HomeMy Public PortalAbout2010-12-16 Assign & Assump Agmt for Constr of Public Works - Fox Theatre Complex - Lundgren Mgmt - GOP Electric
ASSIGNMENT AND ASSUMPTION AGREEMENT
OF AGREEMENT FOR CONSTRUCTION OF PUBLIC WORKS
This ASSIGNMENT AND ASSUMPTION AGREEMENT OF AGREEMENT FOR
CONSTRUCTION OF PUBLIC WORKS ("Assignment") is entered into as of this 16th day of
December ,20lQ, to be effective as of the Effective Date, by and between FULLERTON
REDEVELOPMENT AGENCY, a public body, corporate and politic ("Agency" or "Assignor"),
and LUNDGREN MANAGEMENT, a California Corporation ("Lundgren" or "Assignee").
R~.G!IALS.
A. On or about September 9, 2010, Agency and Lundgren entered into that certain
Professional Services Agreement for Construction and Program Management ("CM/OR
Agreement"), which provided for Lundgren to provide construction management/owner's
representative services to the Agency for the Renovation and Rehabilitation of the Fox Theatre
Complex ("Project") to be constructed on the Project Site, located at 510 N. Harbor Boulevard,
Fullerton, California.
B. On or about the date of this Assignment, Agency and GOP Electric
("Contractor") entered into that certain Agreement for the Construction of Public Works
("Agreement for the Construction of Public Works"), which provided for Contractor to provide
construction related services for the portion of the Project specified in that agreement
C. In order to facilitate the respective rights and obligations of Agency, Lundgren,
and Contractor pursuant to the CM/OR Agreement and the Agreement for the Construction of
Public Works, Agency and Lundgren must execute, and Contractor acknowledges its acceptance
of, this Assignment.
AGR~~M~NI
Based upon the foregoing Recitals, which are incorporated herein by this reference, and
for good and valuable consideration, the receipt and sufficiency of which is acknowledged by
both parties, Agency and Lundgren hereby agree as follows:
1. Definitions. Any capitalized terms contained in this Assignment which are not
deflOed herein shall have the meaning given in the CM/OR Agreement, unless expressly
provided to the contrary herein.
2. Effective Date. Upon the complete execution of this Assignment by Assignor and
Assignee, this Assignment shall be effective immediately after complete execution of the
Agreement for the Construction of Public Works, on the date specified therein (the "Effective
Date").
3. Assilmment and Reservation of Specified Rights. As of the Effective Date,
Assignor assigns to Assignee all of Assignor's right, title and interest in and to the Agreement
2399to61334.QOIO
1128479.03aI2l16/10
-9-
for the Construction of Public Works subject to the following reservation of rights and
exclusions from assignment:
A. Agency hereby reserves its right to review and approve, in
accordance with Sections 4.5 of the Agreement for the Construction of Public
Works, any additional compensation requested by Contractor.
B. Agency hereby reserves its right to review and approve any change
order, in accordance with Section 7, in its entirety, of the Agreement for the
Construction of Public Works, that would result in additional time or an increase
in cost for the work to be completed by Contractor.
C. Agency hereby reserves its right to liquidated damages, in
accordance with Section 7.2.2 of the Agreement for the Construction of Public
Works, in the amount designated as Agency's liquidated damages set forth in the
CM/OR Agreement.
D. Agency hereby reserves its right to participate in any dispute
resolution proceedings, in accordance with Section 7.3 of the Agreement for the
Construction of Public Works.
E. Agency hereby reserves the right and benefit in Section lOin the
Agreement for the Construction of Public Works, such that all Performance
Bonds, Labor and Material Bonds and Contractor Warranty Bonds shall remain in
favor of Agency.
F. Agency hereby reserves its right to the ownership and possession
of all finished and unfinished Project Design and Construction Documents, in
accordance with Section 11.1 of the Agreement for the Construction of Public
Works.
G. Agency hereby reserves its right to all warranties for all material
and equipment furnished under the Agreement for the Construction of Public
Works, in accordance with Section 13.6 therein.
