HomeMy WebLinkAboutBolsa Chica Conservancy - 1992-04-20 (5)' � V
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1,9j,"le CITY OF HUNTING'T ON BEACH
. 2000 MAIN STREET CALIFORNIA 92648
OFFICE OF THE CITY CLERK
CONINIE BROCKWAY
CITY CLERK
August 5, 1992
Bolsa Chica Conservancy
204 - 5th Street
Huntington Beach, U 92548
Enclosed is an executed copy of Lease Agreement between the Redevelopment
Agency of the City of Huntington Beach and the Bolsa Chica Conservancy
for a portion of the property located at 204-5th Street, Huntington Beach.
which was approved by Council on April 20, 1992.
Connie Brockway
City Clerk
CB:bt
Enc.
iT•raphon.: 714-536-52271
` REQUEST FOR CITY COUNCIL/
REDEVELOPMENT AGENCY ACTION
ED 92-20
Date
April 20, 1992
Submitted to: Honorable Mayor/Chairman & City Council/Redevelopment Agency M
Submitted by: Michael T. 1Jberuaga, City Administrator/Executive Directo�
Prepared by: Robert J. Franz, Deputy City Administrator/Administrative Servic
Barbara A. Kaiser, Deputy City Administrator/Economic
APPR VED BY CITY COUNCIL
Subject: Shank House Leases
Consistent with Council Policy? bd Yes [ ] New Policy or Exceptiqn
Statement of Issue, Recommendation, Analysis, Funding Source, Alternative
The Redevelopment Agency of the City of Huntington Beach has proposed leasing the
upper floors of the property Iocated at 204 Fifth Street, Huntington Beach, known as the
Shank House. The following are two prospective tenants and the areas in the building they
would be leasing:
1) The Huntington Youth Shelter, upstairs unit #204.
2) The Bolsa Chica Conservancy, upstairs unit #203. x
RECOMMENDATION: G"' n *;
;rs..
Ca = yes
Approve the two leases and authorize the Chairman and Agency Clerk to execute these_ F-r
documents.
h
ANALYSIS: r
The Redevelopment Agency of the City of Huntington Beach owns the historic structure
known as the Shank House, located on the corner of 5th Street and Walnut Avenue in
downtown Huntington Beach. The Redevelopment Agency has renovated the structure as
close to its original condition as reasonably possible. The property is currently a police
substation on the ground floor. The remaining vacant rooms are proposed to be used for
non-profit organizations in which to maintain their offices. Each tenant will pay their
equitable share of utilities and maintenance for the continued proper care of this historic
structure. The property will thereby be maintained In an efficient manner.
Each of the leases is month -to -month with 30 days termination notice and nominal ($10
per year) rent paid to the Agency. The leases include a clause which provides no
relocation benefits upon termination of the lease.
The property was originally purchased with the intent of a sale with lease back, with an
option to repurchase by the City. The City intended to sublease the property to Pier
Realty with an option to purchase. These agreements were never executed and the City
Council terminated negotiations on February 4, 1991. On May 20, 1991, the City Council
approved the use of the Shank House as a police substation.
M,
NO 41"
14
Since there is little demand for office space downtown, staff recommends against
competing with the private sector in leasing the remaining second floor office space in the
Shank House. Office space is currently available in (1) Pierside Pavilion, (2) Robert
Koury's building, (3) the second block of Main Street buildings, (4) Town Square, and (5) the
proposed Abdelmuti project. Therefore, staff recommends that the second floor of the
Shank House be leased to non—profit organizations, including the Huntington Beach Youth
Shelter and Bolsa Chica Conservancy.
In addition, the remaining office will be used by the Public Works Department as a
construction site office to monitor the Main Street public improvements project recently
approved by the City Council.
FUNDING SOURCE:
None.
Do not lease the structure.
ATTACHMENT:
Copies of the two leases
MTU/RJF/BAK:ls
0099U
0
LEASE AGREEMENT BETWEEN THE REDEVELOPMENT AGENCY OF
THE CITY OF HUNTINGTON BEACH AND THE BOLSA CHICA
CONSERVANCY FOR A PORTION OF THE PROPERTY
LOCATED AT 204 5TH STREET, HUNTINGTON BEACH
THIS AGREEMENT is made and entered into this 20th day
of April 2
, 1991, by and between the REDEVELOPMENT
AGENCY OF THE CITY OF HUNTINGTON BEACH, a public entity of the
State of California (hereinafter referred to as "LESSOR"), and
the BOLSA CHICA CONSERVANCY, a nonprofit California corporation
(hereinafter referred to as "LESSEE" or "TENANT").
