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2020-21 PWLC II, Inc Change Order 2 - L&L AD 89-1 Lands Maint Project 2018-30Revised May 2017 M E M O R A N D U M TO: Jon McMillen, City Manager FROM: Bryan McKinney, Public Works/Engineering Director DATE: June 1, 2020 RE: PWLC II, Inc., Lighting & Landscape Assessment District 89-1, Landscape Maintenance Contract, Project No 2018-30 Attached for your signature is a Contract Change Order #2 with PWLC II, Inc for Landscape Maintenance of Lighting & Landscape Assessment District 89-1. Please sign the attached agreement(s) and return to the City Clerk for processing and distribution. NA The term of this bond runs from July 1, 2020 to June 30, 2021 and maybe renewed by a New Bond. If not renewed it does not subject the surety to a claim on this bond. SECTION 1310 PERFORMANCE BOND Bond No. 1001124633 KNOW ALL PERSONS BY THESE PRESENTS: THAT WHEREAS, the City of La Quinta (hereinafter referred to as "City") has awarded to PWLC II, Inc. , (hereinafter referred to as the "Contractor") an agreement for Project no. 2018-30, Landscape Maintenance (hereinafter referred to as the "Contract"). Services WHEREAS, the work to be performed by the Contractor is more particularly set forth in the Contract Documents for the Project dated May 22. 20113 , (hereinafter referred to as "Contract Documents"), the terms and conditions of which are expressly incorporated herein by reference; and WHEREAS, the Contractor is required by said Contract Documents to perform the terms thereof and to furnish a bond for the faithful performance of said Contract Documents. NOW, THEREFORE, we, PWLC II, Inc. the undersigned Contractor and U.S. Specialty Insurance Company as Surety, a corporation organized and duly authorized to transact business under the laws of the State of California, are held and firmly bound unto the City in the sum of See * Below DOLLARS, ($ 596,342.00 ), said sum being not less than one hundred percent (100%) of the total amount of the Contract, for which amount well and truly to be made, we bind ourselves, our heirs, executors and administrators, successors and assigns, jointly and severally, firmly by these presents. * Five Hundred Ninety Six Thousand Three Hundred Forty Two and no/100 THE CONDITION OF THIS OBLIGATION IS SUCH, that, if the Contractor, his or its heirs, executors, administrators, successors or assigns, shall in all things stand to and abide by, and well and truly keep and perform the covenants, conditions and agreements in the Contract Documents and any alteration thereof made as therein provided, on its part, to be kept and performed at the time and in the manner therein specified, and in all respects according to their intent and meaning; and shall faithfully fulfill all obligations including the one-year guarantee of all materials and workmanship; and shall indemnify and save harmless the City, its officers and agents, as stipulated in said Contract Documents, then this obligation shall become null and void; otherwise it shall be and remain in full force and effect. As a condition precedent to the satisfactory completion of the Contract Documents, unless otherwise provided for in the Contract Documents, the above obligation shall hold good for a period of one (1) year after the acceptance of the work by City, during which time if Contractor shall fail to make full, complete, and satisfactory repair and replacements and totally protect the City from loss or damage resulting from or caused by defective materials or faulty workmanship, Surety shall undertake and faithfully fulfill all such obligations. The obligations of Surety hereunder shall continue so long as any obligation of Contractor remains. Nothing herein shall limit the City's rights or the Contractor or Surety's obligations under the Contract, law or equity, including, but not limited to, California Code of Civil Procedure section 337.15. Whenever Contractor shall be, and is declared by the City to be, in default under the Contract Documents, the Surety shall remedy the default pursuant to the Contract Documents, or shall promptly, at the City's option: (1) Take over and complete the Project in accordance with all terms and conditions in the Contract Documents; or (2) Obtain a proposal or proposals for completing the Project in accordance with all terms and conditions in the