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HomeMy WebLinkAboutCOI - Golden Bay Fence plus Iron Works, Inc. - Expires 2023-10-0107/27/2023 Toste Insurance Services Inc. 3501 Coffee Road, Suite 1A Modesto, CA 95355 License #: 0I56011 Sam Bell (209)338-3585 (209)338-0737 sam@tosteins.com 00000595-14177815 886 Golden Bay Fence Plus Iron Works Inc. 4104 S B St Stockton, CA 95206 The Travelers Indemnity Company of Connecticut 25682 A Y Y CO-0P705777-22 10/01/2022 10/01/2023X X X 1,000,000 300,000 10,000 1,000,000 2,000,000 2,000,000 Travelers Property Casualty Company of America 25674 B Y Y BA-0P636270-22 10/01/2022 10/01/2023 X 1,000,000 Travelers Property Casualty Company of America 25674 B Y Y CUP-0P707501-22 10/01/2022 10/01/2023X X X 10000 10,000,000 10,000,000 Travelers Property Casualty Company of America 27847 C Y UB-7S251698-22 10/01/2022 10/01/2023 Y X 1,000,000 1,000,000 1,000,000 Travelers Property Casualty Company of America 25674 B 660-0P807898-TIL-22 10/01/2022 10/01/2023Inland Marine Scheduled Equipment843,904 /1K DED Travelers Property Casualty Company of America 25674 B 660-0P807898-TIL-22 10/01/2022 10/01/2023Installation Floater Builders Risk 1.5k/1.5mil/2500ded **Pollution Coverage applies: Policy #G28296174004 Carrier: Westchester Surplus Lines Insurance Company NAIC #: 10172 Effective Date: 05/15/2023 - 05/15/2024 Coverage: 1 mil each occur/ 2 mil aggregate ded: 2,500 **Professional Liability coverage applies: Policy #PCAB-5018242-1022 (continued on ACORD 101 Additional Remarks Schedule) South County Regional Wastewater Authority 1500 Southside Dr. Gilroy, CA 95020 (SNB) Printed by SNB on 07/27/2023 at 11:07AM ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD DATE (MM/DD/YYYY) PRODUCER CONTACTNAME: FAXPHONE(A/C, No):(A/C, No, Ext): E-MAILADDRESS: 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 AGG $JECT OTHER:$ 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 LIMIT $DESCRIPTION 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. The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DocuSign Envelope ID: 7F5E2EF1-716B-4CA2-9DC9-A5F75FA5DA5C Printed by SNB on July 27, 2023 at 11:07AM 00000595 2 Toste Insurance Services Inc. N/A Multiple Carriers Golden Bay Fence Plus Iron Works Inc. 25 Certificate of Liability Insurance (continued from Description of Operations) Carrier: Berkley Assurance Company NAIC #: 39462 Effective Date: 10/01/2022 - 10/01/2023 Coverage: 1 mil each claim / 1 mil Aggregate ded: 10,000 Workers Comp: Nick Chavez - Excluded Paul Chavez - Excluded Workers Comp: Nick Chavez - Excluded Paul Chavez - Excluded Additional Remarks: Re: Project - CH2M Hill SCRWA Ops Job #: 21-148-022 GBF Job #: 23195 South County Regional Wastewater Authority, its officers, representative, agents and employees are included as Additional Insured, respects General Liability, per attached endorsement CG D6 04 02 19, and Auto Liability, per attached endorsement CA T4 74 02 15. Coverage is Primary and Non-Contributory. Waiver of Subrogation applies per attached endorsement CG G3 16 02 19, respects General Liability, CA T3 53 02 15, respects Auto Liability and WC99 03 76, respects Workers Compensation. Excess Liability is follow form and extends over the underlying General Liability, Auto Liability and Employers Liability. All as required by written contract or agreement. AGENCY NAMED INSURED POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: AGENCY CUSTOMER ID: LOC #: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER:FORM TITLE: ADDITIONAL REMARKS ACORD 101 (2008/01)© 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Page ofADDITIONAL REMARKS SCHEDULE DocuSign Envelope ID: 7F5E2EF1-716B-4CA2-9DC9-A5F75FA5DA5C DocuSign Envelope ID: 7F5E2EF1-716B-4CA2-9DC9-A5F75FA5DA5C DocuSign Envelope ID: 7F5E2EF1-716B-4CA2-9DC9-A5F75FA5DA5C DocuSign Envelope ID: 7F5E2EF1-716B-4CA2-9DC9-A5F75FA5DA5C DocuSign Envelope ID: 7F5E2EF1-716B-4CA2-9DC9-A5F75FA5DA5C DocuSign Envelope ID: 7F5E2EF1-716B-4CA2-9DC9-A5F75FA5DA5C DocuSign Envelope ID: 7F5E2EF1-716B-4CA2-9DC9-A5F75FA5DA5C DocuSign Envelope ID: 7F5E2EF1-716B-4CA2-9DC9-A5F75FA5DA5C DocuSign Envelope ID: 7F5E2EF1-716B-4CA2-9DC9-A5F75FA5DA5C DocuSign Envelope ID: 7F5E2EF1-716B-4CA2-9DC9-A5F75FA5DA5C DocuSign Envelope ID: 7F5E2EF1-716B-4CA2-9DC9-A5F75FA5DA5C DocuSign Envelope ID: 7F5E2EF1-716B-4CA2-9DC9-A5F75FA5DA5C DocuSign Envelope ID: 7F5E2EF1-716B-4CA2-9DC9-A5F75FA5DA5C DocuSign Envelope ID: 7F5E2EF1-716B-4CA2-9DC9-A5F75FA5DA5C DocuSign Envelope ID: 7F5E2EF1-716B-4CA2-9DC9-A5F75FA5DA5C Certificate Of Completion Envelope Id: 7F5E2EF1716B4CA29DC9A5F75FA5DA5C Status: Completed Subject: Complete with DocuSign: Golden Bay Fence labor Contract.pdf Source Envelope: Document Pages: 31 Signatures: 3 Envelope Originator: Certificate Pages: 5 Initials: 0 Gina Bonnell AutoNav: Enabled EnvelopeId Stamping: Enabled Time Zone: (UTC-08:00) Pacific Time (US & Canada) 1100 NE Circle Blvd