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Home My Public Portal About2003-05-06 Insurance - Olivas Valdez12f0212003 00:14 8054844426 COAST!_GENERAL_IN5 r~Ut b1lb4 A CoR~D,~ C E RTI ~ t LATE Q F L. CAB I L ITY I iV S u RAtV C~ GATE (MMIDDIYYVY) PRODUCER 12/02/2003 Coast General Insurance Brokers 805 383-4046 ONI,YCANbFCONFERSSNO RIGHTS UPONRTHE I CERTIFIACATE 365 Willis Avenue HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Camarillo, CA 93010 ALTER THE COVERAGE AFFORDED BY THE POI.ICIE3 BELOW. License #OD56584 4; ~ : INSURERS AFFORDING COVERAGE INSURED NAIL ~ INSURER A: ~., Olives Valdez Inc. INSURER a: ATN CpM ~~~~p~s Y ND Francisco Olives ~ -" ~; F ~ °~ P AT N ~~t,~ P. O. BDx 4576 INBURERC: T_ PAUL S PL S LI_ NES I_ NS CO Covina, CA 9'i 724 - ' - INSURER D: ~w~w . ~_~ ~ - INSUFiF.R E: THG POLICIES OF INSURANCE LISTED BELOW NINE BEAN 1SSUE0 TO THE INSUREb NAMED ABOVE POR THE POLICY PERIOD INDICATEp ANY REDUIRCMENT. TERM OR CONDITrON OF ANY C~N'CRACT NOTWITHSTANDING , OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CCRTIFICATE MAY 8E ISSUED 0R MAY ~RTAlN, TWE INSURANCE AFFORDED BY TFIE POLICIErS DESCRIBED HEREIN IS SUBJECT TD AL6 THE TERMS POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE B EyCCLUSIQNS AND CONDITI EEN REDUCED BY PAID CLAIMS. ADD'I, , ONS OF SUCH POLICY NUMBER POLICY EFFECTIVE POLICY EKPIRATrON A X °~ ' uM ITs ERALLIABtLI T1/ VCGP007024 8/02/2003 8/02/2004 EACH O COMMERCIAL GENERAL uABrLIIY CCURRENCE ~ .~,000.ooc CLAIMS MADE ~ OCCUR P F 5ES (Ea oc Urtlnca S SO,OO( MED FXP An oqe person S rJ,000 PERSONAL A ADV INJURY S ~ • , GEN'L AGGREGATE LIMIT APPLIES PER; GENERAL AOCyREGATQ g , , POLICY pRC• LOC PRODUCTS - COMP/OP AGG ~ ~ ,000,OOa Au7pMODILE uA91LITY ANY auto 07588594. 3/14/2003 3/14/2004 COMBINED $1NGLE 1,IM1iAT E s 1 000 000 ALl OwNCD AUT05 ( aEacclden-) , , X SCHEDULED AUTOS BODILY INJURY X HIRED AUTOS (Ptu p9teon) ~ X NON•OwNED AUTOS BODILY INJURY (Pgf etxldnnt) ~ PROPERTY DAMAGE (For accrdenl) ~ GARAGE LIABILITY ~ ~ ~„~ t ANY AUTO A ~ ~, A A~ E AUTO ONLY • EA ACCID$tVT ~ OtHER TMAN EA ACC i 0%CEeSRJMBRELW LIAB0.17'1' ; AUTO ONLY. AGG $ OCCUR ~ ~ %' CLAIMS MADE EACW OCCURRENCE S ~AT AGGREGATE ~ DEDUCTIBLE S ~~, RETENTION ~, $ B WDRKEI~ COMpEN9ATION AND EMPLOYeRS' UAeILITY 665305803 8/01 /2003 8/01 /2004 aN X we srnru. orH. S Y PROPRIETpRJPARTNHR~cECUTIVE OFFlCERIMEMBF.R EXOWQEp? E.L. EACH ACCIDENT S ~ ,000 OOO If dg9~c unOEif SPECIAL PROVrgION9 Delow O,L. DISEASE - EA EMPLOYEE , S ~ OOO OOO OTWER C S C.L. DISEASE .POLICY LIMIT S ~ OOO OOO CHEDULE EQUIP/ACV SF05521826 11/26/2003 11/26!2004 LEgSE/RENTED EQUIP $107,279 $200,000 DESCRIPTION OP OPERATIONS I roCATIDNS /VEHICLES / E><CLUSIONS ADDED ~ LNOOggEMENT / SPECIAI. PROV1810N3 DEDUCT LE OOO 10 DAY NOTICE FOR NON PAYMENT OF PREMIUM. CERTIFICATE HOLDER IS NAMED ADDITIO ' ' NAL IAI I WE INSURANCE AFFORDED THE CITY ,ITS OFFICERS, EMPLOYEES AND VOLUNTEERS SH IN SURED, ALL BE PRIMARY SURANCE AND NOT CONTRIBUTING WITH ANY OTHER INSURANCE OF THE CITY PROJECT NO,; 4558 - CHAPMAN q~/E ~, BERKELEY AVE AND CW APMgN AVE 8 LEMON ST SHOULD aNY OP THE ABOVE DESCRIBm F~O~ICI@9 gE CANCEI,I,6D BEFORE TWe aPIRATION CITY OF FULLERTON DATE Ttl@REOF, THE ra6utNG INSURER wn,L ENO$AVCR TO MAIL ,~_ PAYS wwTTEN ENGINEERING DEPT. NOTtCR TO THR CERTIFICATE HOWER rJAMED TO THE LEFT, SUT FAILURE Tp DO 80 SFIALL 303 WEST COMMONWEALThI AVE IMPOSE NO OeI,IGATION OR LraMILITY OF ANY KIND UPDN TWe INSURER Rg AGENTS OR FULLERTON CA 92832-1775 REPREB ATIVES, AUTWORIZE REPRESENTATIVE ACORD 25 0001/0~) D CORPORATIO 1888 12I02~2003 00:14 8054844426 C;Ul~S I ! _UtN~.K€~L_1N5 rAUt n.