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Home My WebLink AboutBRIAN PETERSON (3)INSURANCE ON FILE N-2021-16 7A WORK MAY PROCEED UNTIL INSURANCE EXPIRES CLEIK' C 1U `� I2022 FIRST AMENDMENT TO MURAL AGREEMENT c� CVA(T-ewk e -) CAu) P THIS FIRST AMENDMENT to the above -referenced agreement is entered into on May 11 , 2022, by and between Brian Peterson ("Artist"), 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 Agreement No. N-2021-167, dated July 12, 2021, by which Artist agreed to paint One (1) interior mural that consists of two (2) walls ("Artwork") for the new Homeless Navigation Center ("Project") located at 1815 Carnegie Avenue, Santa Ana, California 92705 ("Site") ("Agreement"). B. Artist completed the Artwork at the Site, but City is now requesting that Artist return to the Project to complete maintenance and restoration work on the Artwork pursuant to Exhibit A of the Agreement, which provides that Artist shall be compensated $200/hour by the City for maintenance and/or restoration services rendered with prior written authorization. C. Accordingly, the parties now wish to increase the maximum amount of compensation that may be expended under the Agreement to cover the costs of the required maintenance and restoration of the Artwork. The Parties therefore agree: 1. Section 2.1, Funding, is amended to increase the total not -to -exceed amount by $1,600 for the extended term, which shall cover up to eight (8) hours of maintenance and restoration of the Artwork pursuant to Exhibit A, such that the new total amount to be expended during the term of this Agreement shall not exceed $14,600. 2. Except as modified by this First Amendment, all terms and conditions of said Agreement shall remain in full force and effect. N N N N Page 1 of 2 N-2021-167A IN WITNESS WHEREOF, the parties hereto have executed this First Amendment to said Agreement on the date and year first written above. ATTEST s Daisy Gomez �w Clerk of the Council APPROVED AS TO FORM Sonia R. Carvalho City Attorney Ryan Attorney FOR APPROVAL Steven Mendoza Executive Director Community Development Agency CITY OF SANTA ANA Kristine Ridge City Manager ARTIST Brian Peterson Page 2 of 2 myltany signed byTnn PWsnn TOO PiersonDins: 2021.1e1e 08:3211 moor a`oRo° CERTIFICATE OF LIABILITY INSURANCE DAM /13/2021 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(ies) 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 lieu of such endorsement(s). PRODUCER State Farm Insurance License # OG54371 14210 Culver Dr, Suite A, Irvine CA 92604 1 CONTACT RICHARD TAY NAME: PHONE(949) 559 8866 Me N.: (949) 269 0683 ADDRESS: PRODUCERCUSTOMER ED S. 75-3018 INSURERS AFFORDING COVERAGE NAIC # INSURED BRIAN PETERSON ART DBA FACES OF MANKIND 738 N SANTIAGO ST SANTAANACA 92701-5361 INSURER A: State Farm General Insurance Company 25151 INSURER B: INSURER C: INSURER D: INSURER E: 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 LTR TYPE OF INSURANCE ADOLSUBR POLICY NUMBER POLICY EFF MIMIOD POLICY EXP MWDO LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FRIOCCUR E� 92-EYM1.6.81 10/30/2021 10/3012022 EACH OCCURRENCE $ 1,000,000 PREMISES _REfTr I5_ $ 50,000 MED EXP(Any one Person) $ 5,000 PERSONAL& ADV INJURY $ 1,000,000 GENERALAGGREGATE $ 2,000,000 GENT AGGREGATE x POLICY LIMIT APPLIES PER: JECTPRo- LOC PRODUCTS - COMP/OP AGO $ 1,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS ❑❑ COMBINED SINGLE LIMIT (Ea amidenl) S BODILY INJURY (Per parson) $ BODILY INJURY (Per a¢ident) $ PROPERTY DAMAGE (Peraccident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE OF EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/ N ANY PROPRIETOR/PARTNEMEXECUTIVE OFFICERIMEMBER EXCLUDED? � fiMandatory In NN) f yes, describe under NIA ❑ WC STATU- I OTH- S ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT $ olo DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Addidonal Remarks Schedule, if more space is required) WITH RESPECT TO GENERAL LIABILITY, NAMED ADDITIONAL INSURED FROM August 06 2021 TO November 20th, 2021 is: The City of Santa Ana, its officers, employees, agents, volunteers & representatives for the location of : 1815 Carnegie Avenue, Santa Ana CA 92705 City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana, CA 92701 lililY V CLLN 1 1 V IY Rbk MRyalml D'Mtlm SHOULD ANY OF THE ABOVE DESCRIBED I Ink RENEVIE➢&ARPRwmB'r. EXPIRATION DATE THEREOF, NOTICE WILL BE ^�ou Du1=drt POLICY PROVISIONS. � ��— Rne Mn,a9enxntOmral Pitle AUTHOR= REPRESENTATNE Iris Tay <iris.tay.mgms@statefarm.com> C'V /. /a @ 1988- 2009 ACORD CORPORATION. All rlifits reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD 1001486 132849.4 02-11-2010 Policy No. 92 EYM168 1 CMP-4786.1 Page 1 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CMP-4786.1 ADDITIONAL INSURED — OWNERS, LESSEES, OR CONTRACTORS (Scheduled) This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 92 EYM168 1 Named Insured: BRIAN PETERSON ART INC DBA FACES OF MANKIND 738 N SANTIAGO ST SANTA ANA CA 92701-3951 Name And Address Of Additional Insured Person Or Organization: CITY OF SANTA ANA RISK MANAGEMENT DIVISION 20 C.IVIC CENTER PLAZA SANTA ANA, CA 92702 SECTION II — WHO IS AN INSURED of SECTION II — LIABILITY is amended to in- clude, as an additional insured, any person or organization shown in the Schedule, but only with respect to liability for "bodily injury', "property damage", or "personal and advertis- ing injury" caused, in whole or in part, by: a. Ongoing Operations (1) Your acts or omissions; or (2) The acts or omissions of those acting on your behalf; in the performance of your ongoing opera- tions for that additional insured; or b. Products — Completed Operations "Your work" performed for that additional insured and included in the "products - completed operations hazard". However, Paragraph 1. above is subject to the following: b. If coverage provided to the additional in- sured is required by a contract or agree- ment, the insurance provided to the additional insured will not be broader than that which you are required by the contract or agreement to provide for such addition- al insured; and c. If the contract or agreement between you and the additional insured is governed by California Civil Code Section 2782 or 2782.05, the insurance provided to the additional insured is the lesser of that which: (1) Is allowed for the satisfaction of a de- fense or indemnity obligation by Cali- fornia Civil Code Section 2782 or 2782.05 for your sole liability; or (2) You are required by contract or agreement to provide for such addi- tional insured. a. The insurance afforded to the additional We have no duty to defend or indemnify the insured only applies to the extent permit- additional insured under this endorsement un- ted by law; til a claim or "suit' is tendered to us. O. Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. CONTINUED R%kM&vV..dMft „ Tau �rex.er xawru,,.e�amoiaa 2. Any insurance provided to the additional in- sured shall only apply with respect to a claim made or a "suit" brought for damages for which you are provided coverage. 3. With respect to the insurance afforded to the additional insured, the following is added to SECTION II — LIMITS OF INSURANCE: If coverage provided to the additional insured is required by contract or agreement, the most we will pay on behalf of the additional insured will be the lesser of the amount of insurance: a. Required by the contract or agreement; or b. Available under the applicable Limits Of Insurance shown in the Declarations. This endorsement shall not increase the ap- plicable Limits Of Insurance shown in the Declarations. 