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HomeMy WebLinkAboutWHITE, MATTIE D. 7AGREEMENT TERMINATION Please complete this form when the attached agreement is no longer in efN f ' M e00 Return form to the Sr. Deputy Clerk of the Council (M-30). Call 647-57 n have any questions. The agreement with { %%�;� * No. A x -a (7) LOIp was completed on �' o and final payment has been made. * p-2009-1 IA) Revised 8-7-03 Department: i Signature: � A. 11s ck"O Date: (St IUt.tq City of Santa Ana Clerk of the Council INSURANCE NOT ON FILE A-2004-187 WORK MAY NOT PROCEED CLERK OF COUNCIL CONSULTANT AGREEMENT DATE: _��,�,,`�,,,,/ THIS AGREEMENT made and entered into this -90 day ofVetJrC/Rt76< 2004 by C.I°�GS and between Mattie D. White (hereinafter "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 (hereinafter "City"). RECITALS A. The City desires to retain a consultant having special skill and knowledge in the field of preschool education. B. Consultant represents that Consultant is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Consultant represents that it is knowledgeable in its field and that any services performed by Consultant under this Agreement will be performed in compliance with such standards as may reasonably be expected from a professional consulting firm in the field. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions hereinafter set forth, the parties agree as follows: 1. SCOPE OF SERVICES Consultant shall perform those services as set forth in Exhibit A to this Agreement. 2. COMPENSATION a. City agrees to pay, and Consultant agrees to accept as total payment for its services, the rates and charges identified in Exhibit A. The total sum to be expended under this Agreement, shall not exceed $13,050.00 during the term of this Agreement. b. Payment by City shall be made within thirty (30) days following receipt of proper invoice evidencing work performed, subject to City accounting procedures. Payment need not be made for work which fails to meet the standards of performance set forth in the Recitals which may reasonably be expected by City. 3. TERM This Agreement shall commence on the date first written above and terminate on June 30, 2005, unless terminated earlier in accordance with Section 12, below. The parties acknowledge that Consultant has provided services since July 1, 2004, which services shall be included within the Scope of Services of this Agreement. The tern of this Agreement may be extended upon a writing executed by the Executive Director of Parks, Recreation and Community Services and the City Attorney. 4. INDEPENDENT CONTRACTOR Consultant shall, during the entire term of this Agreement, be construed to be an independent contractor and not an employee of the City. This Agreement is not intended nor shall it be construed to create an employer -employee relationship, a joint venture relationship, or to allow the City to exercise discretion or control over the professional manner in which Consultant performs the services which are the subject matter of this Agreement; however, the services to be provided by Consultant shall be provided in a manner consistent with all applicable standards and regulations governing such services. Consultant shall pay all salaries and wages, employer's social security taxes, unemployment insurance and similar taxes relating to employees and shall be responsible for all applicable withholding taxes. 