HomeMy WebLinkAboutCAG2018-0050 - Original - All Around Fence Company - Kent Memorial Park Wiffle Ball Area - Fence and Gate Install - 11/07/2018 ENT Records Management Document
CONTRACT COVER SHEET
This is to be completed by the Contract Manager prior to submission
to the City Clerk's Office. All portions are to be completed.
If you have questions, please contact the City Clerk's Office at 253-856-5725.
❑ Blue/Motion Sheet Attached
❑ Pink Sheet Attached
Vendor Name: ALL AROUND FENCE COMPANY
Vendor Number (]DE): 33539
Contract Number (City Clerk):
Category: Contract Agreement
Sub-Category (if applicable): Choose an item,-_.
Project Name: Fence and Gate Installation-Kent Memorial Park Wiffle Ball Area
Contract Execution Date: 11/7/2018 Termination Date: 12/31/2018
Contract Manager: Ben Levenhagen Department: Parks
Contract Amount: $6,836.51
Approval Authority: k Superintendent ❑ Director ❑ Mayor ❑ City Council
Other Details: Contractor to supply labor and materials to install fence and gate at the
Wiffle Ball area at Kent Memorial Park, located at 850 Central Avenue North, Kent WA
PUBLIC WORKS AGREEMENT
between City of Kent and
All Around Fence Company
THIS AGREEMENT is made by and between the City of Kent, a Washington municipal corporation
(hereinafter the "City"), and All Around Fence Company organized under the laws of the State of Washington,
located and doing business at 14323 161h Street East, Sumner, WA 98390-9633, Mailing Address: P.O. Box
1029, Ravensdale, WA 98051-8101. Contact: Ron Dagley, Phone: 253-863-4895, Fax: 253-863-0704
(hereinafter the "Contractor").
AGREEMENT
The parties agree as follows:
I. DESCRIPTION OF WORK.
Contractor shall perform the following services for the City in accordance with the following described
plans and/or specifications:
Per attached Estimate # 2018-3450, marked as Exhibit A, located at Kent Memorial Park, Wiffle
Ball Area, 850 Central Avenue North, Kent, WA, supply labor and materials to install
approximately 140 feet all black 4 foot tall, type 1-2"x8x4'11 core fence and supply labor and
materials to install approximately 1#4 foot main gate.
Contractor further represents that the services furnished under this Agreement will be performed in
accordance with generally accepted professional practices within the Puget Sound region in effect at the
time such services are performed.
II. TIME OF COMPLETION. The parties agree that work will begin on the tasks described in
Section I above immediately upon execution of this Agreement. Upon the effective date of this Agreement,
Contractor shall complete the work described in Section I by December 31, 2018.
III. COMPENSATION. The City shall pay the Contractor a total amount not to exceed SIX
THOUSAND EIGHT HUNDRED THIRTY SIX DOLLARS AND FIFTY ONE CENTS ($6,836„51), including any
applicable Washington State Sales Tax, for the work and services contemplated in this Agreement.. The City
shall pay the Contractor eighty-five percent (85%) of the Contract amount upon completion and acceptance
of the work by the City, or at such earlier time as the City may determine is appropriate. The City will pay
the remaining Contract amount upon fulfillment of the conditions listed below and throughout this
Agreement.
A No Payment and Performance Bond. Because this contract, including applicable sales
tax, is $150,000 or less, and pursuant to Chapter 39.08 RCW, the Contractor, in lieu
of providing the City a payment and performance bond, has elected to have the City
retain the final ten percent (10%) of the Contract amount for a period of thirty (30)
days after the date of final acceptance, or until receipt of all necessary releases from
the State Department of Revenue, the State Department of Labor & Industries, and
PUBLIC WORKS AGREEMENT - 1
($20K or Less and No Performance Bond)
the State Employment Security Department, and until settlement of any liens filed
under Chapter 60.28 RCW, whichever is later.
B, Rekainagg. The City shall also hold back a retainage in the amount of five percent
(5%) of any and all payments made to contractor for a period of sixty (60) days
after the date of final acceptance, or until receipt of all necessary releases from the
State Department of Revenue, the State Department of Labor & Industries, and the
State Employment Security Department, and until settlement of any liens filed under
Chapter 60.28 RCW, whichever is later. The amount retained shall be placed in a
fund by the City pursuant to RCW 60.28.011(4)(a), unless otherwise instructed by
the Contractor within fourteen (14) calendar days of Contractor's signature on the
I
Agreement.
C. Deff Give or �nauthorized Work. The City reserves its right to withhold payment
from Contractor for any defective or unauthorized work. Defective or unauthorized
work includes, without limitation: work and materials that do not conform to the
requirements of this Agreement; and extra work and materials furnished without the
City's written approval. If Contractor is unable, for any reason, to satisfactorily
complete any portion of the work, the City may complete the work by contract or
otherwise, and Contractor shall be liable to the City for any additional costs incurred
by the City. "Additional costs" shall mean all reasonable costs, including legal costs
and attorney fees, incurred by the City beyond the maximum Contract price specified
above. The City further reserves its right to deduct the cast to complete the
Contract work, including any Additional Costs, from any and all amounts due or to
become due the Contractor.
D, Final Paymenk: Waiver of Claims. THE CONTRACTOR'S ACCEPTANCE OF FINAL
PAYMENT (EXCLUDING WITHHELD RETAINAGE) SHALL CONSTITUTE A WAIVER OF
CONTRACTOR'S CLAIMS, EXCEPT THOSE PREVIOUSLY AND PROPERLY MADE AND
IDENTIFIED BY CONTRACTOR AS UNSETTLED AT THE TIME FINAL PAYMENT IS MADE
AND ACCEPTED.
IV. INDEPENDENT CONTRACTOR. The parties intend that an Independent Contractor-
Employer Relationship will be created by this Agreement. By their execution of this Agreement, and in
accordance with Ch. 51.08 RCW, the parties make the following representations:
A. The Contractor has the ability to control and direct the performance and details of its
work, the City being interested only in the results obtained under this Agreement.
B. The Contractor maintains and pays for its own place of business from which
Contractor's services under this Agreement will be performed.
C. The Contractor has an established and independent business that is eligible for a
business deduction for federal income tax purposes that existed before the City
retained Contractor's services and is a service other than that furnished by the City,
or the Contractor is engaged in an independently established trade, occupation,
profession, or business of the same nature as that involved under this Agreement.
D. The Contractor is responsible for filing as they become due all necessary tax
documents with appropriate federal and state agencies, including the Internal
Revenue Service and the state Department of Revenue.
E. The Contractor has registered its business and established an account with the state
Department of Revenue and other state agencies as may be required by Contractor's
business, and has obtained a Unified Business Identifier (UBI) number from the
State of Washington.
PUBLIC WORKS AGREEMENT - 2
($20K or Less and No Performance Bond)
F. The Contractor has a valid contractor registration pursuant to Ch. 18.27 RCW or an
electrical contractor license pursuant to Ch. 19.28 RCW.
G. The Contractor maintains a set of books dedicated to the expenses and earnings of
its business.
i
V. TERMINATION. The City may terminate this Agreement for good cause. "Good cause"
shall include, without limitation, any one or more of the following events:
A. The Contractor's refusal or failure to supply a sufficient number of properly skilled
workers or proper materials for completion of the Contract work.
B. The Contractor's failure to complete the work within the time specified in this
Agreement.
C. The Contractor's failure to make full and prompt payment to subcontractors or for
material or labor.
D. The Contractor's persistent disregard of federal, state or local laws, rules or
regulations.
E. The Contractor's filing for bankruptcy or becoming adjudged bankrupt.
F. The Contractor's breach of any portion of this Agreement.
If the City terminates this Agreement for good cause, the Contractor shall not receive any further
money due under this Agreement until the Contract work is completed. After termination, the City may
take possession of all records and data within the Contractor's possession pertaining to this project which
may be used by the City without restriction.
VI. PREVAILING WAGES. Contractor shall file a "Statement of Intent to Pay Prevailing
Wages," with the State of Washington Department of Labor & Industries prior to commencing the Contract
work. Contractor shall pay prevailing wages in effect on the date the bid is accepted or executed by
Contractor, and comply with Chapter 39.12 of the Revised Code of Washington, as well as any other
applicable prevailing wage rate provisions. The latest prevailing wage rate revision issued by the
Department of Labor and Industries is attached.
VII. CHANGES. The City may issue a written change order for any change in the Contract work
during the performance of this Agreement. If the Contractor determines, for any reason, that a change
order is necessary, Contractor must submit a written change order request to the person listed in the
notice provision section of this Agreement, section XV(D), within fourteen (14) calendar days of the date
Contractor knew or should have known of the facts and events giving rise to the requested change. If the
City determines that the change increases or decreases the Contractor's costs or time for performance,
the City will make an equitable adjustment. The City will attempt, in good faith, to reach agreement with
the Contractor on all equitable adjustments. However, if the parties are unable to agree, the City will
determine the equitable adjustment as it deems appropriate. The Contractor shall proceed with the
change order work upon receiving either a written change order from the City or an oral order from the
City before actually receiving the written change order. If the Contractor fails to require a change order
within the time specified in this paragraph, the Contractor waives its right to make any claim or submit
subsequent change order requests for that portion of the contract work. If the Contractor disagrees with
the equitable adjustment, the Contractor must complete the change order work; however, the Contractor
may elect to protest the adjustment as provided in subsections A through E of Section VIII, Claims, below.
The Contractor accepts all requirements of a change order by: (1) endorsing it, (2) writing a
separate acceptance, or (3) not protesting in the way this section provides. A change order that is
accepted by Contractor as provided in this section shall constitute full payment and final settlement of all
claims for contract time and for direct, indirect and consequential costs, including costs of delays related
to any work, either covered or affected by the change.
PUBLIC WORKS AGREEMENT - 3
($20K or Less and No Performance Bond)
VIII. CLAIMS. If the Contractor disagrees with anything required by a change order, another
written order, or an oral order from the City, including any direction, instruction, interpretation, or
determination by the City, the Contractor may file a claim as provided in this section. The Contractor shall
give written notice to the City of all claims within fourteen (14) calendar days of the occurrence of the
events giving rise to the claims, or within fourteen (14) calendar days of the date the Contractor knew or
should have known of the facts or events giving rise to the claim, whichever occurs first . Any claim for
damages, additional payment for any reason, or extension of time, whether under this Agreement or
otherwise, shall be conclusively deemed to have been waived by the Contractor unless a timely written
claim is made in strict accordance with the applicable provisions of this Agreement.
At a minimum, a Contractor's written claim shall include the information set forth in subsections A,
items 1 through 5 below.
FAILURE TO PROVIDE A COMPLETE, WRITTEN NOTIFICATION OF CLAIM WITHIN
THE TIME ALLOWED SHALL BE AN ABSOLUTE WAIVER OF ANY CLAIMS ARISING IN
ANY WAY FROM THE FACTS OR EVENTS SURROUNDING THAT CLAIM OR CAUSED
BY THAT DELAY.
A. Notice of Claim. Provide a signed written notice of claim that provides the following
information:
1. The date of the Contractor's claim;
2. The nature and circumstances that caused the claim;
3. The provisions in this Agreement that support the claim;
4. The estimated dollar cost, if any, of the claimed work and how that estimate
was determined; and
5. An analysis of the progress schedule showing the schedule change or
disruption if the Contractor is asserting a schedule change or disruption.
B. Re s. The Contractor shall keep complete records of extra costs and time incurred as a
result of the asserted events giving rise to the claim. The City shall have access to any of
the Contractor's records needed for evaluating the protest.
The City will evaluate all claims, provided the procedures in this section are followed. If the
City determines that a claim is valid, the City will adjust payment for work or time by an
equitable adjustment. No adjustment will be made for an invalid protest.
C. Contractor's Duty to Cornpltp Protested Work. In spite of any claim, the Contractor shall
proceed promptly to provide the goods, materials and services required by the City under
this Agreement.
D. Failure to Protest Constatutea_,,,,,,,,,,,,,,,,,, W is ver. By not protesting as this section provides, the
Contractor also waives any additional entitlement and accepts from the City any written or
oral order (including directions, instructions, interpretations, and determination).
E. Failure to Follow Procedures Constitutes Waiver. By failing to follow the procedures of this
section, the Contractor completely waives any claims for protested work and accepts from
the City any written or oral order (including directions, instructions, interpretations, and
determination).
