HomeMy WebLinkAboutCRUZ, MIGUEL TORRES<► City of Santa Ana
-�t Clerk of the Council coTc Office Use Only
AGREEMENT TERMINATION FORM
Please complete this form in its entirety when the attached agreement and all
amendments (if any) are no longer in effect.
Note: If your agreement is grant related, please ensure that all grant retention requirements
have been satisfied prior to signing the termination form.
Is the agreement(s) a permanent record? Yes No - -_
7
Uuh
Return form to the Clerk of the Council Office (M-30).
Call 647-1520 if you have any questions.
The agreement with
N-2019-254
No. was completed on (L �I Z� and final payment has been made.
(List all amendments. Use space below if needed.)
Department:
Phone/Ext.:
Signature: SM wkdkeiJ &L-
Date:
Revised: 10-18-16
N-2019-254
0, COA-C°p)
CJi�� dw
, uSURANCE ON r Lt
WORK MAY PROCEED
UNTIL INSURANCE EXPIRES
CLERK OF COUNCIL
DATE. S S 8 JU19
AN CULTURE ARTIST GRANT PROGRAM AGREEMENT BETWEEN
THE CITY OF SANTA ANA AND MIGUEL TORRES CRUZ
This Artist Grant Agreement ("Agreement") is made and entered this 201h day of August, 2019, by
and between the City of Santa Ana, a charter City and municipal corporation organized and
existing under the Constitution and laws of the State of California ("City"), and Miguel Torres Cruz
("Grantee") for the purpose of providing grant funding pursuant to the Investing in the Artist Grant
Program. City and Grantee may herein individually be referred to as a "Party' and collectively be
referred to as the "Parties" to the Agreement.
RECITALS:
A. On July 18, 2019, the Arts and Culture Commission reviewed all applicants and
recommended that Grantee be awarded an artist grant based on its Application for its
artwork ("Project"). A true and correct copy of Grantee's Application is attached hereto as
Exhibit A and incorporated herein by reference.
B. In undertaking the performance pursuant to this Agreement, Grantee represents that it is
skilled and knowledgeable in the arts and culture arena and that the Project created or
performed hereunder will be created or performed in compliance with such standards as may
reasonably be expected from an artist.
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. Term. This Agreement shall be effective upon signature by both Parties and shall expire one
year from the date first written above, unless terminated earlier in accordance with this
Agreement.
2. Fundina.
2.1. Subject to Grantee's performance of all required actions under this Agreement, City shall
provide funding, in two disbursements, as detailed below, of an amount not to exceed Five
Thousand Dollars ($5,000) ("Grant Amount" or "Grant").
2.2. Grantee will be paid in two (2) installments. First payment will be two-thirds of the funding
amount provided above or $3,350.00 and will be provided within thirty (30) days of the full
execution of the Agreement by the parties along with a complete invoice submitted by Grantee.
The second and final payment will include the remaining amount of $1,650.00 and will be issued
within thirty (30) days after the Grantee submits to the City all the proper receipts, invoices, and
final report for the Project.
2.3. Appropriate performance of the Grantee will be determined by City in its sole discretion. City
reserves the right to cease funding after the first disbursement detailed above, and to be
reimbursed the initial payment, if Grantee's performance is determined to be insufficient or
unacceptable in the City's sole discretion.
2.3. City represents that there is no correlation or connection between its selection of individuals
for grant awards and an individual's business relationship or potential business relationship with
City.
3. Grant Activities. Grantee agrees:
1
3.1. To perform the activities described in the Grant Application and Timeline submitted to City
for consideration dated May 30, 2019, a copy of which is attached as Exhibit A and incorporated
into this Agreement as if set out in full.
3.2. To submit all reports (each, a "Report"), which shall include, at a minimum, the items set forth
as required by the Application. No personally identifiable information shall be included in any of
the Reports, except where specifically requested. The Reports shall be in a format that is
reasonably acceptable to City. City may request additional information as City, in its sole
discretion, determines is necessary to monitor performance of this Agreement. City shall have the
right to use any Reports submitted by Grantee, or any portion thereof, for any reason.
