HomeMy WebLinkAboutC. Epting, Inc. - 2021-10-22 SERVICE AGREEMENT BETWEEN
THE CITY OF HUNTINGTON BEACH AND
C. EPTING, INC.
FOR
WRITE/I-IOST/PRODUCE "HIDDEN HUNTINGTON BEACH" AND "LEGENDARY
LOCALS" FOR CHANNEL 3, SURF CITY
THIS AGREEMENT (`Agreement') is made and entered into by and between the CITY
OF HUNTINGTON BEACH a municipal corporation of the State of California, hereinafter
called the "CITY". and C. EPTING, INC.. a California Corporation hereinafter referred to as
"CONTRACTOR".
WHEREAS, CITY desires to engage the services of a contractor to write, hose. produce
"Hidden Huntington Beach" and "Legendary Locals" for Channel 3, Surf Cit -, and
Pursuant to document on file in the office of the City Clerk, the provisions of the
Huntington Beach Municipal Code, Chapter 3.02, relating to the procurement of service contacts
have been complied with: and
CONTRACTOR has been selected to perform these services,
NOW, THEREFORE:, it is agreed by CITY and CONTRACTOR as follows:
1. SCOPE OF SERVICES
CONTRACTOR shall provide all services as described in Exhibit "A", which is attached
hereto and incorporated into this Agreement by this reference. These services shall sometimes
hereinafter be referred to as the "PROJECT."
CONTRACTOR hereby designates Chris Epting 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 CONTRACTOR in the
performance of this Agreement.
3. TERM: TIME OF PERFORMANCE
Time is of the essence of this Agreement. The services of CONTRACTOR are to
commence as soon as practicable after the execution of this Agreement by CITY (the
"Commencement Date"). This Agreement shall automatically terminate three (3) years from the
Commencement Date. unless extended or sooner terminated as provided therein. All tasks
specified in Exhibit "A" shall be completed no later than three (3) years from the
Commencement Date of this Agreement. The time for performance of the tasks identified in
Exhibit "A" are generally to be shown in Exhibit "A". This schedule may be amended to benefit
the PROJECT if mutually agreed to in writing by CITY and CONTRACTOR.
In the event the Commencement Date precedes the Effective Date. CONTRACTOR shall
be bound by all terms and conditions as provided herein.
4. COMPENSATION
In consideration of the performance of the services described therein. CITY agrees to pay
CONTRACTOR on a time and materials basis at the rates specified in Exhibit "B". which is
attached hereto and incorporated by reference into this Agreement.
>. 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". CONTRACTOR will undertake such 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.
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6. METHOD OF PAYMENT
CONTRACTOR shall be paid pursuant to the terms of Exhibit "Q".
7. DISPOSITION OF PLANS, ESTIMATES AND OTHER DOCUMENTS
CONTRACTOR agrees that title to all materials prepared hereunder, including, without
limitation, all original drawings, designs, reports, both field and office notices, calculations
computer code, language, data or programs, maps, memoranda.. letters and other documents,
shall belong to CITY. and CONTRACTOR shall turn these materials over to CITY upon
expiration or termination of this Agreement or upon PROJECT completion. whichever shall
occur first. These materials may be used by CITY as it sees fit.
3. HOLD HARMLESS
CONTRACTOR hereby agrees to protect, defend, indemnify and hold harmless CITY, its
officers, elected or appointed officials, employees, agents and volunteers from and against any
and all claims, damages, losses, expenses, judgments, demands and defense costs (including,
without limitation. costs and fees of litigation of even nature or liability of any kind or nature)
arising out of or in connection with CONTRACTOR's (or CONIRACTOR's subcontractors, if
any) negligent (or alleged negligent) performance of this Agreement or its failure to comply with
any of its obligations contained in this Agreement by CONTRACTOR, its officers, agents or
employees except such loss or damage which was caused by the sole negligence or willful
misconduct of CITY. CONTRACTOR will conduct all defense at its sole cost and expense and
CITY shall approve selection of CONIRACTOR's counsel. This indemnity shall apply to all
claims and liability regardless ol'whether any insurance policies are applicable. The policy limits
do not act as limitation upon the amount of indemmnification to be provided by CONTRACTOR.
