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HomeMy WebLinkAboutMILLER & PIDSKALNY - 2015INSURANCE ON FILE WORK MY PROCEED UNTIL INSURANCE EXPIRES CLERK OF COUNCIL - y 2 02015 DATE: Agreement No. 0: Civ ci) ON-THE-JOB TRAINING AGREEMENT UNDER THE WORKFORCE INVESTMENT ACT N-2015-075 THIS AGREEMENT is made and entered into this 6th day of May, 2015 between the City of Santa Ana, a charter city and municipal corporation duly organized and existing under the Constitution and laws of the State of California (hereinafter "CITY") and Miller & Pidskalny Custom Woodwork Inc. (hereinafter "EMPLOYER"). WITNESSETH Recitals: A. CITY has been designated a Local Workforce Investment Area ("LWIA") pursuant to Section 116 of the Workforce Investment Act ("WIA"), P.L. 105-220, 29 USC Section 2801, to receive federal funds to promote effective delivery of job training services to local area residents. B. The State of California has created the California Workforce Investment Board pursuant to Section 111 of the Workforce Investment Act, P.L. 105-220, 29 USC 2821 to administer the WIA programs operated by the State of California. C. As a LWIA, CITY is entitled to receive federal fiinds to establish programs to prepare eligible unskilled youth, adults and dislocated workers for entry into the labor market, and to provide job training to those individuals who face serious barriers in obtaining productive employment ("said Program"). D. EMPLOYER is able and willing to train eligible unskilled applicants for entry into the labor market and is willing to operate said program pursuant to the WIA and applicable federal, state and local laws. WHEREFORE, for and in consideration of the respective and mutual covenants and promises hereinafter contained and made, and subject to all the terms and conditions hereof, the parties hereto do hereby agree as follows: Term. The effective term of this Agreement is for the period beginning May 06, 2015 and ending November 04, 2015. The tenn of this Agreement may be extended upon agreement of all parties and execution of an amendment of the teen. 2. Scope of Work. The EMPLOYER shall employ and train one employee (hereinafter "Trainee") in the occupation and in accordance with the OJT Training Outline set forth in Exhibit A, attached hereto and incorporated herein by this reference. Said Trainee shall be referred by the City of Santa Ana W/O/R/K Center. Training must significantly raise the Trainee from his/her prior position in both level of skill and salary by the end of the training period. 3. Funding. CITY shall reimburse the EMPLOYER an amount not to exceed $5,460 in accordance with the Cost Computation included in Exhibit A. EMPLOYER shall bill the CITY monthly on an invoice provided by CITY for actual and reasonable cost for providing the services described in this Agreement. Reimbursement of EMPLOYER under this Agreement shall be limited to the costs incurred during the basic work week, excluding overtime and any paid holidays or sick leave. 4. Subcontracting Prohibited. The EMPLOYER shall not subcontract or assign the OJT Training. Any attempt by the EMPLOYER to delegate or assign OJT training duties under this Agreement shall void, and permit CITY to immediately terminate, this Agreement. 5. Employer Obligations. During the training, the EMPLOYER shall ensure that the Trainee: a. is on the EMPLOYER's payroll, not paid as a contracted employee/independent contractor; and, b. receives the Baine benefits as EMPLOYER's other employees performing similar work; and, C. is paid the salary as indicated in Exhibit A with appropriate payroll taxes withheld and reported; and, d. is provided Worker's Compensation Insurance coverage, pursuant to state law; and, e. is provided by EMPLOYER with safety instructions and equipment necessary for reasonable protection against injury and damage. CONTRACTOR shall maintain appropriate standards for health and safety in work and training situations. Where special clothing or equipment is provided to the EMPLOYER's regular employees, EMPLOYER shall provide the same type of clothing or equipment to the Trainee performing similar work. 6. Employment of Trainee. The EMPLOYER shall employ the Trainee as a regular member of EMPLOYER's work force. If EMPLOYER wants to continue to employ the Trainee upon the successful completion of the training period under this Agreement, said employment shall be subject to the same conditions of employment applied to EMPLOYER's other regular employees, including termination for unsatisfactory performance. 