5. INSURANCE Prior to undertaking performance of work under this Agreement, Consultant shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Commercial General Liability Insurance. Consultant shall maintain commercial general liability insurance naming the City, its officers, employees, agents, volunteers and representatives as additional insured(s) and shall include, but not be limited to protection against claims arising from bodily and personal injury, including death resulting therefrom and damage to property, resulting from any act or occurrence arising out of Consultant's operations in the performance of this Agreement, including, without limitation, acts involving vehicles. The amounts of insurance shall be not less than the following: single limit coverage applying to bodily and personal injury, including death resulting therefrom, and property damage, in the total amount of $1,000,000 per occurrence. Upon execution of this Agreement, Consultant shall supply City with a fully executed additional insured endorsement in substantially the form attached hereto as Exhibit B, for approval by the City Attorney. b. Worker's Compensation Insurance. In accordance with the provisions of Section 3300 of the Labor Code, Consultant, if Consultant has any employees, is required to be insured against liability for worker's compensation or to undertake self-insurance. Prior to commencing the performance of the work under this Agreement, Consultant agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. c. The following requirements apply to the insurance to be provided by Consultant pursuant to this section: z (i) Consultant shall maintain all insurance required above in full force and effect for the entire period covered by this Agreement. (ii) Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved in form by the City Attorney. (iii) Certificates and policies shall state that the policies shall not be canceled or reduced in coverage or changed in any other material aspect without thirty (30) days prior written notice to the City. d. If Consultant fails or refuses to produce or maintain the insurance required by this section or fails or refuses to furnish the City with required proof that insurance has been procured and is in force and paid for, the City shall have the right, at the City's election, to forthwith terminate this Agreement. Such termination shall not effect Consultant's right to be paid for its time and materials expended prior to notification of termination. Consultant waives the right to receive compensation and agrees to indemnify the City for any work performed prior to approval of insurance by the City. 6. INDEMNIFICATION Consultant agrees to and shall indemnify and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives from liability: (1) for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal injury, including health, and claims for property damage, which may arise from the direct or indirect operations of the Consultant or its contractors, subcontractors, agents, employees, or other persons acting on their behalf which relates to the services described in section 1 of this Agreement; and (2) from any claim that personal injury, damages, just compensation, restitution, judicial or equitable relief is due by reason of the terms of or effects arising from this Agreement. This indemnity and hold harmless agreement applies to all claims for damages, just compensation, restitution, judicial or equitable relief suffered, or alleged to have been suffered, by reason of the events referred to in this Section or by reason of the terms of, or effects, arising from this Agreement. The Consultant further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and costs for special counsel to be selected by the City, regarding any action by a third party challenging the validity of this Agreement, or asserting that personal injury, damages, just compensation, restitution, judicial or equitable relief due to personal or property rights arises by reason of the terms of, or effects arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. 