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AGREEMENT TERMINATION
Please complete this form when the attached agreement is no longer in effect
Return form to the Sr. Deputy Clerk of the Council (M -30). Call 647 -5238 if-you have, any
questions.
The agreement with
was completed on �1,3 6) 0 Y and final payment has been made.
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Department: T �s 4
Signature:
Date: w o 114
City of Santa Ana
Revised 8 -7 -03 Clerk of the Council
INSURANCE ON FILE
WORK MAY PROCEED
UNTIL INSURANCE EXPIRES
I-I o~9
CLERK OF COUNCIL
DATE: ~, o,~~
(~~. 1~rksR~c (~~
FIRST AMENDMENT TO AGREEMENT
N-2007-020-01
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~`~ la I ~ THIS FIRST AMENDMENT TO AGREEMENT is made and entered into this 15`h day of May,
2008 by and between the City of Santa Ana, a charter city and municipal corporation of the State
of California ("City") and Marlena Shaw ("Consultant").
RECITALS:
City and Consultant entered into Agreement N-2007-020, dated January 1, 2007,
hereinafter "said Agreement", by which Consultant has instructed Belly Dancing
classes through the City's leisure class program.
2. In accordance with the terms and conditions of said Agreement, the parties wish to
renew said Agreement for an additional one-year period.
WHEREFORE, in consideration of the mutual and respective covenants contained in said
Agreement, and subject to all the terms and conditions of said Agreement, City and Consultant
agree as follows:
Section 3, TERM, shall be amended to extend the term of said Agreement through
June 30, 2009.
2. Except as herein amended, all terms and conditions of said Agreement shall remain in
full force and effect.
IN WITNESS WHEREOF, City and Consultant have executed this First Amendment to
Consultant Agreement on the day and year first set forth above.
ATTEST: CITY OF SANTA ANA
u
PATRICIA E. HEALY GERARDO MOU
Clerk ofthe Council Executive Directo -Parks, Recreation and
Community Services Agency
APPROVED AS TO FORM:
JOSEPH W.FLETCHER
City Attorney
. 7
By: ~
La Sheedy, Asst. City ttorney
EVANSTON INSLTR ANCE COMPANY
CERTIFICATE NO.: 2008-15
CERTIFICATE OF INSURANCE
EXCLUDES COVERAGE FOR NOMINEE EVENTS. SEE SEPARATE APPLICATIONS FOR NOMINEE EVENTS.
SPECIAL EVENT LIABILITY PROGRAM
PRODUCER: PUBLIC ENTITY (ADDITIONAL INSURED)
City of Santa Ana
Alliant Insurance Services, Inc. in conjtmction with 20 Civic Center Plaza, M-28
Apex Instuance Services Santa Ana, CA 92701
P. O. Bax 6450 9 f~ ry ~~ c/~
Newport Beach, CA 92658 N _ ~ u l,' I ~ ~V
(949)660-8135
License No: OC 36861
NAMED INSURED (EVENT HOLDER): EVENT INFORMATION:
Marlene L. Shaw TYPE: Dance
14446 Pimlico Road DATE(S): Mav 1 2008 -December 31. 2008
Westminster, CA 92683 LOCATION: Salirado Center
*Liquoz Liability Yes ^ No
**Li uor Liabili after 12 amends before 2 am ^
This is to certify that the policies of inslrrance listed below have been issued to the insured named above for the policy period
indicated. Notwithstanding any requirements, terms or conditions of any contract or other document with respect to which this
certificate tray be issued or may pertain, the instuance afforded by the policies described herein is subj ect to all the terms,
exclusions and conditions of such policies. Limizs shown may have been reduced by paid claims.
INSURANCE CARRIER: Evanston Insurance Company
MASTER POLICY NUMBER: 04SEP1000001-4
MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2008 EXPIRATION: JANUARY 1, 2009
COMMERCIAL GENERAL LIABQ.ITY OCCURRENCE FORM DEDUCTIBLE: NONE
General Aggregate Limit $ 2,000,000
Products & Completed Operations 1,000,000
Personal & Advertising Injury 1,000,000
Each Occurrence limit 1,000,000
Fire Damagc (Any One Fire) 50,000
Medical Payments (Any One Person) 5,000
Liquor Liability (If purchased) 1,000,000
The limits of insurance apply separately w each event insured by [his policy as if a sepetatcpolicy ofinsurance has been issued for that event.
"Who is insured" is amended to include, as an insured, O:e person or organira[lon shown in this schedule, but on}y with respect to liability arising out of the
ownership. maintenance or use of tlx premises used by the named insured (even[ holder). This insurmroe deer not apply to: Any "occurtrnce" which mkes place
after the event hairier ceases to be a tenant in Ourt premises.
OTAER ADDITIONAL INSUREDS
CANCELLATION: Should the above described policy to cancelled befarc the expinfion date thereof, [he iswing company will rnail 30 days written notice to the
cerdFeate holder and additional insureds listed.
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AUTHORIZED REPRESENTATIVE:
DATE ISSUED: