O khthbb COMIJANY BUILDER Monica (a Z48--8433 Page: 003-003 Policy Ntambar CADOODW303-03 CC xn[n 07 ad Eff:cbvc Bare:07f27/2t}04 TLUS C"ORSEMENT CRAIV S TIE P0LIICV. PLEASE READ IT CARErULLY. ADDITIONAL INS�RED - OWNERS, LESSEES OR CONTRACTORS - SCHEDU LM PERSON OR ORGANIZATION This cntiorsemerts fYlndiftcs itlsuTanceproal wndcr tl�c following: WMMhRCIAL GF?NERAL LIAF3 COVERAGE PART SC1f�6.atr�.H N*mc Of Ad4itinnot Imured lr'tTs�*b) Or L4% &%) Of Co.cred Opersoonx ANY t;NITIY FOR.WHOM YOU ARE PERF C, ALL C+OV1alEDPROJECTS ONGOING Oft.&ATIONS_BUT ONLY TF R1E�013Y WP rfTEN COKUCf PRIOR TC3 AN'"OOC1VR3t;rNCEm OR LOSS. CITY OF SAN JUAN CARISTRANO,CA. Torm-nAacm r hood to corapjctt&I Schedule i�not gkown above,will be shown tis*a Daclnratimm A. S*cdon 0-Who L Aa l<haured is uxmp,d to Th6 iasurancc docs not apply to"bodily cajmsr or orchitic ay en addfQona]raastued&c p<st*I)CW "properfy d=-1 jc"o--rr*=Rct: olgan;aan*%)%h own is for 5chedukw bus oily with 1. All work,including n atctlialt,pans or tVipwr m rc5pec9 W 4-biw$ffri'ltadnuy iilim",'Vm'eky 1lrrrtas bcd,in wnmmnon wob lrtx'n work,on ftr dncrsatgc"or"peeeovs3 sad wh-r tuma iA! uy"tamxd prujecr(uthrr tun scrsrie:e,majnttif=e or m whole of its part,lby rcpaun)to be p=rfmmvd by or iota behalf at the i. addibonal insutrQsy ar The locadan of thr, T. corercd operatrans hm butt complerad;or behalf; Z. DIRT pot4ian OF"yPV4,Work"OUT of whirl*thr m tht perfot*iarwa of your ocgoing op"Atio fbr the uyary or d2mage laset l a-t 6ccrr put to rtF .ddir:onAa rnvvrc.f(a).t tlr lo'atian(s)Jc .W, rcd intended wee by any peraon of ozlpaa.,zat.00 odwr above, tbap anotbrT C01*40or ar sabconwictar ctlgaged in perfarmirag operanans far 8 principal as a part $_ �+1.th r=spoct to dx nzwurgncc x(lordtd to Rhc of the gime project, tcfidttionsl ms[ucds,t'hc 6ollo�irlR adQitianal CxClusiam apply- cc pplyCc 10 to 87 04 t ISO properties.Inc.,2004 p4ty 1 aI L 0 ate: 10/4/2004 Time: 1Z : 51F "M TO : FRIERS COMPANY BUI1 :RS (Fries @ 248-8433 Page: 00--002 POLICYHOLDER COPY STATE P.0.BOX 420807, SAN FRANCISCO,CA 94142-0807 COMPENSATION tNSURANCK FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 10-04-2004 GROUP: POLICY NUMBER: 1594111-2004 CERTIRCATE ID: 77 CERTIFICATE EXPIRES: 07-01-2045 07-01-2004/07-01-2005 CITY OF MISSION VIEJO 200 CIVIC CENTER MISSION VIEJO CA 92691 This is to certify that we have issued a valid Worker's Compensation insurance policy in a form approved by the Califomia Insurance Commissioner to the employer named below for the policy period indicated. This polity is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance.notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend,extend or alter the coverage'afforded by the policy listen herein.Notwithstanding any requirement,term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain,the