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HomeMy WebLinkAboutCLIMB IT (3)-2017City of Santa A 7 Clerk of the Council AGREEMENT TERMINATION FORM COTC Office Use �?Q F Please complete this form in its entirety when the attached agreement and al '6 PPS [: 22 amendments (if any) are no longer in effect. Cl T $ Note: If your agreement is grant related, please ensure that all grant retention requirements CL F Up- r'i NH 0 t- AN.4 have been satisfied prior to signing the termination form. C0(/j(C/` Is the agreement(s) a permanent record? Yes No Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. The agreement with Na N-2017-037 was completed on YL;c n and final payment has been made. (List all amendments. Use space below if needed.) (� Department: PPC5A Phone/Ext.: tqR Signature: Date: Revised: 10-18-16 C NA1PLETE LE N-2017-037 d114SUIASCE Tama WORK KU W-IM N CD DATA: �$ `8 2011. AMUSEMENT DEVICE PROVIDER AGREEMENT a 2 THIS AGREEMENT is made and entered into this 27"' day of March, 2017, by and p between Climb It ("Provider") and 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"). RECITALS A. The City desires to retain a provider to supply one mobile Rockwall for the Dia de los Nihos event that the City is hosting on April 22, 2017 ("Event"). B. Provider represents that Provider is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Provider represents that it is knowledgeable in its held and that any services performed by Provider under this Agreement will be performed in compliance with such standards as may reasonably be expected. 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 Provider shall furnish one (1) mobile Rockwall and one (1) attendant as more fully described in Exhibit A attached hereto and incorporated by reference. City grants Provider the right to enter its property for the purpose of delivery, set-up, and pick-up. The Rockwall shall be sat up and ready for operation by start of Event at a location to be specified by City and shall be disassembled and removed immediately at the conclusion of the Event. 2. COMPENSATION a. City agrees to pay, and Provider agrees to accept as total payment for its services the amount of Sic Hundred. and Twenty Five Dollars ($625.00). The cost is identified in Exhibit A, attached hereto and incorporated by reference. b. Payment by City shall be made within thirty (30) days following receipt of a proper invoice evidencing work performed, subject to the City's accounting procedures. Payment need not be made for work which fails to meet the standards of performance set forth in the Recitals which may reasonably be expected by the City. 3. TERM This term of this Agreement shall commence on the above -referenced date and end on April 30, 2017, unless terminated earlier in accordance with Section 11 below. Page 1 of 7 4. INDEPENDENT CONTRACTOR Provider 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 an employer -employee relationship, a joint venture relationship, or to allow the City to exercise discretion or control over the manner in which Provider performs the services which axe the subject matter of this Agreement; however, the services to be provided by Provider shall be provided in a manner consistent with all applicable standards and regulations governing such services. Provider shall pay all salaries and wages, employer's social security taxes, unernploytnent insurance and similar taxes relating to employees and shall be responsible for all applicable withholding taxes. Provider is not an agent, representative or employee of City and Provider shall have no authority to act on behalf of the City. 5. INSURANCE Prior to undertaking performance of work under this Agreement, Provider shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Commercial General Liability Insurance. Provider shall maintain commercial general liability insurance which 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 Provider'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 and $2,000,000 in the aggregate, including coverage of sexual misconduct. Such insurance shall (a) name the City, its officers, employees, agents, volunteers and representatives as additional insured(s); (b) be, primary and not contributory with respect to insurance or self- insurance programs maintained by the City; (c) contain standard separation of insured provisions; and (d) contain a waiver of subrogation. 