2 Patent, Copyrights and Rights in Data. The EMPLOYER will disclose to the CITY any invention, written product, computer program developed or data assembled as a result of performance of work under this Agreement within seventy four (74) days of invention, development or assembly. The CITY, State of California, and U.S. Department of Labor will have the right to patent any invention and copyright any written product or computer program or data generated by EMPLOYER. Upon written request, EMPLOYER will transfer all pertinent information, specifications and right, title and interest to the designated agency. 8. INVENTIONS, PATENTS AND COPYRIGHTS. A. Reporting Procedure. If any project produces patentable items, patent rights, processes, or inventions in the course of work under a U.S. Department of Labor (DOL) grant or agreement, the CONTRACTOR shall report the fact promptly and fully to the CITY. The CITY shall report the fact to the Grant Officer, at the DOL. Unless there is a prior agreement between the CITY and the DOL and its representative on these matters, the DOL shall determine whether to seek protection on the invention or discovery. The DOL and its representative shall determine how the rights in the invention or discovery, including rights under any patent issued thereon, will be allocated and administered in order to protect the public interest consistent with the "Governmental Patent Policy" (President's Memorandum for Heads of Executive Departments and Agencies, August 23, 1971, and Statement of Government Patent Policy). B. Copyright Policy. 1. Unless otherwise provided in the terms of the grant or agreement, when copyright -able material is developed in the course of or under a DOL Grant or agreement, the author and the CITY which developed the work is free to copyright material or to permit others to do so. The EMPLOYER and the Workforce Investment Board (WIB) shall have a royalty - free, nonexclusive and irrevocable license to reproduce, publish, use and to authorize others to use all copyrighted material. 2. The DOL reserves a royalty -free, nonexclusive, and irrevocable license to reproduce, publish or otherwise use, and to authorize others to use, for Federal Government purposes: (a) The copyright in any work developed under any grant, sub -grant, or contract under a grant or subgrant; (b) Any right of copyright to which a grantee, subgrantee or a EMPLOYER purchases ownership with grant support; and (c) EMPLOYER shall comply with the requirements of 29 CFR Part 97.34. C. Rights to Data. The DOL and the CITY shall have unlimited rights to any data first procured or delivered under this Agreement. 9. Hold Harmless. The EMPLOYER shall indemnify, defend and hold harmless CITY, and its officers, agents and employees, from and against any and all damages to property or injuries to or death of any person or persons, including property and employees or agents of CITY, and shall indemnify, defend and hold harmless CITY, and its officers, agents and employees, from any and all claims, demands, suits, actions or proceedings of any kind or nature, including, but not limited to, workers' compensation claims, resulting from or arising out of the negligent acts, errors or omissions of EMPLOYER, its employees, agents or subcontractors. 10. Insurance. The EMPLOYER shall obtain at its sole cost and file with the City of Santa Ana — Santa Ana W/O/R/K Center, upon execution of this Agreement, and maintain for the period covered by this Agreement, a policy or policies of commercial general liability insurance or a certificate of such insurance, satisfactory to the City Attorney of CITY, naming CITY, and its officers, agents and employees, as insured or additional insured (see attached Additional Insured Endorsement, Exhibit C), which provides coverage not less than that provided in the form of a comprehensive general liability insurance policy against liability for any and all claims and suits for damages or injuries to persons or property resulting from or arising out of operations of EMPLOYER, and its officers, agents, or employees. Said policy or policies of insurance shall provide coverage for both bodily injury and property damage in no less than One Million Dollars ($1,000,000). Said policy or policies shall also contain a provision that no termination, cancellation or change of coverage or of insured or additional insured shall be effective until after thirty (30) days notice thereof has been given in writing to CITY. EMPLOYER shall give to CITY prompt and timely notice of claims made or suit instituted against said policy. EMPLOYER shall procure and maintain at its own costs and expense, any additional kinds and amounts of insurance which, in its own judgment, may be necessary for its proper protection. 11. Record Keeping. CITY, the State of, California and the United States government and/or their representatives shall have access for purposes of monitoring, auditing and examining of EMPLOYER'S activities, performance, books, documents, papers, and records of EMPLOYER'S subcontractors, bool&eepers and accountants, and employees and participants related to this Agreement. Such agencies or representatives shall also schedule on-site monitoring in their discretion. Monitoring activities may also include, but are not limited to, questioning employees and participants and entering any premises or onto any site in which any of the services or activities funded hereunder are conducted or in which any of the records of EMPLOYER are kept. Nothing herein shall be construed to require access to any privileged or confidential information as set forth in federal or state law. In the event EMPLOYER does not make the above -referenced documents available within the City of Santa Ana, California, EMPLOYER agrees to pay all necessary and reasonable expenses incurred by CITY in conducting any audit at the location where said records and books of account are maintained. All accounting records and evidence pertaining to all costs of EMPLOYER and all documents related to this Agreement shall be kept available at the location where EMPLOYER conducted the program, as well as in the County of Orange, for the duration of this Agreement and thereafter for three (3) years after completion of an audit. Records which relate to (a) complaints, claims, administrative proceedings or litigation arising out of the performance of this Agreement, or (b) costs and expenses of this Agreement to which CITY, the State of California or the United States Government take exception, 9 shall be retained beyond the three (3) years until resolution of disposition of such appeals, litigation, claims, or exceptions. 12. Government Funding. This Agreement is valid and enforceable only if sufficient funds are made available to the State by the United States Government for the same Fiscal Year as for this Program. In addition, this Agreement is subject to any additional restrictions, limitations, or conditions enacted by Congress or any statute enacted by Congress which may affect the provision, terms or funding of this Agreement in any manner. 13. Payment Cap. Based on the size of Employer, City's OJT payments to EMPLOYER shall not exceed a maximum of fifty percent (50%) of the wages paid by EMPLOYER during the training period specified in Exhibit A. 14. Amendment of Agreement. No alteration or variation of the terms of this Agreement shall be valid and/or binding unless made in writing and signed by both parties. There are no oral understandings or agreements between the parties. 15. Breach/Sanctions. If, through any cause, EMPLOYER violates any of the terms and conditions of this Agreement, or if EMPLOYER reports inaccurately or if any Audit Report makes disallowances, EMPLOYER shall promptly remedy its acts or omissions and/or repay CITY all amounts due CITY as a result of EMPLOYER's violation. For any such failures or violations, CITY shall also have the right at its sole discretion to either: (1) discontinue program support until such time as EMPLOYER fulfills its obligations or remedies all violations of this agreement or prior agreements; and/or (2) collect outstanding amounts as determined by CITY due CITY by offsetting or debiting from current claims or invoices, if after thirty (3 0) days' written notice EMPLOYER has failed to repay same or a repayment schedule has not been made; and/or (3) terminate this Agreement by giving written notice to EMPLOYER of such termination in accordance the notice provision in Paragraph XVIII herein below. 16. Termination. Either party may terminate this Agreement upon thirty (30) days prior written notice to the other party. However, the CITY may immediately terminate this Agreement at such time as funds are not made available to CITY through the United States Department of Labor or the State of California Employment Development Department for the purpose of carrying out this Agreement. 