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Home My WebLink AboutLE, CHOC 2JCity of Santa Ana Clerk of the Council AGREEMENT TERMINATION FORM ._ nrvl� 3' i Please complete this form when the attached agreement and all amendments (if any) are no longer in effect. Return form to the Clerk of the Council Office (M-30). Call 647-6520 if you have any questions. The agreement with Le, Choc ail f<1. COTC Office Use Only No. A-2004-122 (�2&)' was completed on 6/30/09 and final payment has been made. (List all amendments. Use space below if needed.) /p� Czf) (29) A-2005-149, A-2006-145, A-2004-122-03,011) ' Department: PRCSA f-A-2004-122-04,tA-2004-122-05 t2f) t2j) - Phone/Ext.: 5254 0-2000-(WbC2.) core '+A•2003.WC20 +N-2001-101Jc24)' 4A•2003-197 t N-ISO 2.-047 CZb)' Signature: S1A��(i� P��+imtly� Date: Revised 08-23-10 INSURANCE NOT ON FILE WORK MAY NOT PROCEED CLERK OF COUNCIL DATE.. 5. 0 ?&, ks R C.�r. (z) FIFTH AMENDMENT TO AGREEMENT A-2004-122-05 THIS FIFTH AMENDMENT TO AGREEMENT is entered into on April 24, 2008, by and between CHOC LE, a sole proprietor ("Consultant") and the City of Santa Ana, a charter city and municipal corporation of the State of California ("City"). RECITALS: A. The parties entered into Consultant Agreement A-2004-122, dated June 21, 2004, (hereinafter "said Agreement") by which Consultant has provided martial arts instruction for participants registered through the City's Parks, Recreation and Community Services Agency. B. In accordance with the terms and conditions of said Agreement, the parties wish to extend the term for an additional one-year period. WHEREFORE, in consideration of the covenants contained in said Agreement, and subject to all the terms and conditions of said Agreement, except those amended in this Fifth Amendment to Agreement, the parties agree as follows: 1. Section 3, TERM, shall be amended to extend the termination date from June 30, 2008 to June 30, 2009. 2. Except as herein amended, all terms and conditions of said Agreement shall remain in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this Fifth Amendment to Consultant Agreement on the date and year first written above. ATTEST -wPATRICi ' . HEALY Clerk of the Council APPROVED AS TO FORM: JOSEPH W.FLETCHER City Attorney Laura Sheedy, Asst. City ttomey CITY OF SANNTTA ANA GERARDO MOU Executive Director - PRCS Owi CH C LE r ACORDDATE (MA IWYY) CERTIFICATE OF LIABILITY INSURANCE 0111512008 M PRODUCER Phul»: (600)395-6075 Fare (658)519-0 22 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION FITNESS AND WELLNESS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 380 STEVENS AVENUE, SUITE 206 HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. SOLANA BEACH CA 92075 i I INSURERS AFFORDING COVERAGE NAIC 9 tgEcc ucR:03ltf_5 --i -- __ "NSURERA: Philadelphia Indemnity lnauzanCB Company INSURED CHOC V. LE 1,NSURER B: 4 FABRIArNC INSURER C -------_ IRVINE CA 92620-2576 -""--- _ -- INSURER❑ INSURER E GOVCHnlaea THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEJ TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING OTHER DOCUMENT 'I RESPECT TO WHICH THIS CERTIFICATE MAY SE ISSUED OR ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR THE POLICIES DESCRIBED HEREIN IS SUBJECT. TO ALL THE TERMS. ExCLUSIONS AND CONDRIONS OF SUCH MAY PERTAIN. THE INSURANCE AFFORDED BY POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. RIXICY Will ro.TLY FJVAIAmN LIMITS A aw TYPEOFINSURANCE POLICY NUMBER L-Vi IMS1 WTE NY100 i GENERAL LIAl PHPK215316 12117/07 12117/06 EACH OCCURRENCE IS 1,000,000 DAMA6E1'OAEMEC 100,000 X COMMERCIAL GENERAL LIABILDYi PREMISE¢ M.+ CLAIMS MADE CX,I OCCUR: MEO..EXP IMARY y..wAparsw) Y _2,500 PERSONAL 8 ADV INJURY IS. 1,000,000 A _ GENERAL AGGREGATE JS 3,000,000 I GI AGGREGATE LIMIT APPLIES PER; � I PROOUCTSLOMPIOP AGO 13 31000,000 PRO � X ; POLICY n JECT `LOCI I ADTOMOBAE LABILITY COM&NED SINGLE LIMIT 5 ANY AUTOBOO IEA octldenLl ._ ALLOWNEDAVTOS (P., INJURY (Par LY N.I IS SCHEDULED AUTOS y HIRED AUTOS IBOOILYWIURY 1 IlPer actidenl) 40N-0'NNED AUTOS I , - PROPERTY DAMAGE 5 _ I I I � actidenl) GARAGE LABILITY II',fPEr (AUTO ONLY FAACCIDENT.