HomeMy WebLinkAboutDISPLAY CITY, INC. 2City of Santa / [ C 2004
Clerk of the Council
AGREEMENT TERMINATION
Please complete this form when the attached agreement is no longer in effect.
Return form to the Clerk of the Council Office (M-30).
Call 647-6520 if you have any questions.
------------
agreement with any -
No.
N-2008-109-01
and final payment has been made.
N- nos -coq
�,W 1M7�
..V
was completed on
Department
Phone/Ext.: �Cn "► • /t
Signature:
Date:
INSURANCE ON FILE
WORK MAY PROCEED
UNTIL INSURANCE EXPIRES
to
-L
CLERK OF COUNCIL
DATE: R-99-6'
o CDA AA�;1. (D)
(- 41 Lvme k
CONTRACTOR AGREEMENT
N-2008-109
THIS AGREEMENT made and entered into this 22"d day of July, 2008 by and between
Display City, Inc., a California corporation (hereinafter "Contractor"), 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 contractor having special skill and knowledge in the field
flag and banner installation.
B. Contractor represents that Contractor is able and willing to provide such services to the
City.
C. In undertaking the performance of this Agreement, Contractor represents that it is
knowledgeable in its field and that any services performed by Contractor 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
Contractor shall provide install flags and/or skyline banners along 4`h Street in Santa Ana,
as set forth in Exhibit A to this Agreement. City may request additional services, in writing,
during the term of this Agreement.
2. COMPENSATION
a. City agrees to pay, and Contractor 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 $10,000.00 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,
2009, unless terminated earlier in accordance with Section 12, below. Flag and banner
installations provided by Contractor since July 1, 2008 shall be included in the Scope of Service
of this Agreement. The term of this Agreement may be extended upon a writing executed by the
Deputy City Manager for Development Services and the City Attorney.
4. INDEPENDENT CONTRACTOR
Contractor 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
Contractor performs the services which are the subject matter of this Agreement; however, the
services to be provided by Contractor shall be provided in a manner consistent with all
applicable standards and regulations governing such services. Contractor 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, Contractor shall
maintain and shall require its subcontractors, if any, to obtain and maintain insurance as
described below:
a. Commercial General Liability Insurance. Contractor 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 Contractor'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. Contractor shall supply City with a fully executed
additional insured endorsement in substantially the form attached hereto as Exhibit B upon
execution of this Agreement and shall be approved in form by the City Attorney.
b. Business automobile liability insurance, or equivalent form, with a combined single
limit of not less than $1,000,000 per occurrence. Such insurance shall include coverage for
owned, hired and non -owned automobiles.
c. Worker's Compensation Insurance. In accordance with the provisions of Section 3300
of the Labor Code, Contractor, if Contractor 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, Contractor agrees to obtain and maintain any
employer's liability insurance with limits not less than $1,000,000 per accident.
d. The following requirements apply to the insurance to be provided by Contractor
pursuant to this section:
(i) Contractor 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.
e. If Contractor 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 Contractor's right to be paid for its
time and materials expended prior to notification of termination. Contractor 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
Contractor agrees to and shall indemnify and hold harmless the City, its officers, agents,
employees, contractors, special counsel, and representatives from liability 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 Contractor or its contractors, subcontractors, agents,
employees, or other persons acting on their behalf which relates to the services described in
section I of this Agreement.
CONFIDENTIALITY
If Contractor receives from the City information which due to the nature of such
information is reasonably understood to be confidential and/or proprietary, Contractor 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 Contractor disclosed in a publicly available source; (c) is in rightful possession of the
Contractor without an obligation of confidentiality; (d) is required to be disclosed by operation of
law; or (e) is independently developed by the Contractor without reference to information
disclosed by the City.
8. CONFLICT OF INTEREST CLAUSE
Contractor 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 Council
City of Santa Ana
20 Civic Center Plaza (M-30)
P.O. Box 1988
Santa Ana, California 92702
Telefacsimile 714-647-6956
With courtesy copy to:
Executive Director of the Community Redevelopment Agency
City of Santa Ana
20 Civic Center Plaza (M-25)
P.O. Box 1988
Santa Ana, California 92702
telefacsimile (714) 647-6736
To Contractor: Display City, Inc.
5507 Windward Avenue
Long Beach, California 90814
telefacsimile (562) 961-5659
A party may change its address by giving notice in writing to the other party. Thereafter,
any communication shall be addressed and transmitted to the new address. If sent by mail,
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, 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 local holidays shall be
excluded.
10. EXCLUSIVITY AND AMENDMENT
This Agreement represents the complete and exclusive statement between the City and
Contractor, 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 Contractor. 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 Contractor 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 Contractor,
Contractor 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 contractors retained by City.
