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19-020 Griffin Painting, Inc., for Cupertino Teen Center PaintingCITY OF
m PUBLIC WORKS CONTRACT
$60,000 OR LESS
C UPERTINO
1. PARTIES
This public works contract ("Contract") is made and entered into on _...,I J ..... ;;.,__.j __ )_J ..... 9....__ ____ _
("Effective Date") by and between the City of Cupertino, a municipal co~poration ("City"), and
Griffin Painting Inc. , a Corporation
("Contractor") for Cupertino Teen Center Painting
2. SCOPE OF WORK
Contractor will perform and provide all labor, materials, equipment, supplies, transportation and any
other items or work necessary to perform and complete the work required for the Project ("Work"), as
required in the Scope of Work, attached here and incorporated as Exhibit A, and in accordance with
the terms and conditions of this Contract.
3. TIME FOR COMPLETION
3.1 Term. This Contract begins on the Effective Date and ends on March 31, 2019
("Contract Time") unless terminated earlier as provided herein. Contractor's Work shall begin on the
date shown on a written Notice to Proceed ("NTP") and must be fully completed within the Contract
Time or on the date specifically provided in the Notice to Proceed. The City Engineer will not issue a
NTP until the Contract is fully executed by both parties and City has received satisfactory proof of
insurance and any performance and payment bonds that may be required.
3.2 Time is of the essence for Contractor's performance and completion of the Work. Contractor
must have sufficient time, resources, and qualified staff to deliver the work on time.
3.3 Liquidated damages of$ 200.00 will be charged for each day of unexcused delay,
or City may deduct the amount from Contractor's payments. Liquidated damages are based on
reasonably foreseeable consequences of delay and may include intangible losses which the Parties
agree may be difficult to ascertain, such as loss of public confidence in City and its contractors,
interference or loss of use of public facilities, and extended disruption to the public.
4. COMPENSATION
4.1 Maximum Compensation. City will pay Contractor for satisfactory performance of the Work
an amount that will based on actual costs but that will be capped so as not to exceed $ 8 800. 00
("Contract Price"), for all of Contractor's direct and indirect costs, including all labor, materials,
supplies, equipment, taxes, insurance, bonds and all overhead costs.
4.2 Invoices and Payments. Contractor must submit an invoice on the first day of each month,
describing the Work performed during the preceding month, itemizing labor, materials , equipment and
Public Works Project Cupertino Teen Center Painting
Public Works Contract $60,000 /Rev. Jan. 02, 2019
Page l of 11
any incidental costs incurred. Contractor will be paid 95% of the undisputed amounts billed within 30
days after City receives a properly submitted invoice. Any retained amounts will be included with
Contractor 's final payment within 60 days of City's acceptance of the Work as complete .
5. INDEPENDENT CONTRACTOR
5.1 Status. Contractor is an independent contractor and not an employee of City . Contractor is
solely responsible for the means and methods of performing the Work and for the persons under this
employment. Contractor is not entitled to worker 's compensation or any other City benefits.
5.2 Contractor's Qualifications. Contractor warrants on behalf of itself and its subcontractors that
they have the qualifications and skills to perform the Work in a competent and professional manner and
according to the highest standards and best practices in the industry.
5.3 Permits and Licenses. Contractor warrants on behalf of itself and its subcontractors that they
are properly licensed, registered , and/or certified to pe1form the Work as required by law, and have
procured a City Business License . Contractor shall possess a California Contractor's License in good
standing for the following classification(s): C33 , which
must remain valid for the entire Contract Time .
5.4 Subcontractors. Only Contractor's employees are authorized to work under this Contract.
Prior written approval from City is required for any subcontractor, and the terms and conditions of this
Contract will apply to any approved subcontractor.
5.5 Tools, Materials and Equipment. Contractor will supply all tools, materials and equipment
required to perform the Work under this Contract.
5.6 Payment of Taxes. Contractor must pay income taxes on the money earned under this
Contract. Upon City's request, Contractor will provide proof of payment and will indemnify City for
violations pursuant to the indemnification provision of this Contract.
6. CHANGE ORDERS
Amendments and change orders must be in writing and signed by City and Contractor. Contractor's
request for a change order must specify the proposed changes in the Work, Contract Price, and
Contract Time. Each request must include all the supporting docwnentation , including but not limited
to plans/drawings , detailed cost estimates, and impacts on schedule and completion date.
7. ASSIGNMENTS; SUCCESSORS
Contractor shall not assign, hypothecate, or transfer this Contract or any interest therein, directly or
indirectly , by operation of law or otherwise, without prior written consent of City. Any attempt to do
so will be null and void . Any changes related to the financial control or business nature of Contractor
as a legal entity is considered an assignment of the Contract and subject to City approval, which shall
not be unreasonably withheld. Control means fifty percent ( 50%) or more of the voting power of the
business entity. This Contract is binding on Contractor, its heirs, successors and permitted assigns
Public Works Project Cupertino Teen Center Painting
Public Works Contract $60,000 /Rev. Jan. 02, 20 19
Page 2 of 11
8. PUBLICITY/ SIGNS
Any publicity generated by Contractor for the Project during the Contract Time, and for one year
thereafter must credit City contributions to the Project. The words "City of Cupertino" must be
displayed in all pieces of publicity , flyers, press releases, posters, brochures, interviews, public service
announcements and newspaper articles. No signs may be posted or displayed on or about City
property, except signage required by law or this Contract, without prior written approval from the City.
9. SUBCONTRACTORS
9.1 Contractor must perform all the Work with its own forces, except that Contractor may hire
qualified subcontractors to perform up to 20 % of the Work, provided that each subcontractor
is required by contract to be bound by the provisions of this Contract. Contractor must provide City
with written proof of compliance with this provision upon request.
9.2 City may reject any subcontractor of any tier and bar a subcontractor from performing Work on
the Project, if City in its sole discretion determines that subcontractor's Work falls short of the
requirements of this Contract or constitutes grounds for rejection under Public Contract Code Section
4107. If City rejects a subcontractor, Contractor at its own expense must perform the subcontractor's
Work or hire a new subcontractor that is acceptable to City. A Notice of Completion must be recorded
within 15 days after City accepts the Work if the Contract involves work by subcontractors.
