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Home My WebLink AboutMERCY HOUSE LIVING CENTERS (ESG 2003a) (2) ~NDMENTTOAGREEMENTFOR'l1SE A- z()ol.... OI.{,>,fJ'f-' OF EMERGENCY SHELTER GRANT FUNDS THIS AMENDMENT, made and entered into this 7"1i; day ofA<<il. 2003, by and between Mercy House Transitional Living Center, a California nonprofit organization~brecipient") and the of the City of Santa Ana, a charter city and municipal corporation of the State of California ("City"). RE.cIIALS A. The City and Subrecipient entered into that certain Agreement Between the City of Santa Ana and Mercy House Transitional Living Center for the Use of Emergency Shelter Grant Funds dated April 1, 2002, hereinafter referred to as "said Agreement", for Subrecipient to receive Emergency Shelter Grant Funds (ESG) in the amount of Twenty Thousand Five Hundred Dollars ($20,500.00) for the operation of an emergency shelter program for the homeless. B. The parties hereto now desire to amend the amount of the grant to increase it with an additional Five Thousand Five Hundred Ten Dollars ($5,510) for this fiscal year. This additional money is part of prior year funding that had been awarded to three subrecipients that were unable to expend their entire grant amounts in the federally mandated 24-month period. C. City Council authorized this reallocation at its regular meeting of April 7, 2003. 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 total Grant Award to Subrecipient will be amended to include the additional Five Thousand Five Hundred Ten Dollars, for a total grant award of Twenty Six Thousand Ten Dollars ($26,010.00) in ESG funds. 2. 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: A TRIClA E. HEAL Clerk of the Council CITY OF SANTA ANA UAtZ DAVID N. REAM City Manager f:3 "" ii: ....ffi~ .... N) :WL&.I. -" u..yC,) ~~ ZOZ:, 00::4...0:3l .:::::- 0.."'",0-""::,, .... >-:::>N CO". '-' "" ""'-~ u.. '<:f RCYHOUSE ~:;;~, 0 c:::: ::s::: .,..toJ\ :::'::.i4i =:l 0:: += ffi+- "'zoz .....iI< _3:::) un CJ>'! ~ O;L(~ 0~- APPROVED AS TO FORM: JOSEPH W. FLETCHER t4. ~ 'l" /17;:;::; _ i By: Lisa E. Storck Assistant City Attorney Name: V" Cl."j V\C.S Title: ~.eC.W::\\'IC~ 't>\(~c:lc ("'" ACOQ!)_ CERTIFICA TE OF LIABILITY INSURANC~Rgi~lH I DATE {MMlDOIYY} . 06/04/03 PRaOt'CER """ THIS CERTIFICATE. UED AS A MATTER OF INFORMATION . ONLY AND CONFER o RIGHTS UPON THE CERTIFICATE Huntington Pacific Ins. Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 18672 Florida St. Ste. 302D ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Huntington Beach CA 92648 INSURERS AFFORDING COVERAGE Phone: 714-841-6283 INSURED INSURER A: Great American Insurance CO. INSURER B: . - Mercy House Transitional INSURER C; 1T J'-1-1I?H7 -/(>'-;__ 7 J LivinR Center ETAL P.O. ox 1905 INSURER 0: Santa Ana CA 92702 I INSURER E: - \.uvr:i-<AGES 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 MAYBE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LlMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I~f~) TYPE OF INSURANCE POLICY NUMBER DATEIMMiDDrI?