7. CONFIDENTIALITY If Consultant receives from the City information which due to the nature of such information is reasonably understood to be confidential and/or proprietary, Consultant agrees that it shall not use or disclose such information except in the performance of this Agreement, and further agrees to exercise the same degree of care it uses to protect its own information of like importance, but in no event less than reasonable care. "Confidential Information" shall include all nonpublic information. Confidential information includes not only written information, but also information transferred orally, visually, electronically, or by other means. Confidential information disclosed to either party by any subsidiary and/or agent of the other party is covered by this Agreement. The foregoing obligations of non-use and nondisclosure shall not apply to any information that (a) has been disclosed in publicly available sources; (b) is, through no fault of the Consultant disclosed in a publicly available source; (c) is in rightful possession of the Consultant without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (e) is independently developed by the Consultant without reference to information disclosed by the City. 8. CONFLICT OF INTEREST CLAUSE Consultant covenants that it presently has no interests and shall not have interests, direct or indirect, which would conflict in any manner with performance of services specified under this Agreement. 9. NOTICE Any notice, tender, demand, delivery, or other communication pursuant to this Agreement shall be in writing and shall be deemed to be properly given if delivered in person or mailed by first class or certified mail, postage prepaid, or sent by telefacsimile or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Clerk of the City Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 Santa Ana, CA 92702-1988 telefacsimile (714) 647-6956 With courtesy copies to: ME Executive Director of Parks, Recreation and Community Services City of Santa Ana 20 Civic Center Plaza (M-23) P.O. Box 1988 Santa Ana, California 92702 telefacsimile (714) 571-4235 City Attorney City of Santa Ana 20 Civic Center Plaza (M-29) P.O. Box 1988 Santa Ana, California 92702 telefacsimile (714) 647-6515 To Consultant: Mattie D. White 3201 South Deegan Drive Santa Ana, California 92704 A party may change its address by giving notice in writing to the other party. Thereafter, any notice, tender, demand, delivery, or other communication shall be addressed and transmitted to the new address. If sent by mail, any notice, tender, demand, delivery, or other communication shall be effective or deemed to have been given three (3) days after it has been deposited in the United States mail, duly registered or certified, with postage prepaid, and addressed as set forth above. If sent by telefacsimile, any notice, tender, demand, delivery, or other communication shall be effective or deemed to have been given twenty-four (24) hours after the time set forth on the transmission report issued by the transmitting facsimile machine, addressed as set forth above. For purposes of calculating these time frames, weekends, federal, state, County or City holidays shall be excluded. 10. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Consultant, and supersedes any and all other agreements, oral or written, between the parties. In the event of a conflict between the terms of this Agreement and any attachments hereto, the terms of this Agreement shall prevail. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Consultant. The parties agree that any terms or conditions of any purchase order or other instrument that are inconsistent with, or in addition to, the terms and conditions hereof, shall not bind or obligate Consultant nor the City. Each party to this Agreement acknowledges that no representations, inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which are not embodied herein. 