insurance afforded by the policy described herein is subject to all the terms,exclusions,and conditions,of.such.policy. AUTHOR#ZELI REPREs€NrAnvE PRF$I0FNT RMFIOYER°S LIABILITY' LIMIT 'IYFCLUDING DEFENSE COSTS. -,$1;%000',000•-PER'-0CC_"URRBNCzo. ENDORSEMENT #1600 - kENNETH E. FRIFSS, SEC, FRES --EXCLUDED: - ENDORSEMENT #1600 - DAMEL FRIERS, PRESIDENT - RXCLUDED. INDO1it3EblANT #2065 ENTITLED CERTIFICATE HOLDERS- NOTICE EFFECTIVE 07-01-2001 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. E4APLOYPR FRIESS COMPANY BUILDERS,INC. FRIESS CONSTRUCTION, INC. 31.656 RANCHO VIEJO RD ST'E S SAN JUAN CAPO CA 92675 01.,'14/OG 05: Zpm P. 001 STATE FARM INSURANCE COMPANIES ,JOHN MCMAHAN , AGENT 32221 CAMINO CAPISTRA.NO SAS] JUAN CAP -ST ANO , CA 92675 FACSIMILE TRANSMITTAL. SHF ET -- TU FROM: CCJMF' 'NY: DATF.t PAX NI R 'TOTAL NCS. B PAAES INCLUDING COVE riEiO1IF fJ BFR: S17d77Ek2'5 ItI E1L�ABNCE Nl1IvTBE32: 49)661--0485 KI3: YOUR REFERENCE NUMBFK, CI URGENT C#FOR IAF VIF-W PLEASE COMMENT T PLEASE REPLY 13 PLEASR AECYCLE 01/14,'05 0-E-. pm P. C)OS r•a� p• �F CERTIFICATE OF INSURANCE SUCKWSb RANCE AS RESPECTS THE INTEREST OF TIME 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: M STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois ❑ STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois [I STATE. FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas, Texas , or El STATE FARM INDEMNITY COMPANY of Bloomington, Illinois has coverage in force forthe Following Named Insured as shown below: NAMFD INSURED: RTESS COMPANY AUTT13'PS, TTTc ADDRESS OF NAMED INSURED". SAN juAN c:AP15 T.'FtA.N(,, €:A 911>F'115 POLICY NUMBER (:99 7185 -C2'i 150.12 10433 D29 'ate T,. :; 7525-A.15-75G, 143 880'1 T,, 4-'Y5F -EFFECTIVE BATE i OF POLICY 0t?/25%04-03/25/05 :0/29/09-04/29/0' 1.!"I` /(5-1IIti/06 1.0/14fI)7. Q'=lt �l3 DESCRIPTION OF I.994 E't)RD F-150 VEHICLE(Including 1/tN) 1998 Gml,- SAV.ANA i 199) ll( DGE RANI PU STAKE FET) I W3 ) I om) I E7 I t7 --- --- _, ...... LIABILITY CCOVIERAGYES ❑ NO ❑YES ❑ NO N YES Ll NO N YES ❑ NO LIMITS OF LIABILITY a Bodily Injury I I Each Iverson Each Accident I b. Property Damage -- - i Each Accident _. a C. Bodily Injury& I Property Damage Single Limit � Each Accident $1 1.300,[)00 $I,oo00,, $3.,L)©U,0�3C $t,COO i)00 ---------- PHYSICAL VCRRG DAMAGE .. _ -YES ❑ NO _ - -_ C ❑YES ❑ NO ❑ YES [� NO [ YES ❑ NO a. Comprehensive - $ Dedubtible $ Deductible $ -- Deductible $ Deductible YES ❑ NO ❑YES ❑ NO ❑ Yes ❑ NO E, YES ❑ No b. Collision '._-.. DedMUIDJe Deductible I $ Deduct€Ne $ Deductible EMPLOYE~F25 NON-©WNF CAR LIABILITY COVERAGE ❑ YE5 [I NO YES F1NO ❑ YES ❑ NO ` ❑ YES ❑ NO HIRED CAR LIABILITY i - COVERAGE ❑ YIES ❑ NO I ❑ YES ❑ NO ❑ YES ❑ IVO ❑ YEs ❑ NO I FI EET COVERAGE FOR ALLEIHANI LICENSED MOTORC]TOR VEWIClES El YES El NO ❑ YES �] NO [ ] YES ❑ NO ❑ YES El NO OR AGENT 7: _8323 D:L/14/C):1 -.... ........ ... .... ------ Ignature of gut n ze Re serrtabve Title _... Agent's Code Number Sate Name and Address of Certificate Holde€ Name and Address of Agent - - _ .. .....— ...._ _.. EY O ;.FN Ti1711 L2.P75'SRI�PIC) jCEIhT R. MC II�EIIT LSC 0!17N9' RECAF,DING SRRF.A. VISTA PROJECT 32221 CAMINO CAUZ5T'RANC3, B-105 3030[ CAM1,NC) C.�p rr,f,RAN a SwN Jt3AN r}1Pz5mRA\i0, CA, 51AN JtTAN CAP ISTRANO, CA =,2675 3 ..... _._.. INTERNAL STATE FARM USE ONLY [I Request permanent Certificate of Insurance for[lability coverage. _ 01/14/OS 0F:2Zpm P. ©OZ 4tRtf sRNM r=uP CERTIFICATE OF INSURANCE SUCHvINS RANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDEN 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 AUTOM0131LE 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 Inas coverage in force for the following Named Insured as shown below: ----- ._.... ..... _.—._ NAMED INSURED. FATESS COMPANY BUILDEP> ;, INC- 3103,8 RANCHO VTF,,T0 PD 5'T Fi ADDRESS OF NAMED INSURED: SAN JUAN CAPITRAIiO, CA 92675 � POLICY NUMBERi}�41 ?95�; � 13F Jl9 6s ti[?4 1 16� 9936 DU7 1"3 R�)1 68 C.1`�-7`� ....... ...... ....... ............. ............ . ..... 3 EFFECTIVE DATE I OF FOIACY i /19/G4 06/1.9/05 Ufa/04/04-02/04/051.0/0710 T -04/07/05 100.1 04--04/14/00 DESCRIPTION OF 1998 GMC STAKE 2003 FORD 7.250 2002 VOLKsWALW)N EMPLUYFRS NON— VEHICLE(Including VIN) SEI) SUPER D-TY PU JETTA TATAGON OWNED ACtTO __,__ _. __.... LIABlI ITY COVERAGE N YES ❑ NO ❑YES ❑ NO �YES ❑ NO N YES E, NO LIMITS OF LIABILITY a, Bodily Injury Each Person Each Accident i b. Property Damage I Each Accident c. Bodily Injury& Property IDarriage Single Limit _ Each Accident $I,0(J0,OOCiS1.000,000 g;3,C)(,G,0r)0 51,0()(),O00 COVERAGES C ] YE5 [] NO ._ PHYSICAL DAMAGE - �� ❑ YES ❑ N0 -1 YES ❑ No ? DYES ❑ NO a. Comprehensive $.. .. __._.._.._. Deductible i._ _. _Deductible $ Deductible _ Deductible – D YES ❑ No [ ] YES ❑ NO ❑ YES ❑ No ❑ YEs ❑ No b CoillsTon $ Deductible $ Deductible $ Deductible $ Deductible EMPLOYERS NON-OWNED � CAR LIABUTY COVERAGE E] YES ❑ NO ❑ YES ❑ NO YES [I NO ❑ YES [-INO - --- – HIRED CAR LIABILITY i YES NO YES ❑ NO y COVERAGE ❑ t.� ❑ ❑ ES ❑ NO ❑ YES ❑ NO FLEET-COVERAGE FOR ALL OWNED AND CLES NsI a ❑YES 1:1 NO I ElYES ❑ NO YES [J NO ❑ YES ❑ NO MOTOR VEHICL s AGENT 7.'a-23:3 C1]4/0Ti 0nature A Authorized Represeotative Title Agent's Code Number Date arae and Address of Certificate Halder Dame and Address of Aq, Int_.. Li I"r 3 C n JJ AN CrlP;S'Irlttd0 C J .:ItT ?. NCMMAv LiC Q5769'73 Ftr'GARDILN S1'RRRA VISTA -_PRc)CTE07 3237.1. C:kMIINO (:APiS'-PRANG, t3 105 30300 (.:AMINO ; APTSTP.]'NO SAN MAN CAT?i `PANG , CA i1�N t?�t\T (AI'L.STP.A?t), (-,A i i TNTEF2NAL STATE f ARM USE ONLY: ❑ Request perrnaaent Certificate of Insurance for liabMy coverage.