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Home My WebLink AboutGALAXY PARTY RENTALSCity of Santa Ana �Pt Clerk of the Cou, 'I AGREEMENT TERMINATION FORM Please complete this form in its entirety when the attached agreement and all 1 amendments (if any) are no longer in effect. 2020 FBI® -6 PM 4: 23 Note: If your agreement is grant related, please ensure that all grant retention requirements 1 have been satisfied prior to signing the termination form. CITY � F S A N TA A h A Is the agreement(s)apermanent record? Yes _ No CLERK OF COUNCIL Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. The agreement with N-2018-160-01 No. was completed on (List all amendments. Use space below if needed.) Revised: 10-1 & 16 and final payment has been made. Department: QR�C A Phone/Ext.: Q Signature:`! Date: Lad INSURANCE ON FILE N-2018.160-01 1'=,K MAY PROOEE7 UNTIL. IN. t1RANCE EXPIRES c� N OI'0 ,I� MAR 1 1 2019 i)ATE. FIRST AMENI)bTENT I"O AGREEMENT �VITI3 GALAZY PAR`T`Y RENTALS O`. Q�C,S RV's S�W�. C. 'ITIS FIRST AMENUMEN"I' Ccr the above -referenced agrecI nt is entered into on February 27, 2019, by and between Galaxy Party Rentals {"Consultant"), and the City of Santa Ana, a charter city and municipal corporation organized and existing under the Constitution and laws of the State of California ("City"). RECITALS A. The parties entered into an Agreement No. N -20I8-160 dated August 1, 2013 to provide rental equipment for special events held by the Parks, Recreation and Community Services Agency ("Agreement"). I3. The parties wish to amend the Agreement to add a comprehensive list of party rental equipment for the City to choose from for events. The previous list of party recital equipment did not include some items such as canopies, which are often needed for various barks, Recreation and Community Services Agency events. The Parties therefore agree: 1. Section 1, SCOPE OF SERVICES, Exhibit A, is replaced with Exhibit A-1. 2. Except as modified by this First Amendment, all terns and conditions of the Agreement shall remain in fall force and effect. IN WITNESS WHEREOF, the parties hereto have executed this First Amendment to the Agreement on the date and year first written above. ATTEST 1-5 , rv1 A NORMA MITRE Acting Clerk of the Council v APPROVED AS TO FORM SONIA R. CARVALHO City Attorney LAURA A. ROSS Senior Assistant City Attorney CITY OF SANTA ANA iTEVEkMEN OZA Acting City Manager CONSULTANT ROBERTO ZAVAL Owner of Galaxy Party Rentals Pap 1 of RECOMMENDED FOR APPROVAL LISA,VD OFF Execut e Director, Parks, Recreation and Community Services Agency [First Amendment -Agreement with Galaxy Party Rentals] Page 2 of 3 EXHIBIT A-1 Revised Scope of Services Page 3 of 3 SIZE (In Feet') PRICE 10x14 .................. I....... ,,,. $75,00 10x20.... .......................... I..... I.... .. $150,00 1000 ........................................... $225.00 10x40........................................... $300.00 10x50 ........................................... $375.00 10x60 ............... I... .....,... $450.00 10x70........................................ $525.00 15x15 ................................ I.... $135.00 15x20........................................... $180.00 1500 ..... .............................. I..... .. $270.00 15x40..... ...... ............ ....... I........ I... $360.00 15x50........................................... $450.00 15x60........................................... $540.00 1500 ...I....................................... $630.00 20x20 ........ ......................... .,.. $200.00 2000 ...„...................................... $295.00 20x40............. I........... ._... I........ I... $395.00 20x50 .................................. $500.00 20x60 ............ .................... I...... ... $600.00 2000 ........................................... $705.00 20x80 .... ....... I.............................. $805.00 20x90........................................... $910.00 Galaxy Party Rentals Canopy Prig (January 2019) 3000 ........................................... $440.00 30x40 .......................................... $585.00 30x50 ... ..... ........... I ...... ................. $735.00 30x60 ........................................... $880.00 3000 ... I ..................... $1030.00 30x80........................................... $1270.00 30x90...................................... $1320.00 40x40 ........................................... $750.00 40x50....................................... $940.00 40x60 ................................... $1125.00 40x70............I .............................. $1315.00 40x80... ...................... .......... I....... $1500.00 4000 ........................................... $1690.00 40x100 ..................................... $1880.00 Standard Samsonite White............... ................................... .85 Fanback White ................................................ 1.35 Children Purple/Reclaue.................................... 1,25 White................................................. 125 Calk Vienna White................................................ 1.50 Caf6 Bistro Black................................................. 1.50 Plastic Resin w/ Padded Seat White................................................ 2.50 Black................................................ 2.50 Wood Resin w/ Padded Seat Fruitwood ........................................... 2.75 Natural.............................................. 2.75 Chiavari (cushion included) White................................................ 4.75 Mahogany............................... ......... 4.75 Gold................................................. 4.75 Silver................................................ 4.75 Barstool (Natural Wood) ............................. 4.00 Barstool (Swivel Seat/Black) .................. 6.00 Rectangular COO" (Seats 8) ................................... 6.50 Adjustable height 6'x30" .............................. 7,00 8'x30"(Seats 10) .................................. 8.00 Round 48" Diameter (Seats 6-8) ........................ 7.00 60" Diameter (Seats 8-10) ....................... 8,00 72" Diameter (Seats 10-12) .................... 10.00 Cocktail 36" Diameter ..................................... 9.00 (Available 4130" or 40" fieiahts) Specialty 6'x18" Conferenee/Classroom .................... 9.50 8'x18" Confcrence/Classroom .................. 10.50 *Serpentine (8ft).................................... 12.50 *Serpentine Riser (811) .............................. 10.00 Serpentine Bar w/ Drapes (811) ..............— 75.00 60" Round Moon ................................... 10.50 Polyester (Solid Colors) Napkins 20"x20" .................................... .65 Galaxy Party Rentals 11787 Cardinal Circle, Garden Grove, CA 92843 www.gal axypartyrent,i.com 90" Diameter (Round) ................... 9.50 102" Diameter (Round) ......................... 11.00 108" Diameter (Round) ......................... 12.50 120" Diameter (Round) ......................... 14.50 132" Diameter (Round) ...............-....... 17.50 60"x120" (Rectangular) .......................... 9.00 40" Square (Overlay) ............................. 7.25 54" Square (Overlay) ............................. 7.25 60" Square (Overlay) ......... I ................... 7.25 88"x130" (6ft Table Drape) .................... 14.00 88"x156" (BttTable Drape) .................... 15.00 Cocktail Spandex Cover 36"x 42" ............. 16.00 Table Runner 18"xt08" (1 Sin x 9ft) .....,...... 3.50 Chair Cover (Samsonite) ......................... 3.00 ChairSash .......................................... 1.00 Skirt Drapes / 60 Round Skirt Drape. . ................... -... 10.50 13.5' Table Skirt w/ Velcro Clips .............. 18.0( 88"x 130" Oft) Skirt Drape .................... 22.00 88"x156" (8ft) Skirt Drape ..................... 25.00 Satin .55 Napkins 20"x20" .................................. 1.20 90" Diameter (Round) ........................... 19.00 l08" Diameter (Round) ......................... 20.00 120" Diameter (Round) ......................... 25.00 132„ Diameter (Round) ......................... 27.00 60"x120" (Rectangular) ............................ 20.00 88"x130" (6ft fable Drape) .................... 23.00 88"x 156" (8 ft Table Drape) .................... 27.00 60" Square (Overlay) ........................... 11_00 ,Glassware Champagne Flute (6oz) ............................... .65 Water Goblet (8oz)....................................55 Wine Glass (12oz)............................................ .65 Avalon 10" Dinner Plate ..................................... .65 7" Plate ............................................... .60 6" Plate .............................................. .55 Gold Rim 10" Dinner Plate ..................................... .70 7" Plate ........ .............. ........................ , .65 6" Plate ............................................... .65 Charger Gold or Silver .............................. . ......... 1.00 Fanfare............................................... .50 Avalon................................................ 55 Galaxy Party Rentals 11787 Cardinal Circle, Garden Grove, CA 92843 www.galaxyparty,ents.com Chafing Dish w/ Burners (I Compartment) ... 20.00 Chafing Dish w/ Burners (2 Compartments).. 25.00 Deluxe Chafing Dish w/ Burners (I Corry)-. 30.O0 40 -Cup (8 oz.) Coffee Maker ..................... 17.00 Beverage Tub (Red Plastic) ...................... 4.00 Ice Chest (I20gt)................................ . 18.00 Ice Chest (150gt)................................. 22.00 Champagne Bucket ................................ 5.00 CaZos (Stainless Steel) (Top Diameter x Depth x Bottom Diameter) 26 Yz" x 13" x 18" ............................... 30.00 23 'h" x 15" x 17" ............................... 35.00 30" x 13" x 2 .................................... 35.00 Cazo Burners 15.00 14.5"Diameter................. ................. I5.00 19.5" Diameter,. 15.00 23" Diameter ..................................... 15.00 Double Griddle (w/ 5 Gal Propane Tank,).... 65.00 5 Gallon Propane Tank ......................... 25,00 Dance floor Oak Parquet (3'x3' Sections) 9x9................................................. 96.75 9x12 ............................................... 129.00 12x12 ............................................. 172.00 12x15 ............................................. 215.00 15x15 ............................................. 263.75 Additional Section ............................... 10.75 Astro Turf Green (sq. ft.) ........................................ .40 Black (sq. ft.) ......................................... .40 Carpet Runners Iced Carpet 3' x 25', ....... .......... 75.00 Red Carpet 3'x 50' ............................... t20.00 Staging 40 Section (6in-2H High) ...................... 25.00 4x4 Section (Over 211) ........................... 30.00 Stage Step (6" High) ................................ 15.00 Stage Stairs (2' High) W/O Handrail ..... ,..... 25.00 Stage Stairs (2" High) W/ Handrail ............ 30.00 Stage Stairs (3' High) W/ Handrail ............... 65.00 Stage Skirts (I'-2' High) Per Foot .............. 1.50 Stage Skins (30"-3 High) Per Foot ....... ---- 2.00 Galaxy Party Rentals 11737 Cardinal Circle, Garden Grave, CA 92343 www. galaxyp artyrents.com *:N *Safety Rail (4') 12.00 ***Diagonal Bracing 12.00 Stage Stairs W/ Cat -pet and Handrail (2' 1-1) ... 65.00 Stage Stairs W/ Carpet and Handrail (3' H) ... 95.00 Stage Ramp Set (I' High)--- ..................... 95.00 Stage Ramp Set (2' High) ............................ 215.00 Stage Ramp Set (3' High) ............................. 350.00 *** Safety Rails required for stages 30" high and over *** Diagonal Bracing repaired for steges 30" high twd over U t ,t ` U' o Divider Free Standing Drapery: Adjustable Height (6'-10') and Adjustable Length (6'-I0') ................ 40.00 Steel Barricade 7' (Bike Rack) ................. 20.00 Roman Colonnade (9 Pieces) ................. 175.00 Roman Column (4') ............................. 17.00 Raman Column (6') ............................. 27.00 White Balustrade (4') ................................... 25.00 Patio Umbrella ................................... 15.00 Umbrella Base .... ................................. 5.00 Te per lureControl 8' Sunglo Patio Heater 70.00 Forced Air Heater (80,000 BTU) 85.00 Forced Air Heater W/ Duct and Diffuser ..... 125.00 18" Industrial Floor Fan ........................ 30.00 Par Can 38 ......... 20.00 ParCan 56 ........................................ 25.00 Pole Lights w/ 3 Par Can 38 .................... 50.00 Pole lights w/ 3 Par Can 56 .................... 65.00 String Lighting w/ installation (Per Foot) ....... 1,50 Canopy Accessories Solid Sidewall 8' High (per foot) ............... 1.50 Window Sidewall 8' High (per foot) .......... 