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04-1108_FRIESS COMPANY BUILDERS_Fee and Developer Deposit Computation Form DC- .�•.. City of San Juan Capistrano at Planning-Department 32400 Paseo Adelanto San Juan Capistrano,California 92675 FEE AND DEVELOPER DEPOSIT COMPUTATION FORM GENERAL-&PERMIT FEES ACCO tlN No; -- F – C2 Research: hours $25/hour Land Use Adjustment $300 Sign Permit $100 Grand Opening&Promotional Banner $25 Sign Monument(not part of AC application) $300 Special Event.Permit lication varies see fee resolution Street Banner $80, Tem ra Si n Permit $25. . Temporary Use Permit $150 Zone Variance $750 Site Plan Review $500 Exception to Radio/Dish Antenna Regulations $100 Exception to Tide 9 Regulation $750 Pre-application Consulta#ion/Preiimina. Review $150 Other .:./L � D,690S: .I— A 7 aZ 75. 00 1 A' 7,275% ACCOt1N1T W..014521 General Plan Ma $5.00 each Zonin Ma $5.00 each Los Rios Specific Plan Ma $5.00 each Pt 13UCATIONS-A 'COUNT NO.01.4521 General Plan or General Plan EIR $32 each General Plan Appendices $46 each Title 9 Land Use Code sold in City Clerk's Office Demographic Statistics $3.50 each Las Rios Sp2cific Pian $9.00 each Architectural 222!2n Guidelines $13.50 each Plann!29 Commission minutes(copies of tapes) $20.00/1 st+ $5.00/2"d or 314 Copies: pages I $0,20/page CONSULTANT CONTRACT FEE$.-ACCOUNT NO.18- Project Dame: Log.No. DEVELOPER DEPOSIT-ACCOUNT NO. 'IB- Project Name: Log No: Prepared by: � Date: r Check No: .90�420050.2 Total: 7, 7S Check Payor: Receipt No: ft IHSS 6,In /" R\PlanningkPlan sharediDept.FonnsTormFeeComp.wpd . p'a„' Ti4iS�M 1="f:OhE*AF2EA�OF 7:F:ii=aC70' UIN i+i7,�CMi4•N.fiES"ti.0is [3 fiD•ILLL*lla�`1V©, YEhL?f�FECt]fJ[, WlkR1 TOa�1:�H'f 1!�€t•:H C,�,AF.it6LFi -REASzBOTFi:QP ANL7•BOTFOIN. - y DO 3 IRS ,"` '�,,�p£�+i.` 3' ::°�i s;.e '� '�`a�-� a ?.y P ,�� ,E '�,�,��'t P�°e•�", ti' � n •w. 7�I,:..*.p•�`�`ti�: E !'.'f: '✓'°�'.9 ::s�' ? C .,.^^` �i" �I• ,s^ i',e , �. ,r'..3s r�E ✓ a- � , t��� - p' >_�: B:% r re , �� ,N3 :��s - �� ��^��_,M�a��;.r.�„a ��'-C"K: � i�9�`! �, s,'�,�.�y��`•'- �'w�ld'^tl, .�^`.� -t'S�•>,� i', a�ze;-; ee�-.,',, UNION e ;",0'64,,✓'r sl-tom :e#` n -z� 5 .r'A#E i49e- f- .:Fs �" F si +t 4:i- 4 �=' ( st.--z:" 's a g a' ` SAf1PtUs� t� bfrcf# zdrgztfirt - tV9" frt�771,T1Dh8J3sfFat NDreTtibeLT9,2 �4 8 CITY CF SAN JUAN�AF?IS T OR[7E�t OF RAN© REMFTTEf? �ANt L 1R$FRI S ..:. - (A THOR1ZE SIGNA E)- PY7RM OD2S5 t3(n191z9f2o03) ov0dey lD 00241-'T3(01W:141204) ._._...._,._ _to =»a.,•�...='a-. � _.._.::,mss........,...-.:.M.,.•. 