10. RECORDS AND DAILY REPORTS
10.1 Contractor must maintain daily reports of the Work and submit them to City upon request and
at completion of Project. The reports must describe the Work and specific tasks performed, the number
of workers, the hours, the equipment, the weather conditions, and any circumstances affecting
performance. City will have ownership of the reports, but Contractor will be permitted to retain copies.
10.2 If applicable, Contractor must keep a separate set of as-built drawings showing changes and
updates to the Scope of Work or the original drawings as changes occur. Actual locations to scale must
be identified for all major components of the Work, including mechanical, electrical and plumbing
work; HV AC systems; utilities and utility connections; and any other components City determines
should be included in the final drawings of the Project. Deviations from the original drawings must be
shown in detail, and the location of all main runs, piping, conduit, ductwork, and drain lines must be
shown by dimension and elevation.
10.3 Contractor must maintain complete and accurate accounting records of its Work, in accordance
with generally accepted accounting principles, which must be available for City review and audit, kept
separate from other records, and maintained for four years from the date of City 's final payment.
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Public Works Contract $60,000 !Rev. Jan . 02 , 2019
Pa ge 3 of 11
11. INDEMNIFICATION
11.1 To the fullest extent allowed by law, and except for losses caused by the sole and active
negligence or willful misconduct of City personnel , Contractor shall indemnify , defend, and hold
harmless City , its City Council, boards and commissions , officers, officials , employees , agents,
servants , volunteers and consultants ("Indemnitees"), through legal counsel acceptable to City, from
and against any and all liability , damages , claims , stop notices, actions, causes of action, demands ,
charges , losses and expenses (including attorney fees , legal costs and expenses related to litigation and
dispute resolution proceedings), of every nature arising directly or indirectly from this Contract or in
any manner relating to any of the following:
(a) Breach of contract, obligations, representations or warranties;
(b) Performance or nonperformance of the Work or of any obligations under the Contract by
Contractor, its employees, agents , servants, subcontractors or subcontractors ;
(c) Payment or nonpayment by Contractor or its subcontractors or sub-subcontractors for Work
performed on or off the Project Site; and
(d) Personal injury, property damage, or economic loss resulting from the work or performance of
Contractor or its subcontractors or sub-subcontractors .
11.2 Contractor must pay the costs City incurs in enforcing this provision. Contractor must accept a
tender of defense upon receiving notice from City of a third-party claim, in accordance with California
Public Contract Code Section 9201. At City's request, Contractor will assist City in the defense of a
claim , dispute or lawsuit arising out of this Contract.
11.3 Contractor 's duties under this entire Section are not limited to Contract Price, Workers '
Compensation or other employee benefits , or the insurance and bond coverage required in this
Contract. Nothing in the Contract shall be construed to give rise to any implied right of indemnity in
favor of Contractor against City or any other Indemnitee .
11.4 Contractor's payments may be deducted or offset to cover any money the City lost due to a
claim or counterclaim arising out of this Contract, a purchase order or other transaction .
12. INSURANCE
Contractor shall comply with the Insurance Requirements , attached and incorporated here as Ex hibit
B. Contractor must provide satisfactory proof of insurance and maintain it for the Contract Time or
longer as required by City . City will not execute the Contract until City has approved receipt of
satisfactory certificates of insurance and endorsements evidencing the type, amount, class of operations
covered, and the effective and expiration dates of coverage. Failure to comply with this provision may
result in City, at its sole discretion and without notice, purchasing insurance at Contractor 's expense,
deducting the costs from Contractor 's compensation, or terminating the Contract.
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Public Wo rks Contract $60,000 /Rev. Jan. 02, 2019
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13. COMPLIANCE WITH LAWS
13.1 General Laws. Contractor shall comply with all laws and regulations applicable to this
Contract. Contractor will promptly notify City of changes in the law or other conditions that may affect
the Project or Contractor's ability to perform. Contractor is responsible for verifying the employment
status of employees performing the Work, as required by the Immigration Reform and Control Act
13.2 Labor Laws.
(a) Contracts of $1,000 or more are subject to the requirements of the California Labor Code,
including but not limited to:
(i) Prevailing wage laws under Labor Code Section 1775 , which require Contractor
to pay prevailing wages applicable in Santa Clara County for each craft,
classification , or type of worker needed to perform the Work, including health,
pension and vacation . The prevailing wage rates are on file with the City
Engineer's office and are available online at http ://www.dir .ca .gov/DLSR;
(ii) Apprenticeship requirements under Labor Code Section 1777 . 5 for Contacts
$30 ,000 or more ;
(iii) Maintain certified payroll records in accordance with Labor Code Sections 1776
and 1812, and electronically submit them to the Labor Commissioner as
required by the regulations of California, Department oflndustrial Relations
("DIR");
(iv) Comply with DIR Monitoring, Enforcement and Registration requirements of
Labor Code Section 1725.5.
(b) Contractor must compensate workers who are paid less than prevailing wages or required to
work more than a legal day's work. Contractor will also be required to pay City a penalty of
$ 200.00 per worker for each day of violation.
( c) As required by Labor Code Section 1861, by signing this Contract Contractor certifies as
follows: "I am aware of Labor Code Section 3700 which requires every employer to be insured
against liability for workers ' compensation or to undertake self-insurance in accordance with
the provisions of that code, and I will comply with such provisions before commencing the
Work on this Contract."
13.3 Discrimination Laws. Contractor shall not discriminate on the basis of race , religious creed,
color, ancestry , national origin, ethnicity, handicap , disability, marital status , pregnancy , age, sex,
gender, sexual orientation, gender identity, Acquired-Immune Deficiency Syndrome (AIDS) or any
other protected classification . Contractor shall comply with all anti-discrimination laws, including
Government Code Sections 12900 and 11135, and Labor Code Sections 1735, 1777 and 3077 .5.
Consistent with City policy prohibiting harassment and discrimination, Contractor understands that
harassment and discrimination directed toward a job applicant, an employee, a City employee, or any
other person, by Contractor or Contractor1s employees or sub-contractors will not be tolerated.