3.3. Grantee shall maintain all pertinent financial and accounting records pertaining to this
Agreement in accordance with generally accepted accounting principles and other procedures
reasonably specified by City. Upon termination or expiration of this Agreement or request by City,
Grantee shall provide, at its expense, copies of all financial and accounting records produced by
it arising out of this Agreement.
3.4. Grantee shall allow audits, compliance or special reviews and inspections, including on -site
inspection, with or without prior notice, of Grantee's facilities by City or by third parties designated
by City, or their authorized representatives. Grantee shall provide its full cooperation for any such
audit, review or inspection, including providing timely access, for examination and copying of
records (including computerized records) pertinent books, documents, papers, computer
programs and records and reasonable access to its personnel.
3.5. Grantee shall ensure that any areas utilized for the Project are maintained and restored to a
well -maintained, safe, sanitary, and clean condition, and kept free of any hazardous waste at all
times. All equipment associated with the installation of the artwork, trash and debris shall be
removed and cleaned up on a daily basis. Grantee shall place a drop cloth or similar barrier on
the ground below the artwork while installation is underway, which barrier shall be removed each
day upon completion of an installation session.
3.6. The Project may not contain advertising, religious art, sexual content, negative or violent
imagery, convey political partisanship or include any hidden, subliminal, or camouflaged
messages or statements of any kind or nature. Appropriateness of the content of the Project will
be determined by City in its sole discretion.
3.7. The Project may not include any breach of intellectual property, trademarks, brands, or
images of illegal activity, and the Grantee must be the copyright holder for the Project.
4. Termination.
4.1. City may immediately terminate this Agreement upon one or more of the following:
4.1.1. Grantee's violation of any federal, state or local law or regulation.
4.1.2. Grantee's breach of any of the terms or conditions of this Agreement, including the
Application and Timeline, or any unapproved deviation from said documents that has not
been cured within 30 days of written notice of such breach.
4.2. In the event the Agreement is terminated under Section 4.1, City reserves the right to require
Grantee to refund any or all grant funds awarded to Grantee under this Agreement, and Grantee
agrees to refund to City any or all grant funds awarded under this Agreement.
5. Limitation of Liabili
5.1. IN NO EVENT SHALL CITY BE LIABLE FOR ANY INDIRECT, SPECIAL, INCIDENTAL OR
CONSEQUENTIAL DAMAGES OR EXPENSES FOR ANY NEGLIGENCE, BREACH OF
CONTRACT OR ANY OTHER ACT ARISING OUT OF OR RELATING TO THIS AGREEMENT
OR THE ACTIVITIES COVERED HEREUNDER.
5.2. Section 5 and Section 6 do not limit Grantee's rights, including its ability to seek recovery,
against anyone other than City, its directors, officers, employees, agents, successors and
assigns.
6. Indemnification
6.1. Grantee shall defend, indemnify, protect and hold harmless the City, and its elected and
appointed officers, employees, members or agents from and against all claims for damages,
liability, cost and expense (including without limitation attorney's fees) arising out of or alleged by
third parties to be the result of the negligent acts, errors or omissions or the willful misconduct of
the Grantee, and Grantee's employees, subcontractors or other persons, agencies or firms for
whom Grantee is legally responsible in connection with the execution of the work covered by this
Agreement. Grantee shall have no duty to indemnify or hold harmless the City if claims, damages,
liability, costs, expenses (including without limitation, attorney's fees) arise from the sole
negligence or sole willful misconduct of the City subsequent to declaration by the Grantee.
Grantee's obligations shall survive the termination of this Agreement.
6.2. Grantee agrees to hereby fully release and forever discharge the City from any and all claims,
demands, damages, losses, and liabilities (hereinafter collectively referred to as "claims"), which
are or may be related to or in any way connected with the negligence or willful misconduct of its
officers, officials, employees, or agents in connection with the creation, painting, performance or
installation of the Project hereunder.
