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HomeMy WebLinkAbout6671 DocuSign Envelope ID:3D28E1AB-5994-4F9D-AFB6-F750092CD019 Portable Restroom Services Funding Reimbursement Memorandum of Understanding The City of Bremerton ("City") and Gather Together Grow Together ("G2G2"), a non- profit corporation in the state of Washington at: 419 Park Avenue Bremerton, WA 98337-1426, referred to collectively as the "Parties," agree to enter into the following Memorandum of Understanding for reimbursement of Homeless Encampment Health and Sanitation services: L Scope: G2G2 provided the following service for the benefit of the City: Placement, maintenance and removal of portable toilets at, 819 Dr. Martin Luther King, Jr. Way, Bremerton, Washington. The City's role in this Agreement is only reimbursement of expenses for services provided of three thousand, two hundred and forty-eight dollars and zero cents, $3,248.00. The City has no interest, control, or liability regarding the agreements between G2G2 and third parties. IL Term: The City and the G2G2 agree that the placement, maintenance, and removal of public toilets took place prior to execution of this Agreement and without direction or oversight from the City. By execution of this agreement and reimbursement for services provided, the City is not required nor does the City agree to reimburse additional, future, or continuing services. III. Compensation: In consideration of the services provided by G2G2, the City shall pay G2G2 $3,248.00. G2G2 has submitted billing statements totaling$3,248.00 detailing the services for which G2G2 has contracted and the amount paid for the deployment and removal of portable toilets at 819 Dr. Martin Luther King, Jr. Way. IV. Relationship of Parties: G2G2 represents that it is skilled in the matters addressed in the scope of this agreement and has performed and is performing independent functions and responsibilities within its field of expertise. G2G2 and its personnel are independent entities and not employees of the City. G2G2 and its personnel have no authority to bind the City or to control the City's employees and other consultants. None of the benefits provided by the City to its employees, including, but not limited to, compensation, insurance, and unemployment insurance are available from the City to the employees, agents, representatives, or sub-consultants of G2G2. G2G2 will be solely and entirely responsible for its acts and for the acts of G2G2's agents, employees, representatives and sub-G2G2contractors during the performance of this Agreement. As an independent entity, G2G2 is responsible for its own management. The City's administration and enforcement of this Memorandum of Understanding shall not be deemed an exercise of managerial control over G2G2 or its personnel. As an independent entity, G2G2 is responsible for payment of all taxes and licensing fees necessary to perform its obligations under this Agreement. Page 1 of 4 DocuSign Envelope ID:3D28E1AB-5994-4F9D-AFB6-F750092CD019 V. Indemnification: A. G2G2 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 performance of this Memorandum of Understanding. IT IS FURTHER SPECIFICALLY AND EXPRESSLY UNDERSTOOD THAT THE INDEMNIFICATION PROVIDED HEREIN CONSTITUTES G2G2'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. The provisions of this section shall survive the expiration or termination of this Memorandum of Understanding. VI. Insurance: G2G2 procured and maintained for the full duration of the Services provided and resulting Agreement, insurance against claims for any injuries to persons or damage to property or property values which may arise from or in connection with the performance of the work hereunder by G2G2, its agents, representatives, employees, or