Public Works Project Cupertino Teen Center Painting
Public Works Contract $60,000 !Rev. Jan . 02 , 2019
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13.4 Conflicts of Interest. Contractor, its employees , subcontractors , servants and agents , may not
have , maintain or acquire a conflict of interest in relation to this Contract in violation of law, including
Government Code section 1090 and Government Code section 81000 and their accompanying
regulations . No officer, official , employee, consultant, or other agent of the City ("City
Representative") may have , maintain, or acquire a "financial interest" in the Contract, as that term is
defined by state law, or in violation of a City ordinance or policy while serving as a City
Representative or for one year thereafter. Contractor, its employees, subcontractors, servants and
agents warrant they are not employees of City or have any relationship with City officials , officers or
employees that creates a conflict of interest. Contractor may be required to file a conflict of interest
form if it makes certain governmental decisions or serves in a staff capacity, as defined in section
18700 of the California Code of Regulations . Contractor agrees to abide by City rules governing gifts
to public officials and employees.
13.5 Remedies. Any violation of Section 13 constitutes a material breach and may result in City
suspending payments, requiring reimbursement, or terminating the Contract. City reserves all rights
and remedies under the law and this Contract, including seeking indemnification.
14. BONDS .
For contracts of $25,000 or more, Contractor must obtain a payment bond and a performance bond,
each in the penal sum of 100% of the Contract Price, using the Bond Forms attached and incorporated
here as Exhibit C. Each bond must be issued by a surety admitted in California, with a financial rating
from A.M. Best Company of Class A-or higher , or as otherwise acceptable to City. If an issuing surety
cancels a bond or becomes insolvent, Contractor must provide a substitute bond from a surety
acceptable to City within seven calendar days after written notice from City. If Contractor fails to do
so, City may in its sole discretion and without prior notice, purchase bonds at Contractor 's expense,
deduct the cost from payments due Contractor, or terminate the Contract. City will not execute the
Contract nor issue the NTP until the required bonds are submitted .
15. UTILITIES, TRENCHING AND EXCAVATION
15.1 Contractor must call the Underground Service Alert ("USA") 811 hotline and request marking
of utility locations before digging or commencing Work. For underground service alerts for street
lighting and traffic signal conduits , City's Service Center must be called at (408) 777-3269 .
Government Code Section 4215 requires Contractor to notify City and Utility in writing if it discovers
utilities or utility facilities not identified in the Contract.
15.2 Pursuant to Government Code Section 7104, Contractor must stop work , notify City in writing,
and wait for instructions if one of the conditions below is found at the worksite. City will work with
Contractor to amend the Contract or issue a change order if the discovered conditions materially
change the Work/Performance, Contract Time or Contract Price.
(a) Material believed to be hazardous waste under Health and Safety Code Section 25117, and
which requires removal to a Class I , Class II , or Class III disposal site pursuant to law;
(b) Subsurface or latent physical conditions at the Project worksite differing from those
indicated by information about the worksite made available to Contractor; and
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Public Works Contract $60,000 /R ev. Jan. 02, 2019
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(c) Unknown physical conditions at the Project worksite of any unusual nature, materially
different from those ordinarily encountered and from those generally recognized as inherent
in the character of the Work.
15.3 For contracts $25 ,000 or higher that require excavation or involve trenches five feet or more in
depth, Contractor must submit a detailed plan for City approval, per Labor Code Section 6705 prior to
commencing work. The plan must show the design of shoring, bracing , sloping and other provisions
for worker protection from cav ing ground and other hazards . The protective system must comply with
all Construction Safety Orders. If the plan varies from shoring system standards , it must be prepared
by a registered civil or structural engineer.
16. URBAN RUNOFF MANAGEMENT
16.1 All Work must fully comply with federal, state and local laws and regulations concerning storm
water management. Contractor must avoid creating excess dust when breaking asphalt or concrete and
during excavation and grading. If water is used for dust control, Contractor will use only the amount of
water necessary to dampen the dust. Contractor will take all steps necessary to keep wash water out of
the streets , gutters and storm drains . Prior to the sta1t of the Work, Contractor will implement erosion
and sediment controls to prevent pollution of storm drains, and must upgrade and maintain these
controls based on weather conditions or as otherwise required by City . These controls must be in place
during the entire Contract Time and must be removed at the end of construction and completion of the
Work. Such controls must include, but will not be limited to , the following requirements :
(a) Install storm drain inlet protection devices such as sand bag barriers, filter fabric fences, and
block and gravel filters at all drain inlets impacted by construction . During the annual rainy
season, October 15 through June 15 , storm drain inlets impacted by construction work must be
filter-protected from onsite de-watering activities and saw-cutting activities. Shovel or vacuum
saw-cut slurry and remove from the Work site;
(b) Cover exposed piles of soil or construction material with plastic sheeting. Store all construction
materials in containers ;
(c) Sweep and remove all materials from paved surfaces that drain to streets, gutters and storm
drains prior to rain and at the end of each work day. When the Work is completed, wash the
streets , collect and dispose of the wash water off site in lawful manner;
( d) After breaking old pavement, remove debris to avoid contact with rainfall/runoff;
(e) Maintain a clean work area by removing trash, litter, and debris at the end of each work day
and when Work is completed. C lean up any leaks, drips , and other spills as they occur.
16.2 These requirements must be used in conjunction with the California Stormwater Quality
Association and California Best Management Practices Municipal and Construction Handbooks, local
program guidance materials from municipalities, and any other applicable documents on stormwater
quality controls for construction . Contractor's failure to comply with this Section will result in the
issuance of noncompliance notices, citations, Work stop orders and regulatory fines .
Public Work s Project Cupertino Teen Center Paintjnq
Public Works Contract $60,000 /Rev . Jan . 02, 2019
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17. PROJECT COORDINATION
City Project Manager. City assigns Ty Bloomquist as
the City representative for all purposes under this Contract, with authority to require compliance with
the Scope of Work City may substitute Project Managers at any time and without prior notice to
Contractor.
