Loading...
HomeMy WebLinkAboutHERITAGE MUSEUM OF ORANGE COUNTYINSURANCE ON FILE WORK MAY PROCEED UNTIL INSURANCE EXPIRE' CLERK OF COUNCIL DATE: JUN 23 2017 HERI AGE 11 LVS PJM Short Term Facility Agreement The City of Santa Ana (hereinafter referred to as the "Lessee"), and Heritage Museum of Orange County (hereinafter referred to as "HMOC"), do hereby agree to the following terms: N-2017-116 1.) HMOC agrees to allow Lessee for a term of Two and One -Half 2.5 hours commencing on Thursday. June 29`h, 2017, the use of the Heritage Museum exterior grounds; located at 3101 West Harvard Street, Santa Ana, CA 92704 for the purpose of the Santa Ana- Celebrate the City Mixer (hereinafter called "the Event"). 2.) The scheduled event will begin at 5:30 am and end at 8 nm . Set up begins at 3:30 nm . The museum grounds must be cleaned to its original state and vacated by 9 nm, on Thursday. June 29`", 2017. 3.) Two (2) HMOC representatives will be on the premises during the Event and respond to facility emergency situations and will answer any questions about the use of the facilities or clarify issues pertaining to the facility agreement. HMOC representatives will not be required to give tours, provide security, coordinate agreements or vendor services, or assist in the preparation, and/or serving or cleaning during the course of the Event. The Lessee will provide all necessary equipment, supplies and security for the Event. Lessee may not use the name or logo of HMOC for any purpose without prior consent. 4.) Fees: Non-refundable deposit (A portion may be tax-deductible. Consult with your tax professional) $ BLa Facility Use Fee (Shall be paid on or before 90 days before the Event Date. If the Event is cancelled by User less than 120 days from the Event Date then no portion of the Facility Use Fee will be refunded.) $2Q Security Deposit (The Security Deposit shall be paid on or before 90 days before the Event Date. The User shall leave all HMOC property in equal or better condition as it existed immediately prior to the Event, in which case the Security Deposit will be fully refunded. If there is damage to HMOC property, or if the HMOC is required to expend additional effort or expense to clean the Event Facilities as a result of the Event, the Security Deposit may be applied to the extent necessary to cover such costs, and User agrees to pay any additional costs beyond the amount of the Security Deposit within 10 days after HMO C's notice. $200 TOTAL AMOUNT DUE 3101 West Harvard Street, Santa Ana, CA 92704 www.heritagemuseumoc.org HERITAGE MUSEUM Notice of cancellation must be submitted in writing at least 120 days prior to scheduled date of Event. Any cancellations received thereafter will not be refunded any monies and Lessee will be financially responsible in complying with the terms of this agreement. S.) HMOC and its representatives reserve the right to enter upon the premises at any time during the Event. 6.) Lessee hereby agrees and will not hold liable HMOC and its representatives, the responsibility for any articles lost or damaged as a result of the Lessee's use of these premises. 7.) LIABILITY AND INSURANCE. Except where caused by the intentional acts or negligence of the HMOC, Lessee hereby agrees to hold HMOC harmless for any and all liability, which maybe incurred by itself or third parties, as a result of the Lessee's use of the premises. Lessee must also purchase and provide an "Event Policy" certificate of insurance that applies for the duration of their Event (including set-up and clean-up time) for general liability coverage in the amount of $1,000,000.00 with HMOC as the named insured. Information regarding a reputable insurance firm for such a policy may be provided by HMOC for the Lessee's convenience. The Lessee MUST provide written proof of such coverage at least 30 days prior to the Event. AGREED, on the day of Jamie of ATTEST: MARIA D. HUIZAR Clerk of the Council {Signatures continued on next page) 2017. Signature CITY OF SANTA ANA CY�1f V HIA J. KURTZ Interim City Manager 3101 West Harvard Street, Santa Ana, CA 92704 www.heritagemuseumoc.org HERITAGE MUSEUM r_» 2 MGZL0i_V1111.11010 LIFi p SONIA R. CARVALHO City Attorney By:e..4µi Lisa Stto-rrck Assistant City Attorney RECOMMEND APPROVAL: Executive Director Planning& Building Agency 3101 West Harvard Street, Santa Ana, CA 92704 www.heritagemuseumoc.org 760-728-3851 12:2210 p.m. 05-18-2012 2l2 Fon W-9 Request for Taxpayer Give Form to the [Rev. December 2011) the Treasury =anus Identification Number and Certification isre arde n page resident alien, sole proprietor, or disregarded entity, see the Part I Instructions on page 3. For other requester. Do not send to the IRS. Memel Revenue Service _ m -� entitles, It is your employer Identification number (EIN). If you do not have a number, see Wow to get a Noe shown on your Income tax return 7�I (a,( i +0 '-A V S 2u � � et -\ C CQ U n -E Note. If the account Is in more than one name, see the chart on page 4 for guidelines on whose Iv1 c V e_ number to enter. of Business name/disregarded k9yname, If different from above m m I. m Check appropdale box for federal tax classification: 0 N Q Individual/sale proprietor Q CCorpomtlon ❑SCorporation ❑ Partnership ❑TrusVestete as Lmited liabilitycompany. Enter the tax classification (C=C corporation, S=S corporation, P= artnershi P) ► El Exempt payeev 0 2 N yOther 0 lsee lnsWclfons)► Q r0- E Adtlress (number, street, and epi. or sults no,) I Requester's name and address (options) a 3l O l -4 � c1 c U cL- (-d .S-4 e e j - m N City, state, and ZIP code