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Home My WebLink AboutVERIZON WIRELESS (LOS ANGELES SMSA LIMITED PARTNERSHIP) (5)DocuSign Envelope ID: ACEF09FA-6A28-49C5-13630-1 F89E84E4683 A-2020-047A 0 ouriANGE ON FILE �K MAY PROCEED 0 NZ-0 �Qti l NTIL INSURANCE EXPIRES (,, .� KOF-COUNCIL SUPPLEMENTAGREEMENT 71�}A ()�y'• tw 120btnS��a4 Oct 16, 2020 Thhis Supplement ("Supplement'), is approved by Licensor this day of 120 (the date executed by all parties, referred herein as "Supplement Effective Date"). 1. Supplement. Licensee has submitted an application for approval to use a Municipal Facility pursuant to that certain Municipal Facility License Agreement between Licensor and Licensee dated August 12, 2020 ("Agreement'). Licensor has reviewed the application and grants approval subject to the terms of this Supplement. All of the terms and conditions of the Agreement are incorporated hereby by reference and made a part hereof without the necessity of repeating or attaching the Agreement. In the event of a contradiction, modification or inconsistency between the terms of the Agreement and this Supplement, the terms of this Supplement shall govern. Capitalized terms used in this Supplement shall have the same meaning described for them in the Agreement unless otherwise indicated herein. IF THE SUPPLEMENT IS NOT COUNTER- SIGNED BY LICENSEE AND RETURNED TO LICENSOR WITHIN 30 DAYS AFTER LICENSOR HAS GRANTED APPROVAL, THE SUPPLEMENT SHALL BE VOID AND OF NO LEGAL EFFECT. IF LICENSEE STILL WANTS TO USE THE MUNICIPAL FACILITY, LICENSEE WILL BE REQUIRED TO SUBMIT A NEW APPLICATION AND ASSOCIATED FEES. 2. Licensed Area Description and Location. Licensee shall have the right to use the space on the specific Municipal Facility (the "Licensed Area") depicted in Attachment 1 attached hereto to install Equipment as further listed in Attachment 2 attached hereto. 3. Equipment. The Equipment to be installed at the Licensed Area is described and depicted in Attachment 1. 4. Term. The term of this Supplement shall commence on the Supplement Effective Date and continue for the life of the Agreement, as described in Paragraph 2 of the Agreement. 5. License Fee/Alternate License Fee. The initial fee for this Supplement shall be as follows per year: $270.00. This fee is subject to annual increase as provided in the Agreement, and is payable in accordance with the Agreement. 6. Performance Bond. The Performance Bond [circle one] is / is no covered by existing performance bond. If not covered by existing performance bond, a bon is required pursuant to Section 8 of the Agreement. 7. Miscellaneous. [Signature page follows] A-1 DocuSlgn Envelope ID: ACEF09FA-6A28-49C5-B630-1FB9E84E4683 A-2020-O47A IN WITNESS THEREOF, the parties hereto have caused this Supplement to be legally executed in duplicate, effective upon execution by both parties. Accepted: Licensor: CITY OF SANTA ANA, CA By: apt-" ti(!= Name: Nabil Saba Title: Executive Director Public Works A ency Date: 09/14/2020 Licensee: By: Name: Title: sr. Manager - Real Estate Date: ` Attachments: Attachment 1— Licensed Area (ANTPRK 079) Attachment 2 — Equipment List and Description A-2 DocuSign Envelope ID; ACEF09FA-6A28-4905-13630-1 FB9E84E4683 Attachment 1 Licensed Area [Map showing licensed area of applicable Municipal Facility and showing proposed Equipment installation.] FIV DocuSign Envelope ID: ACEF09FA-6A28-49C5-B630-1FB9E84E4683 OD m - � CO 0000 q O m N E S t u m cl 0 Q ° O c Q Q � Of V m .` yy U7 L y m N a m' i 0- m m a o i H iW Z � Iz 1 . li= LU I Q � a U o�2 i ' As • a 11 I "VIE) DocuSign Envelope ID: ACEF09FA-6A28-49C5-B630-1FB9E84E4583 venzonv' Attachment 2 Equipment List: • (1) 27' Galvanized Steel Streetlight with Faux Concrete Fetish • (I) 48" Tri-Sector Antenna SIu-oud • (1) 12" Architectural Transition Shroud • (3) Panel Antennas mounted within the 48" Tri-Sector Antenna Shroud IO rranane K. Francine R Villareal Date: 1120.09.02 Villareal 10:18:53-07'00' '4� �® CERTIFICATE OF LIABILITY INSURANCE OMMIDDN DATE(MMro020 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(ies) must have