Contractor Project Manager. Subject to City approval , Contractor assigns Mark Griffin
-------------------as its single representative for all purposes under
this Contract, with the responsibility to ensure progress with the Work Contractor's Project Manager
is responsible for coordinating and scheduling the Work and must regularly update the City Project
Manager about the status and any delays with the Work, consistent with the Scope of Work Any
substitutions must be approved in writing by City.
18. ABANDONMENT AND TERMINATION
18.1 City may abandon or postpone the Project or parts therefor at any time . Contractor will be
compensated for satisfact01y Work performed through the date of abandonment and will be given
reasonable time to close out the Work With City's pre-approval in writing, the time spent in closing
out the Work will be compensated up to 10% of the total time expended in performing the Work.
18.2 City may terminate the Contract for cause or without cause at any time. Contractor will be paid
for satisfactory Work rendered through the termination date and will be given reasonable time to close
out the Work
18.3 Final payment will not be made until Contractor
1
delivers the Work and provides records
documenting the Work , products and deliverables completed. Nothing in the Section below is intended
to delay, abridge or bar City 's right under this Section.
19. GOVERNING LAW, VENUE AND DISPUTE RESOLUTION
This Contract is governed by the laws of State of California. Venue for any legal action shall be the
Superior Court of the County of Santa Clara, California. The dispute resolution procedures of Public
Contract Code Section 20104 , incorporated here by reference, apply to this Contract and Contractor is
required to continue the Work pending resolution of any dispute. Prior to filing a lawsuit, Contractor
must comply with the claim filing requirements of the California Government Code. If the Parties elect
arbitration, the arbitrator 's award must be supported by law and substantial evidence and include
detailed written findings of law and fact.
20. ATTORNEY FEES
If City initiates legal action, files a complaint or cross-complaint, or pursues arbitration, appeal , or
other proceedings to enforce its rights or a judgment in connection with this Contract, the prevailing
party will be entitled to reasonable attorney fees and costs .
Public Work s Project Cupertjno Teen Center Painting
Public Works Contract $60,000 !Rev. Jan. 02, 2019
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/
21. SIGNS/ADVERTISEMENT
No signs may be displayed on or about City's property, except signage which is required by law or by
the Contract, without City 's prior written approval as to size, design and location.
22. THIRD PARTY BENEFICIARIES
There are no intended third party beneficiaries of this Contract.
23. WAIVER
Neither acceptance of the Work nor payment thereof shall constitute a waiver of any contract
provision . City waiver of any breach shall not constitute waiver of another provision or breach.
26. WARRANTY
Contractor warrants that materials and equipment used will be new, of good quality, and free from
defective workmanship and materials, and that the Work will be free from material defects not intrinsic
in the design or materials . All Work, materials and equipment should pass to City free of claims , liens
or encumbrances. Contractor warrants the Work and materials for one year from the date of City 's
acceptance of the Work as complete ("Warranty Period"), except when a longer guarantee is provided
by a supplier, manufacturer or is required by this Contract. During the Warranty Period, Contractor
will repair or replace any Work defects or materials, including damage that arises from Contractor's
Warranty Work, except any wear and tear or damage resulting from improper use or maintenance.
27. ENTIRECONTRACT
This Contract and the attachments, documents , and statutes attached , referenced, or expressly
incorporated herein, including authorized amendments or change orders constitute the final and
complete contract between City and Contractor with respect to the Work and the Project. No oral
contract or implied covenant will be enforceable against City. If any attachment or incorporated
provisions conflict or are inconsistent with the terms of this Contract, the Contract terms will control.
28. SEVERABILITY /PARTIAL INVALIDITY
If a court finds any term or provision of this Contract to be illega l, invalid or unenforceable, the legal
portion of said provision and all other contract provisions will remain in full force and effect.
28. SURVIVAL
The contract provisions which by their nature should survive the Contract or Completion of Project,
including without limitation all warranties , indemnities , payment obligations , insurance and bonds ,
shall remain in full force and effect after the Work is completed or Contract ends.
Public Works Project Cupertino Teen Center Painting
Public Works Contract $60,000 !Rev. Jan. 02, 2019
Page 9 of 11
29. INSERTED PROVISIONS
Each provision and clause required by law to be inserted in this Contract will be deemed to be included
and will be inferred herein. Either party may request an amendment to cure mistaken insertions or
omissions of required provisions .
30. CAPTIONS
The captions, titles, and headings in this Contract are for convenience only and may not be used in the
construction or interpretation of the Contract or for any other purpose.
31. COUNTERPARTS
This Contract may be executed in counterparts, each of which is an original and all of which taken
together shall form one single document.
20. NOTICES
All notices , requests, and approvals must be sent in writing to the persons below and will be
considered effective on the date of personal delivery, the date confirmed by a reputable overnight
delivery service, on the fifth calendar day after deposit in the United States Mail, postage prepaid,
registered or certified , or the next business day following electronic submission:
To City of Cupertino:
10300 Torre Avenue, Cupertino CA 95014
Attention: Ty Bloomqui st
Copy to : carlv@cupertino.org
Email : ty b@cupertino.org
30. VALIDITY OF CONTRACT
To Contractor:
Griffin Painting Inc .
Attention: Mark Griffin -------------
Copy to :
Email : mark@griffinpainting.com
This Contract is valid and enforceable only if (a) it complies with the purchasing and contract
provisions of Cupertino Municipal Code Chapters 3.22 and 3 .23, (b) is signed by the City Manager or
an authorized designee , and (c) is approved for form by the City Attorney's Office.
32. EXECUTION
The persons signing below warrant they have the authority to enter into this Contract and to legally
bind their respective Parties . If Contractor is a corporation, signatures from two officers of the
corporation are required pursuant to California Corporations Code Section 313.
Public Works Proj ect Cupertino Teen Center Painting
Public Works Contract $60 ,000 /Rev. Jan. 02 , 2019
Page 10 of 11
IN WITNESS WHEREOF , the parties have caused this Contract to be ex ecuted as of the Execution
Date first above written.
CONTRACTOR Griffin Painting Inc.
Corporation By .~~¥·
Title: Owner //?resict./2 .-/-
7 .