11. ASSIGNMENT Inasmuch as this Agreement is intended to secure the specialized services of Consultant, Consultant may not assign, transfer, delegate, or subcontract any interest herein without the prior written consent of the City and any such assignment, transfer, delegation or subcontract without the City's prior written consent shall be considered null and void. Nothing in this Agreement shall be construed to limit the City's ability to have any of the services which are the subject to this Agreement performed by City personnel or by other consultants retained by City. 12. TERMINATION This Agreement may be terminated by the City upon thirty (30) days written notice of termination. In such event, Consultant shall be entitled to receive and the City shall pay Consultant compensation for all services performed by Consultant prior to receipt of such notice of termination, subject to the following conditions: a. Payment need not be made for work which fails to meet the standard of performance specified in the Recitals of this Agreement. 13. DISCRIMINATION Consultant shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in the recruitment, selection, training, utilization, promotion, termination or other employment related activities. Consultant affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 14. JURISDICTION - VENUE This Agreement has been executed and delivered in the State of California and the validity, interpretation, performance, and enforcement of any of the clauses of this Agreement shall be governed by and construed in accordance with the laws of the State of California. Both parties further agree that Orange County, California, shall be the venue for any action or proceeding that may be brought or arise out of, in connection with or by reason of this Agreement. 15. PROFESSIONAL LICENSES Consultant shall, throughout the term of this Agreement, maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by the laws and regulations of the United States, the State of California, the City of Santa Ana and all other governmental agencies. Consultant shall notify the City immediately and in writing of her inability to obtain or maintain such permits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement. 16. MISCELLANEOUS PROVISIONS a. Each undersigned represents and warrants that its signature hereinbelow has the power, authority and right to bind their respective parties to each of the terms of this Agreement, and shall indemnify City fully, including reasonable costs and attorney's fees, for any injuries or damages to City in the event that such authority or power is not, in fact, held by the signatory or is withdrawn. b. All Exhibits referenced herein and attached hereto shall be incorporated as if frilly set forth in the body of this Agreement. H H H H IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: PATRICIA E. HEALY Clerk of the Council APPROVED AS TO FORM: JOSEPH W.FLETCHER City Attorney La u(a Sheedy Assistant City Attorney RECOMMENDED FOR APPROVAL: GERARDO MO T Executive Director of e Parks, Recreation and Community Services Agency CITY OF SANTA ANA DAVIr5 N. REAM City Manager CONSULTANT i MATTIE D. ITE Tax ID# EXHIBIT A I. SCOPE OF SERVICES A. Consultant shall conduct Tiny Tot classes for preschool children. Curriculum will consist of kinder preparation exercises and activities. B. Classes shall be three -hours, four days a week, conducted in one -month sessions during the months of September through November and January through May. December and June shall be three-week sessions. C. Consultant shall work with City staff in setting a schedule for classes, including the location, days and hours when class will be held and holidays to be observed. D. Consultant shall provide materials and supplies and be responsible for equipment, records, personnel and clean up of the facilities and materials necessary to ensure the safety and effectiveness of instruction. II. CLASS SIZE — REGISTRATION A. The minimum number of registered and paid participants is 10 children per class. The maximum number is 25. B. In the event the minimum number of enrollees is not realized by the first class, the class may be canceled by mutual agreement of Consultant and City. In such event, no compensation shall be owed Consultant. III. FEES A. The class is $90.00 per session per participant, except participants shall pay $70.00 for the months of December and