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HomeMy WebLinkAboutGAME THEATRE, LLC-2017City of Santa Ana Clerk of the Council AGREEMENT TERMINATION FORM Please complete this form in its entirety when the attached agree rt a Pii li �3 amendments (if any) are no longer in effect. Note: If your agreement is grant related, please ensure that all grant retention requiremm y OF C A it TA ANA have been satisfied prior to signing the termination form. CLERK, OF COUNCIL Is the agreement(s) a permanent record? Yes No Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. The agreement with N-2017-040 No. was completed on Li and final payment has been made. (List all amendments. Use space below if needed.) {� Department: MUSA Phone/Ext.: yR (q Signature: (G�j Date:laoa Revised: 10-18-16 N-2017-040 iSSt1RANCE ON, FILE WORK MAY PROCEED UNTIL INSURANCE PIR CLERAMUSEMENT DEVICE PROVIDER AGREEMENT GI.t.RK QP Ggll�1ClL -DATA% THIS AGREEMENT is made and entered into this 28"' day of Match, 2017, by and Mbetween Mobile Game Theatre, LLC ("provider') and the City of Santa Ana, a charter city and 0 municipal corporation organized and existing under the Constitution and laws of the State of u California ("City„). a T 0 N RECITALS A. The City desires to retain a provider to supply one mobile game theater for the Dia de Eos Nihos event that the City is hosting on April 22,. 2017 ("Event".). B. Provider represents that Provider is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Provider represents that it is knowledgeable in its field and that any services performed by Provider under this Agreement will be performed in compliance with such standards as may reasonably be expected. 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: L SCOPE OF SERVICES Provider shall furnish one (1) mobile garde track and one (1) attendant as more fully described in, Exhibit A attached hereto and incorporated by reference, City grants Provider the right to enter its property for the purpose of delivery, setup, and pickup. The mobile game truck shall be set up and ready for operation by start of Event at a location to be specified by City and shall be disassembled and removed: immediately at the conclusion of the Event. 2. COMPENSATION a. City agrees to pay, and Provider agrees to accept as total payment for its services the amount of Six Hundred Dollars ($600.00). The cost is identified in Exhibit A, attached hereto and incorporated by reference. b. Payment by City shall be made within thirty (30) days following; receipt of a proper invoice evidencing work performed, subject to the City's 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 the City. 9 This terra of this Agreement shall commence on the above -referenced date and end on April 30, 2017, unless terminated earlier in accordance with Section 11 below. Page 1 of 7 4. INDEPENDENT CONTRACTOR Provider 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 manner in which Provider performs the services which are the subject matter of this Agreement; however, the services to be provided by Provider shall be provided in a manner consistent with all applicable standards and regulations governing such services. Provider 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. Provider is not an agent, representative or employee of City and Provider shall have no authority to act on behalf of the City. 5. INSURANCE Prior to undertaking performance of work under this Agreement, Provider shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Commercial General L'iab'ility Insurance. Provider shall maintain commercial general liability insurance which 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 Provider'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 and $2,000,000 in the aggregate, including coverage of sexual misconduct. Such insurance shall (a) name the City, its officers, employees, agents, volunteers and representatives as additional insured(s)•, (b) be primary and not contributory with respect to insurance or self- insurance elfinsurance programs maintained by the City; (c) contain standard separation of insured provisions; and (d) contain a waiver of subrogation, 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 California state law, Provider, if Provider 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, Provider 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 Provider pursuant to this section: (i) provider shall maintain all insurance required above in full force and effect for the entire period covered by this Agreement. Certificates Page 2 of 7 of insurance shall be furnished to the City upon execution