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 California state law, Provider, if Provider 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 AgreenmQat, Provider agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. d. The following requirements apply to the insurance to be provided by Provider pursuant to this section, (i) Provider shall maintain all insurance required above in full force and effect for the entire period covered by this Agreement. Certificates Page 2 of 7 of insurance shall be furnished to the City upon execution of this Agreement and shall be approved in form by the City. (ii) 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. e. If Provider 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 Provider's right to be paid for its time and materials expended prior to notification of termination. Provider 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 Provider agrees to and shall defend, indemnify and hold harmless the City, its officers, agents, employees, contractors, special counsel, and representatives from liability for personal injury, damages, just compensation, restitution., judicial or equitable relief arising out of claims for personal injury, including death, and claims for property damage, which may arise from the negligent acts or operations of the Provider or its contractors, subcontractors, agents, employees, or other persons acting on their behalf which relates to the services described in section 1 of this Agreement. The Provider 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 asserting; personal injury, damages, just compensation, restitution, judicial or equitable relief due to personal or property rights arising by reason of the terms of, or effects arising from this Agreement. City may make all reasonable decisions witli respect to its representation in any legal proceeding. 7. CONFLICT OF INTEREST Provider 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. 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 fax or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Clerk of the Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 Page 3 of 7 Santa Ana, CA 92702-1988 Facsimile (714) 647-6956 With copy to: Executive Director of Parks, Recreation and Community Services City of Santa Ana 20 Civic Center Plaza (M-23) P.O. Box 1988 Santa Ana, California 92702 Facsimile (714) 571-4211 To Provider: Climb -It Mobile Rock Climbing 2565 Royal Crest Drive Escondido, CA 92025 Telephone (760) 519-7951 Email l(atielealivasCa)gmail.com A party may change its address by giving notice in writing to the other party. Thereafter, any communication shall be addressed and transmitted to the new address. If sent by mail, 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 fax, communication shall be effective or deemed to have been givers 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. 9. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Provider regarding the subject matter herein, 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 Provider, 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 Provider or -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 is not embodied herein. I.O. ASSIGNMENT The experience, knowledge, capability and reputation of Provider were a substantial inducement for City to enter into this Agreement. Therefore, Provider may not assign, transfer, delegate, or subcontract any interest herein 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. Page 4 of 7 11. TERMINATION This Agreement may be terminated by the City upon seven (7) days written notice of termination. In such event, Provider shall be entitled to receive, and City shall pay Provider, compensation for all services rendered prior to the effective date of terrrunation, 12. RECORDS Provider shall keep records and invoices in connection with the work to be performed under this Agreement. Provider shall maintain complete and accurate records with respect to the costs incurred under this Agreement and any services, expenditures, and disbursements charged to the City for a minimum period of three (3) years, or for any longer period required by law, from the date of final payment to City under this Agreement. Provider shall allow inspection of all work, data, documents, proceedings, and activities related to this Agreement for a period of three (3) years from the date of final payment to City under this Agreement. 13. NON-DISCRtiIMINATION Provider 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, teaching, training, utilization, promotion, termination or other employment related activities or in connection with any activities under this Agreement. 