Alameda City Council
March 15, 2022

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City of Alameda • California
Certification of Compliance
With the City of Alameda’s Vaccination Requirement
The City of Alameda (“City”) requires all individuals who perform work for the City to be fully vaccinatedi against COVID-19. All service providers and contractors for the City must sign the following statement certifying compliance with this requirement.

By signing below, I certify that all of our personnel who are performing work for the City are fully vaccinated against COVID-19. I also acknowledge that the City reserves the right to review any relevant records to demonstrate our compliance with this requirement.

I declare under penalty of perjury that the foregoing is true and correct.

Andrew M. Jordan Inc. DBA A&B Construction Date: ______________________ __________________________________
By: Rami El Khoury
Its Vice President

i For the purposes of this Certification of Compliance, an individual is considered to be fully vaccinated if two weeks have passed since their second dose in a 2-dose series (such as the Pfizer or Moderna vaccines) or if two weeks have passed since receiving their single-dose vaccine (such as Johnson & Johnson’s Janssen vaccine).

DocuSign Envelope ID: 1EFCF1D5-8CC4-4B2C-A6D8-F934B623A10B ______________
2/16/2022













































































































































































































































































































































































































































































































































































































































































































































































SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.

CANCELLATION
ACORD 28 (2016/03)
© 2003-2015 ACORD CORPORATION. All rights reserved.

NOYES
NOYES
If YES, LIMIT: DED:Subject to Different Provisions:

Subject to Different Provisions:

NAMED STORM INCL
DED:If YES, LIMIT:

If YES, LIMIT:

If YES, LIMIT:

If YES, LIMIT:

If YES, LIMIT:

If YES, LIMIT:

If YES, LIMIT:

RENTAL VALUE
N/A
FUNGUS EXCLUSION (If "YES", specify organization's form used)

LIMITED FUNGUS COVERAGE
$
EARTH MOVEMENT (If Applicable)

WIND / HAIL INCL

ORDINANCE OR LAW
EQUIPMENT BREAKDOWN (If Applicable)

COINSURANCE

AGREED VALUE

REPLACEMENT COST
DED:

IS DOMESTIC TERRORISM EXCLUDED?
IS THERE A TERRORISM-SPECIFIC EXCLUSION?
Attach Disclosure Notice / DECTERRORISM COVERAGE

BLANKET COVERAGE
YES NO

COVERAGE INFORMATION
FLOOD (If Applicable)

PERMISSION TO WAIVE SUBROGATION IN FAVOR OF MORTGAGE

HOLDER PRIOR TO LOSS
If YES, %
DED:

COMMERCIAL PROPERTY COVERAGE AMOUNT OF INSURANCE: DED:

PERILS INSURED BASIC BROAD SPECIAL
- Demolition Costs
- Incr. Cost of Construction
- Coverage for loss to undamaged portion of bldg
DED:

DED:

DED:

DED:

DED:

If YES, indicate value(s) reported on property identified above: $ BUSINESS INCOME If YES, LIMIT: Actual Loss Sustained; # of months:

If YES, LIMIT:

AUTHORIZED REPRESENTATIVE

ADDITIONAL INTEREST

NAME AND ADDRESS

LENDER SERVICING AGENT NAME AND ADDRESSCONTRACT OF SALE

MORTGAGEE

LENDER'S LOSS PAYABLE

LOCATION / DESCRIPTION
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTA NDING

ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EVIDENCE OF PROPERTY INSURANCE MAY

BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. (ACORD 101 may be attached if more space is required) BUILDING OR BUSINESS PERSONAL PROPERTY

THIS EVIDENCE OF COMMERCIAL PROPERTY INSURANCE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ADDITIONAL INTEREST NAMED BELOW. THIS EVIDENCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS EVIDENCE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE ADDITIONAL INTEREST.

ADDITIONAL NAMED INSURED(S)

NAMED INSURED AND ADDRESS
CODE:

AGENCY
CUSTOMER ID #:

SUB CODE:

E-MAIL
ADDRESS:
(A/C, No, Ext):

PHONE
FAX
(A/C, No):

PRODUCER NAME,

CONTACT PERSON AND ADDRESS

EXPIRATION DATEEFFECTIVE DATE
THIS REPLACES PRIOR EVIDENCE DATED:

TERMINATED IF CHECKED

CONTINUED UNTIL

IF MULTIPLE COMPANIES, COMPLETE SEPARATE FORM FOR EACH
COMPANY NAME AND ADDRESS NAIC NO:

POLICY TYPE

POLICY NUMBERLOAN NUMBER

EVIDENCE OF COMMERCIAL PROPERTY INSURANCE

DATE (MM/DD/YYYY)
The ACORD name and logo are registered marks of ACORD

PROPERTY INFORMATION

LOSS PAYEE
2/17/2022
408-973-9500 27960
Arthur J. Gallagher & Co. Insurance Brokers of CA., Inc. 160 West Santa Clara Street Suite 300
San Jose, CA 95113
License#: 0726293
408-257-2985
Illinois Union Insurance Company
303 W Erie St Ste 310
Chicago, IL 60654
Andrew M. Jordan dba A & B Construction, Inc.
1350 4th Street
Berkeley CA 94710
I11196226 001
03/15/2022 11/05/2023
2/16/2022
RE: Project No. 11-19-55 Alameda Point Adaptive Reuse Area Replacement Infrastructure Phase 1 and 2X $28,434,248 $10,000
X
X
X
X
X
X $150,000
X
X
X
X
X
X Incl
X $1,000,000
X $1,000,000
X $1,412,712
X $10,000,000
X X
X X
X
City of Alameda
Public Works
950 W Mall Square, Suite 110
Alameda, CA 94501































ACORD 101 (2008/01)
The ACORD name and logo are registered marks of ACORD
© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS
ADDITIONAL REMARKS SCHEDULE Page of
AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED
EFFECTIVE DATE:
11 Arthur J. Gallagher & Co. Insurance Brokers of CA., Inc.

I11196226 001
Andrew M. Jordan dba A & B Construction, Inc.
1350 4th Street
Berkeley CA 94710
Illinois Union Insurance Company 27960 03/15/2022
28 EVIDENCE OF COMMERCIAL PROPERTY INSURANCE
REMARKS:

Earth Movement - $1,412,712 Limit, Deductible 2.5% Min $100,000 Flood - $10,000,000Limit, Deductible 5% Min $500,000
Mortgagee/Loss Payee: City, its City Council, boards, commissions, officials, employees, agents and volunteers