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9. WORKERS COMPENSATION INSURANCE
CONTRACTOR shall carry workers compensation insurance as required by law for the
protection of its employees during the progress of the work. Contractor understands that it is an
independent contractor and not entitled to any worker's compensation benefits under any City
program.
10. GENERAL LIABILITY INSURANCE-"
CONTRACTOR shall obtain and furnish to CITY a comprehensive general liability
insurance policy covering the work performed by it hereunder. This policy shall provide
coverage for CONTRr1CTOWs general liability in an amount not less than One Million Dollars
($1.000,000.00) per occurrence and a separate "Additional Insured Endorsement" page listing
both the policy number and naming the `City of Huntington Beach, its officers, elected or
appointed ojjicials, employees. agents and volunteers" as additional insured on the endorsement.
The above-mentioned insurance shall not contain a self-insured retention, "deductible" or any
other similar form of limitation on the required coverage except with the express written consent
of CITY.
11. AUTOMOTIVE LIABILITY INSURANCE
CONTRACTOR shall obtain and furnish to CITY an automotive liability insurance
policy covering the work performed by it hereunder. This policy shall provide coverage for
CONTRACTOR's automotive liability in an amount not less than One Million Dollars
($1.000,000.00) per occurrence and a separate "Additional Insured Endorsement" page listing
both the policy number and naming the "City of Huntington Beach, its officers, elected or
appointed officials, employees, agents toad volunteers" as additional insured on the endorsement.
The above-mentioned insurance shall not contain a self' insured retention, "deductible" or any
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other similar form of limitation on the required coverage except with the express written consent
ofclTY.
12. CERTIFICATE OF INSURANCE
Prior to commencing performance of the work hereunder, CONTRACTOR shall furnish
to CITY a certificate of insurance subject to approval of the City Attorney evidencing the
foregoing insurance coverage as required by this Agreement; the certificate shall:
a. provide the name and policy number of each carrier and policy:
b. state that the policy is currently in force; and
c. promise that such policy shall not be suspended, voided or canceled by either party,
reduced in coverage or in limits except after thirty (30) days' prior written notice;
however. ten (10) days' prior written notice in the event of cancellation for nonpayment
of premium.
CONTRACTOR shall maintain the foregoing insurance coverage in force until the work
under this Agreement is fully completed and accepted by CITY.
The requirement for carrying the foregoing insurance coverage shall not derogate from
CONTRACTOR's defense, hold harmless and indemnification obligations as set forth in this
Agreement. CITY or its representative shall at all times have the right to demand the original or a
copy of the policy of insurance. CONTRACTOR shall pay, in a prompt and timely manner, the
premiums on the insurance hereinabove required.
13. INDEPENDENT CONTRACTOR
CONTRACTOR is, and shall be, acting at all times in the performance of this Agreement
as an independent contractor herein and not as an employee of CITY. CONTRACTOR shall
secure at its own cost and expense, and be responsible for any and all payment of all taxes, social
security, state disability insurance compensation, unemployment compensation and other payroll
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deductions for CONTRACTOR and its officers, agents and employees and all business licenses,
if any, in connection with the PROJECT and/or the services to be performed hereunder.
ld. TERMINATION OF AGREEMENT
All work required hereunder shall be performed in a good and workmanlike manner.
CITY may terminate CONTRACTOR's services hereunder with or without cause, and whether
or not the PROJECT is fully complete. CITY may terminate this Agreement with or without
cause by giving CONTRACTOR written notice ("Notice of Termination"), which clearly
expresses CITY's intent to terminate the Agreement. Notice of Termination shall become
effective no less than thirty (30) calendar days after CONTRACTOR receives such notice. In the
event of termination. all finished and unfinished documents, exhibits, report, and evidence shall,
at the option of CITY, become its property and shall be promptly delivered to it by
CONTRACTOR.
