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HomeMy WebLinkAboutMARTINEZ, ADRIANA (3)0City of Santa Ana COTC Office Use Only '� t Clerk of the Council 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TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect.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 Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. The agreement with Mm fh rga j 1 kl no, - No. N-2019-214-02 was completed on U and final payment has been made. (List all amendments. Use space below if needed.) _ I Department: �� IThis 3oil L�� Phone/Ext.: ' %5 p{ 5355 Signature: T�+A QU nUk—) Date: Q Z1 itagreementsfermsform- agreement termination form goldenrod. doe INSURANCE ON FILE WORK MAY PROCEED N-2019-214-02 MAY 0 g 2021 UNTIL INSURANCE EXPIRES CpA tD) (iYh1Y11.23DATE: OFEUCOND AMENDMENT TO ARTS AND CULTURE ARTIST GRANT PROGRAM AGREEMENT THIS SECOND AMENDMENT TO ARTS AND CULTURE ARTIST GRANT PROGRAM AGREEMENT is made and entered into this 17th day of March, 2021, by and between 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"), and Adriana Martinez ("Grantee'). RECITALS A. City and Grantee entered into Arts and Culture Artist Grant Program Agreement number N-2019-214, dated August 20, 2019, for the purpose of providing grant funding pursuant to the Investing in the Artist Grant Program ("said Agreement'). B. In accordance with the terms and conditions of said Agreement, the parties desire to amend Section 1 — Term, to extend said Agreement until June 30, 2022. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions of said Agreement, except as herein modified, the parties agree as follows: 1. Section 1, Term, shall be amended to read as follows: "This Agreement shall commence on the date first written above and terminate on June 30, 2022, unless terminated earlier in accordance with this Agreement. The term of this Agreement may be extended upon a writing executed by the City Manager and the City Attorney." 2. Except as hereinabove modified, all terms and conditions of said Agreement shall remain in full force and effect. Page t of 2 N-2019-214-02 IN WITNESS WHEREOF, the Parties have executed this Second Amendment to Arts and Culture Artist Grant Program Agreement the date and year first above written. ATTEST: DAISY GOMEZ Clerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By: Ryan O. Hodge Assistant City Attorney RECOMMENDED FOR APPROVAL: STE ENN AMENDOZA Executive Director Community Development Agency CITY OF SANTA ANA KRISTINE RIDGE City Manager GRANTEE: Adana Artist 1'agc 2 of 2 Francine K. Villareal Villareal n.fe, omr na r n n., AM ,acoizo® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) F 1 03/26/2021 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(les) 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 endorsements). PRODUCER Statil Eddie Quillares Jr. State Farm Insurance A.415 N. Broadway Santa Ana, Ca 92701 CONTACT Eddie Quillares Jr. NAME: PHONEs. 714-617-7150 A/c Na 714-617-7158 nDDRESS: Eddie@EddieQinsurance.com INSURERS) AFFORDING COVERAGE NAIC # INSURERA: State Farm Fire and Casualty Company 25143 INSURED INSURER B : INSURER C : Adrlana Yazmin Martinez 548 Colston Ave INSURER D : La Puente, CA 91744 INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER: 75-0450 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 LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDD/YYYV LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS MADE I OCCUR DAMAGE RENTED PREMISESS ( Ea occurrence) $ 300,000 MED EXP (Any one person) $ 5,000 Loss of Income X Deductible$500 PERSONAL B ADV INJURY $ 300,000 B Y Y 92-G8-B485-3 03/26/2021 03/26/2022 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2.000,000 POLICY ❑ PRO - POLICY ❑ LOG PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident ( ) $ HIRED NON -OWNED AUTOS ONLY AUTOSONLY PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DEO RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICERIMEMBER EXCLUDED? NIA IPER OTH- STATUTE I I ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Additional Insured: The City of San Ana, 20 Civic Center Place Santa Ana, Califorrnia 92701; Its officers, employees, agents and volunteers are named as additional Insureds. Certificate of Insurance shall provide thirty (30) day prior written notice of cancellation. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS. Risk Management Division AUTHORIZED REPRESENTATIVE 20 Civic Center Plaza, 4th P Santa Ana, CA 92702 / ,� Risk MamagemenEDiviaiart e� f\ REVIEWED&APPROVED BY. © 1988.2015 ACORD C ACORD 25 2016103 The ACORD name and logo are registered marks of ACORD ( ) 9 9 ------ Risk Management Analyst Exhibit B ADDITIONAL INSURED ENDORSEMENT FOR COMMERCIAL GENERAL LIABILITY POLICY Insurance Company: State Farm Insurance This endorsement modifies such insurance as is afforded by the provisions of Policy Number: 92-G8-B485-3 relating to the following: 1) The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California, 92701; its officers, agents, and employees are to be named as "additional insured" with regard to liability and defense of suits arising from 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 to contributing with any other insurance carried by or for the benefit of the additional insured. 3) This insurance applies separately to each insured against whom claim is or suit is brought except with respect to the company's limit of liability. This inclusion of any person or organization as an insured shall not affect any right which is such person or organization would have as claimant if not so included. 4) With respect to the additional insured, this insurance shall not be cancelled, or materially reduced in coverage or limits except after thirty (30) written notice has been given to The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California, 92701. Effective January 01, 2021 this endorsement form as a part of Policy Number: 92-G8-B485-3. Issued to Adriana Yazmin Martinez. K Countersigned by g� g Authorized Representative Rtelc Management Division MR—UNWOMMOR R�nevr:o &'Mt,+tItovm B�r�dd. 14, Risk Management Analyst To Whom it May Concern, will not be using a vehicle (Any Auto Or Owned, Hired Autos, Non -Owned Autos) for activities related to my artist grant project. The term of my agreement is from January 20, 2021 to June 30, 2022. March 23, 2021 Adriana Martinez wele MRnagente d DMsinn + �= Remo & APPROVED BY. Risk Management Analyst CITY of SANTA ANA RISK MANAGEMENT a 4wacaa ad HUMAN RESOURCES Managing Wk ~ Positive Change WORKERS' COMPENSATION DECLARATION I, A R*H�hl(N M hereby affirm under penalty of perjury, the (Name/Title) following declaration: I certify on behalf of Myself (Adriana Martinez) that during the term (Consultant/Camponyy Name) of my contract for . 'yU� (_i(l&ervices with the City of Santa Ana, (Type of .service provided) 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 the provisions and provide proof of workers' compensation coverage immediately. Date: Print Name: Print Title: Signature: Telephone: FA �.�. n0011 UPME • !� 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 1N SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. I:�RlskMgmtklnsuranceRegulrementSkWCDeclaration 08152019 �3 REVIEWED& APPROVED By. ' �user,�.c.c �, U:,ffsauk 1 Risk Management Analyst