HomeMy WebLinkAboutBOYS AND GIRLS CLUB 3C - 2003�2
CUK
AGREEMENT 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Please complete this form when the attached agreement is no longer in effect.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.
The agreement with Qbc j S (s r r 16 C No A _ � 005 —
was completed on e �% —(J 5� and fjual-payment has been made.
i� 20O 3 ' 152
CO* (3) Department.
R 2001`117- (3a) Signature:
N (3b)
Date:
Revised 8 -7 -03
City of Santa Ana
Clerk of the Council
A- 2005 -175
SECOND AMENDMENT TO AGREEMENT
e. ck,A
THIS SECOND AMENDMENT, made and entered into this 19`h day of July, 2005, by and between the Boys
and Girls Club of Santa Ana ( "Contractor") and the City of Santa Ana, a charter city and municipal corporation duly
organized 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 leadership training and work experience for disadvantaged youth who are in- school.
Said Agreement was previously amended on or around July 19, 2004.
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:
1. The "City's Obligation" section of said Agreement will be amended to read:
..a sum not to exceed %141,904.00,"
2. The "Time Period of Agreement" section of said Agreement will be amended to read:
" ...shall have been performed by Se temher t0,2005."
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 Second Amendment to said Agreement the date
and year first above written.
ATTEST:
1
Patricia E. Healy
Clerk of the Council
APPROVED AS TO FORM:
By: Lisa E. Storck
Assistant City Attorney
V;E;E FOR APPROVAL:
,/ �� & Patricia C. Whitaker, Executive Director
Community Development Agency
CITY OF SANTA ANA
David N. eam, City Manager
BOYS & GIRLS CLUB OF SANTA ANA
Aalw "44
By: Shawn M. Ward
Title: Director of Operations
INSURANCE ON FILE.
WORK MPY PROCEED
UNTIL INSURANCE EXPIRES
i - I — vO
CLERK OF COUNCII
DATE: -tQ -os
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YOUTH BUDGET NARRATIVE
ATTACHMENT C
BUDGET PLANNING FORM THROUGH 9130/05
* attach a separate sheet detailing these costs
Administrative
Program
Total WIA
Match/In
Kind
Personnel
Salaries*
3 0.80
92,021,46 95,362.26
Benefits
961 69-
26 IS6 97 27,118.66
Other (list)*
Total Personnel
4302.49
118 178.43
1
Operating Expenses
Rent or user fee*
Utilities
_
550.00
559.00
Phones
Internet fees
Parking fees
Security
Maintenance
300.00
300.00
Insurance
Equipment*
Rental fees
Purchase
Vehicle lease charges
(vehicles may not be
purchased)
Office expenses
(consumables)
5521.28
5521.28
Accounting Services
Legal services
Auditing services
Indirect costs
(attach indirect cost
rateplan * *)
284.28
10,732.52
10 732.52
Staff tramin
Staff travel /mileage
sio.N
510.00
Customer Training*
Support services*
525 00
Profit (for profits only)
Other (list)*
Total Operating Ex enses
,242.52
11,526.80
GRAND TOTAL
(Total Personnel f Total 4586.77
Operating Expenses)
129 420.95
141 904.00
* attach a separate sheet detailing these costs
Mar 17 05 11:12a Boys & Girls Club Of Sant 714 - 565 -1099
/ply Number.
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Oat* EnbDwL 3JI612005
ACQR�L CERTIFICATE OF LIABILITY INSURANCE
3/16/2003
maum aerwwxtxoarm Imsurance ads
22912 Peaifia Park Or 0200
Ali" Viejo, CA 92656
i94Bi215 -3431
123 656
7NI8 CERnIFICATE 15 ISSUED AS A � MATTEN CP INFORMATION
OHLV AND CONFERS NO RIGHTS UPON THE[ CERTIFICATE
MOLDER THIS CERTIFICATE DOEIII NOT AMEND EXTEND OR
ALTER THE COVERAGE 8EMM BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
NAIL•
MW0 Boys L Girls of ssnta Ana, CA 92703
Soya 6 Girls Of Banta Ana Foundation
950 W. Highland
Aanta Ana, CA 92103
rauRAX Ak"larx Snsurs0ss CAMP
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POLICIES.
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TERM OR CONWON (WARY CONTRACT OR OTRER DOCUMENT WITH RESPECT TO MO NTHIS CERTWCATE NARY BE ISSUED OR
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBWECT TO ALL r TERMS. EXCWSWpS AND CONESTION50F SUCH
AOORECATE AABTS SHOWN MAY HAVE BEEN REDUCED SY PAD CLAMS.