15. ASSIGNMENT AND DELEGATION
This Agreement is a personal service contract and the work hereunder shall not be
assigned, delegated or subcontracted by CONTRACTOR to any other person or entity without
the prior express written consent of CITY. If an assignment, delegation or subcontract is
approved, all approved assignees, delegates and subcontractors must satisfy the insurance
requirements as set forth in this Agreement.
16. CITY EMPLOYEES AND OFFICIALS
CONTRACTOR 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.
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17. NOTICES
Any notices, certficates, or other communications hereunder shall be given either bN
personal delivery to CONTRACTOR's agent (as designated in Section I hereinabove) or to
CITY 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, to the addresses below.
CITY and CONTRACTOR may designate different addresses to which subsequent notices,
certificates or other communications will be sent by notifying the other party via personal
delivery, a reputable overnight carrier or U.S. certified U.S. certified mail-return receipt
requested:
TO CITY: TO CONTRACTOR:
City of I-luntinmon Beach C. Fpting, Inc.
Attn: Oliver Chi Attn: Chris Fpting
2000 Main Street 16835 Algonquin Street, 4293
Huntington Beach. CA 92648 Huntington Beach, CA 92647
18. CONSENT
When CITY's consent/approval is required under this Agreement, its consent/approval
for one transaction or event shall not be deemed to be a consent/approval to any subsequent
occurrence of the same or any other transactions or event.
19. MODIFICATION
No waiver or modification of any language in this Agreement shall be valid unless in
writing and duly eaccuted by both parties.
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20. SECTION HEADINGS
The titles, captions, section, paragraph and subject headings. and descriptive
phrases at the beginning of the various sections in this Agreement are merely descriptive and are
included solely for convenience of reference only and are not representative of matters included
or excluded from such provisions, and do not interpret. define. limit or describe, or construe the
intent of the parties or affect the construction or interpretation of any provision of this
Agreement.
21. INTERPRETATION OF THIS AGREEMENT
The language of all parts of' this Agreement shall in all cases be construed as a
whole, according to its fair meaning, and not strictly for or against any of the parties. If any
provision of this Agreement is held by an arbitrator or court of competent jurisdiction to be
unenforceable. void, illegal or invalid, such holding shall not invalidate or affect the remaining
covenants and provisions of this Agreement. No covenant or provision shall be deemed
dependent upon any other unless so expressly provided here. As used in this Agreement, the
masculine or neuter gender and singular or plural number shall be deemed to include the other
whenever the context so indicates or requires. Nothing contained herein shall be construed so as
to require the commission of any act contrary to law, and wherever there is any conflict between
any provision contained herein and any present or future statute, law, ordinance or regulation
contrary to which the parties have no right to contract, then the latter shall prevail, and the
provision of this Agreement which is hereby affected shall be curtailed and limited only to the
extent necessary to bring it within the requirements of the law.
22. DUPL,ICATE ORIGINAL
The original of this Agreement and one or more copies hereto have been prepared
and signed in counterparts as duplicate originals, each of which so executed shall, irrespective of
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the date of its execution and delivery. be deemed an original. Each duplicate original shall be
deemed an original instrument as against any party who has signed it.
23. ININ11GRATION
CONTRACTOR 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.
24. LEGAL SERVICES SUBCONTRACTING IIROI41BITED
CONTRACTOR 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. CONTRACTOR 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
CONTRACTOR.
25. CONFIDENTIALITY
CONTRACTOR recognizes that in the performance of its duties under this Agreement, it
must conduct its activities in a manner designed to protect information of a sensitive nature from
improper use or disclosure. CONTRACTOR warrants that it will use reasonable efforts
consistent with practices customary in the facilities management industry in recruiting, training
and supervising employees and in otherwise performing its duties hereunder in order to achieve
this result. In the furtherance of this. CONTRACTOR agrees, at the request of the CITY. to
require its employees to execute written undertakings to comply with the foregoing
confidentiality provision.
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26. A'I"I'ORNEY'S ITES
In the event suit is brought by either party to construe, interpret and/or enforce the terms
and/or provisions of this Agreement or to secure the performance hereof,each party shall bear its
own attorney's fees, such that the prevailing party shall not be entitled to recover its attorney's
fees from the nonprevailing party.