Signature Date: ~m,/; q ,
APPROVED AS TO FORM:
CITY OF CUPERTINO,
a Municipal Corporation
By P L
~Timm'13aetl
I Title: Director of Public Works
Signature Date: ~
By: 1 ~-_.,,.,,-
ROCIO ~r..-F IERRe \.\-~CA \"1.,,.e ( ~ rY\ (I{\ e \
Cupertino City Attorney
ATTEST:
By: ~w 3-::---r1
GRACE SCH1\1IDT, City Clerk
Public Works Project Cupertino Teen Center Painting
Public Works Contract $60,000 iR ev. Jan . 02, 2019
Page 11 of l l
Proposal Amount
Griffin Painting
Cupertino Teen Center Painting
$ 6,800.00
Description patch, paint -'----'-'-------------------
Account#
Proposal Amount
Description
Account#
Proposal Amount
Description
Account#
Unforeseeables/Extras
SUBTOTAL
Contingency
CONTRACT TOTAL
$
$
$
PW Project Manager Ty Bloomquist
6,800.00
2,000.00
8,800.00
Carl Valdez -Superintendent Date
Proposal
EXHIBI T 11 A11
Griffin Painting Inc.
3580 Haven Ave. #2
Redwood City, CA 94063
CA Lie# 599026
(650) 368-3190 Fax (650) 368-3192
CLIENT: COCU
City Of Cupertino
10300 Torre Ave.
Cupertino , CA 95014-3202
PROPOSAL: 003553
Cupertino Teen Center
PROJECT: 023516
Cupertino Teen Center
DATE: 01/10/19
Contractor agrees to furnish all equipment , materials, supplies , services and labor in accordance with all applicable
labor, building and Building Plans and Specifications and to complete the following work:
Proposal Scope of Work:
Attn: Ty
Patch walls as needed .
Paint walls with 2 coats of finish . (Color Cottage White)
Blue walls might take 3 coats.
Prepare and enamel door and window frames .
Signed: __________________ _
Dated: ---------
Title:
TOTAL BID: $6 ,800 .00
'PUBLIC WORKS CONSTRUCTION CONTRACTS
'Small Projects -$60,000
Insurance Requirements: Exhibit B
Contractor shall procure and maintain for the duration of the contract, and for five years following the completion of
the Project, insurance against claims for injuries to persons or damages to property which may arise from or in
connection with the performance of the work hereunder by Contractor, its agents, representatives, employees or
subcontractors.
MINIMUM SCOPE AND LIMIT OF INSURANCE
Coverage shall be at least as broad as:
l. Commercial General Liability (CGL): Insurance Services Office (ISO) Form CG 00 01 covering CGL .on an
"occurrence" basis, written on a comprehensive general liability form, and must include coverage for liability
arising from Contractor's or Subcontractor's acts or omissions, including Contractor's protected coverage,
blanket contractual, products and completed operations, vehicle coverage and employer's non-ownership liability
coverage, with limits of at least $2,000,000 per occurrence. The CGL policy must protect against any and all
liability for personal injury, death, property damage or destruction, and personal and advertising injury. If a general
aggregate limit applies, either the general aggregate limit shall apply separately to this project/location (ISO CG
25 03 or 25 04) or the general aggregate limit shall be twice the required occurrence limit.
a. It shall be a requirement under this agreement that any available insurance proceeds broader than or in excess
of the specified minimum insurance coverage requirements and/or limits shall be made available to the
Additional Insured and shall be (1) the minimum coverage/limits specified in this agreement; or (2) the broader
coverage and maximum limits of coverage of any insurance policy, whichever is greater.
b. Additional Insured coverage under Contractor's policy shall be "primary and non-contributory," will not seek
contribution from City's insurance/self-insurance, and shall be at least as broad as ISO CG 20 01 04 13
c. The limits of insurance required may be satisfied by a combination of primary and umbrella or excess
insurance, provided each policy complies with the requirements set forth in this Contract. Any umbrella or
excess insurance shall contain or be endorsed to contain a provision that such coverage shall also apply on a
primary and non-contributory basis for the benefit of City before the City's own insurance or self-insurance
shall be called upon to protect City as a named insured.
2. Automobile Liability: ISO Form CA 00 01 covering any auto (Code 1), or if Contractor has no owned autos, then
hired autos (Code 8) and non-owned autos (Code 9), with limit no less than $1,000,000 per accident for bodily
injury and property damage.
3. Workers' Compensation: As required by the State of California, with Statutory Limits, and
Employer's Liability Insurance ofno less than $1,000,000 per accident for bodily injury or disease, or as otherwise
required by statute. If Contractor is self-insured, Contractor must provide a Certificate of Permission to Self-Insure,
duly authorized by the DIR.
D N/A if box checked (Contractor provides written verification it has no employees).
4. Professional Liability with limits no less than $1,000,000 per occurrence or claim, and $2,000,000 aggregate .
.,&l NIA if box checked (Contract is not design/build).
5. Builder's Risk. Course of Construction insurance utilizing an "All Risk" (Special Perils) coverage form, with
limits equal to the completed value of the project and no coinsurance penalty provisions.
~ NIA if box checked (Project does not involve construction or improvements/installations to property).
Insurance Requirements for Construction Contracts -$60,000 Version: Jan. 2019
6. Contractors' Pollution Legal Liability and/or Asbestos Legal Liability and/or Errors and Omissions with limits
no less than $1,000,000 per occurrence or claim, and $2,000,000 policy aggregate.
g' NIA if box checked (Project does not involve environmental hazards).
If Contractor maintains broader coverage and/or higher limits than the minimums shown above, City requires and
shall be entitled to the broader coverage and/or higher limits maintained by the contractor. Any available insuranc e
proceeds in excess of the specified minimum limits of insurance and coverage shall be available to the City.
Self-Insured Retentions. Self-insured retentions must be declared to and approved by City. At City's option, either:
(1) Contractor shall cause the insurer to reduce or eliminate self-insured retentions as respects City, its officers,
officials, employees, and volunteers; or (2) Contractor shall provide a financial guarantee satisfactory to City
guaranteeing payment of losses and related investigations, claim administration, and defense expenses. The policy
language shall provide, or be endorsed to provide, that the self-insured retention may be satisfied by either the named
insured or the City.
