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21-003 Amendment #1 07-01-20211
FIRST AMENDMENT TO AGREEMENT 21-003
BETWEEN THE CITY OF CUPERTINO AND ABODE
SERVICES; ALLIED HOUSING, INC. FOR PROVIDING
TEMPORARY HOUSING, SUPPORT AND FINANCIAL
SERVICES FOR WOLFE RD ENCAMPEMENT E
This First Amendment to Agreement 21-003 between the City of Cupertino and Abode
Services, Allied Housing, Inc., or reference dated June 28, 2021, is by and between the City of
Cupertino, a municipal corporation (hereinafter "City") and Abode Services Allied Housing Inc., a
corporation (“Contractor”) whose address is 40849 Fremont Blvd, Fremont, CA 94538, and is made
with reference to the following:
RECITALS:
A. On January 4, 2021, Agreement 21-003 (“Agreement”) was entered into by and
between City and Contractor for Providing temporary housing, support and financial services
for Wolfe Rd Encampment E.
B. City and Contractor desire to modify the Agreement on the terms and conditions set
forth herein.
NOW, THEREFORE, it is mutually agreed by and between and undersigned parties as
follows:
1. Paragraph 3 of the Agreement is modified to read as follows:
TIME OF PERFORMANCE
3.1 This Agreement begins on the Effective Date and ends on June 30, 2022 (“Contract Time”),
unless terminated earlier as provided herein. Contractor’s Services shall begin on effective date and
shall be completed by June 30, 2022. The City’s appropriate department head or the City Manager
may extend the Contract Time through a written amendment to this Agreement, provided such
extension does not include additional contract funds. Extensions requiring additional contract funds
are subject to the City’s purchasing policy.
3.2 Schedule of Performance. Contractor must deliver the Services in accordance with the
Schedule of Performance, attached and incorporated here Exhibits B and B-1.
3.3 Time is of the essence for the performance of all the Services. Contractor must have
sufficient time, resources, and qualified staff to deliver the Services on time.
2. Paragraph 4 of the Agreement is modified to read as follows:
4.1 Maximum Compensation. City will pay Contractor for satisfactory performance of the
Services an amount that will based on actual costs but that will be capped so as not to exceed
2
$234,672.03 (“Contract Price”), based upon the scope of services in Exhibits B and B-1 and
the budget and rates included in Exhibits C and C-1, Compensation attached and
incorporated here. The maximum compensation includes all expenses and reimbursements
and will remain in place even if Contractor’s actual costs exceed the capped amount. No extra
work or payment is permitted without prior written approval of City.
4.2 Invoices and Payments. Monthly invoices must state a description of the deliverable
completed and the amount due for the preceding month. Within thirty (30) days of completion
of Services, Contractor must submit a requisition for final and complete payment of costs and
pending claims for City approval. Failure to timely submit a complete and accurate payment
requisition relieves City of any further payment or other obligations under the Agreement.
3. Exhibits B-1 and C-1, attached hereto, are added to the Agreement.
4. Except as expressly modified herein, all other terms and covenants set forth in the
Agreement shall remain the same and shall be in full force and effect.
SIGNATURES CONTINUE ON THE FOLLOWING PAGE
3
IN WITNESS WHEREOF, the parties hereto have caused this modification of Agreement
to be executed.
CITY OF CUPERTINO
By
Title
Date
APPROVED AS TO FORM
City Attorney
ATTEST:
City Clerk
Date
ABODE SERVICES; ALLIED HOUSING,
INC.
By
Title
Date
CEO
Jul 1, 2021
Heather M. Minner
Jul 1, 2021
Interim City Manager
Jul 1, 2021
Exhibit A: Scope of Services
Overview
Abode Services, (Contractor) will perform the following work for the City of Cupertino (the
City) related to providing temporary housing, as well as supportive services, and the ability to
provide other financial services to support participants’ needs for up to 10 individuals living or
previously occupying in the Wolfe Road Encampment.