14. JURISDICTION — VENUE This Agreement has beezr 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. LICENSES Provider 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, IC SEVERABILITY In the event that one or more of the phrases, sentences, clauses, paragraphs or sections contained in this Agreement shall be declared invalid or unenforceable by valid judgment or. decree of a court of compctent jurisdiction, such invalidity or unenforceability shall not affect any of the retraining phrases, sentences, clauses, paragraphs or sections of this Agreement, which shall be interpreted to carry out the intent of the parties hereunder. Page 5 of 7 17. EXHIBITS All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. 18. AUTHORITY The person(s) executing; this Agreement on behalf of the parties hereto warrant that they are duly authorized to execrate this Agreement an behalf ofsaid parties and that by so executing this Agreement, the parties hereto are formally bound to the provisions of this Agreement. IN WITNESS WHEREON, the parties hereto have executed this Agreement the date and year first above written. ATTEST: MI,AR.iA D. HUIZAR "ler of tl�e Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By-(14 U. J N M. FUND Assistant City Attorney RECOMMENDED FOR APPROVAL: .� JEANNIE JURADO Acting Executive Director of Parks, Recreation and Community Services Agency CITY OF SANTA ANA A 4A401a 4ERARDO MO ET ... . Acting City Manager PROVIDER. By. a Name: -G t�_P-S 'title: Owl Page 6 of Exhibit A SCOPE OF SERVICES VENDOR INFORMATION; CLIMB -IT MOBILE ROCK CLIMBING 2565 Royal Crest Dr., Escondido, CA 92025 (760)519-7951 E-mail: katiekalivas@gmail.com www.rnobilerockwalls.com EVENT: Santa Ana Public Library's Entertainment Shows SERVICE DATE(S); April 22, 2017 COMPENSATION: Not to exceed $625.00 DESCRIPTION: Climb -It will be supplying one mobile Rockwall that will be used by visitors of the event. The mobile Rockwall will have one attendant for the duration of the Dia de los Ninos event taking place Saturday, April 22, 2017. The mobile Rockwall is a stand still activity, there are no games associated with them. Climb It! has previously participated in the same event. Setup/teardown- Event will setup on Saturday morning at 10 a.m. and tear down Saturday afternoon at 2:00 p.m. Open Hours — Event will open 11:00 a,m. -- 2.00 p.m, Page 7 of 7 fDDfY ` CERTIFICATE CIF LIABILITY INSURANCE D 7 /22� /22/201s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, MEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT SVWEEN THE: ISSUING INSURER(S), AUTHORIZED REPRESSNTAME OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the polloy(tes) must be endorsed. If SUBROGATION IS WANTED, subject to the terms and conditions of the policy, certain polic let may require an endorsement, A Statement on this cartlfiante does not Confer rights to the certificate holder In 4eu of such endarsement(s). PRODUCER GA ACT Shellsy Escobar CT5R James G Parker insurance Associates oNe (559)222-7772 arC (5591222-LT21 License #0554959 RL , aelgaobarg jglsarker. cam ADDRr$URER E? O Sax 3947 S AFPCRAINO COVERAG6 NAIL R Fresno CA 93950 $URQRA:SCl7ttsdale Insuranco caMEany 41297 INaURED IH U ER 5 : ISxti,e Kalivaas dba Climb Ib INSURERC: 2565 Royal Crest: Drive INSURER 0 i SURER E : Escondido CA 92025 INSURERr: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE; MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1LTA TYPEGFIN$URANce POLICY NUMBER AND PP YIY LIMETS R COMMERCIAL DaNERAL LIASILITY EACH OCCUAMENCQ I 1, one, coo R CLAIMS -MADE ' i{._: OCCUR PR tlE$F$1£a a�un�eea S 100,000 - MED�1tPtAn aneA4r m1 T 5,000 C092SI1143 7/13J2016 7/13/2017 PERSONAL 6 ADV INJURY S 1,000,000 GEN'LACGREOATELIMIT APPLIES PEA: N_ GENERAL AGGREGATE S 21000,000 X POL4Y JgC ' LOC PRODUCTS -COMPICPAGG 1 2,000,000 S OTHER. AUTOMOBILE LIABILITY IN GL IM1T S ANY AUTO SCOR,Y MLJURY (ParpuSpn) S LL OWNED NELI AUTOS AUTOS ROCKY W KYINJURYtPermddeall S MIRED AUT05 AUT SWNED y #J PROP6itTY DAAW , S { Y � $ 1��e 0 ON 1 UMBRELLA VAS OCCUR i EACH OCOUiipENGti S E%CE93 LtAB CLAIMS.MADE � AGGREGATE ED RETSNrO14 SS WORXERS COMPMATION AND EMPLOYERS` pP S R UABIUTY E.L.F.AGHACODINT S ANY PROPRIETORIPAATNERVCCVt" -- — OFFECERUMIEMSEREXCLLIOE07 (Myyaa�ndawy is NIIN) .d WA / � f kco�r� E.L. DISEASE. LEA EMPLOYE S e G�! Y^� E« DISEASE.POLIGYUM1T S OESCaAto ONOFefP RATIONS below c,P A Participant Liability CP22S111/3 1p?, 7/13/2016 7/13/20,11 P,troccumm $25,000 I A44muele $50 , 000 DESCRIPTION OF OPERA710143 1 LCCAnoNFs I VSKICLES iACORD 101, AddlUonaN Remake Sc:neula, may ba S"Chad If mere apada le nqulmd) city Of Santa Alta, its Offi,aara, Agents, and r4P10yee3 