of this Agreement and shall be approved in form by the City. (ii) 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 Provider 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 affect Provider's right to be paid for its time and materials expended prior to notification of termination. Provider 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 provider agrees to and shall defend, 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 death, and claims for property damage, which may arise from the negligent acts or operations of the Provider 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. The Provider 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 asserting personal injury, damages, just compensation, restitution, judicial or equitable relief due to personal or property rights arising 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. CONFLICT OF INTEREST Provider 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. 8. 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 rail, postage prepaid, or sent by fax or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Cleric of the Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 Page 3 of 7 Santa Ana., CA 92702-1988 Facsimile (714) 647-6956 With copy to: Executive Director of Parks, Recreation and Community Services City of Santa Ana 20 Civic Center Plaza (M-23) P.O. Box 1988 Santa Ana, California 92702 Facsimile (714) 571-4211 To Provider: Mobile Game Theatre, LLC 7315 Sitio Castano Carlsbad, CA 92009 Telephone (619) 723-6060 Email shano cc, aincoz��arty.conr 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 snail, duly registered or certified, with postage prepaid, and addressed as set forth above. If sent by fax, communication shall be effective or deemed to have been given twenty-four (24) hours after the tirne 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. 9. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Provider regarding the subject matter herein, 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 Provider. 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 Provider or 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 is not embodied herein, 10. ASSIGNMENT The experience, knowledge, capability and reputation of Provider were a substantial inducement for City to enter into this Agreement. Therefore, Provider 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. Page 4 of 7 11. TERMINATION This Agreement may be terminated by the City Upon seven (7) days written notice of termination. In such event, Provider shall be entitled to receive, and City shall pay Provider, compensation for all services rendered prior to the effective date of termination. 12. RECORDS Provider shall beep records and invoices in connection with the work to be performed under this Agreement. Provider shall maintain complete and accurate records with respect to the costs incurred under this Agreement and any services, expenditures, and disbursements charged to the City for a minimum period of three (3) years, or for any longer period required by law, from the date of final payment to City under this Agreement. Provider shall allow inspection of all work, data, documents, proceedings, and activities .related to this Agreement for a period of three (3) years from the date of final payment to City under this Agreement. 13. NON-DISCRIMINATION Provider 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, teaching, training, utilization, promotion, termination or other employment related activities or in connection with any activities under this Agreement. 14. JURISDIC'T'ION — 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. LICENSES Provider shall, throughout the tei n 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 governraental agencies. 15. SEVERABILITY In the event th.at one or more of the phrases, sentences, clauses, paragraphs or sections contained in this Agreement shall be declared invalid or unenforceable by valid judgment or decree of a court of competent jurisdiction, such invalidity or unenforceability shall. not affect any of the remaining phrases, sentences, clauses, paragraphs or sections of this Agreement, which shall be interpreted to carry out the intent of the parties hereunder. Page 5 of 7 17. EXHIBITS All ExWbits referenced herein and attached hereto shall be incorporated as if fully set fortl, ill the body of this Agreerneat. 