Term of Contract
The term of this Agreement shall commence on July 1, 2021 and, unless terminated earlier as
provided herein, end on the earlier of (i) June 30, 2022 and (ii) such time as all funds under this
Agreement have been exhausted.
Contract Services/ Eligible Costs
The Contractor shall run support the individuals through a combination of the following
activities, depending on the need of each individual.
Outreach and Engagement of Wolfe Road encampment residents;
Pay hotel costs/ fees associated with the placement of up to 10 encampment residents
Support participants in storing their belongings.
Provide guest orientation to indoor city-sponsored outdoor location.
Coordinate with motel and storage sites to safely store guest belongings
Respond to the crisis using de-escalation techniques;
Provide referral and linkage to housing and supportive services;
Maintain administrative and financial records;
Provide administrative oversite, support, and reporting.
Publicity
A. Except as otherwise required by law, the City of Cupertino shall not use the name of
Abode Services its related entities, officers, directors, employees, or agents, in
advertising, publicity releases, or other similar external communications without securing
the prior written consent of Abode Services in each instance.
B. Notwithstanding anything in this Section, City of Cupertino may describe the project in
advertising, publicity releases, or other similar external communications, including a
website, provided that the external communication references that Abode is a Service
Partner in the project.
Exhibit B-1: Schedule of Performance
July 1, 2021 – June 30, 2022
Placement of up to 10 Wolf Road encampment residents into a hotel setting.
Service Coordination for 10 Wolf Road encampment residents who have been moved
into hotel settings.
Ongoing coordination with the city and county to assess participants’ eligibility for
county housing programs.
Performance Target
The goal of the Program is to provide motel site coordination, support for up to 10 people
previously residing in the Wolfe Road encampment. Services include a combination of:
Service Coordination
Placement/ rental of hotel rooms
Support in storing for belongings
General outreach and engagement
Program Deliverables and Evaluation
The Contractor shall provide a Monthly Progress Report of program capacity, demographics, and
a narrative of services provided. Progress reports are due within 15 calendar days after the end of
the reporting month.
Exhibit C-1: Payment Schedule
A. The maximum compensation paid to the Contractor under this Agreement shall not
exceed the maximum financial obligation of this Agreement. As a result of these services
the not to exceed the amount of Two hundred Thirty-Four thousand, Six hundred
Seventy-Two dollars and Three cents ($234,672.03).
B. The Contractor shall be paid by the City Cupertino for its actual, reasonable, necessary,
and allowable costs incurred up to the maximum compensation, for the performances of
services.
C. The Contractor must submit for invoice for the full Two hundred Thirty-Four thousand,
Six hundred Seventy-Two dollars and Three cents ($234,672.03) at the start of the
contract and provide verification of eligible costs incurred with the quarterly performance
reports. Any unspent dollars spent at the end of the contract needs to be return to the City
of Cupertino.
Estimated Costs (Funds can be moved between line items as needed with authorization by the City.)
Expense Category Description of Eligible
Expenses
Not to Exceed
Direct Client Expenses Motel, Storage,
Transportation, Moving
Costs
$199,872.03
Staffing Costs Service Coordination,
Outreach, Admin Costs
$34,800.00
FY 2021 – 2022 Budget
Expense City of Cupertino CDBG-CARES
Hotel/Motel
Casa De Novo $145,000.00 $34,672.03
Other Hotel $ -
Repair/Flex Fund Contingency $10,000.00
Total Hotel/Motel $155,000.00 $34,672.03
Storage $10,200.00
Total Storage $10,200.00
Staffing (Outside of Casa De
Novo)
$6,000.00
Admin @ 13% $28,800.00
TOTALS $200,000.00 $34,672.03
Exh. D-Insurance Requirements for Design Professionals & Consultants Contracts
1
Form Updated Sept. 2019
Consultant shall procure prior to commencement of Services and maintain for the duration of the contract, at
its own cost and expense, the following insurance policies and coverage with companies doing business in
California and acceptable to City.