are named as additional insured as respects general liability and per Form CG2026 attached. City of Santa Ana Its Officers, Agents and Emgloyeas Atkin: Purchasing Department 2D Civic Center Plaza Santa Ana, CA 92701 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE GANC9LLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILT. BE DELIV£REA IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE z Parker III/SCG At-wnu 4a j4U 14ruTI I he ACORD name and toga are registered marks of ACORD INS025 r7n,an+l ACC>RVr CERTIFICATE OF LIABILITY INSURANCE DAn-IMWDarYrrri 7/19/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TH19 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 parley{ies) 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 dghta to the certificatb holder In lieu of such endorsement(s}. PRODUCER ZaUmtes G Parker Insurance Associates N& ShelleyEscobar CISR PHONE {559)222-7722 "'� o,iSS712Z2.1710 Liaande #0554939 H O Son 3947 Fresno CA 93650 CDIL ;sescobar@jgparker,cam INSURER S AFFOR NG COVERAGE MAIL t IN2URERA;SC0ttadal& Insurane Caffmany 41297 INSURED IM UMER e S Katie Kalivas dba Climb it 2565 Royal Crest Drive I SURERD: IN RBR E I+Eddrid'`G�p CA gxQ2 INSURERP; tAJVt:KAUI25 CERTIFICATE NUMEIER!15-17 GL/Partic Litih OPMU1491n i hillhIRTFD• 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 ISSUEO OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 19 SUBJECT TO ALL THE TERMS, EXCLV64ONS AND CONDITIONS OF SUCH POLICIES, LIMITS LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IRBR OF INSURANCE ADMTYPO f i NUYA R POLIC f L CY P LIMITS is COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE f 1,000,00F S Es : 100,000 A CLAIMS MAgis E X OCCUR MFA EXP IAn nna Pasony s s, eaa _ _ G�9Zs311d7 7/13/201d 7/23/2017 PERSONAL S ACV INJURY i 1, 00O , 004 .___....,._„..„_.„„,...,p..__........................_ p8M£RALAGGRflpATc $ r005,004 GEWLAGGRECATHLLIL�LIIT X APPLIES PER POLICY im i✓ 1 LOC PRODUCTS • CGMPFiJP AtfO s x, t7ao, nos $ OTHER: AUTOMOBILE LiAMLrrY CEO Ip[B 111M Limiti 9ODP.Y INJURY IPor p nmt S ANY AUTO ALL AUTOSA OWNED SUTO$UL$O A MREOAUTO5 ASWNE0 BODILY INJURY IPeracddeml I P�RCFERe LAMA s $ UMBRILLAUAB OCCUR EXCE99 LIAD CLAMS -MADE V' �� EACHOCCURRSNCE s AGOREGATE $ 0tlO R�NTtC1N S WORKERS COMPENSATION AND FMPLOYERV UADILIt"Y YIN ANY ifRgPRIETORlPARTNERJF_7IECUTME _ (F" :ERIMEMeER EXCLUOW? _, {Myy+adainry 1n NN) dfif OESCRId PTiON pt: OP TI N5 pates NIA Q,.yO V OTH- .EACHACCICEMT ; EL. 015ME - FA EMPLOY $ E.C_ DISEASE, POLICY LIMTT $ A Participant Liability I CPS251114 �� � 7/ ' �C� 71 LZQ17 t 1, POFOCCUMAM $25,000 Aygiiowle $50, 000 DESCRIPnOR OP OPBRATtONSI LCCATIOMS IVEHICLES IACORD i0i, 444104,mf Ramaty 3g11e►161 anaehrd It mostspa s is roqulntli Rock Climbing Wall Rentals Katie Kalivas dba Climb it 2565 Royal Crest Drivel Eacondido, CA R2025 SHOULD ANY OF! THE ABOVE DFSCRISED POLICIES BE CANCELLED B EPORL THE EXPIRATION DATE THEREOF, N0710E MLL se DEnLNERLO IN ACCORDANCE MIN THE POLICY PItbVIStONS. AUTHORIZED REPRESENTATIVE s Parker 11ZISCG 01988-2014 ACORD CORPORATION. All rights rasar ACORD 25 [2014101j The: ACORD name and logo are registered marks of ACORD WS(125 ni)um E POLICY NUMBER CPS511143 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_ L.LABIL17TY COVERAGE PART SCHEDUL9 Name Of Additional Insured Person(s) Or Organization(s): City of Santa Ana, It's Officers, Agents and Employees 20 Civic Center Plaza Santa Ana, CA 92701 Information re aired to coal late 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 "faddy 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 s contract or agreement, the most we will pay on behalf or the additional insured is the amount or 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 Ir mvw shown in the Declarations Vie ?Ipel t3 CG 20 26 04 13 0 Insurance Services Office Inc 2012 Page i of 1 WQRMR.S' COMI'ENSATIpN DECLARATION I %PXIv4kio-S� hereby affirm under penalty of perjury, the following declaration : I certify on behalf of tab- that during the term of my R (ConsoRwtiComWy Namo) connet for oy6u 1' Get 1 V,0 services with the 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 if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, i shall forthwith comply with those provisions and provide proof of workers' compensation coverage. BATE: , _ ��Y ��(� By: L ► t� "�t�1til �. Name: C6wtf12. �tt'yaS Title-,� Telephoner WARNING. FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLAR 100,000). IN ADDITION TO THE COST OF COMPENSATION, DAAkggtI�ELi FOR IN SECTION 3706 OF THE LABOR CODE, INTERESTORNEY'S FEES. A.