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HomeMy WebLinkAboutBRIAN PETERSON (2)rb Z\� INSURANCE ON FILE WORK MAY PROCEED MAYOR UNTIL INSURA CE EXPIRES Vicen M YORtPROrTEMto 2b22. Phil Bacerra CLERK OF COUi CIL COUNCILMEMBERS DATE: Johnathan Ryan Hernandez Jessie Lopez Nelida Mendoza David Penaloza Thai Viet Phan CITY OF SANTA ANA COMMUNITY DEVELOPMENT AGENCY 20 Civic Center Plaza • P.O. Box 1988 Santa Ana, California 92702 W .santa-ana.orc 8 . (OR C1Ixyi46 v )b) I.r• December 17, 2021 Brian Peterson 738 N. Santiago St. Santa Ana, CA 92701 Re: Extension of Mural Agreement (N-2021-167) Dear Mr. Peterson, N-2021-167-01 CITY MANAGER Kristine Ridge CITY ATTORNEY Sonia R. Carvalho CLERK OF THE COUNCIL Daisy Gomez Pursuant to Section 1 ("Term") of the above -referenced Agreement, entered into by Brian Peterson and the City of Santa Ana, dated July 12, 2021, the time period of the Agreement is hereby extended for an additional six (6) month period through June 30, 2022. Any insurance certificates are required to be extended and/or renewed to cover this extension. All other terms and conditions of the Agreement remain unchanged and in full force and effect. Sincerely, Steven Mendoza Executive Director, Community Development Agency CITY OF SANTA ANA Kristine Ridge City Manager W:u Sonia City /, Ryan 0.1 Assistant ATTEST Daisy Gomez, MMC Clerk of the Council ARTIST Brian Peterson SANTA ANA CITY COUNCIL Vicente 3almiento Phil Pao.. Thai Viet Phan David Penaloza Jessie Lopez JohnaPan Ryan HemanGez Nelida Mendoza Mayor Mayor Pro Tear, Ward C Ward! 1 Ward Wdld3 Ward5 Ward rmientdVe,Ma2na ora pbaCe rtaa(OlSanla-ana alp tphaniMsante-ana.am doenel,zaaantaana oN sielooezlyearlta-anaod wanhemandez5santa2naom nmendodr5santa,ana am Tori Pierson01g1fa11ys1gnetlbyionr1 non pat elan Jod6oe inv oros A`"R br CERTIFICATE OF LIABILITY INSURANCE An /13/202"1 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 endorsement(s). PRODUCER State Farm Insurance License # OG54371 O14210 Culver Dr, Suite A, Irvine CA 92604 NAAI : RICHARD TAY Exul 949) 559 8866 1 ac N,: (949) 269 0683 EaAM. UL ADDRESS: PRODUSTUCER 75-3018 INSURERS AFFORDING COVERAGE I Hai INSURED BRIAN PETERSON ART DBA FACES OF MANKIND 738 N SANTIAGO ST SANTA ANA CA 92701-5361 INSURER A: State Farm General Insurance Company 1 25151 INSURERB: INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE LTR ADOL SUBRi POLICY NUMBER POLICY EFF a U POLICY EXP MWDD LIMITS GENERAL LIABILITY A GEN _ xCOMMERCIAL GENERAL LIABILITY _ CLAIMS -MADE 11, x OCCUR _ GENT AGGREGATE LIMIT APPLIES PER: X POLICY ^ I Pi JECT F LOC II7� 92-EYM1-6-81 1 1 10/30/2027 10/30/2022 EACH OCCURRENCE S 1,000,000 PREMISES _R5NTE occurrence) S 50,000 MED EXP(Any one person) $ 5,000 PERSONAL& ADV INJURY $ 1,000,000 GENERALAGGREGATE S 2,000,000 PRODUCTS - COMP/OP AGO $ 1,000,000 $ AUTOMOBILE LIABILITY — —ANY AUTO _ALL OWNED AUTOS — SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS IF '1. ❑I. COMBINED SINGLE LIMB (Ea mxk1em) E BODILY INJURY (Par person) E BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Peraccldent) E S $ UMBRELLA LIAR OCCUR EXCESS LIAR _ CLAIMS -MADE❑ ❑I Ili EACH OCCURRENCE $ AGGREGATE $ _'. DEDUCTIBLE ".. RETENTION $ $ S WORKERS COMPENSATION ANDEMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? yeMe'dalory In NH1 flfl a, describe un8er N/A �'' - WC STATU- IOTH- TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ANach ACORD 101, Addldmal Remarks Schedule, N more apace Is required) WITH RESPECT TO GENERAL LIABILITY, NAMED ADDITIONAL INSURED FROM August 06 2021 TO November 20th, 2021 is: The City of Santa Ana, its officers, employees, agents, volunteers & representatives for the location of: 1815 Carnegie Avenue, Santa Ana CA 92705 LJCK I Hiii VA I C K V LUCK VAKGCLLA I I V K Rult Management Drkii City of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED I EXPIRATION DATE THEREOF, NOTICE WILL BE 1 - REm sursi a"ovaa By l • Risk Management Division POLICY PROW SIONS. tlfi.1 76-d yP4m,ae clumm 20 Civic Center Plaza esmm.,n,.,eenn,toel,.,taar Santa Ana, CA 92701 AUTHORIZED REPRESENTATIVE Ids Tay <iris.tay.mgms@statefann.com> ACORD 25 (2009109) © 1988- 2009 ACORD CORPORATION. The ACORD name and logo are registered marks of ACORD All rights reserved. 