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HomeMy WebLinkAboutVERIZON WIRELESS (LOS ANGELES SMSA LIMITED PARTNERSHIP) (19)City of Santa Ana - Clerk of the Council 5,P) VS AGREEMENT TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect. Note: If your agreement is grant related, please ensure that all grant retention requirements have been satisfied prior to signing the termination form. Is the agreement(s) a permanent record? Yes No is Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. COTC Office Use Oniv ANA CITY CLERK 14123 AM11:34 The agreement with lOS pINC^1f`IF$ SMSA llrllTrro Pft1ZtNFKtsltllo DIRIA V614UN N 112E1£SS No. A ^ 202o — ol4 iiii was completed on 262t and final payment has been made. (List all amendments. Use space below if needed.) Department: PhR - VF4 . FNh. Phone/Ext.: 014*w41— T+0.3 Signature: � T Ili Date: dcl. lei. IZ02-L !agreementoformemmin agreement termination form_goldenrod,doc DocwSign Envelope ID: 8311AFD8-49FF-4221-BC6C-8031B4B6B923 A'2020-0471/V ,Ja V ON f Il- L�tiO ^I,}'InrYPRO _tr) 1 � I iiflt IiV5U11PN(r fXPl�iiti Jfi CIC�)UNGil. ' SUPPLEMENT AGREEMENT Y Q� This Supplement ("Supplement'), is approved by Licensor this day ofoct 14, 2020 20_ (the date executed by all parties, referred herein as "Supplement Effective Date"), 1, Supplement. Licensee has submitted an application for approval to use a Municipal Facility pursuant to that certain Municipal Facility License Agreement between Licensor and Licensee dated August 12, 2020 ("Agreement'). Licensor has reviewed the application and grants approval subject to the terms of this Supplement. All of the terms and conditions of the Agreement are incorporated hereby by reference and made a part hereof without the necessity of repeating or attaching the Agreement. In the event of a contradiction, modification or inconsistency between the terms of the Agreement and this Supplement, the terms of this Supplement shall govern. Capitalized terms used in this Supplement shall have the same meaning described for them in the Agreement unless otherwise indicated herein. IF THE SUPPLEMENT IS NOT COUNTER- SIGNED BY LICENSEE AND RETURNED TO LICENSOR WITHIN 30 DAYS AFTER LICENSOR HAS GRANTED APPROVAL, THE SUPPLEMENT SHALL BE VOID AND OF NO LEGAL EFFECT. IF LICENSEE STILL WANTS TO USE THE MUNICIPAL FACILITY, LICENSEE WILL BE REQUIRED TO SUBMIT A NEW APPLICATION AND ASSOCIATED FEES. 2. Licensed Area Description and Location. Licensee shall have the right to use the space on the specific Municipal Facility (the "Licensed Area") depicted in Attachment I attached hereto to install Equipment as further listed in Attachment 2 attached hereto. 3. Equi ment. The Equipment to be installed at the Licensed Area is described and depicted in Attachment 1, 4. Term. The term of this Supplement shall commence on the Supplement Effective Date and continue for the life of the Agreement, as described in Paragraph 2 of the Agreement. 5, License Fee/Alternate License Fee. The initial fee for this Supplement shall be as follows per year: $270.00. This fee is subject to annual increase as provided in the Agreement, and is payable in accordance with the Agreement. 6. Performance Bond. The Performance Bond [circle one] is / is no covered by existing performance bond. If not covered by existing performance bond, a bon is required pursuant to Section 8 of the Agreement, Miscellaneous. [Signature page follows] A-1 DocuSign Envelope ID: 8311AFD8-49FF-4221-BC6C-8031B4B5B923 i A-2020-047VV IN WITNESS THEREOF, the parties hereto have caused this Supplement to be legally executed in duplicate, effective upon execution by both parties. Accepted: Licensor: CITY OF SANTA ANA, CA Name: Nabil Saba Title: Executive Director Public Works Agency Date: 09/14/2020 Licensee: By: Nam— Title: sr. manager - Real Estate Date: Oct 14, 2 220 Attachments: Attachment 1 — Licensed Area (STHCST 368) Attachment 2 — Equipment List and Description A-2 DocuSign Enyelope ID: 8311AFD8-49FF-4221-BC6C-8931B4B5B923 Attachment 1 Licensed Area [Map showing licensed area of applicable Municipal Facility and showing proposed Equipment installation.] A-3 Ooeu Sign Envelope ID: 8311AFD8-49FF-4221-BC6G-8031B4B5B923 cu N N d m h 4 a m i N — 0 N C) I J E m W C O O -a Q O V .N 1L' In w • rc G w G • I ' i I � I .1a�aaa��e 0 X Go CN N M • nco n <� Er u) r- 0 — M � M cn e•a u i • • I T C , R�u�.r a aw t; • __ s _ ter' � �?