OTHER INSURANCE PROVISIONS
The insurance policies are to contain, or be endorsed to contain, the following provisions:
Additional Insured Status
The City of Cupertino, its City Council, officers, officials, employees, agents, servants and volunteers are to be covered
as additional insureds on the CGL policy with respect to liability arising out of the Services performed by or on behalf
of Contractor including materials, parts, or equipment furnished. Endorsement of CGL coverage shall be at least as
broad as ISO Form CG 20 10 11 85 or if not available, through the addition of both CG 20 10, CG 20 26, CG 20 33,
or CG 20 38; and CG 20 37 if a later edition is used.
Primary Coverage
For any claims related to this Project, Contractor's insurance coverage shall be "primary and non-contributory" and
at least as broad as ISO CG 20 01 04 13 with respect to City, its officers, officials, employees and volunteers, and shall
not seek contribution from City's insurance. If the limits of insurance are satisfied in part by Umbrella/Excess
Insurance, the Umbrella/Excess Insurance shall contain or be endorsed to contain a provision that such coverage shall
also apply on a "primary and non-contributory" basis for the benefit of City.
Notice of Cancellation
Each insurance policy required shall provide that coverage shall not be canceled, except with notice to the City. Each
certificate of insurance must state that the coverage afforded by the policy is in force and will not be reduced, cancelled
or allowed to expire without at least 30 days advance written notice to City, unless due to non-payment of premiums,
in which case ten days advance written notice must be provided to City. Such notice must be sent to City via certified
mail and addressed to the attention of the City Manager.
Builder's Risk
Contractor may submit Builder's Risk insurance in the form of Course of Construction coverage, which shall name
the City as a loss payee, as its interest may appear. The Builder's Risk policy must be issued on an occurrence basis,
for all-risk coverage on a 100% completed value basis on the insurable portion of the Project, with no coinsurance
penalties, and for the benefit of City. If the Project does not involve new or major reconstruction, City may elect, acting
in its sole discretion, to accept an Installation Floater policy instead of Builder's Risk. For such projects, the Property
Installation Floater shall include improvement, remodel, modification, alteration, conversion or adjustment to existing
buildings, structures, processes, machinery and equipment, and shall provide property damage coverage for any
building, structure, machinery or equ ipment damaged, impaired, broken, or destroyed during the performance of the
Work, including during transit, installation, and testing at the City's site.·
insurance Requirements for Construction Contracts -$60,000 Version: Jan. 2019
2
Waiver of Subrogation
Each required policy must include an endorsement providing that the carrier agrees to waive any right of subrogation
it may have against City. Contractor agrees to waive rights of subrogation which any insurer of Contractor may acquire
from Contractor by virtue of the payment of any loss . Contractor agrees to obtain any endorsement that may be
necessary to affect this waiver of subrogation. The Workers' Compensation policy shall be endorsed with a waiver of
subrogation in favor of the City for all work performed by the Contractor, its employees, agents and subcontractors .
Acceptability of Insurers
Insurance must be issued by insurers acceptable to City and licensed to do business in the State of California, and each
insurer must have an A.M. Best's financial strength rating of "A" or better and a financial size rating of'_'VII" or better.
Verification of Coverage
Contractor shall furnish the City with original certificates and amendatory endorsements, or copies of the applicable
insurance language, effecting coverage required by this contract. All certificates and endorsements are to be received
and approved by the City before work commences. The City reserves the right to require complete, certified copies
of all required insurance policies, including endorsements, required by these specifications, at any time.
Subcontractors
Contractor shall require and verify that all subcontractors maintain insurance meeting all the requirements stated
herein, and Contractor shall ensure that City is an additional insured on insurance required from subcontractors . For
CGL coverage subcontractors shall provide coverage with a form at least as broad as CG 20 38 04 13.
Surety Bonds
As required by Contract and described in the Contract Documents. The Payment and Performance Bonds shall be in a
sum equal to the Contract Price . If the Performance Bond provides for a one-year warranty a separate Maintenance
Bond is not necessary. If the warranty period specified in the Contract is for longer than one year a Maintenance Bond
equal to 10% of the Contract Price is required. Bonds shall be duly executed by a responsible corporate surety,
authorized to issue such bonds in the State of California and secured through an authorized agent with an office in
California.
Special Risks or Circumstances
City reserves the right to modify these requirements , based on the nature of the risk, prior experience, insurer, coverage,
or other circumstances.
Insurance Requirements for Construction Contracts -$60,000 Version : Jan. 2019
3
ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MM /DD/YYYY )
~ 1/7/2019
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(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and cond iti ons of the policy , certain policies may require an endorsement. A statement on this certificate does not confer rights to t he
certificate holder in lieu of such endorsement(s).
PRODUCER ~2~~~CT Arlene Huerta
Insurance Management Corporation P.~~NE_ "•"· (925) 673-2200 I FAX IA/C No l : (925 ) 673 -2212
P.O . Box 1217 ~DMDA~~""' ar lene@ imcinsurance . com
License# OC54731 INSURER(Sl AFFORDI NG COVERAGE NAIC #
Clayton CA 94517 I NSURER A :James Ri ver Insurance Companv
INSURED I NSURER B :Financial Indemnitv Comnanv
Griffin Painting, Inc. INSURER c :Tokio Mar i ne Specialty Insurance Compan',
3580 Haven Ave I NSURER D :Insurance Company of the West
Suite #2 INSURER E :Arch Specialtv Ins Co
Redwood City CA 94063 I NSURER F :
COVERAGES CERTIFICATE NUMBER:CL141202323 REVISION NUMBER:
THI S IS T O CERTI FY TH AT THE POLI CIES OF IN SURANC E LI STED BELOW HAVE BEEN ISSU ED TO THE INSURED NA MED A BOVE FO R THE PO LI CY PERIOD
INDI CATED . NOTWI TH STAND ING A NY RE QUIRE MENT , TER M O R CO NDITI ON OF A NY CO NTRAC T OR OTHER DOC UMENT WI TH RES PE CT T O WHI C H THI S
C ERTIFI CA TE MAY BE ISSUED OR MAY PERTA IN , THE IN SURAN CE AFF ORDED BY THE POLI CIES DE SC RIBED HEREIN IS SUB JECT TO A LL THE TERM S,
EXC LU SIONS A ND CO NDITI ONS OF SU CH POLI CIE S. LI MIT S SHOW N MAY HAVE BE EN REDU CED BY PAID C LAIMS.