1001486 132849.4 02-11-2010 Policy No. 92 EYM168 1 CMP-4786.1 Page 1 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CMP-4786.1 ADDITIONAL INSURED — OWNERS, LESSEES, OR CONTRACTORS (Scheduled) This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 92 EYM168 1 Named Insured: BRIAN PETERSON ART INC DBA FACES OF MANKIND 738 N SANTIAGO ST SANTA ANA CA 92701-3951 Name And Address Of Additional Insured Person Or Organization: CITY OF SANTA ANA RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLAZA SANTA ANA, CA 92702 SECTION II — WHO IS AN INSURED of SECTION II — LIABILITY is amended to in- clude, as an additional insured, any person or organization shown in the Schedule, but only with respect to liability for "bodily injury", "property damage", or "personal and advertis- ing injury" caused, in whole or in part, by: a. Ongoing Operations (1) Your acts or omissions; or (2) The acts or omissions of those acting on your behalf; in the performance of your ongoing opera- tions for that additional insured; or b. Products — Completed Operations "Your work" performed for that additional insured and included in the "products - completed operations hazard". However, Paragraph 1. above is subject to the following: a. The insurance afforded to the additional insured only applies to the extent permit- ted by law; b. If coverage provided to the additional in- sured is required by a contract or agree- ment, the insurance provided to the additional insured will not be broader than that which you are required by the contract or agreement to provide for such addition- al insured; and c. If the contract or agreement between you and the additional insured is governed by California Civil Code Section 2782 or 2782.05, the insurance provided to the additional insured is the lesser of that which: (1) Is allowed for the satisfaction of a de- fense or indemnity obligation by Cali- fornia Civil Code Section 2782 or 2782.05 for your sole liability; or (2) You are required by contract or agreement to provide for such addi- tional insured. We have no duty to defend or indemnify the additional insured under this endorsement un- til a claim or "suit" is tendered to us. m, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. CONTINUED - RmkM gm DHtlm n-. I�inenm 6 Mvaw®ar. ; %u F7rGSJar rs"k m..,ugemnn am��.tiae 2. Any insurance provided to the additional in- sured shall only apply with respect to a claim made or a "suit' brought for damages for which you are provided coverage. 3. With respect to the insurance afforded to the additional insured, the following is added to SECTION 11— LIMITS OF INSURANCE: If coverage provided to the additional insured is required by contract or agreement, the most we will pay on behalf of the additional insured will be the lesser of the amount of insurance: a. Required by the contract or agreement; or b. Available under the applicable Limits Of Insurance shown in the Declarations. This endorsement shall not increase the ap- plicable Limits Of Insurance shown in the Declarations. 