17. Independent Contractor. The EMPLOYER, and any agents and employees of the EMPLOYER, in the performance of this Agreement, shall act in an independent capacity as independent contractors and not as officers, employees, or agents of the CITY. This Agreement is not intended not shall it be construed to create an employer-employee relationship between EMPLOYER and CITY, nor a joint venture relationship. The EMPLOYER shall not subcontract in the name of the CITY. 18. Equal Employment Opportunities. The EMPLOYER warrants that it will comply with Title VI of the Civil Rights Act of 1964, and the requirements relating to equal employment opportunities set forth in Executive Order No. 11246, as amended by E.O. 5 11375 and supplemented by the requirements of 41 CFR Part 60. EMPLOYER will also comply with all applicable federal and state laws and regulations, and particularly those assurances and certifications set forth in Exhibit B attached hereto and by this reference incorporated herein. 19. Prohibitions. The EMPLOYER shall not use any of the training funds provided under this Agreement for political or sectarian activities. 20. Grievance Procedure. The EMPLOYER shall continue to operate, or shall establish and maintain a grievance or complaint handling procedure relevant to the terms and conditions of employment and the EMPLOYER's activities and programs, which shall meet at a minimum the requirements set forth in Section 101(3 1) of the Act and 663.700- 710 and regulations promulgated by the State or Federal Government. Employers that do not have a grievance or complaint handling procedure shall use the procedures prescribed by the CITY. 21. Guidelines. The CITY shall make the WIA applicable federal regulations and policy guidelines available to EMPLOYER at CITY — W/O/R/K Center, 1000 E. Santa Ana Blvd., Suite 200, Santa Ana, California 92701. The CITY shall also inform the EMPLOYER of changes in the WIA regulations or policy guidelines if such changes affect the operation of this Agreement. 22. Drug Free Workplace. The EMPLOYER agrees to provide a drug-free work place and to execute a certification as set forth in Exhibit D attached hereto and incorporated herein by this reference. 23. Notices. All notices, reports and correspondence between the parties hereto respecting this Agreement shall be in writing and deposited in the United States mail, postage prepaid, addressed as follows: CITY: City of Santa Ana — Santa Ana WORK Center 1000 E. Santa Ana Blvd., Suite 200 Santa Ana, CA 92701 Attention: WORK Center Director EMPLOYER: Miller & Pidskalny Custom Woodwork Inc. 1940 Blair Ave Santa Ana, CA 92705 ATT: Leslie Miller 24. Debarment. To protect the public interest and ensure the integrity of Federal programs, CITY may only conduct business with responsible persons and may not make any award or permit any award to any party which is debarred or suspended or is otherwise excluded from or ineligible for participation in Federal assistance programs under Executive Order 12549, "Debarment and Suspension". See also 29 CRF Parts 97.35 and 98.510. EMPLOYER must review and sign Exhibit E "Debarment", which is attached hereto and incorporated herein by this reference. 24. Merger. This Agreement, together with the attachments hereto, expresses the total understanding of the parties. There are no oral understandings of the parties or terms and conditions other than as stated herein. 25. Validity. The invalidity in whole or in part of any provision of this Agreement shall not void or affect the validity of any other provision of this Agreement. 26. 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. IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: �-2 i lel t ,C)= Maria D. Huizar Clerk of the Council APPROVED AS TO FORM: Sonia R. Carvalho City Attorney By: Lisa Storck Assistant City Attorney C � Kelly Ree ers Executive hector Community Development Agency E61MIK9IWIINAON_II:V:hn David Cavazos City Manager EMPLOYER: YA'J">7 � Leslie Miller Owner Tax ID#: 0284783 Exhibit A TRAINING PLAN I. GENERAL Name of OJT Employer: Miller & Pidskalny Custom Woodworks Inc. 2. Address of OJT Work -site: 1940 East Blair Ave. Santa Ana CA 92705 3. Phone Number: 949-216-8912 4. Training Supervisor: 5. Name of OJT Trainee: Rodney Christopher Hitchcock 6. Application Number of Trainee: 43298069 7. Grant/Program: OJT -201 8. Proportion of trainees/employees: (at time Agreement