4. With respect to the insurance afforded to the additional insured, the following is added to Paragraph 3. Duties In The Event Of Occur- rence, Offense, Claim Or Suit of SECTION II — GENERAL CONDITIONS: The additional insured must: a. See to it that we are notified as soon as practicable of an 'occurrence" or an of- fense which may result in a claim. To the extent possible, notice should include: (1) How, when and where the "occur- rence' or offense took place; (2) The names and addresses of any in- jured persons and witnesses; and CMP-4786.1 CMP-4786.1 Page 2 of 2 (3) The nature and location of any injury or damage arising out of the "occur- rence" or offense; b. Tender the defense and indemnity of any claim or "suit' to us and to all other insur- ers who may have insurance potentially available to the additional insured; and c. Agree to make available any other insur- ance the additional insured has for de- fense or damages for which we would provide coverage under SECTION II — LIABILITY. 5. With respect to the insurance afforded the ad- ditional insured, the following replaces SEC- TION II —LIABILITY of Paragraph 7. Other Insurance of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: a. This insurance is primary to and will not seek contribution from any other insurance available to the additional insured, provided that the additional insured is a named in- sured under such other insurance. b. Regardless of any agreement between you and the additional insured, this insur- ance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional in- sured has been added as an additional in- sured on other policies. There will be no refund of premium in the event this endorsement is cancelled. All other policy provisions apply. O, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services office, Inc., with its permission. 1007033 148011 08-21-2014 We4 A4nga,m(DMuon RE\nen['m6�M1PROJD)ar. '. • �1.1 I; 6e rrCWON RUN MarugmnnUmralAitle Policy No. 92 EYM168 1 CMP-4787 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CMP-4787 WAIVER OF TRANSFER OF RIGHTS OR RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 92 EYM168 1 Named Insured: BRIAN PETERSON ART INC DBA FACES OF MANKIND 738 N SANTIAGO ST SANTA ANA CA 92701-3951 Name And Address Of Person Or Organization: CITY OF SANTA ANA RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLAZA SANTA ANA, CA 92702 The following is added to Paragraph 10.b. of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for injury or damage arising out of: a. Your ongoing operations; or b. 'Your work" done under contract with that person or organization and included in the "products - completed operations hazard". This waiver applies only to the person or organization shown in the Schedule. All other policy provisions apply. CMP-4787 1006225 137715.1 11-19-2013 0, Copyright, State Farm Mutual Automobile Insurance Company, 2008 Includes copyrighted material of Insurance Services Office, Inc., with its permission. asxin,�gema�,umreiae� (Polley Provisions WCOOOOOOC) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: Trumbull Insurance Company ONE HARTFORD PLAZA HARTFORD CT 06155 NCCI Company Number: F 19666 Company Code: H POLICY NUMBER: 76 WEG AL4KRS Previous Policy Number: New 1. Named Insured and Mailing Address: BRIAN PETERSON ART, INC (No., Street, Town, State, Zip Code) 738 N SANTIAGO ST SANTA ANA CA 92701 FEIN Number: 84-3115161 State Identification Number(s): The Named Insured is: Corporation Business of Named Insured: Fine Arts Schools Other workplaces not shown above: 738 N SANTIAGO ST SANTA ANA CA 92701 2. Policy Period: From 04/21/21 To 04/21/22 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: AP INTEGO INSURANCE GROUP LLC 375 WOODCLIFF DRIVE STE 103 FAIRPORT NY 14450 Producer's Code: 76250846 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (8771287-1316 Total Estimated Annual Premium: $470 Deposit Premium: Policy Minimum Premium: $450 CA Audit Period: ANNUAL Installment Term: The policy is not binding unless countersigned by our authorized representative. suffix LARSTTRENEWAL Countersigned by C1' d- C� � 04/29/21 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Process Date: 04/29/21 Page 1 `° ,' RbkNmga od DMYan Policy E: iau Drc+so« ' xxxnt �ee,�„ umraia�e 00 INFORMATION PAGE (Continued) Policy Number. 