WHEREAS, LESSOR owns certain real property thereinafter
referred to as the "PREMISES"), in the City of Huntington
Beach, and TENANT desires to lease said premises for the use
and purposes set forth below,
NOW, THEREFORE, the parties covenant and agree as follows:
1. DESCRIPTION OF PREMISES
LESSOR hereby leases to LESSEE that certain real
property commonly known and described as Unit 203, a portion of
204 5th Street, located in the City of Huntington Beach, County
of Orange, State of California, and more fully described in the
attached Exhibit "A" and incorporated herein by this reference.
2. USE —OF —PREMISES
LESSEE shall use the premises for general office
related purposes only, meeting the zoning and licensing
regulations of LESSOR and the State of California. Any other
related uses must be approved, in writing, by the LESSOR.
3. BENT
LESSEE shall pay a rental fee of TEN DOLLARS ($10) per
year, due on the first day of each year hereof, in advance, for
the first twelve months of this lease agreement.
4. TERM
The term of this Agreement shall be month -to --month.
5. TERMINATION
This Agreement is subject to termination by LESSOR
upon giving to LESSEE, thirty (30) days'notice, in writing.
6. SERVICES -AND -UTILITIES
LESSEE shall pay for electrical and utility services,
which are jointly metered to the PREMISES, on a rate of ten
percent (10%) of total electrical and utility services per
month. LESSEE shall arrange for and pay for its own janitorial
services for their individual space. LESSEE shall contribute
to the maintenance of the common area on a rate of twenty
percent (20%) of monthly services.
7. ATTORNEY'S, FEES
LESSOR shall be reimbursed by contractor for all costs
or attorney's fees incurred by LESSOR in enforcing this
obligation.
- 2 -
B. ASS I GNMENT _ AND, UBLETTING
Without the prior written consent of LESSOR, LESSEE
shall not assign this lease, or subject or grant any license to
use the premises, or any part thereof. A consent by LESSOR to
one assignment, subletting, or license, shall not be deemed to
be consent to any subsequent assignment, subletting, or
license. An assignment, subletting, or license without the
prior written consent of LESSOR, or an assignment or subletting
by operation of law, shall be void, and shall, at LESSOR's
option, terminate this Agreement.
9. INDEMNIFICATION, DEFENSE, HOLD HARMLESS
LESSEE hereby agrees not to sue and to release,
protect, defend, indemnify and hold harmless LESSOR, its
officers and employees against any and all liability, claims,
judgments, costs and demands, however caused, including those
resulting from death or injury to LESSEE's employees and damage
to property caused either by the condition of the premises, or
some negligent act or omission of LESSEE, or its agents,
officers, employees, invitees or contractors. LESSEE will
conduct all defense at its sole cost and expense. Any costs of
defense or attorney's fees incurred by LESSOR in enforcing this
obligation will be reimbursed to LESSOR by LESSEE or may be
awarded to LESSOR by a court of competent jurisdiction as costs
pursuant to California v § 1021.
10. WORKERS' COMPENSATIQN I11SURANCE
Pursuant to California 12abor Cooe Section 1861, LESSEE
acknowledges awareness of Section 3700 et seq. of said code,
3 -
which requires every employer to be insured against liability
for Workers' Compensation; LESSEE covenants that it will comply
with such provisions prior to commencing performance of the
work hereunder.
LESSEE shall maintain such Workers, Compensation
Insurance in an amount of not less than Five Hundred Thousand
Dollars ($500,000) bodily injury by accident, each accident,
Five Hundred Thousand Dollars ($500,000) bodily injury by
disease, each employee, and One Million Dollars bodily injury
by disease, policy limit, at all times incident hereto, in
forms and underwritten by insurance companies satisfactory to
LESSOR; and LESSEE shall, prior to the commencement of this
Agreement, furnish to LESSOR, on a form approved by the City
Attorney, a certificate evidencing such insurance; said
certificate shall include a provision that the insurer shall
notify LESSOR at least thirty (30) days prior to any
cancellation or modification of said insurance policy; and
LESSEE shall notify LESSOR at least thirty (30) days prior to
any cancellation or modification of such policy. Said
insurance shall not derogate from the provision for
indemnification of LESSOR by LESSEE under Section 7 of this
Agreement.