sub-contractors. Before reimbursement described in this Agreement, G2G2 shall provide a Certificate of Insurance evidencing: 1. Commercial General Liability insurance written on an occurrence basis with limits no less than $1,000,000 combined single limit per occurrence and general aggregate for personal injury, bodily injury and property damage. Coverage shall include but not be limited to: blanket contractual; products/completed operations/broad form property damage; explosion, collapse and underground (XCU) if applicable; and 2. Workers Compensation insurance as statutorily required by the Industrial Insurance Act of the State of Washington, Title 51, Revised Code of Washington and employer's liability with limits not less than $1,000,000. VII. General Conditions: A. Work Performed at G2G2's Risk: G2G2 is responsible for the safety of its employees, agents, and sub-G2G2s in the performance of the work hereunder and utilizing all protection necessary for that purpose. All work was at G2G2's own risk, and G2G2 is responsible for any loss of or damage to materials, tools, or other articles used or held for use in connection with the work. Page 2 of 4 DocuSign Envelope ID:3D28E1AB-5994-4F9D-AFB6-F750092CD019 B. Entire Agreement: This Agreement is the entire agreement between the Parties, and the Parties acknowledge that there are no other agreements, written or oral,that have not been set forth in the text of this Agreement. C. Severability: Should any part of this Agreement be found void, the balance of the Agreement shall remain in full force and effect. D. Modification: This Agreement may only be modified by written instrument signed by both Parties. E. Written Notices: All communications regarding this Agreement shall be sent to the parties at the addresses listed below by registered or 1st class mail, or by personal service, 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. Notices to be sent to: Notices to be sent to: CITY: G2G2: Attn: Melinda Monroe Attn: Marwan Cameron City of Bremerton Gather Together Grow Together 345 6th Street, Suite 100 419 Park Avenue, Bremerton, WA 98337-1891 Bremerton, WA 98337 F. Waiver: Failure to enforce any provision of this Agreement shall not be deemed a waiver of that provision. Waiver of any right or power arising out of this Agreement shall not be deemed waiver of any other right or power. G. Non-Waiver of Breach: The failure of the City to insist upon strict performance of any of the covenants and agreements contained herein, or to exercise any option herein conferred in one or more instances shall not be construed to be a waiver or relinquishment of said covenants, agreements or options, and the same shall be and remain in full force and effect. H. Compliance with Laws: G2G2 shall comply with all applicable Federal, State, and local laws in performing its obligations under this Agreement. L Choice of Law and Venue: This Agreement shall be interpreted according to the laws of the State of Washington. Any judicial action to resolve disputes arising out of this Agreement shall be brought in Kitsap County Superior Court. J. Attorneys' Fees: In the event of litigation to enforce any of the terms or provisions herein, each party shall pay all its own costs and attorney's fees. K. Assignment: Any assignment of this agreement by the Contractor without the written consent of the City shall be void. Page 3 of 4 DocuSign Envelope ID:3D28E1AB-5994-4F9D-AFB6-F750092CD019 VIII. Nondiscrimination: G2G2 shall not discriminate in employment or services to the public on the basis of race, color, national origin, sex, religion, age, marital status, disability, or sexual orientation except for employment actions based on bona fide occupational qualification. IN WITNESS WHEREOF, the