12. TERMINATION
This Agreement may be terminated by the Agency upon thirty (30) days written notice of
termination. In such event, Contractor shall be entitled to receive and the City shall pay Contractor
compensation for all services performed by Contractor 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
Contractor 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. Contractor 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 determined and governed by 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
Contractor 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. Contractor shall notify the City
immediately and in writing of its 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 fully set
forth in the body of this Agreement.
W WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year
first above written.
ATTEST:
IC
IC Z
PATRICIA E. HEALY
City Clerk
APPROVED AS TO FORM:
JOSEPH W.FLETCHER
City Attorney
By: v
Laura Sheedy
Assistant City Attorney
RECOMMENDED FOR APPROVAL
ta"
l� YNTHItJ J. NELSON
v Deputy Ny Manager for
Development Services
CITY OF SANTA ANA
`4
DA V ID N. RE
City Manager
DISPLAY CITY, I
ERIC PETERSO
Principal
Tax ID# �3-42't9�73
August
.Overhead Sidewalk Sale 2 425.00 850.00
September
5- 9 Am Flags
Labor Day
35 11.50
EXHIBIT A
October
Flag Schedule 2008 verison 1.0
Santa Ana 4th Street Project
Sidewalk sale
Display City, Inc.
85o.00
November
Up- Down date
Type
Event
Quantity
Vetrans Day
35 11.50
January
16-2o
Am Flags
MLK Birthday
35
10.00
350.00
February
13-17
Am Flags
Presidents Day
35
10.00
350.00
March
scheduled-fmm 7/1/08-12/31/08
April
May
22-26
Am Flags
Memorial Day
35
10.00
350.00
June
12-15
Am Flags
Flag Day
35
10.00
350.00
16-23
Overheads
Sidewalk Sale
2
400.00
800.00
July
June 30 - July 7
Am Flags
4th of July
35
10.00
350.00
August
.Overhead Sidewalk Sale 2 425.00 850.00
September
5- 9 Am Flags
Labor Day
35 11.50
402.50
October
Overhead
Sidewalk sale
2 425.00
85o.00
November
10 -12 Am Flags
Vetrans Day
35 11.50
402.50
Overhead
Sidewalk Sale
2 425.00
850.00
1
December Overhead
Sidewalk Sale
2 425.00
850.00
Dates for Sidwalk Sales yet to determined, tentatively 4
scheduled-fmm 7/1/08-12/31/08
7
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
4 relating to the following:
I . 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 g _
Issued to
this endorsement form as a part of
Named Insured
Countersigned by
Authorized Representative
eC hhAAC' CZ12o1K + M.0 2-9
DATE (MMIDOAY)
03/05/08
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
PRODUCER
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
BLISS & GLENNON, INC.
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
C/0 GIAMMONA INSURANCE AGENCY
2641 CROW CANYON ROAD #6
COMPANIES AFFORDING COVERAGE
SAN RAMON CA 94583AANAUTILUS
INSURANCE COMPANY
INSURED
COMPANY
DISPLAY CITY, INC.
B
5507 WINDWARD AVE
COMPANY
LONG BEACH, CA 90814
Q
COMPANY
D
TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
THIS
THIS IS
NOTWITHSTANDING ANY REQUIREMENT, TERM OR
CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH
INDICATED, BY THE POILICIES DESCRIBED IS SUBJECT TO ALL THE TERMS,
PERTAIN, THE HOWN AYY
MCE
HAVE BEEN REDUCED BY PAID CLAIMSORDED
AND SUCH POLICIES. LIMITS SY .