~t; I ",l'A"Ii~.l'~i6'6"rI?';" LIMITS ~~= EACH OCCURRENCE '1,000,000 A X COMMERCIAL GENERAL LIABILITY PAC653621S 05/02/03 05/02/04 FIRE DAMAGE (Any Olle fire) .200,000 CLAIMS MADE ~ OCCUR MED EXP (Ivlyone person) '10,000 PERSONAL & ADV INJURY .1,000,000 , , , I uE~~RAlAGGREG~I~ S;:, :.~~, CCtJ ~ -- ---+- GEN'L AGGREGATE LIMIT APPLlES PER: PRODUCTS. GQMPfOP AGG .1,000,000 !xl ,nPRO- n X POLlCY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT '1,000,000 I-"- (Eaaccidenl) ANY AUTO f-- - ALL OWNED AUTOS 800rl Y INJURY . SCHEDULED AUTOS (Per person) - PAC653621S 05/02/03 05/02/04 A ~ HIRED AUTOS BODILY INJURY . ~ NON.oWNED AUTOS (Per accident) PROPERTY DAMAGE . (Per accident) GARAGE LIABILITY AUTO ONLY. EA ACCIDENT . R ANY AUTO OTHER THAN EA ACe . APPROVED AS Tu r-u '- ~ ~. AUTO aNt Y: AGG . EXCESS LIABILITY ~j EACH OCCURRENCE . b OCCUR D CLAIMS MADE vi, AGGREGATE . Laur11 ShL~.. dy OJ'ht . . R DEDUCTIBLE P.,puty CilY At RETENTION . . I WORKERS COMPENSATION AND I ;'ocRW~I"Y-iS I IU~;;- EMPLOYERS' LIABILITY E.L. EACH ACCIDENT . .. , I Li._ DISEASE - [,.., .....i.., :'::;":":::i ... -- - - - I I e, L DISEASE. POLICY L1MrT I $ OTHER I DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDEO BY ENDORSEMENTISPECIAL PROVISIONS I\'ith respects to the additional insureds, this insurance shall not be cancelled or materially reduced in coverage or limits except after (30) days written notice has been given to the City of Santa Ana. C':-',,:-'~:j':-'r; .>i;-' ;'q:-,-: n~'-i -".'-' --p-.'... -'-.'--...-- City of Santa Ana, Community Development Agency M-25 Att: John Maloney P.O. Box B88 Santa Ana CA 92702-1988 I y I ADDITIONAL INSURED; INSURER LETTER: SANTANA CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ~'!f""' fe MAlL ~ DAYS WRITTEN NonCE TO THE CERTIFICATE HOLDER NAMED laTHE lEFT, ~ rjrfJJrt...".. Raf-. r~ pfif~r;IJ''''ft~JlBfl~~ 'rO'fTrJ"'I"rpf+I#sM CERTIFICATE HOLDER I ACORD 25-S (7197) AUTHORIZED REPRESENT~~E Don Heberden 1JJ(/'tV ~ @ACPRDCORPORATION 1988 4-),."J."r. __ "';'.#:'/.~>':i'"" "'" '-' IMPORTANT If the certificate holder is an ADDITIDNAL INSURED, the pOlicy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25.S (7/97) rI'<U', . ~HX NU. :tlq b4(-oJq~ :Jc. .J c:.t::.It:h:, ....L~-I 1..,.J ~ ". . " ""'" "-t/ ADDITIONAL INSURED ENDORSEMENT FOR COMM_ERCIAL miNERAL LIABILITY POLICY Insurance Company Great American Insurance Company This endorsement modifies such insurance as is afforded by the provisions of Policy # PAC6536218 relating to the following: 1. The City of Santa Ana, 20 Civic CenterPla7..a, Santa AM, 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 behalfllfthe named insured, 2, With respect to claims arising out of the operations and u.