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HomeMy WebLinkAboutPLATINUM POOL & SPA 2City of Santa Ana Clerk of the Council AGREEMENT TERMINATION FORM Please complete this form when the attached agreement and all amendments (if any) are no longer in effect.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 No. AJ -i/ 7 was completed on (List alt amendments. use space below if needed.) Department: Phone /Ext: Signature: Date: Revised 0&- 23-10 c zo�a cOTC office Use Only 7011 E JAH 2 S PIN 3= 53 4i 0 =�,r s 3 svi_ and final payment has been made. INSURANCE ~YQT ON FILE N-2009-076 WORK MAY OT PROCEED CLERK OF COUNCIL DATE; jU~ l 3 2069 CONSULTANT AGREEMENT C.>~, C i~A/Z lie , Sa=d Ccr~a yip F~.,~I? ~'t THIS AGREEMENT, made and entered into this ls` day of July, 2009 by and between Platinum Pool and Spa, a privately owned and operated company (hereinafter "Consultant"), and the Community Development Agency for 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 caring for and maintaining the fountain at the Santa Ana Regional Transportation Center. 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 $3,000.00 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, 2010, unless terminated earlier in accordance with Section 12, below. The term of this Agreement may be extended upon a writing executed by the Deputy City Manager for Development Services. 1 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 insureds) 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. Consultant 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, 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. d. If Consultant is or employs a licensed professional such as an architect or engineer: Professional liability (errors and omissions) insurance, with a combined single limit of not less than $1,000,000 per claim. 2 e. The following requirements apply to the insurance to be provided by Consultant pursuant to this section: (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. f. 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 3 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 An notice, tender, demand, delivery, or other communication pursuant to this y 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 Fax 714- 647-6956 With courtesy copies to: Deputy City Manager for Development Services City of Santa Ana 20 Civic Center Plaza (M-25) P.O. BOX 1988 Santa Ana, California 92702 Fax 714- 647-6736 and City Attorney City of Santa Ana 20 Civic Center Plaza (M-29) P.O. Box 1988 Santa Ana, California 92702 Fax 714- 647-6515 4 To Consultant: Platinum Pool and Spa 5753 Santa Ana Canyon Rd. Anaheim Hills, CA 92807 Attn: Jason Hunt 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 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: 5 a. As a condition of such payment, the Deputy City Manager may require Consultant to deliver to the City all work product completed as of such date, and in such case such work product shall be the property of the City unless prohibited by law, and Consultant consents to the City's use thereof for such purposes as the City deems appropriate. b. 