parties below have executed this Agreement. CITY: G2G2: CITY OF BREMERTON GATHER TOGETHER GROW TOGETHER DocuSigned by: DocuSigned by: ji#V4y aLekeA, howttv, (Amt,ratA, By: BAF4cuuoEzsE7 y' 7614E FC�� i arwan Cameron Print Name: �' eg wheeler Print Name: Its: Mayor Its: Executive Director Date: 4/3/2024 Date: 4/3/2024 APPROVED AS TO FORM: ATTEST: DocuSigned by: DocuSigned by: By: Novux B D6F6 00582b4A1... Y k~ 24E[6EME45C4-1-F... Kylie J. Finnell, Bremerton City Attorney Angela Hoover, City Clerk Page 4 of 4 DocuSign Envelope ID:3D28E1AB-5994-4F9D-AFB6-F750092CD019 Exhibit Summary of Scope of Work and associated costs G2g2 Portable Restroom Reimbursement Invoice no. Description date of service Amount 1 Monica Caps Parking stall rental 09/01/23 300.00 1 Monica Caps Parking stall rental 10/01/23 300.00 1 Monica Caps Parking stall rental 11/01/23 300.00 200139195 DTG Recycle Portable Restroom rental 10/12/23 734.30 200145342 DTG Recycle Portable Restroom rental 11/09/23 734.30 8807 Moran's Portable Restrooms Inc.-on call cleani 09/05/23 250.00 200133083 DTG Recycle Portable Restroom rental 09/14/23 629.40 Total Estimate Cost 3,248.00 DocuSign Envelope ID:3D28E1AB-5994-4F9D-AFB6-F750092CD019 From:The Conduit<marwancameron@gmail.com> B 2 Sent:Saturday,September 23,2023 12:08 PM To:City Council <City.Council@ci.bremerton.wa.us>; Greg Wheeler <Greg.Wheeler@ci.bremerton.wa.us>; Legal <Legal@ci.bremerton.wa.us> Subject: Porta Potty Invoice Bremerton City Council Mayor City Attorney 345 6th Street, Suite 600 Bremerton, WA 98337 Subject: Reimbursement and Continued Support for Porta Potties on MLK Dear Members of the Bremerton City Council, Mayor, City Attorney I hope this letter finds you in good health and high spirits. I am writing to you today on behalf of Gather Together Grow Together, Rock the Block, and in collaboration with several other dedicated entities and individuals who have worked to address a pressing issue within our community. Firstly, I would like to express our gratitude for your attendance and support at the Gather Together Grow Together Pancake Breakfast held on October 26, 2022. Your presence was greatly appreciated, and it demonstrated your commitment to our community's welfare. The event served as a catalyst for positive change, bringing together various stakeholders, including Councilman Coughlin, the Foundation for Homeless and Poverty Management, the Lived Experience Coalition, Salvation Army, Living Life Leadership, PCHS, KPHD, Resilient Ecosystems, G2 Housing, Bailey Tupai, KCR, BHA, Kitsap County(Kirsten Jewell), the HEART Program, Surviving Change, NW Hospitality, Food not Bombs, and many others. If you wish to revisit the event, you can watch the video here: Pancake Breakfast Workgroug. During this event, the City Council took decisive action by earmarking $10,000 for the installation of porta potties on Martin Luther King Jr. Way(MLK). This allocation was a significant step toward addressing the pressing needs of our unhoused neighbors and enhancing public health and sanitation in the area. However, as you are aware, the journey to establish these porta potties faced numerous challenges and delays. It was only on August 31st, 2023, that G2 Housing successfully delivered and installed the porta potties on MLK, thanks in part to the collaboration and efforts of Rock the Block and other dedicated partners. I am pleased to report that since their installation, the porta potties have been in operation without incident. Providing a porta potty for the homeless benefits both the unhoused individuals and the broader community in several ways. Firstly, it enhances the dignity and well-being of homeless individuals by offering them access to a clean and safe restroom facility, helping to maintain