ADDITIONAL INSURED provisions or 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 endomement(s). PRODUCER ADD Risk Services Northeast, Inc. New York NY Office One Liberty Plaza 165 Broadway, suite 3201 CONTACT NAME: PHONE (g66) 283-7122 FAX (NC. No. Eat): pro_No,; (800) 363-0105 E-MAIL ADDRESS: New York NY 10006 USA INSURER(S) AFFORDING COVERAGE NAIL# INSURED LOS Angeles SMSA LP dba Verizon wireless INSURERA: National Uni On Fire Ins CO of Pittsburgh 19445 INSURER B: AIL Insurance Company 19399 INSURER C: American Home Assurance Co. 19380 1095 Avenue of the Americas New York NY 10036 USA INSURER D: New Hampshire Insurance Company 23841 INSURER E: INSURER F: THIS 15 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. Limits shown are as requested INSR TYPE OF INSURANCE POLICY NUMBER LTR INSD MD MMn1GrYyYy MMID-I LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y GL EACH OCCURRENCE $2,000,005 CLAIMS -MADE X❑ OCCUR D A ETO N ED PREMISES Ea ccwpre nce $2,000,000 X MED EXP (Any one Person) $10, 000 XCU Coverage Is Included PERSONAL a ADV INJURY $2,000,000 GEN-LAGGREGATE LIMITAPPLIES PER: PRO- X POLICY JECT LOG GENERALAGGREGATE $S,000,000 PRODUCTS-COMPIOPAGG $5,000,000 OTHER: A AUTOMOBILE LIABILITY CA 4594298 ADS 06/30/2020 06/30/2021 COMBINED SINGLE LIMIT a accidentl $1,000,000 BODILY INJURY( Per person) A X ANYAUTO CA 4594299 06/30/2020 06/30/2021 A OWNED SCHEDULED AUTOS ONLY AUTOS HIREDAUTOS NON -OWNED ONLY AUTOSONLY MA CA 4594300 VA 06/30/2020 06/30/2021 BODILYINJURY(PBr acPdI PROPERTY DAMAGE Peracddenl A See Next Page 06/30/2020 06/30/2021 UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAR H CLAIMS -MADE AGGREGATE DEG RETENTION B C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR I PARTNER I EXECUTIVE OFFICERIMEMBER EXCLUDED? IMandI in NH) If yes, descnbe under NIA WC045886576 ADS WCO4SHg6575 CA 06/30/2020 06/30/202006/30/2021 06 30/2021 X PER STATUTE OTH- R EL EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 E.L. DISEASEPOLICYLIMIT $1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The above -referenced General Liability policy shall cover the tort liability of the Certificate Holder assumed under the underlying agreement between parties for which the certificate has been issued. City of Santa Ana, its council members, officers and employees are included as Additional Insured with respect to the General Liability policy. The General Liability policy shall apply as Primary and Non -Contributory Insurance to each Additional Insured listed herein. Where permitted by law, the Named Insured parties listed herein waive all rights against City of Santa Ana, its council members, officers and employees. listed herein for recovery of damages to the extent these damages are covered by the above -referenced General Liability policy and, as further limited by written contract between the parties. m m m do 0 ur r 0 2 N u E ar U CERTIFICATE HOLDER CANCELLATION -� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE J POLICY PROVISIONS. city of Santa Ana AUTHORIZED REPRESENTATIVE - Risk Management Division 20 Civic Center Plaza, 4th Floor Santa Ana CA 92701 USA 'VIM (O`� J"imadiJr wrLM.R.dDNaDr 01988-2015 ACORD CO WVMED s APPROVED a' ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ��. F' W. -a.e Q, W&WAI Risk Management Analyst AGENCY CUSTOMER ID: 570000027366 LOC #: AnnITIONA1 REMARKS SCHEDULE Page _ of _ AGENCY NAMED INSURED Aon Risk Services Northeast, Inc. LOS Angeles SMSA LP POLICY NUMBER See certificate Number: 570083738856 CARRIER NAIC CODE EFFECTIVE DATE: see certificate Number: 570083738856 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 26 FORM TITLE: Certificate of Liability Insurance INSURER(S) AFFORDING COVERAGE NAIC # INSURER INSURER INSURER INSURER ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD certificate form for policy limits. INSR Um TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFFECTIVE DATE (MM[B])nYj POLICY EXPIRATION DATE (MM/DDA` Y'Y) LIMAS AUTOMOBILE LIABILITY A CA 4594301 NH - Primary 06/30/2020 06/30/2021 A CA 4594302 NH - EXCess 06/30/2020 06/30/2021 WORKERS COMPENSATION 