~es perfomted by or on behalf of the named insured, such insurance as is afforded by this policy is prirllllry 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 sui~ 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 organi7.ation 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 eovcrage 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 Mav 3, 2003 , this endorsement form as a part of PAC6536218 Mprry HOllse Transitional Livinq Center ETAL Named Insured Countersigned by Y{~'~ Authorized Represen ative Robin Hatfield - Broker APPROVJ:D'S' ", /', ~ .^" 10 FORM ~NY; , 'i -..- i I: , ( ~;Jur,l Sheedy 7'_______.' ) I~tnv C' . I . ~ ". ty A (forn~l' A CORD_ CERTIFICATE OF LIABILITY INSURANC~ CSR DH I DATE (MMlDDrtY) RCY-l 06/04/03 P~l'CER ... \..i THIS CERTIFICATE SUED AS A MA ITER OF INFORMATION ONLY ANO CONFER NO RIGHTS UPON THE CERTIFICATE Huntington Pacific Ins. Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 18672 Florida St. Ste. 302D ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Huntington Beach CA 92648 INSURERS AFFORDING COVERAGE Phone: 714-841-6283 INSURED INSURER A; Great American Insurance CO. INSURER 8: .J-- Mercy House Transitional Livini Center ETAL INSURER c: 1f ,1'-)-1 tJ.l52 -, (>L;" :a P.O. ox 1905 INSURER 0: Santa Ana CA 92702 I INSURER E: . \.vvr.:i-(AGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISsueD TO THE INSURED NAMEDA80VE FOR THE POLICY PERroo 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 ~~D CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IrTRI TYPE OF INSURANCE POLICY NUMBER I DATetMMlDDNYi" DATE rMM'i~DrN"i LIMITS ~r~ EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL lIABILITY PAC6536218 05/02/03 05/02/04 FIRE DAMAGE (Anyone fire) $200,000 CLAIMS MADE ~ OCCUR MEO EXP (Anyone person) $10,000 PERSONAL & ADV INJURY $1,000,000 , , , I ~c~~RAlAGGREGAI~ S ~ ,~';'~,C:':'''-j .. ---- GEN'l AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 1,000,000 'Xl '..0 PRO. nLOC - X POLICY JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 - (Eaaccidenl) ANY AUTO - ALL OWNED AUTOS BODilY INJURY - (Per person) $ SCHEDULED AUTOS - PAC6536218 05/02/03 05/02/04 A ~ HIRED AUTOS BODILY INJURY (Peraccldent) $ ~ NON.QWNEO AUTOS PROPERTY DAMAGE $ (Peracc:idenl) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ R ANY AUTO OTHER THAN EAACC S APPROVED AS Tv j-.\..} '\..~~. AUTO ONLY: AGG $ EXCESS LIABILITY ~h ",j", EACH OCCURRENCE S ~ OCCUR o CLAIMS MACE . AGGREGATE S Y LauV, "1'" "y ornt . " ...'IL.", =j DEDUCTIBLE poputy City At . RETENTION . . I WORKERS COMPENSAT'ON AND , I TORy'UMITSI I'ER EMPLOYERS. lIASlllTY E.l. EACH ACCIDENT . I I t.;.. DISEASE. [,;, '-~,:"::;";'::i .. I I re.l. DISEASE. POLICY liMIT J S OTHER DESCRIPTION OF OPERATIQNSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENOORSEMENTISPECtAL PROVISIONS l'iith respec ts to the additional insureds, this insurance shall not be cancelled or materially reduced in coverage or limits except after (30 ) days written notice has been given to the City of Santa Ana. '::7: ::::H,j::::O, k,:;-' ~'8:.;.:Otl:J CERTIFICATE HOLDER I y I ADDITIONAL INSURED; INSURER LETTER: SANTANA CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATlO.'J DATE THEREOF, THE ISSUING INSURER WILL ~~, j3 MAlL ~ DAYS WRITTH,' NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, ~ r'j,(~<JEt V' rfo,-~ rtf1 ~~"'V'rJj' r,~JlB}!.