111100 L. 5000 50 2111 1: 12 1000 49 71: 0 5 P 600000 6fE" :< BANK —' CEIVCI7 TRANSIT CHECKS $CASN DATE NAME , pE'SC IPTION 8Y INVALID Q$$� SIGNATURE 1776 CITY OF SAN JUAN CAPISTRANO 32400 PASEO ADELANTO SAN JUAN CAPISTRANO, CALIFORNIA 92675 ccztr�zs prsa) DATEIMMIDDfYM ACDRP, CERT FICA) OF LIABILITY INSURAiiCE 12/13/24441 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 ssion Viejo, CA 92691 INSURERS AFFORDING COVERAGE NAIC# INSURED Friess Company Builders Inc; INSUREtA: Admiral Insurance Company/Stewart Smith Wes- Friess Construction Inc. INSURERS: State Camp Insurance Fund 210 31658 Rancho Viejo Rd #B INSURERC: QBE Insurance Corpo rat i on/c/oDeaiis Homer San .Juan Capi strand,Ca. 92675 INSURER D INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS, INSR DD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY CA 0000303-03 07/27/2004 07/27/2005 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50,000 CLAIMS MADE rX OCCUR MED EXP(Any one person)PR5MISr1;Irg on i. $ EXCLUDED A Xff�: PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 2,000,000 X POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINE€}SINGLE LIMIT $ ANY AUTO Ea accident) ALL 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 S ANY AUTO EA ACG $ . OTHER THAN _ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE S OCCUR ❑ CLAIMS MADE AGGREGATE $ - DEDUCTIBLE $ --- RETENTION $ $ WORKERS COMPENSATION AND 15941.17-04 07/01/2004 07/01/2445 X We sTATU- OTH- EMPLOYYERS'LIABILITY B ANY PROPRIETORIPARTNERIEXECtUTIVE E EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under ..._ SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1 $ 1,000,00 OTHER 2612656 11/03/2004 11/03/2005 BPP:$60,000./special/RC Ded us-Iness Personal C roperty;Contr. Equip I $500;Contr Equip $36,800/ACV Newly Aquired $25,000. DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS E: SERRA VISTA - PROJECT #02-270, 30300 CAAMINO 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 11 EXCEPT 10 [SAYS 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 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 11-arryHines/JESSIC ACORD 25(2001108) OOACORD 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 1S 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(2009!08) 02/03/2005 09: 1.6 FAX 9494893340 , FRIESS OOI l U ESS CONSrRUCrION GROUP 3165'Tea"6hO VZSIO RORG9, suit,- $ . SG7VtJuavt CapiGts'av+.a CAJ--1675 rcZepAOAe:y 914�7y7-0r; FAX:j4jl-?49-943 TOFrom.: Fax- pages:3 r1653 p���e5: !�! C n�-e-A Phone: - r U 02/03/2005 09: 18 FAX 9494893340 FRIESS LEUUV4 te: Z/:3/Z00b 'i'iM6: 9 : Ib AM J'Q :! FliIEbb (:Ui"!P1A.1 Y 13U1LDEIC. Monica td 2413-84:33 Page: 002-003 ! 10A AC-QD,I CERTIFICATE OF LIABILITY INSURANCE 1,/ i3/�'roz PRODuccA .(949)S8Z-S770 FAX (949}592-3 12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 5 P I B Insurance Agency Inc. ONLY AND CONFERS NO RIGH`[S UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR License Number 0119264 ALTER THE COVERAGE AFFORDED BY YHE!POLICIES BELOW. 