INSURANCE POLICIES AND MINIMUMS REQUIRED
1.Commercial General Liability (CGL) for bodily injury, property damage, personal injury liability for
premises operations, products and completed operations, contractual liability, and personal and
advertising injury with limits no less than $2,000,000 per occurrence (ISO Form CG 00 01). If a
general aggregate limit applies, either the general aggregate limit shall apply separately to this
project/location (ISO Form CG 25 03 or 25 04) or it shall be twice the required occurrence limit.
a.It shall be a requirement 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 (i) the minimum coverage/limits specified in this agreement; or (ii) the
broader coverage and maximum limits of coverage of any insurance policy, whichever is greater.
b.Additional Insured coverage under Consultant'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
Form CG 20 10 (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 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 CA 00 01 covering any auto (including owned, hired, and non-owned
autos) with limits 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 of no less than $1,000,000 per occurrence for bodily injury or disease.
Not required. Consultant has provided written verification of no employees.
4.Professional Liability for professional acts, errors and omissions, as appropriate to Consultant’s
profession, with limits no less than $2,000,000 per occurrence or $2,000,000 aggregate. If written on a
claims made form:
a.The Retroactive Date must be shown and must be before the Effective Date of the Contract.
b.Insurance must be maintained for at least five (5) years after completion of the Services.
c.If coverage is canceled or non-renewed, and not replaced with another claims-made policy form with
a Retroactive Date prior to the Contract Effective Date, the Consultant must purchase “extended
reporting” coverage for a minimum of five (5) years after completion of the Services.
OTHER INSURANCE PROVISIONS
The aforementioned insurance shall be endorsed and have all the following conditions and provisions:
EXHIBIT D
Insurance Requirements
Design Professionals & Consultants Contracts
Exh. D-Insurance Requirements for Design Professionals & Consultants Contracts
2
Form Updated Sept. 2019
Additional Insured Status
The City of Cupertino, its City Council, officers, officials, employees, agents, servants and volunteers
(“Additional Insureds”) are to be covered as additional insureds on Consultant’s CGL and automobile
liability policies. General Liability coverage can be provided in the form of an endorsement to Consultant’s
insurance (at least as broad as ISO Form CG 20 10 (11/ 85) or both CG 20 10 and CG 20 37 forms, if later
editions are used).
Primary Coverage
Coverage afforded to City/Additional Insureds shall be primary insurance. Any insurance or self-insurance
maintained by City, its officers, officials, employees, or volunteers shall be excess of Consultant’s insurance
and shall not contribute to it.
Notice of Cancellation
Each insurance policy shall state that coverage shall not be canceled or allowed to expire, except with written
notice to City 30 days in advance or 10 days in advance if due to non-payment of premiums.
Waiver of Subrogation
Consultant waives any right to subrogation against City/Additional Insureds for recovery of damages to the
extent said losses are covered by the insurance policies required herein. Specifically, the Workers’
Compensation policy shall be endorsed with a waiver of subrogation in favor of City for all work performed
by Consultant, its employees, agents and subconsultants. This provision applies regardless of whether or not
the City has received a waiver of subrogation endorsement from the insurer.
Deductibles and Self-Insured Retentions
Any deductible or self-insured retention must be declared to and approved by the City. At City’s option, either:
the insurer must reduce or eliminate the deductible or self-insured retentions as respects the City/Additional
Insureds; or Consultant must show proof of ability to pay losses and costs related investigations, claim
administration and defense expenses. The policy shall provide, or be endorsed to provide, that the self-insured
retention may be satisfied by either the insured or the City.
Acceptability of Insurers
Insurers must be licensed to do business in California with an A.M. Best Rating of A-VII, or better.
