HomeMy WebLinkAboutp21-22; Cerrification by Contractor_s Insurance BrokerCERTIFICATION BY CONTRACTOR'S INSURANCE BROKER
This Document Must be Fullv Executed By Contractor's
Insurance Broker and Submitted With the Bid
le
11-I 4KS- 66 VlLtl' 1/V)/ LUCS#— /NX�Aw�5- am an authorized representative of
(individual's name an rokerage name)
This company is the insurance broker
(Insurance Company)
for Flowline Contractors, Inc. ("Contractor")
(Contractor)
By my signature below, I hereby attest to the following:
1. I have reviewed the insurance requirements for the South Tahoe Public Utility
District's 2024 Herbert Walkup Pipeline Replacement Project ("Project"), including the
requirements set forth in Section 00 73 00, Supplementary Conditions, Part 2.01 of the Contract
Documents.
2. The Contractor is eligible to be insured for the policies necessary to satisfy the
insurance requirements for the Project.
This certification is not intended to be binding of coverage and does
terms and conditions of the insurance policies issued to Contractor.
Date:
for
(Sig
alter the
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California )
) ss.
County of r31GiC�E }
On ;2 Aefore me, Ure j" personally appeared
who prove to me on the basis of satisfactory evidence to be the
person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they
executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the
instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph
is true and correct.
IIWrl�
WITNESS m and and official seal. ALEXI8 LEWIS
COMM. / 2418497
NOTARY PUBLIC - CALIFORNIA
v... COUNIY OF SACRAMMM
o ary Pu is � coim rob SEP• 25 2025 l�
NOVMEBER 2023 SECTION 00 41 00
2024 HERBERT WALKUP PIPELINE REPLACEMENT PROJECT BID FORMS
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NOVMEBER 2023 SECTION 00 41 00
2024 HERBERT WALKUP PIPELINE REPLACEMENT PROJECT BID FORMS
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