IX. LIMITATION OF ACTIONS. CONTRACTOR MUST, IN ANY EVENT, FILE ANY LAWSUIT
ARISING FROM OR CONNECTED WITH THIS AGREEMENT WITHIN 120 CALENDAR DAYS FROM THE DATE
THE CONTRACT WORK IS COMPLETE OR CONTRACTOR'S ABILITY TO FILE THAT CLAIM OR SUIT SHALL BE
FOREVER BARRED. THIS SECTION FURTHER LIMITS ANY APPLICABLE STATUTORY LIMITATIONS PERIOD.
X. WARRANTY. Contractor warrants that it will faithfully and satisfactorily perform all work
provided under this Agreement in accordance with the provisions of this Agreement. The Contractor shall
PUBLIC WORKS AGREEMENT - 4
($20K or Less and No Performance Bond)
promptly correct all defects in workmanship and materials: (1) when Contractor knows or should have
j known of the defect, or (2) upon Contractor's receipt of notification from the City of the existence or
discovery of the defect. In the event any parts are repaired or replaced, only original replacement parts
shall be used—rebuilt or used parts will not be acceptable. When defects are corrected, the warranty for
that portion of the work shall extend for an additional year beyond the original warranty period applicable
to the overall work. The Contractor shall begin to correct any defects within seven (7) calendar days of its
receipt of notice from the City of the defect. If the Contractor does not accomplish the corrections within
a reasonable time as determined by the City, the City may complete the corrections and the Contractor
shall pay all costs incurred by the City in order to accomplish the correction.
XI. DISCRIMINATION. In the hiring of employees for the performance of work under this
Agreement or any sub-contract, the Contractor, its sub-contractors, or any person acting on behalf of the
Contractor or sub-contractor shall not, by reason of race, religion, color, sex, age, sexual orientation,
national origin, or the presence of any sensory, mental, or physical disability, discriminate against any
person who is qualified and available to perform the work to which the employment relates.
Contractor shall execute the attached City of Kent Equal Employment Opportunity Policy
Declaration, Comply with City Administrative Policy 1.2, and upon completion of the contract work, file the
attached Compliance Statement.
XII. INDEMNIFICATION. Contractor shall defend, indemnify and hold the City, its officers,
officials, employees, agents and volunteers harmless from any and all claims, injuries, damages, losses or
suits, including all legal costs and attorney fees, arising out of or in connection with the Contractor's
performance of this Agreement, except for that portion of the injuries and damages caused by the City's
negligence.
The City's inspection or acceptance of any of Contractor's work when completed shall not be
grounds to avoid any of these covenants of indemnification.
Should a court of competent jurisdiction determine that this Agreement is subject to RCW
4.24.115, then, in the event of liability for damages arising out of bodily injury to persons or damages to
property caused by or resulting from the concurrent negligence of the Contractor and the City, its officers,
officials, employees, agents and volunteers, the Contractor's duty to defend, indemnify, and hold the City
harmless, and Contractor's liability accruing from that obligation shall be only to the extent of the
Contractor's negligence.
IT IS FURTHER SPECIFICALLY AND EXPRESSLY UNDERSTOOD THAT THE INDEMNIFICATION
PROVIDED HEREIN CONSTITUTES THE CONTRACTOR'S WAIVER OF IMMUNITY UNDER INDUSTRIAL
INSURANCE, TITLE 51 RCW, SOLELY FOR THE PURPOSES OF THIS INDEMNIFICATION. THE PARTIES
FURTHER ACKNOWLEDGE THAT THEY HAVE MUTUALLY NEGOTIATED THIS WAIVER.
In the event Contractor refuses tender of defense in any suit or any claim, if that tender was made
pursuant to this indemnification clause, and if that refusal is subsequently determined by a court having
jurisdiction (or other agreed tribunal) to have been a wrongful refusal on the Contractor's part, then
Contractor shall pay all the City's costs for defense, including all reasonable expert witness fees and
reasonable attorneys' fees, plus the City's legal costs and fees incurred because there was a wrongful
refusal on the Contractor's part.
The provisions of this section shall survive the expiration or termination of this Agreement.
XIII. INSURANCE. The Contractor shall procure and maintain for the duration of the
Agreement, insurance of the types and in the amounts described in Exhibit A attached and incorporated by
this reference.
XIV. WORK PERFORMED AT CONTRACTOR'S RISK. Contractor shall take all necessary
precautions and shall be responsible for the safety of its employees, agents, and subcontractors in the
performance of the contract work and shall utilize all protection necessary for that purpose. All work shall
PUBLIC WORKS AGREEMENT - 5
($20K or Less and No Performance Bond)
be done at Contractor's own risk, and Contractor shall be responsible for any loss of or damage to
materials, tools, or other articles used or held for use in connection with the work.
XV. MISCELLANEOUS PROVISIONS.
A. Recyclable Materials. Pursuant to Chapter 3.80 of the Kent City Code, the City requires its
contractors and consultants to use recycled and recyclable products whenever practicable. A price
preference may be available for any designated recycled product.
B. Nan er of Breach. The failure of the City to insist upon strict performance of any of the
covenants and agreements contained in this Agreement, or to exercise any option conferred by this
Agreement in one or more instances shall not be construed to be a waiver or relinquishment of those
covenants, agreements or options, and the same shall be and remain in full force and effect.
C. Resolution of Disputes and Governing Lay. This Agreement shall be governed by and
construed in accordance with the laws of the State of Washington. If the parties are unable to settle any
dispute, difference or claim arising from the parties' performance of this Agreement, the exclusive means
of resolving that dispute, difference or claim, shall only be by filing suit exclusively under the venue, rules
and jurisdiction of the King County Superior Court, King County, Washington, unless the parties agree in
writing to an alternative dispute resolution process. In any claim or lawsuit for damages arising from the
parties' performance of this Agreement, each party shall pay all its legal costs and attorney's fees incurred
in defending or bringing such claim or lawsuit, including all appeals, in addition to any other recovery or
award provided by law; provided, however, nothing in this paragraph shall be construed to limit the City's
right to indemnification under Section XII of this Agreement.
D. Written Ngk ce. All communications regarding this Agreement shall be sent to the parties at
the addresses listed on the signature page of the Agreement, unless notified to the contrary. Any written
notice hereunder shall become effective three (3) business days after the date of mailing by registered or
certified mail, and shall be deemed sufficiently given if sent to the addressee at the address stated in this
Agreement or such other address as may be hereafter specified in writing.
E. Assignment. Any assignment of this Agreement by either party without the written consent
of the non-assigning party shall be void. If the non-assigning party gives its consent to any assignment,
the terms of this Agreement shall continue in full force and effect and no further assignment shall be
made without additional written consent.
F. Modification. No waiver, alteration, or modification of any of the provisions of this
Agreement shall be binding unless in writing and signed by a duly authorized representative of the City
and Contractor.
G. Entire Agreement. The written provisions and terms of this Agreement, together with any
Exhibits attached hereto, shall supersede all prior verbal statements of any officer or other representative
of the City, and such statements shall not be effective or be construed as entering into or forming a part
of or altering in any manner this Agreement. All of the above documents are hereby made a part of this
Agreement. However, should any language in any of the Exhibits to this Agreement conflict with any
language contained in this Agreement, the terms of this Agreement shall prevail.
H. C m li nce with Laws. The Contractor agrees to comply with all federal, state, and
municipal laws, rules, and regulations that are now effective or in the future become applicable to
Contractor's business, equipment, and personnel engaged in operations covered by this Agreement or
accruing out of the performance of those operations.
I. Publie Records Act. The Contractor acknowledges that the City is a public agency subject to
the Public Records Act codified in Chapter 42.56 of the Revised Code of Washington and documents,
notes, emails, and other records prepared or gathered by the Contractor in its performance of this
Agreement may be subject to public review and disclosure, even if those records are not produced to or
possessed by the City of Kent. As such, the Contractor agrees to cooperate fully with the City in satisfying
the City's duties and obligations under the Public Records Act.
PUBLIC WORKS AGREEMENT - 6
($20K or Less and No Performance Bond)
J. City Business License Re wired. Prior to commencing the tasks described in Section I,
Contractor agrees to provide proof of a current city of Kent business license pursuant to Chapter 5.01 of
the Kent City Code.
K. unterparts and Signatures 12y„Fax ar Emaii. This Agreement may be executed in any
number of counterparts, each of which shall constitute an original, and all of which will together constitute
this one Agreement. Further, upon executing this Agreement, either party may deliver the signature page
to the other by fax or email and that signature shall have the same force and effect as if the Agreement
bearing the original signature was received in person.
IN WITNESS, the parties below execute this Agreement, which shall become effective on
the last date entered below. All acts consistent with the authority of this Agreement and prior
to its effective date are ratified and affirmed, and the terms of the Agreement shall be deemed
to have applied.
a
CONTRAC R CITY O �KENT;
Z/1
BY: By. � „
(sign,a�ure) (signature)
Print Name.40
Printl`ame: Garin Lee
Tts kytAi¢ nn1- Its: Superintendent, Parks Operations
�
y y (title) yy
DATE: 1Qtq � DATE: '8
_. _. .... ._....... _
NOTICES TO BE SENT TO: NOTICES TO BE SENT TO:
CONTRACTOR: CITY OF KENT:
Ron Dagley Ben Levenhagen
All Around Fence Company Support Services Field Supervisor
P.O. Box 1029 City of Kent
Ravensdale, WA 98051-8101 220 Fourth Avenue South
Kent, WA 98032
(253) 863-4895 (telephone)
(253) 863-0704 (facsimile) (253) 856-5133 or (telephone)
(253) 508-9548 (cell)
(253) 856-6120 (facsimile)
— ATTEST: .........
Kent City Clerk
PUBLIC WORKS AGREEMENT - 7
($20K or Less and No Performance Bond)
DECLARATION
CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY POLICY
I
The City of Kent is committed to conform to Federal and State laws regarding equal opportunity.
As such all contractors, subcontractors and suppliers who perform work with relation to this
Agreement shall comply with the regulations of the City's equal employment opportunity
policies.
The following questions specifically identify the requirements the City deems necessary for any
contractor, subcontractor or supplier on this specific Agreement to adhere to. An affirmative
response is required on all of the following questions for this Agreement to be valid and binding.
If any contractor, subcontractor or supplier willfully misrepresents themselves with regard to the
directives outlines, it will be considered a breach of contract and it will be at the City's sole
determination regarding suspension or termination for all or part of the Agreement;
The questions are as follows:
1. I have read the attached City of Kent administrative policy number 1.2.
2. During the time of this Agreement I will not discriminate in employment on the basis of
sex, race, color, national origin, age, or the presence of all sensory, mental or physical
disability.
3. During the time of this Agreement the prime contractor will provide a written statement to
all new employees and subcontractors indicating commitment as an equal opportunity
employer.
4. During the time of the Agreement I, the prime contractor, will actively consider hiring and
promotion of women and minorities.
5, Before acceptance of this Agreement, an adherence statement will be signed by me, the
Prime Contractor, that the Prime Contractor complied with the requirements as set forth
above.
By signing b w, I a ree to fulfill the five requirements referenced above.
By: ._...... _: . .... ....
For: _. A
Title: � ��S�WX/�
Date: 1V 3
EEO COMPLIANCE DOCUMENTS - 1
CITY OF KENT
ADMINISTRATIVE POLICY
NUMBER: 1.2 EFFECTIVE DAT
E: January 1, 1998
SUBJECT: MINORITY AND WOMEN SUPERSEDES: April 1, 1996
CONTRACTORS APPROVED BY Jim White, Mayor
POLICY:
Equal employment opportunity requirements for the City of Kent will conform to federal and
state laws. All contractors, subcontractors, consultants and suppliers of the City must guarantee
equal employment opportunity within their organization and, if holding Agreements with the City
amounting to $10,000 or more within any given year, must take the following affirmative steps:
1. Provide a written statement to all new employees and subcontractors indicating
commitment as an equal opportunity employer.
2. Actively consider for promotion and advancement available minorities and women.
Any contractor, subcontractor, consultant or supplier who willfully disregards the City's
nondiscrimination and equal opportunity requirements shall be considered in breach of contract
and subject to suspension or termination for all or part of the Agreement.
Contract Compliance Officers will be appointed by the Directors of Planning, Parks, and Public
Works Departments to assume the following duties for their respective departments.