76 WEG AL4KRS 3 A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the slates listed here CA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3 A. The limits of our liability under Part Two are. Bodily Injury by Accident $1,000,000 each accident Bodily Injury by Disease $1,000,000 policy limit Bodily Injury by Disease $1,000.000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here: ALL STATES EXCEPT NORTH DAKOTA. OHIO. WASHINGTON, WYOMING. U.S.TERRITORIES AND STATES DESIGNATED IN ITEM 3.A OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: SEE ENDORSEMENT -WC 99 03 68 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium Total Standard Premium Expense Constant Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement Estimated Annual Premium (before Surcharges) Total Estimated Surcharges `See the attached Schedule(s) of Operations for Location and State Level Premium Information Total Estimated Annual Premium: $470 Deposit Premium: Policy Minimum Premium: $450 CA Interstate/intrastate Identification Number: Refer to Schedule of Operations NAICS: 611610 Labor Contractors Policy Number: SIC: 5231 Form WC 00 00 01 A (1) Printed in U.S.A. Process Date: 04/29/21 S250 $200 $3 $453 $17 g b. R1@4Mmvgar4dDW m Paget - R�iArrxw®er Policy Expiration DatMOM Rek NNn.�ge,rer,I Clmcal.4Je IAAN,I N DaU To whom it may concern, I am writing this letter to verify that my one employee will not be working on the Navigation Mural. My employee will be staying in the office and will not be out in the location with me. The employee will not be on any lifts or painting. If you have any questions, you can contact me at (786) 543-7787. Sincerely, Brian Peterson Founder of Faces of Mankind 4� RNIMO�OMQU�W[�1 RP/IEWID 6 MrRw81 Bv: %au �rtwex ftkm—tam�iade --ft" W-1. -- July 28, 2021 City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana, CA, 92702 RE: Auto Insurance Requirement Dear City of Santa Ana Risk Management Division: Brian Peterson Art Inc. has intent to enter into an engagement with the City of Santa Ana. Throughout the course of this agreement, Brian Peterson Art Inc. attests to the following: 3. Brian Peterson Art Inc. consultant/independent utilize their personal vehicle for transportation to and from work and if applicable carry their own automobile insurance. By signing below, I Brian Peterson attest that I possess the legal authority to enter into an agreement with the City of Santa Ana as well as the legal authority to attest to the statements above. If at any time it is found that Brian Peterson Art Inc. is not adhering to any/all statements in this document and has not provided the minimum Auto Liability insurance coverage of $1 million per occurrence, the contract will be considered null and void and the company will be held fully liable for any and all damages. Brian Peterson Founder & CEO of Brian Peterson Art Inc. Brian Peterson Art Inc. (786) 543-7787 info&brianpetersonart.com m,. wkiob". R+ne 6Arn Br: %u �icsaoK Rak ManagenmtOmrnlpdr PDA State Farm e Providing Insurance and Financial Services PO Box 853919 Richardson, TX 75085.1919 StateFarm A. Attached as requested are your replacement insurance identification cards. If the attached cards are not accepted by a law enforcement agency or your Department of Motor Vehicle