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 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 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 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. 6 IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST• CITY OF SANTA ANA PATRICIA E. HEALY DAVID N. M Clerk of the Council City Manager APPROVED AS TO FORM: JOSEPH W.FLETCHER City Attorney LISA E. STORCK Assistant City Attorney RECOMMENDED FOR APPROVAL: CONSULTANT CYNTHIA J. ELSON J HUNT Deputy City Manager for O er Development Services Employer ID # or Individual SS # PLATINUM POOLS 5743-G Santa Ana Canyoci Rd. #224 Anafiei~ Hi~1s, Ca 8Z8D7 {7I~4) _9(~6-820'1 Santa Ana Ttirain Station 6/23/09 p`ROF'OSALRF ACCEPTED CONTRACT Weekly Service: One year of service from June 31, ?009 to June 3I, 2010 -Service includes all Chemicals and Weekly Service S l 90.00 iti,aAal charges for any yr Services ResPectfi~lly Submitted Jason ~CAt;cep€ant~: Signature: C(ient#1339U€3&F iJPA70RAf: ~ ACQRp~ CEE~TlF1CATE CAF l..lAB1~lTY IN~~' URANCE °A'~~'~,°°„`'°r`, 1 FROnucea THtS CERTIFICATE tS ISSUED A~ A ts~Ti`ER OF lfa1FORMATiflN USt Saufttern C8€itotnia ~ 0#~LYAND CONFERS <vO R16HT$ UPOM THE CERTIPICA'i'E I Lfc ~'t335t 162 HOLDER. THIS CER~3FtGATE €1{aE5 NQTAI~END, EXTEMO CSR k ALTER THE COVERAGE AF~ORDEO BY'TMi= POI_!C{S3 $EL,fltY. { 2t6fJQ C+xna~cf'Sfteet, Bth moor ---Y, I ( WocdEand NY(!s, CA 9t36'~ _ tM$UAERS AFFOF3DIN;~ Cf?VEF~A~E ; 111~1}C FNSU.afn ~ ~r~5ua~aA. I~mari~~~Jlnsuran~e company ~ 2t&~7 URA tftT7-©t^enga County ~ 30145outh ManitoEsa Diva "~>`~ae».' itr~~ ~ 1 Santa Ana. 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Icon-papmeni o! {trem(urt~ i R~: Bt~andttn Yaung '~.-~~~"1 ~~k~7 ~ ~ TFee~itydfSanta~ina,Rsoificers,ernpioyees,agentsant3rapresentatr~rss t~a~ra ~ti Sh~~dy~ (Sae Attached [?esgrtp~~pns) r~sisttttC ~tty .#tir~rr~vk. CERTIFICATE HOLDER CkNCELLA7tON i5H(ll'LU :.I .L AAOFE 6£S.fl C PUU~^tc5 C~E.CA+/CELLEA 8Ef6R£TNE EXE'ViR'tlCttt Cityq#San~Ana - ~n;,Tenr~ err-,r{rr~a~!N~ Hs~,r„~~w;~~~~r~~, __~i nar~w~rreu The I~pot at ~saRta Ana ~ ~ wflrc~ F r Fagr~cars~.~.~e>; rFara~ ro ~r ~ ; ma=r, 360f? East Sania Aaa Bfvd. Ste.108 Santa Ana, ~A 92~Q1 ~ ~ ~ ++atd~ ~~.~s,,err~n~~ ACOF3Cl2S ~200fJ08j } at 3 ~M389Q76~ PC6,~A t; ACORD C~f,7}2ROAATlUN 4988 itUf P~?RT,~ ~T ff the c~r'tt6Cate ho(~er is an AODiTlfl~A~ fivSL3~EL~, the pnlicy(ies} mus"t ue endorsed. F~ statc~~ner~t cn this ceriifc~ie does nat ;~n`e~ rig'rtsYc the a~rti#~cate hcider to lieu of :i~c:; endar emertf~}. If SU9i,,C~~FtTfOh! iS W~IVcC3, subl~ to the terms and cc,^~dir,`onsot the n;,r~y, crsrsn ~tlicies €na}# require an endorsement. s'3ternent arti tht5 cARift~te dies ;rest cti~`~- rights to,ttre cetv{ic~~ ro4dsr ~ lieu of s;.rrh enda-sem~rrt(sJ. I~~SCLATi1~E~i- The C~rtifiC2*p of i,° .._3n~ OdY t<;~ rE 'c`C ,~'u . ` '~~,ia ~ r, _rF. "1.,. t'_.C a i:-t ~etv,sen ih6 isSUit~~ ui_urer{; -,ihoKi~ed tsar ~r p;~J~r an. 7~ i.