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Home My Public Portal AboutC-19-061 - Straightline Backflow, Inc. Amendment No. 1, Backflow DevicesAMENDMENT NO. 1 TO AGREEMENT FOR CONTRACT SERVICES d THIS AMENDMENT TO THE AGREEMENT FOR CONTRACT SERVICES ("Amendment No. I") by and between the CITY OF CARSON, a California municipal corporation ("City") and STRAIGHTLINE BACKFLOW INC., a California corporation ("Contractor") is effective as of the 13th day of August, 2020. RECITALS A. City and Contractor entered into that certain Agreement for Contractual Services dated August I4, 2019 ("Agreement") whereby Contractor agreed to provide testing, repairing and replacing services for approximately 180 City backflow preventers for a term of one year and a total contract sum of $24,000. B. Due to the number of City backflow preventers that had to be tested, repaired, and/or replaced, Contractor needs additional time to complete the testing for the remaining backflow preventers. C. City and Contractor now desire to amend the Agreement to extend the term for one year, ending August 13, 2021, to complete the testing for the remaining backflow preventers and increase compensation by $11,000 to cover the remaining services for a total not -to -exceed contract sum of $35,000. TERMS 1. Contract Changes. The Agreement is amended as provided herein (new text in bold italics, deleted text in strike-tkeagk). A. Section 2.1, Contract Sum, is amended to read as follows: "Subject to any limitations set forthlin this Agreement, City agrees to pay Contractor the amounts specified in the "Schedule of Compensation" attached hereto as Exhibit "C" and incorporated herein by this reference. The total compensation, including reimbursement for actual expenses, shall not exceed Twenty Lour- Thousand Dollars ($24,000) Thirty Five Thousand Dollars ($35,000) (the "Contract Sum"), unless additional compensation is approved pursuant to Section 1.10." B. Section 3.5, Term, is amended to read as follows: "Unless earlier terminated in accordance with Article 7 of this Agreement, this Agreement shall continue in full force and effect until completion of the services but not exceeding one (1) two (2) years from the date hereof, except as otherwise provided in the Schedule of Performance (Exhibit "D"). 01007.0006/671104,.1 C. Section I of Exhibit "C", Schedule of Compensation, is amended to read in its entirety as follows: "Contractor shall perform the following tasks at the following rates: 01007.0006/671104.1 RATE TIME SUB -BUDGET A. Backflow Test $44.00 ea. (August Flat Rate $8,08088 14, 2019- August 13, 2020) $16,000.00 $50.00 ea. (August 14,2020—August 13, 2021) B. Repair of Backflow S' $120.00 ea. Flat labor rate only ?888:88 to 1.25" $2,500.00 C. Repair of Backflow $150.00 ea. Flat labor rate2,00099 1.5" to 2.00" (August 14, 2019- only August 13, 2020) $2,500.00 $160.00 ea. (August 14, 2020 — August 13, 2021) D. Repair of Backflow $180.00 ea. Flat labor rate $3,,000.00 2.5"" to 3.00" (August 14,2019- only August 13, 2020) $3,500.00 $220.00 ea. (August 14, 2020 — August 13, 2021) E. Repair of Backflow $220.00 ea. Flat labor rate $3,000.08 4.00" to 6.00" (August 14,2019- only August 13, 2020) $3,500.00 $260.00 ea. (August 14, 2020 — August 13, 2 02 1) F. Repair of Backflow $320.00 ea. FIat labor rate $ ,000.08 8.00" to 10.00" (August 14, 2019- only August 13, 2020) $2,500.00 01007.0006/671104.1 G. Materials and Parts for Repairs $360.00 ea. (August 14, 2020 — August 13, 2021) TBD Material Cost $4000.00 $4,500.00" 2. Continuing Effect of Agreement. Except as amended by this Amendment No. 1, all provisions of the Agreement shall remain unchanged and in full force and effect. From and after the date of this Amendment, whenever the term "Agreement" appears in the Agreement, it shall mean the Agreement, as amended by this Amendment No. 1 to the Agreement. 3. Affirmation of Agreement; Warranty Re Absence of Defaults. City and Contractor each ratify and reaffirm each and every one of the respective rights and obligations arising under the Agreement. Each party represents and warrants to the other that there have been no written or oral modifications to the Agreement other than as provided herein. Each party represents and warrants to the other that the Agreement is currently an effective, valid, and binding obligation. Contractor represents and warrants to City that, as of the date of this Amendment No. 1, City is not in default of any material term of the Agreement and that there have been no events that, with the passing of time or the giving of notice, or both, would constitute a material default under the Agreement. City represents and warrants to Contractor that, as of the date of this Amendment No. 1, Contractor is not in default of any material term of the Agreement and that there have been no events that, with the passing of time or the giving of notice, or both, would constitute a material default under the Agreement. 