H. Agency hereby reserves its right to consent to any waiver of any
breach, term, covenant or condition of the Agreement for the Construction of
Public Works, in accordance with Section 13.12 therein.
I. Agency hereby reserves its right to review and approve any
modification and/or amendment to the Agreement for the Construction of Public
Works, in accordance with Section 13.13 therein.
4. Assumotion. As of the Effective Date, Assignee accepts the above described
assignment, and agrees to assume, keep, perform, and fulfill all of the terms, conditions,
covenants, and obligations required to be kept, performed, and fulfilled by Assignor under the
Agreement for the Construction of Public Works as assigned by this Assignment.
2399106t334.()OIO
1128479.03 d2116110
.Jl).
5. Joint Benefit of Indemnity and Insurance Provisions.
5.1 Indemnities. Upon the Effective Date of this Assignment, Contractor's
(and Subcontractor's, if applicable) obligations to indemnify, defend and hold harmless the
"Indemnified Parties," as defined and applied in Section 8 of the Agreement for the Construction
of Public Works, shall extend and apply to both Assignor and Assignee, and their respective
directors, officials, officers, agents, volunteers and employees.
5.2 Insurance. Upon the Effective Date of this Assignment, Contractor's (and
Subcontractor's, if applicable) insurance obligations to Agency set forth in Section 9 of the
Agreement for the Construction of Public Works shall extend to and apply to both Assignor and
Assignee, such that, in addition to other applicable provisions set forth in that Section 9,
Assignor and Assignee, and their respective directors, officials, officers, agents, volunteers and
employees, shall be named as insureds for all required insurance.
6. Miscellaneous.
6.1 Attornev's Fees. In the event any legal proceeding is instituted to enforce
any term or provision of this Assignment, each party in said legal proceedings shall be
responsible for its attorney's fees and costs.
6.2 Inurement. This Assignment shall inure to the benefit of Assignor and
Assignee and their respective heirs, assigns, and successors in interest
6.3 Governing Law. This Assignment shall be construed in accordance with
the internal laws of the State of California without regard to conflict of law principles.
6.4 Execution in Countelllart. This Assignment may be executed in
counterparts, each of which shall be deemed to be an original, and such counterparts shall
constitute one and the same instrument.
6.5 Assignee to Deliver Notice. No later than five (5) days after the Effective
Date of this Assignment, Assignee shall deliver (0 Contractor notice of this Assignment and
Assignee's contact information for all notices that mayor are required to be delivered under the
Agreement for the Construction of Public Works.
[SIGNATURES ON FOLLOWING PAGE]
23991061334..0010
1128479.03a12f16J10
.11.
IN WITNESS WHEREOF, the parties hereto have entered into this Assignment to be
effective as of the Effective Date.
"ASSIGNOR"
FULLERTON REDEVELOPMENT AGENCY, a
::~-'1:re~;~
Robert M. Zur Sc ie
Executive Director
ATTEST:
.~.~
Agency Secretary
"ASSIGNEE"
LUNDGREN MANAGEMENT, a California
:_tiOO~, C4f---
Dale Lundgren
President
ACKNOWLEDGMENT AND CONSENT: The undersigned representative hereby
acknowledges and consents to the terms and conditions of this Assignment:
"CONTRACTOR"
GOP Electric
By:
()CTAviAN 'I6?E-SCM.
~NER..
Its:
23%1106133<1-0010
112847903al2116/10
-12-
JRN-12-2011 09:36 From:GOP ELECTRIC
8187802012
To: 16612571805
JAN.l1.20114:50PM
NO. 678
IN WI1NESS WHEREOF. the parties hereto have entered iDto this Assignment to be
effective as of the Effective Date.
"ASSIGNOR"
FULLERTON REDEVELOPMENT AGENCY, II
public body, corporate and politic .
BY.~~h~~
i! R~;M Zur So .
Executive Di.reetor
ATTEST:
Agency Scct:etazy
"ASSIGNEE"
LUNDGREN MANAGEMENT. a California
corporation
By;
Dale Lundgren
President
P.3/3
P. 3
ACKNOWLEDGMENT AND CONSENT: The undetlligned representative hereby
acknowledges and consents to me temia and conditions of this Assigmnent:
"CONTRACTOR"
GaP Electric
By: (Je..7A-vIAN 16-?i25CM..
Its:
13~1334-0alD
111_"'016114110
-12-
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303 W:st CcnmonweaIlh Avenue.
Fldlerton. CA 92B32
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BLANKET ADDITIONAL INSUREDS-
OWNERS, LESSEES OR CONTRACTORS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Polley Number: 04-10132312 Endorsement Effective: 11312011
Named Insured: Countersigned By:
OCTAVIAN POPESCU ~~ ~
DBA: G 0 P ELECTRIC
SCHEDULE
Name of Person or Organization:
LUNDGREN MANAGEMENT CORP.
26330 CITRUS STREET
VALENCIA, CA, 91355
Location:
500 N. HARBOR BLVD, FULLERTON, CA, 92832
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
A. Section II - Who Is An Insured is amended to include as an insured the person or
organization shown in the Schedule, but only to the extent that the person or organization
shown in the Schedule is held liable for your acts or omissions ansing out of your ongoing
operations performed for that insured.
B. With respect to the insurance afforded to these additional insureds, the following exclusion is
added:
2. Exclusions
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 site of the covered operations has been
completed; or
(2) That portion of ''your work" out of which the Injury or damage anses has been put to
its intended use by any person or organization other than ancther contractor or
subcontractor engaged in performing operations for a principal as a part of the same
project.
C. The words "you' and "your" refer to the Named Insured shown In the Declarations
D. 'Your work" means work or operations performed by you or on your behalf; and materials, parts
or equipment furnished in connection with such work or operations.
Primary Wordina
If required by written contract or agreement: Such insurance as Is afforded by this policy shall be
primary insurance, and any insurance or self-insurance maintained by the above additional
insured(s) shall be excess of the insurance afforded to the named insured and shall not contribute
to it.
Waiver of Subroaation
If required by wrItten contract or agreement: We waive any right of recovery we may have against an entity
that is an additional insured per the terms of this endorsement because of payments we make for injury or
damage arising out of 'your work" done under a contract with that person or organization.
ANF- ES 043 (512006)
BLANKET ADDITIONAL INSUREDS-
OWNERS, LESSEES OR CONTRACTORS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Polley Number: 04-10132312 Endorsement Effective: 11312011
Named Insured: Countersigned By:
OCTAVIAN POPESCU ~~ ~
DBA: GO P ELECffilC
SCHEDULE
Neme of Person or Organization:
FULLERTON REDEVELOPMENT AGENCY
303 WEST COMMONWEALTH AVENUE
FULLERTON,CA,92832
Location:
500 N. HARBOR BLVD, FULLERTON, CA, 92382
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
A. Section II - Who Is An Insured is amended to include as an insured the person or
organization shown In the Schedule, but only to the extent that the person or organization
shown in the Schedule is held liable for your acts or omissions arising out of your ongoing
operations performed for that insured.
B. W~h respect to the insurance afforded to these additional Insureds, the following exclusion' Is
added:
2. Exclusions
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 add~lonal Insured(s) at the s~e 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.
C. The words "you" and ''your" refer to the Named Insured shown In the Declarations.
D. "Your work" means work or operations performed by you or on your behalf; and materials, parts
or equipment furnished in connection with such work or operations.
Primarv Wordlna
If required by written contract or agreement Such Insurance as is afforded by this polley shall be
primary insurance, and any insurance or self.insurance maintained by the above additional
insured(s) shall be excess of the insurance afforded to the named insured and shall not contribute
toil.
War"er of Subroqatlon
If required by written contract or agreement: We waive any right of recovery we may have against an entity
that is an additional insured per the terms of this endorsement because of payments we make for injury or
damage arising out of "your workll done under a contract with that person or organization.