6.3. Grantee further agrees that City may in good faith and on reasonable terms settle any such
claims and that City's right to indemnification shall extend to any such settlement, provided City
has given notice of such claim and its intent to settle. City's right to indemnification is in addition
to, and may be exercised independently of, any remedy held by City under this Agreement, at law
or in equity. The indemnity provision set forth in this Agreement shall survive the termination or
expiration of this Agreement indefinitely.
7. Insurance
7.1 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:
Commercial General Liability Insurance. Consultant shall maintain commercial
general liability insurance naming the City, its officers, employees, agents,
volunteers and representatives as additional insured(s) and shall include, but not
be limited to protection against claims arising from bodily and personal injury,
including death resulting therefrom and damage to property, resulting from any act
or occurrence arising out of 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, with $2,000,000 in the
aggregate. Such insurance shall (a) name the City, its officers, employees, agents,
and representatives as additional insured(s); (b) be primary and not contributory
with respect to insurance or self-insurance programs maintained by the City; and
(c) contain standard separation of insureds provisions.
b. Worker's Compensation Insurance. In accordance with the provisions of Section
3700 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.
C. 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 by the City.
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.
iv. Where the amounts or coverage provided by the certificates of insurance
provides coverage greater than those listed by this Agreement, the
amounts provided by the certificates of insurance shall be incorporated by
reference into the Agreement.
V. Consultant shall supply City with a fully executed additional insured
endorsement.
d. 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 affect
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.
8. General Provisions.
8.1. Grantee shall acquire prior written permission from City for any use of the City name or logo
in association with its Project.
8.2. If any parts of this Agreement are held to be invalid or unenforceable, the remaining parts of
the Agreement shall continue to be valid and enforceable.
8.3. Grantee shall comply with all governmental requirements that may now or in the future
become applicable to its activities under this Agreement.
8.4. This Agreement, including Exhibit A, Application, and any amendments or schedules hereto,
contain the full understanding and agreement of the Parties with respect to its subject matter, and
no waiver, alteration or modification of any of the provisions to this Agreement shall be binding
unless in writing and signed by an authorized officer of both Parties.
8.5. No waiver by either Party or any breach, default, or series of breaches or defaults, and no
failure, refusal, or neglect of either Party to exercise any right, power, or option given to it under
this Agreement or to insist upon strict compliance with the terms of this Agreement shall constitute
a waiver of these provisions with respect to any subsequent breach or waiver by either Party or
its right at any time thereafter to require exact and strict compliance with provisions of this
Agreement.
8.6. Any notice or other communication required or permitted to be made or given by either Party
pursuant to this Agreement will be in writing and will be deemed to have been duly given: (i) five
(5) business days after the date of mailing if sent by registered or certified U.S. mail, postage
prepaid, with return receipt requested; (ii) when transmitted if sent by facsimile, provided a
confirmation of transmission is produced by the sending machine; or (iii) when delivered if
delivered personally or sent by express courier service. All notices to City shall include a reference
to the Project title.
All notices will be sent to the other Party at its address as set forth below or at such other address
as such Party will have specified in a notice given in accordance with this section:
Grantee: Miguel Torres Cruz
15130 Brookhurst St #216
Westminster, CA 92683
City: City of Santa Ana
Clerk of the Council (M-30)
20 Civic Center Plaza
P.O. Box 1988
Santa Ana, CA 92702
FAX (714) 647-6956
8.7. This Agreement is subject to all applicable local, State and Federal laws. 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.
8.8. Grantee agrees to comply with all applicable equal opportunity and affirmative action laws as
appropriate, Grantee 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. Grantee affirms that it is an equal opportunity employer (if
applicable) and shall comply with all applicable federal, state and local laws and regulations.
8.9. Any funds provided under this Agreement that are not expended, obligated or otherwise
committed by the termination or expiration of this Agreement shall be immediately returned to
City.
