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HomeMy WebLinkAboutJOHNSON & VERCLIFF, LLC -2008INSURANCE ON FILE WORK MAY PROCEED UNTIL INSURANCE EXPIRES y, l ~{ _ 0~1 CLERK OF COUNCIL DATE: ~, of ~ ~. ~rcws7 ~~ Y~~rc Egg. (a-) AGREEMENT BETWEEN THE CITY OF SANTA ANA AND JOHNSON & VERCLIFF, LLC N-2008-077 pz~e g; or~lo ~ + ~ 1o THIS AGREEMENT, made and entered into this ~ day of June, 2008 by and between the Johnson & Vercliff, LLC (hereinafter "Consultant"), and the Crty of Santa Ana, a charter crty and municipal corporation organized and existing under the Constitution and laws of the State of California (hereinafter "City"). RECITALS A. The City desires to retain a consultant having special skills and knowledge to prepaze a Request for Proposal to define the Scope of Work for Step 2 of the OCTA Go Local Program. B. Consultant represents that Consultant is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Consultant represents that it is knowledgeable in its field and that any services performed by Consultant under this Agreement will be performed incompliance with such standards as may reasonably be expected from a professional consulting fum in the field. 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. SCOPE OF SERVICES Consultant shall prepare a Request for Proposal to define the Scope of Work for Step 2 of the OCTA Go Local Program in accordance with its Proposal dated May 15, 2008, attached hereto and incorporated herein as Exhibit A. The Step 2 analysis will include the following three components of the Transit Vision: Modern Streetcar -Implementation of a modern streetcar between the SARTC and Civic Center and Harbor Boulevard to connect to the planned Bristol Street, Westminster, and Harbor Boulevazd bus rapid transit (BR'1~ lines. SARTC Expansion -Expansion of the SARTC to support the expansion of Metrolink services in 2009, the modem street car, and planned BRT, newly expanded SARTC would provide new station areas, additional pazking, bus, pedestrian, and bicycle access all integrated into transit-oriented development on and adjacent to the SARTC site. Multi-Modal Use of the PE ROW -The PE ROW would transform from an abandoned lineaz corridor into a dynamic multi-modal transportation facility that integrates the modem strcetcaz, BRT, autos, bicycles, and pedestrians. Transportation options include development of an arterial street, extension of the streetcar and an interchange to the arterial street at SR-22. 2. COMPENSATION a. City agrees to pay, and Consultant agrees to accept as total payment for its services, the rates and chazges identified in Exhibit A. The total sum to be expended under this Agreement, shall not exceed Twenty Five Thousand Dollazs ($25,000.00) during the term of this Agreement. b. Payment by City shall be made within thirty (30) days following receipt of proper invoice evidencing work performed, subject to City accounting procedures. Payment need not be made for work which fails to meet the standazds of performance set forth in the Recitals which may reasonably be expected by City. 3. TERM This Agreement shall continence on the date first written above and terminate on June 30, 2009, unless terminated earlier in accordance with Section 12, below. The term of this Agreement may be extended upon a writing executed by the Executive Director of the Public Works Agency and the City Attorney. 4. INDEPENDENT CONTRACTOR Consultant shall, during the entire term of this Agreement, be construed to be an independent contractor and not an employee of the City. This Agreement is not intended nor shall it be construed to create anemployer-employee relationship, a joint venture relationship, or to allow the City to exercise discretion or control over the professional manner in which Consultant performs the services which aze the subject matter of this Agreement; however, the services to be provided by Consultant shall be provided in a manner consistent with all applicable standazds and regulations governing such services. Consultant shall pay all salaries and wages, employer's social security taxes, unemployment insurance and similaz taxes relating to employees and shall be responsible for all applicable withholding taxes. 