4. Adequate Consideration. The parties hereto irrevocably stipulate and agree that they have each received adequate and independent consideration for the performance of the obligations they have undertaken pursuant to this Amendment No. 1. 5. Authority. The persons executing this Agreement on behalf of the parties hereto warrant that (i) such party is duly organized and existing, (ii) they are duly authorized to execute and deliver this Agreement on behalf of said party, (iii) by so executing this Agreement, such party is formally bound to the provisions of this Agreement, and (iv) the entering into this Agreement does not violate any provision of any other Agreement to which said party is bound. [SIGNATURES ON FOLLOWING PAGE] -3- 01007 00061671104.1 WMCM MMUMOF, ffic IgUM 1 $raze 0=35ICd dES AMMdM= No_ I GM dw s) sa ft& iddow wkb Emb=1 dol d65 Ameodakema Nb � 4mN be cff=tnc as cir Aninwa 13,2020- APPROVED AS -M 10M AfEE&WYNMR, LLP ,- Smmy K. Solt Cily Awrm-y [tel CONTRACTOR: STRAIGHTLINE BACKFLOW, INC_ Un Shawn- — Chief Financial Officer Address- 1639 Armour Lane Redondo Beach, Ca 90278 Date 2020 Two corporate office signatures required whey Contractor is a corporati with oat siZratme frwm each of the following groups: 1) Chairman of the Board, President or any Vice Presidmh and 2) Secretary, any Atsttmt Secretary, Chief Financial Officer or any Assistant Treasurer. CONTRACTOR'S SIGNATURES SHALL BE DULY NOTARIZED, AND APPROPRIATE ATTESTATIONS SHALL BE INCLUDED AS MAY BE REQUIRED BY 771E BYLAWS, ARTICLES OF INCORPORATION, OR OTHER RULES OR REGULATIONS APPLICABLE TO CONTRACTOR'S BUSINESS M=- -4- 01W7.000&%71104.1 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT j A notary public or other officer completing this certificate verifies only the identity of the individual who signed I Ithe document to which this certificate is attached, and not the truthfulness, accuracy or validity of that document. f STATE OF CALIFORNIA COUNTY OF LOS ANGELES On pct ?1 2020 before me, -' personally appeareds uaum DriS 1 .. proved to me on the basis of satisfactory evidence to be the persono) whose names(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoin paragraph is true and correct. PAIGE KIM Notary Public - California WITNESS my hand and official seal. cos Anjeles County Commission M 2310386 My Comm. Expires Oct 24, 2023 Signature: OPTIONAL Though the data below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent reattachment of this form. CAPACITY CLAIMED BY SIGNER DESCRIPTION OF ATTACHED DOCUMENT ❑ INDIVIDUAL ❑ CORPORATE OFFICER 01007.0006/671104.1 TITLE OR TYPE OF DOCUMENT NUMBER OF PAGES DATE OF DOCUMENT OTHER THAN NAMED ABOVE TTtLE(S) ❑ PARTNER(S) ❑ LIMITED ❑ GENERAL ❑ ATTORNEY-IN-FACT ❑ TRUSTEE(S) ❑ GUARDIAN/CONSERVATOR ❑ OTHER SIGNER IS REPRESENTING: (NAME OF PERSON(S) OR ENTITY(IES)) 01007.0006/671104.1 TITLE OR TYPE OF DOCUMENT NUMBER OF PAGES DATE OF DOCUMENT OTHER THAN NAMED ABOVE CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy or validity of that document. STATE OF CALIFORNIA COUNTY OF LOS ANGELES On OC+ 7Z"A 2020 before me, �m personally appeared r proved to me on the basis of satisfactory evidence to be the person(s) whose names(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the Iaws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal.PAIGE Kik Notary r_c sc - cadorlia Las M�elrs County 1 ComMuton N 2310386 Signature: Kv Comm, moires Oct 24, 2023 OPTIONAL Though the data below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent reattachment of this form. CAPACITY CLAIMED BY SIGNER ❑ INDIVIDUAL ❑ CORPORATE OFFICER TITLE(S) ❑ PARTNER(S) ❑ LI7VIITED ❑ GENERAL ❑ ATTORNEY-IN-FACT ❑ TRUSTEE(S) ❑ GUARDIAN/CONSERVATOR ❑ OTHER SIGNER IS REPRESENTING: (NAM, OF PERSON(S) OR EPMTY(IES)) 01007.0006/67 1 1 04.1 DESCRIPTION OF ATTACHED DOCUMENT TITLE OR TYPE OF DOCUMENT NUMBER OF PAGES DATE OF DOCUMENT OTHER THAN NAMED A13OVE STRAPAC-01 LFLIJAI - r _ CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDNYYYI 9!912020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO FLIGHTS 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 holler Is an ADDITIONAL INSURED, the policy(les) 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 endorsemen s . PRODUCER CT Auto Club Services, LLC 2601 S. Figueroa St MS H302 PAICD Ro EYS ; 888 416-2402 A Nal: Los Angeles, CA 90007 INSURE!HSI AFFORDING COVERAGE NAICB INSURER A:Infinit( Select 20280 DAMAGE TO RENTED MED EXP arta S INSURED -INSURER B INSURER Stralghtiine Backlfow Inc Paul Drissel 1639 Armour Ln INSURERD: INSURER E: Redondo Beach, CA 90278 INSURER F 5/2512020 CAVFRO[,FS CFRTIFICA TF NIIMRr-R- REVISION MLIMRFR- 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, INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR C OCCURRENCE E DAMAGE TO RENTED MED EXP arta S PERSONAL b ADV INJURY GENLAGGREGATE LIMIT APPLIES PER POLICY El 30a 0 LOC OTHER GENERALAGGREGATE S PRODUCTS-COMPIOPAGG S A AuTomOBILE LIABILITY ANY AUTO OWNED X SCHEDULED AAUTO$ ONLY AAMOSSyy� o AUTOS ONLY AUTOS pfY X X 504610140348001 5/2512020 6125/2021 COMBINED SINGLE LIMIT S 11000,000 BODILY INJURY War n BODILY INJURY Par aeeideM �OaE�f Ym AMAGE S UMBRELLA LWBOCCUR EXCESS LIAR HCLAIMS-MADE EACH OCfURRFKE AGGREOAW S DED I I RETEMION5 S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIIETO�RR1PAR NEERRIE ECUI IVE ❑ In NAI IIyea dncAbe under DESCRIPTION OF OPERATIONS 6e k 1 A PER ETH - E.L. EACH ACCIDENT E.L. 019 S - ga NPLOY9 S EL. DISEASE • POUCY LIMIT S DESCRIPTION OF OPERATIONS! LOCATIONS /VEHICLES `ACORD 101 Additional Remarks Schedule, me ba attached If men apace Is mqulredl IT IS AGREED THAT THE CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED. '30 DAY NOTICE OF CANCELLATION EXCEPT FOR NON-PAYMENT -10 DAY NOTICE OF CANCELLATION FOR NON-PAYMENT ONLY. ' Waiver of Subrogation applies' SHOULD ANY OF TETE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE NO City of Carson ACCORDANCE WITH THE O ICYREOFPROVISIONgCE WILL BE DELIVERED IN 701E Carson St Carson, CA 90745 AUTHORIZED REPRESENTATIVE 4/10/2020 L A ACORD 25 (2016103) 01888-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD KEMPER Auto RM -1114 Y Infinity Commercial Auto 11700 Great Oaks Way, Suite 450 Alpharetta, GA 30022 Underwritten by: Infinity Select Insurance Company Customer Service. 800-722-3391 Claims Service: 800-334-1661 WAIVER OF SUBROGATION CALIFORNIA Copy To Policy ID Number Expiration Date STRAIGHTLINE BACKFLOW INC 504-61014-0348-001 06/28/2021 12:01 AM 1639 Armour Ln Named Insured do Beach, CA 90278 STRAIGHTLINE BACKFLOW INC n This endorsement is attached to and forms a part of the listed policy. No changes will be effective prior to the ttme changes are requested. In return for your premium payment shown below, we agree that our rights of subrogation or rights of recovery under the policy will not apply against the following person or organization: City of Carson 701 E. Carson St Carson, CA 90745 Additional premium in the amount of $25.00 will be retained by us regardless of any early termination of this endorsement or the policy. All other policy provisions remain unchanged. 50461SWF01 Amend Date: 09/09/2020 ----1 Policy Number CCP889752 Date Entered: 2/24/2020 ^C:;P#?" CERTIFICATE OF LIABILITY INSURANCE DATE (MM1DDNYYYI OMMA7fl 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(les) must 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). PRODUCER Cole Bogue GA Contractors Insurance Services, Inc 9646 Business Park Drive Suite H I, G N. (916) 363-2663 (916) 363-2662 AVOR e cerliRcates®cdsbands.com INSURERIS) AFFORDING COVERAGE MAIC 0 Sacramento, CA 95627 INSURER A: -Century Surety Group 36951 $ 5,000 INSURED INSURER & National Union Fire Insurance of Pittsburgh PA 19445 STRAIGHTLINE BACKFLOW INC 1639 ARMOUR LN REDONDO BEACH, CA 90278 INSURER C: INSURER D-. INSURER E: POLICY PROJECT LOC INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMRFR! THIS IS TO CERTIFY THAT THE POLICIES OF THE 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. Carson, CA 90745 LTR TYPE OF INSURANCE I� SR WVDa POLICY NUMBER (MWD�D! YWj (MMIDD POLICY LIMITS 6Aq - GENERAL LIABILITY CCP889752 3!212020 312!2021 EACH GCCURENCE # 1,000,000 A X COMMERCIAL GENERAL LIABILITY x X DAMAGE TO RENTED 100,0,0 PREMISES (Ea oocurence) CLAIMS MADE X OCCUR MED EXP (Any one porton) $ 5,000 PERSONAL dADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER? PRODUCTS -COMPIOP-AGG $ 2,000,000 POLICY PROJECT LOC AUTOMOBILE UA13JUTY