8.10. Grantee grants to City a non-exclusive, irrevocable, transferable, royalty free, worldwide
license to use, reproduce, display, distribute, and prepare derivative works, in any form or media
at the discretion of the City for the Project conceived, performed or created as a result of this
Agreement.
8.11. Grantee and any of the Grantee's agents, employees or representatives are, for all purposes
under this Agreement, an independent contractor and shall not be deemed to be an employee of
the City, and none of them shall be entitled to any benefits to which City employees are entitled
including but not limited to, overtime, retirement benefits, work's compensation benefits, injury
leave or other leave benefits.
8.12. Neither Party shall assign any rights or obligations under this Agreement.
8.13. Each Party 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.
8.14. Each Party warrants that they have executed this Agreement knowingly, freely and
voluntarily and with full knowledge of its legal consequences. All parties involved warrant and
represent that, prior to executing this Agreement, each Party has had the opportunity to review
and consider this matter with legal counsel, and that the terms of this Agreement, and its
consequences, are fully understood by each Party.
8.15. This Agreement represents the entire agreement and understanding between the parties,
and supersedes any and all prior agreements and understandings between the parties, whether
oral or written.
8.16. Each undersigned represents and warrants that its signature herein below 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.
{Signatures on following page}
3
IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year
first above written.
ATTEST:
DAISY GOMEZ
Clerk of the Council
APPROVED AS TO FORM:
SONIA R. CARVALHO
RECOMMENDED FOR APPROVAL:
c�—
STEVEN A. MENDOZA
Executive Director
Community Development Agency
CITY OF SANTA ANA
KRISTINE RIDGE
City Manager
GRANTEE:
NamgMIGUEL •
ARTIST
EXHIBIT A
INVESTING IN THE ARTS GRANT PROGRAM
APPLICATION
Line Item
Input your information directly onto this form (2 pages) and upload onto Submittable.com.
E
Description of Personnel
Grant
(artist fees, consultants, administrative
Total Compensation
Funds
fees, etc.)
Requested
ao v _ av
, az , m
ebb , o�
Srt INN
t ate• ati
6
EQUIPMENT, MATERIALS, AND SUPPLIES
Item
(equipment, materials, supplies)
Quanti
ty
Unit
Cost
Total
Cost
Grant
Funds
Requested
S
•OS'
(Zv
! pU
ra\ld r9I u7a 00
Description I Grant Funds
(permits, fees, facility rental for project) Total Cost Requested
City of Santa Ana, Community Development Agency
20 Civic Center Plaza, M-25, Santa Ana, CA 92701(714) 647-5360
Line Item {
Enter budget categories and proiected expenditures for the orrmosed nrngram-
Category
Expenditures
Funded By
Santa Ana Grant
Expenditures
Funded By Other
Sources
(Including in -kind)
Total Project
Budget
Personnel Total
�-
2�u-10•Q?
�i0i
Equipment Total
#10- 6D
q U , 8Z)
Supplies Total
Materials Total
Additional Expense Total
TOTAL�i
l�•�
�/�) j�� 6i%
ID�a2O.GU
PROJECT REVENUE
LIST ALL OTHER PROJECT RESOURCES
"Funding Source" total must equal "Total Proiect Budget" listed ahnve
FUNDING SOURCE
AMOUNT
Santa Ana Artist Grant
6. IV)
TOTAL PROGRAM BUDGET
q ZA-
City of Santa Ana, Community Development Agency
20 Civic Center Plaza, M-25, Santa Ana, CA 92701(714) 647-5360
PROJECT TIMELINE
Date
Action
Outcome
March 2, 2020
Workshop: Reading.
Finalize the script.
We will workshop the script by
bringing in actors from the
community and theatre students
from Santa Ana College who will
help in the fine-tuning of the script
before it goes to production.
May 1, 2020
1st production meeting.
Set direction of the show
all aspects of design and
This meeting will bring the team
production.
together to begin the work of the
production: costume, sound,
lighting, set designers and director
will meet to set a direction for the
production of the show.
June 2, 2020
Auditions.
To find a potential cast.