office, please contact your agent to receive additional assistance. Thank you for choosing State Farm for your insurance needs. -----------------------------------------�ect StateFarm • ••n BRIAN A IMPORTANT - IDENTIFICATION CARDS STATE FARM CALIFORNIA StateFarm THIS CARD MUST BE KEPT IN THE INSURED MOTOR INSURANCE CARD VEHICLE FOR PRODUCTION UPON DEMAND. NUMBER 4667259•DO2-75C S MAKE TOYOTA TACOMA VIN 31 R TAY INS AND P N SVCS IN ry IF YOU HAVE AN ACCIDENT • NOTIFY THE POLICE IMMEDIATELY 1. Get name, addressee, and phone numbers of persona immNed and wtneeeae. MUTL Also get driver license numbee of persons imobed and license plate VOL numbers/statas of vehida. 2. Don't atlmA result or discuss the accident wAh anyone but State Farm or pulse. 3. Promptly notify your agent log on to statefarm.come, or use the Slate Farm mobile WP to file a claim. For EMERGENCY ROAD SERVICE use the Slale Tons motile epp, lag an 1. deal ermcamor cdl EFFECTIVE 14P£27475I. EXAMINE POLICY EXCLUSIONS CARER/LLY. THIS FORM DOES 121 TO OCT 022021 NOT CONSTITUTE ANY PART OF YOUR INSURANCE PoUCY- M048947 How to Identify your coverage. See policy for full name and definition 8018•ACt A Debildy H Emergency Road Service U Unbmurad Mamr Vehicle MUM LIABILITY UNITS C Medical Payments L Physical Damage Ut Uninsured Molar Vehicle PO D Comprehensive Ri Car BemalanlTravel Eamerr Z Wasof Famings 6 Collision S Dmth.Dwemberneemand KEEP A CARD IN YOUR CAR. THIS CARD IS INVALID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATED. KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF THIS CARD. ONE COPY OF THIS FORA SHOULD BE CARRIED IN THE VEHICLE AT ALL TIMES. THE FORM MAY BE NEEDED AS EVIDENCE OF INSURANCE IN COURT. SUBMIT ONE CARD, OR A PHOTOCOPY OF A CARD, WITH YOUR VEHICLE REGISTRATION RENEWAL Emergency Road Se was intormetla is loomed a your Insurance and. — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —j IMPORTANT - IDENTIFICATION CARDS STATE FARM StateFarm StateFarm CALIFORNIA THIS CARD MUST BE KEPT IN THE INSURED MOTOR ® INSURANCE CARD A. VEHICLE FOR PRODUCTION UPON DEMAND. Farm Mutual Automobile Insurance Company PETERSON, VANESSA LUCIA A MUTL BRUIN A VOL ICYNUMBER 4667259•DO2.75C EFFECTIVE 2018 MAKE TOYOTA APR 022021 TO OCT 022021 IEL TACOMA VIN 3TMDZ5BN9dMO48947 NIT R TAY INS AND RN SVCS INC 3018•AC7 IF YOU HAVE AN ACCIDENT • NOTIFY THE POLICE IMMEDIATELY 1. Gat names, addressee, and phone ambers of persona imoNed and aitnewom. Also gat driver !cane numbers of persona Imolved and license plate numbereletata of whiclee. 2. Dont arms fault or discuss the accident win emyone but Slate Farm or police. 3. Prompt really your agent log on to etatefazm.come, or use the State Fans mobile epp to file a claim. For EMERGENCY ROM SERMCE use IM1e Seat Farm mobile app.lagan lonelelermcamoreell 14774274757. EXAMINE POLICYEXCLUSIONS CAREFULLY. THIS FORM ODES NOT CONS77TUTE ANY PART OF YOUR INSURANCE POLICY. How to identity your coverage. See policy for full name antl deimmon f9491559-8886 NAIC 25178 A Dooley H Fnuo"ar, yRned Seruce GE PROVIDED BY THE POLICY MEETS THE MINIMUM LIABILITY UNITS J C Medical Paymeme L Physics! Damage BED BY LAW. D Camprehanow R1 Car Hemel and Travel Datum .=ey RbRM.%"wiDMd. GES A m ODD GIM H U UI G Caliision S Oean4 Dismembermcm and Rewad EOAAp Br, Loa of Sl y�' KEEP A CARD IN YOUR CAR. 70Te P&14der THIS CARD IS INVALID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATE[ ai:eM,ag�„�.u,>:vlwde KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF THIS ONE COPY OF TMS FORM SHOULD BE CARRIED IN ME VEHICLE AT ALL RME9. THE FORA MAYBE NEEDED AS EVIDENCE OF INSURANCE IN COURT. SUBMIT ONE CARD, OR A PHOTOCOPY OF A CARD, WITH YOUR VEHICLE REGISTRATION RENEWAL 143295.3 (01 ecatd) 01-15.2018 Emer,mW Road Service informal is Ioated a your nneuranoe card. FEB 24 g1121