June. No refunds shall be made to participants unless the class is cancelled as set forth in Section II.B, above. B. City shall register and collect fees from each participant in the class during the period of registration. City shall pay Consultant seventy percent (70%) of the total fees collected each month. City shall retain thirty percent (30%) of the fees collected as an administrative fee. C. City shall be entitled to audit Consultant's records to ensure compliance with this Agreement. D. Only registered and paid participants may participate in class. EXHIBIT B ADDITIONAL INSURED ENDORSEMENT FOR COMMERCIAL GENERAL LIABILITY POLICY Insurance Company This endorsement modifies such insurance as is afforded by the provisions of Policy 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. 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 Policy # Issued to this endorsement form as a part of Named Insured Countersigned by Authorized Representative 02/03/2005 14:34 7145714209 PARKS AND RECREATION PAGE 03 I ILO/40" IV. DV rAA DV54.74JUVA ALLUMU 1NSUHANUt SVUS 19 VV•t VUI A e= CERTIFICATE OF LIABILITY ..TMID INSURANCE TE 11/29e/'04 I �D ■ CCOAb INSURANCE SERVICES J 1 SOX 4405 0666200 Thousand Oaks CA 913$9-1455 vi0 . 73.9434 QWIFICATFISSUED A9 TIDN ONLY ANO COERB NO RIOMTB YPON THE CERMICArE NPHOLDER, THIS CBRTIMCATE DOES NOT AMENO, EXTEND OR ALTER THE COVERAGE AFFORDED DY THE POUGEs 11I INSURERS AFfO1tDINp COVERADE 4 :IAEYME Mattia D TPtfite k _;1001t_/g 'T Siny Tat Preschool 3201 E Deegan Drive Santa Ana,CA 92704 NaIAfR• Scottsdale lnsur a Com an Iufu■cA9 ASURIAfc INeunin oe A ICOMMAGES TTIE POLICIES O': INOLRANCELINTEDNLOW NAVE BEEN 15EUEDTO THE INEURIONAMrmDAEOVt FOR THE PDUeYPEAIODINDIOATEO 1407WT14E7AHMNO AHY A90WIMMENT, TERM OR CONDITION OF ANY CONTM4r OR 07HER OCCUMENT WIrM RENECT TO LIWCN TM1E Ol"FrATE IMY BE IBEUED OR MAY PERTAIN, THE INSURANCE AFFERM BY THE POLICIES pE$CIUOm MlRIIN IE SVEJECT TO ALL THE 7ERMs, 9Xt`,LUBIONEAND CONDITICNi OR EUCN MIME. AODREW7E LIMITS WOWN MAY INVfiBElN AEDUC BYPAIDCLAIMa L mR 0l IIIINRANCI F■ Wni(A L A aERAAALUAeu7Y X Car+MlnckL OirAFA6 LLYNYTY W C■3wDf �CCU DR PrDty-a_ElDnel- Cn50031777RC-2 12 /2B{04I12/2B/OS I AAOH0044MME Z IL DDD OD FIAT OATIRGF IAIY e�ruN 1 SD DDD ViO EL? ,an•P•�• 5I D RenEDNwA.OdIISAwY 11 000 DO OENRALAOCR96prE 12 D D 0, O D D OCNL rnOR Are Lurt urues re■ x r'GNG', RR Lam. rnooum-t9mrcr�9 42,000,000 14100111011.4 I uAE■m ANY AYTO ALL OANW AUTCA E0140VLi9Auf06 i M■ED AVTG4 nawMlf9AUTYE - - i DDunuEDP�NpLA UaR {ralw■AN 1 IODLY INAIW {�1f pRrlp�) 1 IOdLY WJu" iaalrN t PROPIPIM 06WADE F'If 1E041M1 • aA■AOf LMaYry i A W ALRD I APPROVED A I IAYTQ 9NLh•N�CSIAMr 1 erweq YwN eA ACC AIROCYLY, /ao J 1 IAMN LWOUTY CCCUR � CWMf W77f I OmLRNLC i +' Lauzo7fititt RETEHTJON AWstAK / � Sheed� City Attor I ev EICM OCCURRENCE 1 AE4RROATf 7 1 1 1 ' ' raRnlw mLsmunDlrJo iLT.Le.TPe LueuTY I e. cACNrrcoarr 1 C,L OIlWI•F9ucr LMT 1 OTHER f I pECMrT0ERA0UTONILOOA O CLCLOIICLLa BUOREEREJmEFECaL City of Santa Ana is named as Additional insured per Exhibit 'A' Ths City of Santa Ana 20 Civic Conley P16:6 Banta Ana CA 92701 Attn: No Chiec fax: 714.935.0075 e101,11.9 ARV 9R TNi EEON cuemmo M1.10 a BE "MV.lf1 9ATf TMW. THE IfEIEA6 N/1,11OR MLL7tpB MA WA NOTICE TO TIe 41RRIWTt NDLEER NAIREEW WE UFRO 1 02/03/2005 14:34 7145714209 PARKS AND RECREATION V I/ 11/CVVJ IV vo rAA ovogagvovr rwv�� an v„i •+� � �� _PAGE 04 A 8COiT3DALE INSURANCE COMPANY° . aeT 70 0um .prWetll)p4�d r"imwaaN[VTMAD!TNq �J 7- CLS 008ST" RC-2 I 12i 21j a AM —(TINYTOTPRESIMC4YHNOD OL — AMT77ONAL INSURED UVOR$VaNT INSURANCE COMPANY SCOTT$DALE INSURANCE COMPANY ENDOMEMUNT NO. +.