Page 81 - _ 180314 Special Yucaipa GSA Packet

San Bernardino County
Flood Control Operations Division – Permit Section
825 East Third Street, Room 108
San Bernardino, CA 92415-0835
(909) 387-7995 – FAX (909) 387-1858

CERTIFICATE OF INSURANCE

NOTE TO PERMITTEE: This form shall be completed by your insurance company. Mail completed
form to San Bernardino County Flood Control District, Flood Control Permit Section, 825 East Third
Street, San Bernardino, CA 92415-0835.

In accordance with permit requirements, the undersigned does hereby represent to the San
Bernardino County Flood Control District and the County of San Bernardino the following policy or
policies to fully complies with the following
(name of insured)
Flood Control District insurance requirements.

 PUBLIC LIABLITY AND PROPERTY DAMAGE – The limits of liability in the Public Liability and
Property Damage policy or policies shall not be less than $1,000,000 combined single limit.

Type of Insurance Company & Policy No. Exp. Date Limits of Liability

 ENDORSEMENT NAMING ADDITIONAL INSURED – Both San Bernardino County Flood
Control District AND County of San Bernardino are hereby named as additional insured for the
purpose of Permit No. P- inclusion herein of any person or organization as an
additional insured shall not affect any right which such person or organization would have as a
claimant if not so included.

This insurance shall be primary insurance with respects to the San Bernardino County Flood
Control District and County of San Bernardino.

 30-DAY WRITTEN NOTICE OF CANCELLATION, 10-DAY FOR NON-PAYMENT - Policy shall
state that 30-days prior written notice of cancellation, change or expiration and 10-days for
non-payment shall be given to the San Bernardino County Flood Control District, Flood Control
Permit Section, 825 East Third Street, San Bernardino, CA 92415-0835.

Insurance Company:

By:
Insurance Company Authorized Agent (Signature) Date

Agent’s Address: Agent’s Phone:

Permit No.
File
Rev. 6/11
Yucaipa Groundwater Sustainability Agency - March 14, 2018 - Page 77 of 226