h r� A List account number(s) here (optional) Taxpayer Identification Number (TIN) Enter your TIN In the appropriate box. The TIN provided must match the name given on the "Name" line I SOclal security number ) to avoid backup withholding. For this Is your social security number However, fora isre arde n page resident alien, sole proprietor, or disregarded entity, see the Part I Instructions on page 3. For other _ m -� entitles, It is your employer Identification number (EIN). If you do not have a number, see Wow to get a TIN on page 3. Note. If the account Is in more than one name, see the chart on page 4 for guidelines on whose I Employer identification number number to enter. n�- I_I I. Under penalties of perjury. I certify that: 1. The number shown on this form fa my correct taxpayer Identification number (or I am wafting for a number to be issued to me), and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all Interest or dividends, or (c) the IRS has notifled me that I am no longer subject to backup withholding, and 3. 1 am a U.S, citizen or other U.S. person (defined below). Certification Instructions. You must cross out item 2 above If you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all Interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an Individual retirement arrangement (IRA), and generally, payments other than Interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the Instructions on oaca 4. ,n sign I Signature of �4l pj Here U.S.persono. V� r General lnstruction't Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who Is required to file an Information return with the IRS must obtain your correct taxpayer Identification number (TIN) to report, for example, Income paid to you, real estate transactions, mortgage Interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only If you are a U.S. person (Including a resident alien), to provide your correct TIN to the person requesting It (the requester) and, when applicable, to; 1. Certify that the TIN you are giving Is correct (or you are waiting for a number to be Issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your II bI hof rthl Income from a U S trade or business Date ► Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if It is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S, person If you are: • An individual who Is a U.S. citizen or U.S. resident alien, • A partnership, corporation, company, or association created or organized In the United States or under the laws of the United States, • An estate (other than a foreign estate), or • A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners' share of income from such business. Further, In certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, If you are a U.S, person that Is a partner In a partnership conducting a trade or business In the United States, provide Form W-9 to the partnership to establish your U.S, status and avoid withholding on your share of partnership Income. a oca e s are any pa oars p Is not subject to the withholding tax on foreign partners' share of effectively connected income. Cat. No. 10231% Fonn W-9 (Rev. 12-2011) Acc H CERTIFICATE OF LIABILITY INSURANCE Dq/2g/2017Y) 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(les) 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 andorsement(s). PRODUCER ISU - Dunlap Agency 700 West let St., Suite 8 Tustin CA 92780 CONTNAME: Mary PO]ar PHONE (714)839-3158FAX (714)922-6157 IN Ext) -A/C No : E-MAIL mary@dunlapins. com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:Great American Insurance CO LIMITS INSURED Heritage Museum of Orange County 3101 W. Harvard Street Santa Ana CA 92704 INSURER B:Travelers Insurance CO INSURERCMarkel Insurance Co. INSURER D: INSURER E, INSURER F: COVERAGES CERTIFICATE NUMBER:2016-2017 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 D SUBR WVD POLICYNUMBER POLICY EFF MMIDDIYVYY POLICY EXP MMIDDIYYYY LIMITS X COMMERCIALGENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR DAMAA ETORENTED 300,000 PREMISES RENT mance $ PREMISES MED EXP (Any one person) $ 10,000 PAC 4296301 7/1/2016 7/1/2017 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 %{ POLICY PRO- JECT =1 LOC PRODUCTS - COMP/OP AGO $ 2,000,000 Employee Benefits $ 1,000,000 OTHER: LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accidentAANY BODILY INJURY(Per person) $ POMOBILE AUTO ALLOWNED SCHEDULED AUTOS AUTOS PAC 4296301 7/1/2016 7/1/2017 BODILY INJURY(Per accident) $ NON -OWNED HIRED AUTOS X AUTOS PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DEO RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 H ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) NIA M-OGS42168 7/1/2016 7/1/2017 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,000 A Directors S Officers EPP4915927 7/1/2016 7/1/2017 Aggregate Limit 1,000,000 A Liquor Liability PAC 4296301 7/1/2016 7/1/2017 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) GREAT AMERICAN INSURANCE COMPANY, POLICY #: PAC 4296301, EFFECTIVE DATE: 7/1/2016 TO 7/1/2017 INCLUDES PROFESSIONAL LIABILITY: $2,000,000 GENERAL AGGREGATE AND $1,000,000 EACH OCCURRENCE LIMIT. INCLUDES SEXUAL ABUSE/MOLESTATION LIABILITY: $2,000,000 GENERAL AGGREGATE AND $1,000,000 EACH OCCURRENCE LIMIT. INCLUDES LIQUOR LIABILITY $1,000,000 EACH OCCURRENCE LIMIT. CERTIFICATE HOLDER CANCELLATION ACORD 25 (2014101) INSf romanst ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Proof Of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE A Dean Dunlap/MP ACORD 25 (2014101) INSf romanst ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD