HomeMy WebLinkAboutLAWRENCE ASSOCIATES - 2000-01-03PROFESSIONAL SERVICES CONTRACT BETWEEN
THE CITY OF HUNTINGTON BEACH AND
LAWRENCE ASSOCIATES FOR
PROFESSIONAL PLANNING SERVICES
THIS AGREEMENT is made and entered into this 3 r d day of J a n u a r
2000, by and between the City of Huntington Beach, a municipal corporation of the State of
�r
Califn1a, hereinafter referred to as "CITY," and LAWRENCE ASSOCIATES, a sole
proprietorship, hereinafter referred to as "CONSULTANT."
WHEREAS, CITY desires to engage the services of a consultant to provide professional
planning services on an "as -needed" basis, and
Pursuant to documentation on file in the office of the City Clerk, the provisions of the
Huntington Beach Municipal Code, Chapter 3.03, relating to procurement of professional service
contracts have been complied with; and
CONSULTANT has been selected to perform said services,
NOW, THEREFORE, it is agreed by CITY and CONSULTANT as follows:
1. • WORK STATEMENT
CONSULTANT shall provide all services as described in the Request for
Proposal ("RFP"), and CONSULTANT's Proposal dated October 28, 1999 (both of which are
hereinafter referred to as Exhibit "A"), which are attached hereto and incorporated into this
AGREEMENT by this reference. These services shall sometimes hereinafter be referred to as
the "PROJECT."
CONSULTANT hereby designates Larry Lawrence who shall represent it and be its sole
contact and agent in all consultations with CITY during the performance of this AGREEMENT.
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2. CITY STAFF ASSISTANCE
CITY shall assign a staff coordinator to work directly with CONSULTANT in the
performance of this AGREEMENT.
TIME OF PERFORMANCE
Time is of the essence of this AGREEMENT. The services of CONSULTANT
are to commence as soon as practicable after the execution of this AGREEMENT and all tasks
specified in Exhibit "A" shall be completed no later than twelve (12) months (from the date of
this AGREEMENT. These times may be extended with the written permission of CITY. The
time for performance of the tasks identified in Exhibit "A" are generally to be shown in the
Scope of Services on the Work Program/Project Schedule. This schedule may be amended to
benefit the PROJECT if mutually agreed by CITY and CONSULTANT.
4. COMPENSATION
In consideration of the performance of the services described herein, CITY agrees
to pay CONSULTANT on a time and materials basis, at the rates set forth in Exhibit "A," a fee
not to exceed Nineteen Thousand Nine Hundred Ninety dollars ($19,990).
PRIORITIES
In the event there are any conflicts or inconsistencies between this
AGREEMENT, the CITY's RFP, or the CONSULTANT's Proposal, the following order of
precedence shall govern: 1) AGREEMENT, 2) the CONSULTANT's Proposal, and 3) the
CITY's RFP.
6. EXTRA WORK
In the event CITY requires additional services not included in Exhibit "A," or
changes in the scope of services described in Exhibit "A," CONSULTANT will undertake such
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work only after receiving written authorization from CITY. Additional compensation for such
extra work shall be allowed only if the prior written approval of CITY is obtained.
7. METHOD OF PAYMENT
A. CONSULTANT shall be entitled to progress payments toward the fixed
fee set forth herein in accordance with the progress and payment schedules set forth in
Exhibit "A."
B. Delivery of work product: A copy of every memorandum, letter, report,
calculation and other documentation prepared by CONSULTANT shall be submitted to CITY to
demonstrate progress toward completion of tasks. In the event CITY rejects or has comments on
any such product, CITY shall identify specific requirements for satisfactory completion. Any
such product which has not been formally accepted or rejected by CITY shall be deemed
accepted.
C. CONSULTANT shall submit to CITY an invoice for each progress
payment due. Such invoice shall:
1) Reference this AGREEMENT;
2) Describe the services performed;
3) Show the total amount of the payment due;
4) Include a certification by a principal member of CONSULTANT's
firm that the work has been performed in accordance with the
provisions of this AGREEMENT; and
5) For all payments include an estimate of the percentage of work
completed.
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Upon submission of any such invoice, if CITY is satisfied that CONSULTANT is
making satisfactory progress toward completion of tasks in accordance with this AGREEMENT,
CITY shall promptly approve the invoice, in which event payment shall be made within thirty
(30) days of receipt of the invoice by CITY. Such approval shall not be unreasonably withheld.
If CITY does not approve an invoice, CITY shall notify CONSULTANT in writing of the
reasons for non -approval within seven (7) calendar days of receipt of the invoice, and the
schedule of performance set forth in Exhibit "A" shall be suspended until the parties agree that
past performance by CONSULTANT is in, or has been brought into compliance, or until this
AGREEMENT is terminated as provided herein.
D. Any billings for extra work or additional services authorized by CITY
shall be invoiced separately to CITY. Such invoice shall contain all of the information required
above, and in addition shall list the hours expended and hourly rate charged for such time. Such
invoices shall be approved by CITY if the work performed is in accordance with the extra work
or additional services requested, and if CITY is satisfied that the statement of hours worked and
costs incurred is accurate. Such approval shall not be unreasonably withheld. Any dispute
between the parties concerning payment of such an invoice shall be treated as separate and apart
from the ongoing performance of the remainder of this AGREEMENT.
DISPOSITION OF PLANS, ESTIMATES AND OTHER DOCUMENTS
CONSULTANT agrees that all materials prepared hereunder, including all
original drawings, designs, reports, both field and office notices, calculations, maps, memoranda,
letters and other documents, shall be turned over to CITY upon termination of this
AGREEMENT or upon PROJECT completion, whichever shall occur first. In the event this
AGREEMENT is terminated, said materials may be used by CITY in the completion of the
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PROJECT or as it otherwise sees fit. Title to said materials shall pass to CITY upon payment of
fees determined to be earned by CONSULTANT to the point of termination or completion of the
PROJECT, whichever is applicable. CONSULTANT shall be entitled to retain copies of all data
prepared hereunder.
9. HOLD HARMLESS
CONSULTANT shall protect, defend, indemnify and save and hold harmless
CITY, its officers, officials, and ,employees, and agents from and against any and all liability, loss,
damage, expenses, costs (including without limitation, costs and fees of litigation of every nature)
arising out of or in connection with CONSULTANT's performance of this AGREEMENT or its
failure to comply with any of its obligations contained in this AGREEMENT by CONSULTANT,
its officers, agents or employees except such loss or damage which was caused by the sole
negligence or willful misconduct of CITY.
10. WORKERS' COMPENSATION INSURANCE
Pursuant to California Labor Code Section 1861, CONSULTANT acknowledges
awareness of Section 3700 et seq. of said Code, which requires every employer to be insured
against liability for workers' compensation; CONSULTANT covenants that it will comply with
such provisions prior to commencing performance of the work hereunder.
CONSULTANT shall maintain workers' compensation insurance in an amount of
not less than One Hundred Thousand Dollars ($100,000) bodily injury by accident, each
occurrence, One Hundred Thousand Dollars (S100,000) bodily injury by disease, each employee,
Two Hundred Fifty Thousand Dollars ($250,000) bodily injury by disease, policy limit.
CONSULTANT shall require all subcontractors to provide such workers'
compensation insurance for all of the subcontractors' employees. CONSULTANT shall furnish
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to CITY a certificate of waiver of subrogation under the terms of the workers' compensation
insurance and CONSULTANT shall similarly require all subcontractors to waive subrogation.
11. GENERAL LIABILITY INSURANCE
In addition to the workers' compensation insurance and CONSULTANT's
covenant to indemnify CITY, CONSULTANT shall obtain and furnish to CITY, a policy of
general public liability insurance, including motor vehicle coverage covering the PROJECT.
Said policy shall indemnify CONSULTANT, its officers, agents and employees, while acting
within the scope of their duties, against any and all claims arising out of or in connection with
the PROJECT, and shall provide coverage in not less than the following amount: combined
single limit bodily injury and property damage, including products/completed operations liability
and blanket contractual liability, of $1,000,000 per occurrence. If coverage is provided under a
form which includes a designated general aggregate limit, the aggregate limit must be no less
than S1,000,000 for this PROJECT. Said policy shall name CITY, its agents, its officers,
employees and volunteers as Additional Insureds, and shall specifically provide that any other
insurance coverage which may be applicable to the PROJECT shall be deemed excess coverage
and that CONSULTANT's insurance shall be primary.
Under no circumstances shall the above -mentioned insurance contain a self -
insured retention, or a "deductible" or any other similar form of limitation on the required
coverage.
12. PROFESSIONAL LIABILITY INSURANCE
CONSULTANT shall furnish a professional liability insurance policy covering
the work performed by it hereunder. Said policy shall provide coverage for CONSULTANT's
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professional liability in an amount not less than S1,000,000 per occurrence and in the aggregate.
A claims -made policy shall be acceptable if the policy further provides that:
A. The policy retroactive date coincides with or precedes the professional
services contractor's start of work (including subsequent policies
purchased as renewals or replacements).
B. CONSULTANT will make every effort to maintain similar insurance
during the required extended period of coverage following project
completion, including the requirement of adding all additional insureds.
C. If insurance is terminated for any reason, CONSULTANT agrees to
purchase an extended reporting provision of at least two (2) years to report
claims arising from work performed in connection with this
AGREEMENT.
D. The reporting of circumstances or incidents that might give rise to future
claims.
13. CERTIFICATES OF INSURANCE
Prior to commencing performance of the work hereunder, CONSULTANT shall
furnish to CITY certificates of insurance subject to approval of the City Attorney evidencing the
foregoing insurance coverages as required by this AGREEMENT; said certificates shall:
A. provide the name and policy number of each carrier and policy;
B. shall state that the policy is currently in force; and
C. shall promise that such policies shall not be suspended, voided or canceled
by either party, reduced in coverage or in limits except after thirty (30)
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days prior written notice; however, ten (10) days prior written notice in the
event of cancellation for nonpayment of premium.
CONSULTANT shall maintain the foregoing insurance coverages in force until
the work under this AGREEMENT is fully completed and accepted by CITY.
The requirement for carrying the foregoing insurance coverages shall not derogate
from the provisions for indemnification of CITY by CONSULTANT under the AGREEMENT.
CITY or its representative shall at all times have the right to demand the original or a copy of all
said policies of insurance. CONSULTANT shall pay, in a prompt and timely manner, the
premiums on all insurance hereinabove required.
14. INDEPENDENT CONTRACTOR
CONSULTANT is, and shall be, acting at all times in the performance of this
AGREEMENT as an independent contractor. CONSULTANT shall secure at its expense, and
be responsible for any and all payment of all taxes, social security, state disability insurance
compensation, unemployment compensation and other payroll deductions for CONSULTANT
and its officers, agents and employees and all business licenses, if any, in connection with the
services to be performed hereunder.
15. TERMINATION OF AGREEMENT
All work required hereunder shall be performed in a good and workmanlike
manner. CITY may terminate CONSULTANT's services hereunder at any time with or without
cause, and whether or not PROJECT is fully complete. Any termination of this AGREEMENT
by CITY shall be made in writing, notice of which shall be delivered to CONSULTANT as
provided herein.
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16. ASSIGNMENT AND SUBCONTRACTING
This AGREEMENT is a personal service contract and the supervisory work
hereunder shall not be delegated by CONSULTANT to any other person or entity without the
consent of CITY.
17. COPYRIGHTS/PATENTS
CITY shall own all rights to any patent or copyright on any work, item or material
produced as a result of this AGREEMENT.
18. CITY EMPLOYEES AND OFFICIALS
CONSULTANT shall employ no CITY official nor any regular CITY employee
in the work performed pursuant to this AGREEMENT. No officer or employee of CITY shall
have any financial interest in this AGREEMENT in violation of the applicable provisions of the
California Government Code.