their basic hygiene and health. Moreover, businesses, homeowners, and renters benefit as well, as it reduces the likelihood of public urination and defecation in public spaces, which can otherwise lead to unpleasant and unsanitary conditions. This, in turn, helps maintain property values and preserves the quality of life for residents and business owners alike. DocuSign Envelope ID:3D28E1AB-5994-4F9D-AFB6-F750092CD019 For children in the community, having accessible porta potties contributes to a cleaner and more hygienic environment, reducing potential exposure to health hazards. It also presents a valuable opportunity for parents to teach their children about empathy, compassion, and community engagement by emphasizing the importance of helping those less fortunate. In essence, providing porta potties for the homeless is a win-win solution that promotes the well- being and dignity of the unhoused while fostering a healthier, more harmonious community for all its members. At present, the expenses associated with this initiative amount to $1,604.40 until October 10, 2023, with subsequent monthly costs estimated at$929.40 monthly. Enclosed with this letter, you will find the relevant expense documents for your review and consideration. We kindly request that the Bremerton City Council honor the original intention of the $10,000 allocation by reimbursing the current expenses and committing to cover future costs until the allocated funds are exhausted. Furthermore, we seek your commitment to sustaining this essential service for our unhoused neighbors beyond the initial funding period. By taking responsibility for the porta potties on MLK, you would not only fulfill the intended purpose of the funds but also demonstrate your dedication to improving the lives of those in our community who are most vulnerable. We eagerly await your response and look forward to working collaboratively with you to ensure that this vital service continues. Together, we can make a lasting and positive impact on the lives of our fellow residents who rely on this service daily. Thank you for your attention to this matter, and please do not hesitate to reach out if you require any further information or clarification. Respectfully, Marwan Cameron Executive Director, Gather Together Grow Together Rock the Block Member Marwan Cameron Executive Director gather2grow@g2g2.org g2g2.org marwancameron@gmail.com 360-990-6387 cell (text preferred) Website:theconduitnetwork.org Cashapp: $TheConduitMC Paypal: marwancameron Venmo: marwancameron 501c3 Tax Id 82 4275 446 ye as GatM1erTogethe� MONNNT DocuSign Envelope ID:3D28E1AB-5994-4F9D-AFB6-F750092CD019 DTG Recycle Invoice P.O.Box 14203 Recycle Mill Creek, WA 98082 Customer Focused I Planet Obsessed (425) 549-3000 Marawan Cameron Document# 200133083 Marawan Cameron 821 TOILET Account# ACC8491 821 Doctor Martin Luther King Way Bremerton,Washington 98337 Terms 30 Days Net Invoice of Date 9/14/2023 Due date 10/14/2023 Service Description-Portable Restrooms QTY RATE Price Service Site:Marawan Cameron 821 TOILET(ACC8491 -8539CP1) 821 Doctor Martin Luther King Way Bremerton,Washington 98337 CO Standard-Two Times Per Week- Rent/Advance Service 9/13/2023 To 10/10/2023 2 300.00 PS-Rental 600.00 Order Number:OR47351 Subtotal of Job#Rental 600.00 Marawan Cameron 821 TOILET Subtotal 600.00 excluding taxes and surcharges Invoice Totals Payments to: Subtotal 600.00 DTG Recycle P.O. Box 14203 F.I.C. 29.40 Mill Creek,WA 98082 Current Charges 629.40 Current Outstanding Balance 629.40 - - — -G (Please cut along the line and return with your payment) Payments To: DTG Recycle P.O.Box 14203 Mill Creek,WA 98082 Customer Number: ACC8491 Invoice Number: 200133083 Invoice Total: 629.40 Invoice Address: Marawan Cameron Balance