Verification of Coverage
Consultant must furnish acceptable insurance certificates and mandatory endorsements (or copies of the policies
effecting the coverage required by this Contract), and a copy of the Declarations and Endorsement Page of the
CGL policy listing all policy endorsements prior to commencement of the Contract. City retains the right to
demand verification of compliance at any time during the Contract term.
Subconsultants
Consultant shall require and verify that all subconsultants maintain insurance that meet the requirements of
this Contract, including naming the City as an additional insured on subconsultant’s insurance policies.
Higher Insurance Limits
If Consultant maintains broader coverage and/or higher limits than the minimums shown above, City shall be
entitled to coverage for the higher insurance limits maintained by Consultant.
Adequacy of Coverage
City reserves the right to modify these insurance requirements/coverage based on the nature of the risk, prior
experience, insurer or other special circumstances, with not less than ninety (90) days prior written notice.
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
INSR ADDL SUBR
LTR INSD WVD
PRODUCER CONTACT
NAME:
FAXPHONE
(A/C, No):(A/C, No, Ext):
E-MAIL
ADDRESS:
INSURER A :
INSURED INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY)
AUTOMOBILE LIABILITY
UMBRELLA LIAB
EXCESS LIAB
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
AUTHORIZED REPRESENTATIVE
EACH OCCURRENCE $
DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence)
MED EXP (Any one person)$
PERSONAL & ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $
PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT
OTHER:$
COMBINED SINGLE LIMIT
$(Ea accident)
ANY AUTO BODILY INJURY (Per person)$
OWNED SCHEDULED
BODILY INJURY (Per accident)$AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE
$AUTOS ONLY AUTOS ONLY (Per accident)
$
OCCUR EACH OCCURRENCE
CLAIMS-MADE AGGREGATE $
DED RETENTION $
PER OTH-
STATUTE ER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below
INSURER(S) AFFORDING COVERAGE NAIC #
COMMERCIAL GENERAL LIABILITY
Y / N
N / A
(Mandatory in NH)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
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.
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 have ADDITIONAL INSURED provisions or 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).
COVERAGES CERTIFICATE NUMBER:REVISION NUMBER:
CERTIFICATE HOLDER CANCELLATION
© 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03)
CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
$
$
$
$
$
The ACORD name and logo are registered marks of ACORD
3/29/2021
(626) 799-7000 (626) 441-3233
Abode Services; Allied Housing, Inc.
40849 Fremont Blvd.
Fremont, CA 94538
10855
A 1,000,000
X X 202003766 11/15/2020 11/15/2021 500,000
20,000
1,000,000
2,000,000
1,000,000
SOCIAL PROFESSI 1,000,000
1,000,000A
202003766 11/15/2020 11/15/2021
10,000,000A
202003766UMB 11/15/2020 11/15/2021 10,000,000
0
B
X ABWC240794 4/1/2021 4/1/2022 1,000,000
1,000,000
1,000,000
Re: 15 individuals who used to live at the Wolfe Road Encampment - Per written Agreement
The City of Cupertino, its City Council, officers, officials, employees, agents, servants and volunteers are named as additional insureds per form CG2010 and
CG2037 attached. Waiver and Primary & Non-Contributory forms attached. WC Blanket Waiver endorsement attached.
City of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
ALLIHOU-C1 MSUN
Bolton & Company
3475 E. Foothill Blvd., Suite 100
Pasadena, CA 91107 propcasualty@boltonco.com
Nonprofits' Ins. Alliance
Cypress Insurance Co.
X
X
X
X
X
X
X
X
POLICY NUMBER:COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED – OWNERS, LESSEES OR
CONTRACTORS – SCHEDULED PERSON OR
ORGANIZATION
CG 20 10 04 13
2020-03766
Named Insured:Allied Housing, Inc.; Abode Services*
The City of Cupertino, its City Council, officers,
officials, employees, agents, servants and volunteers
All insured premises and operations.