ANF- ES 043 (512006)
JAN-20-2011 21:15 From:GOP ELECTRIC
8187802012
To: 16612571806
P.2'9
1212812010
UNITRIN
AgenV8rokef for ~nanctallnd.mnity Company:
ULTIMATE AGENCY USA !NC
5232 TOPANGA CANYON BLVD
WOODl.AND HILLS CA 91394
000'318 02 MB O,.SO.l "AUTO TI 0 I~.dil P14C1e 326539 . COl
111'11'1"1,1,1111,11'111111'1"11111'111,1,,1'1'11'1,11"111111'
G 0 P ELECTRIC
7317 HASKELL AVE 114
VAN NUYS CA 91406-3285
Ae: Commercial Vehicle Insurance Policy Number CCFICA2994971.o1
Enclosed are your Policy documents lor tno above commercial vehlole policy. Please take a few minutes to
review the enclosed documents to confirm that all the inlormation In your documents Is correct. Also be sure to
check lhe following:
. That all vehicles and drivers to be covered are shown on the enclosed policy documents.
. That the information on your Prool ollnsuranoe Cards is correct.
. That all optional coverage forms are shown on the policy documents.
. That the policy Declarations Page and/or an Amendatory Endorsement summary form ars enclosed.
Be sure to put those documents In a safe place wnh your other insuranco documents and records.
Your premium bill will be mailed separately. so watch your mailbox lor your premium bill.
"you have any qUestiolls or concerns about your commercial vehicle insurenca. please contsct your
aganVbroker at 818-932-0462.
Thank you for choosing Financial Indemnity Company (UnMn Specially) to serva your commercial vehicle
insurance nseds.
FORM; FOflMs.COVER
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JAN-20-2011 21:15 From:GOP ELECTRIC
8187802012
To: 16612571806
P.3/9
Financial indemnity Company
Administrative Offi099 Located At:
8360 LBJ Freeway. Suite 400, Executive Center II
Dallas, TX 75243
Mall CorrespondBnce To:
PO BOX 223687
Dallas, TX 75222-3687
UNITRIN
"Insurance For U"
California Commercial Vehicle Polley
Amended Declaration Page
Summary
Namad Insurad(8)
G 0 P ELECTRIC
7317 HASKELL AVE 114
VAN NUYS CA 91406
Your Agent/Brokw
ULTIMATE AGENCY USA INO
5232 TOPANGA CANYON BLVD
WOODLAND HILLS CA 91364
818-932-0462
Policy Number
CCFICR2994971-01
Renewal of Policy Number
FC FICV2994971.00
Policy Period
From 0311912010 to 0311912011 12:01 s.m. standard lime
at the address of lho named Insurod as stated herein.
EtfectIve Date of Policy Change: 1212212010
Reason(s) for Policy Change:
. A Designated Covered Parson or Organization ondorsement has been added
this policy change results in an addltlon.1 premium of SSO.OO.
Policy, EndoraemDl1lB, and Amandments Attached 10 Policy
CA-999 (10109) Policy Amendatory Endorsement
U.672 (01194) California Commercial Auto Policy
U.24 (03104) Mileago limitation Endorsement
U-62 (01/87) Deletion of Unlsured Motorist Bodily Injury Coverage from Policy
U-642 (10/03) Daslgnated Insured Endorsament
U-644 (12/03) Single limit 01 liability
U.784 (07/03) Exclusion of Certified Act of Terrorism
Total Premium and Fees
Premium for all Vehicles (See Total Coverege Premium)
Addhionallnsured Fee
Vehicle Assessment Fee
$3.422.00
$75.00
$1.80
Discount(lI)JSurchllfge(8) Appliad To This Policy
Paid In Full 12 Month Term
Total for this Policy Term
$3,498.80
In return for the payment of the premium and subjsct to all the lerms of this policy, we agree w~h you to provide the insurance as
slated in your policy documents.
Declaratlone Print Date: 1212812010
CA-855 (12/07)
F'ORM: SDOCS.DECPGE
Page 1 of 3
Insured's Copy
JAN-20-2011 21:15 From:GOP ELECTRIC
Financiollndamnlty Company
8187802012
To: 166125718'2l6
P.4/9
Policy Numbor: CCFICR299497Hll
Policy Effective Defe: 0311912010
Your Aganl/Broker: ULTIMATE AGENCY USA INC
818-93:l.0462
Coverage la only provided whero a limit oIlleblllty and 8 premium are _ for the coverage.
Coverage
Limits
Premlllm
Pert I . UabDIly Coverage
Combined Single Limit (UAB)
$1 , 000. 000 Each Accident
$3,422
Pal'll! . Medical Paymenl8lPereonellnJurv Protection
Medical Payments (MED) No Co v era g e Each Person
Pal'llll- UnlnsuredlUnderlnsured Motorist Coverage non-etackecl
Bodily inJury (UMBI) No Coverage Each Person
No Cove r age Each Accldant
Total Coverage Premillln
$3,422
. LEGEND: . fNC .Inoludell . UCL -Excluded
to y-V.. .. N..No
. NCY. No Coverage . NA. NOI Applloable
. bED. Deducllble . BCHD. llchodulo
Page 2 of 3
Insurecl's Copy
. ACV. "ctuol C811h Yalu.
. Np. NamocI Peril.
CA-8liS (12107)
JAN-20-2011 21:15 From:GOP ELECTRIC
F1nanciallndemnily Company
8187802012
To: 16612571806
P.5/9
Poli"y Number: CCFICR2994971-0'
Policy Ellec:llve Date: 03119/20'0
Your Allenllllraker: ULTIMATE AGENCY USA INC
818-932-0462
eoveragolo only provided where a limit of liability and a premium ore ahown for tI1a coyorage.
SCHEDULE OF VEHICLES COVERED
VoIl Goroge Cle. Radius LIenI Vo!llclo V1N Vehicle ACV (DEDUCTlBLES)
Hum Zip Terr MOl< Lo.. Doscrlptlon Aa8088rnont OTC/NP COL UMPD
peyoo $ $ $ $
2549 91406 8, 50 N 2001 ISUZ NPR uAL84B14117002549 NCV NCV NCV NCV
82:35 91406 81 50 N 200_ TYTA TUNDRA 5TBJN32104S438235 NCV NCV NCV NCV
COVERAGE PREMIUMS
Coverage 18 prOYlded only lor lhoae vehi,,1e8 where 8 premium 8Itlount is ohawn for 1he covorage.
1834
1588
UMPD
LIMIT
$
NCV
NCV
TOTAL
PREM
$
VoIl
Num
2549
8235
liAS
$
1, ea4
1,595
USTED DRlVER(S)
DRIVER
OCTAvtAN POPESCU
DRIVER
liCENSE NO.
0'61665.4
DATE OF BIRTH
06/21/1976
FINANCIAL
RESPONSIBILITY
FlllNG
N
DRIVER
STATUS
INSURED
VIOLATION!
ACCIDENT
POINTS
o
ADDmONAL INTEREST(S)
TYPE VEHICLE NAME f ADDRESS CITY STATE ZIP
Addtttontll InlSu,..ed ALL FUL~ERTON RED~VELOPMENT AGENCY
303 WEST COMMONWEALTH AVE FULLEJHCN CA 92832
Add, t ionnl In~ured ALL LOS ANGELES UNIFIED "SCHOOL OIS
1000 N MILWAUKEE AVE GlENVIEW IL 60025
Add1t.1onal Insured ALL LUNDGREN MANAGEMENT CORP
26330 CITRUS STREET VALENCIA CA 91355
LEGEND:
. INC. Inoludccl
. V-Villi
. EXeL .ElEoludccl
. N.No
. HCV. No Covorege
. DEl>. Dedvotlble
. NA. Nol 4ppllcoblo
. SCHD. 8chcclul.
. ACV - Aeluel Caah Voluo
. Np. Nomad Perl I.
CA-8S5 (12/07)
Page 3 01 3
Insured's Copy
JRN-20-2011 21:15 From:GOP ELECTRIC
8187802012
To: 16612571806
P.6/9
UNITRIN
AMENDATORY ENDORSEMENT
This endorsement forms a psrt of the policy described below, and is effective from 12:01 a.m. on the Endorsement Effec~ve Date.
Insurenc:a Company: Financial Indemnity Company
Policy Number: CCFICR2994971-0t
Named Insured: GO P ELECTRIC
7317 HASKELL AVE t14
VAN NUYS CA 91406
Policy Effective Date:
Endorsement Effective Date:
03/1912010
12/22J2010
Policy expiration Date: 0311912011
In consideration for your promise to pay any Increase in or change to yaur premium, If applicable, we agree that the following
changers) have been applied to the above referencad policy.
Change: The following have been added as a designated covered person or organi2ation:
Entity Name: FULLERTON REDEVELOPMENT AGENCY Addre88: 303 WEST COMMONWEALTH AVE FULLERTON
CA 92832
Entity Type: Additlonsllnsured
Entity Neme: LUNDGREN MANAGEMENT CORP AddreSe: 28330 CITRUS STREET VALENCIA CA 91355
entity Type: Add~lonal Insured
The change(s) resulted In an increase to your premium of $50.00. II applicable, any additional endorsement(s) associatsd with
the change(s) are listed in this endorsement form and will become a part of your Insurance policy.
Nothing herein contained shell be held to vary. aller, waive. or extend any ot the terms, limits of liability, conditions or.
exclusions In the addltionsl endorsement(s). or In the policy, to which this endorsement Is attached other than as stated above.
U-990 (t2/07)
fORM: sooco.oPTEND
12/28/2010
Copyright, Unltrln. 2007
JRN-20-2011 21:16 From:GOP ELECTRIC
8187802012
To: 16612571806
P.7'9
DESIGNATED INSURED ENDORSEMENT
ThiS endorsement forms a part of Policy No. CCFICR2994971-01 Issued to GO P ELECTRIC
by the (Name of Insurance Company)
Financial Indemnity Company
at Its Agency
located (city and stale) Van Nuys, California
and is effective from 12122J2010 (12:01 a.m. Standard Time).
Name of Person(s) or OrganlZation(s): FULLERTON REDEVELOPMENT AGENCY
Each person or organization Indicated abOve is an inswed for uability Coverage, but only to the extent that person or
organization qualifies as an insured under Part I, Uability 01 the policy.
Nothing herein contelned shall be held 10 vary, aller, waive, or extend any of the terms, limits of liability, conditions or
exclUSIOns of the policy to which this endorsement Is allached, other than as stated above.
ThiS endorsement musl be attached to the revision Declarations when Issued after the policy is written.
U-642 (10/03)
FOAM: 600e&.oP'rSI\lD
JAN-20-2011 21:16 From:GOP ELECTRIC
8187802012
To: 16612571806
P.8/9
DESIGNATED INSURED ENDORSEMENT
This endorsement forms a part of Policy No. CCfICR299497, .0' Issued to G 0 P ELECTRIC
by the (Name of Insurance Company)
Financiallndemnily COmpany
at Its Agency
located (cily and state) Van Nuys, California
and Is effective from 1212212010 ('2:01 a.m. Standard Time).
Name 01 Person(s) or Organlzation(s): LOS ANGElES UNIFIED SCHOOL DIS
Each per;;on or oraanlZatlon Indicated above Is an Insured lor Uabllily Coverage, bul only 10 the extent Ihal person or
organization quallffes as an Insured under Part I, Liablllly of the policy.
Nothing herein conlained shall be held to vary, alter, waive, or extend any 01 the terms, Iimhs olliabilily, conditions or
exclUSions 01 the policy 10 which this endorsement is attached, other than as stated above.
This endorsement must be attached to the revision Declarations when Issued alter the policy is written.
U.642 (10/03)
FORM: 8[X)CS,OP'T1iND
JRN-20-2011 21:16 From:GOP ELECTRIC
8187802012
To: 16612571806
P.9/9
DESIGNATED INSURED ENDORSEMENT
Tl'lIS endorsement torms a part of Policy No. CCFICR2994971-01 Issued to GO P ELECTRIC
by the (Name of Insurance Company)
Rnanclallndemnlty Company
at its Agency
located (city and state) Van Nuys, California
and Is effective from 12/2212010 (12:01 a.m. Standard Time).
Name of Person(s) or Organlzatlon(s): LOS ANGELES UNIFIED SCHOOL DIS
Each person or Ql'ganlzation Indicated above Is an Insured for Liability coverage, but only to the exlent that person or
organization qualllfe5 as an insured under Part I, Uablllty of the polley.
Nothing herein contained shall be held tQ vary, alter, waive, or extend any of the terms, limits otllablllty, conditions or
exclUSions of the pol Icy to which this endorsement Is attached, other than as stated abOve.
This endorsement must be attached to the revision Declarations when issued atter the policy is written.
U-642 (10/03)
FORM: SDOCS 0PTiN0
Best's Credit Rating Center - Company Information for Navigators Insurance Company
Page I of2
Ratings & Analysis Center
'?'l.!.\'t:~''Z: ,:;...wt~i)' ;\.~~"r~.:::,,( ~ :;:::~~ <.1.
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Navigators Insurance Company
(a mernberof NaoAoalllB Il"ISUlance GrouD\ ,.......__h__... .._..~.._.___ '.____
A.M.Bcst":00182S NAIC':42307 FEINt: 1331J83'O(~1O Irn.~~~:jj
'compal'll&S f ~8EST ~ 1~1:
Jlhathave.ln t, /4.' t ',),:i
; our oplnloo, .
: en exceIent abIlly to meet th8Ir
'''~~~:~~-:e.~~~'"::._... _._ i
Acfdi-ea:Reck&on~Palt,6tntemat1Ot1afOI1ve
Rye Bfl)Ok. NY 10573
UNITED STATES
Phone; 914.93HI999
Fu914-934-2355
web: WWW.MVOcom
Belt's Ratinga
FinancIal Strwtgth Rating:> View DefInitions
Rabng: A (Excellent)
Financial Size Calego'Y' X ($500 Million to
$750 MUllen)
Outlook: Stable
Action: Affirmed
EffecUw- Dale' June 22, 2010
Issuer Cntdfl Ratings Voew DafinobOnt
long-loon.a+
OUllook:Stabla
Action. Affirmed
Dale: June 22. 2010
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Data Status~ Conlans dela compiled as of 1/1312011 (QlIllllyCrou CheCklld).
tiIi Be!rt"s Kov Rat/no Guido PmsentBllan ~DOr1. i1'ldudes BesfS Financial Strenglh
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1/1912011
Best's Credit Rating Center - Company Information for Navigators Insurance Company
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Page 2 of2
1/1912011
CERTHOLOER COpy
SC
STATE
COMPENSATION
INSUR^NCe
FUND
P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 12-26-2010
GROUP: 000238
POLICY NUMBER: 0003559-2010
CERTIFICATE ID: 12
CERTIFICATE EXPIRES: 10-01-2011
10-01-2010/10-01-2011
LUNDGREN MANAGEMENT CORP,
26330 CITRUS ST
VALENCIA CA 91355-5323
SC
This is to certify that we have Issued a valid Workers' Compensation insurance policV 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.
t Representalive
~rL
President and CEO
UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING:
THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER DR A HUSBAND AND WIFE EMPLOYER;
EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING
CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNOER CALIFORNIA WORKERS'
COMPENSATION LAW,
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE,
ENDORSEMENT H0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2010-12-26 IS
ATTACHEO TO AND FORMS A PART OF THIS POLICY, NAME OF ADDiTIONAL INSURED:
LUNDGREN MANAGEMENT CORP,
EMPLOYER
iDEe ~ 0 lam
lundgrl!i;n
Mor.€lg\W1\err1
POPESCU, OCTAVIAN OBA: G 0 P ELECTRIC SC
7317 HASKELL AVE APT 114
VAN NUYS CA 91406
M0408
PRINTED
12-28-2010
IREV.8-2010l
Form W-g
(Rev. October 200n
DepllrtmentoftheTr'~
InlOlnal RevenueSlIrvlce
Name (8S shown on your Income talt return)
Request for Taxpayer
Identification Number and Certification
Give form to the
requester. Do not
send to the IRS.
Check. appropriate boll. I2l IndlviduallSole proprietor 0 Corporation 0 partnGrship
o Limited flabdity oompany. Enter the tax classlflcatlon (Oadlsregarded enllty. C_corporation, P=partoershlp) .. .......
o 01har(sellinstructions)....