5. INSURANCE 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: a. Commercial General Liability Insurance. Consultant shall maintain commercial general liability insurance naming the City, its officers, employees, agents, volunteers and representatives asadditional insureds) 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. b. Business automobile liability insurance, or equivalent form, with a combined single limit of not less than $1,000,000 per occurrence. Such insurance shall include coverage for owned, hired and non-owned automobiles. c. Worker's Compensation Insurance. In accordance with the provisions of Section 3300 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. d. RESERVED. e. 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 famished to the City upon execution of this Agreement and shall be approved in form by the City Attorney. (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. f 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 effect 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. 6. INDEMNIFICATION Consultant agrees to and shall indemnifY and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives from liability: (1) for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal injury, including health. and claims for property damage, which may arise from the direct or indirect operations of the Consultant or its contractors, subcontractors, agents, employees, or other persons acting on their behalf which relates to the services described in section I of this Agreement; and (2) from any claim that personal injury, damages, just compensation, restitution, judicial or equitable relief is due by reason of the terms of or effects arising from this Agreement. This indemnity and hold harmless agreement applies to all claims for damages, just compensation, restitution, judicial or equitable relief suffered, or alleged to have been suffered, by reason of the events referred to in this Section or by reason of the terms of, or effects, arising from this Agreement. The Consultant further agrees to indemnifY, hold harmless, and pay all costs for the defense of the City, including fees and costs for special counsel to be selected by the City, regarding any action by a third party challenging the validity of this Agreement, or asserting that personal injury, damages, just compensation, restitution, judicial or equitable relief due to personal or property rights arises by reason of the terms of, or effects arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. 7. CONFIDENTIALITY If Consultant receives from the City information which due to the nature of such information is reasonably understood to be confidential and/or proprietary, Consultant agrees that it shall not use or disclose such information except in the performance of this Agreement, and further agrees to exercise the same degree of care it uses to protect its own information of like importance, but in no event less than reasonable care. "Confidential Information" shall include all nonpublic information. Confidential information includes not only written information, but also information transferred orally, visually, electronically, or by other means. Confidential information disclosed to either party by any subsidiary and/or agent of the other party is covered by this Agreement. The foregoing obligations of non-use and nondisclosure shall not apply to any information that (a) has been disclosed in publicly available sources; (b) is, through no fault of the Consultant disclosed in a publicly available source; ( c) is in rightful possession of the Consultant without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or ( e) is independently developed by the Consultant without reference to information disclosed by the City. 8. CONFLICT OF INTEREST CLAUSE Consultant 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. , 9. NOTICE Any