Contract Documents and upon determination by Surety of the lowest responsive and responsible proposer, arrange for a Contract between such proposer, the Surety and the City, and make available as work progresses sufficient funds to pay the cost of completion of the Project, less the balance of the contract price, including other costs and damages for which Surety may be liable. The term "balance of the contract price" as used in this paragraph shall mean the total amount payable to Contractor by the City under the Contract and any modification thereto, less any amount previously paid by the City to the Contractor and any other set offs pursuant to the Contract Documents. (3) Permit the City to complete the Project in any manner consistent with local, California and federal law and make available as work progresses sufficient funds to pay the cost of completion of the Project, less the balance of the contract price, including other costs and damages for which Surety may be liable. The term "balance of the contract price" as used in this paragraph shall mean the total amount payable to Contractor by the City under the Contract and any modification thereto, less any amount previously paid by the City to the Contractor and any other set offs pursuant to the Contract Documents. Surety expressly agrees that the City may reject any contractor or subcontractor which may be proposed by Surety in fulfillment of its obligations in the event of default by the Contractor. Surety shall not utilize Contractor in completing the Project nor shall Surety accept a proposal from Contractor for completion of the Project if the City, when declaring the Contractor in default, notifies Surety of the City's objection to Contractor's further participation in the completion of the Project. The Surety, for value received, hereby stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Contract Documents or to the Project to be performed thereunder shall in any way affect its obligations on this bond, and it does hereby waive notice of any such change, extension of time, alteration or addition to the terms of the Contract Documents or to the Project, including but not limited to the provisions of sections 2819 and 2845 of the California Civil Code. IN WITNESS WHEREOF, we have hereunto set our hands and seals this 21st day of JUIv , 20-2_0). (Corporate Seal) (Corporate Seal) PWLC II, Inc. Contractor/ Principal By- Title U.S. Specialty Insurance Company S u rety By A-b James Keeling, Attorney -in- t Signatures of those signing for the Contractor and Surety must be notarized and evidence of corporate authority attached. (Attach Attorney -in -Fact Certificate) Title The rate of premium on this bond is $1507 per thousand. The total amount of premium charges, $ 9463.00 (The above must be filled in by corporate attorney.) THIS IS A REQUIRED FORM Any claims under this bond may be addressed to: (Name and Address of Surety) U. S. Specialty Insurance Company (Name and Address of Agent or Representative for service of process in California, if different from above) (Telephone number of Surety and Agent or Representative for service of process in California) 801 So. Figueroa Street, 7th Floor Los Angeles, CA 90017 Keith Clements 619-630-2629 NOTE: A copy of the Power -of -Attorney authorizing the person signing on behalf of the Surety to do so must be attached hereto. NOMA TOKIOMARINE = - —__- kvH C C �— POWER OF ATTORNEY AMERICAN CONTRACTORS INDEMNITY COMPANY TEXAS BONDING COMPANY UNITED STATES SURETY COMPANY U.S. SPECIALTY INSURANCE COMPANY KNOW ALL MEN BY THESE PRESENTS: That American Contractors Indemnity Company; a California corporation, Texas Bonding Company, an assumed name of American Contractors Indemnity Company, United States Surety Company, a Maryland corporation and U.S. Specialty Insurance Company, a Texas corporation (collectively, the "Companies"), do by these presents make, constitute and appoint: James Keeling of Lompoc, California _ its true and lawful Attorney (s)-in-fact, each in their separate capacity if more than one is named above, with fullTsowef and authoritm -_ hereby conferred in its name, place and stead, to execute, acknowledge and deliver any and all bonds, recognizances undertakings or other instruments or contracts of suretyship to include riders, amendments, and consents of surety, providing the bond