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A8: Certificate Bolder is need as additicaul insured as rsapeoha 11Ae upelatiaeaief f1.o named iRBOSed.
CERTIFICATE VOIDER CANCELLATION
The City of Santa Ana, Th. s ane
Aletlsvelopaant Apaaay, 1u, Offiaan, Agxatx
fOOMD AaI wm mlp Asaw O roucai a OANeaLvE DOOM m S0414AMON
RATE rIMRNM, m RAVM4 nnMlAll WILL NNL go BAVe NMTAa
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and ftP1Qyaaa COAL N25 P.O. sox LOSE
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Mar 17 05 03:31p Boys & Girls Club Of Sant 714- 565 -1099
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Mar 17 05 02:460 Goys a Girl& Club Of Sant 714 - 565 -3099 p,Z
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mtufanee company
This endorscruent modifies su cli Jewunnot es is afforded by Ike provisions of Polioy
d' DLO f.R1.G73 d f telatitrs m the tosowi or.
I . The City of So" Ana, 20Ci*CouurPAT14SamaM0.California
92701' , its of cum aoployeer, agents, voluotata sad relzesentadves we named as
additional inemeds ("Additional iasbmW) with regad to liability and derenso of suits
arising 6om to operations and axe performed by or on behalf ofthe named dnsmed.
2. Witt respect to claims arising out of the operatiests and um perkowd, by
or on behalf of to named ms weed, such imersoce as is affatAod by this policy is 1>timis l'
and is tat addeitmai to or contributing with soy orbs Imewaoee caniod by or for the
bendir of Ow additional kwAvds.
3. This insuraeeeepplisr separaWy w each insured against whom ciahn is
made or scat is bcm& exceptwith respect to the aompsoy's Emits of liability. The
inclhsiod of anypecwn or orgabisuies as so ipAtred Shall mot affect ary agM which such
prrson or orgateradw would have ae a elaimaat if not so included.
4. With rowel w the additiaW iomareds, this item occ shalt not be
caaeetled, or materially rodwed in coverage or limits wxgt after tiny (30) days writin
notice has been given to to City of Santa Ana. 20 Civie COW Plate, Santa Ana,
CaUllcemia 92701,
(COnrphttiett Of the following, iatind"oounteraW0IIae, is required to make this
endorewnaa afkaive.)
Effoctivo �dolLr4?/'j' % .20 oS , this asdaaemesn therm as a pan of
Issued to Sys s eirx /.r y
Named bsat:d
Conmorsignedby :�� ,
Autbori tesmtsaive
APPROVED AS TO FORM
aura Stitt Sheedy
Assistant City Attorney
eo /L0 awd 3021`13S.tIj3439 6055- StL -6b6 EO t9I 50GL /LtFEO
CERTHOLDER COPY
STATE P.O. BOX 807, SAN FRANCISCO,CA 94142 -0807
COMPENSATION
INS UWAN C6
FUND CERTIFICATE OF WORKERS` COMPENSATION INSURANCE
ISSUE DATE: 06 -01 -2005 GROUP: 000723
CITY OF SANTA ANA SP
WORKCENTER ATTN: ANABELL YATES
1000 E. SANTA ANA BLVD., #200
SANTA ANA CA 92701
POLICY NUMBER: 0000075 -2005
CERTIFICATE ID: 1
CERTIFICATE EXPIRES: 06 -01 -2006
06 -01- 2005/06 -01 -2006
JOB: ALL OPERATIONS
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 30 days' advance written notice to the employer.
We will also give you 30 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 contract or other document
with respect to which this certificate of insurance 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.
X c .
AUTHORIZED REPRESENTATIVE PRESIDENT
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE.
ENDORSEMENT #001.5 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 06 -01 -2005 IS ATTACHED TO AND
`.FORMS A PART OF THIS POLICY.
'NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA SP
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06 -01 -2005 IS ATTACHED TO AND
FORMS A PART OF THIS POLICY.
EMPLOYER
BOYS. AND GIRLS CLUB OF SANTA ANA
950 HIGHLAND ST
SANTA ANA CA 92703
LEGAL NAME
BOYS AND GIRLS CLUB OF SANTA ANA
(A NON PROFIT CORPORATION)
InEV.3 -03) PRINTED: 05/17/2005