notice, tender, demand, delivery, or other communication pursuant to this Agreement shall be in writing and shall be deemed to be properly given if delivered in person or mailed by first class or certified mail, postage prepaid, or sent by telefacsimile or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Clerk of the City Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 Santa Ana, California 92702-1988 telefacsimile (714) 647-6956 With courtesy copies to: Executive Director Public Works Agency City of Santa Ana 20 Civic Center Plaza (M-21) P.O. Box 1988 Santa Ana, California 92702-1988 telefacsimile (714) 647-5622 and, City Attorney City of Santa Ana 20 Civic Center Plaza (M-29) P.O. Box 1988 Santa Ana, California 92702 telefacsimile (714) 647-6515 To Consultant: Johnson & Vercliff, LLC Post Office Box 501 Seal Beach, CA 90740 Phone: 714.732-8100 Attn: Gary E. Johnson A party may change its address by giving notice in writing to the other party. Thereafter, any notice, tender, demand, delivery, or other communication shall be addressed and transmitted to the new address. If sent by mail, any notice, tender, demand, delivery, or other communication shall be effective or deemed to have been given three (3) days after it has been deposited in the United States mail, duly registered or certified, with postage prepaid, and < addressed as set forth above. If sent by telefacsimile, any notice, tender, demand, delivery, or other communication shall be effective or deemed to have been given twenty-four (24) hours after the time set forth on the transmission report issued by the transmitting facsimile machine, addressed as set forth above. For purposes of calculating these time frames, weekends, federal, state, County or City holidays shall be excluded. 10. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Consultant, and supersedes any and all other agreements, oral or written, between the parties. In the event of a conflict between the terms of this Agreement and any attachments hereto, the terms of this Agreement shall prevail. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Consultant. The parties agree that any terms or conditions of any purchase order or other instrument that are inconsistent with, or in addition to, the terms and conditions hereof, shall not bind or obligate Consultant nor the City. Each party to this Agreement acknowledges that no representations, inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which are not embodied herein. 11. ASSIGNMENT Inasmuch as this Agreement is intended to secure the specialized services of Consultant, Consultant may not assign, transfer, delegate, or subcontract any interest herein (other than working with RMC, Inc.) without the prior written consent of the City and any such assignment, transfer, delegation or subcontract without the City's prior written consent shall be considered null and void. Nothing in this Agreement shall be construed to limit the City's ability to have any of the services which are the subject to this Agreement performed by City personnel or by other consultants retained by City. 12. TERMINATION This Agreement may be terminated by the City upon thirty (30) days written notice of termination. In such event, Consultant shall be entitled to receive and the City shall pay Consultant compensation for all services performed by Consultant prior to receipt of such notice oftermination, subject to the following conditions: a. As a condition of such payment, the Executive Director may require Consultant to deliver to the City all work product completed as of such date, and in such case such work product shall be the property of the City unless prohibited by law, and Consultant consents to the City's use thereof for such purposes as the City deems appropriate. b. Payment need not be made for work which fails to meet the standard of performance specified in the Recitals of this Agreement. 13. DISCRIMINATION Consultant shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, age, national origin, ancestry, or disability, as defmed and prohibited L by applicable law, in the recruitment, selection, training, utilization, promotion, termination or other employment related activities. Consultant affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 14. JURISDICTION - VENUE This Agreement and all questions relating to its validity, interpretation, performance, and enforcement shall be government and construed in accordance with the laws of the State of California. 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. 15. PROFESSIONAL LICENSES Consultant shall, throughout the term of this Agreement, maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by the laws and regulations of the United States, the State of California, the City of Santa Ana and all other governmental agencies. Consultant shall notify the City immediately and in writing of her inability to obtain or maintain such permits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement. 16. MISCELLANEOUS PROVISIONS a. Each undersigned represents and warrants that its signature hereinbelow 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. b. All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. ~ IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. , - CITY OF SANTA ANA: ATTEST: t~~ City Manager PATRICIA E. HEALY Clerk of the Council APPROVED AS TO FORM: JOSEPH W. FLETCHER City Attorney BY:~~ (. ~ Lisa E. Storck Assistant City Attorney RECOMMENDED FOR APPROVAL: CONSULTANT James G. R~ss \ '. Executive Director Public Works Agency City of Santa Ana :/ , Employer ID #: 210 - t!> 00 7 CJ B / o ~. ~s<: ~: May 15, 2008 Mr. David Biondolillo City of Santa Ana Public Works Agency M-93 P. O. Box 1988 Santa Ana CA 92702 J®HNS®l~ $z VEIZCI,IFF, I,LC Consultants to Public Agencies Subject: Letter Proposal for the Santa Ana & Garden Grove Go Local Project -Step 2 Dear David, Thank you for your interest in having Johnson & VerCliff, LLC and RMC, Inc. assist you in advancing the transit vision developed jointly by the cities of Santa Ana and Garden Grove. I understand that you are requesting services from our companies to develop a Scope of Work (SOW) for a fixed guideway, perhaps a modern streetcar that will link the SARTC with the Santa Ana Civic Center and as far west as Harbor Boulevard. Included in this may be the expansion of the SARTC to accommodate the expanded transit services. Mr. Tony Rahimian and I will be the primary staff from our firms in providing these services. Mr. Rahimian and I are currently working on the City of Anaheim SOW for their fixed guideway project and Tony is also currently working on the City of Irvine fixed guideway project. Consequently, we have very recent experience in working with cities and OCTA on the Go Local Step 2 program and are eager to assist you as well. Post Office Box 501 Seal Beach, CA 90740 (714) 732-8100 @• gjohnson@vllc.net ~u'0~'r.`~ ~ ,i We propose to provide the services that are described above on an hourly rate based on the rate sheet attached to this letter. In addition, normal and customary expenses relating to the work will be in addition to the hourly charges Because the Go Local program is so new, many changes are occurring as to how the program is to be implemented. We propose that the first item of work is to establish and agreed upon approach and schedule with OCTA so that we can begin preparation of the SOW confident that we understand the needs and desires of both the cities and OCTA. Based on our current knowledge of the project we anticipate that the work can begin with a $25,000 contract. Additional budget to complete these tasks may be required depending on the complexity and the level of detail necessary to develop the SOW. It is our understanding that performance the work you have requested does not constitute a conflict for either of our companies for future work on this project. Tony and I have agreed that Johnson & VerCliff, LLC will be the prime consultant on this engagement and that RMC, Inc. will be a subcontractor. Thank you for the opportunity to be of service to you. ~~d~.~R~.`i . .