1. Ensuring that contractors, subcontractors, consultants, and suppliers subject to these
regulations are familiar with the regulations and the City's equal employment opportunity
policy.
2. Monitoring to assure adherence to federal, state and local laws, policies and guidelines.
EEO COMPLIANCE DOCUMENTS - 2
i
CITY OF KENT
EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE STATEMENT
This form shall be filled out AFTER COMPLETION of this project by the Contractor awarded the
Agreement.
I, the undersigned, a duly represented agent of,
Company, hereby acknowledge and declare that the before-mentioned company was the prime
contractor for the Agreement known as that was entered into on
the (date), between the firm I represent and the City of
Kent,
I declare that I complied fully with all of the requirements and obligations as outlined in the City
of Kent Administrative Policy 1.2 and the Declaration City of Kent Equal Employment Opportunity
Policy that was part of the before-mentioned Agreement.
By: ......... _..........
For: �_......_.
Title:
Date:
EEO COMPLIANCE DOCUMENTS - 3
BIDDER RESPONSIBILITY CRITERIA
Certification of Compliance with Wage Payment Statutes
This certification is required by state law (RCW 39.04.350(2)) to be submitted to the City
before the contract can be awarded.
The bidder hereby certifies that, within the three-year period immediately preceding the bid
solicitation date (October 12, 2018), the bidder is not a "willful" violator, as defined in RCW
49.48.082, of any provision of chapters 49.46, 49.48, or 49.52 RCW, as determined by a final
and binding citation and notice of assessment issued by the Department of Labor and Industries
or through a civil judgment entered by a court of limited or general jurisdiction.
I certify under penalty of perjury under the laws of the State of Washington that the foregoing is
true and correct.
ALL AROUND FENCE COMPANY
By fi/M -
Signature of Authorized C ficial*
Printed Name:
Title: PY-eSr rlbw-1
II _.
Date: Q 4�Nq
City and State:
-.......
*If a corporation, proposal must be executed in the corporate name by the president or vice-
president (or any other corporate officer accompanied by evidence of authority to sign). If a co-
partnership, proposal must be executed by a partner.
BIDDER RESPONSIBILITY CRITERIA - 1
10/24/2018 about:blank
State of Washington
Department of Labor & Industries
Prevailing Wage Section - Telephone 360-902-5335
PO Box 44540, Olympia, WA 98504-4540
Washington State Prevailing Wage
The PREVAILING WAGES listed here include both the hourly wage rate and the hourly rate of fringe
benefits. On public works projects, worker's wage and benefit rates must add to not less than this
total. A brief description of overtime calculation requirements are provided on the Benefit Code
Key.
Journey Level Prevailing Wage Rates for the Effective Date: 10/24/2018
County Trade jph t`lassificat on YVagg Holiday Overtime Note
King Fence Erectors Fence Erector $41.45 7A 31
King Fence Erectors Fence Laborer $41.45 2A 39
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1/1
EXHIBIT A
AFiLi
All Around Fence Company
Estimate
u - �....1
PO Box 1029 _._._._ _ ._
10/12/2 111 2018 3450
FENCE co„I ," Raven sdale WA 98051 _...
Name / Address lob Site Address
City of Kent KMP Wiffle Ball Area
220 4th Ave S 850 Central Ave N
Kent WA 98032
. Rep .....
,w
RD
Description Total
Supply labor and materials to install approximately S,SOO.00T
140' all black 4' tall, type 1- 2"x8X4'11 core
Supply labor and materials to install approximately 1# 4' man gate 715.00T
----- CHANGE ORDER -----
October 23, 2018
> Added 1 Commercial. (+$715.00)
Total change to estimate +$786.51
-------------------------
Signature Date
Subtotal $6,215.00
Phone # Fax # Sales Tax (10.0%) $621.51
253-863-4895 253-863-0704 Total
$6,836.51
E-mail Web Site
allaroundfence@allaroundfencewa.com www.allaroundfencewa.com
EXHIBIT B
INSURANCE REQUIREMENTS FOR
CONSTRUCTION PROJECTS
Insurance
The Contractor shell procure and maintain for the duration of the Agreeraacnt,insurance
against claims for injuries to persons or damage to property which may arise from or in
connection with the perforrnance of the work hereunder by the Contractor, their agents,
representatives, employees or subcontractors,
A. Minimum Scope of Insurance
Contractor shall obtain insurance of the types described below:
L Automobile Liabili"tv insurance covering all owned,non-owned, hired and leased
vehicles. Coverage shall be written on Insurance Services Office JSO) farm CA 00
0l or a substitute form providing equivalent liability coverage. If necessary, the
policy shall be endorsed to provide contractual liability coverage.
CoRmemial General Liabiii insurance shall be written on ISO occurrence form CG
00 01 and shall cover liability arising from premises, operations, independent
contractors,.products-completed operations,personal injury and advertising iu�ury,
and liability assumed under an insured contract. The Commercial General Liability
insurance shall be endorsed to provide the Aggregate Per Project Endorsement ISO
form CG 25 03 11 85. There shall be no endorsement or modification of the
Commercial General Liability insurance for liability arising from explosion, collapse
or underground property damage. The City shall be named as an insured under the
Contractor's Commercial General Liability insurance policy with
respect to the work performed for the City using ISO additional insured endorsement
CG 20 10 1185 or a substitute endorsement providing equivalent coverage.
2. Workers' Compensation coverage as required by the Industrial Insurance laws of the
State of Washington.
B. Minimum Amounts of Insurance
Contractor shall maintain the following insurance limits:
1, Automobile Liability insurance with a minimum combined single limit
for bodily injury and property damage of $1,000,000 per accident.
2. Commercial General Liability insurance shall be written with limits no
less than$1,000,000 each occurrence, $2,000,000 ,general aggregate
and a$2,000,000 products- completed operations aggregate limit.
EXHIBIT B (Continued)
C. Other Insurance Provisions
The insurance policies are to contain, or be endorsed to contattx, the following provisions
for Automobile Liability, Commercial General liability and Builders Risk insurance:
1. The Contractor's insurance coverage shall be primary insurance as respect the
City. Any insurance, self-insurance, or insurance pool coverage maintained
by the City shall be excess of the Contractor's insurance and shall not
contribute with it.
2. The Contractor's insurance shall be endorsed to state that coverage shall not
be cancelled by either party,except after thirty (30) days prior written notice
by certified marl, return receipt requested,, has been given to the City.
D. Contractor's Insurance For Other Losses
-The Contractor shall assume full responsibility for all loss or damage from any cause
whatsoever to any tools, Contractor's employee owned tools, machinery, equipment, or
motor vehicles owned or rented by the Contractor, or the Contractor's agents, suppliers or
contractors as well as to any temporary structures, scaffolding and protective fences.
E. Acceptability of Insurers
Insurance is to be placed with insurers with a current A.M. Best rating of net less than
AN II.
F. Verification of Coverage
Contractor shall furnish the City with original certificates and a copy of the amendatory
endorsements, including but not necessarily limited to the additional insured
endorsement, evidencing the Automobile Liability and Commercial General Liability
insurance of the Contractor before commencement of the work. Before any exposure to
loss may occur, the Contractor shall file with the City a copy of the Builders R. sk
insurance policy that includes all applicable auditions, exclusions, definitions,teens and
endorsements related to this project.
G. Subcontractors
Contractor shall include all subcontractors as insureds under its policies or shall
furrdsh separate certificates and endorsements for each subcontractor. All
coverages for subcontractors shall be subject to all of the same insurance
requirements as stated herein for the Contractor.
� `�� CEO., �CATE OF LIABILITY INSUfi., °"TIE'""°°" "N
�THIRSTJCEWFFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
ICATIS DOESNOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
OW,. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:, If the aeryN71: 1e holder is an AE I I I I: NAL INSURED, the POH Vs must
the terms and conditions of the if Y require cY'I ) be endorsed.. If SUBROGATION IS WAIVED,subject to
Policy,certain pollcNra may Wro an endorsement A statement on this certificate does not confer rights to the
carti8ute holder in lieu of such endorsement 3 .
PRODUCER
Hell Anderson Agency, Inc.
Carl Maciolek, ACSR
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(425)291-5200 .. ..._..ram
600 SW39tb St, Suite 200 It - '------- --..—_..,_ mm,,, pyv0 pIN„U.L4�51291 5100
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Renton WA 98057 ..°.-,. _-....-.'.—.-._.._PoS,,.C.......__ MO cdwE'.R,epE NA6Cr
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........_....... ..,m...�._.._-
A11 Around Fence Company INSURER s"'-'- —PO Box 1029 '-
IURER 0 _.....�...�. _...
Ravenadale WA 98051 ----
IN SENF: ..__ { .__......�...
COVERAGES CERTIFICATE NUMBBR]CL1712126259 - - -
ISION NUIlil
THIS IS TO CERTIFY 7HAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREDEVNAMED BOVE FOR THE POLICY PERIOD
INDICATED NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO NMICH THIS
CERTIFICATE AND
O ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS
EXC..U SIONS ANO CONDITIONS OF SUCH POLICIES IMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN TYPE OF INSURANCE
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DESCRIPTION OF OPERATIONS Y LOCATgNs/VEHICLES (ACONO 101,AddlUwul RrmNr ScMdulr,mry G rWCNed R,n�
The certificate holder is additional insured ,mel""4#CL
and NCLCA0149 0215. waiver of subrogation per the attached endeoraemen LCG0492 9 091fi, i1CLCG2071 0916
04 Per the attached endor ement CLCG0492 0916 and KCLG0149
0215. Primary & non-contributory coverage per the Attached endorsement ACLCGD529 0916 and #CLCG2071
0916,
CERTWICATE HOLDER CANCELLATION
jedavis2kentwa.gov
:220Folurth
Kent SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATWhI DATE THEREOF, NOTICE WILL HE DELIVERED IN
ntenance ACCORDANCE WITH THE POLICY PROVISIONS,
creation 6 Community Services
Avenue South AUTHOWEO REPRESEN 98032
Jason Webb/CEM - � l_>•'__Q�Q-
ACORD 25(2014101) The ACORD name and I ®1988-2014 ACORD CORPORATION. All rights reserved.
INSO2A,,n,,„ 090 are registered marks of ACORD
COMMERCIAL GENERAL LIABILITY
CL CG 0492 09 16
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY,
GENERAL LIABILITY ULTRA, PLUS ENDORSEMENT
This endorsement modes insurance provided under the following
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SUMMARY OF COVERAGE EXTENSIONS
._-...........
. .
Provision Name Of Coverage Extension Included or Limit of
Insurance
A Miscellaneous Additional Insureds - - ."""` -
-- -- Included
B Expected Or Intended Injury Or Damage --
-- Included
C. Knowledge Of Occurrence `�— """"`"- - -- -
ncluded
D. .w.`.._.. -�.� _,..-._..-(F r" .__.-..m..�-
Legal Labil ty—Damage To Premises Rented To You (Fire, Lightning $300 000
Explosion Smoke, Or Leakago From Automatic Fire Protective SsCemS�
E Medical Payments -------- _.
00(
F- Mobile Equipment Redefined
-- Included —
G. Newly Formed Or Acquired Organization„ Partnership Or Limited Liability - Included '..
Company And Extended Period Of Coverage
H. Who Is An Insured-Amendment _— __--._ _ ._ ..__....
--- ncluded
I. Non-Owned Watercraft(Increased to maxi um length of less than 51� ncluded
—. feet _ �_. .-
J. Supplementary Payments- Increased Limds
1. Bail Bonds
$ 3,000
2. Loss Of Earnings $ 1,000
---- Unintentional Omission O--ni-t_en -onnaa _rro_In.D�isc losureK. _
__..._.
Included
L. Waiver Of Transfer Of Rights Of Recovery Against Others-
Included
M. Liberalization Clause
_ ----- -. _ n cluded
N. . Incidental Medical
Included W
The above is a summary only Please consult the specific provisions that follow for complete information on the extensions provided.
The provisions of the Commercial General Liability additional insured on your policy, provided
Coverage Part apply except as otherwise provided in that
this endorsement, This endorsement applies only if
such Coverage Part is included in this policy a. The written contract or written agreement
A. MISCELLANEOUS ADDITIONAL INSUREDS is
1. Section II - Who Is An Insured is amended (1) Currently in effect or becoming
effective during the term of this
to include as an insured any person or policy, and
organization (referred to as an additional
insured below) described in Paragraphs (2) Fully executed by you and the
A.rl.c.(i) through AA.c.('6) below when you additional insured prior to the "bodily
and such person or organization have agreed injuryI', "property damage" or "per-
in writing in a contract or agreement that sonal and advertising injury,
such person or organization be added as an
CL CG 04 92 09 16 Includes copyrighted material of Insurance Services Office, Inc Page 1 of 7
with its permission
b. The insurance afforded by this provision performed by or on behalf of
does not apply to any person or such additional insured
organization included as an additional
insured by a separate endorsement (4) Lessor Of Leased Equipment
issued by us and made a part of this
Any person(s) or organization(s)
1 policy or coverage part from whom you lease equipment but
C. Only the following persons or organ[- only with respect to liability for "bodily
zations are additional insureds under this injury', "Property damage' or "per.
{ provision, with coverage for such spinal and advertising injury" caused,
additional insureds limited as provided In whole or in part, by your
herein maintenance„ operation or use of
equipment leased to you by such
(1) Managers Or Lessors Of Premises person(s)or organization(s)
A manager or lessor of premises but A person's or organization's status
only with respect to liability arising as an additional insured under this
out of the ownership, maintenance or endorsement ends when their written
use of that part of the premises contract or written agreement with
leased to you and subject to the you for such leased equipment ends
following additional exclusions
This insurance does not apply to any
This insurance does not apply to occurrence" which takes place after
(a) Any "occurrence" which takes the equipment lease expires
place after you cease to be a (5) State, Municipality, Governmental
tenant in that premises Agency Or Subdivision Or Other
(b) Structural alterations, new con- Political Subdivision — Permits Or
struction or demolition operations Authorizations Relating To
performed by or on behaff of Premises
such additional insured. Any state, municipality, govern-
(2) Mortgagee, Assignee Or Receiver mental agency or subdivision or
other political subdivision subject to
A mortgagee, assignee, or receiver the following additional provisions:
but only with respect to their liability
as mortgagee, assignee, or receiver (a) This insurance applies only with
and arising out of the ownership, respect to:
maintenance, or use of a covered (i) The following hazards for
premises by you which the state, municipality,
This insurance does not apply to governmental agency or
structural alterations, new con- subdivision or other political
struction or demolition operations subdivision has issued a
performed by or on behalf of such Permit or authorization in
additional insured. connection with premises
you own, rent or control and
(3) Owners Or Other Interests From to which this insurance
Whom Land Has Been Leased applies.
An owner or other interest from (1.1) The existence,
whom land has been leased to you maintenance, repair,
btrt only with respect to liability construction, erection
arising, out of the ownership, mainte- or removal of adver-
nance or use of that part of the land tising signs, awnings,
leased to you and subject to the canopies, cellar
following additional exclusions entrances, coal holes,
This insurance does not apply to driveways, manholes,
marquees, hoist away
(a) Any 'Occurrence" which takes openings, sidewalk
place after you cease to lease vaults, street banners
that land or decorations and
(b) Structural alterations, new con- similar exposures, or
struction or demolition operations
CL CG 04 92 09 16 Includes copyrighted material of Insurance Services Office, Inc , Page 2 of 7
with its permission
(1.2) The construction, erec- The insurance afforded the
tion or removal of vendor does not apply to
elevators or
(I) "'Bodily injury" or "property
(1.3) The ownership, main- damage" for which the
tenance or use of any vendor is obligated to pay
elevators covered by damages by reason of the
this insurance assumption of liability in a
(ii) Operations performed by you written contract or written
or on your behalf for which agreement. This exclusion
the state, municipality, does not apply to liability for
governmental agency or damages that the vendor
subdivision or other political would have in the absence of
subdivision has issued a the written contract or written
permit or authorization agreement,
(b) This insurance does not apply to (ii) Any express warranty unau-
"bodily injury', "property dam- thorized by you,
age" or"personal and advertising (iii) Any physical or chemical
injury" arising out of operations change in the product made
performed for the state, munici- intentionally by the
pality, governmental agency or vendor,
subdivision or other political
subdivision. (iv) Repackaging, except when
unpacked solely for the
(6) Controlling Interest
purpose of inspection,
Any person(s) or organizations) with demonstration, testing, or the
a controlling interest in the Named substitution of parts under
Insured but only with respect to their instructions from the manu-
liability arising out of facturer, and then
repackaged in the original
(a) Their financial control of you, or container,
(b) Premises they own, maintain or (v) Any failure to make such
control while you lease or occupy inspections, adjustments,
these premises, tests or servicing as the
This insurance does not apply to vendor has agreed to make
structural alterations, new con- or normally undertakes to
struction or demolition operations make in the usual course of
performed by or for such persons) business, in connection with
or organization(s), the distribution or sale of the
(7) Co-Owner Of Insured Premises products,
(vi) Demonstration, installation,
A co-owner of a premises co-owned servicing or repair opera-
by you and covered under this tions, except such operations
insurance but only with respect to the performed at the vendor's
co-owner's liability as co-owner of premises in connection with
such premises the sale of the product,
(8) Vendors (vii) Products which, after distri-
(a) Any person(s) or organization(s) bution or sale by you, have
(referred to as vendor), but only been labeled or relabeled or
with respect to "bodily injury" or used as a container, part or
"property damage" arising out of ingredient of any other thing
your products" which are or substance by or for the
distributed or sold in the regular vendor, or
course of the vendors business.
CL CG 04 92 09 16 Includes copyrighted material of Insurance Services Office, Inc Page 3 of 7
with its permission
(viii)"SodilY n arY or "property Y 3. With respect to the insurance afforded to trie
damage" arising out of the additional insureds within this Provision A.
sole negligence of the Miscellaneous Additional Insureds the
vendor for is own acts or following is added to Section 11 --Limits Of
omissions or those of its Insurance.
employees or anyone else
acting on its behalf How- The most we will pay on behalf of the
ever, this exclusion does not additional insured is the amount of insurance
apply to a. Required
q ed by the written contract or
(1.1) The exceptions wntten agreement, or
contained in Sub- b. Available under the applicable Limits of
paragraphs (iv) or (vi), Insurance shown in the Declarations,
or
(1.2) Such inspections, ad- whichever is less
justments, tests or This endorsement shall not increase the
servicing as the applicable Limits Of Insurance shown in the
vendor has agreed to Dedaratrons
make or normally B. EXPECTED OR INTENDED INJURY OR
undertakes to make in DAMAGE
the usual course of
business, in con- Exclusion 2.a. Expected Or Intended Injury of
nection with the Section I — Coverage A — Bodily Injury And
distribution or sale of Property Damage Liabilffiy is deleted and
the products. replaced by the following
(b) This insurance does not apply to a. Expected Or Intended Injury Or Damage
ainy insured person or organi- "Bodily injury'or"property damage"expected
zatiOn, from whom you have or dntendad from the standpoint of acquired products, Or any theinsured. This exclusion does not apply to
ingredient part or container, "bodily injury" or"property damage" resulting
entering into, products
accompanying or from the use of reasonable force to protect
cantarning such products persons or property
2. With respect to coverage provided by this C. KNOWLEDGE OF OCCURRENCE
Provision A. Miscellaneous Additional
Insureds, the following additional provisions Paragraph 2.a, Duties In The Event Of
apply Occurrence, Offense, Claim Or Suit of Section
a. Any insurance provided to an additional is
— Commercial General Liability Conditions
s deleted and replaced by the following
insured designated under Paragraphs .
A.1.c.(1) through. AA.c.(S) above does a. You must see to it that we are notified as
not apply soon as practicable of an "occurrence" or an
(1) To "bodily injury' or offense which may result in a claim only
"Property damage" included within the when the "occurrence" or Offense is known"products-completed operations to
hazard", or (1) You, if you are an individual,
(2) To "bodily injury". "property damage" (2) A partner, if you are a partnership,
Or "personal and advertising injury
(3) A manager, if you are a limited liability
arising out of the sole negligence of
such additional insured company, or
b. The insurance afforded to such additional (4) An executive officer" or the 'employee,,
insured only applies to the extent designated by you to give such notice, if
permitted by law you are an organization other than a
Partnership or a limited liability company
C. The insurance afforded to such additional
To the extent possible, notice should include
insured will not be broader than that :
which you are required to provide by the (1) How, when and where the "Occurrence"
written contract or written agreement or Offense took place,
CL CG 04 92 09 16 Includes copyrighted material of Insurance Services Office, Inc Page 4 of 7
with its permission
(ii) The names and addresses of any injured you, or in the case of damage by fire,
persons and witnesses, and lightning, explosion, "smoke", or leakage
(iii) The nature and location of any injury or from automatic fire protective systems,
damage arising out of the "occurrence" while rented to you or temporarily
or offense Occupied by you with permission of the
D. LEGAL LIABILITY - DAMAGE TO PREMISES owner
RENTED TO YOU (Fire, Lightning„ Explosion, This limit wilt apply to all damage
Smoke, Or Leakage From Automatic Fire proximately caused by the same event,
Protective Systems) whether such damage results from fire,
lightning, explosion, "srmoka", leakage
If damage to premises rented to you is not from automatic fire protective systems, or
otherwise excluded from this policy or coverage other covered causes of loss or any
Part,, then the fafllowing provisions apply combination thereof
1. Under Section 1 - Coverage A - Bodily 4. Subparagraph b.(1)(a)(ii) of Paragraph 4.
Injury And Property Damage (Liability, the Other Insurance of Section IV -
last paragraph (after the exclusions) is Commercial General Liability Conditions
deleted and replaced by the following is deleted and replaced by the following
Exclusions c. through n, do not apply to dam- (ii) That is fire, lightning, explosion, "smoke'
age by fire, lightning, explosion, "smoke", or or leakage from automatic fire protective
leakage from automatic fire protective systems insurance for premises rented to
systems to premises while rented to you or you or temporarily occupied by you with
temporarily occupied by you with the permission of the owner,
permission of the owner A separate limit of S. Subparagraph a. of Defnticn 9. "Insured
insurance applies to this coverage as
described in Section III - Limits Of contract" of Section V - Definitions is
Insurance deleted and replaced by the following
2. The paragraph immediately after Sub- a. A contract for a lease of premises.
paragraph j.(6) of Paragraph 2. Exclusions However, that portion of the contract for
of Section I - Coverage A - Bodily Injury a lease of premises that indemnifies any
And Property Damage Liability is deleted Person or organization for damage by
and replaced by the following_ fire, lightning, explosion, "smoke" or
leakage from automatic fire protective
Paragraphs (1), (3) and (4) of this exclusion systems to premises while rented to you
do not apply to "property damage" (other or temporarily occupied by you with
than damage by fire lightning, explosion, permission of the owner Is not an
smoke", or leakage from automatic fire "insured contract"
protective systems) to premises including
the contents of such premises" rented to you 6. As used in this Provision D. Legal Liability-
for a period of seven or fewer consecutive Damage To Promises Rented To Your,
days. A separate limit of insurance applies to "Smoke" does not include smoke from
Damage To Premises Rented To You as agricultural smudging, industrial operations
described in Section III - Limits Of or"hostile fire"
Insurance.
3. Paragraph 6. of Section III - Limits Of E. MEDICAL PAYMENTS
Insurance is deleted and replaced by the It Coverage C -- Medical Payments is not
following: otherwise excluded from this policy or coverage
part, the Medical Expense Unr i is changed.
6. Subject to Paragraph 5. above, the subject to the terms of Section Ill Limits Of
greater of: insurance, to the greater of,
a. $300,000, or a. $10,000, or
b. The Damage To Premises Rented b. The Medical Expense Limit shown in the
To You Limit shown in the Declarations.