19. NOTICES
Any notice or special instructions required to be given in writing under this
AGREEMENT shall be given either by personal delivery to CONSULTANT's agent (as
designated in Section 1 hereinabove) or to CITY's Director of Planning as the situation shall
warrant, or by enclosing the same in a sealed envelope, postage prepaid, and depositing the same
in the United States Postal Service, addressed as follows:
TO CITY:
Director of Planning
City of Huntington Beach
2000 Main Street
Huntington Beach, CA 92648
TO CONSULTANT:
Mr. Larry Lawrence, Proprietor
Lawrence Associates
32092 Via Carlos
San Juan Capistrano, CA 92675
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20. IMMIGRATION
CONSULTANT shall be responsible for full compliance with the immigration
and naturalization laws of the United States and shall, in particular, comply with the provisions
of the United States Code regarding employment verification.
21. LEGAL SERVICES SUBCONTRACTING PROHIBITED
CONSULTANT and CITY agree that CITY is not liable for payment of any
subcontractor work involving legal services, and that such legal services are expressly outside
the scope of services contemplated hereunder. CONSULTANT understands that pursuant to
Huntington Beach City Charter Section 309, the City Attorney is the exclusive legal counsel for
CITY; and CITY shall not be liable for payment of any legal services expenses incurred by
CONSULTANT.
22. ATTORI`EY'S FEES
In the event suit is brought by either party to enforce the terms and provisions of
this AGREEMENT or to secure the performance hereof, each party shall bear its own attorney's
fees.
SIGNATURES ON NEXT PAGE
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23. ENTIRETY
The foregoing, and Exhibit "A" attached hereto, set forth the entire
AGREEMENT between the parties.
IN WITNESS WHEREOF, the parties hereto have caused this AGREEMENT to be
executed by and through their authorized offices the day, month and year first above written.
CONSULTANT
LAWRENCE ASSOCIATES, a sole
proprietorship
By:
Larry LY'5c61
roprietor
REVIEWED AND APPROVED:
�Y
City Ad inistrator
CITY OF HUNTINGTON BEACH, a
municipal corporation of the State of
California
Director o anning
Pursuant to HBMC §3.0 .100
APPROVED AS TO FO
City Attorney +�
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State of CALIFORNIA
County of DBANrorm
On /SA/Ou before me,
(DATE)
personally appeared
PHILIP J. HUGHES, NOTARY PUBLIC
MAMEITITLE OF OFFICER-i.s.'JANE DOE, NOTARY PUBLIC')
❑ personally known to me -OR-
PHILIP]. HUGHES
" COMM. # 1163799
ORANGE COUNTy
My Commmio11 ExP- 12n8lDI .a
(SEAL)
C-
{NAMEIS) OF SIGNERISII
proved to me on the
basis of satisfactory
evidence to be the
person($) whose name(($)
Is/a3* ubscribed to the
within instrument and
acknowledged to me that
he/-L--rm,v-y executed the
same In his/her'A+;mW
authorized capacity5 s),
and that by his/4@402lei
signature(g) on the
instrument the person(pl,
or the entity upon behalf
of which the person(
acted, executed the
instrument.
s my hand and official seal.
NOT
RIGHT THUMBPRINT (Optional)
CAP) ITY CLAIMED BY SIGNERIS)
DIVIDUALO
❑CORPORATE
OFFICER(Sl
(TITLES)
OPARTNER(S) ❑LIMITED
❑GENERAL
OATTORNEY IN FACT
❑TRUSTEE(SI
OGUARDIANICONSERVATOR
❑OTHER:
SIGNER IS REPRESENTING:
(Name =of Pereon(a) or Entity(ieel
RIGHT THUMBPRINT (Optionall
CAPACITY CLAIMED BY SIGNER(S)
❑INDIVIDUALIS)
❑CORPORATE
ATTENTION NOTARY
OFFICERS)
The information requested below and in the column to the right is OPTIONAL.
'TITLES'
Recording of this document is not required by law and is also optional.
It could, however, prevent fraudulent attachment of this certificate to any
❑PARTNER(S) ❑LIMITED
unauthorized document.