EXCIUSONS COND T ONS OF
CO
LTR
TY PE OF INSURANCE
POLCYNUMBER
POLICYEFFECTIVE
DAM(MMIDOtM
POUCYE PIRATION LIMITS
DATE (MMIOONY)
GENERAL AGGREGATE E 2, a 0 0, D O
A
GENERAL LIABILITY'
PR7DUCTS'NMPbPAGG f 2 000 a0
X COMMERCLSLGENERALUABIUTY
[
NC731770
10/10/07
10/10/08 PERSONAL& ADV INJURY E 2,000,00(
` CLAIMS MADE OCCUR
EACH OCCURRENCE S 2,000,00(
OWNER'S& CONTRACTORS PROT
100,00(
FIRE DAMAGE ;Any. fire) S
MED EXP (Any aw IXI M) f 5 o a
—'---
AUTOMOBILE
LIABILITY
COMBINEDSINGLELAXT E
ANY AUTO
ALL OWNED AUTOS
BODILY INJURY S
(Per person)
SCHE: ULED AUTOS
HIREDAUTOS
BODILY INJURY S
(PBI eGCitlenn
. NON-OWNED AUTOS
<
PROPERTY DAMAGE S
GARAGE LIANUM
AUTO ONLY-EA ACCIDENT S
OTHER THAN AUTO ONLY. ,4
ANY AUTO
EACHACODENT f
AGGREGATE $
EXCESS LIABILITY
Y
EACH OCCURRENCE f
AGGREGATE E
UMBRELLA FORM
E
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
STATUTORY LIMITS
EACH ACCIDENT
EMPLOYERS' UABILITY
DISEASE-POLICY LIMIT f
THEPROPRIETOR/ INCL
DISEASE -EACH EMPLOYEE $
PARTNERSIEXECUTNE
OFFICERS ARE. EXCL
OMEN
DESCRIPTION OF OPEMTONSJLOCATIONSNEHICLESJSPECML ITEMS
ADDITIONAL INSURED INSURED PER
FORM L804(06/07)
10 DAY NOC FOR NON-PAYMENT OF PREMIUM.
RE: CONSULT BANNER SERVICE AND
LIGHT SERVICE
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
THE CITY OF SANTA ANA
EXPIRATION DATE THEREOF, ME ISSUING COMPANY WILL ENDEAVOR TO MAIL
ITS OFFICERS, EMPLOYEES, AGENTS
AND 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDETI NAMED TO ME LEFT,
REPRESENTATIVES
BUT FAIWRE TO MAIL SUCH NOTICE S U. IMPOSE NO OBLIGATION OR LIABILITY
20 CIVIC CENTER PLAZA
OF ANY KIND UPON THE COMPANY. in AGENTS OR REPRESENTATIVES.
SANTA ANA, CA 92701
AUTHORran FIVJWEMTATIVE ANGELIQU 1
eC hhAAC' CZ12o1K + M.0 2-9
NAUTILUS INSURANCE COMPANY
LIABILITY ENDORSEMENT
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - BLANKET
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
OWNERS g CONTRACTORS PROTECTIVILIASILIiY COVERAGE PART
WHO IS AN INSURED (Section 11) is amended io include as an insured, any Person, organlzetlon, trustee, estate
or governmentei entity to whom or to which you are obligated by:
1. Virtue of a written contract or
2. The issuance or existence of a Parrnit;
to provide insurance such as is afforded by this policy, but only with respect to liability, arising out of
1. Your ongoing operations performed for that insured; or
2. Facilities used by you;
and then only for the fitnits of irabliity specified in such contract, but in no event for limits of iaNRY In excess of e
applicable limits of liability of this policy.
However, such person, organization, trustee, estate or goverrmmental entity
shag be an bee only
with respect
to occurrences taking place alter such written contract has been executed or permit has
Ail other terms and conditions of this policy remain unchanged.
Stas (ce)
ENDORSEMENT
NO. oz
INAUMUS INS g. COMPANY
A-ffACHFO TO AND
mwasw Fecrivt
A PMr OF
VgTla
Is=F&MhNO
Poat:YNUMRER
mo, DAY YR, 12c,61
IWURlt'
PF4DUCER400 6DDE
molpiAy CITY. llqc -
03
IN` CopSapNW;ON OF NO MUME IN PREMIUM, IT IS Im"BY 'AGREED THE FOLLOWING
IS App$D AS ADDITIONAL 1'NS41RE>:+ INSUP= PER FORK LIK04` 06/071 -
THE CITY OF RDSTA AHA
20 -CIVIC'CINT]IR -IPWA
SANTA ANA, CA 92701
GIAKKONA INSURANCE AGENCY - 00'08
DATE 03 -05 -OS
PIS
-INSUPM7
ANGELJOU
f
ENDORSEMENT
NO. 02
I
NAUTILUS INSURANCE COMPANY
ATTACHED TO AND
ENDORSEMENT EFFECTIVE
FORMING A PART OF
(STANDARD TIMET
POLICY NUMBER
M0. DAY YR. 72:01
INSURED
PRODUCER AND CODE
A.M.
DISPLAY CITY, INC.