Declarations,
is the most we will pay under Coverage
F. MOBILE EQUIPMENT REDEFINED
A for damages because of "property Subparagraph li of Definition 12. "Mobile
damage" to premises while rented to equipment" of Section °V-Definitions is deleted'
and replaced by the following
CL CG 04 92 09 16 Includes copyrighted material of Insurance Services Office, Inc Page 5 of 7
with its permission
(1) Equipment with a gross vehicle weight of parturarship or limited liability company
,000 pounds or more and designed primarily are the same or similar to the operations
for of insureds already covered under this
(a) Snow removal; insurance,
(b) Road maintenance, but not construction (v) Coverage only aidi for Chose limited
or resurfacing, or liability companies who have established
(c) Street cleaning; a date of formation as recorded within
the filed state articles of organization,
G. NEWLY FORMED OR ACQUIRED ORGANIZA. certificates of formation or certificates of
TION, PARTNERSHIP OR LIMITED LIABILITY organization, and
COMPANY AND EXTENDED PERIOD OF NO Coverage only applies for those
COVERAGE to of
norships who have established a date of
Paragraph 3. of Section II -Who Is An Insured formation as recorded within a written
is deleted and replaced by the following partnership agreement or partnership
3. Any organization you rawly acquire or form, certificate
other than a joint venture, and aver which H. WHO IS AN INSURED-AMENDMENT
you maintain ownership or The last paragraph of Section II - Who Is An
a. Majority interest of more than 50% if you Insured is deleted and replaced by the following
are a corporation; No person or organization is an insured with
b. Majority interest of more than 50% as a respect to the conduct of any
general partner of a newly acquired or a. Current partnership or limited liability
formed partnership, and/or company, unless otherwise provided, for
c. Majority interest of more than 50% as an under Paragraph, 3. of Section iI - Who Is
owner of a newly acquired or formed An Insured;
limited liability company, b. Current joint venture, or
will qualify as a Named Insured if there is no c. Past partnership, joint venture or limited
other similar insurance available to that liability company,
organization However, for these organiza-
tions. that is not shown as a Named Insured in the
(i) Coverage under this provision is afforded Declarations
only until the next anniversary date of I. NON-OWNED WATERCRAFT
this policy's effective date after you Subparagraph (2) of ExOuslon 2.g. Aircraft,
acquire or form the organization, Auto Or Watercraft of Section I - Coverage A
partnership or limited inability company, - Bodily Injury And Properly Damage Liability
or the end of the policy period, whichever is deleted and replaced by the following
is earlier,
(li) Section p - Coverage A - Bodily injury (2) A watercraft you do not own that is
And Property Damage Liability does (a) Less than 51 feet long, and
not apply to "bodily injury" or "property (b) Not beingused to car
damage" that occurred before you Garry Persons or
acquired or formed the organization, Property for r a charge,
partnership or limited liability company„ J. SUPPLEMENTARY PAYMENTS- INCREASED
(iii) Section I - Coverage 8 - Personal LIMITS
And Advertising Injury Liability does Section I - Supplementary Payments -
not apply to "personal and advertising Coverages A And B is changed as follows
injury" arising out of an offense 1. The limit shown in Paragraph 1.b. for the
committed before you acquired or formed cast of bail bonds is changed from $250 to
the organization, partnership or limited $3,000, and
liability company;
(iv) Coverage 2. The limit shown in Paragraph 1.d. for loss of
of erag newly
only when operations earnings because of time off from work is
theaway acquired organization, changed from $250 a day to$1,000 a day
CL CG 04 92 09 16 Includes copyrighted material of Insurance Services Office, Inc
Page 6 of 7
with its permission
i UNINTENTIONAL OMISSION OR UNINTEW M. LIBERALIZATION CLAUSE
TONAL ERROR IN DISCLOSURE
The following provision is added to Paragraph 6. The following is added to Section IV -
Commercial General Liability Conditions:
Representations of Section ad IV - rrnmeecial
6.
General Liability Conditions If we adopt a. mandatory attachment form change
which broadens coverage under this edition of
However, the unintentional omission of, or
unintentional error in, any information given or additional charge, and those chang the Commercial General Liability C hang for no
re
provided by you shall not prejudice your rights es are
under this insurance g intended to apply to all insureds under this edition
Of CG0001, that change will automatically apply
This provision does not affect our right to collect to your insurance as of the date we implement
additional premium or to exercise our right of the change in your state. This liberalization
cancellation or non-renewal clause does not apply to changes implemented
through introduction of a subsequent edition of
L. WAIVER OF TRANSFER OF RIGHTS OF
RECOVERY AGAINST OTHERS the Commercial General Liability form CGD001.
The following is added to Paragraph 8. Transfer N. INCIDENTAL MEDICAL MALPRACTICE
Of Rights Of Recovery Against Others To Us 1 Paragraph 2.111 of Section II - Who Is
of Section IV - Commercial General Liability An Insured does not apply to a physician,
Conditions nurse practitioner, physician assistant„ nurse,
We waive any right of recovery we may have emergency medical technician or paramedic
against an employed by you if you are not in the
9 y person or organization because of business or occupation of providing medical,
Payments we make for injury or damage arising
out of your ongoing operations or"your work" and nu
rsing
n services
surgical, dental, x-ray or
ni
included in the "products-completed operations Hre ng services
hazard" when you have agreed in a written 2. This provision is excess over any other valid
contract or written agreement that any right of and collectible insurance whether such
recovery is waived for such person or insurance is primary„ excess, contingent or
organization, This waiver applies only to the on any other basis, Any payments by us will
person(s) or organization(s) agreed to in the follow Paragraph 4.b. of Section IV -
written contract or written agreement and is Commercial General Liability Conditions
subject to those provisions.
This waiver does not apply unless the written
contract or written agreement has been executed
prior to the"bodily injury' or"property damage".
However, if any person or organization is
separately scheduled on a separate waiver of
transfer of rights of recovery which is attached to
this policy, then this waiver does not apply
CL CG 04 92 09 16 Includes copyrighted material of Insurance Services Office, Inc
with its permission Page 7 of T
COMMERCIAL GENERAL LIABILITY
CL CG 05 29 10 17
THIS ENDORSEMENT CHANGES THE POLICY" PLEASE READ IT CAREFULLY.
GENERAL LIABILITY ULTRA PLATINUM
ENHANCEMENT COVERAGES
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
A. The following coverage is added:
paragraph 2s. above, the words caused,n
ADDITIONAL INSURED - OWNERS, LESSEES whole or in part by are replaced by the
OR CONTRACTORS - AUTOMATIC STATUS wards arising out of
INCLUDING PRIMARY NON-CONTRIBUTORY
c. The insurance afforded to such additional
1. Section II -Who is An Insured is amended to insured only applies to the extent
include as an additional insured any person(s) Permitted by law,and
or organization(s) for whom you are required
by virtue of a written contract or agreement d. If coverage provided to the additional
that such persons) or Organization(s) be insured is required by a contract or
added as an additional insured on your policyagreement, the insurance afforded to such
additional insured will not be broader than
2. The insurance provided to the additional that which you are required by the contract
insured is limited as follows. or agreement to provide for such
a. Such additional insured.
person or organization is an
adddional insured only with respect to e. This insurance ends at the earliest of the
liability for "bodily injury'' "property following times:
damage" or "personal and: advertising injury"caused in whole or in part by: (1) When any Named Insured(s) work
called for in the written contract has
(1) Ads or omissions of the Named been completed
Insured; or
(2) When all Of any Named Insureds)
(2) The acts or omissions of those acting work done at a job sde has been
on behalf of the Named Insured; Completed if the written contract calls
in the performance of the Named Insureds for work at more than one job site
work for the additional insured(s) specified (3) When that part of any Named
in the written contract provided the Insured(s work done at a fob site has
contract or agreement requires you to been put to its intended use by any
provide the additional insured such person or organization other than the
coverage and is. Named Insured or those acting on the
f. Currently in effect or becomes Named Insured(s)behalf.
effective during the term of this Work that may need service, maintenance,
policy; and correction, repair or replacement, but is
it Was executed p or tO the '"badil otherwise complete, will be treated as
y completed.
injury", 'Property damage" or
"Personaf and advertising Injury' f. This insurance does not apply to any
b. If the written contract specCally raquines additional insured scheduled on your
YOU to provide additional insured coverage policy by separate endorsement
via the 10101 edition of CG2010 (aka CG ll For purposes of paragraph A of this
20 10 TO 01) or via the 11/85 edition of endorsement the terms "you" and "your'
CG2010 (aka CG 20 10 11 85), then in refer to the Named Insured shown in the
Declarations.
CL CG 05 29 10 17 Includes copyrighted material of Insurance Services Office, Inc.,
with its permission. Page 1 of 3
3, Exclusions a. Required by the contract or agreement; or
with respect to the insurance afforded to these
additional insureds, the following additional b. Available under the ap ecarat ns of
exclusions apply to "bodi inu Insurance shown in the Declarations,
PP Y ry i �', "Property
damage" or "personal and advertiaing injury, whichever is less.
arising out of: This endorsement shall not increase the
a. The rendering Of Or failure to render any applicable Limits of Insurance shown in the
professional services by you or on your Declarations.
behalf, but only with respect to either or 5 Other Insurance
both of the following operations.
(i) Providing engineering, architectural or For purposes of this endorsement, the
bolloavn
surveying services to others in your g is added to the Section IV -
capartly as an engineer, architect or Commercial General Liability Conditions, 4.
surveyor; and Other
(2) Providing, or hiring independent Insurance condition and supersedes any
Professionals to provide,. engineering, Provision to the contrary.
archilectural or surveying services.. in This insurance is excess of all other
connection with construction work you insurance available tc an additional
perform Insured whether on a primary, excess,
b. Subject to Paragraph c. below, contingent or any other basis But, if
Professional services include: required by a written contract or written
agreement to be primary and
(1) Preparing, approving, or failing to noncontributory, this insurance will be
prepare or approve, maps, shop Primary 10 and will not, seek contribution
drawings, opinions, reports, surveys, from any insurance on which the additional
field Orders, change orders, or insured is a Named Insured,
drawings and specrfical;ions,and No other coverage or limit in the policy
(2) Supervisory or inspection activities applies to loss or damage insured by this
performed as part of any related coverage
architectural or engineering activHes. B. The following coverage is added:
c. Professional services do not include
services within construction means, CONTRACTUAL LIABILITY -RAILROADS
methods, techniques, sequences and t nth respect to operations performed for a
procedures employed by you or performed Railroad within 50 feet of railroad property, the
by or for the construction manager, its definition Of "insured contract" do Section V -
employoes or its subcontractors in Definitions is replaced by the following.
connection with your ongoing operations.
9. "Insured Contract"means:
This exclusion applies even if the claims
against any insured allege negligence or other a• A contract for a pease of premises
wrongdoing in the supervision, hiring, However, that portion of the contract
employment, training or monitoring of others for a lease of premises that
by that insured, if the "occurrence" which indemnifies any person or
caused the "bodily injury" or "property organization for damage by fire to
damage", or the offense which caused the premises while rented to you or
"personal and advertising injury", involved the temporarily occupied by you with
rendering of, or the failure to render, any Permission Of the owner is not an
professional architectural, engineering or insured contract";
surveying services. b. A sidetrack agreement,
4. Limits of Insurance c. Any easement or license agreement;
Wrth respect to the insurance afforded to these d. An obligation as required by
additional insureds, the following is added to ordnance, to indemnify a murlicparuty,Section III - Limits Of Insurance: except in connection with, work for a.
If coverage provided to the additional insured municrpatity;
is required by a contract or agreement, the e. An elevator maintenance agreement,
most we will pay on behalf of the additional
Insured is the amount of insurance. f. That part of any other contract or
agreement pertaining to your business
Page 2 of 3 Includes copyrighted material of Insurance Services (ice, Inc
with its permission, CL CG OS 29 70 17
(including an indemnification of a C. AGGREGATE LIMITS OF INSURANCE
municipality, in connection with work
performed for a municipality) under The General Aggregate Limit under SECTION III -
which you assume the ton liability of LIMITS OF INSURANCE applies separately to
another party to pay for "bodily injury" each of your.
or property damage" to a third person or orgamzatl'on Tort Inability means a 1. Projects away from premises owned by or
.
liability that would be imposed by law rented to you.
in the absence of any contract or 2. "Locations"owned by or rented to you,
agreement.
"Location" means premises involving the same
Paragraph I. does not include that part or connectinglots, or
of any contract or agreement premises whose
connection is interrupted only by a street,
(1) That indemnifies an architect, roadway, waterway or right-of-way of a
engineer or surveyor for injury or railroad.
damage arising out of: When paragraph B. Construction Project
(a) Preparing, approving or failing General Aggregate Limit on form CL CG 00 20 is
to prepare or approve maps, a part of this policy, then this endorsement
shop drawings, opinions, CL CG 05 29 paragraph, D. Aggregate Limits of
reports, surveys, field orders, Insurance does not apply.
change orders or drawings
and specifications, or
(b) Giving directions or
instructions,. or failing Co give
them, if that is the primary
cause of the injury or damage,
(2) Under which the insured, if an
architect, engineer or surveyor,
assumes Inability for an injury or
damage arising out of the
insured's rendering or failure to
render professional services,
including those listed in Paragraph
(1) above and supervisory,
inspection, architectural or
engineering activities
2. Other Insurance
For purposes of this endorsement, the
following is added to the Section IV-
Commercial General Liability
Conditions, 4. Other Insurance condition
and supersedes any provision to the
contrary:
This insurance is excess of all other
Insurance that is Railroad Protective
Liability or similar Coverage for"your work'
performed for a Railroad, But, if required
by a written contract or written agreement
to be primary and noncontributory, this
Insurance will be primary to and will not
seek contribution from any insurance on
which the Railroad is a Named Insured.
No other coverage or limit in the policy
applies to loss or damage insured by this
coverage.
CL CG 05 29 10 17 Includes copyrighted material of Insurance Services Office, Inc
with its permission. Page 3 of 3
f
COMMERCIAL AUTO
CL CA 01 49 02 15
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
COMMERCIAL AUTOMOBILE EXP
ANSION NSION ENDORSEMENT
- PLATINUM
This endorsement modifies insurance provided under the following
BUSINESS AUTO COVERAGE FORM
With respect to the coverages provided by this endorsement, the provisions of the Business Auto Coverage Form
apply unless modfled by this endorsement
A. NEWLY ACQUIRED OR FORMED ORGANIZA-
TIONS property damage because of the conduct
of an "insured" under Paragraphs a. or b.
The following is added to Paragraph A.I. Who Is under Paragraph A.I. Who Is An Insured of
An Insured of Section II - Covered Autos Liability Section If - Covered Autos Liability Cover-
Coverage age, caused by an "accident" and resulting
Any organization you newly acquire or form, oth- from the ownership, maintenance or use of a
partnership, covered "auto";
er than a
p p, joint venture or limited lia-
bility company or any organization excluded ei- 2. The written contract or agreement described
ther by this Coverage Part or by endorsement, above must have been executed prior to the
and over which you maintain ownership or me- "accident" that caused the "bodily injury" or
forty interest of more than 50 percent will qualify property damage" and be in effect at the
as a Named Insured, However time of such"accident",
1. This insurance does not apply to any newly 3. The insurance afforded to any such addition-
acquired or formed organization that is an al "insured" does not apply to any "accident"
'.Insured" under any other automobile policy beyond the period of time required by the
or would be an "insured" under such policy written contract or agreement described
but for its termination or the exhaustion of its above,
Limit of Insurance 4. The most we will pay on behalf of such addi-
2. Coverage does not apply to "bodily injury" or tional "insureds is the lesser of.
"'property damage" that occurred before you a. The Limits of Insurance specified in the
acquired or formed the organization, written contract or agreement described
3. Coverage under this provision is afforded on- above, or
ly until the 180th day after you acquire or
form the organization or the end of the policy b• The Limits of Insurance shown in the
period, whichever is earlier Declarations
B. ADDITIONAL INSURED BY CONTRACT OR This provision shag not increase the Limit of
AGREEMENT Insurance shown in the Declarations in this
policy or coverage part, and
The following is added to Paragraph A.1., Who Is
An Insured of Section II - Covered Autos Liability 5' The following changes are made to Para-
Coverage: graph 5. Other Insurance of B. General Con-
ditions under Section IV - Business Auto
When you have agreed in a written contract or Conditions:
agreement to include a person or organization as
an additional "insured", such person or organiza-
tion is 'included as an "insured" subject to the fol- If required by the written contract or
lowing. agreement described above, the insur-
1 Such person or organization is an additional ante afforded to the additional insured
"insured" only to the extent such under this provision will be primary to,
organization is liable for "bodily person
or and will not seek contribution from, the
additional insureds own insurance.
CL CA 01 49 02 15 Includes copyrighted material of Insurance Services
Office, Inc., with its permission Page 1 of 5
b. Paragraph 5.c. is deleted in its entirety 1. The Limits of Insurance are increased to $75
6. Paragraph A.t.c. under Section II - Covered per day to a maximum of$2,500.
Autos Liability Coverage is deleted in its en- 2. We will also pay reasonable and necessary
tirety expenses to facilitate the return of the stolen
7. The definition of 'insured contract" under "auto"to you
Section V- Definitions is amended to add the 3. It is agreed and understood and it is our stat-
followi'ng
ad indent that expenses incurred by you un-
An "insured contract" does not include that der the Transportation Expenses Coverage
part of any contract or agreement: Extension will not also be covered or paid
That under the Rental Reimbursement Coverage
pertains to the ownership, maintenance provided by this endorsement or any rental'
or use of an "auto" and which indemnifies a reimbursement coverage added by separate
person or organization for other than the vi- endorsement to this policy.
carious liability of such person or organize-
Ilion for 'bodily injury" or "property damage,, H. EXTENDED COVERAGE -AIRBAGS
caused by your operation or use of a covered The following is added to Exclusion B.3.a. of
auto Section III - Physical Damage Coverage
However, a person or organization is an ad-
ditional "' However, this exclusion does not apply to the un-
Insured" under thus provision only to intended discharge of an airbag.
the extent such person or organization is not
named as an "insured by separate en- This coverage is excess over any other collecti-
dorsement to this policy ble insurance or warranty providing such airbag
C. EMPLOYEES AS INSUREDS coverage
The following is added to Paragraph AA Who Is I. AUTO LOANILEASE GAP COVERAGE
An Insured Section II - Covered Autos Liability The following is added to Section III - Physical
Coverage: Damage Coverage, Paragraph C. Limits of Insur-
Any "employee" of yours is an "insured" while ance
using a covered "auto"you don't own, hire or bor- 4. In the event of a total "oss"to a Covered"au-
row in your business or your personal affairs. to we will pay any unpaid amount due on
D. INCREASED COVERAGE - BAIL BONDS the lease or loan for a covered "auto' less
The Supplementary Payments Coverage Exten- a. The amount under the Physical Damage
Coverage section of the policy, and
soon of Section II - Covered Autos Liability Cov-
erage is amended as follows It. Any
The Limit of Insurance in paragraph A.2.a.(2) is (1) Overdue lease/loan payments at the
increased to $5,000- time of the"loss
E. INCREASED COVERAGE - LOSS OF EARN- (2) Financial penalties imposed under a
INGS lease for excessive use, abnormal
The Supplementary Payments Coverage Exten- wear and tear or high mileage,
sion of Section 11 - Covered Autos Liability Cov- (3) Security, deposits not returned by the
erage is amender{as follows: lessor,
The Limit of Insurance in paragraph A.2.a.(4) is (4) Costs for extended warranties, Credit
increased to $1,000_ Life insurance, Health, Accident or
F. FELLOW EMPLOYEE COVERAGE Disability Insurance purchased with
the loan or tease, and
The Fellow Employee Exclusion contained in
Section 11 - Covered' Autos Liability Coverage (5} Carry-over balances from previous
does not apply, This coverage is excess over
cans or leases.
Ply J, GLASS REPAIR -NO DEDUCTIBLE
any other collectable insurance.
G. COVERAGE EXTENSION - TRANSPORTA- The following is added to Paragraph D. Deducti-
TION EXPENSES bla of Section III - Physical Damage Coverage
Paragraph A.4,a. Transportation Expenses of Any Comprehensive Coverage deductible shown
Section III- Physical Damage Coverage is in the Declarations does not apply to "lass" to
amended as follows glass when you elect to patch or repair rather
than replace the glass,
Page 2 of 5 Includes copyrighted material of Insurance Services
Once. Inc , with its permission CL CA 01 49 0215
K. INCREASED COVERAGE t ELECTRONIC
EQUIPMENT O. HIRED AUTO rnYSICAL DAMAGE COVER-
AGE
The $1,000 limit indicated in Paragraph C.1.b. The following is added to Paragraph A.4. Cover-
increased to$7,500
under Section III - Physical Damage Coverage is age Extensions of Section III - Physical Damage
Coverage:
L. EXTENDED COVERAGE - PERSONAL PROP-
ERTY If hired "autos" are covered "autos" for Covered
Autos Liability Coverage and if Physical
cal
The following is added to Paragraph A-4. Cover- Coverage is provided for any "autut o" youou own,
age Extensions of Section III - Physical Damage then the Physical Damage coverages provided
Coverage, are extended to "autos" you lease, rent, hire or
borrow from Physical Damage Coverage on a covered '"auto" ees" partners memberne s of th thaneir
your "employ.
be their hous
eholds
s Y extended to "I ehol oss"' ds
to our r �,personal I a r Y R pop subtext to the following
arty ar, if you are an Individual, the personal
property of a family member, that Is in the cov- 1. The most we will pay in any one "loss" is the
eyed"auto"'at the time of loss".and caused by an lesser of.
"accident' and resulting from the ownership, a. The actual cash value of the "auto';
maintenance or use of a covered "auto"
The insurance provided by this coverage exten- b. The cost to repair or replace the "auto
sion is excess over any other collectible incur- or
ance. The most we will pay for any one, "loss" C. $100,000
under this coverage extension is $500 However,
our payment for "Voss„ to Personal property will 2. Paragraph a above is subject to a dto the
P t y ble The deductible shall be equal to the
only be For the account of the owner of the prop-
a ty amount of the highest deductible shown for
any owned "auto" of the same classification
Under this provision, personal property does not for that coverage. In the event there is no
Include and we will not pay for"loss" of currency, owned "auto" of the same classification, the
coins, securities or contraband highest deductible for any owned "auto, will
No deductible applies to this coverage extension aPPly for that coverage
M. TOWING No deductible will apply to "loss" caused by
fire or lightning,
Paragraph A.2. Towing of Section III - Physical 3. Hired Auto Physical Damage Coverage is
Damage Coverage, is replaced by the following' subject to the following.
If a private passenger type "auto or light truck a. If symbol 8 is shown in the Covered Auto
auto" (0-10,000 Lbs. GVW) is provided both
section of the Declarations page far any
Comprehensive and Collision Coverage, we will
Pay UP to '$150 for towing and labor costs in-
curred each time such "auto" is disabled if a the Hired Auto Physical Damage cover-
medium, heavy or extra-heavy truck or extra• age described in this endorsement does
heavy Trucks-tractor "auto' (greater than 10,000 not apply
Lbs. GVW) Is provided both Comprehensive qnd b. Other than indicated in Paragraphs a. di-
Collision Coverage, we will pay up to $250 for rectly above, coverage provided under
towing and labor Costs incurred each time such this provision will be excess over any
"auto" is disabled, However, the labor must be other collectible insurance or coverage,
Performed at the place of disablement 4. In addition to the limit set forth in Paragraph
N. FIRE EXTINGUISHER RECHARGE 1. above we will pay up to $500 per day, to a
The fallowing is added to Paragraph A.4. Cover- maximum of$3,500 per"loss"for:
age Extensions of Section IV - Physical Damage a. Any costs or fees associated with the
Coverage: "loss"to a hired "auto", and
When fire extinguishers are kept in your covered b. Loss of use of the hired "auto", provided
"auto" and any are discharged in an attempt to t is the consequence of an "accident" for
extinguish a fire" we witf pay the lesser of the ac- which you are legally liable, and as a re-
tual cost of recharging or replacing such fire ex- cult of which a monetary loss is sus-
tinguisher(s)- tained by the leasing or rental concern
No deductible applies to this coverage However, Paragraph A.4.b, Loss of Use Expens-
es under Section III - Physical Damage Coverage
CL CA 01 49 02 15 Includes copyrighted material Of Insurance Services
Office, Inc., with its permission Page 3 of 5
of the Business Auto Coverage(Form does not 4
apply. (2) Your partners or members, if you are
P. RENTAL REIMBURSEMENT COVERAGE designated in the Declarations as a
partnership orjoint venture
We will pay for rental reimbursement expenses (3) Your members or managers, if you
incurred by you for the rental of an ''auto' be- are designated in the Declarations as
cause of"loss"to a covered "auto a limited liability company,
1. Payment applies in addition to the otherwise (4) Your executive officers if you are
applicable amount of each coverage you designated in the Declarations as an
have on the covered "auto" organization other than an individual,
2. No deductible applies to this coverage. partnership, joint venture or limited
liability company, and
3. We will pay only for those expenses incurred
during the policy period beginning 24 hours (5) The spouse of any person named in
after the "loss" and ending, regardless of the Paragraphs 1.a.(1), through 1.a.(4)
expiration date of the policy, with the lesser while a resident of the same house-
of the following number of days hold,
a. The number of days when the covered Except
"auto" has been repaired or replaced, or (a) Any "auto" owned by that indi-
b. 45 days vidual or by any member of
4. Our payment is limited to the lesser of the fol-
his cr her household.
lowing amounts (b) Any "auto'' used by that individu-
al or his or her spouse while
a. Necessary and actual expenses incurred, working in a business of selling,
or servicing, repairing or
parking
b. Not more than $75 for any one day, "autos"
5. We will pay up to an additional $300 for the 2. Changes In Auto Medical Payments And
Uninsured And LJnderinsured Motorists
reasonable and necessary expenses you in-
Coverages
cur to remove your materials and equipment
from the covered "auto" and replace such The following is added to Who Is An In-
materials and equipment on the rental "auto", sured
6. This coverage does not apply while there are Any individual named in 1.a above and his or
spare or reserve "autos" available to you for her "family members" are "insured" while
your operations "occupying" or while a pedestrian when being
7. If "loss" results from the total theft of a ccv- struck by any "auto' you don't own except
Bred "auto" of the "private passenger type', Any "auto"owned by that individual or by any
we will pay under this coverage only that "family member',
amount of your rental reimbursement ex- 3. Changes In Physical Damage Coverage
parses which is not already provided for un-
der the Physical Damage Coverage Exten- Any private passenger type "auto" you don't
sion of the Business Auto Coverage Form or own, hire or borrow is a covered "auto' while
any endorsements thereto in the care, custody or control of any individ-
However, this provision does not apply to the ual named in Q 1.e. above or his or her
spouse while a resident of the same house-
extent that rental reimbursement is provided
by separate endorsement to this policy hold except:
Q. DRIVE OTHER CAR COVERAGE a• Any "auto" owned by that individual or by
any member of his or her household; or
1. The followinngg is added to Section II - Cov-
eyed Autos s Liability Coverage b. Any "auto" used by that individual or his
or her spouse while working in a busi-
a. Any "auto" you don't own, hire or borrow ness of selling, servicing, repairing or
Is a covered "auto" for Liability Coverage parking "autos".
while being used by: 4. The most we will pay for the total of all dam-
(1) You, if you are designated in the ages under Covered Autos Liability Unin-
Declarations as an individual, sured Motorists Coverage and Underinsured
Motorists Coverage is the Limit Of Insurance
Page 4 of 5 Includes copyrighted material of Insurance Services
Office, Inc ,wrth its CL CA 01 49 02 15
permission
shown in the Declar.,oe s applicable to
owned "autos" 3. At our requtst y „'must provide us with a copy of
the aforementioned written contract or agree..
5'. Our obligation to pay for, repair, return or re- ment
Place damagod or stolen property under T. UNINTENTIONAL OMISSIONS
Physical Damage Coverage, will be reduced
by a deductible equal to the amount, of the The following is added Paragraph B.2. of Section
highest deductible shown for any owned or!_ IV- Business Auto Conditions
vale passenger type '"auto" applicable to that If you fail to disclose any hazards existing at the
coverage If there are no owned private pas- Inception date of this policy, such failure will not
senger type "autos". the deductible shall be prejudice the coverage provided to you Howev-
$250 for Comprehensive Coverage and $500 er, this provision does not affect our right to col-
for Collision Coverage No deductible will lect additional premium or exercise our right of
apply 10"loss"caused by fire or lightning
cancellation or nonrenewal
6. Additional Definition U. LIBERALIZATION
I
As used in this DRIVE OTHER CAR Provi-
sion If we revise this endorsement to provide greater
coverage without additional premium charge, we
'Family member'" means a person related to will automahcWly provide the additional coverage
the individual named in 'I,a by blood, mar- to all endorsement holders as Of the day the revi-
nage or adoption who is a resident of the in- Sion is effective in your state
dividuars household, including a ward or fos-
ter child.
R. KNOWLEDGE OF AN ACCIDENT, CLAIM,
SUIT OR LOSS
The following is added to Paragraph A.2. of Sec-
tion IV- Business Auto Conditions-
Your obPlgation to provide prompt notice of an
"accident", claim, "suit"or"loss"is satisfied if you
or a person designated by you to be responsible
for insurance matters Is notified of, or in any
manner made aware of an "accident", claim,.
"suit" or "loss" and provides us such notice as.
soon as practicable
S. WAIVER OF SUBROGATION BY CONTRACT
OR AGREEMENT
The following is added to Paragraph A.5 of Sec-
tion IV - Business Auto Conditions
We waive any right of recovery we may have
against a person or organization because of
Payments we make for "bodily injury" or"property
damage" when you and such person or organiza-
lion have agreed in writing in a contract or
agreement to waive such right of recovery, pro.
vided.
1. Such written contract or agreement was
a. Made prior to the "accident" or "loss" resulting in
the covered "bodily injury" or "property damage"
and
b. Was in effect at the time of the covered "bodily
injury' or "property damage".
2. The covered ".bodily injury' or"property damage'"
must arise out of the operations specked in such
written contract or agreement.
CL CA 01 49 02 15 Includes copyrighted material of Insurance Services
Office, Inc with its permission Page 5 of 5
e �
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
CONTRACTOR GENERAL LIABILITY PLATINUM ENDORSEMENT
This endorsement modifies insurance provided under the following
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A PROPERTY DAMAGE TO BORROWED EQUIPMENT
1. Paragraph 2.). of SECTION I - COVERAGES, COVERAGE A BODILY INJURY AND
PROPERTY DAMAGE LIABILITY is amended as follows,
Para..graphs (3) and (4) Of this exclusion do not apply to tools or equipment loaned to you,
provided they are not being used to perform operations at the time Of bus.
2. SECTION III—LIMITS OF INSURANCE is deleted and replaced by the following.
The most we will pay in any one 'occurrance' for 'property damage' to borrowed equipment is
$15,000 This limit of insurance is the most we will pay regardless Of the number of.
a. insureds,
b. Claims made or"suits" brought, or
c. Persons or organizations making claims or bringing 'suits"
3. Deductible
a• Our obligation to pay damages on behalf of the insured applies Only 10 the amount of
damages in excess of $250 as applicable to "property damage' as the result of any one
`occurrence' regardless of the number Of persons Or organizations who sustain damages
because of that'occurrence".
b. The terms of this insurance, including those with respect to our night and duty to defend the
insured against any 'suits' seeking those damages; and your duties in the event of an
.occurrence', claim, or"suit"apply irrespective of the application of the deductible amount-
c. We may pay any part or all of the deductible amount to effect settlement of any claim or suit
and, upon note of the action taken; you shall promptly reimburse us for such part of the
deductible amount as we have paid.
B, CONSTRUCTION PROJECT GENERAL AGGREGATE LIMIT
1, For all sums wilier, the insured becomes legally obligated to pay as damages Caused by
accidents Occurrences"
nder COVERAGE C (SECTION 1),ION which can beOr all medical attributed Only to ongoing
caused by
at a single construction project away from premises owned'by or rented to the insurred operations
a. A Single Construction Project. General Aggregate Limit applies to each Construction project
away from premises owned by or rented to the insured, and that limit is eq u
of the General Aggregate Limit shown in the Declarations, ual to the am nt
b. The Single Construction Project General Aggregate Limit is the most we wile pay for the cunt
of all damages under COVERAGE A, except damages because of'kxwe ilj par o 'property
hesum
damage' included in the `products-completed operations hazard", and for medical expenses
under COVERAGE C regardless of the number of,
(1) Insureds;
(2) Claims made or'suits' brought,or
(3) Persons or organizations making claims or bringing "suits'.
c. Any,payments Made under COVERAGE A for damages or under COVERAGE C for medical
expenses shall reduce the Single Construction Project General Aggregate Limit for that
construction project away from premises owned by or rented to the insured. Such payments
shall not reduce the General Aggregate Limit shown In the Declarations nor shall they reduce
any other Single Construction Project General Aggregate Limit for any other separate
Construction project away from promises Owned by or rented to the insured
CL CG 00 20 01 12 Includes copyrighted material of
Insurance ServicesPage 1 of 4
Office,Inc with Its permission
d, The bmils shown jr, the Declarations for Each Occurrence, Fire' Damage and Medical
Expense conloue to apply However, Instead Of being subject to the General Aggregate
Limit shown in the Declarations, such limits w j be Subject to the applicabie Single
Construction Project General Aggregate Limit
2. For all sums vmi& the insured becomes legally obligated to pay as damages caused by
"occurrences" under COVERAGE A (SECTION 1), and for all medical expenses caused by
accidents under COVERAGE C (SECTION 1) which cannot be attributed only to ongoing
operations at a SIR918 designated construction project away from promises owned by or rented to
"insured,
a. Any Payments made under COVERAGE A for damages or under COVERAGE C for medical
expenses shall reduce the amount available under the General Aggregate Limit or the
Products-Comptatsid Operations Aggregate Limit, whichever is applicable, and
i Such Payments shall not reduce any Single Construction Project General Aggregate Limit
1 When Coverage for habifty arising Out of the "products-completed operations hazard" is provided
any payments for damages because Of "bodily Injury or *Prop" damage, included in the
"products-completed operations hazard" will reduce tins Products-CompletedOperations
Aggregate Limit, and not reduce the General Aggregate Limit or the Single Ccnt General Aggregate Limit. struction proXt
4. If the 2PPhcable constructor Project away from premises ses Owned by or rented to the insured has
been abandoned, delayed, or abarld(inad and then restarted, or if the authorized contracting
parties deviate from� plans, blueprints, designs, specifications Of timetables, the Project vv[�Mjil be deemed to be trio same construction project,
5. The promions of Limits Of Insurance (SECTION 111) not otherwise modified by this
endorsement shall continue to apply as stipulated
C. LIMITED JOB SITE POLLUTION
1. Excosior f. Linder Section I— Coverage A is replaced by the following.
2. Exclusions
This insurance does not apply to:
f. Pollution
(1) *80di)y injury' or "property damage" arising out of the actual alleged or threatened
discharge, dispersal, seepage, Migration, release Or escape of I"pollutants,
(a) At or from any promises, site or location on Which any insured or any contractors
Of subcontractors corking direcil or indirectly an any insored's behalf are
performing Operations I the operations are to test for monitor,clean up, remove,
Contain, treat detoxify or neutralize, or in any way respond to or assess the
affects of, "pollutants"; or
(b) At or from a storage tank or other container, ducts or Piping which, is below or
PartaflY below the surface Of the ground or water or which,, at any time, has been
buried under the surface of the ground or water and then subsequently exposed
by erosion, excavation or any other means I the actual alt8jed Or threatened
discharge, dispersal, seepage migration,
release or escape of Pollutants' arises
at or from any promises, site�r Location which any insured or any contractors or
subcontractors workin? direct of indirectly or any isur9d's behaff are
"pollutants'"are brought or or Concha premises, site or
POhleirming operations i the
location in connector
subcontractor, with Such OPer2i by such insured, contractor of
Subparagraph (b) does not apply to *bodily injury" or 'Property damage" arising
out of heat, smoke or fumes from a *hostile fire'
(2) Any loss, cost Or expense arising Out of any
(a) Request, demand, order or statutory or regulatory requirement issued or made
pursuant to any environmental Protection or environmental inability statutes or
regulations that any insured test for, monitor, clean up, remove, contain, treat
dato*fy or neutralize, Of in any way respond to, or assess the effects of pollutants*;or
CL CG 00 20 01 12 Includes copyrighted material of Insurance Services Page 2 of 4
Offce, Inc mph its permission
I
(b) Claim or suit by on on behalf of a governmental authority for damages because of
testing for,monitoring, cleaning up, removing, containing. treating, detaxifytng,or
neutralizing or in any way responding to Of assessing the effects of, "pollutants".
However, this paragraph does not apply to Ilabodity for those Sums the Insured
becomes legally obligated to pay as damages because of"property damage' that the
insured would have in the absence of such request, demand, order ar Statutory or
r,dietary requirement, or such olalrn on "suit" by or on behalf of a governmental
authority,
2. With respect to "bodily injury' or "property damage" arising out of the actual, alleged or
threatened discharge,dispersal, seepage, migration, release or escape of"pollutants
a. The "Each Occurrence Limit"shown in the Dedarat'uns does not apply.
b. Paragraph 7. of Limits Of Insurance(Section III)does not apply.
c. Paragraph 1, of Section III—Limits Of Insurance is replaced by the following:
The Limits Of Insurance shown in this endorsement., or in the Declarations and the rules
below fix the most we will pay regardless of the number of,
(1) Insureds,
(2) Claims made or"suits"brought; or
(3) Persons or organizations making claims or bringing "suits
d. The following are added to Section III—Limits Of Insurance:
8. Subject la 2.or 3. above,whichever applies, the most we Nil pay for the sum of:
a. Damages under Coverage A; and
b. Medical expenses under Coverage C
because of "bodily arhury' or "property damage" arising out of the actual, alleged or
threatened discharge, dispersal, seepage, migration, release or escape of "pollutants is
$100,000 aggregate.