9 N/A wc045886579 NV 06/30/2020 06/30/2021 B N/A wc045886577 FL 06/30/2020 06/30/2021 D N/A WC04SS86578 MA,ND,OH,WI,WY 06/30/2020 06/30/2021 B rv/A IWC045886574 NI,TX,VA 06/30/2020 06/30/2021 ACORD 101 (2008101) The ACORD name and logo are registered marks of ACORD REVENE11) & APPRov® BY: F„L� 2. V: &WAI Risk Manayencnt Analyst POLICY NUMBER: GL 172-88-90 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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 Person(s) Or Organization(s): Any person or organization whom you become obligated to include as an additional insured as a result of any contract or agreement you have entered into. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(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 omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 0 Insurance Services Office, Inc., 2012 Risk Mvrgeeo,FD6vim REoewm & APPRovm Sr. dS Fu. Z V&4,4d f Ruk Management Analy,t ENDORSEMENT This endorsement, effective 12:01 AM. 06/30/2020 forms a part of Policy No. GL 172-88-90 issued to VERIZON COMMUNICATIONS INC. BY NATIONAL UNION FIRE INSURANCE COMPANY OFPITTSBURGH, PA THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LIMITED ADVICE OF CANCELLATION PROVIDED VIA E-MAIL TO ENTITIES OTHERTHAN THE FIRST NAMED INSURED This policy is amended as follows: In the event that the Insurer cancels this policy for any reason otherthan non-payment of premium, and 1. the cancellation effective date is prior to this policy's expiration date; 2. the First Named Insured is under an existing contractual obligation to notify a certificate holder when this policy is canceled (hereinafter, the "Certificate Holder(s)") and has provided to the Insurer, either directly or through its broker of record, the email address of a contact at each such entity; and 3. the Insurer received this information afterthe First Named Insured receives notice of cancellation of this policy and prior to this policy's cancellation effective date, via an electronic spreadsheet that is acceptable to the Insurer, the Insurer will provide advice of cancellation (the "Advice") via e-mail to each such Certificate Holders within 30 days after the First Named Insured provides such information tothe Insurer; provided, however, that if a specific number of days is notstated above, then the Advice will be provided to such Certificate Holder(s) as soon as reasonably practicable afterthe First Named Insured provides such information to the Insurer. Proof of the Insureremailing the Advice, usingthe information provided bythe First Named Insured, will serve as proof that the Insurer has fully satisfied its obligations under this endorsement. This endorsement does not affect, in any way, coverage provided under this policy orthe cancellation of this policy or the effective date thereof, nor shall this endorsement invest any rights in any entity not insured under this policy. The following Definitions apply to this endorsement: 1. First Named Insured means the Named Insured shown on the Declarations Page of this policy. 2. Insurer means the insurance company shown in the header on the Declarations page of this policy. All other terms, conditions and exclusions shall remain the same. 107414 (03/11) A ut arize epresentative or Counters! nature (in States Where Applicable Risk Manarmud otASIM Rentwm 6 AP Room By: ®' Risk Management Analyst ENDORSEMENT # This endorsement, effective 12:01 A.M. 6/30/2020 forms a part of Policy No. CA 459-42-98 issued to VERIZON COMMUNICATIONS INC. By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LIMITED ADVICE OF CANCELLATION PROVIDED VIA E-MAIL TO ENTITIES OTHER THAN THE FIRST NAMED INSURED This policy is amended as follows: In the event that the Insurer cancels this policy for any reason other than non-payment of premium, and 1. the cancellation effective date is prior to this policy's expiration date; 2. the First Named Insured is under an existing contractual obligation to notify a certificate holder when this policy is canceled (hereinafter, the "Certificate Holder(s)") and has provided to the Insurer, either