penalty does not exceed *****Three Million***** Dollars ( "'S3,000,000.00*** ). This Power of Attorney shall expire without further action on April 231d, 2022. This Power of Attorney is granted under and by authority of the following resolutions adopted by the Boards of Directors of the Companies: Be it Resolved, that the President, any Vice -President, any Assistant Vice -President, any_Seqetary og-nt-Assistant Secretary shall be -and is hereby vested -with full power and authority to appoint any one or more suitable persons as-Atto�ne�s i2E ct: represent and act for and on behalf_of,the- Company subject to the following provisions: Attorney -in -Fact may be given full power and authority for and in the name of and on behalf of the Company, to execute, acknowledge and deliver, any and all bonds, recognizances, contracts, agreements or indemnity and other conditional or obligatory undertakings, including any and all consents for the release of retained percentages and/or final estimates on engineering and construction contracts, and any and all notices and documents canceling or terminating the Company's liability thereunder, and any such instruments so executed by any such Attorney -in -Fact shall be binding�ypon the Company as if signed by the President and sealed and effected by the Corporate Secretary. Be it Resolved, that the signature of any authorized officer and seal of the Company heretofore or hereafter affixed to any power of attorney or" certificate relating thereto by facsimile, and any power of attorney or certificate bearing facsimile signature or facsimile seal shall be valid and binding - upon the Company with respect to any bond or undertaking to which it is attached. IN WITNESS WHEREOF, The Companies have caused this instrument to be signed and their corporate seals to be hereto affixed, this 15' day of June, 2018. AMERICAN CONTRACTORS INDEMNITY COMPANY TEXAS BONDING COMPANY UNITED STATES SURETY COMPANY ��%$,PECIALTY IN UIRANCE COMPANY � SiaWof Cafifornla County of Los Angeles ,._a }',. Fi' ` ,� GY `'ii►e*'��� 'Epp*}`_ �� 4 "-*"` Daniel P. Aguilar, Vice President n1„11i1K hM41111N'rc n,wl� �,rli„n1nH 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.f.C' truthful es accurac , or vaWity of that document On this 1st day of June, 2018, before me, Barba O. Carrejo, a notary public, personally appeared Daniel P. Aguilar; Vice PresidgiUP American Contractors Indemnity Company, Texas Bonding Company, United States Surety Company and U.S. Specialty Insurance Company who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument --_ I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.. WITNESS my hand and official seal. so iao.caa;c c /• Notary Puhlic-Catlh.,rrila ^ll La AlgApr O M23 f ^C11110� 4 iii94i9 Signature (seal) +Wcamm. Fra0n.c� •�, ion _ I, Kio Lo, Assistant Secretary American Contractors- Indemnity Company, Texas Bonding Company, United States Surety_ Company and U.S. Specialty Insurance' ompany, do -hereby certify that the above and foregoing is a true and correct copy of a -Power= of Attorney, executed by said Companies; which is -still in full force and effect-, furthermore, the resolutions of the kands'of birfflors set out in the Power of Attorney are in full force and effect. In Witn1pps Whereof, I have hereunto set myy hand and affixed the seals of said Companies at Los Angeles, California this __2—=day of Corporate Seals Bond No. Agency No 19821 ��pr C>'aga� t,. yOtiUlNpc ,+ SlJRE. mn ril -�F �.Wt. ¢� E �b' c+ y 6Lf9.aL fll Fo r'• �'YSrf liio Lo, As;sI Secretary 'k1iA�� �8ci c�tF.11a 'n. � 1•F h„ * r ��rc1ro 1mlmrn" +ne n ,wn" HMSMANPOAN: e , C ! 5 _._visRftmhcc.com/surety for more information CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189 :�s+`•i7.ti!'��isL�ra�.:t�a`s'u'C,t3:3;•4F:tit4 ;a;; ::A` tk°-+F�fl:�''..r:�ti�ks:�.•xs:r�:sk^ar3l�e�xs�sss,'f:`�s°..`.�=a.."i=.r�"bf'�wT:�tii�a6cw'r?::�S.Hci5�+.1�`cs�rjr.