Address (number, street. end apt. or suite no.)
7317 HASKELL AVE. ,A t.114
CIty, state, and ZIP code
VAN NUYS, CA, 91406
Ust a.ccount number(s) here (optional)
Enter your TIN In the appropriate box. The TIN provided must match the name given on Une 1 to avoid
backup withholding. For individuals, thIs Is your social security number (SSN). However, for a resident
alien. sole proprietor, or dIsregarded entity, see the Part I instructions on page 3, For other entities, It la
your employer Identification number (EIN), If you do not have a number, see How to get a TIN on page 3.
Note. If the account Is In more than one name, see the chart on page 4 for guidelines on whose
number to enter,
Certification
oj
.
iO'
0-
c
o
.0
~~
_ 0
02
~.
.Ec
~~
!E
o
.
0-
en
$
<J)
G 0 P ELECTRIC
Business name, if different from above
Tax a er Identification Number N
D Exempt
payee
Requester's name and address (optionaQ
Social security nLlmber
or
Employer identifioatlon number
26: 1707909
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer Identification number {or I am waiting for a number to be Issued to me}, and
2. I am not subject to backUp withholding because' (a) I am exempt from backup withholding, or (b) I have not boon notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all Interest or dividends. or (c) the IRS has
notified me that I am no longer subject to backup withholding. and
3, I am a U.S. citizen or other U.S. person (dei1ned below).
Certlflcatlon Instructions. You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and divIdends on your tax return, For real estate transactions, item 2 does not apply.
For mortgage interest paId, acquisItion or abandonment of secured property, cancellation of debt, contributlons to an Individual retirement
arrangement ORA), and generally, payments other than Interest and dividends. you are not required to sign the Certification, but you must
provide your correct TIN. See the Ins ns on page 4,
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
. An individual who is a U.S. citizen or U,S. resident alien.
. A partnership, corporatIon, company, or association created or
organized in the United States or under the laws of the United
States,
. An estate (other than a foreign estate), or
. A domestic trust (as defined in Regulations section
301.7701-7).
Special rules for partnerships_ Partnerships that conduct a
trade or business In the United States are generally required to
pay a withholdIng tax on any foreIgn partners' share of Income
irom such business. Further, in certain cases where a Form W-9
has not been received, a partnership is required to presume that
a partner Is a foreign person, and pay the withholding tax.
Therefore, if you are a U.S, person that is a partner in a
partnership conducting a trade or business in the United States.
provide Form W.Q to the partnership to establish your U.S.
status and avoid withholding on your share of partnership
income.
The person who gives Form W-9 to the partnership ier
purposes of establishing Its U.S. status and avoIding withholding
on its allocable share of net income from the partnership
conducting a trade or business in the United States is in the
iollowlng cases:
. The U.S. owner of a disregarded entity and not the entity,
Cat No. 10231X Form W-9 (Rav. 10-2007)
Sign
Here
Signature of
U.S. person ..
General Instructio
Section references are to the [ntemal Revenue Gode unless
otherwise noted.
Purpose of Form
A person who is required to file an information return wIth the
IRS must obtain your COlTeCt taxpayer identification number (l1N)
to report, for example. Income paid to you, real estate
transactions. mortgage interest you paid, acquisition or
abandonment of secured property, cancellation of debt, or
contributions you made to an IRA,
Use Form W-9 only if you are a U,S, person (including a
resident alien), to provide your correct TIN to the person
requesting it (the requester) and. when applicable, to:
1. Certify that the TiN you are giving is correct (or you are
waitlng for B number to be issued),
2. Certify that you are not subject to backup wlthhcldlng, or
3. Claim exemption from backup withholding if you are a U.S.
exempt payee, If applicable, you are also certifying that as a
U,S. person, your allocable share of any partnership income from
a U.S. trade or business Is not subject to the withholding tax on
foreign partners' share of effectively connected income.
Note. If a requester gives you a form other than Form W-8 to
request your TIN, you must use the requester's fonn iilt Is
substantially similar to this Form W-Q.