Due: 629.40 Marawan Cameron 821 TOILET 821 Doctor Martin Luther King Way,Bremerton Remitted Kitsap County,Washington 98337 Check#: DOC#200133083 Page 1 of 1 ACC8491 DocuSign Envelope ID:3D28E1AB-5994-4F9D-AFB6-F750092CD019 VAN% DTG Recycle Invoice P.O.Box 14203 Recycle Mill Creek, WA 98082 Customer Focused I Planet Obsessed (425) 549-3000 Marawan Cameron Document# 200145342 Marawan Cameron 821 TOILET Account# ACC8491 821 Doctor Martin Luther King Way Bremerton, Washington 98337 Terms Immediate Net Invoice of Date 11/9/2023 Due date 11/9/2023 Service Description-Portable Restrooms QTY RATE Price Service Site: Marawan Cameron 821 TOILET(ACC8491 -8539CP1) 821 Doctor Martin Luther King Way Bremerton,Washington 98337 CO Standard-Three Times Per Week- Rent/Advance Service 11/8/2023 To 12/5/2023 2 350.00 PS-Rental 700.00 Order Number:OR47351 Subtotal of Job#Rental 700.00 Marawan Cameron 821 TOILET Subtotal 700.00 excluding taxes and surcharges Invoice Totals Payments to: Subtotal 700.00 DTG Recycle P.O. Box 14203 F.I.C. 34.30 Mill Creek, WA 98082 Current Charges 734.30 Current Outstanding Balance 734.30 Prepaid by Credit Card - - - -< (Please cut along the line and return with your payment) Payments To: DTG Recycle P.O.Box 14203 Mill Creek,WA 98082 Customer Number: ACC8491 Invoice Number: 200145342 Invoice Total: 734.30 Invoice Address: Marawan Cameron Balance Due: 734.30 Marawan Cameron 821 TOILET 821 Doctor Martin Luther King Way, Bremerton Remitted Kitsap County,Washington 98337 Check#: DOC#200145342 Page 1 of 1 ACC8491 DocuSign Envelope ID:3D28E1AB-5994-4F9D-AFB6-F750092CD019 VAN% DTG Recycle Invoice P.O.Box 14203 Recycle Mill Creek, WA 98082 Customer Focused I Planet Obsessed (425) 549-3000 Marawan Cameron Document# 200139195 Marawan Cameron 821 TOILET Account# ACC8491 821 Doctor Martin Luther King Way Bremerton, Washington 98337 Terms Immediate Net Invoice of Date 10/12/2023 Due date 10/12/2023 Service Description-Portable Restrooms QTY RATE Price Service Site: Marawan Cameron 821 TOILET(ACC8491 -8539CP1) 821 Doctor Martin Luther King Way Bremerton,Washington 98337 CO Standard-Three Times Per Week- Rent/Advance Service 10/11/2023 To 11/7/2023 2 350.00 PS-Rental 700.00 Order Number:OR47351 Subtotal of Job#Rental 700.00 Marawan Cameron 821 TOILET Subtotal 700.00 excluding taxes and surcharges Invoice Totals Payments to: Subtotal 700.00 DTG Recycle P.O. Box 14203 F.I.C. 34.30 Mill Creek, WA 98082 Current Charges 734.30 Current Outstanding Balance 734.30 Prepaid by Credit Card - - - -< (Please cut along the line and return with your payment) Payments To: DTG Recycle P.O.Box 14203 Mill Creek,WA 98082 Customer Number: ACC8491 Invoice Number: 200139195 Invoice Total: 734.30 Invoice Address: Marawan Cameron Balance Due: 734.30 Marawan Cameron 821 TOILET 821 Doctor Martin Luther King Way, Bremerton Remitted Kitsap County,Washington 98337 Check#: DOC#200139195 Page 1 of 1 ACC8491 DocuSign Envelope ID:3D28E1AB-5994-4F9D-AFB6-F750092CD019 Moran's Portable Restrooms Inc Invoice P. O. Box 1883 Date Invoice# Poulsbo, WA 98370 9/5/2023 8807 360-994-9544 moransportablerestr �::,•mail.com Bill To +. Ship To Marwan Cameron L 8521 Dr Martin Luther King Way 419 Park Ave Bremerton Bremerton, WA 98337 P.O. No. Terms Due Date Upon Receipt 9/5/2023 Description Quantity Rate Amount Customer Owned Unit - On-Call Cleaning 2 100.00 1 200.00 Off-Route Fee 1 50.00 50.00 DAMAGE WAIVER DECLINATION AGREEMENT If you wish to decline coverage at this time.Please sign on the line below,deduct the coverage Total $250.00 charge from you bill&mail a copy of the invoice with your payment. By signing below and deducting the fee;you are agreeing to take full responsibility for the unit(s)that you have rented. Payments/Credits -$250.00 -I wish to decline coverage at this time. Balance Due $o.00 DocuSign Envelope ID:3D28E1AB-5994-4F9D-AFB6-F750092CD019 _- ------- -- -- L r O 4__ // , YY\ LI Oq . moNfoC � C 1 . 