18, AUTHORITY The person(s) executing this Agreement on behalf of the parties bereto warrant that they are duly authorized to execute this Agreement on behalf of said parties and that by so exccutijg t1lis Agreenjelit, the pmlies hereto are foinally bound to the Provisions of this Agrcement, IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. A'17EST- MARIA DAIWIZAR Clerk of the, Council APPROVED AS TO FORM: SOMA R. CARVALI-10 City Attorney By: Axllzt�, K Assistant City Attomey RECOMMENDED FOR APPROVAL: 'k JEAE JURAD-0 — Actij4igzxecutive Director of Parks, Recreation and COmillunity Services Agency CITY OF SANTA ANA ROBERT C. CO RTEZ Deputy City Manager PROVIDER - By: -)VVLW Title'. (0,ovec/7,-- Page 6 of 7 EXHIBIT A SCOPE OF SERVICES EVENT: Santa Ana Public Library's Children's Day/Dia de los Ninos SERVICE DATE(S): April 22, 2017 COMPENSATION: Not to exceed $600.00 DESCRIPTION: Garvie On — Mobile Game Theater is a mobile game theater that will be used by visitors of the event. The mobile theater will have one attendant for the duration of the Dia de los Ninos event taking place Saturday, April 22, 2017. The mobile game truck is a stand still activity. The game truck is equipped with video games located inside the truck for kids to use. Special event will be presented at the Main Library, 26 Civic Center Plaza, Santa Ana CA 9.2701. The City will be responsible for setting up the space for the patrons attending and for advertising the program. Vendor will be responsible for providing all equipment, materials, supplies and personnel necessary to setup the Mobile Game Theater. Event T -lours —10:30a.m. -- 3:00p.m. Mobile Game Theater Reservations — During the duration of 4 hours scheduled from 10:30a.m. -- 2:30p,m. Wage 7 of 7 A'IC R & CERTIFICATE ®F LIABILITY INSURANCE DATE(MMfDDIYYYYj 03/23/2017 PRODUCER THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION East Main Street Insurance Services, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Will Maddux HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR PO Box 1298 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Grass Valley, CA 95945 Phone: (530) 477-6521 Email: info@theeventhelper.com INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Essex Insurance Company 39020 Mobile Game Theatre LLC INSURER B: Michael Haithcock -- 7315 Sitio Castano INSURER C: Carlsbad, CA 92009 INSURER D: INSURER E: COVERAGES 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 SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH _POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRADDT LTR.INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMIDDIYY POLICY EXPIRATION BATE MMII DIYY _ LIMITS GENERAL LIABILITY EACH OCCURRENCE INCLUDES BODILY INURY& PROPERTY DAMAGE $ 1,000,000 A Y ii COMMERCIAL GENERAL LIABILITY CLAIMS MADE [ OCCUR 3DS5450-M 1830244 05/29/2016 05/29/2017 MED EXP (Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 Host Liquor Liability """'''"""GGEEN'LAGGREGATELIMITAPPLIESPER: POLICY LJ PRD- JECT LOC PRODUCTS - COMPIOPAGG $ 1,000,D00 DEDUCTIBLE $ 1,000 Retail Liquor Liability $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ BODILY I NJ URY (Per person) $ ALL OVMV ED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) HIRED AUTOS NON -OWNED AUTOS � DAMAGE (Per (per accident) i $ Pill GARAGE LIABILITY �Cp AUTO ONLY - EA ACCIDENT 5 OTHERTHAN EA AGO AUTO ONLY: AGG $ $ ANY AUTO `\ EXCESSIUM13RELLA LIABILITY ,�_ h� 1� EACH OCCURRENCE $ OCCUR n CLAIMS MADE�d1b ' AGGREGATE $ $ DEDUCTIBLE $ �I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY WC STATU- I I OTH- ` TORY LIMITS ER -_" - — ""-- .- ELEACH ACCIDENT ANY PROPR $--- -EACH E.L. DISEASE - EA EMPLOYE OFFICERIMFMBFR FXCLUDED4 $ If yes, describe under E.L. DISEASE - POLICY LIMIT $ SPECIAL PROVISIONS below OTHER I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES ! EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS Certificate holder listed below is named as additional insured per attached CG 20 26 07 04. Attendance: 1000, Event Type: Vendor at Event. t' -film] a 011\ t �1111 i lq III ■J-4 •f1i0 IN R A III I IQ0 City of Santa Ana, It's officers, agents SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION and employees. Purchasing Dept 20 Civic Center Plaza DATE THEREOF, THE ISSUING INSURER WILL EPHK-MA1d4MAIL 30 DAYS WRITTEN Santa Arra, CA 92701 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 9 T ;"" "^^ T^ ^^ ^^ ^ "' ' AUTHORIZED REPRESENTATIVE �� A%,VKLO 40 t[UU"LIUaj (V AGUKU L UKPUKA I IUN IH?JIf CERTIFICATE OF LIABILITY INSURANCE FO9123'12016(MMI THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOTAFFIRMATIVELY 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: Ifthe certificate holder is an ADDITIONAL INSURED, the policy(Os) 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 t0 the certificate holder in