Location(s) Of Covered Operations
Name Of Additional Insured Person(s)
Or Organization(s)
SCHEDULE
COMMERCIAL GENERAL LIABILITY COVERAGE PART
This endorsement modifies insurance provided under the following:
Wolfe Road Encampment Contract
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Section II – Who Is An Insured is amended to
include as an additional insured the person(s) or
organization(s) shown in the Schedule, but only
with respect to liability for "bodily injury", "property
damage" or "personal and advertising injury"
caused, in whole or in part, by:
1.Your acts or omissions; or
2.The acts or omissions of those acting on your
behalf;
in the performance of your ongoing operations for
the additional insured(s) at the location(s)
designated above.
However:
1.The insurance afforded to such additional
insured only applies to the extent permitted
by law; and
A.
B.With respect to the insurance afforded to these
additional insureds, the following additional
exclusions apply:
This insurance does not apply to "bodily injury" or
"property damage" occurring after:
1.All work, including materials, parts or
equipment furnished in connection with such
work, on the project (other than service,
maintenance or repairs) to be performed by
or on behalf of the additional insured(s) at the
location of the covered operations has been
completed; or
2.If coverage provided to the additional insured
is required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
© Insurance Services Office, Inc., 2012 Page 1 of 2CG 20 10 04 13
2.That portion of "your work" out of which the
injury or damage arises has been put to its
intended use by any person or organization
other than another contractor or subcontractor
engaged in performing operations for a
principal as a part of the same project.
C.With respect to the insurance afforded to these
additional insureds, the following is added to
Section III – Limits Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1.Required by the contract or agreement; or
2.Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the
applicable Limits of Insurance shown in the
Declarations.
© Insurance Services Office, Inc., 2012 Page 2 of 2CG 20 10 04 13
POLICY NUMBER:COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED – OWNERS, LESSEES OR
CONTRACTORS – COMPLETED OPERATIONS
CG 20 37 04 13
2020-03766
Named Insured:Allied Housing, Inc.; Abode Services*
The City of Cupertino, its City Council, officers,
officials, employees, agents, servants and
volunteers
All insured premises and operations.
Location And Description Of Completed Operations
Name Of Additional Insured Person(s)
Or Organization(s)
SCHEDULE
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
This endorsement modifies insurance provided under the following:
Wolfe Road Encampment Contract
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Section II – Who Is An Insured is amended to
include as an additional insured the person(s) or
organization(s) shown in the Schedule, but only
with respect to liability for "bodily injury" or
"property damage" caused, in whole or in part, by
"your work" at the location designated and
described in the Schedule of this endorsement
performed for that additional insured and
included in the "products-completed operations
hazard".
However:
1.The insurance afforded to such additional
insured only applies to the extent permitted
by law; and
A.B.With respect to the insurance afforded to these
additional insureds, the following is added to
Section III – Limits Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
2.If coverage provided to the additional insured is
required by a contract or agreement, the
insurance afforded to such additional insured will
not be broader than that which you are required
by the contract or agreement to provide for such
additional insured.
1.Required by the contract or agreement; or
2.Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the
applicable Limits of Insurance shown in the
Declarations.
© Insurance Services Office, Inc., 2012 Page 1 of 1CG 20 37 04 13
Allied Housing, Inc.; Abode Services*NAMED INSURED:
FORM: NIAC-E26 11 17 POLICY NUMBER: 2020-03766
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS (WAIVER OF SUBROGATION)
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SOCIAL SERVICE PROFESSIONAL LIABILITY COVERAGE FORM
This endorsement modifies insurance provided under the following:
Name of Person or Organization:
SCHEDULE
The City of Cupertino, its City Council, officers, officials, employees, agents, servants and volunteers
Wolfe Road Encampment Contract
Where you are so required in a written contract or agreement currently in effect or becoming effective during the
term of this policy, we waive any right of recovery we may have against that person or organization, who may be
named in the schedule above, because of payments we make for injury or damage.
