Loading...
HomeMy WebLinkAboutBOYS AND GIRLS CLUB 3 A - 2003AGREEMENT TERMINATION Please complete this form when the attached agreement is no longer in effect. Return form to the Sr. Deputy Clerk of the Council (M -30). Call 647 -5238 if you have any questions. - - - - -- --- ----------- - - - - -- p ------------ -. - --- -- The agreement withy was completed on , and final payment has been made. f t - 21 d3 - %sa (3) CO Phi Department: C 04 — 4 1 zop 4 Its fib; 4 3u Tz r 2d Signature: � - S- o � as f3c) Date: City of Santa Ana Revised 8 -7 -03 Clerk of the Council J, A- 2004 -112 t 1XPIRES AMENDMENT TO AGREEMENT THIS AMENDMENT, made and entered into this 7th day of June, 2004, by and between the Boys and Girls G: ACA Club of Santa Ana ( "Contractor ") and the City of Santa Ana, a charter city and municipal corporation duly organized (I-Alor,a) and existing under the Constitution and laws of the State of California ( "City "). RECITALS A. The City and Contractor entered into that certain Agreement dated October 1, 2003, hereinafter referred to as "said Agreement ", to provide career preparation and basic skills services for disadvantaged youth who are in- school. B. The parties hereto now desire to amend the "City's Obligations" amount found in Section 2 and the "Time Period of Agreement" term found in Section 3 of said Agreement. WHEREFORE, in consideration of the mutual and respective covenants and promises hereinafter contained and made, and subject to all of the terms and conditions of said Agreement as hereby amended, the parties hereto do hereby agree as follows: The "City's Obligation" section of said Agreement will be amended to read: "...a sum not to exceed $57,389." 2. The "Time Period of Agreement" section of said Agreement will be amended to read: "...shall have been performed by June 30, 2004." 3. Except as hereinabove modified, the terms and conditions of said Agreement remain unchanged and in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this Amendment to said Agreement the date and year first above written. ATTEST: i atricia E. Healy Z441 Clerk of the Council APPROVED AS TO FORM: By: Lisa E. Storck Assistant City Attorney RECOMMENDED FO/R APPPP/ROVAL: �, G./ Patricia C. Whitaker, Executive irector Community Development Agency CITY OF SANTA ANA David N. Ream, City Manager BOYS & GIRLS CLUB OF SANTA ANA John F. Br wster Executive irector A IM, CERTIFICATE OF LIABILITY INSURANCE DATE . 12/31/20031 PRODUCER (909)587 -2719 FAX (909)587 -6001 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION Anthem Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR 42145 LyndTe Ln., N202 Temecula, CA 92591 License 8 0884551 NSURED Boys and Girls Club 950 Highland St Santa Ana, CA 92703 rn%1FRDGFC INSURERS AFFORDING COVERAGE INSURERA: Markel Insurance Con INSURER B INSURER C: INSURER D. INSURER E'. NAIC 4 THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINI ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I$ SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. II T. DD' HIS TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE POLICYEXPIRATION 01/05/2005 LIMITS GENERAL LIABILITY 8502CY073003 12/20/2003 EACH OCCURRENCE 1 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PRFUIq E 50, 000 CLAIMS MAOE ❑ OCCUR S 5,000 MED EXP (Anyone Person) A X PERSONAL B ADV INJ DRY $ 1,000,000 GENERAL AGGR EGATE E 3,000,000 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS - COMPIOP AGO $ 1,000 000 POLICY PRO JECT LOG AUTOMOBILE LIABILITY ANY AUTO 1002CYC0730044 12/20/2003 01/05/2005 COMBINED SINGLE LIMIT HE. .I E 12000,00 BODILY INJURY (Per person) E A X ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) S HIRED AUTOS NON OWNED AUTOS PROPERTY DAMAGE (Peracclden0 E GARAGE LIABILITY AUTO ONLY EA ACCIDENT S ANY AUTO OTH ER THAN EA ACC S S AUTO ONLY: AGO