lieu of such endorsement(s), PRODUCER GEICO Insurance Agency, Inc. 1 GEICO Blvd CONTACT GEICO Insurance Agency, Inc. NAME: PHONE AIC, No. Ext FAC A1C. Ne E-MAIL ADDRESS' Fredericksburg, VA 22412 INSUREI AFFORDING COVERAGE NAIC # MMIUDIYYYY INSURED INSURER A: NATIONAL LIABILITY& FIRE INSURANCE 20062 INSURER B: COMPANY MOBILE GAME THEATER LLC INSURER c: 7315 SITIO CASTANO INSURER D: $ CARLSBAD, CA 92009 INSURER E: COMMERCIAL GENERAL LIABILITY INSURER F: COVERAGES CERTIFICATE NUMBER' 234,131 REV1StON_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 PC LIC IES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR YMCA OF SAN DIEGO COUNTY ADDL SUBR 3708 Ruffin Rd. POLICY EFF POLICY EXP SAN DIEGO, CA 92123 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIUDIYYYY MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES Ea ocouffenCE $ COMMERCIAL GENERAL LIABILITY CLAIMS -MAD& ❑OCCUR MED EXP (Any One pefson) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ Gil AGGREGATE LIMIT APPLIES PER: PRODUCTS–COMPIOP AGG $ PRO - $ POLICY JECT LOC AUTOMOBILE AUTHORITY COMBINED SINGLE LIMIT Es accident $ NIA ANY AUTO BODILY INJURY (Per Person) $ 25,000 A ALL OWNED SCHEDULED AUTOS AUTOS Y 73APG074186-01 09123/2016 09123/2017 BODILY INJURY (Par accident) $ 60,000 PROPERTY DAMAGE Per accident $ 15,000 HRl AUTOS NON -OWNED AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB ��,o CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ —AND WORKERS COMPENSATION EMPLOYERS' LIABILITY WC STATU- 07H E, L, EACH ACCIDENT $ ANY PRDPRIETORIPARTNERIEXECUTIVE OFFiCERIMEMBF.R EXCLUDED? YIN N!A E. L. DISEASE – EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Je� \ ' E. L. DISEASE– POLICY LIMIT $ $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES {Attach ACORD I I Additional Remarks Schedule, if more space is required) Certificate Holder is named an Additional Insured on this policy. Vehicle Schedule: see attached CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE YMCA OF SAN DIEGO COUNTY EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE 3708 Ruffin Rd. POLICY PROVISIONS, - SAN DIEGO, CA 92123 AUTHORIZED REPRESENTATIVE ACORD 26 (2010106) The ACORD name and logo are registered marks of ACORD M-566211112011) ©1988-2010 ACORD CORPORATION. All rights reserved. 09/23/2016 14:06 29E9F6D5.2F78.439E-93DB-16CS73322EC2 Policy Number: 3DS5450-M1830244 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Persons? Or Oroanization(s) City of Santa Ana, it's officers, agents and employees. Purchasing Dept 20 Civic Center Plaza Santa Ana, CA 92701 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or organi- zation(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omis- sions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 O ISO Properties, Inc., 2004 Page 1 of 1 ❑ L�L L, �\K A hereby affirm wider penalty ofperjaaay,the following declaration., I certify on behall of _ji—ea—Loat drung the lern) of Y11v (Consultant Ompaa� Is'allio) contract for -vices with the City of Santa Ana, J will not employ any persoll in any manner so as to become subject to the workers, compensation laws of California., and agree that 11 1 shoLfid become subject to the workers' compensation provisions of Section 3 700 of the Labor Code, I shall torthwitli c0l"PlY witIl those provisjonswid provide P"001 of workers' compensation coverage, DATE: 5 By: c Name: Title: I elephone: W,U' NIN G. FAIL U Rk- 10 SECU � RE WORKERS � COMPEN S.A I I ON- 'OVEH-MiI. is s UNT-LAW-FUL, AND SHALL SUBJECTAN E-\ [PLOYER TO CRIMINAL PEXALTIE, i7 AND CIVIL FINES I..,P TO ONF HUNDRED 11 -11 -COS] W SECTIONT3706 OFTHE LABOR CODE., INTERJ-ST, ANDATTORNEY'S FF.F.S. WORKERS' COMPEN SAI ION DECLARATION hereby affirm under penalty of peijwy., the following declaration I certify on behaffot 10-4iat duxing the term at nay (ConsultmjCmpny Name) contract for Services with the City of Santa Ana, I will nal: e1uploy ally person. in any manner so as to become subject to the workers' compensation laws of Califonnia, and aggree that ri'l should, become subject to the workers' compensation provisions of Sectiou 3 700 of the Labor Code, I shall forthwith comply with those Provisions and provide Proofot'workers' compensation, coverage, DATE, By. N aine: -- Ale Title: Telephone; WARNING: FAILURETO S1JJRE W010' E1,1,S'(rO1V1PENSAT1ON COVERAuE IS UN .ANVIL, AND SHALL SUBJECT AN EMPLOYER TO MINIMAL PENALTIES AND (1 IL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($ 100,000). IN ADDIHON V0 1),-iL-COS-I'OFCOi%IPENSAlION, l.)A.N.I.A(-;ESASi)ROVII)'EDI-'Ol� IN SECTION3706 OF THE LABOR CODE, INTEJT-ST,AND ATTORNE "S FEES. . 006�Dl \e 7,