9. Subject to S.above,the Medical Expense limit is the most we will pay under Coverage C
for all medical expenses because of "looddly injury" Sustained by any one person arising
out of the actual, alleged or threatened discharge, dispersal, seepage, migration, release
or escape of'pollutants',
D. VOLUNTARY PROPERTY DAMAGE
1. The following is added to Section 1 — COVERAGES:
We will pay, at your request for'Property damage"to that part of any property
a. Which you or any subcontractors working directly or indirectly on your behalf are performing
operations, or
b. That must be restored, repaired or replaced because "your work" was incorrectly performed
on it
This insurance applies only to "property damage" to property of others while in your care,
incidental to your business
custody„ or control, and arising out of operations away from your insured premises and
Exclusions j.(3),(4),(5)and (6)do not apply to this coverage.
This insurance does not apply to "property damage" lnefuded within the "explosion hazard",
the 'collapse hazard"or the "Underground property damage haa:ard'".
2. For the purposes of the coverage provided by D. VOLUNTARY PROPERTY DAMAGE,
SECTION III—LIMITS OF INSURANCE is replaced by the following
A. Limits of Insurance
I. Unless a higher limit is shown in the Declarations, the most. we will pay in any one
`occurrence"for'property damage" under this endorsement)s$15,000.
2. Unless a higher limit is shown in the Declarations, the most we will pay for all covered
°oc mraences'during any one policy period is$15,000 Aggregate Limit of Insurance.
CL CG 00 20 01 12 Includes copyrighted material of Insurance Services
Office, Inc with Its Page 3 of 4
perantsslon
,r-1 r ..i
1"he Limits of insurance of this endorsement apply separately to each consecutive annual'
Period and to any remaining paricd of Jess than 12 months, starting with the beginning of the
pailcy period shown in the Deciarallons, unless the policy period is extended after issuance
for an additional period of less than 12 months. In that case. the additional penal will be
deemed pert of the last preceding period for Purposes of determrndng the Limits of Insurance.
3. Deductible
a. Our obligation to pay damages on behalf of the insured applies only to the amount of
damages In EXCESS of $250 es the result of any one "occurrence", regardless of the
number of persons or organizations who sustain damages because of that"cccurrence'.
b. T'he terms of this insurance, including those wtlttt respect to our right and duty to defend
he Insured against any"suits"seeking those damages, and your duties an the event of an
"occurrence", claims, or "suit" apply irrespective of the application of the deductible
amount.
c. We may pay any park or all of the deductible amount to affect settlement of any claim or
suit and, upon noCificataon of the action taken; h you shall promptly rainaburse us for suc
Part of the deductible amount as we have paid
4. For the purposes of the coverage provided by D. VOLUNTARY PROPERTY DAMAGE
SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows
a. The following is added to paragraph 2. Duties In The Event Of Occurrence, offense,
Claim or Suit
in the event of Moss covered by this endorsement, the insured shall, it requested by us,
replace the property or furnish the labor and mateoals necessary for repairs at actual cost
to the insured, excluding prespeotive profit or overhead charges of any nature. Any
property so paid for or replaced shall, at our option, become our Property. Any payment
made by us Shaul not constitute an admission of liability by an insured, or by us.
b. Paragraph 4. Other Insurance is amended as follows.
(1) Paragraph 4.a. Primary Insurance is deleted.
(2) Subparagraphs (1) and (2) of paragraph 4.b. Excess Insurance are deleted and
replaced with the following:
This insurance is excess over any of the other insurance, whether primary, excess,
contingent or on any other basis.
All other provisions that apply to paragraph 4. Other Insurance contained in the Commercial
General Liability Coverage Form are applicable.
5. For the purposes of the coverage provided by D. VOLUNTARY PROPERTY DAMAGE, the
following definitions are added to SECTION V— DEFINITIONS;
a. "Collapse hazard' includes 'structural property damage" and any resulting "property
damage" to any other property at any time.
b. "Explosion hazard" Includes "Property damage' ansing out of blasting or explosion. The
"expllosion hazard' does not include 'Property damage"arising out of the explosion of air
or steam vessels. piping under pressure, prime movers, machinery or power Iransmltting
equipment.
C. 'Structural property damage" means the collapse of or structural injury to any building or
structure due to:
(1) Grading of land, excavating, borrowing, filling, back-filling, tunneling, pile driving,
cofferdam work or Caisson work; or
(2) Moving, shoring, underpinning, raising or demolition of any building or structure or
removal or rebuilding of any structural support of that building or stricture.
d. "Underground property damage hazard" includes "underground property damage' and
any resulting 'property damage"to any other property at any time.
e. `Underground property damage" means `property damage' to conduits, pipes
,vnres ,
mains, sewers, tanks, tunnels, any similar property, and any apparatusused with them
beneath the surface of the ground or water, caused by and occurnng during the use of
mechanical equipment for the Purpose of grading land, paving, excavating, coifing,
borrowing, filling, back-filling or pile driving,
CL CG 00 20 01 12 Includes copyrighted material of Insurance Services
Office.Inc with Its permission Page 4 of 4
gwvAXP
COMMERCIAL GENERAL LIABILITY
CL CG 20 71 09 16
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES,
CONTRACTORS OR OTHERS - COMPLETED OPERATIONS
- AUTOMATIC STATUS, INCLUDING PRIMARY
ARY
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. SECTION It -WHO IS AN INSURED is amended
to include as an additional insured an n For Purposes of term
endorsement, throughout
or organization(s) when you are Obligated by the policy, the terms "You"and y the Named Insured shown in the OpeC Declarayour'refer tions
virtue of a written contract ar agreement that
such person or Organization(s) be added as an B. Exclusions
additional insured to,your policy
Such Person(s) or organizat+ons) is an additional With respect to the insurance afforded d these
insured only with respect to liability for "bodily exclusion vnsurads, the following additional
y exclusions apply to "bodily injury" and "property
njury" or ^property damage" or "personal and damage"arising out of
advertesing injury"caused. in whole or in part by 1. The rendering
(1) Acts or omissions of the Famed Insured, professional services b you or on ura to ranter any
either or both of or but only with respect to the
(2) The acts or omissions of those acting on following operations"
behalf of the Named Insured a. Providing engineering, architectural or
and included in the "products-completed surveying services to others in your
operations hazard. Capacity as an engineer, architect or
surveyor,and
This insurance applies only when you are required
to add the additional insured by virtue of a written b. Providing, or hiring Independent
contract or agreement, provided the contract or professionals to provide, engineering,
agreement is; architectural or surveying services In
ion
I. Currently in effect or becomes effective during pannect
perform,
with construction work you
the term of this policy; and �,
This exclusion applies even if the claims against
2. Was executed prior to the "bodily injury" or any Insured all
ege property damage" or "perso"nal and wrongdoing in the negligence su n i supervision, hp the
advertising injury" employment, training or monitoring of others by
However that insured„ if the "occurrence"which caused the
a. The insurance afforded to such add' bodilyinjury' or"property damage",ortheaffense
additional
which caused the `persona4 and advertising
insured only applies to the extent permitted by injury". involved the rendering of,
law; and or the failure to
render, any Professional architectural,engineering
b. If coverage provided to the additional insured or surveying services
is required by a, contract or agreement, the 2• subject to Paragraph 3. below, professional
insurance afforded to such additional insured services include:
wAl not be broader than that which you are
a. Preparing, approving, or to Prepare
required by the contract or agreement to
provide for such additional insured or approve„ maps, shop drawings,
opinions, reports, surveys, field orders„
change orders, or drawings and
CL CIS 20 71 09 16 specifications and
Includes copyrighted material of Insurance Services
Office, Inc., with its permission Page 1 of 2
b. Supervisory W clior) activities D. Other "'"�
Performed as Part of any raised Insurer.
architecturai or engineering activities Por purposes of this endorsement, the following is
3 added to the Section, IV - Commercial General
Professional Services do not include services Liability Conditions 4
within Construction Means Methods, , Other Insurance
techniques sequences and procedures Condition and supersedes any provision to the
employed by you or performed by or for the contrary
construction mareger its employees or its This insurance is excess of all other insurance
subcontractors in connection with your as to an additional insured whether on a
ongoing operations Primary, excess, contingent or any other basis
C. Limits of Insurance But, if required by a written contract or written
agreement to be Primary and noncontroutory,this
With respect to the insurance afforded to these insurance will be prima I
additional insureds, ry to and will not seek
the following is added to contribution from any insurance an which the
SOCtioni M -Limits Of Insurance additionaV insured is a Named Insured
If coverage provided to the additional insured is No other Coverage or limit in the policy applies to
required by a contract or agreement, the most we loss or damage insured by this coverage
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
Page 2 of 2 Includes copyrighted material of Insurance Services CL CG 20 71 09 16
Office, Inc , with its permission
GTy OF KE ..^ "+Jess Lcen sing
PoBox A 98
Seattle, WA 1 BL . )SSLICENSF NOTICE
2o-5955
KDwt7 (253)856_521a For Licensing Period
. . aaromerservice@Kenrwn q°� January 1, 2018 - December 31, 2018
)ate Due January 01, 2018 Amount Due $101.00
Check each box asappropriate: New Owner Business License No. BLOC-2171028
—� Kent Relocation J Out of Business
B USiNESS NAME- MAILING ADDRESS (revise below as needed)
LOCATION ADDRESS(IF DIFFERENT)
ALL AROUND FENCE COMPA-Ny
PO BOX 1029 ALL AROUND PENCE COt 4'ANY
R,AVENSDALE, WA 9SO51 14=23 16TH ST E
SUVINER, WA 98=90
]. Business Phone: 253.-863.4895
_._ .---...,...._.._..— ...,_...�_.�...__...._-, Email:
"adLra r,5n. P nM
2. BnS10e35 Ow'per5: Ilinew Owner lease check the 'Vew P Owoar"bae udove the mailing aUdr ess and afar to corer lettu f�(tame: RONALD 8 ROCHELLE DAGLEY oRna tion
Hm.Address: 29032 SE 226TH ST
Csry: MAPLE VALLEY State: WA
Hm Phone: 253-863-4895 Zip Code: 98038
3. Business and Occupation Tax Is Your business registered and filing City of Kent B&O tax?
Please enter your Estimated Annual Gross Receipts? S 0� oa7d NO
1330 tax registration is completed online at-Taxflle.KentWA.GOV^, �^More information can be found at"KentWA.GOVidoing-business(city.gxespB-O-tax"".
4. Emergency Contacts for Business located in Kent:
siffLJ _ �r� _.253-863-4895
. _ .._
Permit (Item 824J Tech Fee ICh njx �NilVll
(item 14?3) �p y � pp Pe"It tt �171028
Customer I(em 754( ) OII�N� Ila�l�l
Petmit lo: 195589
S. Description of Business: FENCE CONTRACTOR '
6. Employees at Kent Location as of 10/31l2017; Full Time: _j��
7, TRN#: Part Time:_ 8. UB[#: 604 100 765 _...�
9. SIC Code: 10. NAICS Code:
-- I Fluor Space Used: Ft
12. Mark if any of the following are on the premises: Ll Amusernm Devrces —1 . n,
Ganr6ling L Karao,FeiCahaet
I herah) certifl that the statements and infoncanon 'Pull Tabs,Punch 8oards,Card Rooms
Aatemenu and informatior furnished by me on this app(!;ca{ion are publicre appliaazion arc(me and COMPtete to the best ofmy knouledgs.I also acknowledge fiat the
a'Ox 260 uuTd'S and an,available nr Public inspection pursuant to Slare et Washington RCA,
Signature r
Data
not Name " ' Mail in the enclosed envelope with Check I
Money Order Payable ta; CITY OF KENT
lob Title ._PhoneIt—`
Email ... '�
Please make a copy of fhe COMPleded form for your records