132cinC;k7Cta • W A • US RC--C_LkNJL 0 3bo _° a V , CK4* -C�o_. pF110.. �= ) c SP 1 t2(� i r-} c- o 4- - ors � � ! 1,,- y� , ; , , t S H 0-s 4,...) ("- L.Dk C_ &C USL 0 a2 TM , of 1 p o RZ P o r- CE-S 1 o S E p__Q C C. 7---1-t )4'0 Nnn L L. - 5A- / Orfi-,-- 04: 7 0 0 -' ' Yfr..5 . . S __ - (2zE ‘ Je- 0 2 Ocr /VOu Za .�Gam '/ , 2. (Z- - ia c=L O ff' S v Game. <._--r--- sp 0-1-- 1 , , 1 --- i-- 36c9 - a 7) - 15 3 ) _ P . D . 13.0x g. o l,-) ci1?3 ' 1 � DATE(MM/DD/YYYY) ACOREP CERTIFICATE OF LIABILITY INSURANCE 04/04/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Tracy King-Krech Chambers Bay Insurance LLC PHO No,Ext): 360-385-0501 FAX,No): 360-639-3312 Expanded Insurance Solutions A DRIESS: tking-krech@chambersbayins.com 7017 27th ST W STE INSURER(S)AFFORDING COVERAGE NAIC# University Place WA 98466 INSURER A: Philadelphia Insurance Company 18058 INSURED INSURER B: Gather Together Grown Together INSURER C: 419 Park Ave INSURER D: INSURER E: Bremerton Wti 98337 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSD VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PHPK2551950 05/05/2023 05/05/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY JECT PRO- LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE PHUB863012 05/05/2023 05/05/2024 AGGREGATE $ 1,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Gather Together Grown Together,419 Park Ave,Bremerton,WA 98337 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Bremerton ACCORDANCE WITH THE POLICY PROVISIONS. 345 6th Street AUTHORIZED REPRESENTATIVE Bremerton WA 98337 / a C�,`� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:3D28E1AB-5994-4F9D-AFB6-F750092CD019 POLICY CHANGE DOCUMENT POLICY NO.: PHPK2551950 Philadelphia Indemnity Insurance Company 126523 Chambers Bay Insurance, LLC NAMED INSURED Gather Together Grow Together MAILING ADDRESS 419 Park Ave Bremerton, WA 98337-1426 POLICY PERIOD: FROM 05/03/2023 TO 05/03/2024 at 12:01 A.M. Standard Time at your mailing address shown above. CHANGE EFFECTIVE 08/15/2023 CHANGE # 3 REVISION # 3 DESCRIPTION In consideration of the premium reflected, the policy is amended as indicated below: Added location(s) to all impacted coverage lines: Location 2 building 1, 818 6th St, Bremerton, WA 98337 GL Class Code: 49452 - Vacant Land - NFP Premium basis of 1 acre Per attached Path ID 16873351 Total Annual Total Prorate Additional/Return Premium$ 1.00 Additional/Return Premium$ 1.00 ADDITIONAL ADDITIONAL COUNTERSIGNED BY (Date) (Authorized Representative) 09/06/2023 Issue Date Insurance Policy Page 1 of 1 DocuSign Envelope ID:3D28E1AB-5994-4F9D-AFB6-F750092CD019 PI-LOC-SCH(08/20) Philadelphia Indemnity Insurance Company Locations Schedule Policy Number: PHPK2551950 Prems. Bldg. No. No. Address 0001 ALL 419 Park Ave Bremerton, WA 98337-1426 0002 0001 818 6th St Bremerton, WA 98337-1441 PI-LOC-SCH (08/20) Page 1 of 1 DocuSign Envelope ID:3D28E1AB-5994-4F9D-AFB6-F750092CD019 rniiaaeipnia inaemnity insurance Company COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL SCHEDULE Policy Number: PHPK2551950 Agent# 126523 Rates Advance Premiums Premium Prem./ Prod./ Prem./ Prod./ Classifications Code No. Basis Ops. Comp.Ops. Ops. Comp.Ops. WA PREM NO. 001 CLUB-CIVIC-BLDG OWN/LEASE-FP 41667 745 165.878 INCL 125 INCL AREA PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 001 SALES/SERVICE ORGANIZATION 47367 71,200 0.893 INCL 65 INCL PAYROLL PROD/COMP OP SUBJ TO GEN AGG LIMIT WA PREM NO. 002 VACANT LAND-NFP 49452 1 2.094 INCL 3 INCL ACRE PROD/COMP OP SUBJ TO GEN AGG LIMIT WA LIABILITY DELUXE 44444 INCL BALANCE TO MEET PREMCOPS SUBLINE MINIMUM 44444 89