27. SURVIVAL
Terms and conditions of this Agreement, which by their sense and context survive the
expiration or termination of this Agreement,shall so survive.
28. GOVERNING LAW
This Agreement shall be governed and construed in accordance with the laws of the State
of California.
29. SIGNATORIES
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 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.
CONTRACTOR'S Initials 8
30. ENTIRETY
The parties acknowledge and agree that they are entering into this Agreement freely and
voluntarily following extensive arm's length negotiation, and that each has had the opportunity
to consult with legal counsel prior to executing this Agreement. The parties also acknowledge
and agree that no representations, inducements, promises, agreements or warranties, oral or
otherwise, have been made by that party or anyone acting on that party's behalf, which arc not
embodied in this Agreement, and that that party has not executed this Agreement in reliance on
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any representation, inducement, promise, agreement warranty, fact or circumstance not expressly
set forth in this Agreement. This Agreement, and the attached exhibits, contain the entire
agreement between the parties respecting the subject matter of this Agreement, and supersede all
prior understandings and agreements whether oral or in writing between the parties respecting
the subject matter hereof.
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31. EFFECTIVE DATE
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by and
through their authorized officers. This Agreement shall be effective on the date of its approval by
the City Manager. This
Agreement shall expire when terminated as provided herein.
R' SAC. CITY OF HUNTINGTON BEACH,
a municipal corporation of the Sate of
MNamCalifornia
By:
City Manager
print name Dated:
ITS:(circle one)Chainnan/Presideni/Vice President
AND INITIATED AND APPROVED:
By:
Director/Chief
print name
ITS:(circle one)Secretary/Chief Financial onicer/Asst.
Secretary-Treasurer
APPROVED AS TO FORM:
City Attorney
City Clerk
COUNTERPART
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31. EFFECTIVE DATE
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by and
through their authorized officers. This Agreement shall be effective on the date of its approval by
the City Manager. This Agreement shall expire when terminated as provided herein.
CONTRACTOR, CITY OF HUNTINGTON BEACH,
a municipal corporation of the *ate of
By: Mc"-L Company Name
City Manager
print name Dated: �0/aala0a (
ITS:(circle one)Chainnan/President/Via President
AND INITIATED AND APPROVED:
By:
r7 for hief
print name
ITS: (circle one)Secretary/Chief Financial Officer/Asst.
Secretary-Treasurer
APPROVED AS T FORM:
City Attorney AM/
4qiftl
City Clerk
COUNTERPART
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EXHIBIT "A"
A. STATEMENT OP WORK: (Narrative of work to be performed)
The City seeks creating programming that will cover unique City stories, events. local sporting
events, community events and concerts; and public access programming created for local
residents and organizations. Under direction of the City's Community Relations Offer and the
FIB 3 Cable Channel team, the Cite Council Communications Committee desires new.
meaningful, and creative content that will attract a diverse audience. Programs must be suitable
for broadcast on the PEG channel and are subject to approve by the City Council, City Council
Communications Committee, and City representatives.
Such programming may include but are not limited to a new. historical show called "Hidden
Huntington Beach" that takes an inside look at unique people and places within the City. and a
show called "Legendary Locals" that covers important. legendary members of Huntington Beach
B. CONSULTANT'S DUTIES AND RESPONSIBILITIES:
Work collaboratively with the CITY via the Cable Channel team and the City's Communications
Committee to create unique programming to be aired on the City's PEG Channel — Surf City TV.
The CONSULTANT shall be able to assist the CITY with the following technical requirements
either through their own acumen or via a sub-contractor. in order to meet the on-call needs of the
City at any given time during the contract terns:
- Script writing
- Voiceover talent
- Producing
- Directing
- Music Licensing
EXHIBIT A
Social Media (e.g. Facebook Live, Instagram, etc.)