entered into) a. Total number of employer's regular employees 4 C. Cumulative number of trainees currently in OJT 0 II. OCCUPATION AND ON-THE-JOB TRAINING OUTLINE: 1. Occupation: Cabinet Manufacturing Assistant 2. Length of Time in Business: 37 years 3. ONET Code: 51-7011.00 SVP Level: (6.0 to < 7.0) 4. Hourly Starting Wage: $ 13/hour Start Date: 05/06/2015 End Date: 11/04/2015 Hours 840 5. State and Federal Tax LD.: State: Federal 6. Basic Work Week Hours: 7. Outline of On -the -Job Training Plan and Method of Assessment: ELEMENTS OF TRAINING HOURS OF TRAINING Objective 1 CAD Design Training to read & interpret CAD designs in order to create cut / material lists for each project. 80 Objective 2 Fabrication training to include but not limited to; Learning how to pre -plan and lay out each build for most efficient fabrication, 360 anticipating both quantity and timing of material needs based on cut lists & method of building, planning alongside the finishing department on how projects need to be built and moved into finishing, learning craftsmen level carving and marquetry of veneer patterns. Objective 3 Finishing training to include but not limited to; color & glaze formulation to match custom color samples, adjusting formulas based on 200 build material / end use of fabricated part & weather conditions during finishing & installation, calculating material budget based on above formulation, paint & glaze application, calculating layering of paints and finished to achieve each custom finish Objective 4 Assembly training to include but not limited to; Understanding how finished items will be transported and installed at 200 various client sites, understanding what final finish will be applied to the items on-site and planning the assembly accordingly, taking tally of all hardware needed for installation, submitting material orders for hardware and misc. parts in anticipation of installation RATING LEVELS: Measurement method: how will it be determined if OJT participant acquired the skill? -Q&A, observation, product review/inspection, etc. PROFICIENT MODERATE MARGINAL H. COST COMPUTATION Hourly Reimbursement: $ 6.50 (50% of $13.00) Training Hours: 840 Cost Per Trainee (Hourly Reimbursement X Training Hours) _ $ 5,460 III. Person"(s) authorized to sign payment invoices for EMPLOYER: Print Name Sigriature Title 04/28/2015 Date Print Name Signature Title Date ASSURANCES A. The EMPLOYER assures that: It will comply with the requirements of the Workforce Investment Act (WIA), the California Unemployment Insurance Code, as amended, and the regulations and policies promulgated thereunder, 2. No OJT participant displaces a regular employee nor shall an OJT participant fill a position of a person who has been laid off from the same or similar position. 3. No current employees are receiving unemployment insurance benefits as a result of layoffs or work reductions. 4. No person in the United States shall on the grounds of race, color, sex, religion, national origin, age, disability, sexual orientation, or marital status be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the applicant receives federal financial assistance and will immediately take any measure necessary to effectuate this Agreement. 5. It will comply with provisions of the Hatch Act, if applicable, which limits the political activities of employees. 6. Individuals receiving training on the job shall be compensated by the EMPLOYER at such rate, including periodic increases, as may be deemed reasonable under regulations prescribed by the Secretary of Labor, but in no event at a rate less than that specified in Section 6 (a) (1) of the Fair Labor Standards Act of 1938 or, if higher, under the applicable State or local minimum wage law. 7. Services and activities provided under this Agreement will be administered by or under the supervision of the EMPLOYER. 8. No relative by blood, adoption or marriage' of the EMPLOYER may be trained under this Agreement. 9. Appropriate standards for health and safety in work and training situations will be maintained. 10. Conditions of employment or training are appropriate and reasonable with regard to the type of work, the geographical region, and the proficiency of the trainee. 11. Training will not be for any occupation which requires less than six weeks of training according to the Specific Vocational Preparation Table (SVP Code). 12. Training will, to the maximum extent practicable, be consistent with every individual's fullest capabilities and lead to employment possibilities. 