~ts t:C: ie x d~~,, at#irrr~tit~dy ar negatively aIT18f}~, ax2ensf or alter t[se _ •u a~`~r,~_ri by p- u_ ,.ems "~er*~on: _ ~QE~~CRlPTIONS (Continued from Page;1~ h are rzamad as additional insured tivith regard #o tiatrifiry and defense of ~ ~ - suits arising from the bpeaatir~ns and uses performed by or on behaff of the named ir~sur~l, Primary. E: a~w~ ~s~ tz~~toe2 ~ at 3 ~ i'CT[_tC~r' 'd[..F?~'S$~Ii: i~'IXC'bU~~b~faf~Q7 L"C?.14'~'It.t~C~.~1_ C.~'~:~k,='tiI_ I_.1.`~E31Lt~l~l' `iil~ L=\~JOiiS~'~i'i;\"I' C~3~ ~~ti(iF,~i I'HF. 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'r,'it re~p~:~t to ~ie 1.r~s~:ra c~ aftn_~.~:,, to ~tiese a.d~',~~.-<~.'_ ~ ,.,~._.~,.s, the toi_os~znq exc2u~ion z~ a~~e~a 2. ~v~~~~sinr:s this rr.~,.ra,r doe. app~r eo .."~f~ y . :i° - ~_>>..a~~` c~ucurring aPt~r: (I;i 3'1 w~yfi, ~nci ~i;ic ^~at~_iaisr marts o~ ~Y~:_,a i~rn,~~.a~ c~~.._>>ti©:~ tiit`r~ suc~: wc~zic, en the Kszoect {r~th er than: s~x~~_ce, L..ter,~ance rt~.,airs} to to pexfnr:ned 'ay ~r ~r ~.~2-, the a~c_~z~onal ~ ~ { a r .4 ~ _ the cc,usre~ ~pezations his beer. ccrple~er~, (21 T'~at ~orticn ar ''{our '~'ar:~c" o::t' which t~:e i 7;~~r~ v a, ~sss has ~~er. .o ~4~ in~e-.deb _ ay rnrrt:a v ,,~-g tr.~r :.a ~..u~ ~O[ttrdt",tuT` Oi" 5tlt3ct~!".._~~CtOrt'.^.~ny^+rGt _:l j,~t?rTt>.Til.:";~~ L Ci'c.Lwv-s i~T :°C%:pfld3 a hurt a{ tine same cr~~e^t. CG 2C 1£- i~ Oi i ACa~~TM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDmmr) 11/19/2009 PRODUCER THIS CERTIFICATE IS ISSSUED AS A MATTER OF INFORMATION AUTO INSURANCE SPECIALISTS, LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE PO BOX 6507 HOLDER. THIS CERFICIATE DOES NOT AMEND, EXTEND OR ARTESIA, CA 90702-6507 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. CA INSURANCE LIC. 0524784 INSURERS AFFORDING COVERAGE NAIC # INSURED Platinum Pools ~ ~ INSURER A: MERCURY CASUALTY COMPANY 11908 401 Hummingbird Drive INSURER 8'•, Brea, CA 92823 , INSURER C: _ _ INSURER D: COVERAGES THE POLICIES OF INSURANCE LSITED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTUVITHSTATNDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT V1ATH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICEES DESCRIBED EHREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLIAIMS. VSR ADD'L POLICY EFFECTIVE POLICY EXPIRATON _TR INSRD TYPE OF INSURANCE POLICY NUMBER DATE MM/O ~ UMITS D/YY) DATE MMlDD/YY GENERAL LIABILITY EACH OCCURENCE $ DAMAGES TO RENTED COMMERCIAL GENERAL LL4BILITY PREMISES Ea OCCUrren08 $ CLAIMS MADE ~ OCCUR MED EXP (Any one person) $ PERSONAL&ADVINJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP $ AGG PRO- POLICY JECT LOC AUTOMOBILE LIABILITY AC11085287 01/17/2009 7/2010 $ A X 'g COMBINED SINGLE LIMIT ANY AUTO ~ ~ (Ea accidenq ALL OWNED AUTOS A ~ $ 1 ~ 000 K BODILY INJURY SCHEDULED AUTOS 5~ I~RC ~ (Per person) SP E' P~°C HIRED AUTOS ` nt G1~ $ 300,000 BODILY INJURY NON-0WNEDAUTOS AS ~ (Pelaccident) $ 50,000 PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY-EA $ ANY AUTO ACCIDENT OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ? CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION S WORKERS COMPENSATION AND WC STATU- OTH- $ EMPLOYERS' LIABILITY TORY ER LIMITS ANY PROPRIETOR/PARTERN/EXECUTNE E.L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA $ If yes, describe under EMPLOYEE SPECIAL PROVISIONS below E.L. DIEASE -POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE EXPIRATION DATE SANTA ANA REGIONAL TRANSPORTATION CENTER THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _30_ DAYS WRITTEN NOTICE TO C/O SANTA ANA PUBLIC WORKS AGENCY THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO 20 CIVIC CENTER PLAZA, M-21 OBLIGATION OR LIABIILTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES SANTA ANA CA 92701 AUTHOR ED REPRENTATIVE ~ i ACORD ~5 110 } c~) AGORD CORPORATION 1988 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 WAVIED, 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 endorsements(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. ~ 4` • , 3 I ACORD 25 (2001108) I ~v-aoo~-o~:~ WORKERS' COMPENSATION DECLARATION I T~i1~111 N(1 N~ OGII~EILhereby affirm under penalty of perjury, the (Name/Tifle) following declaration I certify on behalf of 1l~nl rJm PDoc, ~ SSA' that during the term of my Organizatim Name) contract with the ~DJ'ijm, D~/~ ~TlG~ FDQT~'City of Santa Ana, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. DATE: r 1 - ! t7 ~ yR sy: Name: ~ o w Title: Wit, ,~Frrr+~ P~_ Telephone: fi J y o - ~'),,o WAB.NING: FAII,URE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. - ~ - . ~ ~ ~ ~ - - - i THIS 4~1~"fl~#CATE I ~ssuEO ~ MATTER at+ !~l~a~l~~r~o~ aNi.Y~AHD as ~ ~ ~~~~Q~ o NF RS ND RIQHTS UPQN T~tw ~RTIFICATE HOI.D~~, THIS ~~RT~~IAT~ DDS NOT~A~FI~MATlY~LY OR NECATIY~~Y AM~N~, €END CR ALTAR THE C~V~~A~E AF'~a~~~D 8Y'~H~ p~~lC~~S ~ ' ~t;I.~WF,THIS ~RT~FI4AT~~~I* IIVSURANC~ DOES N4T OI~ST~'l1TE A ~~NTRAT ~8T1NE~N THE i881~l~0 Il~~IIR~l~~~; AUT~~D R~PI~S~~TATfYE OR PRaDUC~R, AND fiH~ Ctf~'~IFICAT~ H4~~1~, - IMP~~YANT~ ~ cats hald~r ~ en D~TI~NA N REIN, the Palley{~#~ mus# he ed~ I ~U~R YON i~ AIV D, e~4 t~ ` - ; the terms e>~~ ce~~ltlor~ e~ p+~lcyr ~e~trt pollcle~ ~~y re~ulr~ a~n en~ar~e~rta A:d~tvme~t on ttr~: t~rt#ti~lte ~eea nat car~fa~r ri ~ to . certtflc~~~ holder In Iles ~ eucl~ ~rlderaerr~nt~:~. ~ ~ ~ F - - U~! S~utl~B~Ca!l~orr~lal ~ ~ . Lip ~-435 ~ ~ e~ 81$ ~~fi~3800 ~ ~ , 216~4,Cxnard street, 8th ~iol~r ~ ool~iarld Hllis, CA 4~36T ~ ~ - • ~ ~ . ~rs~~~~ . ~ ~ ~~au~a~ s ~rr~ cov,~~ e USA #~B~Centr~ Orange Caur~t~ ~Hae~~~?~: Ar~+~rf~at~ lnsuren~e C~m~eny 2i85~` - ~ ~a ~~ex tx8~5 Qreanbrier drive ~~,rRS~c: ~ . `Yorha t.inda CA ~~~8~ ~ ~ ~r~~~ ~ ~ 1~SE1R1$R _ . ~ ~ C~YERA~ES ~~RTI!~ICATE NIJMB~R; ~ - ~ RSV! lOl~ NLiM~I~; . THIS IS T~ CER~FY T~1~` THE PI~I~~ aw>* I~1S~I~JINCE ~.ISTEI~ ~EI.41~ ~fiAV~ AEEN 15S~ED TO T~iE IN~€JC~ NAMED ABgYE ~4#~ THE ~.I~Y P~i~IQD INDIC~Y>E:o. ~DT~5~ANa~~a ANY ~~aLlRR~~~ENI'~ ~~~M an GaNDD`I~N D~ ANY ~~~AACT OR OTHER DOCil~IENT WtTN RasP~CT Tp WHICI~ `~IfS ~ERT~FIC~TE 1wIl1Y @E 153U~a MAY t*ERTAIN,'~E 1~SUftAANE A~EORaE~ 8Y THE POL~E~ ~~SCRiEED €~ER!