We will hold auditions for the
seven roles in the play. Five of
which must be Latino and will be
actors from the community of
Santa Ana.
June 4, 2020
Callbacks.
To finalize a cast.
We will callback actors who we
want in the show to see how and
where they fit in the play and with
each other.
June 30, 2020
2" production meeting.
Communication and
This is a check in to see where the
follow-up concerning
designers and director are in terms
production of show.
June 30, 2020
of the productions; communicate
cont.
any changes, follow-up on needs
and direction.
July 1, 2020
Rehearsal begins.
To bring the show to life.
This is the beginning of the six
week rehearsal period where we
will put the play on its feet, the
actors will memorize their lines,
director will block (map out
movement onstage) the show, and
actors will bring the characters to
life.
August 1, 2020
3rd production meeting.
To finalize design aspects
of the show and
This will be the final production
communicate a plan for
meeting with the director and
design to move into the
designers to finalize the design
theatre.
aspects of the show before it is
moved into the actual theatre and
tech week begins.
August 8, 2020
Tech week begins.
To put the show
together.
This is the week where design and
actors come together to put the
show together. This means the
actors will work with lights,
costume, make-up, and the set to
merge the work they've put in at
rehearsal.
August 14, 2020
Special Opening for the
To share the work with
community of Santa Ana.
the community.
This will be the first of our two free
shows. We want the very first to
be for the community we built the
show for. People of Santa Ana will
be invited to experience the play
for the first time.
August23rd, 2020
Final show.
To share the work with
the community.
The second of our free shows for
the community and closing of the
play. This is will be for those
community members who came to
see our show the first time and
want to bring their family or
friends. The show will be free of
charge.
�c c rtxr CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE. IS ISSUED A$ A MATTER GF INFORMATION ONLY AND CONFERS NO RIGHT$ UPON THE CERTIFICATE HOLDER. T
CERTIFICATE GOES. NOT AFFIRMATIVELY OR NEGATIVELY AMEND. E7(TEND OR ALTER THE COVERAGE AFFORDED BY THE POLICI
BELMV, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSVRERI&i• AUTHORI2
REPRFSENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER.
FIIk3 tem14 And conditions leu f S Ih0 and r. OartelR policies nfdy rpQplrO d0 Ondpr56men4 A 4tdtOnl0Ol on this coNlflcdt@ dpC3 not CpRler riy�nl8 1p
cerl:fil:at6 f7t5ttfer in lieu of suth ondnrsamentisi-
<a,_tsa
NS!'RA.NC;IF 5E RV C E S
;1,. .`ir.a+ fdle1ei'C.il3 E:•Yv
! M1$:flE^t5 A •OI(pltiQ `^YEAADE hA',x
'. lM1S44Ep 1 Y 1.
I .r ♦ ! •LS JPEIk 9
K, INUR4
COVERAGES CERTIFICATE NUMBER. REVISION NUMBER
I t e i ' T EP E.-:'r 5 t'a1.rLaT '9--.. ra E9E `f Iu[ F H S vk, ry (/ D lE r '.Y r I
f�-111,F.;I 'Rb" R r 1. I a
—'ZIP r T ITS R a� i7': i
i _ 61 'ti2� aElrc I/ r
+h, 1r 1 f
_ ...n .. _.. _ P h PIP
X
le 75 18 '2 7 :: 171 1 II l
2 IVID01
e.. I ___...—... _....�__..m._.,T,_ „�._ >,.�. ...._.....dam. ..,,� .....