__ IE rrAUTO GTHERTHM EA 1 ANY AUTO I ONLY: II— f EACH OCCURRENCE EXCFBS]UMBRELLA WBILRY ., r_ --I1 'AGGREGATE IS OCCUR CLMMSMADE IS DEWCTIOLE _ ETEMION S 5 ;WORIfER9 COMPENSATION AND Iw<Enm (OTHER 'r—ITCH DNITEI _ EMPLOYERS LIABB-RY EL. EACH ACCIDENT S `ANr RRaPRMTaaPAATnCe1rvE '.i*IHI.M MEIIBEII EXCLUOEEf ''NY.•.d�etl4•unY. //��i�. EL. DISEASE -EA Pill S IErtC1AL PPd/1lrONE Ltlaa t. ' / E.L. OISEASEPOLIW LIMIT i1 (ENDORSEMENT/ DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIEXCLUSIONS ADDED BY SPECIAL PROVISIONS SEE SUPPLEMENTAL CERTIFICATE INFORMATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE OBSTWICATE HOLDER NAMED TD THE LEFT. al FAILURE Community RedeVelOPment Agency TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE WSURER. of the City of Santa Ana ITS AGENTS OR REFRESENTATNES. 20 Civic Center Plaza (M-25) Santa Ana CA 92701 AUTHORIZED REPRESENTATNE Attention: Jeffrey E. Frick, CEO ACORD 25 (2001108) Certificate R 67706 0 ACORD CORPORATION 1988 DATE SUPPLEMENT TO CERTIFICATE OF LIABILITY INS #67706 JAN1508 DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES!SPECIAL ITEMS It is understood and agreed that the The City of Santa Ana, it's agents, officers, employees, volunteers and representatives are added as an additional insured but only as respects the operations of the named insured except that liability resulting from the additional insureds sole negligence. This insurance Is primary and non-contributory to any other insurance hold by the insured. Additional Insured Endorsement is Effective: 12117107 CG 20 10 1185 DATE: JAN 15 08 POLICY NUMBER: PHPK215316 INSURED NAME: CHOC V. LE 4 FABRIANO IRVINE CA 92620-2576 THIS ENDORSEMENT CHANGES THE POLICY- PLEASE READ IT CAREFULLY ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (FORM 8) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Job/Project: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) WHO IS AN INSURED (Section 11) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out Of "your work' for that insured by or for you. Primary Insurance it is agreed that such insurance as is afforded by this policy for the benefit of the additional insured shown shall be primary insurance, and any other insurance maintained by the additional insured(s) shall be excess and non-contributory, but only as respects any claim, loss or liability arising out of the operations of the named insured(s) or its subcontractors, and only if such claim, loss or liability is determined to be solely the negligence or responsibility of the named insured. Notice of Cancellation or Non -renewal it is agreed that the company will provide the additional insured shown below with 30 days notice of cancellation of this policy in the event of cancellation due to company election only. WAIVER OF SUBROGATION It is agreed that we waive any right of recovery we may have against the person or organization shown in the schedule because of payment we make for injury or damage arising out of 'Your work' done under a contract with that person or organization. The waiver applies only to the person or organization shown in the schedule. SCHEDULE NAME OF PERSON OR ORGANIZATION City of Santa Ana, We Respective Officers, Employees, Agents, Volunteers and Representatives. 20 Civic Center Plaza (M-25) Santa Ana, CA 92701 Amid, Sandra From: Thompkins, Carla Sent: Tuesday, December 09, 2008 11:09 AM To: Amici, Sandra Cc: Schultze, Donna; Valadez, John Subject: FW: Scanned from Toshiba350 12/09/2008 11:51 Attachments: D00081209.pdf Attached for your files is the updated approved insurance certificate for Choc Le (Agreement No. A-2004-122-05). Carla Mack-Thompkins Management Aide City of Santa Ana Parks, Recreation & Community Services Agency 888 W. Santa Ana Blvd., #200 Santa Ana CA 92701 Tel: (714) 571-4222 * Fax: (714) 571-4209 E-mail: cthomokins(dsanta-ana.org 1 ACORD I DATE (MRVOD/YYYYI TM. CERTIFICATE OF LIABILITY INSURANCE 1�J0sre0oa FITNESS AND WELLNESS 380 STEVENS AVENUE, SURE 206 SOLANA BEACH CA 92075 INSURED CHOC V. LE 4 FABRIANO IRVINE CA 92620.2576 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 INSURERS AFFORDING COVERAGE 1 NAIC # Insurance THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERM INDICATED, NGTVnTISTANDING ANY REGUIREMENT, 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 POLICES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EyRN Lm Pppt TYPEOFINSURANCE POLICY NUMBER POLCYEFFECTNE DATBx POLIGYEUmWTEIN DAnimmucrn LIMITS A GENERALLIABILITY X COMMERCIAL GENERAL LIABILITY CLFIMSMADEO OCCUR PHPK284105 12/17/08 12I17f09 EACH OCCURRENCE $ 1,000,000 DMMOE TO RENn:O PREMISE$ ENTEDro $ 1D0,000 MED. EXP(my we Person) $ 2,500 PERSONALS ADV INJURY $ 1.000,000 GENERALAGGREGATE $ 3,000,000 G£N'L AGGREGATE LIMIT APPLIES PER X POLICY JE TT LOCH PRODUCMCOMPIOP AGO. $ 3,000,000 AUTOMOBILE LIABILITY ANY AUTO ALLOWNEDAUTO$ SCHEDULED AUTOS HREDAUTOS NON-0CWNEDAUTOS COMBINED SINGLE LIMIT (EiI=idenl) S SCOLLYINJURY (Perpersonl S SODLYINJURY (Peram4ent) $ PROPERTYDAMAGE (PerI=id9-1 $ GARAGE LIABII/TY ANYAUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC AUTOONLY: AGG $ $ EXCESSfUMSRELULIABILITY OCCUR �CWMS MADE DETECTIBLE RETENTION 8 - 1`r ''-P / _ EACH OCCURRENCE $ AGGREGATE $ $ g WORHERSCOMPENSATIONAND EMPLOYERS' LIA&DTY AXYPROPRETOENARTNEWEItECOFNE OFFICERxRXIeXA e%CLIMFOt Yx SPECIAL IALP Fwd,r PROVaa1N8 Mbw IY /11f,:; ,�„V WC STAT TONYEWT$ OTHER E.L. EACH ACCIDENT S El- DISEASE -EA EMPLOYEE E E.L. DISEASE -POLICY LIMIT E OTHER: DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS SEE SUPPLEMENTAL CERTIFICATE INFORMATION CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORETNE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL W DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO COmmunity Redevelopment Agency DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY NND UPON THE INSURER, II'S of the City Of Santa Ana AGENTS OR REPRESENTATIVES. 20 Civic Center Plaza (M-25) AUTHOJZED REPRESENTATIVE Santa Ana CA 92701 Cel • Attention: Jeffrey E. Frick, CEO ACORD 26(2001/DB) Certificate# 85130 0 ACORD CORPORATION 11988 DATE SUPPLEMENT TO CERTIFICATE OF LIABILITY INS #85180 DEC 508 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS It is understood and agreed that the The City of Santa Ana, it's agents, officers, employees, volunteers and representatives are added as an additional insured but only as respects the operations of the named Insured except that liability resulting from the additional insureds sole negligence. This Insurance is primary and non-contributory to any other Insurance held by the Insured. Additional Insured Endorsement Is Effective: 12717107 Certificate N 85180 CG 20 10 1186 DATE: DEC 5 08 POLICY NUMBER: PHPK284105 INSURED NAME: CHOC V. LE 4 EABRIANO IRVINE CA 92620-2576 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Job/Project: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section 11) is amended to include as an Insured the person or organization shown in the Schedule, but only with respect to liability arising out of "yourwork" for that insured by or for you. Primary Insurance it is agreed that such insurance as is afforded by this policy for the benefit of the additional insured shown shall be primary insurance, and any other insurance maintained by the additional insured(s) shall be excess and non-contributory, but only as respects any claim, loss or liability arising out of the operations of the named insured(s) or its subcontractors, and only if such claim, loss or liability is determined to be solely the negligence or responsibility of the named insured. Notice of Cancellation or Non -renewal it is agreed that the company will provide the additional insured shown below with 30 days notice of cancellation of this policy in the event of cancellation due to company election only. WAIVER OF SUBROGATION It is agreed that we waive any right of recovery we may have against the person or organization shown in the schedule because of payment we make for injury or damage arising out of "your work" done under a contract with that person or organization. The waiver applies only to the person or organization shown in the schedule. SCHEDULE NAME OF PERSON OR ORGANIZATION Community Redevelopment Agency of the City of Santa Ana 20 Civic Center Plaza (M-25) Santa Ana CA 92701