26441 Crown Valley PaekwAy Mission Viejo, CA 92691 INSURERS AFFORDING COVERAGE NAIL A INSURED Friess Company Builders Inc; €NSURERA Admiral Insurance Company/Stewart Smith Woes, ;dba;FM Electric INSURER I. State ICOM Insurance Fund 210 31558 Rancho Viejo Rd #B 1N1!UHLRC QBE Insurance Corporation/c/oDea sHomer San Juan Capistrano,Ca, 91675 lb.ISl€acpn Lloyds of London/E.L.M-Ins.geoke s INSURER E COVERAGE THF POI,ICIFS OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTW ITHSTANDINr ANY REQVIRI~MENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCJMF—NT W!7H RESPFCT TO WHICH THIS CERTIFICATE mAY BE;ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED FIV THE POLICIES PESCRIOEO HEREIN IS SUOJECT TO ALL THE TEAMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS €kco oD TYPE.OF IWAURANCE,' POLICY NUMBER POLICY EFFECT VE POLICY EXPIRATION LIMIT£ GENERALLIARI€.I1Y CAOOOO 0303-03 07/27/2004 07/27/2005 EACH OCCUPPENCE s 1,000 00 COfdntERCwL GENERxL uABIL€T Y DAMAGE TO RENTED S ,50,00 11CCC f�ynrr.n CLAIMS MADE I V I OCCLJQ PEO EXP IAnTonsraenw) S EXCLUDE A X PERSONAL A ADV INJURY S 1,000.0 GENERALAGGREGATE % 2,000,00 CEN'L AGGREGATE LIwT APPLIES PER PRODUCTS-COroWrOP AGG E 21000,000 X POL€CY 1 j,CT O. LOC I AUYONOWLE LIA$ILITY COMBINED S�IGL£1,INft7 ANY AUTO (Ea�cndsn;l ALL OWNED AUTOS aDDILY IWURY $ (Per venon0 SCHEDULED AUTOS WIRED AUTOS BODILY INJURY a (Fer 2coden11 NGNOw;�ED AUTOS j I PROPERTY DAMAGE $ ! €Per eCOEBl1lI GARAGE LIABILITY AUTO ONLY EA ACCIDENT S pNv AUYO OTI IER THAN EA ACC S Au IO ONLY. AGC $ EXCESSIUMBREL.I.A LIABILITY LACII OCCUNKH NCL. S OCCurt CLAIMS MADE I ACCRECATE S i $ OE DUCTIBLE RETENTION 5 1 WOKKE"COMPENSKnONAND 7.594117-04 07/01/2004 07/01./2005 X wcsTATu- OTN� EI�Ps.DYER&tIABtUTY El EACH ACC€DENT S 11.00010 GO B ANY PROPMETORIPARTNOLEXECUTIVE OFFICERWEMBEKtArLUOED' EL D€SEASE-EA£MPL.OYE 1 1 Q O ItyyeS descnoe under E L DISEASE•POLICY LIMN 1 1,000.000 SPEC!AL PROVISIONS an€ow oTTIIft 26126S5 11/03/ZO04 11/03/2005 BPP.$60,00O./speciall/RC ped CBusiness Personal SSOO;COn�[r Equip 535,800/ACV roperty:Contr. Equip Newly Aqui red 515,000. DESCRIPT1On OF OPERATIONS I LOCAYIDNS I VIEWCUE5I EXCLUSIONS ADDIS DY ENOORSEMFNI'I SPECIAL.PRO'+SSIONS E: SERRA VISTA PROJECT #02-270, 30300 CA 1NO CAPISTRANO, SAN JUAN CAPISTRANO, CA 92575 ERTIFICATE HOLDER IS NAMED AS ADDITIONAL ISURED WITH RESPECT TO GENERAL LIABILITY AS PER FORM CGZOZO 07/04) ATTACHE[) 'revised certificate 2/3/OS" EXCEPT 10 DAYS NOTICE OF CANCELLATION FOR � N-PAYMENT OF PREMIUM ERT IFI p CANCELLATION SHOULD ANY OF THE ABOVE DEACR18E0 POLICIES BE CANrELLFD BEFOR@ THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL.E'NDfAVOR TO[MAIL , O DAYS WRMEN NOTICE TO THE CERTIFICATE ROLMR NAMED TO TIIE LrzFT, CITY OF SAN JUAN CAPISTRANO. BUT FAILURE TO"L SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILrT`! 32400 PASEO A[DI LANTO OF ANY XING UPON THE INSURER,ITS AGENTS OR REPRESENTATNES. SCAM 11I@AI rACIYCTIDA►IA CA 01411 i s11Y�an411Fr\�K���>x�IYsafvK r 02/03/2005 09: 17 FAX 9484893340 FRIESS Wcuul) 1 11:3:1i;0i� ','.'ime: 9: 1t Aly TO : PkilEb'-i t;UMPA.NY tWILDE14- �MOXUCa (;_0 ?48--8433 Page: 003-003 PeUcy Numba- CA000OW303-03 cO:o zo 0184 L115mbvc Date-07n712W4 3I WS (ENDORSEMENT CHANG; S T>il(;E POLICY. PLEASE RFAD IT CAREiFU)<LY. ADMIONAL WS�RED - OWNERS, LESSEES OR CONTRACTORS - SCHEDuLED rERSON OR 0 ANIZATION This tmdorsenwrit modifwcs insurance:provi d undcr t6c following; COMMERCIAL OFNEt2,AL LlA BnJTY COVERAGE PART SC1Eifl�laLnE.>lt NAn14 Of Additionxl ilnanred F sy or dr ttu:xrrt7ao a: I 1A" x Of Co*ary d Pocridons ANY ENXTr Y FOR WHOM YOU ARE PFXFC ALT.COVERED!'RWEC S ONGO NG OVE&ATIONS.BUT ONLY IF RE=WREI7 BY wRrrTEN CONTRACT 1?FUO1R.TO AN"OCCZ?7MNC'E" OR LOSS. CITY OF SAN JUAN CAPISTRANO CA. Tn(or(rmtion t vuvd ro co [M yetis Schedule if pot 0cwn above,will be shownto flue Dccl =cions. A- Stedon U—Wko L An.[mlurad in smepeA to Ibis it omuocc docs not apply to"bodily ircj4tr or utict«dr a s axe xddioont)rnxxued�c�tcTsan(c)lor `propcM drtuualgc"oocil nng aftut: oz ation(s)rltoarn un Tbt:Sctaredakq but mdly Wilk 1. All uratic.imluding n ateri th,parts or rquipma-m re5P$tC1 to L ah&y fm'bodity igaM",' fitrn►s"in cats =cm wit vx)l Work.nm Tht daxmege"or"Rer#*vAl abd mfverWxaag lft#uy"CWmv4 project(unser thin scrvicz„maitttcn=e or in whole of in pare,by: rcpaium)to be perfmmed by of on behalf ofilic t. You Orta os 07,bi kWw or additional insacdjs)ax Tbc locsdon of flet; 2. The acts or omumnx of tbo- ecvng an your corercd opmtintts bA3 bm completed;,or behatf. 2. Thar portion of"you-ock"our of which the to rhe perfbkvtA aec of'your aagoing,OwAnol ibr the uyury or damage amet ha4 beer+put tR itr additional on:�xrcJ(x).a the lar.:t.au0s)dcv i�ys6-d wtrnded use by 411y ptT an Or other sbgvc. than snotber contractor or sobconttat:tor engagod iu perforuiing upersrtona for s principal as is pail 8. With rcipact to the is151uvricc a"fTorded to the of the sme aproject. addtuorml msw-uda,ibe f+ollowint additional rxrlusiom apply: c0 20 to 07 04 a ISO Propmics.Inc.,20004 71tir�s 1 of T C3 ate; 10/4/20(]4 Time: 12 ;51" IM TO: FRIESS COMPANY BUD .R (Fries @ 248-8433 Page: 00---002 POLICYHOLDER COPY STAT P.O.Box 424801, SAN FRANCISCO,CA 94142-0807 COMPE14SATION INSuPtA"Cz FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 10-04-2004 GROUP: POLICY NUMBER: 1594117-2004 CERTIFICATE ID: 77 CERTIFICATE EXPIRES: 07-01-2005 07-01-2004/07-01-2006 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 California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advanc*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 after 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 cartiffcate 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;ofsuch