❑GENERAL
do
❑ATTORNEY IN FACT
THIS CERTIFICATE Title or Type of Document
❑TRUSTEE(S)
MUST BE ATTACHED
❑GUARDIANICONSERVATOR
TO THE DOCUMENT Number of Pages Dat of Document
COTHER:
DESCRIBED AT RIGHT:
Signer(s) Other Than Named Above
SIGNER IS REPRESENTING:
(Name of Personlel or Entitylies)
Q1994 FORMS. INC.
WOLCOTTS FORM 63240 Rev. 3.94 (price class 8.2A) WOLCOTTS
ALL PURPOSE ACKNOWLEDGMENT WITH S:GNER CAPACITY1RfPRESENTATIONITWO FINGERPRINTS
III6IIII75�I�I I3I�240I I8
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HUNTINGTON BEACH
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CITY OF HUNTINGTON BEACH
INTER -DEPARTMENT COMMUNICATION
TO: Connie Brockway, City Clerk
FROM: Duane Bankey, Planning Senior Department Analyst Alel
SUBJECT: Documentation Regarding RFP's for the Contract Between the City and
Lawrence Associates for Planning Services Related to Professional
Planning Services on an "As Needed" Basis
DATE: December 20, 1999
Pursuant to Huntington Beach Municipal Code 3.03.060(b), written proposals from not less than
three Consultants are required prior to the City making a selection for a Consultant.
The Consultant selected to perform planning services related to Professional Planning Services
is Lawrence Associates.
Additional bid proposals were requested from:
• Hogle-Ireland, Inc.
• Sid Lindmark
cc: Mary Beth Broeren
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`12/03/99 10:25 FAX 415 543 3182 AonTechBrokers
DE=C-02-1999 09' 00 !
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ACN Risk Servicec Inc, of Northern California
Insumm Services Hag Wg"ndent Cities l?beess Pool
One Masket, Spec Towar, Suite 21W City afBunfinelon asach
Sari Francisco, CA. 94105
QN-'I40-I011 ry. rTa 1T
L&Vrorrce & Associates
320092 Via Carlos
San Juan Capistrano, CA 92575
-pe: iRof&eeional' liability
Close:
Date(s): lac , -,7une 30, 2000
PlrojectDeeMpt}m: P1 ap0 j jig t ultant-
Name of Projeet
Premium: $375.00
A idiflonal Fees and Taxes _Y 1. 72 11:3.2.5 _
This is in eerWy flat the policies of insuranwe listed below have been issued to the insured named aba"
far the policy period indicated. Notwithstanding any nqWMWMnb, tan Le or tamditians of any contract or
athst document with imped W which this enti$cate may be issued or may perWn the insurance
allorded by ti-w policies domed hnein is subject to all the ftms, wdusima and mn&tiaw of such
PROVER AS TO FORM:
INSURANCE CARRIER Evenstmn Immune Camapany
1M1►YMR POLX"Y NUMAER: Tt3D
MASTS POt,I+L7 DATES: V_g LY 1 1999
12 01 a.m. Pad& Standard Time
General Agg Wte Liability
Rath Occurrence Limit
Deductible: Per Claim
aP
GAIL HUTTON, City Attorney
city. Attorney,
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51,000,0M Per each project or
ccmultiAs contract
SLO00,000
d Sao
Cavrsage is primary and not r=tMhuftg with any wau= nce mnhVx zwd by an additional fissured. The
limits of instrag m apply sepamteiy to each event hunusd by Na policy as ff a sapwate poliley of
insurance has been Wrand for that event.
It Is understood and aged that the Ceriii3eat -Holder is an Addfficr i Insured, but ardy as respects its
liabllity adslnR Dist of taus activities of the Neared Insured.
OTiifitt ADDITIDNAL 314M lEt® I OTHER ADS MONAL WSURED
will mail 30 days wrMw tustice to the
AUTHORUTD ATIVE;
lilted.