=• 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 j County of Santa Barbara J} On L 2-1 �'JwQLu before me, F. Stassi , Notary Public Doe Here Insert Name and Title of the Officer personally appeared James Keeli Nome(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(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. F. STASSI Commission #t2199�w Notary Public California SANTA BARBARA COUNTY sloe Fames June 7, 2021 Place Notary Seal and/or Stamp Above I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signatur� l� Signature of Notary Public Completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: Document Date: Signer(s) Other Than Named Above: No Other Capacity(ies) Claimed by Signer(s) Signer's Name: James Keeling ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual ® Attorney in Fact ❑ Trustee ❑ Guardian of Conservator ❑ Other: Signer is Representing: U. S Specialty Insurance Company 02017 National Notary Association Bond Number of Pages: Signer's Name: ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian of Conservator ❑ Other: Signer is Representing: Notary 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 CALI1F�OnRNIA COUNTY OF V lL I On 20�, befo me, I 1 Notary Public, rsonally appeared e l 5 , SrYli. 6CY, , who proved to me on the basis of satisfactory evidence to be the person{) se name) Cis/ -are subscribed to the yvithin instrument and acknowledged to me that e laefhey executed the same in i� •Ie�JtFieir authorized capacity(ies), and that by his/ eir signature(s on the instrument th erson,(%), or the entity upon behalf of which the;r�onW. acted, executed the instrument. :. r •.tiS'� .YiL'i=.S':::.:Y:.'.:'.:'.YJLLYN.M1M1MW i -': . .._ A.�ALL�5CHI COMM. #2200387 x ar° NOTARY PUBLIC o CALIFORNIA RIVERSIDE COUNTY : Commission Expires June 5, 2021 :•r.:' : x: w :........:vr. Though the information below is n relying on the document and could form to another document. CAPACITY CLAIMED BY SIGNER ❑Individual ❑Corporate Officer Title(s) ❑Partner(s) ❑ Limited ❑ General ❑Attorney -In -Fact ❑Trustee(s) ❑ Guardia n/Conservator ❑Other: Signer is representing: Name Of Person(s) Or Entity(ies) I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing pars raph is true and correct, hand and official seal. ry Public OPTIONAL of required by law, it may prove valuable to persons prevent fraudulent removal and reattachment of this DESCRIPTION OF ATTACHED DOCUMENT Title or Type of Document Number of Pages Date of Document Signer(s) Other Than Named Above NOTE: This acknowledgment is to be completed for the Attorney -in -Fact. The Power -of -Attorney to local representatives of the bonding company must also be attached. The term of this bond runs from July 1, 2020 to June 30, 2021 and maybe renewed by a New Bond. If not renewed it does not subject the surety to a claim on this bond. SECTION 1320 PAYMENT BOND Bond No. 1001124633 KNOW ALL MEN BY THESE PRESENTS: THAT the City of La Quinta, a municipal corporation, hereinafter designated the City, has on May 22, 2019, awarded to PWLC II, INC., hereinafter designated as the Principal, a Contract for Project No. 2018-30, Landscape Maintenance Services. Extended term: July 1, 2020 through June 30, 2021. WHEREAS, said Principal is required to furnish a bond in connection and with said Contract, providing that if said Principal, or any of it or its subcontractors shall fail to pay for any materials, provisions, or other supplies used in, upon, for, or about the performance of the work contracted to be done, or for any work or labor done thereon of any kind, the Surety of this bond will pay the same to the extent hereinafter set forth: U.S. Specialty Insurance NOW, THEREFORE, we, the Principal, and f omr,an\/ I as Surety, are held and firmly bound unto the City in the Just and full amount of twenty-five (25) percent of the contract price Five Hundred Nine y Six Thousand Three Hundred Forty Two and _��� DOLLARS ($ 596,342.00 ) lawful money of the United States, for the payment of which sum well and truly to be made, we bind ourselves, our heirs, executors, administrators, and successors, jointly and severally, firmly by these presents. THE CONDITION OF THIS OBLIGATION IS SUCH, that if said Principal, it or its heirs, executors, administrators, successors, or assigns, shall fail to pay for any materials, provisions, or other supplies used in, upon, for, or about the performance of the work contracted to be done, or for any work or labor thereon of any kind or for amount due under the Unemployment Insurance Act with respect to such work or labor, or for any amounts due, or to be withheld pursuant to Sections 18806 of the Revenue and Taxation Code of the State of California with respect to such work or labor, then said surety will pay the same in or to an amount not exceeding