policy. AUTHORiZEl)REPRF_%NT'ArIVE - PRF510FNT - ZMPL6Y[ER'9 LIAZILITY'LIMIT INCLUDING DEFENSE COSTS. $1y004,000'-PER-OC°CURRENCE 9NDORSEMENT- #16-00 - KENNETH E. FRIESS, SEC, TRES - EXCLUDED. ... .. . ._. ENDORSEMENT #1600 - DANIEL FRIESS, PRESIDENT - EXCLUDED. ENDORSMCENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE RFFECTIVE 07-01-2041 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER FRIESS COMPANY BUILDERS,INC. FRIESS CONSTRUCTION, INC . 37.658 RANCHO VIEJO RD STE B SAN JUAN CAPo CA 92675 01,,142015 0S:ZZpm H. W01 STATE FARM INSURANCE COMPANIES JOHN MCMATIAN , AGENT 32221 CAMINO CAPISTRANO SAN JUAN CAP I-STRANO , CA 92675 FACSIMILE TRANSMITTAL SHEET TO; FROM: NY comp NY; ....2........... ........ 9 INCLUDING COVER: PAX N r TOTAL SENDER'S REFERENCE NUMBER; (049) 061-W5 RE: YOUR REFERENCE NUMBER:. O URGENT 13 FOR REVIEW q PLEASE COMMENT O PLEASE REPLY PLEASE Rbc CL8 01/14 '06 05:22pm P. 003 CERTIFICATE OF INSURANCE S.UCHiNS RANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE n*Ne 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: 0 STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois F] STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois [,] STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas,Texas , or F.1 STATE FARM INDEMNITY COMPANY of Bloomington, Illinois has coverage in force for the following Named Insure-da,s shown below: NAMED INSURED, FRIESS COMPANY RUT.LBERS, INC. 31.6558 RANCHO VIE,70 RD STE B i ADDRESS OF NAMED N8URFD: SAN JUAN CAPTSTRANO, CA 92675 POLICY NUMBER 71851-_C25__,75C D12 8435--D29 "7SC L36 '7525-A15-75G P43 8807 ..714 75F. .................. .... ......... EFFECTIVE DATE OF POUCY 110/25/0,1-03/25/05 10/29/04-04/29/05- 10/14/04-04/14/05 DF SCRIPFION OF 19G1 FORD F��50 VEHICLE(Inalluftg VIN) 19q8 GFIC SAVANA. 1999 DODGE RAM PU STAKE, BED 19B9 FORn F250 PU LIABILITY COVERAGE YES 1-1 NOYE S El NO Dq YES L] NO ® YIDS El NO ...................... LIMITS OF LIABILITY a. Bodily Injury Each Person Each Accident b Property Damage Fach Accident c. Bodily Injury& Property Damage Single Limit Each Accident $1,000,000 j 1,j,D(10,D00 $�L,Coo,000 ...................... .... PHYSICAL DAMAGE COVERAGES 0 YES ❑ NO F1 YES El NO ❑ YES El NO [:1 YES El NO a. Comprehensive I $ Deductible $ Deductible $ Deductible $ DeduObie 0 YES Ll NO LIYES [-I NO 0 YES EINO FI YES ED] No- b. Collision $ Deductible Deductible i $ Deductible $ Deductible EMPLOYERS NON-OWNED RED COVERAGFE 0 YES D NO DYES F1 NO F -1 YES El NO Ej YES FINO ................