DATE MUM December 2, 1999
minim fan Rick A*arvitwx
TOTAL P.02
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EXHIBIT H
CITY OF HUNTINGTON BEACH
APPLICATION FOR INSURANCE REQUIREMENTS WAIVER OR MODIFICATION
1. Nam e/Title/Department of 3equestint
2. Date of Request: / Y Y 4,1�7
3, Name of Contractor/Permittee:
4. Description of work to be performed:
5, Length o Contract:
6. Type of Insurance Waiver or
Staff
cation Requested:
(a) Limits _ (b) Coverage:
7. Reason for Request for Waiver or Reduction of Limits: C.�
8. Identify the risks to the City if this request for waiver or modifications granted:
Department head Signature:
(This section to be completed by the Risk Manager)
Recommendation:
Y
Approve ✓ Deny Risk Manager's Signature/Date
(This section to be
Recommendation
Approve — Deny City Attorney's 5
by dre City Attorney)
1-" .1 /,Z-/ za 1; �-
Settlement Committee approval [is is not] r quired for this waiver. If Settlement Committee approval is required, submit
form to City Artorney's Office to be p the agenda. Recommendation: Approve Deny
City Council approval [is is notj r uired for is waiver. If City Council approval is required, attach this form to tie
RCA after consideration by t nt Committee. This insurance waiver [is] [is not] on City Council agenda.
jmplklresoutionlinsregl2/6/98
7
AroRa. CERTIFICA OF LIABILITY INSUR NC ,ID �� °ATE(MMlpDlYfj
11/16/8,
nRODUCER _ THIS CERTIFICATE 1 ED AS A MATTER OF INFORMATION
'i)i�{�rrkONLY AND CONFERS RIGHTS UPON THE CERTIFICATE
2StT North American Ins Agency00 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. Box 7248 WD,I C CC0N1 0S ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Orange CA 92863-7248 qW t( _da)00&
INSURERS AFFORDING COVERAGE
rnone:714-771-7400 Fax:714-633-8065 I,_ v
Lawrence Associates
Attn: I2oa
32092 V aarry Carlswr®nce
San Juan Capistrano CA 92675
COVERAGES
INSURERA: Commercial Union Insurance
INSURER M ,
INSURER C:
INSURER D:
INSURER E:
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 OOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 9E ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUS IONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
LTR
I TYPE OR INSURANCE
POLICY NUMBER
TE MTIV
IIIW—
DATE MMlDOIY
LIMfT9
A
GENERAL LIABILITY
X COMMERCIALGENERt�ALLIAWLITY
CLAIMSMADE 7X OCCUR
CALR402380
11/05/99
11/05/00
EACH OCCURRENCE
11 000,000
'FIRE DAMAGE (Any one firs)
1100 000
MEDEKP(Any one person)
S5,000
PERSONALAAOVINJURY
I arxcluded
GE4ERALAGGREGATE
12,000,000
GEN'LAGOREGATEUMITAPPUESPOU
POLICY j'T LOC
PRODUCTS -COMPIOPAGO
$ 2000 r GOO
AUTOMO&LELIAINUTY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIREDAUTos
NON -OWNED AUTOS
APPROVED AS
G►IL UUTTON,
�8 t
TO FORM"
City AttO
City Urn
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/
01
COMBINED SINGLE LIMIT
(Es aeddenq
S
BODILY INJURY
(Per person)
S
BOOftYINJURY
(Par aacldanp
i
PROPERTY DAMAGE
IP.I aesidenn
1
GARAGE LIABILITY
ANYAUTO
y[,�
AUTO ONLY - EA ACCIDENT
s
OTHER THAN EA ACC
AUTO ONLY: AGO
1
1
MEW LIABIUTY
OCCUR ED CLAIMS MADE
DEDUCTIBLE
RETENTION 1
EACH OCCURRENCE
1
AGGREGATE
I
S
1
s
WORKERS COMPENSATION AND
F-MPLOYERS LABILITY
TORY LIMITS ER
E.L. EACH ACCIDENT
s
E.L. DISEASE- EA EMPLOY
s
E.L. DISEASE- POLICY LIMIT I
1
OTHER
DESCRIPTION OF OPERAT]ONSILOCATIONSNEHICLESrE7CCLUSIONSADDED BY ENDORSEVENTISPEOAL PROVISIONS
Certificate Bolder its Agents, Officers, and Employees are hereby named
Additional Insured with respects to General Liability per attached
endorsement. *10 day notice of cancellation for non-payment of premium. i
CERTIFICATE HOLDER Y I ADDITIONAL INSURED; INSURER LETTER: A GANGtLLA I IUN
CITYOFH I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 8E CANCELLED BEFORE THE
City of Huntington Beach
Attn: Mary Beth Broeren
2000 Main Street
Huntington Beach CA 92648
EXPIRATION OATETHEREOF, THE ISSUING INSURER WILL APAMMMM
30 * DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FA URETO DO SO MALL IMPOSE NO OBLIGATION OR LIABILITY OF
ANY KIND Uf 3 THE INSWER, ITS,4ENTS OR REPRESENTATIVES
ACORD 25-S (7197) v " - ACORD CORPORATION 1
• . LAWRENCE ASSOCIATES 11/0*-11/05/00
cL 690
ISU NORTH CR AMERIC
R 10 93 INS AGENCY (10-93)
ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:_
COMMERCIAL GENERAL LIABILITY COVERAGE PART '
This endorsement changes the policy effective on the inception date of the policy unless another date Is indicated.