13. The program will, to the maximum extent feasible, contribute to the occupational development or upward mobility of individual participants. 14. Training will be in accordance with the training plan, which plan incorporates documentation that must be completed by EMPLOYER before end of contract. 15. *Dot and **SVP code books will be used to determine length of OJT period. The training time may not be longer than the SVP Code allows; however, contractors are encouraged to negotiate EXHIBIT B 16. OJT trainees shall not number more than 40% of the EMPLOYERS work force 17. All EMPLOYER training payments (reimbursements) must be exclusive of any and all EMPLOYER fringe benefits, pard holidays, paid sick days and overtime compensation. 18. The participating EMPLOYER must keep an- accurate and up-to-date time sheet for the OTT trainee. 19. Payroll records, time and attendance records and job duties retained on file by the participating EMPLOYER for each OJT trainee are subject to review. -c- 2&� /Employer Signature EXHIBIT B 2 Date `'� b® CERTIFICATE OF LIABILITY INSURANCE 4/16/2015 Y) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(fes) must be endorsed. 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). PRODUCER The Contractors Choice Agency PO Box 13645 Chandler AZ 85248 NT NAME:CT Jon Rock PHONE (800)918-3584 WC .FAX .(877)684-9951 EDpAIE .JorlNnginsuranceonl ine. core INSURER(S) AFFORDING COVERAGE NAIC # INSURER A:Preferred Contractors Insurance 12497 INSURED Miller & Pidskalny Custom Woodwork Inc. 1940 Blair Ave Santa Ana CA 92705 INSURER 8: INSURER C: INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:CL134420823 REVISION NUMBER: THIS IS TO CERTIFY THAT 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 MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL JNSR 8UBR AM POLICY NUMBER POLICY EFF MM DO YYV POLICY EXP M D YYV LIMITS A GENERALUABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ®OCCUR Robert Rock/JON {--�'--C�- C0006754-00 5/19/2014 --- 5/19/2015 EACH OCCURRENCE $ 11000,000 PREMISES(Ed occurrence) $ 50,000 MED EXP (Anyone person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE X POLICY LIMIT APPLIES PER: PRO LOC PRODUCTS - COMP/OP AGG $ 11000,000 $ q OMOBILE LIABILITY ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NO -OWNED COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ _ er PPROa ERTn DAMAGE $ $ UMBRELLA LIAB EXCESS LAS OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIVE [--I OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If as, describe under DESCRIPTION OF OPERATIONS below N/A WC STATU- 0111 - FIR E.L. EACH ACCIDENT $ E.L, DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 181, Additional Remarks Schedule, If more space is required) The City of Santa Ana its officers, employees, agents and volunteers are named as additional insured per Form 10. CERTIFICATE HOLDER CANCELLATION ACORD 25 (2010/05) © 1988.2010 ACORD CORPORATION. II righ,,tskes ve . INS025(201005).01 The ACORD namo apdXrp�p�r9,regtstered marks of ACORD ���V�/.C(n YJkI e3'M CC II II II 11.. � J SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS. 20 Civic Center Plaza AUTHORIZED REPRESENTATIVE Santa Ana, CA 92702 Robert Rock/JON {--�'--C�- ACORD 25 (2010/05) © 1988.2010 ACORD CORPORATION. II righ,,tskes ve . INS025(201005).01 The ACORD namo apdXrp�p�r9,regtstered marks of ACORD ���V�/.C(n YJkI e3'M CC II II II 11.. � J DocuSign Envelope ID: 3C9C2C95-5601-4E77-AEAE-OEB12F915D5E EXHIBIT C ADDITIONAL INSURED ENDORSEMENT Insurance Company : Preferred Contractors Insurance Company This endorsement modifies such insurance as is afforded by the provisions of Policy # PCO006754-00 relating to the following: 1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92702; its officers, employees, agents and volunteers 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 canceled, 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 92702. (Completion of the following, including countersignature, is required to make this endorsement effective.) Effective, April 20, 2015, this endorsement form as a part of Policy # PCO006754-00 Issued to The City of Santa Ana, its officers, employees, agents and volunteers. Named Insured o QSigned by: 66� F6& 4/20/2015 Countersigned by F94799F DE499- Authorized Representative a- i Exhibit C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B POLICY INFORMATION PAGE ENDORSEMENT The following item(s) X Insured's Name (WC 89 06 01) ❑ Policy Number (WC 89 06 02) ❑ Effective Date (WC 89 06 03) ❑ Expiration Date (WC 89 06 04) ❑ Insured's Mailing Address PC.890605) ❑ Experience Modification (WC 89 04 06) ❑ Producer's Name (WC 89 06 07) ❑ Change In Workplace of Insured (WC 89 06 08) ❑ Insured's Legal Status (WC 89 06 10) ❑ Item 3,A.States MC890611) (Ed. 7-01) ;❑ Item 3:13. Limits (WC 89 06 12) ❑ Item 3.C. States (WC 89 06 13) ❑ Item 3.D. Endorsement Numbers (WC 89 06 14) ❑ Item 4.