+�` �4 • L�_1 s; Do uSign, Envelope ID: 8311AFD8-49FF-4221-BC6C-8031B4B5B923 1 verizonl/ Attachment 2 Equipment List: • (1) 27' Galvanized Steel Streetlight with Faux Concrete Finnish • (1) 48" Tri-Sector Antenna Shuoud • (1) 12" Architectural Transition Shroud • (3) Panel Antennas inounted within the 48" Tri-Sector Antenna Shroud M rranane ri. Francine R. Villareal Date: 2020.09.02 Villareal ,0:18:53 -0T00' "✓ CERTIFICATE OF LIABILITY INSURANCE OATEW3112020Y Y) 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 endomement(s). PRODUCER Ann Risk services Northeast, Inc. NV Office oNewne LYorkiberty One Liberty , Plaza Broadway, Suite 3201 CONTACT NAME: PHONE (866) 283-7122 IE-MAIL.E#): DVC No): (800) 363-0105 E-MAIL ADDRESS: New New York NV 10006 USA INSURER(S) AFFORDING COVERAGE NAIC W INSURED Los Angeles SNSA LP dba Verizon wireless INSURER A: National Union Fire Ins CO of Pittsburgh 19445 INSURER B: AIU Insurance Company 19399 INSURER C: American Home Assurance Co. 19380 1095 Avenue of the Americas New York NY 10036 USA INSURER D: New Hampshire Insurance company 23841 INSURER E: INSURER F: 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. Limits shown are as requested INSR TYPE OF INSURANCE bush L POLICY LTR INSD WVD POUCYNUMBER MMIDDM'YY MMIDDMlYY LIMITS A X COMMERCIALGENERALUABILITY CLAIMS -MADE ❑X OCCUR y y GL EACHOCCURRENCE $2,000,000 A E D PREMISES Ea occurrence $2, 000, 000 X MED EXP (Any one person) $10.000 XCU Coverage is Included PERSONAL& ADV INJURY $2,000,000 GEMLAGGREGATE LIMITAPPLIES PER: ❑ PR ❑ % POLICY JECT LOC GENERALAGGREGATE $510001000 PRODUCTS -COMPIOPAGG $5,000,000 OTHER' A AUTOMOBILE LIABILITY CA 4594298 ADS 06/30/202D 06/30/2021 COMBINED SINGLE LIMIT IEa accitlenf $1,000,000 BODILY INJURY (Per person) A X ANYAUTO CA 4594299 06/30/2020 06/30/2021 A OWNED SCHEDULED AUTOS ONLY AUTOS HIREDAUTOS NON -OWNED ONLY AUTOS ONLY MA CA 4594300 VA 06/30/2020 06/30/2021 BODILY INJURY (Per accitlenq PROPERTY DAMAGE Per accident A See Next Page 06/30/2020 06/30/2021 UMBREI.LALIAB OCCUR EACH OCCURRENCE EXCESS LIAB Cl-AIMS-MADE AGGREGATE DED RETENTION B C WORKERS COMPENSATION AND EMPLOYERSLIABILITY YIN ANY PROPRIETOR/ PARTNERI EXECUTIVE OFFICERIVEMBER EXCLUDED? ❑ (Mandatoryin NH) If yes, describe under NIA WC045886576 ADS WC045886575 CA 06/30/2020 06/30/20201 06/30/2021 06/30/20Z1 X PER STATUTE OTH- EL EACHACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 DESCRIPTION OF OPERATIONS belaw E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached d more space is required) The above -referenced General Liability policy shall cover the tart liability of the Certificate Holder assumed under the underlying agreement between parties for which the certificate has been issued. City of Santa Ana, its council members, officers and employees are included as Additional Insured with respect to the General Liability policy. The General Liability policy shall apply as Primary and Non -Contributory Insurance to each Additional insured listed herein. where permitted by law, the Named Insured parties listed herein waive all rights against City of Santa Ana, its council members, officers and employees listed herein for recovery of damages to the extent these damages are covered by the above referenced General Liability policy and, as further limited by written contract between the parties. CERTIFICATE HOLDER CANCELLATION =ii City of Santa Ana Risk Management Division 20 Civic Center Plaza, 4th Floor Santa Ana CA 92701 USA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE i el . rwaragemo¢ urwswr ©1988-2015 ACORD CO REVIEWED& APPROVED Sr. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD lit® ® Kek ManTgerlent Analyst ENDORSEMENT This endorsement, effective 12:01 AM. 06/30/2020 forms a part of Policy No. GL 172-88-90 issued to VERIZON COMMUNICATIONS INC. BY NATIONAL UNION FIRE INSURANCE COMPANY OFPITTSBURGH. PA THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LIMITED ADVICE OF CANCELLATION PROVIDED VIA E-MAIL TO ENTITIES OTHER THAN THE FIRST NAMED INSURED This policy is amended as follows: In the event that the Insurer cancels this policy for any reason other than non-payment of premium, and 1. the cancellation effective date is prior to this policy's expiration date; 2. the First Named Insured is under an existing contractual obligation to notify a certificate holder when this policy is canceled (hereinafter, the "Certificate Holder(s)") and has provided to the Insurer, either directly orthrough its broker of record, the email address of a contact at each such entity; and 3. the Insurer received this information afterthe First Named Insured receives notice of cancellation of this policy and prior to this policy's cancellation effective date, via an electronic spreadsheet that Is acceptable to the Insurer, the Insurer will provide advice of cancellation (the "Advice") via e-mail to each such Certificate Holders within 30 days after the First Named Insured provides such information to the Insurer, provided, however, that if a specific number of days is not stated above, then the Advice will be provided to such Certificate Holder(s) as soon as reasonably practicable afterthe First Named Insured provides such information to the Insurer. Proof of the Insurer emailfngthe Advice, usingthe information provided by the First Named Insured, will serve as proof that the Insurer has fully satisfied its obligations under this endorsement. This endorsement does not affect, in any way, coverage provided underthis policy or the cancellation of this policy or the effective date thereof, nor shall this endorsement invest any rights in any entity not insured under this policy. The following Definitions appty to this endorsement: 1. First Named Insured means the Named Insured shown on the Declarations Page of this policy. 