2.00 Food Mesh Sidewall (per foot) 2.5C High Bay Light ................................... 50.00 Fire Extinguisher (8 lb,) .......................... 15.00 "No Smoking" Sign .............................. 2.00 Lighted "Exit" Sign .............................. 25.00 Water Barrel (50 Gallon) ........................ 12.00 Steel Weight (90 LBS) ...................................... 5.00 Popcorn Machine (w/ 50 People hit) .......... 65.00 Popcorn Machine (Machine Only) ............ 50.00 Additional Popcorn Kit (50 People) .......... 20.00 Cotton Candy Machine (w/ 50 People Kit) ... 65.00 Cotton Candy Machine (Machine Only) ....... 50.00 Additional Cotton Candy Kit (50 People) ... 20.00 Galaxy Party Rentals 11787 Cardinal Chicle, Garden Grove, CA 92843 www. gataxvp utyreiits.com Snow Cone Machine (w/ 100 People Kit) ... 65.00 Snow Cone Machine (Machine Only) ........ 50.00 Additional Snow Cone Kit (50 People) ....... 20.00 Pretzel Warmer .................................. 35.00 Trash Bins w/ Liner (32 Gallons) ............... 7.50 Generator 45amps (Quiet) ..................... 300.00 Mahogany Lectern/Podium .... .................... ..... 20.00 1 Dozen Balloons (Latex) ................................ 15.00 Labor Charles Chair Set -Up and Take Down (per chair).. ..... . 35 Cable Tic Chairs (Customer Provide `Cies).......25 Table Set -Up and Take Down (per Table) ... .....75 Linen Set -Up and Take Down (Per Cloth)...... 1.10 r�Io Sed-L)t nf'Nr�pkirrs** Galaxy Party Rentals 11787 Cardinal Circle, Garden Grove, CA 92843 www.galaxypattyrents.co m d CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD YY) 2/13/2019 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: lithe certificate holder Is an ADDITIONAL INSURED, the policy(les) must 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 Ileu of such endorsement(s). PRODUCER A J INSURANCE 1000 Macarthur Blvd #66 Santa Ana, CA 92707 OP57419 NTA T PHONE 714 673-5549 AI 5"N°I AIL a inatlrance ive.com INSURERS) AFFORDING COVERAGE_ NAICY MESA UNDERWRITERS SPECIALTY INS. 36838 INSURED GALAXY PARTY RENTALS f �_� (., �/�n �' ZAVALA, ROBERTO AND EUGENIO PEREZ 11787 CARDINAL CIR GARDEN GROVE, CA 92843 INSURER B INSURER—• _• SURERD-i INSURER E. GCIVFRA(;FS r]GRTIFIr1ATR MI IftmPP- DRVlclnnt aaTnawcR• 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 CONTRACTOR 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 MAV HAVE BEEN REDUCED BYPAID CLAIMS. LTR TYPEOFINSURANCE ISR YWD POLICYNUMBER IV IL Y P LIMITS GENERAL LIABILITY EACH OCCURRENCES Z ,,,000 000 X COMMERCIAL GENERAL LIABILITY UAWQIE+.x nen�8 S 100,000 CLAIMS -MADE El OCCUR MED EXP An one a,aenya 5.000 A X LIED: $500 MR0004014000837 09/26/1809/26/19 PERSONAL &ADV INJURY s 1,000,000 GENERAL AGGREGATE s 2,000,000 GEN'LAGGREQATELIMITAPPLIES PER: PRODUCTS. OMP/ PAGG a 24000,000 X P PRO S AUTOMOeaEUABILITr L L $ ( Per person) S ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS (Paraccldenq $ HIREDAUTOS NON -OWNED AUTOS PROPERTYDAMAGEs FAGGREGA S UMBRELLA UAS OCCUR B NOs S EXCESS IIAB CLAIMS -MADE WORKERS COMPENSATIONT AND EMPLOYERS LIABIUTY ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA X OR . E.L.EACH ACCIDENT S E.L. DISEASE. EA EMPI,OVE $ (Mandatory in NH) R es, dePT Untl&' E -P V CONTENTS: A PROPERTY MP0004014000837 09/26/1809/26/1 $250,0000 DED: $1,000 DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (AtWoh ACORO 101,AddilWnal Remares Scbedule,if mmspaoe istaquired) PARTY RENTAL STORE: ,,LL City of Santa Ana, its officers, agents and employees are named as addit\,\ �iN$ d. Cit Of Santa Ana Public Libras SHOULD ANY OF THE ABOVE D meED Pw?,IQS'BE CANCELLED BEFORE Y y HE EXPIRATION DATE TH ", NOTIDE WILL W DELIVERED IN 26 Civic Center Plaza ACCORDANCE WITH THE POLICYPROVISIONS. Santa Ana, CA 92701 / AUTHORIZED REPRESENTAFI' / y ,✓'F I 9 1988-20 " / }� 'eserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD PO ♦P ADDITIONAL INSURED ENDORSEMENT Insurance Company MESA UNDERWRITERS SPECIALTY INS. This 04dU 14 U 0 Gt flg2 ifies such insurance as is offered by the provisions of Policy Number: relating to the following: 1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; it officers, employees, agents and representative are named as additional Insureds ("additional insureds') with regard to liability and defense of suits arising from the operations and uses performed by or on behalf of the named insured. 