11. INSURANCE
In addition to LESSEE's covenant to indemnify LESSOR,
LESSEE shall obtain and furnish to LESSOR, the following
policies of insurance:
- 4 -
A. General Liability Insurance. A policy of general
liability insurance, including coverage for bodily injury,
property damage, products/completed operations, and blanket
contractual liability. Said insurance shall also include
automotive bodily injury and property damage liability
insurance. All insurance shall be underwritten by insurance
companies in forms satisfactory to LESSOR for all operations,
subcontract work, contractual obligations, product or completed
operations and all owned vehicles and non -owned vehicles. Said
insurance shall name the LESSOR, its officers, agents and
employees and all public agencies as determined by the LESSOR
as Additional Insureds. LESSEE shall subscribe for and
maintain said insurance policies in full force and effect
during the life of this Agreement, in an amount of not less
than One Million Dollars ($1,000,000.00) combined single limit
coverage. If coverage is provided under a form which includes
a designated general aggregate limit, such limit shall be no
less than twice the per occurrence limit. In the event of
aggregate coverage, LESSEE shall immediately notify LESSOR of
any known depletion of limits. LESSEE shall require its
insurer to waive its subrogation rights against LESSOR and
agrees to provide certificates evidencing the same.
B. Fire Insurance. LESSEE shall maintain in force
during the term of this Agreement, a standard broad form fire
insurance policy for full replacement of the structure itself,
in which the LESSOR is named and which any and all losses are
made payable to LESSOR. The face amount of said policy shall
- 5 -
be One Hundred Thousand Dollars ($100,000.00). LESSOR may,
upon thirty (30) days written notice to LESSEE, require said
fire insurance coverage to be increased by an amount determined
by LESSOR.
Prior to the commencement of this Agreement, LESSEE
shall furnish to LESSOR certificates of insurance subject to
approval of the City Attorney evidencing the foregoing
insurance coverages; said certificates shall provide the name
and policy number of each carrier and policy, and shall state
that the policy is currently in force and will not be cancelled
without thirty (30) days written notice to LESSOR. LESSEE
shall maintain the foregoing insurance coverages in force
during the entire term of this Agreement unless waived in
writing by the LESSOR's Risk Manager.
The requirement for carrying the foregoing insurance
shall not derogate from the provisions for indemnification of
LESSOR by LESSEE under Section 7 of this Agreement. LESSOR or
its representative shall at all times have the right to demand
the original or a copy of all said policies of insurance.
LESSEE shall pay, in a prompt and timely manner, the premiums
on all insurance hereinabove required.
12. TAXES
LESSEE shall pay before they become delinquent, all
real property taxes, or possessory interest taxes and
assessments levied or assessed against the PREMISES by any
governmental agency, including any special assessments imposed
on or against the PREMISES for the construction or improvement
- 6 -
of public works, in, on, or about the PREMISES.
13. CARE OF PREMISES
LESSEE shall at all times maintain the rented premises
in conformity with all state and local laws and regulations,
and no unlawful activities shall be conducted on the PREMISES.
At all times during the term of this Agreement, LESSEE, at its
own cost and expense, shall keep and maintain the PREMISES in a
neat, clean and orderly condition, and shall keep the interior
of the building in good condition and repaired and painted.
Upon demand, LESSEE shall repair any damage to the heating or
water apparatus or electrical lights or wires, or any fixtures,
appliances or appurtenances of the PREMISES, caused by the act
or neglect of LESSEE, or any person in the employ or under the
control of LESSEE.
15. IMPROVEMENTS
LESSEE shall not make any alterations, additions or
improvements to the PREMISES without the consent of LESSOR.
All approved alterations, additions or improvements made by
LESSEE, except movable household or commercial furniture, are
to become the property of LESSOR, and shall remain on the
PREMISES as part thereof, and be surrendered with the PREMISES
at the termination of this Agreement.