Vlog
Short and long version programming
C. CITY'S DUTIES AND RESPONSIBIL,I-TIES:
The CITY shall work collaboratively with the CONSULTANT to identify appropriate staff
members to work with CONSUTANT to advance the goals of the City Council and the
Communications Committee to create quality, creative programming for the City's PEG
Channel. CITY will not control the manner or means of CONSULTANT's services.
D. WORK PROGRAM/PROJECT SCI-IEDULE:
While the term of this agreement is for three years, the CITY and CONSULTANT' will work
collaboratively to set a schedule of work to be completed on a per-project basis.
EXHIBIT A
EXHIBIT "B"
Payment Schedule (Fixed Fee Payment)
I. CONSULTANT shall be entitled to monthly progress payments toward the fixed fee
set forth herein in accordance with the following progress and payment schedules.
S1,200.00 per episode for Hidden Huntington Beach
Hidden Huntington Beach — Season Three
1. The historic churches of Huntington Beach
2. The hidden history of the Huntington Beach Speedway
3. The hidden history of the wetlands
4. The hidden history of the Mushroom Farm
5. The hidden history of the Holly Sugar Factory
G. The hidden history of other factories- (tile, broom, etc)
7. The hidden history of the "Encyclopedia lots'
8. The hidden history of oil in Huntington Beach
9. The hidden history of the all-black Pacific Beach Club
10. The hidden history of Wintersburg village
11. The hidden history of street names in Huntington Beach
12. The hidden history of Good Shepherd Cemetery
13. The hidden history of surf culture in Huntington Beach
$1,000.00 per episode for Legendary Locals
1. Nerio family —Japanese-American family that owned Meadowlark airport
2. Dean Torrance— famed musician
3. Bill Kettler— 99 Near old teacher/local historian
4. Bob "The Greek Bolen — famed surfer
2. 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.
3. CONSULTANT shall submit to CITY an invoice for each monthly progress payment
due. Such invoice shall:
A) Reference this Agreement.
B) Describe the services performed:
C) Show the total amount of the payment due:
D) 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
E) For all payments include an estimate of the percentage of work completed.
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
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 ofthe reasons for non-approval and the schedule
of performance set forth in Exhibit "A" may at the option of CITY be suspended until the parties
agree that past performance by CONSULTANT is in, or has been brought into compliance. or until
this Agreement has expired or is terminated as provided herein.
d. Any billings for extra work or additional services authorized in advance and in writing
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 kyith 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.
Su ity CITY OF HUNTINGTON BEACH
2000 Main Street, Huntington Beach, CA 92648
Declaration of Non-Employer Status
The State of California requires every enterprise or business to provide workers
compensation insurance coverage. If you have no employees, you may make a
declaration to that effect by completing and signing this form and returning to:
City of Huntington Beach
2000 Main Street
Huntington Beach, CA 92648
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.
I authorize the City of Huntington Beach to immediately and retroactively
revoke the license or permit issued under this declaration if I hire any
employee(s) or become subject to the provision of the laws requiring Workers'
Compensation Insurance.
Company Name: l� IrL1v<, a
Address: ax�� 1 '�
` .
Applicant v % y
Applicant's Signature:
Title: fms- (( '� (
Date Signed: I D 2U 2
Telephone Number:
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CITY OF HUNTINGTON BEACH
2000 Main Street
H Hnntin n Beach, CA 9264s
DECLARATION OF PEPMITTEE
I certify that no vehicle(s) will be used or operated in the performance of the
task(s) or event(s) for which this permit is granted.
I authorize the City of Huntington Beach to immediately and retroactively revoke
the license or permit issued in connection with or in the performance of said task(s)
or event(s) if any vehicle(s) is
Signature of P rmittee
Print name l' "�!�l �6, I ,
Company name
lIofappiicabk)
Date signed
1640 EXHIBIT I
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THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
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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,Ilia pollcy(los)must have ADDITIONAL INSURED provisions or he endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of(he policy, certain policies may require an endorsement. A statement on
This certificate does not confor rights to the certificate holder In lieu of such endorsenent S .
i'ItOpVCER 1ACT
HO Oq IE. Dianne Thompson
SfateFarm Dianne Thompson,Agent PHONE
a4W 714.698.0202 INC.IT J,
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Huntington Beach,CA 92048 INSNWR(Bf AFFORDING COVERAGE NAICIT
INSURER A: State Farm General Insurance Company 25151
INSURED
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16835 Algonquin St ll 293 INSURER D
Huntington Beach,CA 02649 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
IRDICAIED. NOTWITHSTANDING ANY REQUIREMENT, 'TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 10 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.