EXCESSIUMBRELLA LIABILITY OCCUR �CLAIMSMADE 4602CY0730105 1212012003 01/05/2005 EACH OCCURRENCE E 5,000,00 AGGREGATE $ 5,000,00 A X E DEDUCTIBLE E X RETENTION E 10,00 S WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS' LIABILITY ANY PROPMEICHIPARTNER /EXECUTIVt Oyes de/MEMBER EXCLUDED? Ryes dLPRO In 1" "G- - --�. L. ! �. E. L. EACH ACCIDENT E E.I. DISEASE - EA EMPLOYEE E E . DISEASE -POLICY LIMIT 1 SPECIAL PROVISIONS below 16IO L. : OTHEs 10 Gay cancel non payment of premium DESCRIPTION OF OPERATIONS 1 LOCATION`I VEHICLES F• ri+v ,.F C� +_ ems., — ic I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ____ -_ -------- _ _. .... _ a,R „.,Ile. a. ......anal Insures respects the operations of the named insured. City of Santa Ana 20 Civic Center Plaza Santa Ana, CA 92701 ACORD 25 (2001108) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOr, THE ISSUING INSURER WILL lII)WOOM MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, kwwxkwtkx*xv&1EDcx&woGYIXIXX Auxa(AKo kx)o)txxKYIwtKxX AUTHORIZED © ACORD CORPORATION 1888 lkwa �.- EXHIBIT B Insurance Company Markel Insurance Company This endorsement modifies such insurance as is afforded by the provisions of Policy # 8502CY073003 relating to the following: 1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; its officers, employees, agents, volunteers and representatives 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. r. 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 to 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 12 -20 -03 this endorsement form as a pan of Policy # 502CY073003 Issued to Named Insured Countersigned bySZ�`♦\ Authorized Representative 2/z 10 SP ` CERTHOLDER COPY STATE P.O. BOX 807; SAN FRANCISCQCA 94142 -0807 COMPENSATION INSURANCE f FUND CERTIFICATE OF WORKERS' COMPENSATION 'INSURANCE ISSUE DATE: 06 -01 -2004 GROUP: 000723 POLICY NUMBER: 0000075 -2004 CERTIFICATE ID: 1 CERTIFICATE EXPIRES: 06 -01 -2005 06 -01- 2004/06 -01 -2005 CITY OF SANTA ANA SP JOB; ALL OPERATIONS WORKCENTER ATTN: ANABELL YATES 1000 E. SANTA ANA BLVD., #200 SANTA ANA CA 92701 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the fund except upon 10days' advance written notice to the employer. We will also give you 10 days' advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies . listed herein. Notwithstanding any requirement, term, or condition of any contractor other document . with respect to which this certificate of insurance may be or may pertain,: the insurance afforded by the policies described herein is subject to all the terms, exclusions and conditions of such policies. AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S. LIABILITY LIMIT INCLUDING DEFENSE COSTS:: $1,000,000.00 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL. INSURED EMPLOYER EFFECTIVE 06 -01- 2004.: IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA SP V�E�I/JAS TC) a _ — LISA E. ssistant City .4ttorr EMPLOYER - -LEGAL NAME BOYS AND GIRLS CLUB OF SANTA ANA BOYS AND GIRLS CLUB OF SANTA ANA 9 50 HIGHLAND ST (A NON PROFITI CORPORATION): SANTA ANA CA 92703 PRINTED: 05/17/2004 P0408 IREV.3 -031 Mar 17 05 11:12a Boys 6 Girls Club Of Sant 714 -565 -1099 ot,a A- AWy- /FoR Nurnbu' p.2 Dow ErEered: 3/16/2005 ASR. CERTIFICATE OF LIABILITY INSURANCE 3716//2000331 ,Mum aulfee aauraaee aaa 22912 PAai£ia Perk Dr 8200 Aliao W_sja, CA 92656 19491215 -3431 123 456 THIS CERTIROATE 95 ISSUED AS � MATTER OF INFORMATION ONLV AND CONFERS NO RIGHT IIPON THE CERTIFICATE T SCET 3I�7E RHE COVEME W 13Y Y T� EL� OR INSURERSAFFOROINOCOVERAOE NNCa *MOM Soya G Girls of saata RDA, CA 92703 Soya 6 Sirle Of Santa Ana poundation 950 W. Highland Rama Ana, CA 92703 y1rlAFAA aWalare na9ran0e CMWN..w urn DUUAENa A ia4wwla euEaAtyMLIry ooIle6ACwalrESALIIIreuTr CRAMS SAGE � occuN 0. 