INSR TYPE OF INSURANCE ADDL SUBR c~~MEiv ~~> ,~2rl%Yv~Vv1 LIMITS LTR I""'" WVD POLICY NUMBER
GENERAL LIABILITY EACH OCCURR ENCE $ V 1 ,ooo,ooo -DAMAGE , u RENTED
X COMMERC IA L GENERAL LI AB ILITY PREM ISES IEa occurrence\ $ 100 ,000 -~ CLAIMS-MADE Ci] OCCUR X X 00 00 0 0 3 2 0 v 1 /1 /2 019 1 /1 /202 0 \I A MED EXP (Any one pe rson) $ 5 000 -
PERSO NA L & A DV IN JURY $ 1,000,000 -
GENERAL AGGREGATE $ V 2,000,000 -
GEN'L AGGR EGATE LIM IT APP LI ES PER: PROD UCTS -COMP/OP AGG $ 2,000,000
-i POLI CY rxi ~t/?;: n LOC $
AU TOMOBILE LIABILITY COMBINED SINGLE LIMI T v 1 000 000 IEa accident\ $ -
X ANY AUTO BO DILY IN JURY (Per person) $
B -ALL OWNED -SC HEDU LED 4 1 28 734 02 / 1 /1/2 01 9 1 /1 /2 0 20 !' X X BO DI LY INJURY (Per accident) $ -AU T OS -AUTOS
X X NON-OWN ED PROP ERTY DAMAGE $ -HIRED AUTOS -AUTOS (Per accident\
Hired/borrowed $ ,,,,,.------....., "
UMBRELLA LIAB H OCCUR EAC H OCCURRE NCE / V s ,000,000 -
C X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000
OED I I RE TENTION$ PUB 6 60007 1 /1 /2019 1 /1 /2 02 0.J ~
D WORKERS COMPENSATIO N x I /;i,gJTtT1¥s I I OTH-'-~ FR AND EMPLOYERS" LIABILIT Y Y /N
$ .,/ 1 ANY PROPR IETOR/PARTNER/EXECUT IVE D N/A E.L. EACH ACCI DEN T 000 000
OFF ICER/MEMBER EXCLUOED? 1 /1 /2 019 1 /1 /2 0 20 \/ (Mand atory in NH) X wSA50353 69 -02 E.L. DISEASE -EA EM PLOYEE $ 1 000,000
If yes , describe under
DESCR IPT ION OF OPE RATIONS below E.L. D ISEASE -PO LI CY LI M IT $ 1 000,000
E Contractors Pollution Each Claim 1,000,000
Liability 12C PL 11872 00 5/11/2018 5/11/2019 V Po licy Aggreagate 2 ,000 ,000
DES C RIPTION OF OPERATIONS / LOCATIONS/ VEHICLES (Atta c h ACORD 101 , Addit io nal Rem arks Sc h edule, if m o r e s pa ce is r equired )
The City of Cupertino , including its City Council, boards and commissions , officers, officials, agen t s,
consultants and volunteers shall be named as additional i nsured with respects to the General Liability and
Auto Liability for All CA Operations. Waiver of subrogation shall be applied to the General Liability, Auto
Liability and Workers Comp. Insurance shall be primary and non-contri butory
CERTIFICATE HOLDER
City of Cupertino
10300 Torre Ave.
Cupertino , CA 95014-3202
ACORD 25 (20 10/05)
INS025 (201oos ).01
CANCELLATION 10 D N t · av o i ce o f C ance 11 t· f a 10n or Non Pavment of Pr emi um.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF , NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS .
AUTHORIZED REPRESENTATIVE
/1 ' ftcc: (12.,•.--'j-.,._,, C'.
Arlene Huerta
© 1988-2010 ACORD CORPORATION . All rights reserved.
The ACORD name and logo are registered marks of ACORD
~
)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY AND NON CONTRIBUTORY
· ENDORSEMENT
This endorsement modifies insurance provided under the following:
ALL COVERAGE PARTS
Name Of Additional Insu red Person(s)
Or Organization(s):
The City of Cupertino, including its City Council , boards and commissions,
officers, officials, agents, consultants and volunteers
If no entry appears abo ve , this endorsement applies to all Additional Insureds covered under
this policy.
Any co verage provided to an Additional Insured under this policy shall be ex cess over any other
valid and collectible insurance available to such Additional Insured whether primary, excess,
contingent or on any other basis unless a written contract or written agreement specifically
requires that this insurance apply on a primary and noncontributory basis .
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
AP503 1 US 04-10 Page 1 of 1
Kemper Specialty
Financial Indemnity Company
POLICY NUMBE . 21-12873402 BUSINESS AUTOMOBILE LIABILITY
Griffin Paint Inc.
01/01/2019 -0 2020
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
DESIGNATED INSURED ENDORSEMENT (CA 20 48)
Name of Person(s) or Organization(s)
The City of Cupertino, including its City Council, boards and commissions, officers,
officials, agents, consultants and volunteers
BUSINESS AUTO COVERAGE
Each person or organization indicated above is an "insured" for Liability Coverage, but only to the
extent that person or organization qualifies as an "insured" under the Who Is An Insured provision
contained in SECTION II of the Coverage Form.
CA20 48 07 87
COMMERCIAL GENERAL LIABILITY
CG 20 37 07 04
SEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED -OWNERS, LESSEES OR
CONTRACTORS -COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following :
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Location And Description Of Completed Opera-
Or Organization(s): tions
The City of Cupertino, including its City
Council, boards and commissions, officers,
officials, agents, consultants and volunteers
Information required to complete this Schedule, if not shown above, will be shown in the Declarations .