SCHEDULE
Name of Person or Organization: City of Huntington Beach., its Agents,officers,&employees
2000 Main Street, Huntington Beach, CA 92648
WHO 1S AN INSURED (Section 11) is amended to Include as an Insured the person or organization shown In the Schedule, but
only with respect to liability arising out of your ongoing operations performed for that insured.
POLICY NUMBER: CALK40238 0 AGENT COPY
.Nov=1S-99 02:04P Lauer ee ASsoCiaZeS 949 61 4828 P-OZ
.arv—+.r1977 1.]•l;JJN � � p.01r$I
lobftwrhe"b ,ta, 2000 main $treat California 91648
(SAX: 71V3Zk1597)
DECLARATION of NON-fMPLOYIER STATt1S
In order to comply with City Council Resolution No. 6277. you are eequiced to provide proof of
Workers' Compensation insurance. if you have no employees, this Farm must be signed and returned
to:
City of Huntington Beach
Risk Management Division
2000 Main Strtet
Huntington Beach, CA 92643
1 certify that in the performance of the activity or work for which this permit is issued, I shall not employ
any person in any manner so as to become subject to California Workers` Compensation insurance
requirements.
1 authorize the City of Huntington Beath to immediately and retroactively revoke the kense or permit
issued under this declaration if I hire any ernployce(s) or heenme subject to the provisions of the laws
requiring Workers' Compensation Insurance.
Applicant/Company Name-
Add►ess: 32o9 Z U,� ��,•/ So.� . ,Tls� (r.�/S1 a 9�071
Applicant's Signatur � � Date: L l I J CA
Title:
Location Slgned:
Telephone Number: 9 Y 9 — -- if/
TOTAL P.01
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CITY -OF HUWrINGTON BEACH
APPLICATION FOR INSURANCE REQUIREME','US WAIVER OR MODIFICATION
IDePattment ai
1. Name/Title/Department of R uesdng Staff l`iember
2. Date of Reques ATIT
3. Name of Contractor/Perrrdne _ ✓!ZL^�G , A 7`4 5
4. Description of work to be performed
5. Length of Contract
b. T}pe of Insurance Waivrr or Modificarion R P
vested:
(a) Lirrdts: (b) Coverage
7. Reason for Request for Waiver or ReducL Dn of Limits
S. Identifi, the 'sks to ttie City if this request for v.•airer or modifications granted cow'
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Department H d Signature
(This section to be cornplered by the RrskManager)
Recommendation:
Approve -,/ Deny Risk Manager's SipatureMa l�l
(this section to be completed by the City Atrorxe39-
Recommendation :
Approve Deny City Attorney's SignatuteMate I I U" i -C �' 4 IAT
Settlement Comcninee approv ii equir:d fcr this waiver. If Settlement Comminee approval is required,
submit form to City Anorney' placed on the agenda. Recommendation: Approve Deny
City Council appros n egwred for this N%jit•er. If City Council approval is required, attach this form to the
RCA after consideration _ S ement Committee. This insurance waiver [is) its not) on City Council agenda.
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