-. Attachments (2) 0 JOHNS®1®1 ~ VEIZ~LI~~, LLC Consultants to Public Agencies ~~o~ &~~~ o .. '~ SCHEDULE OF FEES HOURLY RATE SCHEDULE POSITION PRINCIPAL Note: This is a "fully loaded" rate. Post Office Box 501 Seal Beach, CA 90740 (714) 732-8100 ~johnson@jvllc.net HOURLY RATE Szzs SCHEDULE OF FEES HOURLY RATE SCHEDULE All rates are "fully loaded", i.e., includes all overhead costs, general, administrative and profit. (See Note 1) Position Hourly Rate Principal $195 - $240 Project Manager $180 - $205 QA/QC Manager $180 - $205 Senior Engineer /Project Engineer $160 - $185 Associate Engineer /Planner $120 - $145 Junior Engineer $65 - $110 Project Controls Manager $ 115 - $150 Project Coordinator $85 - $110 Administrative Assistant $65 - $85 Engineering Intern $45 - $60 NOTE 1 All hourly rates are valid through December 31, 2008. !XHI~I !` ~, ~.~QBD~ CERTIFICATE OF LIABILITY INSURANCE ~'~~'~~' PRODUCER THIS CERTIFICATE IS ISSUEDAS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT'S UPON THE CERTIFICATE PRIME INSQRANCE SERVICES, INC. HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9891 IRVINE CENTER DRIVE #160 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. IRVINE, CA 92618-4319 _ _ INSURERSAFFORDING COVERAGE NAICft INSURED JOIiNSON & VERCLIFF LLC. INSURER 0. , INSURER B: 120 TBIRD ST INSURER c 5`72LT• BEACB CA 90']130 INSURER q , INSURER E: COVERAGES THE POUGES OF INSURANCE LISTED BELOW HAVE BEEN 153UFD TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INgCATED. NOTWITHSTANDING ANY REpUIREMENi, TETBA OR CONDITION OF ANY CONTRACT OR OTHER gJCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAV PERTAIN, THEINSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IGSUBJECT TOALLTHETERMS, EXCLUSIONS AND CONgTIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAID CWMS. POLICY EFFECTVE POLICY IX%RATIIXJ TYPE OF INSURANCE POLICY NUMBER DATE MMlD DATE D UMffS GENERAL LIABILITY EACH OCCURRENCE E 1 QQ oO X COMMERCIAL GENERAL LIABILITY PREMISES (Ea aurence) E Q CWMSMADE ~IOCCUR MED IXP(A~ryanaperson) $ A X 72SBMIA4897 OS~14~O8 OS~14~O9 PERSONALSADV INJURY E ]~ OQQ OQ GENERAL AGGREGATE E GEN'L AGGREGATE LIMB APPLIESPER: PRODUCTS-COMPIOP AGG E PR0. POLICY JECT LOC AUTOMOBILE LWBILITY COMBINED SINGLE LIMIT E ANYAUTO (Ea arriCeM) ALLOWNED AUTOS (( ~~ BODILY INJURY E Y ~ ~ (Per person) SCHEDULED AUTOS l~ ~ HIRED AUTOS O ~ BODILY INJURY w (Pera¢Hant) E NON~WNED AUT03 r ~ PROPERTY DAMAGE O G`~ (Per acciCenq E GARAGE LIABILITY ~ C F~~OC ALRO ONLY- EAACCIDENT E ~ ~~ T` ANYAUTO ~\ ~ h OTHER THAN EAACC $ `yt$~ ~y AUTO ONLY: AGG E EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $ I OCCUR CICUIMS MADE AGGREGATE b a DEDUCIiBLE Y RETENTION 3 $ WgRKERS COMPENSATION ANO TORY LIMITS ER EMPLOYERS' LIABILITY £%ECUI WE MIY PROPRIEfOfLPARrNER E.L. E4CH ACCIDENT' E i OFFILERRAEMBEft EXCLUDEDi EL. DISEASE- EAEMPLOYEE $ Ifyes, descAbauntler GPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT E OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS !VEHICLES / E%CLUSIONS ADDED BYENDORSEMENi I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES eE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O DAYS WRITTEN CITY OF SANTA ANA NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO W SO SNALL BOX 1988 P O . . IMPOSE NO OBUGATON OR LIABILITY OE ANY KING UPON THE INSURER RS AGENTS OR SANTA ANA, CA 92702 REPRESEMATIVES. AUTHORIZED REPRESENTATIVE f^ r- ACORD 25 (2D07108) ©ApORD CORPORATION 1888 ~ CERTIFICATE OF INSURANCE 0 SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE CANCELED OR OTHERWISE TERMINATED WITHOUT GNING 70 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM THE DATE WRITTEN. THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED BELOW. This certifies that: ®STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois ^ STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois ^ STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas, Texas ^ STATE FARM INDEMNITY COMPANY of Bloomington, Illinois, or ^STATE FARM GUARANTY INSURANCE COMPANY of Bloomington, Illinois has coverage in force for the following Named Insured as shown below: NAMED INSURED: GARY E JOHNSON ENDORSEMENT EFFECTIVE 6-5-08 ADDRESS OFNAMEDINSURED: 120 3R0 sTREET SEAL BEACH cA 907 90 POLICY NUMBER L35 ez37- co3-75 EFFECTIVE DATE OF POLICY 03-03-OB TO 09-03 -08 DESCRIPTION OF 2002 MERCEDEs VEHICLE (Including VIN) WDBJF70J5 2B408360 LIABILITY COVERAGE ®YES ^ NO ^YES ^ NO ^YES ^YES ^ NO LIMITS OF LIABILITY ~`~ a. Bodily Injury 1, ooo, ooo $ 9 g. Each Person Each Accident 1, 000, 000 5~0 ~gCnOy b. Property Damage ~.