CG 20 37 07 04
Section II -Who Is An Insured is amended to include
as an additional insured the person(s) or organiza-
tion(s) shown in the Schedule , but only with respect to
liability for "bodily injury" or "property damage" caused,
in whole or in part, by "your work" at the location desig-
nated and described in the schedule of this endorse-
ment performed for that additional insured and included
in the "products-completed operations hazard".
© ISO Properties, Inc., 2004 Page 1 of 1 D
POLICY NUMBE COMMERCIAL GENERAL LIABILITY
CG 24 04 05 09
F TRANSFER OF RIGHTS OF RECOVERY
AGAINST OT HERS TO US
This endorsement modifies insurance provided unde r the following :
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Person Or Organization:
The City of Cupertino, including its City Council , boards and commissions, officers,
officials, agents, consultants and volunteers
Information required to complete th is Schedule , if not shown above , will be shown in the Declarations .
The following is added to Paragraph 8. Transfer Of
Rights Of Recovery Against Others To Us of
Section IV -Conditions:
We waive any right of recovery we may have against
the person or organ ization shown in the Schedule
above because of payments we make for injury or
damage arising out of your ongoing operations or
"your work" done under a contract w ith that person
or organization and included in the "products-
completed operations hazard". This waiver applies
only to the person or organization shown in the
Schedule above.
CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 D
Cl I IJJCI Uf.JC\....IClllY
nancial Indemnity Company
OLICY NUMBER:41287340 2
riffin Painting Inc.
1/01/2019 -01/01/2020
15. AUTO LEASE PHYSICAL DAMAGE
EXTENSION
The following is added to SECTION Ill -·
PHYSICAL DAMAGE COVERAGE, C. Limit Of
Insurance provision:
6. If, because of damage, destruction or theft
of a covered "auto", which is a long-term
leased "auto", the lease agreement between
you and the lessor is terminated, "we" will
pay the difference between the amount paid
under paragraph C. LIMIT OF INSURANCE
1. or 2. and the amount due at the time of
"loss" under the terms of the lease
agreement applicable to the leased "auto"
which you are required to pay: less any fees
to dispose of the auto ; any overdue
payments; financial penalties imposed under
a lease for excessive use , abnormal wear
and tear or high mileage; security deposits
not refunded by the lessor ; cost for extended
warranties , Credit Life Insurance, Health,
Accident or Disab ility Insurance purchased
with the loan ; and carry over balances from
previous leases.
This coverage applies only to the initial lease for
the covered "auto" which has not previously
been leased. This coverage is excess over all
other collectible insurance .
SECTION IV -BUSINESS AUTO CONDITIONS
16. DUTIES IN THE EVENT OF ACCIDENT,
CLAIM, SUIT OR LOSS
The following is added to SECTION IV -
BUSINESS AUTO CONDITION, A. Loss
Conditions, 2. Duties In The Event Of
Accident, Claim, Suit Or Loss:
d. Knowledge of any "accident", claim,
"su it" or "loss" will be deemed
knowledge by you when notice of such
"accident", claim, "suit" or "loss" has
been received by:
(1) You , if you are an individual;
(2) Any partner or insurance manager if
you are a partnership; or
(3) An executive office or insurance
manager if you are a corporation .
---.l 17 . BLANKET WAIVER OF SUBROGATION
Paragraph 5. Transfer Of Rights Of Recovery
Against Others To Us, SECTION IV -
BUSINESS AUTO CONDITIONS, A. Loss
Conditions is replaced by the following:
5. Transfer Of Rights Of Recovery
Against Others To Us
If any person or organization to or for
whom we make payment under this
Coverage Fo rm has rights to recover
damages from another, which have
not been waived through the
execution of an "insured contract",
written agreement, or permit, prior to
the "accident" or "loss" giving rise to
the payment , those rights to recover
damages from another are transferred
to us. That person or organization
must do everything necessary to
secure our rights and must do nothing
after the "accident" or "loss" to impair
them.
18 . UNINTENTIONAL FAILURE TO
DISCLOSE INFORMATION
The following is added to SECTION IV
BUSINESS AUTO CONDITIONS. B. General
Conditions, paragraph 2. Concealment,
Misrepresentation Or Fraud:
Your unintentional error in disclosing, or
failure to disclose, any material fact existing
after the effective date of this Coverage
Form shall not prejudice your rights under
this Coverage Form . However, this
provision does not affect our right to collect
additional premium or exercise our right of
cancellation or nonrenewal.
SECTION V -DEFINITIONS
19. MENTAL ANGUISH
Paragraph C. "Bodily Injury", SECTION V-
DEFINITIONS is replaced by the following:
C. "Bodily Inju ry" means bodily injury, sickness
or decease sustained by a person including
death or mental anguish resulting from any
of these.
Includes copyrighted material of Insurance Services Office, Inc . with permission .
Copyright , Insurance Services Office, Inc., 1996
(__
WORKERS COMPENSATION AND EMPLOYERS LIABlLITY INSURANCE POLICY WC 04 03 06
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -
CALIFORNIA
We have the right to recover our payments from anyone liable for an injury covered by this policy . We will not
enforce our right against the person or organi zation named in the Schedule. (This agreement applies only to the
extent that you perform work under a written contract that requires you to obtain this agreement from us.)
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in
the work described in the Schedule.
The additional premium for this endorsement shall be 2% of the California workers' compensation premium
otherwise due on such remuneration .
SCHEDULE
PERSON OR ORGANIZATION
ANY PERSON OR ORGANIZATION FOR WHOM THE
NAMED INSURED HAS AGREED BY WRITTEN
CONTRACT TO FURNISH THIS W AIYER
JOB DESCRIPTION
BLANKET WAIVER OF SUBROGATION
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated .
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective: 01/01/2019
Insured : Griffin Painting, Inc.
Policy No . WSA5035369-02
Insurance Company: ICW GROUP Insurance Company
Premium$ INCL.
.-) ~-._,y._e-c-:
Countersigned By:---------------------------
-1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.
From the WCIRB's California Workers' Compensation Insurance Forms Manual -1999.
6