16. INSPECTION
LESSOR and LESSOR's agents, including the Police
Department, shall have the right to enter the rented premises
at all reasonable times to inspect same for security purposes.
LESSOR and LESSOR's agents shall be permitted to make repairs,
- 7 -
additions or alterations as may be deemed necessary by LESSOR
with reasonable notice to LESSEE, and to put and keep upon the
doors and windows of the PREMISES a notice indicating that said
premises are for rent at any time within thirty (30) days
before termination of this rental.
17. RELETTINGQFPREN,ISES
If LESSEE abandons or vacates the PREMISES, or is
dispossessed for cause by LESSOR, before the termination of
this Agreement, or any renewal thereof, the PREMISES or any
part thereof, may be relet by LESSOR for such rent and on such
terms as LESSOR may see fit, and if the full rental payable
hereunder by LESSEE shall not thus be realized, LESSEE hereby
agrees to pay all deficiencies for a period of three (3)
months, including any expenses incurred by LESSOR by reason of
such reletting.
18. )DEFAULT ._W�IVER
LESSOR's failure to take advantage of any default on
the part of LESSEE shall not be construed as a waiver thereof,
nor shall any custom or practice that may grow up between the
parties in the course of administering this Agreement be
construed to waive to LESSEE the right of LESSOR to insist on
the performance of the provisions hereof.
19. DESTRUCTION OF PREMISES
In the event the entirety of the PREMISES is destroyed
or rendered untenable by fire, storm, earthquake, or other
Casualty not caused by negligence of LESSOR, this Agreement
shall be at an end from such time except for the purpose of
enforcing rights that may have accrued hereunder. The rental
shall then be accounted for between LESSOR and LESSEE up to the
time of such injury or destruction of the PREMISES, LESSEE
paying up to said date, and LESSOR, refunding the rents
collected beyond such date.
Waij P ; i m *
LESSEE understands and agrees that upon surrender of
possession it will not be entitled to a moving cost payment or
any other relocating payment under any State or Federal
Relocation Assistance Program. LESSEE acknowledges that in the
event the Redevelopment Agency decides to vacate or demolish
this rental that LESSEE will receive no relocation benefits.
21. NONCE
Any written notice, given under the terms of this
Agreement, shall be either delivered personally or mailed,
postage prepared, addressed to the party concerned, as follows:
LESSOR:
Mr. Robert Franz
Director of Administrative
Services
City of Huntington Beach
2000 Main Street
Huntington Beach, CA 92648
y! i
LESSEE
Bolsa Chica Conservancy
204 5th Street
Huntington Beach, CA 92648
LESSOR and LESSEE agree that this lease constitutes
the entire agreement between the parties.
- 9 -
IN WITNESS WHEREOF, the parties hereto have caused this
Agreement to be executed by their authorized officers on the
date above written.
LESSEE:
BOLSA CHICA CONSERVANCY,
a California nonprofit
corporation
By: Har'r�ieett Wieper
it s4 k.a►f'ti-� >-A J
:Peter Denniston
Its: 11
City Clerk
i
REVIEWED AND APPROVED:
City Administrator
REVIEWED AND APPROVED:
Real Property Manager
LESSOR: REDEVELOPMENT AGENCY OF THE
CITY OF HUNTINGTON BEACH,
a municipal corporation
Mayor
APPROVED AS TO FORM:
U -
Cit Attorney ��� �� /� 5/
'�-/-9 Z.
- 10 -
e
DESCRIPTION
THE LAND REFERRED TO IN THIS GUARANTEE IS SITUATED IN THE STATE OF
CALIFORNIA, COUNTY OF ORANGE, CITY OF HUNTINGTON BEACH, P-ND IS
DESCRIBED AS FOLLOWS:
PARCEL l:
LOTS 2 AND 4 OF BLOCK 204 IN THE HUNTINGTON BEACH TRACT, AS PER MAP
RECORDED IN BOOK 3, PAGE 36 OF MISCELLANEOUS MAPS, IN THE OFFICE OF
THE COUNTY RECORDER OF SAID COUNTY.
EXCEPT THEREFROM THE SOUTHEASTERLY 44 FEET.
PARCEL 2:
LOT 6 OF BLOCK 204 IN THE HUTINGTON BEACH TRACT, AS PER MAP RECORDED
IN BOOK 3, PAGE 36 OF MISCELLANEOUS MAPS, IN THE OFFICE OF THE COUNTY
RECORDER OF SAID COUNTY.