~ Pt G s~ \ 3 Each Accident 1, 000, ooo st ) c. Bodily Injury 8 ,~ Property Damage Single Limit Each Accident PHYSICAL DAMAGE COVERAGES ®YES ^ NO ^YES ^ NO ^YES ^ NO ^YES ^ NO a. Com rehensive $ 500 Deductible $ Deductible $ Deductible $ Deductible ® YES ^ NO ^YES ^ NO ^YES ^ NO ^YES ^ NO b. Collision $ 1000 Deductible $ Deductible $ Deductible $ Deductible EMPLOYERS NON-OWNED CAR LIABILITY COVERAGE YES ^ ®NO ^YES ^ NO ^YES ^ NO ^YES ^ NO HIRED CAR LIABILITY YES ^ ®NO ^YES ^ NO ^YES ^ NO ^YES ^ NO COVERAGE FLEET-COVERAGE FOR ALL OJUNED AND DCENSED YES ^ ®NO ^YES ^ NO ^YES ^ NO ^YES ^ NO MOTOR VEHICLES c AGENT 7797 06-05-2008 azure of AUtnonzea rcepresenranve Title i+genrs voce rvumoer uace ame and Address of Certificate Holder Name and Address of Aaent CITY OF SANTA ANA P.O. BOX 1988 SANTA ANA, CA 92702 1066 BOLSA AVENUE SEAL BEACH CA 90740 INTERNAL STATE FARM USE ONLY: ^ Request permanent Cert~cate of Insurance for liability wverage. tzzazs.s Rev. o7-2s-zoos ®Request Certificate Holder to he added as an Additional Insured. STATE FARM INSURANCE J Binder of Insurance Pending issuance and delivery of a policy pursuant to the application of the insured and to all the terms and conditions of the policy issued by the company the State Farm Mutual Automobile Insurance Company Does hereby insure: GARY E JOHNSON 120 3RD ST SEAL BCH, CA 90740-6007 Policy Number: L35 8237-C03-75B Year Make 2002 MERCEDES E430 4DR Liability 1M/1M/1M Vehicle Identification Number (VIN) WDBJF70J52B408360 Coverages Comprehensive $500 Collision Ded $1000 Effective June O5, 2008, expiring not to exceed thirty (30) days hence and to become void immediately upon the issuance of a policy in place hereof. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. Date ~-J~ o~"d~, Q / Authorized Representative A5 ~~ FpR~ RYYR~~D ~`gp E• SZ ARtorne`J nt C~~Y \ ~S~sta~ k 3 J `'7 N ~ d-(j)0~ 0'/1 STATE fARM &> INSURANCE JOHNSON, GARY E 120 3RD ST SEAL BCH CA 90740-6007 H PHONE: MUTL L35 8237-C03-75C OCTOBER 20, 2008 (562) 596-7317 IRG: 24 LRG: 03 ZIP: 90740 CLASS: 6B30CV1M ACC FREE: MAR-03-82 BIRTH: APR-10-47 AUTO POLICY STATUS 02 MERCEDES E430 4DR VIN: WDBJF70J52B408360 STATUS: PAID AMT DUE: DUE DATE: TERM DATE: TOT PREM: 0.00 OXD:MAR-03-82 COV DATE:JUN-05-08 PREV PREM: 358.23 356.74 A 1MM /lMM /lMM C5000 D500 G1000 H 175.38 U 30 /60 11. 98 U1 37.96 110.30 2.99 16.27 3.35 AMT PAID: 358.23 DATE PAID: AUG-15-08 YLR 45, GRP 06/14/96, CDR SR 345.44, MCD 82.75, LD 6 78.00, CGDD 89.57, VSD 20% 3.00, ODM 8 09-01, MLD 22% $100.21 HOMEOWNERS & PLUP. NAME: JOHNSON,GARY E REPLACED POLICY: L358237-75B H PHONE: (562) 596-7317 POLICY FORM: 9805A EXCEP. & 92702. DRVR GARY END: ADD'L INSURED - CITY OF SANTA ANA PO BOX 1988 SANTA ANA CA DT OF LIC RL NXT RL-DT 04/10/1963 SR ACC/CONV DATE INFORMATION REC CHG: cov. S & Z NAMES S AMT Z INSUIANCI 8 JIM CONRAD 1066 BOLSA SEAL BEACH. CA 90740 562598-2415 714 827-9642 Q.,'I) 'tlW.\A -3'~'09 C'Sc..P .IATI 'AaM .tit N,",~'D0<6-0'l'7 WORKERS' COMPENSATION DECLARATION I Gary Johnson, CEO hereby affirm under penalty of perjury, the following declaration: I certify on behalf of Johnson & VerCHff, LLC contract with the Public Works Agency, City of Santa Ana, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that in should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. DATE: 10/21/2008 By: Name: Title: ae-D Telephone: ?!i-' 1-S-Z ~ / t:> i) 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 ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. 4{OVED AS TO FOl\M ,- (z#r~~ LISA E. STORCK Assistant City Attorney