4. With respect to the insurance afforded to the additional insured, the following is added to Paragraph 3. Duties In The Event Of Occur- rence, Offense, Claim Or Suit of SECTION II — GENERAL CONDITIONS: The additional insured must: a. See to it that we are notified as soon as practicable of an "occurrence" or an of- fense which may result in a claim. To the extent possible, notice should include: (1) How, when and where the 'occur- rence" or offense took place; (2) The names and addresses of any in- jured persons and witnesses; and CMP-4786.1 CMP-4786.1 Page 2 of 2 (3) The nature and location of any injury or damage arising out of the "occur- rence" or offense; b. Tender the defense and indemnity of any claim or "suit' to us and to all other insur- ers who may have insurance potentially available to the additional insured; and c. Agree to make available any other insur- ance the additional insured has for de- fense or damages for which we would provide coverage under SECTION II — LIABILITY. 5. With respect to the insurance afforded the ad- ditional insured, the following replaces SEC- TION II —LIABILITY of Paragraph 7. Other Insurance of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: a. This insurance is primary to and will not seek contribution from any other insurance available to the additional insured, provided that the additional insured is a named in- sured under such other insurance. b. Regardless of any agreement between you and the additional insured, this insur- ance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional in- sured has been added as an additional in- sured on other policies. There will be no refund of premium in the event this endorsement is cancelled. All other policy provisions apply. 1007033 148011 08-21-2014 C. Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services office, Inc., with its permission Rid, Mvrgn ithw ihme gARVRw®ar. RuhM1Urugemmt<In„a�AiAe Policy No. 92 EYM168 1 CM7 e 1 8 9 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CMP4787 WAIVER OF TRANSFER OF RIGHTS OR RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 92 EYM168 1 Named Insured: BRIAN PETERSON ART INC DBA FACES OF MANKIND 738 N SANTIAGO ST SANTA ANA CA 92701-3951 Name And Address Of Person Or Organization: CITY OF SANTA ANA RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLAZA SANTA ANA, CA 92702 The following is added to Paragraph 10.b. of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for injury or damage arising out of: a. Your ongoing operations; or b. "Your work" done under contract with that person or organization and included in the "products - completed operations hazard". This waiver applies only to the person or organization shown in the Schedule. All other policy provisions apply. CMP-4787 p, Copyright, State Farm Mutual Automobile Insurance Company, 2008 1006225 137715.1 11-19-2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Rid MvYge llM (� RenE6%MVRwm ar. nWFn All. aO Y JON Rukhtaraage�em�Omc�l Aide (Policy Provisions WCOOOOOOC) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: Trumbull Insurance Company ONE HARTFORD PLAZA HARTFORD CT 06155 NCCI Company Number: 196G6 Company Code: H Suffix LARS RENEWAL POLICY NUMBER: 76 WEG AL4KRS Previous Policy Number: New 1. Named Insured and Mailing Address: BRIAN PETERSON ART, INC (No., Street, Town, State, Zip Code) 738 N SANTIAGO ST SANTA ANA CA 92701 FEIN Number: 84-3115161 State Identification Number(s): The Named Insured is: Corporation Business of Named Insured: Fine Arts Schools Other workplaces not shown above: 738 N SANTIAGO ST SANTA ANA CA 92701 2. Policy Period: From 04/21/21 To 04/21/22 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: AP INTEGO INSURANCE GROUP LLC 375 WOODCLIFF DRIVE STE 103 FAIRPORT NY 14450 Producer's Code: 76250846 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (877)287-1316 Total Estimated Annual Premium: $470 Deposit Premium: Policy Minimum Premium: $450 CA Audit Period: ANNUAL Installment Term: The policy is not binding unless countersigned by our authorized representative. Countersigned by 04/29/21 Authorized Representative Date Form WC 00 00 Ot A (1) Printed in U.S.A. Page 1 < M""gvnvf 0h aon Process Date: 04/29/21 ItvIO &APPR fly Policy E: ��� %u Prnae« RekMttugennIClmcalNtle INFORMATION PAGE (Continued) Policy Number: 76 V/EG AL4KRS 3 A. Workers Compensation Insurance: Pan one of the policy applies to the Workers Compensation Law of the states listed here CA Employers Liability Insurance: Pan Two of the policy applies to work in each state listed in Item 3 A The limits of our liability under Pan Two are Bodily Injury by Accident $1,000,000 each accident Bodily injury by Disease $1.000.000 policy limit Bodily injury by Disease S1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the slates, if any , listed here. ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.&TERRITORIES AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: SEE ENDORSEMENT -WC 99 03 68 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium Total Standard Premium Expense Constant Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement Estimated Annual Premium (before Surcharges) Total Estimated Surcharges 'See the attached Schedule(s) of Operations for Location and State Level Premium Information Total Estimated Annual Premium: $470 Deposit Premium: Policy Minimum Premium: $450 CA Interstate/intrastate Identification Number: Refer to Schedule of Operations Labor Contractors Policy Number: Form WC 00 00 01 A (1) Printed in U.S.A. Process Date: 04/29/21 NAICS: 611610 SIC:5231 $250 $200 S3 $453 S17 Paget f.`r+roa nreawrn er. Policy Expiration Dat RohFNr,age,nrn Omei�Ai°e 00 MA. NDat- To whom it may concern, I am writing this letter to verify that my one employee will not be working on the Navigation Mural. My employee will be staying in the office and will not be out in the location with me. The employee will not be on any lifts or painting. If you have any questions, you can contact me at (786) 543-7787. Sincerely, 0W; Brian Peterson Founder of Faces of Mankind witr.. aw" IR1nE1VEDi MPROVID Bv: %u �!icWerc Rkk M1LiruRmmi OniralN4 -11, " - � at — July 28, 2021 City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana, CA, 92702 RE: Auto Insurance Requirement Dear City of Santa Ana Risk Management Division: Brian Peterson Art Inc. has intent to enter into an engagement with the City of Santa Ana. Throughout the course of this agreement, Brian Peterson Art Inc. attests to the following: 3. Brian Peterson Art Inc. consultant/independent utilize their personal vehicle for transportation to and from work and if applicable carry their own automobile insurance. By signing below, I Brian Peterson attest that I possess the legal authority to enter into an agreement with the City of Santa Ana as well as the legal authority to attest to the statements above. If at any time it is found that Brian Peterson Art Inc. is not adhering to any/all statements in this document and has not provided the minimum Auto Liability insurance coverage of $1 million per occurrence, the contract will be considered null and void and the company will be held fully liable for any and all damages. �011- Brian Peterson Founder & CEO of Brian Peterson Art Inc. Brian Peterson Art Inc. (786)543-7787 info@brianpetersonart.com aak�.q�io� ,.. R"n 6N%VOJm RY. trkWrwg—tOm fAde PCA State Fe cm S Providing Insurance and Financial Services PO Bo: 95MS Richardson, TIT 75095.5919 StateFarm db ••„ Attached as requested are your replacement insurance identification cards. If the attached cards are not accepted by a law enforcement agency or your Department of Motor Vehicle office, please contact your agent to receive additional assistance. Thankyou for choosing State Farm foryour insurance