INsft TYPE OF INSURANCE AWL S BP POLICY EFF POLICY EXP
POLICYNUMBER M1 DD LIMITS
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X POLICY ZJECT ❑X LOC PRODUCTS-CAA!PA3P AGO S 2.000.000
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The Corlificato holder Is also the Additional Insured.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
The City of Huntington Bench
2000 Main St if 5 AUTHORIZED REPRESENTA71W
Huntington Beach,CA 92.647 �—
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0 1988-2 01 5 ACORD CORPORATION. All rights reserved,
ACORD 25(2016103) The ACORD name and logo arc registered marks of ACORD
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ADDITIONAL„ INSURED ENDORSEAIENT
OWNERS, LESSEES Olt CONTRACTORS (FORM B)
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POLICY NO: 92-XP-4029-7C,
NAMED INSURED:
C Epting Inc.
16835 Algonquin St 11 293
Huntington Reach, CA 92649
NAME Ole PERSON Olt ORGANIZATION:
C Epting Inc.
ADDITIONAL INSURED:
City of Iluntinglon Reach
2000 Main St.
Huntington Beach, CA 92647
The City of Iluntinglon Beach, its officers, elected or appointed officials, employees, agents and
VOlunlccrS.
WHO IS AN INSURED, UNDER SECTION S II DESIGNATION OF INSURED, IS
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SHOWN ABOVE, BUT ONLY WITH RESPECT TO LIABILITY ARISING OUT OF
YOUR WORK FOR TILE INSURED BY OR FOR YOU.
TILE INSURANCE AFFORDED BY THE POLICY FOR TAE ADDITIONAL
INSURED(S) IS PRIMARY INSURANCE AND ANY OTHER INSURANCE
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. State Farm•
POIACY NO: 92-J3-1.618-1, 92-C;9-1)233-3
NAMED INSIJRb;D:
C Cpting Inc.
16835 Algonquin St it 293
Huntington Beach, CA 92649
ADDITIONAL, INSURED:
City of Huntington Beach
2000 Main St.
Huntington Hcach, CA 92647
Thu City of Huntington Beach, its officers, elected or appointed officials, emptoyces, agents and
volunteers.
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Su ity CITY OF HUNTINGTON BEACH II
2000 Main Street, Huntington Beach, CA 92648
Huntin Beachm
Declaration of Non-Employer Status
The State of California requires every enterprise or business to provide workers
compensation insurance coverage. If you have no employees, you may make a
declaration to that effect by completing and signing this form and returning to:
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City of Huntington Beach
2000 Main Street
Huntington Beach, CA 92648
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.
I authorize the City of Huntington Beach to immediately and retroactively
revoke the license or permit issued under this declaration if I hire any
employee(s) or become subject to the provision of the laws requiring Workers'
Compensation Insurance.
Company Name:
Address: �
16(� � j(T�v, L
Applicant s
Applicant's Signature:
Title: f 4es-
Date Signed: il D UL 2
Telephone Number:
L ..........................
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4L2000
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CITY OF HUNTINGTON BEACH
Main Street
Huntin n Beach, CA 92648
DECLARATION OF PERMIiME
I certify that no vehicle(s) will be used or operated in the performance of the
task(s) or event(s) for which this permit is granted.
I authorize the City of Huntington Beach to immediately and retroactively revoke
the license or permit issued in connection with or in the performance of said task(s) i
or event(s) if any vehicle(s) is ed.
Signature of//P�� rmppittee �y,,1 j
Print name
Company name (irapplirabte)
Date signed
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1640= EXHIBIT I
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