Suite 300 Corvallis, OR 97330 Gina.Bonnell@jacobs.com IP Address: 174.85.92.181 Record Tracking Status: Original 8/21/2023 9:26:04 AM Holder: Gina Bonnell Gina.Bonnell@jacobs.com Location: DocuSign Signer Events Signature Timestamp Andy Faber andy.faber@berliner.com City Attorney Security Level: Email, Account Authentication (None)Signature Adoption: Pre-selected Style Using IP Address: 68.121.158.241 Sent: 8/21/2023 9:31:49 AM Resent: 9/6/2023 11:43:52 AM Viewed: 9/8/2023 9:26:35 AM Signed: 9/8/2023 9:27:18 AM Electronic Record and Signature Disclosure: Accepted: 8/24/2023 9:35:50 AM ID: 91956afe-ee76-465e-a421-deba1dc4b982 Jimmy Forbis Jimmy.Forbis@ci.gilroy.ca.us City Administrator Security Level: Email, Account Authentication (None)Signature Adoption: Pre-selected Style Using IP Address: 66.189.161.134 Sent: 9/8/2023 9:27:22 AM Resent: 9/8/2023 9:27:55 AM Viewed: 9/8/2023 9:32:20 AM Signed: 9/8/2023 9:32:36 AM Electronic Record and Signature Disclosure: Accepted: 9/8/2023 9:32:20 AM ID: cc3cd279-2c7d-4dee-ae36-a905f6d0e6c3 Saeid Vaziry saeid.vaziry@ci.gilroy.ca.us Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style Using IP Address: 147.160.149.208 Sent: 9/8/2023 9:32:40 AM Viewed: 9/11/2023 9:46:15 AM Signed: 9/11/2023 10:12:31 AM Electronic Record and Signature Disclosure: Accepted: 9/11/2023 9:46:15 AM ID: 2196055a-a086-4ea0-9cae-4af3994b85e1 In Person Signer Events Signature Timestamp Editor Delivery Events Status Timestamp Agent Delivery Events Status Timestamp Intermediary Delivery Events Status Timestamp Certified Delivery Events Status Timestamp Carbon Copy Events Status Timestamp John Edgar john.edgar@jacobs.com Security Level: Email, Account Authentication (None) Sent: 9/11/2023 10:12:35 AM Electronic Record and Signature Disclosure: Accepted: 8/14/2023 10:34:58 AM ID: 580ea3ca-e00d-491d-8be6-6e0d2703f865 Gina Bonnell gina.bonnell@jacobs.com Security Level: Email, Account Authentication (None) Sent: 9/11/2023 10:12:36 AM Resent: 9/11/2023 10:12:41 AM Viewed: 9/11/2023 11:00:09 AM Electronic Record and Signature Disclosure: Not Offered via DocuSign Witness Events Signature Timestamp Notary Events Signature Timestamp Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 8/21/2023 9:31:49 AM Envelope Updated Security Checked 9/11/2023 10:08:53 AM Certified Delivered Security Checked 9/11/2023 9:46:15 AM Signing Complete Security Checked 9/11/2023 10:12:31 AM Completed Security Checked 9/11/2023 10:12:36 AM Payment Events Status Timestamps Electronic Record and Signature Disclosure ELECTRONIC RECORD AND SIGNATURE DISCLOSURE From time to time, Jacobs Engineering Group Inc. (we, us or Company) may be required by law to provide to you certain written notices or disclosures. Described below are the terms and conditions for providing to you such notices and disclosures electronically through the DocuSign system. Please read the information below carefully and thoroughly, and if you can access this information electronically to your satisfaction and agree to this Electronic Record and Signature Disclosure (ERSD), please confirm your agreement by selecting the check-box next to ‘I agree to use electronic records and signatures’ before clicking ‘CONTINUE’ within the DocuSign system. Getting paper copies At any time, you may request from us a paper copy of any record provided or made available electronically to you by us. You will have the ability to download and print documents we send to you through the DocuSign system during and immediately after the signing session and, if you elect to create a DocuSign account, you may access the documents for a limited period of time (usually 30 days) after such documents are first sent to you. After such time, if you wish for us to send you paper copies of any such documents from our office to you, you will be charged a $0.00 per-page fee. You may request delivery of such paper copies from us by following the procedure described below. Withdrawing your consent If you decide to receive notices and disclosures from us electronically, you may at any time change your mind and tell us that thereafter you want to receive required notices and disclosures only in paper format. How you must inform us of your decision to receive future notices and disclosure in paper format and withdraw your consent to receive notices and disclosures electronically is described below. Consequences of changing your mind If you elect to receive required notices and disclosures only in paper format, it will slow the speed at which we can complete certain steps in transactions with you and delivering services to you because we will need first to send the required notices or disclosures to you in paper format, and then wait until we receive back from you your acknowledgment of your receipt of such paper notices or disclosures. Further, you will no longer be able to use the DocuSign system to receive required notices and consents electronically