needs, ------------------------------------------ IMPORTANT - IDENTIFICATION CARDS STATEFARM StateFarm IN& arm CALIFORNIA THIS CARD MUST BE KEPT IN THE INSURED MOTOR � 4� o INSURANCE CARD VEHICLE FOR PRODUCTION UPON DEMAND. Farm Mutual Automobile Insumma s Company PETERSON, VANESSA LUCIA A MUTL BRIAN A VOL NUMBER 4667259-1302.75C EFFECTIVE S MAKE TOYOTA APR 022021 TO OCT 022021 TACOMA VIN 3TMDZ5BNSJMG98947 R TAY INS AND RN SVCS INC 8018-AC7 Of9497559.8866 NAIC 25178 BYVIDE SY THE POLICY MEETS THE MINIMUM UABIUTY UNITS 3ED:ES A DID00 G7000 H U U1 IF YOU HAVE AN ACCIDENT - NOTIFY THE POLICE IMMEDIATELY 1. Get names, addressee, and phcm numbers of persons involvetl and wilneeeec. Also gat driver license numbers of persona Involved and loans plate numbers/states of vehicles. 2. Don't admit result or discuss the accident with mryane but State Form or police. 3. Promptlyy nobly your agent, log on to etaterannomnS, a use the State Farm mobile opp to Igo a clam. Far EMERGENCY ROAD SERVICE.., hr ts Femmabile opp.lop on la oterelennwom or doll 14774 740S7. EXAMINE POLICY=UMONS CAREFULLY. THIS FORM ODES NOT CONSTITUTE ANY PART OF YOUR INSURANCE POLICY How to Identify your coverage. See policy for full name and delni0on A Usbitty N Rnagency Rued Service U Urcwured Motor Vehicle C Medkel PaymeasL Physical Barrage Ul Unhsumd Mom Vehicle PU B Campreheneive RI Car Rentd end Travel Fnpemes Z Lass of Fim ags G Collision S Desth.0ismemhmmentsM KEEP A CARD IN YOUR CAR. THIS CARD IS INVALID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATED. KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF THIS CARD. ONE COPY OF THIS FORM SHOULD BE CARRIED IN THE VEHICLE AT ALL TIMES. THE FORM MAY BE NEEDED AS EVIDENCE OF INSURANCE IN COURT. SUBMIT ONE CARD, OR A PHOTOCOPY OF A CARD, WITH YOUR VEHICLE REGISTRATION RENEWAL Emergency Road Service Information Is located on your insurance card. — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — IMPORTANT - IDENTIFICATION CARDS STATE FARM StateFarm S12. m CALIFORNIA THIS CARD MUST BE KEPT IN THE INSURED MOTOR INSURANCE CARD VEHICLE FOR PRODUCTION UPON DEMAND. • Mutual Automobile Insurance Company MUTL VOL NUMBER 4667259-002.75C EFFECTIVE 9 MAKE TOYOTA APR 022021 TO OCT 022021 TACOMA VIN STMDZSBNSJM043947 R TAY INS AND RN SVCS INC 3018-AC7 (949_j559.8866 NAIC 25178 A Deblly, H Emergency Rood Service P VIDED BY THE POLICY MEETS THE MINIMUM UABIUTY LIMITS C Medical Payments L Phyanl DemeGe BED BY LAW. 0 Comprehensive RI Cm rental and Travel Espem RLb Mmsgmnd Dlz; ,.ES A DI G1000 X U U1 fi Cartel. S Deah,Oumembement end ITEVIE 6 APPpw® Or. .ofS KEEP A CARD IN YOUR CAR. �Ou Pr`RJO" THIS CARD IS INVALID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATE[ map Mang—ra—lAde KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF THIS ONE COPY OF THIS FORM SHOULD BE CARRIED IN THE VEHICLE AT ALL TIMES THE FORM MAY BE NEEDED AS EVIDENCE OF INSURANCE IN COURT. SUBMIT ONE CARD, OR PHOTOCOPY OF A CARD, WITH YOUR VEHICLE REGISTRATION RENEWAL FEE 24 W21 If YOU HAVE AN ACCIDENT - NOTIFY THE POLICE IMMEDIATELY 1. Get names, ad* esass. end pham mumbers of pemom involved and wilneeees. Also gat driver loans numbers of persona Immhred and Lcehes plate numbers/elates or vehicle,. 2. Don1 admit rmlR a discuss the accident vdth anyone but State Farm at patch. 3. Franptly holy your soon, log on to statdam.cam9, a use the Side Farm mobile Opp to bole a clam. For EMERGENCY ROAD SERVICE use that Nee Bra mobile opp,loF onadatdemoom ar snit 14-51 7742757. EXAMINE POLICYEXCLUSIONS CAREFULLY 7?US FORM DOES NOTCONSRTUTE ANY PART OF YOUR INSURANCE POLICY. How to identity your coverage. See policy for hull name and definition 143295.3 (a1 eocald) 01-15-2018 Emergen v Road Service infamehoa I. located on Your rmursnz card.