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Insurance Certificates 2012/14 Alta Verde (AV) Construction, LLCAVCONS1 OP ID: DM '44 � � CERTIFICATE OF LIABILITY INSURANCE DATE 11/12/2013Y) 11 /12/2013 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 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 Phone:714-516-2960 Rohm Insurance Agency 26 Plaza Square, Suite 200 Fax: Orange, CA 92866 CONTACT NAME: PHONE FFAX A/c No Ext : A/C No): ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: American Safety Indemnity Co. 25433 INSURED AV Construction, LLC 71905 Highway 111, Ste G Rancho Mirage, CA 92270 INSURER B : INSURERC: INSURER D INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 2,000,00 PREMISES Ea occurrence $ 60,00 A X COMMERCIAL GENERAL LIABILITY X ESL10018101201 11/12/2012 11/12/2014 MED EXP (Any one person) $ EXCLUDE CLAIMS -MADE I—X I OCCUR PERSONAL & ADV INJURY $ 2,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,00 POLICY 7 PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) S ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED AUTOS NON -OWNED AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ []� AGGREGATE $ CESS LIAB CLAIMS -MADE OEDI I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE WC STATU- OTH- TQRY LIMITS ER E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? F7 N I A E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) THE CITY OF LA QUINTA, ITS OFFICERS, AND EMPLOYEES ARE NAMED ADDITIONAL INSURED GENERAL LIABILITY PER ATTACHED ENDORSEMENT. RE: STORM WATER MANAGEMENT/BMP FACILITIES AGREEMENT NO. 2013-001, TM 34243, AVENUE 58, LA QUINTA, CA CERTIFICATE HOLDER CANCELLATION LAQUIN2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CITY OF LA QUINTA ATTN: PUBLIC WORKS DEPT AUTHORIZED REPRESENTATIVE P.O. BOX 1504 LA QUINTA, CA 92253 -�,yf rLs, © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 0 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. MAN 05 001 03 05 SPECIAL ENDORSEMENT ( ADDITIONAL INSURED ENDORSEMENT -- OWNERS, LESSEES OR CONTRACTORS (MODIFIED FORM B) ) This Endorsement shall not serve to increase our limits of insurance, as described in the LIMITS OF INSURANCE section of the policy. It is agreed that the following changes are incorporated into the policy: This Endorsement shall not serve to increase our limits of insurance, as described in SECTION III - LIMITS OF INSURANCE. Name of Person or Organization: City of La Quinta, its officers, and employees Attn: Public Works P.O. Box 1504 La Quinta, CA 92253 Re: Storm Water Management/BMP Facilities Agreement, No. 2013-001, TM 34243, Avenue 58, La Quinta, CA Effective Date: 1 /3/2013 In consideration of the payment of premiums, it is agreed that the following changes are incorporated into the policy: WHO IS AN INSURED (SECTION II) is amended to include as an insured the person or organization shown above, but only with respect to defense and liability arising out of "your work." This endorsement applies only to ongoing operations performed by the Named Insured for the Additional insured and only if performed on or after the effective date of this endorsement. Coverage under this Endorsement applies only as respects a legally enforceable written contract with the Named Insured when such person or organization is required to be named as an Additional Insured in a written contract with the Named Insured entered into prior to the loss or damage. Coverage under this Endorsement for defense and indemnity applies only when the "suit" for damages is based on the Named Insured's sole negligence. Coverage applies only for "bodily injury" or "property damage," not owned by any insured, caused by an "occurrence" under Coverage A not otherwise excluded in the policy to which this endorsement applies. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed or have been put to their intended use by a third person other than another contractor, whichever is earliest. If this policy includes a self -insured retention or deductible endorsement, such endorsement shall apply to each insured and affect our obligations pursuant to the policy. It is further agreed that irrespective of the number of entities who qualify as insureds under this policy in no event shall our limits of liability exceed the limits of liability designated in the Declarations. All other terms, conditions and exclusions under the policy are applicable to this Endorsement and remain unchanged. MAN 05 001 03 05 Copyright© 2005 American Safety Indemnity Company Page 1 of 1 www.amsafetv.com