Page 1 of 1NIAC-E26 11 17
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Policy #: 201903766NPO202003766
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Endorsement Effective: Policy No.:
Insured:
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 99 04 10 C
(Ed. 01-19)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA
BLANKET BASIS
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 organization named in the Schedule. (This agreement applies only to the extent that you
perform wor k under a written contract that requires you to obtain this agreement from us.)
The additional premium for this endorsement shall be calculated by applying a factor of 2% to the total manual
premium, with a minimum initial charge of $350, then applying all other pricing factors for the policy to this calculated
charge to derive the final cost of this endorsement.
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule
Blanket Waiver
Person/Organization
Blanket W aiver – Any person or organization for whom the Named Insured has
agreed by written contract to furnish this waiver.
Waiver Premium (prior to adjustments)
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 No.:
Premium $
Insurance Company:
WC 99 04 10 C
Countersigned by ______________________________________
(Ed. 01-19)
Job Description
All CA Operations
Cypress Insurance Company
ABWC240794
20500.00
04/01/2021
Wolfe Rd Encapment
Final Audit Report 2021-07-01
Created:2021-06-30
By:City of Cupertino (webmaster@cupertino.org)
Status:Signed
Transaction ID:CBJCHBCAABAAZMbUnTXU9Db4X84n9VMImgzFV3dKZw1G
"Wolfe Rd Encapment" History
Document created by City of Cupertino (webmaster@cupertino.org)
2021-06-30 - 11:21:34 PM GMT- IP address: 35.229.54.2
Document emailed to Araceli Alejandre (aracelia@cupertino.org) for approval
2021-06-30 - 11:22:54 PM GMT
Document approved by Araceli Alejandre (aracelia@cupertino.org)
Approval Date: 2021-06-30 - 11:28:50 PM GMT - Time Source: server- IP address: 73.170.27.253
Document emailed to Louis Chicoine (lchicoine@abodeservices.org) for signature
2021-06-30 - 11:28:51 PM GMT
Email viewed by Louis Chicoine (lchicoine@abodeservices.org)
2021-07-01 - 0:08:42 AM GMT- IP address: 96.90.247.201
Document e-signed by Louis Chicoine (lchicoine@abodeservices.org)
Signature Date: 2021-07-01 - 5:03:22 PM GMT - Time Source: server- IP address: 76.103.228.147
Document emailed to Heather M. Minner (heatherm@cupertino.org) for signature
2021-07-01 - 5:03:23 PM GMT
Email viewed by Heather M. Minner (heatherm@cupertino.org)
2021-07-01 - 7:42:56 PM GMT- IP address: 45.41.142.28
Document e-signed by Heather M. Minner (heatherm@cupertino.org)
Signature Date: 2021-07-01 - 7:43:13 PM GMT - Time Source: server- IP address: 52.39.49.65
Document emailed to Dianne Thompson (diannet@cupertino.org) for signature
2021-07-01 - 7:43:15 PM GMT
Email viewed by Dianne Thompson (diannet@cupertino.org)
2021-07-01 - 9:15:25 PM GMT- IP address: 99.179.16.200
Document e-signed by Dianne Thompson (diannet@cupertino.org)
Signature Date: 2021-07-01 - 10:17:58 PM GMT - Time Source: server- IP address: 99.179.16.200
Document emailed to Kirsten Squarcia (kirstens@cupertino.org) for signature
2021-07-01 - 10:18:00 PM GMT
Email viewed by Kirsten Squarcia (kirstens@cupertino.org)
2021-07-01 - 10:19:35 PM GMT- IP address: 104.47.74.126
Document e-signed by Kirsten Squarcia (kirstens@cupertino.org)
Signature Date: 2021-07-01 - 10:20:00 PM GMT - Time Source: server- IP address: 69.110.137.176
Agreement completed.
2021-07-01 - 10:20:00 PM GMT