~r n4 IMPORTANT If the certificate holder is an A~DITIONA-L INSURED, the policy(les) must be endorsed. A slat®ment on this certifcate does not confer rights to the certificate holder In (ieu of such endorsement(s), If SUBROGATION IS WAIVE, subject t0 the terms and conditions of the policy, c®rtain polici®s may require an endorsement. A statement on this certlflcato does not Confer rights to the certificate holder in Ileu of Such endorsement(s). AISCL,AIMER The Cert(ficate of Insurance on the reverse aide of this form does not constitute a contract between the issuing insurer(s), authorized representative yr producer, and the certificate holder, nor does ;t affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. 25 (x001/08) 111.b1/1bb~ bb:14 ~ib54~i4441b ~;UAS 19 _utNtK~L_1N5 rHlat n4! k74 POLICY NUM~EIt: VCGP007024 NUNIBE~; 007 EFFECTIVE i)~ATT: 12/2/03 7'IIIS ENDORSEIV,[EN'x CI~ANGES TIDE POLICY. PLEASE READ I'I` CARE ~'UI.~LY. ADDITIONAL INSURED (BLANKET) This endvrsemEnt modifies in.su.rar~ce provided under the followin : g CO~~ERC,TAL GE~]'ERAL LIABILITY COVERAGE PART OWNERS AND CON"~'R-ACTORS PROTECTNE LIAgII,TTX COVERA PRODUCTS/COMPLETED OI'ERA'I'zONS LI,A$ILITY Cp~g~AGE GE PART PART CITY OF .l'~,LERTON ENGINEERING DEPT. 303 WEST, CO,MM,ONWE,AL'I'H AVE. FULLERTON CA 92$32,1775 WHO IS AN INSURED (Section Ti) is arncnded to include aS an insared aa~ crson ernmentai entity to whom or to which you arc obligated, by virtue of a written contract oar b ization, trustee, estate or Gov. a pem~it, tv provide insurance such as is afForded by thi,~ policy, but only with res cct to v ~ the tss1tance or cxistcr~ce of your behalf or to facilities used by you and then only for the limiks of Liability s ecif ed I P ra.t~or~s perforrz~ed by you or on limits of liability in excess of the applicable Iixnit,5 of liability of this policy; rovlded such contrACt, but in no event for P that such person, organiza.tiou, trustee, cstaic yr Governmcnta.l entity shall be an Insured only witb~ respect o occurrences tski been executed or such permit ha,R been issued. ~ PIaCe a~cr such written contract has PRrIVIA.RY woxniNG Subject to all other tuxms and provisions of, the policy, such insurance a.s rovide Buc oply with zespeci to work perfoctncd by or for the named insuxed in connec 'd by Chas endorsement shall be deemed primary Lion with the above described contract PROJECT # 4555 CI~iApMAN AVE & BERKELEY AD 66 020195 AVE AND C~A.PMAN AVE & LEMON 5T. Page 1 of 1 ^ S~'A~''~ P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 COMPENSATiO.?N N S U R A.N G E ~~ N ® CERTIFICATE O!~ 1NQRKERS' COMPENSATION INSURANCE SEPTEMBER 30, 2003 6653058 - 03 POLICY NUMBER: ~-1-~4 CERTIFICATE EXPIRES: CITY OF FULLERTON THIS SUP'ERSEDES.AND- ENGINEERI~TG DEPT `CORRECTS THE; CERTIFICATE 0a3 W COi'~10NWEALTH AVE _ ISSUED ON 08-14-03:" EULLERTON CA 92832--1775 JOB: PROJECT #4558 CHAPMAN AVE &_BERKELEY GHAPMAN AVE & LEMON ST This is to certify that we have issued avalid Workers' Compensation insurance policy in a form approved by the California _ Insurance Commissioner to the employer named below for the poli,~x period indicated. _ This policy is not subject to cancellation by the Fund except upon t days' advance written notice to the employer. 30 We will also give you ~1 days} advance notice should this policy be cancelled prior to its normal expiratidn. This certificate of>insuranc~ is not an ihsurance policy and does not amend, extend'or alter the coverage afforded by he policies Fisted herein. Notwithstanding any '::requirement, term, or .condition `of any contracf or other document with respect to :which his certificate'of insurance may be issued or may pertain; the`' insurance afforded by the policies described herein is subject to all the terms, exclusipns>and cohd'tions of such policies. _ ~~~ [~-~ ~- AUTI-10RIZlrD 'REPRESENTATIVE " PRESIDENT EMPLOYER'S LIAEILITY LIMIT INCLUDING DEFENSE <~fl~TS: $l,Oa0,000 PER OCCURRENCE. ENDORSEMENT #2055 ENTITLED CERTIFICATE HOLDERS'NOTICE EFFECTIVE OS/01~03 IS ATTACHED TO AND-FORMS A FART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 09,/30/03 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY'NAME: CITY OF FULLERTON - EMPLOYER _. C?LZVAS"-VALDEZ INC PO BOX 4576 GOVINA CA 91723 (REV. 3-03) ~~_