1./1/2005 R9uaEAe a,Cn OCCUArIEHCa V THE POLICIES OF WSURANCELISTED SELOW HAVE am HWED TO THE INSURED NAMED ABOVE FOR YHE POLICY PERIOD WDICAT=. NDTWONSTAIAWC ANY REOUSIENENT, TEW OR CONDITION OFANY CONTRACT OR OTHERDOCUNENT WOH RESPECT TO VINCH THIS CERTM ICATE MAY 8E ISSUEDOR MAY PERTAW, THE INMMNCE AFPORMffY THE PONCAES DFSCRIIW NEPEIN 18 GUIWECT TOALL r TEWM6. EXCLUSPOOS AND CANMIONS OF SUCH POLICIES. AGGREGATE UNNIT6 SHOM MAY HAVE SEEN REDUCED BY PAD CWSS. 10W Imaw- Not DATE TI IN10F, We Orin aMllaN 04- �p�...�. •� N4a 30 Daa wwne AaIOW apTNIE tO TNe QR1RMWa MOIOM NAlra lIYTEEYR 'I and SWP1*yau COW IW25 P.O. Soa 1949 urn asses Aoe. G 92702 A X euEaAtyMLIry ooIle6ACwalrESALIIIreuTr CRAMS SAGE � occuN 6040798273 -05 1./1/2005 1/1/2006 a,Cn OCCUArIEHCa 41,0 " yy 30,000 / 3 r D � 4jAO *Mpy 41,000,000 DENt AOtaa:0A1E row+ wAWAP4Ves PER. 4WID. lx +.COIAaTPAaO 41,000,000 A X AYf44rMU UNINUTT ANYAOTO ALLDA4EDMR0a 9CrIEF0UlL0 AUYDS WFOAUID6 radWWR0AVT06 10- 0179Y247 -05 1/1/2005 1/1/2006 i OOIUNEo*,aEUnT 't,000,0000 - a70M1YYUI.FV fAWrPWeO � 4 rm.Y INJURY PY(i:VOSN � .4 rro9eATr0ureE (WS404e111 4 oAa4a444ASaIn MIYAU/D Yr AOOOAWY a aTHERTHVI FAAcc AUWO W1 : ACA l l A Xx sla3sile�4rrlJn• OCCUR ❑Cwas A+ar RETEWON 41o,00a - 5YO9 - 05 APPRO ED AS O FORM; 3,000,009 / r o0,0o i wentmeawnwo mao 4w6onar lrwm ANY Pa WADDaNMAnaAO•EfNTAP La ' -X/ f/N� -- EL riDpoFNT IS - NEMPIMC! ra Stit edy JG!77 ey auDNleaEparui0JAW0allyal04,Ea1 E119LtlrDIrADaIDaY dOM(METI al6dlLPaWeIOla Ra: Certificate Bolder is need as additional inearad Be raepecta tlw OparStsOAela£ the eased iaaored. s;rnrlrv4.xlc m+AarcrW - /YOra AeY OF WYi Yr9E OwgE®POlKx7Es} EatsiAN�eLLLED ANder THE ENNNRDa 'Zbe city of aeeta Ana, the am" DATE TI IN10F, We Orin aMllaN 04- �p�...�. •� N4a 30 Daa wwne sedevolopeent Apeney, Its, OffiaerS. Agents apTNIE tO TNe QR1RMWa MOIOM NAlra lIYTEEYR 'I and SWP1*yau COW IW25 P.O. Soa 1949 asses Aoe. G 92702 AUTHORIZED REWAS MlNa nnsewavvu4 saAA ACORD 25 (=111011) E0 /T0 39VA 372EIO51143438 6055 -STZ -606 OZ:TT 9DGZ /LT /E0 Mar 17 OS 03:31p Boys & Girls Club Of Sant 714 -565 -1099 Mar 17 05 02:46(+ Boys a Girls Club 0i Sant 714 -565 -1099 ri 1 -sveo �s..�+n rw yvv,.. nab, -AW 1v .,< o reaw 1EXHtWT ti ' a ; ae .• flputamee C°mMmy_ wwG /ti S This eedomement modifies mcb iaearaege as is afibrdod by the provisions of Policy tP �6oyQ2I .R.t)3- oStelalinfimtpofolloai� 1. The City OfSS tNaen a.20 di* Center Plw,SAULAA%C.Efomia 92701; ks offieam employees, noses, volunta is and r uesem olives are named as additional ianrelr ("additional issuiW) with re&W to liability aadekfmtse Of BUM arising from Una operwom std Wu ppfaaned by or oa behalfof the mooed h umvea. 2. With respect to chime tuising oat of rho opastiaw sod us" ptafonoed by or on boWfoftbm tamed insmal, such insutaaea as is afforded by this policy is prirairy and is nos additional to at coial ibuting with say odue itsumnce cAviod by or for the benefit of the sddWottal it si cads, 3. Thus ittsv v=apphos sepatatdy to sack im ned a AmK wtn&n claim is made of sditis broa* exceptwid& A to the a0mpamys hiodts of liability. The inuJusion of >oypensan or orgabiadina as ten dttaured "I not affect any rifbt which such Person Or msgim-tian would have a a claimtan if not m Waded. 4. Wilt rmWct 10 the additional insureds, Oda *aW*no *Wl net be camaelled, or masuialiy rmduced in covmrage at limits "t afterddtty (30) days written Wise has hose give& ten the City of Satda Ana, 20 Civic CadtRPlex&, Sara Ana, Calilbmia 92701. (Completion Of Ibis following, including cousi 4aabnt, is r"Wrad to take this endoreetnat et4eriva.) Etfactivo '-4,104e X .r d3 , this andarsenxad form a a pat of pohcyp t6a'L'0���'.:.4� Issued to L4, vs .. r.^.: -/1 e--1 -4 •_f _X --'4rr Cotatlpsigned by APPROVED AS TO FORM �LLc;a Stitt Sheedy "-- Assistant City Attornev p.2 p.2 zelze -.xd 321aros113343H 6059- SiZ -fib6 E0;9t 500E /LtlEO