* Class, Rate, Other (WC 89 0415) ❑ Interim Adjustment of Premium (WC 8904 16) ❑ Carrier Servicing Office (WC 89 08 17) ❑ Interstate/Intrastate Risk ID Number (WC 89 06 18) ❑ Carrier Number (WC 89 00 19) ❑ Issuing Agency/Producer Office Address (WC 89 06 25) is changed to read: Effective 8/16114 amend the first named insured to read Miller & Pidskalny Custom Woodwork *Item 4. Change To: Total Estimated Annual Premium :$ 42,527 Minimum Premium $ All other terms and conditions of this poloyremain unchanged. Deposit Premium $ This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 08-16-2014 Policy No, Premium Basis Rate Per $100 ATW 005341-00 Classifications Code Total Estimated. of Estimated 08-16-2014 No. Annual Annual Premium Countersigned by Remuneration Remuneration 3 (Ed. 7-01) Exhibit C ® 2001 National Council on Compensation Insurance, Inc. Total Estimated Annual Premium :$ 42,527 Minimum Premium $ All other terms and conditions of this poloyremain unchanged. Deposit Premium $ This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 08-16-2014 Policy No, Endorsement No..1 Insured ATW 005341-00 Premium Included Miller & Pidskalny Custom Woodwork (A Corp Policy Effective Insurance Company 08-16-2014 Republic Underwriters Insurance Company Countersigned by WC 89 06 00 B 3 (Ed. 7-01) Exhibit C ® 2001 National Council on Compensation Insurance, Inc. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Republic Underwriters Insurance Company INFORMATION PAGE WC040001A (Ed. 7-98) Policy No. ATW 005341-00 Insurer ID No(s). 24538 Prior Policy No. 1. Named Insured: Miller & Pidskalny,Custom Woodwork (A Corp) Individual LLC Mailing Address: 1940 E. Blair Avenue x Corporation LLP Santa Ana, CA 92705 Partnership Other: FEIN: 33-0284783 Intra/Interstate Risk ID No. 4328565 Other workplaces not shown above: See Schedule of Locations 2. The policy period is from 08-16-2014 to 08-16-2015 12:01 A.M. standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: CA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed Here: NONE D. This policy includes these endorsements and schedules: See Scheduled of Forms 4. The premium forthis policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit, Code No. Classifications Premium Basis Estimated Annual Remuneration See Schedule of Classifications Experience Modification: Minimum Premium: $750 Premium Adjustment Period: Rate Per Estimated $100 of Annual Remuneration Premium Total Estimated Annual Premium: $42,527 Deposit Premium: Countersigned By: Producer Information: RID Insurance Sales, Inc. DBA The Empire Company 550 North Park Center Drive, Suite 205, Santa Ana, CA 92705 Servicing/Issuing Office: Atlas General Insurance. Services Date: _ 9/19/2014 4365 Executive Drive; Suite 400 San Dieao, CA 92121 Exhibit C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 00 02 (Ed. 07.98) EXTENSION OF INFORMATION PAGE Schedule of Named Insured Item 1 Named Insured Policy No. ATW 005341-00 FEIN Miller & Pidskalny Custom Woodwork (A Corp)33-0284783 Exhibit C Certification Regarding Drug -Free Workplace Reguirements The certification set out below is a material representation upon which reliance is placed by the U.S. Department of Housing and Urban Development in awarding the grant. If it is later determined that the contractor knowingly rendered a false certification, or otherwise violates the requirements of the Drug -Free Workplace Act, the U.S. Department of Housing and Urban Development, in addition to any other remedies available to the Federal Government, may take action authorized under the Drug -Free Workplace Act. CERTIFICATION A. The contractor certifies that it will provide a drug-free workplace by: (a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the contractor's workplace and specifying the actions that will be taken against employees for violation of such prohibition; (b) Establishing a drug-free awareness program to inform employees about — (1) The dangers of drug