2. Insurer means the insurance company shown in the header on the Declarations page of this policy. All other terms, conditions and exclusions shall remain the same. Aut orize epresentative or Countersignature (in States Where Applicable) 107414 (03/11) rsEvRIAM DMisim Rtsk Management Malys[ ENDORSEMENT # This endorsement, effective 12:01 A.M. 6/30/2020 forms a part of Policy No. CA 459-42-98 issued to VERIZON COMMUNICATIONS INC. By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LIMITED ADVICE OF CANCELLATION PROVIDED VIA E-MAIL TO ENTITIES OTHER THAN THE FIRST NAMED INSURED This policy is amended as follows: In the event that the Insurer cancels this policy for any reason other than non-payment of premium, and 1. the cancellation effective date is prior to this policy's expiration date; 2. the First Named Insured is under an existing contractual obligation to notify a certificate holder when this policy is canceled (hereinafter, the "Certificate Holders)") and has provided to the Insurer, either directly or through its broker of record, the email address of a contact at each such entity; and 3. the Insurer received this information after the First Named Insured receives notice of cancellation of this policy and prior to this policy's cancellation effective date, via an electronic spreadsheet that is acceptable to the Insurer, the Insurer will provide advice of cancellation (the "Advice") via e-mail to each such Certificate Holders within 30 days after the First Named Insured provides such information to the Insurer; provided, however, that if a specific number of days is not stated above, then the Advice will be provided to such Certificate Holder(s) as soon as reasonably practicable after the First Named Insured provides such information to the Insurer. Proof of the Insurer emailing the Advice, using the information provided by the First Named Insured, will serve as proof that the Insurer has fully satisfied its obligations under this endorsement. This endorsement does not affect, in any way, coverage provided under this policy or the cancellation of this policy or the effective date thereof, nor shall this endorsement invest any rights in any entity not insured under this policy. The following Definitions apply to this endorsement: 1. First Named Insured means the Named Insured shown on the Declarations Page of this policy. 2. Insurer means the insurance company shown in the header on the Declarations page of this policy. All other terms, conditions and exclusions shall remain the same. / Authorized R 107414 (03/11) Risk M.&"nad DMim �m w6 APPROVE] Or ® R¢tMm,'gert,ent nnayst ' THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ` This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following " attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 06/30/2020 forms a part of Policy No. WC 0458-86-576 Issued to VERIZON COMMUNICATIONS INC. By NEW HAMPSHIRE INSURANCE COMPANY LIMITED ADVICE OF CANCELLATION PROVIDED VIA E-MAIL TO ENTITIES OTHER THAN THE NAMED INSURED (WORKERS' COMPENSATION ONLY) This policy is amended as follows: In the event that the Insurer cancels this policy for any reason other than non-payment of premium, and 1. the cancellation effective date is prior to this policy' s expiration date; the Named Insured or, if applicable, any other employers named in Item 1 of the Information Page is under an existing contractual obligation to notify a certificate holder when this policy is canceled (hereinafter, the " Certificate Holder(s)" ) and the Named Insured has provided to the Insurer, either directly or through its broker of record, the email address of a contact at each such entity; and 3. the Insurer received this information after the Named Insured receives notice of cancellation of this policy and prior to this policy's cancellation effective date, via an electronic spreadsheet that is acceptable to the Insurer, the Insurer will provide advice of cancellation (the " Advice" ) via e-mail to each such Certificate Holders within 30 days after the Named Insured provides such information to the Insurer; provided, however, that if a specific number of days is not stated above, then the Advice will be provided to such Certificate Holder(s) as soon as reasonably practicable after the Named Insured provides such information to the Insurer. Proof of the Insurer emailing the Advice, using the information provided by the First Named Insured, will serve as proof that the Insurer has fully satisfied its obligations under this endorsement. This endorsement does not affect, in any way, coverage provided under this policy or the cancellation of this policy or the effective date thereof, nor shall this endorsement invest any rights in any entity not insured under this policy. The following definitions apply to this endorsement: Named Insured means the insured first named employer in Item 1 of the Information Page of this policy. 2. Insurer means the insurance company shown in the header on the Information Page of this policy. All other terms, conditions and exclusions shall remain the same. Diviaum WC 0 0 99 56 rtV 11 v f+�«c:k � Vet♦ (Ed. 9 M9k Managernent Analyst