~li~ 15 5#JBJ~~;T TOALL THE TERMS, ~JLC~.E~5f~f5 ANA ~Qi~IDlYI S~1~H l~D1~S~ L~MfTE ~H MAY i~AVE SEEN RE~~~} PAID Cl.A1M3, 1'1fP~ ~$URA,hIC~ _ ~ !~Y ~U1H~~t' F ~ ~ kl~~~S A o~~~we~~ M~4045B8761~ ~ xl~1~4~4 ~TlD~I~4~1 r~~H~cc~~~ ~ co~~~c~. o~xa~. LUBIea~'V c~~ ~ vice~~ - ~ 4'40 ~ ~ . ~ PD Qed;~4Q - . ~ Plr~saw~, r~ ~~v ~ruu~r s~ X04 X00 o~A~v~~ ~4 404 ~E~ti ~~oREC3n11~ ~~Pt~~ ~ ~s - ro~tP~~AC•~ r~ 441 440 P0~1CY ~ Auroelas~~~~ ~~~~~mr ' ~ CO1~81H~~ SiNG~E L11~T ~ ' A12Y Al~'4 ` ~ ~ ~ ~ ~ ~#dmt~ SCHEDI~.~~l~~1T0~ ~a~I~.Y II~UAY ~P~r ~ ' HiRl:~hl#TE~ - ~ P~~PERTY~1rM~E H~WN~~~~7~ ~ ~ ~f ~ Ul>~~t~~LA f,~b ~CCI~R ' El(Cl~B~ ~~l1$ ~ ~ EACH ~CCIIR~ENC~ ~~1~~~E ' IIY~R~fE~S COMPgH8J4~~0~ ~~~~oY~~~ r.u~ul~r y p tea} ~ sT~?r 4.~~ ~T~ ~a'Itillif ~ ~ ~ ~i FIAV~IN+V~ 1 ~M1d11+0~ X11 H~~ ~ ~k Ir~~~ ~ ~ #f . A ~oli~til~n ~lear~up M7~C8048~8~'S~~ 7'14~1~4~4 4~'~0~1~4~ 1 ~~,044 o~SC~1~TrGN CF ~F6RA'~~f8 (t1171~~ E 1f~#~1~~ (Atual~ ACb~4D ~ 6~,1k~d~~io~ R~mrrlu ~hMdc~l~ mare ~ nqu~nd~ ' ~u~ren# ~embar; Ja~tan Hunt ~ ~~'lAl~l~ The City ot: ~er~t~ A11e, its af~cers, employees, and and repre~entatt~res ~e Attached ~eaat~~tf~rts} . - - , Il'tCA E l~D~ ~ ~ CEt. N en# - - ~ - ~ a~lou~c a~ Aea~e c~scnie~~ ~auci~s cArlc~~~~n e~o~~ ' . , Clt~l Of S~11~ Ti~~ ~]~~~4TigN D?~TE,T~IEREDE, TiCE WIC ~E D~~~ER~~ fH - AC~aR~AI~CE l~i~'M x1i~ Pa1.#tfY PROV#S1~H-S~ ~o Publ~a W~r~s Agl~~~y~'he spot . . ~ - . ~0 civic Center ~~e, M•2~ ~ ~A - ~ ~ ~~~88-~404AC~RD ~~RP~RATIONi AI# rte roeervedr ACRD ~~OOSJ~$ o~ ~ "I'he ACaIR~ ~el'T?e +a~d l04o a~ related marks o~ ADaRD - _ - ~ - + r ~ i ~ ~ ~ ~ 1 y • - R , . I ~ i..I4 ~ #wf ~I Y 1J~ l 1I ~ i f i ~••f ~ jj ~ ~ t ~ - ' r ~ ~ _ _ ~ . ; ~ . ~ ~ ~h~~. ~~d~xaent modl~i~~ ~•naur~anoe pxovided •undax ~hs~ fgllow~n' ' - _ _ - - . ~IA$~~~' .Ca~l~ DART • ~ ~ ~arn~ o~ Paraot~ a~ pxgan~~a~f on x ~ ~ • ~ ~ • per ~~~~riti' ~on~~~a~. ~I~ na entry appears ~.abo~s~ ~~~v~cm~~~on •~e u~red ~o o . will be shown In ~t~e Deo~~~cat~ar~s as ~a ~ a mple~e~ end~xseman~ . _ _ Viable ~t~~s endoxsement,~ - o~ ,ar~ar~~,~ata.ar~ spawn #.n the Sahad ~ , ~~c~,ud~ ss an ~r~st~red p~rsori u ~r bud on],y w~~h. xospec~ . ~o ~,i.ab~~,i~y • ar~.s~r~q auk of your or~go~.ng ~p$ra~~on~ par armed far ~~a~ ir~surs . d~ . ~~tn xa~pa~ ~o the ~nsr~rs~a~ a~~ax~dsd to these - ~ - addi~~ona~. ~n~~reds, ~ha i ~~~,~.owing ex~lus~on is added t ~ ~ . • ~ Shia ~.nsuras~aa doss nod apply ~o "bad~.3, ux r~ • yy~~~y wl~h ~uah work, an the xo eot a~h~ ~ pmen~ ~urn~.sYred ~n conne~~~i~n . p 3 , ~ dr ~t~~in ssr~~ce, ~+a~.n~er~~nc~ or rapa3.~c,s~ ~a ~e pe~c~ar~ted ~y ar an beba~~ a~ ohs add~;t~ana~ ~nsuxed~s} a~ the s~. ~~vored opaxations has been comp3~ted; or ~ ~ a~•tha • ~ ~`ha~ pvr~~an a~ "you~c wa~k~' ~ vu~ o~ w~~c~i ' ~ee~ pub ~a ~~s ~~.n~ended-use b ~rh the fn~r~xy ar damage ar~aes has i Y y pe~soz~ or ~ o~~an~ ~s~~ar~ athex khan ano~hex . ~ ~ con~rac~or • ~r su~~on~~ac~or en~a~ed ~n psr~orm~,'r~q aper~~ia~s for . a park o~ •~he• sa~n~ .p~o~ e~ ~ ~ prir~c~pa~ as C~ ~ ! 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