2. With respect to claims arising out of the operations and uses performed by or on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds. 3. This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or organization as an insured shall not affect any right which such person or organization would have as a claimant if not so included. 4. With respect the additional insureds, this insurance shall not be cancelled, or materially reduced in coverage or limits except after thirty (30) days written notice has been given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701. (ComPletion of the following, including countersignature, is required to make this endorsement effective.) Effective n / i / , this endorsement form part of ,A • I 1 1 W, WA Issued to (Name Insured) GALAXY PARTY RENTAL 0 Countersigned by ti,_p tt• ACC: bF VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE DATE(MWDD"YM 02113/2019 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. This form Is used to report coverages provided to a single Specific vehicle or equipment. Do not use this form to report liability coverage provided to multiple vehicles under a single policy. Use ACORD 25 for that purpose. PRODUCER StateFarm Sarieh Devereaux-BamentosH(AI A. State Farm Agent 1202 W let StOF3324 ° °T Sarlah Devereaux , EMI: 714-541-7280 .714384-3892 L o sar45417280.co PR OF33249 Santa Ana CA 92703 INSURER ($) AFFORDING COVERAGE NAIC E wsuafiq NSU E . State Farm Mutual Automobile Insurance Company 25178 Roberto Zoveia Cardenas & Crlatine Zavala Reyes DBA Galaxy Party Rentals I Su RB: wsURE R p__ 14132 Kerry St GARDEN GROVE CA 92844 _ I SURER D INSURER E: YEAR MAKE I MANUFACTURER MODfit BDDV TYPE VEHICLE IDENTIFICATION NUMBER 1994 GMC 3500 Box Truck 1GDKC34N9RJ519011 DESCRIPTION VEHICLEIEQUIPMENTVALUE EERIALNUMBER X VEHICLE UA8ILIIY UUVENA1JI=N CFRTIFICATE NIIMRFR! REV!S!0H m9meCD. THIS IS TO CERTIFY THAT THE POLICY(IES) OF INSURANCE LISTED BELOW HA$1HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD($) 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 POLICY(IES) DESCRIBED HEREIN ISIARE SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). Mom LTR INaRo j% TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE DATE(MWDDIYyY'n POU"UPIRATION DATE(MWDDIYYYY) LIMITS X VEHICLE UA8ILIIY COMBINED SINGLE LIMIT S 1,000,000 BODILY INJURY (Per parer) S A 1957791-F12.75B 02113/2019 12112/2019 BODILY INJURY (Per ■curtent) $ PROPERTYDAMAGE S GENERAL LIAsiLrrY EACH OPOURENCE $ OCCURRENCE GENERAL AGGREGATE S CLAIMS MADE Med Pay S 5,000 ILIMNSR LTR LOb AYr TYPE OF INSURANCE POLICY NUMBER POUCYEFFECTNE DATE (aMR1D1YYYYi POLJICY DATEMXPVMTION DATE (YWDD/riYY) LIMITS IDEDUCTIBLE VEH COLLISION LOSS (]. ACV ❑AGREED AMT $ UMIT 11[3 STATEDAMT 6 DED VEHCOMP VEH OTC I] ACV ❑ AQREEOAMT Y LIMIT ❑ ❑ STATED ANT S DED EQUIPMENT BASIC BROAD SPECIAL ❑ ACV ❑ AGREED AMT ® RC 13 STATED AMT ❑ i UMIT S DED REMARKS (INCLUDWGSPECW. CONDITIONS I OTHER COVERAGES) (AftaO AGORD 101, AddIUOMI Ranladre ECMdurs, )f Mals split M required) Comprehensive deductible: 100; Collision deductible: 500; Uninsured motorist protection: 250,0001500,000 a\I'�•y aolapt orn or tho rollooring: TMaddY i InWatditaibedbatty Hes been added to Supolry(he)IIetW heHen by PdkynMloer(s). A t)1m DeeDaub ID, add MS eddilbnel MHV*) deMdbad beb lO the PoIcy(ias VMICLEIEQUIPMtwrwfmw.. I (LEASED I IFDUNCE) NAME AND ADORES, OF ADDITIONAL W M93T F� CITY OF SANTA ANA 20 CIVIC CENTER PLAZA SANTA ANA CA 92701 N — SHOULD ANY OF THE ABOVE BEFORE THE EXPIRATION OA DELIVERED IN ACCORDANCE ADWTK)NALINSURED LENDER'S LOSS PAYER N/LEASENUMBER ACORD 23 (2010/03) The ACORD name and logo ars registered marks of ACORD 'Y looeas) uaMts m-ae•aole WOMERS' COMPENSATION DECLARATION I Roberto Zavala hereby affirm under penalty of perjury, the (Nanerrtlle) following declaration: I certify on behalf of Cialany PggtyReg4als that during the term of my (C0nSU1Mn0CMPMy Now) contract for Santa Ana Public Uhra-rx services with the City of Santa Ana, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions and provide proof of workers' compensation coverage. DATE: By: Name: Roberto Zavala Title: Co-GWner Telephone: 714-569-1638 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.