- -------- HIRED CAR UABILITY [I YES ONO COVERAGE 7 YES D No E]YES F1 NO -1 YES ❑0 NO FLEET-COVERAGE FOR ALL OWNED AND LICENSED I, 0 I MOTOR VEOGLES YES [:1 NO [I YES D NO DYES ❑El N D YES El NO ................... . . ...................... --------- AGENI'_ 75-8323 01/14/05 igrrature of i Arlt b6il(ze' ReWsurn6 tive- Title Agent's Code Number Date Name and Address of Certificate Holder Name and Address of Agent CITY OF SAN JUAN CAPISTRANO JOIN R. MCMLHAN LIC 0576973 REGARDING SERRAVISTA PROJECT 32221 CAMINO CAPIETR7-1,N0, 13-105 30300 CAMINO CAPISTRANO SAN JTTAN CAPISTRANO, C.A. SAN JUAN CAPTSTRAN10, CA 92675 INTERNAL STATE FARM USE ONLY, [I Request permanent Certificate of Insurance for liability coverage. 01/14/06 O5z22pm P. OOZ ILTAII SJ CERTIFICATE OF INSURANCE S4"4NS. RANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE OR OTHERWISE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM THE DATE WRITTEN, THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED BELOW. This certifies that: Z STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois El STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois El STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas,Texas , or F1 STATE FARM INDEMNITY COMPANY of Bloomington, Illinois has coverage in force for the following Named Insured as shown below: NAMED INSURED: 77TESS COMPANY BUILDERS, INC. 31CibE RANCHO iTTFJO PD STE 'R ADDRESS OF NAMED INSURED: sAN j-uAN cAPISTRANO, cup, 92675 POLICY NUMBERP47 3958-719 73E 074 6-i4-,'-B04-75 068 9916-D-07-75 R51 5 C 568- '5-71;1' EFFECTIVE DATE-_ OF POLICY 1,0/07/04-04/07/05 ID/14/04-04/3.4/05 DESCRIPTION OF 1998 GMC STIA171 2003 FORD F250 2002 VOLKSTkkGON EMPLOYERS VEHICLE(Including VIN) SUPER DUTY PU JETTA t,TACON O-KNED AUDO I LIABILITY COVERAGE YES ❑ NO 0 YES El NO M YES El NO Z YES 0 NO LIMITS OF LIABILITY a. Bodily Injury Each Person ................................... Each Accident b. Property Darnage Each Accident c. Bodily Injury& Property Damage Single Limit Each Accident $1,()00,oflo $1'0-00,000 $ 1 ,000,ODO coo, 00 PHYSICAL DAMAGE COVERAGES F-jYES El NO FYES [j NO YES El NO 0 YES El NO ❑ a. Comprehensive $ Deductible $ Deductible I Deductible $ beduObie DYES ❑ NO F] YES FINO ❑ YES El NO F YES NO b. Collision $ Deductible $ Deductible Deductible $ Deductible EMPLOYERS NON-OWNED CAR LIABILITY COVERAGE Fj YES E] NO 0 YES FINO F1 YES L] NO EIYES NO HIRED CAR LIABILITY COVERAGE ❑YES [I NO Ej YES E] NO ❑ YES El NO El YES [:1 NO .......... FLEET-COVERAGE FOR ALL OWNED AND LICENSED YES NO YES ❑ NO D YES [:1 NO DYES LJ NO \MOTOR VEHICLES ❑ ....................................... AGENT T-'�-8323 0114/05 rJnatur nt Authorized Representative Title AgentES Code Number Date ame and Address of Certificate,Holder Name and Address of Agent CITY F0 Ss'-\N JUAN CAPTSTRkNO --T-j6,,2FP,. MC-IMH7,1,1 LIC 05769'?3 REGA1-1j)ING SERRA VISTA. PROJECT 132221 CAMINO CAPiSTRANO, 2-105 30300 CMAINO CA-PTSTRANO SAN JUAN CAP1512RANO, (,A SAN IJUANI CAPISTRANO, CA 926-/5 INTERNAL STATE FARM USE ONLY: 0 Request permanent Certificate of insurance for liability coverage,