~~ 'Yn/f'rY'V'orPf+.t,l:.sM City of Santa Ana, Community Development Agency M-25 Att: John Maloney P.O. Box 1988 Santa Ana CA 92702-1988 I ACORD 25.S (7/97) AUTHORIZED REPRESENT~'7\E Don Heberden Ji)(/'r1J ~ @ACPRD CORPORATION 1988 '"11,..{ .-1/'. __ '-~''i!'~'-- . "" '-" IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed, A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLI\.IMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it ".. affirmatively or negatively amend, extend Of alter the coverage afforded by the policies listed thereon. ACORD 25-S (7/97) rt<U'1 Ii t-I-LX. NU. ; (lq-~ (--0;)4=-, .=Ie:: .L:7 4::.~~.c:. .L.....t:N"1l1 ~~ ;; '"'" ...,; ADDITIONAL INSURED ENDORSEMENT FOR COMMERCIAL UENERAL LIABILITY POLICY In~ur.mce Company Great American Insurance Company This endorsement modilies such insurance as is afforded by the provisions ot' Policy # PAr.6536218 relating to the following: '. 1. The City of Santa Ana, 20 Civic CenterPla7..a, 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 use.,~ performed by (lr (In behalf of the named insured. 2. With respect to claims arising out of the operations and uses perfo~d 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 sui~ is brought except with rcspect to thc company's limits of liability. The inclusion of any person or organization as an insured shall not affect any right which such person or organi7.ation would have as a claimant if not so included. . . 4. With respect to the additional insureds, this insurance shall nolba 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 effecti ve.) Effective Policy # Issued to Mav 3. 2003 , this endorsement form as a part of PAC6536218 M~rr:y t!Cltl<;e 'I'ransitional Livinq Center ETAL Named Insured Countersigned by 'i5~'~~ Authorized Represen ative Robin Hatfield - Broker APPROVfOD .' '. . / ". ~ !-,~ 10 FORM ;{2"'Y; . , '".' - ,.:,.. f {; {1 (. .-'1Ur,l Shccdv -7______ ~ Ill/tv C' . / . ~ ..ry At(OfnQ\, NOV-05-2002 03:20 PM r . C':iI House- '-' 714 36 7901 'wi P.02 Hur~ington Pacific Ins. Agency ~B672 r10rida St. Ste. 304D Huntington Beach CA 92.48 ... ACORD. ..CSRrJFICAJJ$OF:j.JABlldtYJN$ORANCE~$R'.~~.... ....... ................ .. ......... .................... ..................... ....................... ............... ...~\<c:!)r. J. ..... 