the amount hereinabove set forth, and also will pay in case suit is brought upon this bond, such reasonable attorney's fees to the City as shall be fixed by the court. This bond shall insure to the benefit of any and all persons, companies, and corporations named in Section 3181 of the Civil Code of the State of California so as to give a right of action to them or their assigns in any suit brought upon this bond. And the said Surety, for value received, hereby stipulates and agrees that no change, extension of time, alteration, or addition of the terms of the Contract or to the work to be performed thereunder or the specifications accompanying the same shall, in any way, affect its obligations of this bond, and it does hereby waive notice of any change, extension of time, alteration, or addition to the terms of the contract or to the work or to the specifications. Said Surety hereby waives the provisions of Sections 2819 and 2845 of the Civil Code of the State of California. Page I 1 Payment Bond 1320-1 IN WITNESS WHEREOF, the Principal and Surety have executed this instrument under their Corporate seals this 21st day of July _ 2020 the name and corporate seal of each corporate party being hereto affixed and these presents duly signed by its undersigned representative, pursuant to authority of its governing body. _PWLC II, Inc. Principal (Seal) Signature Title of Signatory U.S. Specialty Insurance Company Surety (Seal) J'h--� V'� -- Signature for Surely 9 James Keeling, Attorney in Fact Title of Signatory 501 W. Broadway, Suite 1470 San Diego, Ca 92101 Address of Surety 619-630-2629 Phone # of Surety Keith Clements Contact Person for Surety P a g e 1 2 Payment Band 1320 2 TOKIOMARINE H C C POWER OF ATTORNEY AMERICAN CONTRACTORS INDEMNITY COMPANY TEXAS BONDING COMPANY UNITED STATES SURETY COMPANY U.S. SPECIALTY INSURANCE COMPANY KNOW ALL MEW -BY THESE PRESENTS: That American Contractors Indemnity Company, a California corporation, Texas Bonding Company, an assumed name of American Contractors Indemnity Company, United States Surety Company, a Maryland corporation and U.S. Specialty Insurance Company, a Texas corporation (collectively, the "Companies"), do by these presents make, constitute and appoint: James Keeling of Lompoc, California its true and lawful Attorney(s)-in-fact, each in their separate capacity if more than one is named above, with full power and authanty_= - _- hereby conferred in its name, place and = stead, to execute, acknowledge and deliver any and all bonds,.=recognizances, undertakings or other instruments or contracts of suretyship to include riders, amendments, and consents of surety, providing the bond penalty does not exceed *****Three Million***** Dollars '*`$3 000,000.00— . This Power of Attorney shall expire without further action on April 23rd, 2022. This Power of Attorney is granted under and by authority of the following resolutions adopted by the Boards of Directors of the Companies: =_wit=Resolved, that the President, any Vice -President, any Assistant Vice-President, _any_Secretary or anNMistant Secretary shall be and is hereby vested with full power and authority to appoint any one or more suitable persons as=Attorney_ (sy=in-Fact ta�e�resent and act for and on behalf of the Company subject to the following provisions: Attorney -in -Fact may be given full power and authority for and in the name of and on behalf of the Company, to execute, acknowledge and deliver, any and all bonds, recognizances, contracts, agreements or indemnity and other conditional or obligatory undertakings, including any and all consents for the release of retained percentages and/or final estimates on engineering and construction contracts, and any and all notices and documents canceling or terminating the Company's liability thereunder, and -any such instruments so executed by any such Attorney -in -Fact shall be binding upon - the Company as if signed by the President and sealed and effected by the Corporate Secretary. Be it Resolved, that the signature of any authorized officer and seal of the Company heretofore or hereafter affixed to any power of attorney or any certificate relating thereto by facsimile, and any power of attorney or certificate bearing facsimile signature or facsimile seal shall_be=_valid-and binding upon the Company with respect to any bond or undertaking to which