abuse in the workplace; (2) The contractor's policy of maintaining a drug-free workplace; (3) Any available drug counseling, rehabilitation, and employee assistance program; and (4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; (c) Making it a requirement that each employee who will be engaged in the performance of the grant be given a copy of the statement required by paragraph (a); (d) Notifying the employee in the statement required by paragraph -(a) that, as a condition of employment under the contract, the employee will - (1) Abide by the terms of the statement; and (2) Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five days after such conviction. E (e) Notifying the U.S. Department of Housing and Urban Development within ten days after receiving notice under subparagraph (d)(2) from an employee or otherwise receiving actual notice of such conviction; (f) Taking one of the following actions, within 30 days of receiving notice under subparagraph (d)(2), with respect to any employee who is so convicted - ( 1) Taking appropriate personnel action against such an employee, up to and including termination; or (2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; (g) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e) and (f). B. The contractor shall insert in the space provided on the attached "Place of Performance" form the site(s) for the performance of work to be carried out with the grant funds (including street address, city, county, state, and zip code) .the contractor further certifies that, if it is subsequently determined that additional sites will be used for the performance of work under the contract, it shall notify the U.S. Department of Housing and Urban Development immediately upon the decision to use such additional sites by submitting a revised "Place of Performance" form. Dated: 6/&,e Z,24., � Employer Signature EXHIBIT D DIVISION OF EMPLOYMENT SERVICES PLACE OF PERFORMANCE FOR CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS Name: ! li /( er F' d 5 kcal ✓1 C�`r��wt IJP d Wo,,te Name of Contractor: Contractor Number: Date: 4/-z6/ gDzDrJZ 20 /5 The Contractor shall insert in the space provided below the site(s) expected to be used for the performance of work under the contract covered by the certification: Place of Performance (include street address, city, county, state, zip code for each site): F, 616it'r Aue AlLc� , c,9 q2�v� EXHIBIT D Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 29 CFR Part 98, Section 98.510, Participants' responsibilities. The regulations were published as Part VII of the May 26,1988 Federal Register (pages 19160-19211). (BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS FOR CERTIFICATION - Attached) (1) The prospective recipient of federal assistance funds certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency. (2) Where the prospective recipient of federal assistance funds is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. Name and Title of Authorized Representative Z, ?;� LI�2e->IZy Signa ire Date EXHIBIT E 1. By signing and submitting this proposal, the prospective recipient of federal assistance funds is providing the certification as set out below. 2. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective recipient of federal assistance funds knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the Department of Labor (DOL) may pursue available remedies, including suspension and/or debarment. 3. The prospective recipient of federal assistance funds shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective recipient of federal assistance funds learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 4. The terms 'covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," "person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549, You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations. 5. The prospective recipient of federal assistance funds agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the DOL. 6. The prospective recipient of federal assistance funds further agrees by submitting this proposal that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and voluntary exclusion - Lower Tier Covered Transactions," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to check the List of Parties Excluded from Procurement or Non - Procurement Programs. 8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the DOL may pursue available remedies, including suspension and/or debarment. EXHIBIT E