05/03/02 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE DATE (MM/COIVY) Robin Hatfield Phon. No 714-841-6283 INSUREO 'ox No. 714-842-2538 A -26a2-.0S".Z(, JfI -2bCl. -"C/~ -~q Mercy House Transitional Living Center IlTAL A-./24n-dY3-~~ P.O. Box 1905 Santa Ana CA 92702 COMPAN)' A Great American Insurance Co. COMPANY B COMPANY C ~OVERAGEi?':.: .. ::: .. ." .. '.. .....: ..:::.. . ...........::.::....:.... ..' ::: :.::... . .... THIS IS TO CERTIFY THAT THE POL.IClES OF INSURANCE LISTED BElOW HAVE BEEN ISSUED TO THe INSU~D NAMED ABOVE FOR ntE POL.ICY PERIOD INDICA TED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION Of ANY CONTRAcT OR OTHER DOCUMENT 'vYITH RESPeCT TO WHICH THIS CERTIFICATE MAY Be JSSUEO OR MAY peRTAIN, THE &NSURANCE AfFORDED BYTHe POLICIES DESCRIBED HEREIN IS SlI!JecT TO ALL THE TERMs. EXCLUSIONS AND CONOITIONS OF SUCH POLICIES. LIMITS SHOWN MAV fiAVI: ~19i REDUCED BY PAID CJ.AIMS. COMPANY o co LTR . TYPE OF INSURANC' POL.ICY NUMBER ~OLICYEFFECTIVE POUCY€XPIftATION DAT! (MWOOJYY) DATE {MMIO-'/'r"i) LIMITS ~ERAL LIABILITY A X COMMeRCIALGENERALL.IA8IUTY PAC65362l8 2W ClAJUS MADE [jJ OCCUR _ OWNER'S & CONTRACTOR's PROT n'NeL nOCl ADDDnVFI) AS HI FORI\; ~LJ/d/~ Lllura Sheedy I Deputy City Attorne GENERAL AGGREGATE $2,000,000 05/02/02 05/02/03 PRODUCTS. COMP/OP AGG '1,000,000 PERSONAL & ACV IHJURY sl,Ooo,ooo EACH OCCURRENCE 11,000,000 FIRE DAMAGE (Any ~ Ira) '200,000 MED EXP (My one~) '10,000 COM8INED SlNGL.e UMrr '1,000,000 BOOIlY INJUA:Y . (Perpet1on) 05/02/02 05/02/03 BeOIL Y IHJURY . (Pefilcclden4l PROPERTY OAMAGE . AUTO ONL. V. EA ACCIDENT iz OTHER THAN AUTO ONLY: EACH ACClDEHT . AGGRfGATE . EACH OCCURRENCE . AGGREGATE . AUTOMOBItE LLABJUTY ~ A....V AUTO ALL OWNED AUTOS f- r-- SCHEDUl.EO AUTOS A ~ HIRED AUTOS _~ NON-OWNEtI AUTOS PAC.53.218 ~RAGE LIABIL.ITY _ ANY AUTO - EXCess lIABILITY RUMBRElLA FORM OTHEA THAN UMBRELLA FORM WORKEAS COMPENSATION ANO EMPL.OYERS' L.IABILITY THE "RQPRIETORI PARTNE~ECUTNE OFFICERS ARE: OTHER . IOJ~' .....:...:.:>:......:...::::::.::... . . EL. DISEASE. EA EMPL.OYEE $ lY;Co~~~lJI;, I EL EACH ACCIO&NT El 04SEASE. POUCY LJMIT OESCRJPTION OF OPERATION'SflOCATIONSlVEHJClESlSPECIAL.ITEMS With respects to the additional insureds, this insurance shall not be cancelled or materially reduced in =verage or limits except after (30) days written notice has beet1 given to the City of Santa ana. CERTIFl<;AtpI:IOLDER::::::::.: .... .... ... .... .. ..:................ .. ...:::<c.<\NGEL!;!l:T:!Q"F:;:::;::,:.:::.........::::. ... :: ... ..:....::..... ....... City of Santa Ana,~nitY Development Agenc~ ~25' Att: John Maloney P.O. Box 1.988 Santa Ana CA 92702-1988 SANTANA SHOULD ANY OF THE ABOVE DESCRIBED POL.ICIES BE CANCEL.LED BEFORE THE fXPJRATION CATE THEREOF. THE ISSUING COMPANY WIL.L .,t/'IJfnctMAIl 30 DAYS Yo"A:lTTeN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE L.En, ~wr"~J?<~~~~~ ......... ............... ..~. AUTHORIZED REPREseNTATIVE ACPRi:j:2:;;$'ll~)..:.. Robin Hatfield ,.,.,. .,,'" ..... 