• niWQ+nYe6001 . . GMNIOee4e11aML e01MCr I Q40iD THE ENDORSEMENT MODIDIN 9uCR 2NSt7 WCE AS Ie APPONDED BY TYE PROVISIONS OF POLICY M CLS oe35717 AC-2 RBLATTNG TO THE POLLOWIRGI 1, THE CITY OF SAYTA ANA, 70 CIVLC CENTW PLAZA. SAFTA ANA, CALZLFORNIA 93701, LT6 OPDICAAS, 4WLOYEa8, A[IENTa, VOLVNTSERS AND REPRWXNIATIV38 ARE NAMED AS ADDITIONAL TWZUREDS ("ADDITIONAL INSUR®tl") WITH RaGARD TO LIABILITY AND DEFENSE OF SUITS ARISING PROM TNB OH$RAMIONS AND USES MFORMED BY 01 ON BEHALF OF TZZ NAMED INSURED. Z, WITH RESPECT TO CLAIMS ARISING OUT OP TBB OPERATIONS AND USES PERFORMED BY OR ON BEHALF OF THE NAMED INlVRZD, SUCH INSURANCE AS Ia AFFORDED BY =13 POLICY " 9RIMARY AND 15 `,POT ADDITIOM TO AR CONTRIBUTING NITR ANY OTHER INSURANCE CARRIED BY OR FOR THE aaNat2T OF THE ADDITIONAL ImSURDD9. 3, THIS E94VRANCS APPLIES SEPARATELY TO EACH INRVRBD AGAINST WHOM CLAIM IS WE OR SUIT TS BROUGHT WINDT WITH REBPRCT TO T= COMDANY's LIMITS OF LIABILITY. THE INOLUS20N OF ANY i+ERSON OR ORQAMIiATTON AS AN INSURED SHALL NOT AFFECT ANY RSGHT WHICH auCH PERaW OR ORGANIZATION WOULD HAVE AS A CLAIMANT IP NOT SO INCLUDED, 4. WITH RE8PEQ3' TO THE ADDIITgRAL INIMMEDS, THIS INSURANCE OHALL NOT BE CANCELLED, OR )mTERZALLY RIDUCRD IN COVERAGE OR L2HITa BHCBPI APTBR TBIRTY no) DAYS WRITTEN NOTIItlt HAS BEEN BIVffii TO THE CITY OF SANTA ANA, 70 CIVIC CENTER PLAZA, EANTA ANA, CALTrakNIA r2701. APPROVED AS TO FORM Laura Stitt Sheedy - ASSiStant City Attorney COUNTERSIGNATURE DATE T� LT" (I.DI) 02/03/2005 14:34 7145714209 PARKS AND RECREATION PAGE 05 .V1/11/2VU5 14. Uf fAA IrVo404JaV4 Aubunu lneunn11u1 u.uu v J k $COrfSDALE INSURANCE COMPXNYm COMMERCIAL GENERAL UABILITY COVERAGE PART SUPPLEMENTAL DICLARATIONS Them 9uppMmerlral Oedareeoee torn a part of polloy number at■ Selo,,, Sea _ L pri OP eYBURANCB I,QaMMW Aeprepate Lanit Mther Then PNadUaMC lirplero Operslene) ; a, ■aa,000 Products -Completed 00eretlona Aggregate LWM : l.sss.00e Personal and Adrerlreing Injury Limit (Bach Odowrerde Limit a 1_wo,00v e sv, Doc any one fln 'FiroOamepeLlmk - - � �1 600600 any One person !Msdlml Expense Limo — MUaINEea CGSCRPrnON AND LOCIAMON OP Pa ISES FormerBudneee Indlvldwl U jofil VOnlun = Parulenhlp Cerperarion rower Sun P■MYM4p o• Jorn Wmuro) ii Rua!neseDescription; aer coos Location of All PWnbas You 00. ROM or Occupy: 70I a. 4PneP aTRM• VWMA amr Ch 12704 -- PIRMWM Prerrdum ! pOpmae7an Code No. ' Premlwe Mole PdCa All OSrar PrICO All Olr r I Wj Casa mmose Meer anN Now walk gar19 4171e o)Mlk MINIM 7t a ;PCL 3 Mas#. rnommi/dtllL 070s wn eta 91"1es" 1O i Tell auesseeM eormmraa r xt AMMOML immm mow. look FULLY sham l 1 lee. set. i Tessa Ye Mou 1100, j PoalMi AND lNDOII emT (t)Btar than, applicable firms and enoonownse shown swewhsre In tine policy) Fennoand&WOM M4MYM1M10tlrhLbwspePeriandmad■putofehNPelb►ratereelseernr SAM as per EsplrWB PNey •,(a) Ama,(c) Tatar Cost (m) Admlaaion, (p) Payroll, (a) Grose Bela, (u)LInite. (0) Other THIS aUPPLEMENTA4 DECLARATIONS AND THE COMMERCIAL LIABILITY DECLARATIONS, TO(iEINER WITH THE COMMON POLICY CONDITICNa, COVERAGE FORM(S) AND ENDORSEMENTS COMPLETE THE ABOVE NUMBERED POLICY CLe4&11(2AQ 02/03/2005 14:34 7145714209 PARKS ANT) RECREATION '.PAGE"'0G Ulfll/CUUV 14 Vf tAm OV1464JDV% 84UVnU Indunmi VL JYUV �x RENEWAL CERTIFICATE erlisisew—. J 7� 3COTT&DALE INSURANCE COMPANY* W?l Nenh Gary Cenler pdve, Scdbdele , Anson a6265 A STOCK COMPANY 111111 T, Nalmed ln.VA tl WW 104II1M Address: NI M7 D. WRIVE 11A, TZ1Y I'M nuaImeL 1704 ■. a Uff SARI AID, CA 02704 Ahemt NinN II00 A011rose' -_ Camb:idd4 01"ata1 Agahoy 1o0 Vine Strost Suits 230 CLa eef e777 1C-1 Polloy Number San 7raneieeo, Ca 94111 AoanlNo: 04010/tlDLr► „ Item 2. Pdk.V PIFK M4rpaL Prom: if4e-f4 To: if df•06_ 12-01 A.M. tttirreal TINe et 1N edeleivi of Rho NAM®14iURW ee slated horoln, In mnptl4MWn Of me tenelsel pwnlYm SYhtl, the a00W nuamMed psli0y N renewe4 Mlhe peltod apedfte4 Mlt>)4C1 b the bolt and eondklom then . syAmpt as othomin sawfed hereln. INSPECTION Pat = 240a.pa '1 4 9E.91 sTATOTAXAND STAMPINAFIE { 3.6SS.05 70TA1.P0L4YPREMIUM I i No prniies from previous born. �K. I nqp on ena0rwment eeiew e1e ePpiudM WNn eesw n"W" AIOR l C1J-E>7•i (7-92) A MIZI. Cs 2429 (07/04) un-i Isa) CountersiCned i.i)..OA t.abCNaMO►/eb DATE By cauAelllgnsture 2 5% 11MVIKIW imarned Premium NO FLAT CANCELLATION 6CNCIt& AOENrl COPY