directly or through its broker of record, the email address of a contact at each such entity; and 3. the Insurer received this information after the First Named Insured receives notice of cancellation of this policy and prior to this policy's cancellation effective date, via an electronic spreadsheet that is acceptable to the Insurer, the Insurer will provide advice of cancellation (the "Advice") via e-mail to each such Certificate Holders within 30 days after the First Named Insured provides such information to the Insurer; provided, however, that if a specific number of days is not stated above, then the Advice will be provided to such Certificate Holder(s) as soon as reasonably practicable after the First Named Insured provides such information to the Insurer. Proof of the Insurer emailing the Advice, using the information provided by the First Named Insured, will serve as proof that the Insurer has fully satisfied its obligations under this endorsement. This endorsement does not affect, in any way, coverage provided under this policy or the cancellation of this policy or the effective date thereof, nor shall this endorsement invest any rights in any entity not insured under this policy. The following Definitions apply to this endorsement: 1. First Named Insured means the Named Insured shown on the Declarations Page of this policy. 2. Insurer means the insurance company shown in the header on the Declarations page of this policy. All other terms, conditions and exclusions shall remain the same. e 1 Authorized R 107414(03/11) RA R-AEwm� e Sr FMc K Z vj&,Ac[ Rnk Manage nt Analyst THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following " attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 06/30/2020 Issued to VERIZON COMMUNICATIONS INC- By NEW HAMPSHIRE INSURANCE COMPANY forms apart of Policy No. WC 0458-86-576 LIMITED ADVICE OF CANCELLATION PROVIDED VIA E-MAIL TO ENTITIES OTHER THAN THE NAMED INSURED (WORKERS' COMPENSATION ONLY) This policy is amended as follows: In the event that the Insurer cancels this policy for any reason other than non-payment of premium, and 1. the cancellation effective date is prior to this policy' s expiration date; 2. the Named Insured or, if applicable, any other employers named in Item 1 of the Information Page is under an existing contractual obligation to notify a certificate holder when this policy is canceled (hereinafter, the " Certificate Holder(s)" ) and the Named Insured has provided to the Insurer, either directly or through its broker of record, the email address of a contact at each such entity; and 3. the Insurer received this information after the Named Insured receives notice of cancellation of this policy and prior to this policy's cancellation effective date, via an electronic spreadsheet that is acceptable to the Insurer, the Insurer will provide advice of cancellation (the " Advice" ) via e-mail to each such Certificate Holders within 30 days after the Named Insured provides such information to the Insurer; provided, however, that if a specific number of days is not stated above, then the Advice will be provided to such Certificate Holder(s) as soon as reasonably practicable after the Named Insured provides such information to the Insurer. Proof of the Insurer emailing the Advice, using the information provided by the First Named Insured, will serve as proof that the Insurer has fully satisfied its obligations under this endorsement. This endorsement does not affect, in any way, coverage provided under this policy or the cancellation of this policy or the effective date thereof, nor shall this endorsement invest any rights in any entity not insured under this policy. The following definitions apply to this endorsement: Named Insured means the insured first named employer in Item 1 of the Information Page of this policy. 2. Insurer means the insurance company shown in the header on the Information Page of this policy. All other terms, conditions and exclusions shall remain the same. WC 99 00 56 (Ed. 04/11) REviEwED 6 Arrttty eo er. F+A.Y.:ne R. Vj/Ai a Nak Management Analyst