'O!U>oIlAilON::i91ia: ........AWRPCJ........... .... .... , NOV-21-2002 C314:11 PM M......c.... House 714 S36 7901 p..e3 11120/2082 22:56 7148~538 <I 'wi PAGE 02/02 rora.rr ; f1:ll( In 17U-647-Ei34S Sep. 15/ 2ee2 11: UlAI1 l"3 ADurnONAL INSURRn RNDORsBMEN'l' FOR COMMRRCTAf. OnNHRAL trARrLtrY ..OLlCY In!I1TiIIlCl: ComptllY GrGat Ameri.can Insur= Corr;>&ly This tndorsmx:nt modifies S1.lch iniW'UICC as is afforded by tho l'fOvislOllS of :Policy # PAC65:l6218 re1atine: 10 the /bitewing: I. The City ofSanlllAn., 20 Civic Centa- Plaza, SllJ)ta AlllI, r::allfmnfa 92701; ill officcrs, emplU)'llel, apnlI, vohmlNrs IlIIcl ropll:llel\tII&iv;a Ill: lI8llliXI BlI additlonal ilUlUl'llda ("&dd!tlotW iIlaun:ds') wi1l1 rcgsrd to UabUlly tIl4 dcfcnso of suits arIsIDaJ from lh= opcratiolW and IlilllS pcriHmlld by 01' on belwlf nr the IIlIIIIed IIlSUI'ed. 2. With ~ to claims arls1ns out of lhc opcrat:1011S lIIld "'*' JloWlI..,.u<<l by 01' on bdIAIf ofthellllllJlld mt=nd, IIIlOh inSlll'lll1ce III is Ilfl'orded Il7Ibis poiie)' iI ptitnary Md Is not additional 10 or COIla\lluUnj: with any OIber il1JtIl'8IlCC caniccI by or ~ the bene:!it of'tbe lKIdi\iQllll1IDsulllCl.. 3. 'Chis imunnce applies seJ*llle!)' to cId1l.11S111'Od ,.,.;"'11: whom l~altn IllIlade or I1IIt is btoU&ht except w1111 tcIp!lCt to tbe ClJmplIIIts limits of liability. The IncluelOA of llIlf pIlrson or ol'pDilOlllioo U III insuTcd shall n(lt .ff""t MY rlght which luc:h pcmm or orpnlzatlon -ul4 hivll .. .. oleimam If not 10 IncJ\ldQd. 4. With rupeet 10 the additicmallMuredsj this ins~ sbalJ not b<l cll11celled, 01' materillly reduced in COVI%lIgc or !imitlllXcopt 8fIl:r thirty (30) days written notlet 1uas beea GJV1lD to the City ofBmta Ana. 20 Civic CmrtarPboza, &uta AiIa, Cr.Iifmnia 92101. (Com,pletlOll of the following. including ClOC.IlMrsipture, i8 requirecl to make this cndorscm6Ilt effel;tive,) Et!'ccdve Poli"l' # lssl1cd to MaV 3. 2002 PAC6536218 Morr:y Hem".. ~ansit100al Livinq Center ETM. Named InslU'Cd .1:hI, cndoncmcnt Ibrm as ~ part of C01llllcfliaDodby 1., ~^~.tL uthorl~ ~e vtl Robin Hatfield - BrOker APPROVED AS TO FORM . AJt/tl~t; L".(ira Sheedy , f)':j1!lty City Attorney ::~.:~.:t.:,.':t.'.:;//~~.~t:',?:,::)\~,~~':~:'f~~5l.\t~}:"~;-;~2~ji\';~:~:'~~.'/"::';~::~'~";:' '_'J, ,. ~..,. v' ". .'.., \:,-~..". I" ". ~Jf~" '.n "",_ X",> S:,.; . " , ,,//.- .. .'. .' .';":"';:e;:"~t;'~:1;:'~ff;::.~.~,!:~'~~;;~:t.1;'0K~1;~~~ :(;': -S(fAT.:L~i:,p:o.~'80t:SAN FRANCisco,CA 9410 1-0a07,>;<:-.};.,;,<:( - .. <F~,,',,;:. '1 < COMPEN'SA"T:ION \, '""":. '-;J '/' '~;..~' ;:",~" :~_. -,""". '~ ,,.. _ INS U RAN o'e Be,', "':'~:i'" \ ; ( F U'N ,0 CERTIFICATE OF,WORKERSi'COMPENSATIOI\IIN;URANCE 1.",,0" r:i :~.~ . ':'. ,'~~ --. , , POLICY NUMBER: 1209902 - 02 ISSUE .DATE: 10-01-02 CERTIFICATE EXPIRES: 10-01-03 C.ITY OF SANTA ANA COMMUNITY'DEVELOPMENT AGENCY /1-25 POBOX 1988 ATTN JOHN,MALONEY SANTA ANA CA 92702 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'adva,.,ce notice should this policy be cancelled prior to its normal expiration. This certifi~ate:~bf;'inslir:.~ric:e _ is,nat_an i~surance policy and does not amend. extend' or alter_ the.,co~e'rag~ "afforded by the poJicjes'li~ted herei~~_:J"otwithstanding anv.,-f.e_quire_/'lI4:!nt. term. or condition of any contra,cLer ether docurT!enL_. with respect to Which this certificate of irisurarice may. be ;i,ssued or may 'pertain,,-'the insurance afforded ;bv. the' policies de:scribed herein is subject to all ~he t~rnis. exclusiQns and conditions of such policies. o ' " ,;.- ". . .~/' ,~. ~ /1>/7 1/i/ ";.'L4'~ ...... ;" ',PRESIDENT , ,,' . r EM~LOVE~.'\LIABI~IT)' L'IM,IT INCLUDING DEFENSE CD~TS: $rOOO.Oll~.OO P~RlCF~RENCE. "ENDoRSEMENT"'206S '~NTI1rL~DCERTIFICATE HOLDERS' 'NOTICE EFFECTIVE'"10/01/02: IS ATTACHED .TO AND FORMS A PART 'OF' THIS poqCY 0;' . ... ", "- 'i .... , , . APPROVED AS]O FORl'vi ):~;.~7 Deputy C:ry J\ttorne'y LEGAL NAME EMPLOYER " MERCY,HOUSE TRANSITIONAL LIVING CENTERS f PO BOX 1905. i . " SANTA ANA CA'92702 MERCV, HOUSE'. TRANSITIONAL ,LIVING CENTERS (A NON-PROFIT'ORG, h' .. ..... ,., " ,,;;~~~;~'~~~_f~~~~j --:,~;>--:' :'~/;.,;_/ .,;' ,.:- :~::i<'.~~~~,;'.~:~~>:~;-, -. ".,~, -< ; . .' '.. . i' . '. ...<, ;";;'6::r~;02/ 1':ilillf'~IJlfjl~~..:"l-~~,j;t:l{.j=lIit,~.~:t~',~'I:ro~~<~<;i.~:'~~~~'~jl~" :i~;~~I;~~J:.~ .""" ...,; SP S'TATE CO......PENsA'rrON INSU~ANCE FUND CERTIFICATE <~Fi WORKEFlS'COMPENSA TION)NSURANCE ) .j ISSUE DATE: 10-01-02 POLICY NUMBER: . 1209902 - 02 CERTIFICATE EXPIRES: 10-01-03 Cn(OF SANTA. A.NA. COMl'\UNTTV "DEVElOPMENLAGE~CYM-25 POBOX. 1988 /' iA.TTN.';OHN,MAlONEY SANTA A.NA.CA ,92702, . 'h ;, 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' ,ldvI'nee written' notice to the employer. ,-,,:' .' We will also give YO~39'da)"sf' aqva?CEI notice shouldthis _policy be cancelled prio'r to .;its -norrnalexpiration, .:. .'.....,. .:" ,'" :, .,- '-: '-,' ,:":., -, This certif'lcate'bf.fins'~(~rtc,~,_is,nCft_,~nirisurance,'policyand does not amend~ eXl~m1i'or'",,,lter__th~,p~yerage afforded by the pqlicjes listed hereip:,Nptwithstandir}QanY"f!3QU,ire.mfmt. term.orcoQditi_oF') Q,fany contract, or other docu~_enL<, with resp(i!:ct to which this certificate of insursnce,,.,,ay be "i~suedormay pertain.:-'the insurance afforded:by the ~ policies de~ci-ibed herein is sUbject to all ~he t~rrns. excl~siqns ,and conditi~ns of ' such policies. t- t >, ;:) co" '..// d~ ~isIDENT '..~, ',~, EMPLOYER'S LIABILITY L'lMIT INCLUDING DEFENSE CDSTS: $1;000',000.00 PER,DCCURRENCE. >: ' - ~., 1/-,\"-,; _'~'--." > ;" ",;: . ENOORSEMENT #2065 ~NTiTL"D CERTIFICATE HOLDERS'NOTICE EFFECTIVE '10/01/02 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. " . \ '.' . " . .. \ Cy6~ ~ -lt~ ~ E"SGj , ~~: ""''t r~N..~i ~~. " Ai'l'ROVED AS TO FORM -~Luh L~~~heedY, ... ...... Deputy City Attorney EMP~OYER OL..~o3 LEGAL NAME MERCY'HOUSE TRANsITIONAL LIVING CENTERS . ; PO BOX 1905 . , .. SANTA ANA CA 92702 MERCY,HOUSE.TRANS;TIONAL LIVING CENTERS (I< NON-PRDFIT:ORG; ) 'J ..: ~ . . , .. THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND selF I026StREV 2",1) 'b9~i 8-02