007568
03
03
08
X
MORGAN #0432-00
NC731770
Additional Amouncs
Premium $ 300.00
1 State Tax $ 9.00
Stamp Fee $ .37
Total $ 309.37
IN CONSIDERATION OF AN ADDITIONAL PREM" OF $300.00, IT IS HEREBY AGREED
THE FOLLOWING ADDITIONAL INSURED IS REVISED TO BE ADDED PER FOAMS
LBOS(06/07) AND L803(06/07):
THE CITY OF SANTA ANA
(SEE ATTACHMENT A)
20 CIVIC CENTER PLAZA
SANTA ANA, CA 92701
AI
ME
P/R .605
GIAPM".ONA INSURANCE AGENCY - 007568
DATE 04-04-08
PLS
Countersignature
-INSUREO-
ANGELIOU
ATTACHMENT A
NAUTILUS INSURANCE COMPANY
The City of Santa Ana, 20 Civic Center Plaza, 'Santa Ana, California 92701;
its officers, employees, agents and representptives are named as additional
insured (additicmal insured) with regard to 4ability and defense of suits
arising from the operations and uses performell by or on behalf of the named
insured.
i
i
MW
EFFECTIVE
ATTACHED TO AND
(STANDARD TIME)
FORMING APART OF
MO. DAY YR. 12:01
INSURED
PRODUCER
POLICY NUMBER
A.M.
DISPLAY Cl#, INC.
NC731770
10 10 07 X
MORGAN #0432-00
The City of Santa Ana, 20 Civic Center Plaza, 'Santa Ana, California 92701;
its officers, employees, agents and representptives are named as additional
insured (additicmal insured) with regard to 4ability and defense of suits
arising from the operations and uses performell by or on behalf of the named
insured.
i
i
MW
NAUTILUS INSURANCE COMPANY
COMMERCIAL GENERAL LIABILITY 0OVERAGE PART DECLARATIONS
onI ICYNUMBER: NC731770 «__.>. n .e• , n_n 12.01 A.M. Standard Time
6cten510n Of Declarations 15 attached. uo+..nry
LIMITS OF INSURANCE ❑ If box is checked, refer to f ran S132 for Limits of Insurance.
Aggregate limit (Other Than Products/Completed eratioms) $ 2 000.000
General 2,000,000
products/Completed Operations Aggregate Limes $
2,000,000 Any One Person Or Organization
Personal and Advertising Injury Limit
$ z 000,090
Each Occurrence Limit
Damage To Premises Rented To You Limit E 100 000 Any one Premises
$ 5. 000 Anyone Person
Medical Expense Limit
RETROACTIVE DATE JCG 00 02 ONL
"bodily injury", "property da age" or "personal and advertising injury' which occurs
This insurance does not apply to
before the Retroactive Date, if any, shown here: NONE _ (Enter Date or "NONE" if no Retroactive Date applies)
BUSINESS DESCRIPTION AND LOCATION OF PREMISES s
BUSINESS DESCRIPTION:
LOCATION OF ALL PREMISES YOU OWN, RENT, OR OCC4PY: ❑ Location address is same as mailing address.
1.5507 WINDWARD AVE LONG BEACH, CA 90614
2. i
Additional locations (if any) will be shown on form 8170.
LOCATION OF JOB SITE (If Designated Projects are to be S�heduled):
PREMIUM
RATE
ADVANCE
CODE # CLASSIFICATION
*
BASIS
PR/CO
All Other
PREMIUM
41667 CLUBS, SERVICE OR SOCIAL
p
33,600
INCL '2.436
!�
1
1,500
HAVING BUILDING OR
PREMISES OWNED OR LEASED
OTHER TITAN -NOT FOR-
i
PROFIT -INCL. PRODUCTS
AND/OR COMPLETED OPER.
THESE PRODUCTS -COMPLETED
OPERATIONS ARE SUBJECT
TO THE GENERAL AGGREGATE
LIMIT.
i
49950 BLANKET ADDITIONAL
e
1
!FLAT
250
INSURED CHARGE UP TO 10
i
t = Products/Completed Operations are subject to the General Aggregate Limit
PREMIUM BASIS SYMBOLS
o =Total Operating Ex enses S = Gross Sales (par 31,OOD of Gross Sales)
a =Area (per 1,o00 sq. ft. of area)
c = Total Cost (per $1,000 of Total Cost) (per $1,000 Total O acing Expenditures) t = Sae Classification
m= Admissions (pet l.000Adm,swona = Payroll (per $1,000 Pa roll u = Units r unit
P EMIUM FOR THIS COVERAGE PART 1, 750.00
FORMS AND ENDORSEMENTS other than applicable Forms and Endorsements shown elsewhere in the policy)
Forms and Endorsements applying to this Coverage Part and'ymade part of this policy al time of Issue.
Refer to S902 Schedule of FDrms and Endorsements
n.¢ nF TUF in15L1RFO AND THE POLICY PERIOD.
THESE DECLARATIONS ARE PART OF THE PUDUT uecr.xnn - perm -
Includes Copyrighted material of Insurance S 'ccs Office, Inc, with its permission,
5150 (10104) Copyright I50 Prop es, Inc,, 2000
-INSURED-1