COMBINED SINGLE LIMIT (CEO cddwQ $ ANYAUTO BODILY INJURY (Por parson} AAIUTOS ED SCHEDULED BODILY INJURY (Pa acddent) $ HIRED AUTOS NON -OWNED PROPERTY DAMAGE $ AUTOS (Par acddent) UMBRELLA LIAR X OCCUR EBU048425468 3/2/2020 3/2/2021 EACH OCCURRENCE B $ 3000.000 EXCESS LIAR CLAIMS -MADE AGGREGATE $ 3.000,GOO DED RETENTION S WORKERS COMPENSATION WCSTATU• OTH. AND EMPLOYERS' LIABILITY YM NIA TORYL[MITS ER ANY E L EACH ACCIDENT $ PROPRI ETO R/PARTN ERIEXE C UTI V E (Mandatory in NIH) E L DISEASE - EA EMPLOYEc $ If yes, describe under DESCRIPTION OF OPERATIONS below E. L DISEASE - POL CY LIMIT $ DESCRIPTION OF OPERATIONSILOCATIONS IVEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) City of Carson is named as additional insured on the General Liability policy, per attached endorsements. Insurance is primary and noncontributory. Waiver of subrogation included for the General Liability. 30 day written notice of cancellation, 10 day notice of nonpayment of premium. Umbrella to fallow form. License # 1028209 CERTIFICATE FOLDER CANCELLATION Twp f� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE p City of Carson 701 E Carson Street EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Carson, CA 90745 4/7.0/2020 6Aq - ACORD 25 (2010105) M 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks cf ACORD CGL 1816 0216 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS -- SCHEDULED PERSON OR ORGANIZATION, PRIMARY AND NON-CONTRIBUTORY This endorsement modifies insurance provided under the following: CONTRACTORS LIMITED CLAIMS MADE GENERAL LIABILITY COVERAGE FORM CONTRACTORS LIMITED CLAIMS MADE AND REPORTED GENERAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name of Additional Insured Person(s) or Organization Location(s) of Covered Operations Any person or organization as required by written contract to be named as additional insured Various locations as per contract with the named insured A. 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 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. 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. 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. CGL 1816 0216 Includes copyrighted material of Insurance Services Office, Inc., used with its permission. page 1 of 2 CGL 1816 0216 C. The insurance provided for the benefit of the above scheduled additional insured(s) shall be primary and non- contributory, 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 in the Schedule above. D. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits of Insurance and Deductible: 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 All other terms and conditions of this policy remain unchanged. CGL 1816 0216 Includes copyrighted material of Insurance Services Office, Inc., used with Its permission. Page 2 of 2 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE of Person or Organization. ny person or organization for whom you are required to waive your right of recovery on this Coverage Part under written contract or agreement 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 organization 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 with 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 QInsurance Services Office, Inc., 2008 Page I of 1 POLICYHOLDER COPY SC P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 09-09-2020 CITY OF CARSON SC 701 E CARSON ST CARSON CA 90745-2224 GROUP: POLICY NUMBER: 9249212-2020 CERTIFICATE I1): 31 CERTIFICATE EXPIRES: 04-17-2021 04-17-2020/04-17-2021 THIS CERTIFICATE SUPERSEDES AND CORRECTS CERTIFICATE # 28 DATED 09-02-2020 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2020-09-02 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF CARSON ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2020-09-09 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF CARSON ENDORSEMENT #1851 - DRISSEL,PAUL PRESIDENT - EXCLUDED. ENDORSEMENT #1B51 - SHAWN DRISSEL SEC,TRES - EXCLUDED. EMPLOYER STRAIGHTLINE BACKFLOW INC SC 1639 ARMOUR LN REDONDO BEACH CA 90278 [P1K,HOI IREVJ-20141 PRINTED : 09-09-2020 WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: 1. Please be advised that a waiver of subrogation requires that a 3% surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on jobls for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job: Sample Rate: Regular Premium equals: Surcharge: Additional Waiver charge: Total premium equals $5,000.00 13.30% $ 665.00 3.00% $ 19.95 $ 684.95 (665.00 + 19.95)