from us or to sign electronically documents from us. All notices and disclosures will be sent to you electronically Electronic Record and Signature Disclosure created on: 6/11/2021 4:28:40 AM Parties agreed to: Andy Faber, Jimmy Forbis, Saeid Vaziry, John Edgar Unless you tell us otherwise in accordance with the procedures described herein, we will provide electronically to you through the DocuSign system all required notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to you during the course of our relationship with you. To reduce the chance of you inadvertently not receiving any notice or disclosure, we prefer to provide all of the required notices and disclosures to you by the same method and to the same address that you have given us. Thus, you can receive all the disclosures and notices electronically or in paper format through the paper mail delivery system. If you do not agree with this process, please let us know as described below. Please also see the paragraph immediately above that describes the consequences of your electing not to receive delivery of the notices and disclosures electronically from us. How to contact Jacobs Engineering Group Inc.: You may contact us to let us know of your changes as to how we may contact you electronically, to request paper copies of certain information from us, and to withdraw your prior consent to receive notices and disclosures electronically as follows: To contact us by email send messages to: ITDocuSignAdministrators@jacobs.com To advise Jacobs Engineering Group Inc. of your new email address To let us know of a change in your email address where we should send notices and disclosures electronically to you, you must send an email message to us at ITDocuSignAdministrators@jacobs.com and in the body of such request you must state: your previous email address, your new email address. We do not require any other information from you to change your email address. If you created a DocuSign account, you may update it with your new email address through your account preferences. To request paper copies from Jacobs Engineering Group Inc. To request delivery from us of paper copies of the notices and disclosures previously provided by us to you electronically, you must send us an email to ITDocuSignAdministrators@jacobs.com and in the body of such request you must state your email address, full name, mailing address, and telephone number. We will bill you for any fees at that time, if any. To withdraw your consent with Jacobs Engineering Group Inc. To inform us that you no longer wish to receive future notices and disclosures in electronic format you may: i. decline to sign a document from within your signing session, and on the subsequent page, select the check-box indicating you wish to withdraw your consent, or you may; ii. send us an email to ITDocuSignAdministrators@jacobs.com and in the body of such request you must state your email, full name, mailing address, and telephone number. We do not need any other information from you to withdraw consent.. The consequences of your withdrawing consent for online documents will be that transactions may take a longer time to process.. Required hardware and software The minimum system requirements for using the DocuSign system may change over time. The current system requirements are found here: https://support.docusign.com/guides/signer-guide- signing-system-requirements. Acknowledging your access and consent to receive and sign documents electronically To confirm to us that you can access this information electronically, which will be similar to other electronic notices and disclosures that we will provide to you, please confirm that you have read this ERSD, and (i) that you are able to print on paper or electronically save this ERSD for your future reference and access; or (ii) that you are able to email this ERSD to an email address where you will be able to print on paper or save it for your future reference and access. Further, if you consent to receiving notices and disclosures exclusively in electronic format as described herein, then select the check-box next to ‘I agree to use electronic records and signatures’ before clicking ‘CONTINUE’ within the DocuSign system. By selecting the check-box next to ‘I agree to use electronic records and signatures’, you confirm that:  You can access and read this Electronic Record and Signature Disclosure; and  You can print on paper this Electronic Record and Signature Disclosure, or save or send this Electronic Record and Disclosure to a location where you can print it, for future reference and access; and  Until or unless you notify Jacobs Engineering Group Inc. as described above, you consent to receive exclusively through electronic means all notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to you by Jacobs Engineering Group Inc. during the course of your relationship with Jacobs Engineering Group Inc..