it is attached. IN WITNESS WHEREOF, The Companies have caused this instrument to be signed and their corporate seals to be hereto affixed, this 151 day of June, 2018. �tat-e:of-1 alifcrnia County of Los Angeles AMERICAN CONTRACTORS INDEMNITY COMPANY TEXAS BONDINGCOMPANY UNITED STATES SURETY.COMPANY U.S-.45PECIALTY INSURANCE CQMPANY Daniel P. Aguilar, Vice President 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 On this 111 day of June, 2018, before me, Sonia O. Carrejo, a notary public, personally appeared Daniel P. Aguilar, Vice President of American Contractors Indemnity Company, Texas Bonding Company, United States Surety Company and U.S. Specialty Insurance Company who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument. I certt� under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and --correct.= WITNESS my hand and official seal. �Wia�kauo �W.ryPu4iIC • GillwY. • � e Signature (seal}:yCamm- Cspires Apr ?]. Ip71 I, Kio Lo, Assistant Secretary American Contractors: Indemnity Company, Texas Bonding Company, United _States Surety Company and U.S. Specialty Insurance Company, do hereby certify that the above and foregoing is a true and correct-eop�aRPo_wer of Attorney, executed by said Companies, which is still in full force and effect; furthermore, the resolutions of the-HbMrd�roT Drredo-r0 set out in the Power of Attorney are in full force and effect. In Witness Whereof, Lhpve hereunto set mX hand and affixed the seals of said Companies at Los Angeles, California this Z_l At _day of %3uLZA Corporate Seals Bond No. Agency No. 19821 vx 2 i Kio Lo, A�Secrut:�ry HC �•�'IAN!'OA0512019 visit tmhcc.com/surety for more information CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189 . ::�i.'�KYSI`�•iaa'k n.3-:C'.: •�,.y�fa`:i fi.E°r:3:•;:+t�ti��: E#' . ::hhie`-i:--:�5-.i-Srs�Vi 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 Santa Barbara On d i Zoz b before me, F. Stassi , Notary Public Date Here Insert Name and Title of the Officer personally appeared James Keelin Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(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. F. SASS' Commission 421998W Notary Public California SANTA BARBARA COUNTY M V Cam Fos June 7, 2021 Place Notary Seal and/or Stamp Above I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signatur Signature of Notary Public OPTIONAL Completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: Bond Document Date: Signer(s) Other Than Named Above: No Other Signers Capacity(ies) Claimed by Signer(s) Signer's Name: James Keeling ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual ® Attorney in Fact ❑ Trustee ❑ Guardian of Conservator ❑ Other: Signer is Representing: U. S Specialty Insurance Company 02017 National Notary Association Number of Pages: Signer's Name: ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian of Conservator r1 Other - Signer is Representing: Notary 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 On Dom? (° 20C , be f e TeAkI L I , Notary Public, On-4appeared � } , who proved to me on the basis of satisfactory evidence to be the person(§)y 09se nameW C/a.re subscribed to the. within instrument and acknowledged to me that of ey executed the same in I�hv7 eir authorized capacity(4ce), and that by;�%' .h eeir signature(, -}on the instrument taerson(s), or the entity upon behalf of which the on:() acted, executed the instrument. StiV.1'1LSSSV Yh'h'N!V VYYGYr'{� A.PALLESCFII COMM. #2200387 x xNOTARY PUBLIC + CALIFORNIA } RIVERSIDE COUNTY Commission Expires June 5, 2021 1.: V h•.:Y.LY.y1^.•.Y.:titi1S•.� Though the information below is n relying on the document and could form to another document. CAPACITY CLAIMED BY SIGNER ❑Individual ❑Corporate Officer Title(s) ❑Partner(s) ❑ Limited ❑ General ❑ Attorney -In -Fact ❑Trustee(s) ❑Guardian/Conservator ❑Other: Signer is representing: Name Of Person(s) Or Entity(ies) I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing p�x�r�.r is true and correct. ( .INN SS my hand and official seal. k GV%l Hato a of Na r",—A — y Public OPTIONAL of required by law, it may prove valuable to persons prevent fraudulent removal and reattachment of this DESCRIPTION OF ATTACHED DOCUMENT Title or Type of Document Number of Pages Date of Document Signer(s) Other Than Named Above NOTE:This acknowledgment is to be completed for Contractor/Principal.