EXCEPT THEREFROM THE SOUTHEASTERLY 44 FEET.
PARCEL 3:
THE SOUTHWESTERLY 3 FEETOF THE SOUTHEASTERLY 48 FEETOF LOT 8 OF BLOCK
204 IN THE HUNTINGTON BEACH TRACT, AS PER MAP RECORDED IN BOOK 3,
PAGE 36 OF MISCELLANEOUS MAPS, IN THE OFFICE OF THE COUNTY RECORDER
OF SAID COUNTY.
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PARCEL NUMBERS BOOK 24 PAGE /4
15
SHOWN /N CIRCLES COUNTY OF ORANGE
StiA"� �o.<< - Zoo 5-H 5-,1t_ i
EXHIBIT "A"
-♦
IF-IFICATE OF INSURANCE!%,DATE: 06/30/9c
------------------ ------------------------------- ------------ ---------------------------------------------- --_---
I 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INCORMATIOH CHLY AND CONFERS I
1 (703) 351-7400 1 NO RIGHT UPCH THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, i
1-800-LAND INS I EXTEND OR ALTER THE COVERAGE AFFORDED BY THE PGLICIES BELOW I
I+ I-------------------------------------------„---------------------------1
! ffnsutuzg fL I COMPANIES AFFORDING COVERAGE I
kI-------------------------------------------------------------------------1
i COnsztvaEianisEs i CO,",PANY A Insurance Cc2pany of N.-rth Aaerica !
1 1655 Ft. Myer DI.. Suite 640, Arlington, VA 22209 1 LETTER I
iI-------------------------------------------------------------------------I
I --------------------------------------------------------I COnANY B I
I INSURED I LETTER:
iI -------------------------------------------------------- ---------------i
i kolsa Chica Conservancy I CO!'I;ANY C I
I I LETTER IN CALIFORNIA I
! P.O. 'Fax 3376 1--------- ------------- x- G-REEN -MIBR EL•A-------------------I
1 Huntington Beach, CA S2695 I COMPANY D I
i 1 LETTER INSURANCE SERVICES" 1
! I--------------`------------------- ------- - ---------------------------)
I I CMANY E I
i I LETTER i
[_==== COVERAGES
I THIS IS 70 CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NPnED ABC' FOR THE POLICY PERIOD I
1 INDICATED. NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DGCUMENT WITH RESPECT TO L'HICH THIS I
1 CERTIFICATE KAY BE ISSUED OR KAY PERTAIN 1h INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERIMS, I
I EXCLISIONS, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN PAY HAVE BEEN REDUCED BY PAID CLAIIS I
I--------------`-------------------------------------------------------------------------------------------------------------------)
I I I I POLICY i POLICY 1 I
ICU I I IEFFECTIVE IEXPIRATIOHI 1
ILTRI TYPE OF INSURANCE I POLICY NUMBER I DATE 1 DATE I ALL LIMITS IN TNGUSANDS [
I--- I -------------- --------- -------------- I --------------------- I----------1---------- 1----------------------------------- —r_----i
I I GENERAL LIABILITY I I I, i GERrRAI AGGREGATE I Me I
I A I EX3 COnhERCIAL GEH£RAL LIABILITY ! D23623484 1 19/17/31 1 10/17/12 1 PRRUC73-COIPICPS AGGREGATE S 2D2a I
I I I I E 3 CLAIMS MADE EX] OCCURRENCE I I I ! PERSONAL d ADVERTISING INJURY i 10aa I
I I t 3 0Ii4ER'S S CONTRACTORS PROTECTIVEI I I I EACH OCCURRENCE t IM I
I I C 3 I I I I FIRE DAMAGE (ANY ONE FIRE) i 58 I
1 I C 3 ! I I I MEDICAL EXPEi;SE(AHY CHE PERSOti5$ S 1
1---I------------------------------------- I-------- ------------- I---------- I---------- I--------------------- -----------------------I
i I AUTOns1ILE LIABILITY I ! ! i I I I
I I I I I ! CSL I i leee I 1
! A I C 3 A4Y AUTO 1 E362648A ! 19/17131 1 19/17/32 i----------------i------- ------ I I
I I E 3 ALL CUNED AUTOS I I I I BODILY INJURY 1 I 1
I I C 3 SCVZOULED AUTOS 4 �, 1 1 (DER PER5ON1 I f I 1
! I EX] HIRED AUTOS AP;'ROVED AS TO } OI?t' I I----------------I--------------I 1
I 1 [X3 N0'I-Or'iED AUTOS G1'IL VUTTO:i city ttorneYI I BODILY INJURY I I !
I I I GARAGE LIABILITY B; DepLty ty ,11;l.orney I Y I (PER ACCIDENT) I t I 1
1 I C 3 �1 ! �'� I'---------------I--------------1 1
I I I I� 22 1 I FRI:F'ERTY I I
t I 1l 1 4 DA"AGE I f I -I
I---I-------------------------------------I---------- 7- - 1 --------1-------------------------------------------
I I EXCESS LIABILITY 1 I I I EACH OCCURRENCE I AGGREGATE I
I I I UMBRELLA FORS 1 ! 1 I ----------------- I-----------------i
I I C] OTHER THAN UMBRELLA I I I 1 1 $ 1 S f
i---I---------------------- --------------- l---------------------- I---------- I---------- I--------------------------------------------1
! I I 1 1 I STATUTORY I i
! I WC.RKEIRS' COMPENSATION I I I I ---------------------------------- ^---------1
1 I AND 4 ' I I I S (EACH ACCIDENT) I
1 ! EI'►•L0YEkS' LIABILITY , - 1 I 1 I S (DISEASE-PCtICY LIMIT) I
I I I I ! I 13 (DISEASE -EACH E.VLOYEE)i
i---i------------------------------------- 1--------------------- 1---------- I---------- 1--------------------------------------------i
1 I I I 1
f l ) 1 1 1 !
t----------------------------`------`------------------------------------------------------------------------`---------------------I
I DESMPTITI OF C'.'ERATIti7"+S/LOCATiUHS/V£HICLES1Si ECIA't IIEAS !
i Certificate holder is named as additional insured as respects resises 1
I occupied bj Balsa Chica Conservanry at 204 5TH Street, panting 3n i
I .ead,, CA ATIKA. I
( I
I I
l===== CEP.TITICATE
i I SHOULD ANY GF ThZ APGvE DESCRIBED POLICIES FE�CANCELLED BEFORE IHE EX- 1
i Ecc.=aic Developm21-111 Depd-taeTit I PIRA11014 DAIZ Iil£fiE6F, TiiE ISSUDIZ C0r-4'H; GILL ',rO►C _TU Cri:i 1
I ATT: Michael Gifford 1 32 AYS WRITTEN N311i.E TO THE CERTIFICATE hOL,LE'n EA-".ED TO T�;I
1 Citr of iiuntinyton Beach I L F. 1 FKLUi 1 ` "~rs. r -��,�, �y• � 1
I Mc3d Kai Street �+ f} � ! L -_" __V - --�' �- -�-- '------�--� F -_` 4�---1
I H.Lntir;gran Bean, CA 1no I' `
i } A;.'T!:''•:IIE REGF:E"- �»TIC£ I
r i
2000 MAIN STREET
CALIFORNIA 92648
RISK MANAGEMENT DIVISION
(714) 536-5990
In order to comply with City Council Resolution No. 6023,
you are required to provide this office with a worker's
compensation Certificate of Insurance. If you use no
employees in the performance of the work for which this
permit is issued, then you must sign this form and return
it at your earliest convenience to the Risk Management
office at 2000 Main Street, Huntington Beach, California
92648, Attn: Julie Fittery
I certify that 'in the performance of the activity and/or
work for which this permit -is issued, I shall not employ
any person in any manner so as to become subject to the
worker's compensation laws of California.
APPLICANT'S SIGNATURE: '
DATE:. I//U/ Z
LOCATION:
/YG/hi7i�y7py> ,pP��
(in which city you are signing this form)
NAME AND ADDRESS OOFF APPLICANT/INSURED:
/�O/52 G•G9 / �Q ��I.SC�YI�i11GL
PO x 3
PHONE NUMBER: 0j�z�� -�-.
This form is not required where permit fee is $100.00 or less.
11