Ggfv_A'n9 X, .,
X _ }r:v 15JGQC�f ?.. ?: IC 'L1 ..-- •»..'„ S ' 1�
kMC�E>.l.Y9 _ -
I b r YP I
e5A p n r f.•tlYPA N...R 1CA1 ij45"fE:�nC48S Pira r R.^,y^{�4 I4! AdJ., w,+i 4e•e ar4Y 9. ntlx�15 �f x naycn .n rn+ywt/tE�
- •. rtr- - -5 Oy2 °} A'A9 I r@.-_ 'i Vol ;AP ? T wTeJ sS .i`.'It 11, -..n51 J 7 r-.I's (- � ,;,-y
-
7 $;.I ll-Ij py. es y
SHO'AD ANI OF THE ABOVE DESCRIBED POLICIES BE CANCEL' EO 0erORE
1 C t al ,svn THE EXP'RATION GATE THEIEOr, NOTICE WU 8E DELIVERED IN
RtB I ,p f1L;;yr. ""((�� AE�T]I� ACCORnANCU WITH THE POLICY PROVISIONS
REV[ YY f I.eI T.A i�{ PRID • ..AIGkJ REP ESFi�.T.it .u.�.._ �^^.._-^....
By R MANAGCMENT � i+!Qy: 1t
T a,19 r�9a.]a04 AC04tp VHYVF41TIOf7. Ail rrghta :vJdr•cJ
A;'-: 4C 25 :209.09, t.(.�i s D are reg[storod marks of ACORD
;CU u9 :9
SAMANTHA M. LAMBERT
C1TYoi1$ANiAANA
RISK MANAOEMEN-r o rdt mo* 4HUMAN RESOURCES
Managing RM *vqA Posiuva Change t
WORKERS' COMPENSATION DECLARATION
I, � �/ hereby affirm under penalty of perjury, the
(Namejl"ttleJ
following declaration:
I certify on behalf of_ ���_��"s 4:' g. ?-- _ that during the term
(ConsultanVCompony Name)
of my contract for �ervices with the City Of Santa Ana,
Type of service provldedJ
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 the provisions and provide proof of workers' compensation coverage.
Date;
Print Name:
Print Title:
1
Telephone,J J
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND
SHALLSUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARS ($100,000). IN ADDITIONAL 'TO THE COST OF COMPENSATION, DAMAGES
AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
& APPROVED
�GFmFm DiViSION
4 2019
l:IRisk Mgmtllnsurance RequirementslWC Declaration 08152019
September 22, 2019
'ro whom it may concern,
My name is Miguel Torres Crtrz and I am one of the recipients of the Arts and C:'uttwe
.flriirt Grant.
I am writing to inform you that I will not be using a vehicle (any auto or owned, hired
autos, non -owned autos) for activities related to my artist grant project. The term of
my agreement is from IAugust 20, 2019 to .August 19, 2020.
'I'hanls you so much,
IREV WED & APPROVED
By S MANACIEMENT DiVISiON
042019
M,LAAMBERT
R pwTEIMMiDU'YYYYI
AC'C I CERTIFICATE OF LIABILITY INSURANCE D3;o4+znzo II -
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 pallcy(les) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the forms 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 Ileu of such endorsemenf(s).
PRODUCER I NAME ' Regina Escuata
PHONE 81 R.CjgO-�0.0 FAX Bt iy-B40-7066
CSCau'l0 In3llta'IYb' acrY lGaS IA'C. No. Ee!`: _. IA'C NI.
'712 'A'Magruka Blvd. nnoRfss: nelpdesK�lesGL CIO -I ns.CUm
Bur -ark CA 91506 INsURERISI AFFORDING COVERAGE _ NAICN
INSURER A. t;5L1 25B95
INSURED INSURER a:
Cra'B T yrl - Tbc 'PVayn.ard ArliM INSURER C _
Grand Central Arts Ccl i:CKE INSURER a -.
125 V Nnaadv.ay INSURER E.
Sane Ana, CA 927U1 INSURER F
rmrcewrCe CFRTIPICATF NIIMRFR REVISION NUMBER:
T Y CI-1 T T= F + OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
-=2�uIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VVH:UFI THIS
'ERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HFREIN IS SUBJECT TO ALL THE TERMS.
'OLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSS -7 - 4u-OL SVBR' POLICY EFF POLICY EXP LIMITS
LTR RI POLICY NUMBER MM,OOlYYYY
X CUM MERCIA'. CENE3A. L+=1-I i I EACH OCCURRENCE $ 1,000,ODD
x
��// CAnv;uE-a t 1 100.000
PREMISES {Ee uccurren;al _ S
.V.EOEAT IAI'y 11, 1e'a01. 5 5,000
1 ---- % NPP15797199 12'16i2019 1221&2020 PEHEONAL8 AUV INJURY s 1,000,000
3[•.L.+]r_:-::Anti •.fr:•'F'.-5 ='E �. rFNFRAI AGGREGATE S 2.000,01)O
X r,. ...--uHr PRODuc c_covrrar AGc t INCLUDED
f:p4:arYFn $INGI c LBaI-
AUTOMOaRE4waa]iY � iCu :c_cerill �
AFY AL r.J I 500-Y N UK'1P01 pereael 5
u `JELL SCIIEO.._E
ALTOE.CNL. AL'Oy bIVRYiPnr n::Pi::nnli-5
H "_F`YJPI-.t;+;Nt'J FRG'EF rY DAVAbE _
AL' cy ,:;^.:' AL-Ci5 Cd.LY ;Fir a;a anp >
X UMaftE_'-A LIAa X ;JrLrVH FA.H OCCJ:AReM]F 5 2.000,C OD
A EZL_ss LL li Ira==•apt X XL 1592459A 12.'21i2019 121'21?202D AGGREGATE c 2.000,C00
I=O RE TEN -ION 3 S
WORKER'S C Or.1PEN5 A I ION PER ^-
H-
ANDEliGI'ERaLIABILITY YIN STA`LITE tR
ASrr'G'nit It t.=2F"Ar-:-,:i;:V n'vF NIAi EL EACH ACCIDENT t
C-fFIE \IE•,le F._arLL�pEEn
(Manea!ory in NH EL UIEtA5_-EA SMI'LCYEc
'rye colclta uI.V
GEECR ETC?. C: Cr E4P.iliM13 bvvc F p13FA$P- PC; I1-Y I.I0.11T
OL'SCRIPTION OF OPERATIONS I LOCATIONS: VEHICLES IACORD 131. Additional RamsrNg Sehedulx, may be attached If more space Is requlrsa)
City ul Santa Araoff.Cers, agents. employees. and volunteers are named as additionally insured on this policy pursuant to written contract, agreerr:enl, Or
rnurrumrcum rcf undars:anding. Such insurance as Is afforded by this policy shall be pr'mary, and any nsurance, carried by City shall be excess and
nonccnlntutor..
REVIEWED & APPROVED
By Risk MANAGEMENT DIVISION
City of Santa Ana
Risk Management Division
20 Civic. Center Plaza, 4th floor
^k. A 'en n�Trr,
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Orl
i-is. Ci
reserved,
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
0TYOFSANTAANA
RISK MANAGEMENTa dio[ecou 4HUMAN RESOURCES
Managing Risk m t Positive Change )
WORKERS' COMPENSATION DECLARATION
I, k a, ' �� hereby affirm under penalty of perjury, the
(Name/Title)
following declaration:
I certify on behalf of Liz _ that during the term
(Consultant/Company Name)
of my contract for Arc .,_/1// �, xr. its^ services with the City of Santa Ana,
(Type of service provided
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 the provisions and provide proof of workers' compensation coverage.
Date: 'Il-,Zo/A/
Print Name: Obtimb •.sl,
• Telephone
WARNING: FAILURE 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 ADDITIONAL TO THE COST OF COMPENSATION, DAMAGES
AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
RBE IIiEWM D & APPRANACiEMENIpOV ION
AR
k: RiskMgmtllnsuranceRequiremenislWCDeclaration 08152019
September 22, 2019
To whom it may concern,
My name is Miguel Torres Cruz and I am one of die recipients of the Arts and Culture
Artist Grant.
I am writing to inform you that I will not be using a vehicle (arty auto or owned, hired
autos, non -owned autos) for activities related to my artist grant project. The term of
my agreement is from August 20, 2019 to August 19, 2020.
Thank you so much,
REVIEWED :APPROVED