Loading...
HomeMy WebLinkAbout04756 - JOHN TRUEBLOOD ARCHITECT SIGNATURE CUSTOMS CHANGE ORDER NO. 1 PROJECT TITLE:General Aviation Processing Facility U.S. Customs and Border Protection CONTRACT DATE:August 11,2003 CONTRACTOR:John R.Trueblood,Architect The following changes are hereby made to the Contract Documents: 1. Addition: Architectural Revisions 2. Addition:Plumbing Revisions 3. Addition: Mechanical Revisions 4. Addition: Electrical Revisions 5. Addition:Glass Breakage Intrusion System to Electrical Plans 6. Addition: Reimbursable Expenses JUSTIFICATION: Revisions to architectural, mechanical and electrical plans made necessary by Bureau of Customs mandated changes to previous documents. CHANGE TO CONTRACT PRICE Original Contract Price:$24,300 Current Contract Price, as adjusted by previous change orders: $24,300 The Contract Price due to this Change Order will be increased by:$1,960.31 The new Contract Price due to this Change Order will be:$26,260.31 CHANGE TO CONTRACT TIME: None. APPROVALS REQUIRED: To be effect(ve,this order must he approved by the City of Palm Springs if it changes the scope of the objective of the project,or as may otherwise be required under the terms of the Contract Documents. Requested by; :e Date: /o G � ct( erector of Aviation Ordered by: 2f Dafe: City of Palm Springs Approved by: Date: eder I Aviation Date: n Accepted by: Date: J R. rue load,Architect �)� G n (��� L1 0 John Trueblood Architectural Services AGREEMENT #4756 CM signed 8-28-03 CITY OF PALM SPRINGS CONTRACT SERVICES AGREEMENT FOR ARCHITECTURAL SERVICES (SHORT FORM) THIS CONTRACT SERVICES AGREEMENT (herein "Agreement') is made and entered into this 11'h day of August, 2003, by and between the CITY OF PALM SPRINGS, a municipal corporation (herein "City") and John R. Trueblood, Architect, a professional firm acting in a consulting capacity, (herein "Contractor"). NOW, THEREFORE, the parties hereto agree as follows: 1.0 SERVICES OF CONTRACTOR 1.1 Scope of Services. In compliance with all of the terms and conditions of this Agreement,the Contractor shall perform the work or services set forth in the"Scope of Services" attached hereto as Exhibit "A" and incorporated herein by reference. Contractor warrants that all work and services set forth in the Scope of Services will be performed in a competent, professional and satisfactory manner. 1.2 Compliance With Law. All work and services rendered hereundershall be provided in accordance with all ordinances, resolutions,statutes, rules, and regulations of the City and any Federal, State or local governmental agency of competent jurisdiction. 1.3 Licenses, Permits. Fees and Assessments. Contractor shall obtain at its sole cost and expense such licenses, permits and approvals as may be required by law for the performance of the services required by this Agreement. 2.0 COMPENSATION 2.1 Contract Sum. For the services rendered pursuant to this Agreement, Contractor shall be compensated in accordance with the "Schedule of Compensation" attached hereto as Exhibit"B"and incorporated herein bythis reference, but not exceeding the maximum contract amount of Twenty Four Thousand Three Hundred Dollars($24,300) ("Contract Sum"). 2.2 Method of Payment. Provided that Contractor is not in default under the terms of this Agreement, Contractor shall be paid as outlined in Exhibit "B" Schedule of Compensation. 3.0 COORDINATION OF WORK 3.1 Representative of Contractor. John Trueblood is hereby designated as being the principal and representative of Contractor authorized to act in its behalf with respect to the work and services specified herein and make all decisions in connection therewith. C:\DATA\WP\contract—services_agreement—trueblood_3.wpd %iL9N�p36� �lfn ?�F�a+ G U August 11,2003 -1- 3.2 Contract Officer. Lawrence Wedekind,Landside Operations Manager, is hereby designated as being the representative the City authorized to act in its behalf with respect to the work and services specified herein and make all decisions in connection therewith ("Contract Officer"). The City Manager of City shall have the right to designate another Contract Officer by providing written notice to Contractor. 3.3 Prohibition Against Subcontracting or Assignment. Contractor shall not contract with any entity to perform in whole or in part the work or services required hereunder without the express written approval of the City. Neither this Agreement nor any interest herein may be assigned or transferred, voluntarily or by operation of law, without the prior written approval of City. Any such prohibited assignment or transfer shall be void. 3.4 Independent Contractor. Neither the City nor any of its employees shall have any control over the manner, mode or means by which Contractor, its agents or employees, perform the services required herein, except as otherwise set forth. Contractor shall perform all services required herein as an independent contractor of City and shall remain under only such obligations as are consistent with that role. Contractor shall not at any time or in any manner represent that it, or any of its agents or employees, are agents or employees of City. 4.0 INSURANCE, INDEMNIFICATION AND BONDS 4.1 Insurance. The Contractor shall procure and maintain, at its sole cost and expense, in a form and content satisfactory to City, during the entire term of this Agreement including any extension thereof, the following policies of insurance: (a) Commercial General Liability Insurance. A policy of commercial general liability insurance written on a per occurrence basis with a combined single limit of at least$1,000,000 bodily injury and property damage including coverages for contractual liability, personal injury, independent contractors, broad form property damage, products and completed operations. The Commercial General Liability Policy shall name the City of Palm Springs as an additional insured in accordance with standard ISO additional insured endorsementform CG2010(1185) or equivalent language. (b) Worker's Compensation Insurance. A policy of worker's compensation insurance in an amount which fully complies with the statutory requirements of the State of California and which includes $1,000,000 employer's liability. (c) Business Automobile Insurance. A policy of business automobile liability insurance written on a per occurrence basis with a single limit liability in the amount of$1,000,000 bodily injury and property damage. Said policy shall include coverage for owned, non-owned, leased and hired cars. (d)Additional Insurance. Additional limits and coverages, which may include professional liability insurance, will be specified in Exhibit B. C:\DATA\W P\contract_services_agreement_trueblood_3.wpd August 11,2003 -2- All of the above policies of insurance shall be primary insurance.(Reference Section 4.4 regarding sufficiency.) The insurer shall waive all rights of subrogation and contribution it may have against the City, its officers, employees and agents, and their respective insurers. In the event any of said policies of insurance are canceled, the Contractor shall, prior to the cancellation date, submit new evidence of insurance in conformance with this Section 4.1 to the Contract Officer. No work or services under this Agreement shall commence until the Contractor has provided the City with Certificates of Insurance, endorsements orappropriate insurance binders evidencing the above insurance coverages and said Certificates of Insurance, endorsements, or binders are approved by the City. The contractor agrees that the provisions of this Section 4.1 shall not be construed as limiting in any way the extent to which the Contractor may be held responsible for the payment of damages to any persons or property resulting from the Contractor's activities orthe activities of any person or persons for which the Contractor is otherwise responsible. In the event the Contractor subcontracts any portion of the work in compliance with Section 3.3 of this Agreement the contract between the Contractor and such subcontractor shall require the subcontractor to maintain the same polices of insurance that the Contractor is required to maintain pursuant to this Section. 4.2 Indemnification. Contractor agrees to indemnify the City, its officers, agents and employees against, and will hold and save them and each of them harmless from, any and all actions, suits, claims, damages to persons or property, losses, costs, penalties,obligations,errors, omissions or liabilities, (herein "claims or liabilities")that may be asserted or claimed by any person, firm or entity arising out of or in connection with the negligent performance of the work, operations or activities of Contractor, its agents, employees, subcontractors, or invitees, provided for herein, or arising from the negligent acts or omissions of Contractor hereunder, or arising from Contractor's negligent performance of or failure to perform any term, provision, covenant or condition of this Agreement, whether or not there is concurrent passive or active negligence on the part of the City, its officers, agents or employees but excluding such claims or liabilities arising from the sole negligence orwillful misconduct of the City, its officers, agents or employees, who are directly responsible to the City, and in connection therewith: (a) Contractor will defend any action or actions filed in connection with any of said claims or liabilities and will pay all costs and expenses, including legal costs and attorneys' fees incurred in connection therewith; (b) Contractorwill promptly pay anyjudgment rendered againstthe City, its officers, agents or employees for any such claims or liabilities arising out of or in connection with the negligent performance of or failure to perform such work, operations or activities of Contractor hereunder; and Contractor agrees to save and hold the City, its officers, agents, and employees harmless therefrom; (c) In the event the City, its officers, agents or employees is made a party to any action or proceeding filed or prosecuted against Contractor for such damages or other claims arising out of or in connection with the negligent performance of or failure to perform the work, operation or activities of Contractor hereunder, Contractor agrees to payto the City, its officers, agents or employees, any and all costs and expenses incurred by the City, its officers, agents or employees in such action or proceeding, including but not limited to, legal costs and attorneys' fees. C:\DATA\WP\contract—services_agreement—trLieblood-3.wpd August 11,2003 -3- 4.3 Performance Bond. Concurrently with execution of this Agreement, Contractor shall deliver to City a performance bond in the sum of the amount of this Agreement, in the form provided by the City,which secures the faithful performance of this Agreement, unless such requirement is waived by the Contract Officer. The bond shall contain the original notarized signature of an authorized officer of the surety and affixed thereto shall be a certified and current copy of his power of attorney. The bond shall be unconditional and remain in force during the entire term of the Agreement and shall be null and void only if the Contractor promptly and faithfully performs all terms and conditions of this Agreement. 4.4 Sufficiency of Insurer or Surety. Insurance or bonds required by this Agreement shall be satisfactory only if issued by companies qualified to do business in California, rated "A" or better in the most recent edition of Best's Key Rating Guide or in the Federal Register, unless such requirements are waived by the City Manager or designee of the City Manager due to unique circumstances. In the event the City Manager determines that the work or services to be performed under this Agreement creates an increased or decreased risk of loss to the City, the Contractor agrees that the minimum limits of the insurance policies and the performance bond required by this Section 4 may be changed accordingly upon receipt of written notice from the City Manager or designee; provided that the Contractor shall have the right to appeal a determination of increased coverage by the City Manager to the City Council of City within ten (10) days of receipt of notice from the City Manager. 5.0 TERM 5.1 Term. Unless earlier terminated in accordancewith Section 5.2 below, this Agreement shall continue in full force until August 10, 2004. 5.2 Termination Prior to Expiration of Term. Either party may terminate this Agreement at any time, with or without cause, upon thirty (30) days written notice to the other party. Upon receipt of the notice of termination, the Contractor shall immediately cease all work or services hereunder except as may be specifically approved by the Contract Officer. In the event of termination by the City, Contractor shall be entitled to compensation for all services rendered prior to the effectiveness of the notice of termination and for such additional services specifically authorized by the Contract Officer and City shall be entitled to reimbursement for any compensation paid in excess of the services rendered. 6.0 MISCELLANEOUS 6.1 Covenant Against Discrimination. Contractor covenants that, by and for itself, its heirs, executors, assigns and all persons claiming under or through them,that there shall be no discrimination against or segregation of, any person or group of persons on account of race, color, creed, religion, sex, marital status, national origin, or ancestry in the performance of this Agreement. Contractor shall take affirmative action to ensure that applicants are employed and that employees are treated during employment without regard to their race, color, creed, religion, sex, marital status, national origin or ancestry. 6.2 Non-liability of City Officers and Employees. No officer or employee of the City shall be personally liable to the Contractor, or any successor in interest, in the event of any default or breach by the City or for any amount which may become due to the C:\DATA\W P\contract_services_agreement_trueblood_3.wpd August 11,2003 -4- Contractor or to its successor, or for breach of any obligation of the terms of this Agreement. 6.3 Conflict of Interest. No officer or employee of the City shall have any financial interest,direct or indirect, in this Agreement norshall anysuch officer or employee participate in any decision relating to the Agreement which effects his financial interest or the financial interest of any corporation, partnership or association in which he is, directly or indirectly interested, in violation of any State statute or regulation. The Contractor warrants that it has not paid or given and will not pay or give any third party any money or other consideration for obtaining this Agreement. 6.4 Notice. Any notice, demand, request, document, consent, approval, or communication either party desires or is required to give to the other party or any other person shall be in writing and either served personally or sent by prepaid, first-class mail, in the case of the City,to the City Manager and to the attention of the Contract Officer, City of Palm Springs, P.O. Box 2743, Palm Springs, California 92263, and in the case of the Contractor, to the person at the address designated on the execution page of this Agreement. 6.5 Interpretation. The terms of this Agreement shall be construed in accordance with the meaning of the language used and shall not be construed for or against either party by reason of the authorship of this Agreement or any other rule of construction which might otherwise apply. 6.6 Integration: Amendment. It is understood that there are no oral agreements between the parties hereto affecting this Agreement and this Agreement supersedes and cancels any and all previous negotiations,arrangements,agreements and understandings, if any, between the parties, and none shall be used to interpret this Agreement. This Agreement may be amended at any time by the mutual consent of the parties by an instrument in writing. 6.7 Severability. In the event that part of this Agreement shall be declared invalid or unenforceable by a valid judgment or decree of a court of competent jurisdiction, such invalidity or unenforceability shall not affect any of the remaining portions of this Agreement which are hereby declared as severable and shall be interpreted to carry out the intent of the parties hereunder unless the invalid provision is so material that its invalidity deprives either party of the basic benefit of their bargain or renders this Agreement meaningless. 6.8 Waiver. No delay or omission in the exercise of any right or remedy by a nondefaulting party on any default shall impair such right or remedy or be construed as a waiver. A party's consent to or approval of any act by the other party requiring the party's consent or approval shall not be deemed to waive or render unnecessary the other party's consent to or approval of any subsequent act. Any waiver by either party of any default must be in writing and shall not be a waiver of any other default concerning the same or any other provision of this Agreement. 6.9 Attorneys'Fees. If either party to this Agreement is required to initiate or defend or made a party to any action or proceeding in any way connected with this Agreement, the prevailing party in such action or proceeding, in addition to any other relief C:\DATA\WP\contract—services_agreement—trueblood-3.wpd August 11,2003 -5- which maybe granted,whether legal or equitable,shall be entitled to reasonable attorney's fees, whether or not the matter proceeds to judgment. 6.10 Corporate Authority. The persons executing this Agreement on behalf of the parties hereto warrant that (i) such party is duly organized and existing, (ii)they are duly authorized to execute and deliver this Agreement on behalf of said party, (iii) by so executing this Agreement,such party is formally bound to the provisions of this Agreement, and (iv) the entering into this Agreement does not violate any provision of any other Agreement to which said party is bound. C:\DATA\WP\contract—services—agreement—trueblood-3.wpd August 11, 2003 -6- WITNESS WHEREOF,the parties have executed and entered into this Agreement as of the date first written above. CITY OF PALM SPRINGS ATTEST: a municipal corporation By:r'/ ">�%i'z J .'f/ , '.. `°, .;X�f . By. /je�CIty Clerk C , 'r' City Manager Agreement.QW/un�ide$5,000 f APPROVED AS TO F M:Z Reviewed and approved by Procurement & C011tractpug City Attot'ney By: � IniN22s Date � a P.O. Number CONTRACTOR: Check one:_Individual_Partnership_Corporation Corporation requir two notarized signature : O'a from each of the following: A. Chairman of Board, President, or any Vice Pr�esi`dent 1{ DB cretary,As s ist ecr ary, reasurer,Assistant Treasurer,or Chief Financial Officer). Signature(notarized Signature(notarized) Na e: b 5 r �9� � j�°'B_" Name: Title: /J�`<;t�('<.. S' `d� /Z. Title: State of State of I County of /A.o•w¢, rle )ss County of Iss 5 / On%-:a,beforeme,F-?�1/eJc Z-&,�����E'lx.�lS l��rA-/'�i."�.�e,,[,On before me, personallyappeared ;/z i , J z. t `,ry• �'�E�e-✓��`-d-�"— personally appeared personally-known_t6.-me-(er proved to me on the bas's of personally known to me (or proved to me on the basis of satisfactory evidence)to be the person( sj whose name(g is)are satisfactory evidence)to be the person(s)whose names)is/are subscribed to the within instrument and acknowledged o me subscribed to the within instrument and acknowledged to me thakNi jbhe/they executed the same it`gii�lher/their authorized that he/she/they executed the same in his/her/their authorized capacity(ies), and that,by('higher/their signature(pf on the capacity(ies), and that by his/her/their signature(s) on the instrument the person(gj,or the entity upon behalf of which the instrument the person(s),or the entity upon behalf of which the person�4)acted,executed the instrument. person(s)acted,executed the instrument. WITNESS my hand and official seal. / WITNESS my hand and official seal. Notary Signature: i'' % Y/!�aP1/rlG? Notary Signature: Notary Seal: Notary Seal: Contractor Address: John R.Trueblood,Architect 121 South Palm Canyon Drive, Suite 204 Palm Springs, CA 92262 r _ EWNE L.WEDEKIND ,�.,1,,,, .,__-,.�__...,.n"—v,�._; �L..�., �'.,.,.'Z- _ Comminlon*1399015 Notary Public=Califomia Riverside County k' aMy Comm.Explres Feb 8,2007 4 II - '7wYr. _. ':WkYlx`I.�M�'M�i. �'..�I.i •t .i EXHIBIT "A" SCOPE OF WORK Contractor shall provide architectural services for remodeling of existing facilities within the Signature Flight Support executive terminal building to provide a processing facility forthe use of the Bureau of Customs and Border Protection. The new facilities are to be designed to meet the Technical Standards for a General Aviation Processing Facility and current Americans with Disability Act (ADA) requirements. Remodeling shall specifically include limited demolition of certain areas of the existing building, the installation of new flooring, walls and ceilings, restroom facilities, counter sinks, revision to the HVAC ductwork, installation of new lighting and power outlets,and new or re-connections of building utilities. Also included will be a new entry door from the AOA and modification of the west building entrance to the Signature offices. Services included: Task 1 — Pre-Design 1. Review all available record plans 2. Visit site and determine visible conditions Task 2 — Preliminary Design 1. Develop preliminary layout 2. Submit for approval 3. Make revisions requested Task 3 — Construction Documents 1. Based on approved preliminary layout prepare Construction Documents setting forth in detail the requirements for construction of the project, including architectural , fire protection, plumbing, HVAC and electrical work. 2. Assist the City in submitting the Documents to the Bureau of Customs & Border Protection for their review and revise documents as necessary. Task 4 — Building Review 1. Obtain City Building Department plan check comments regarding the final Documents. 2. Respond to all appropriate comments and revise the Documents as required. Task 5 — Bidding_Assistance 1. Provide bidding assistance and review Requests for Information (RFIs). 2. Provide responses to RFIs to the City for use in issuance of appropriate Addenda. 3. Provide bidding interpretation and bid review analysis. Task 6 — Construction Phase 1. Provide bidding assistance and respond to all legitimate requests for Information (RFIs) regarding the Documents.. 2. Provide bidding interpretation and bid review analysis. 3. During construction review and respond to the contractor's legitimate requests for information regarding the Documents. 4. Make weekly visits during construction to become familiar with construction progress and advise the City in this regard. 5. Advise the City regarding the Contractor's request for payments. 6. Review submitted shop drawings for compliance. The Contractor understands the City's requirement to produce the completed remodeled facilities as soon as is possible and based on that need the Contractor will endeavor to produce the Construction Documents by August 31, 2003. EXHIBIT "B" SCHEDULE OF COMPENSATION PRE-DESIGN 1,800 Review all available record plans. 400 Site survey. 800 Miscellaneous services. 600 PRELIMINARY DESIGN 3,400 Develop preliminary layout. 1,600 FIS review & approval. 200 Revisions. 600 Miscellaneous services. 1,000 CONSTRUCTION DOCUMENTS 12,800 Architectural. 7,800 Fire Protection. 1,000 Plumbing & HVAC 2,000 Electrical 2,000 BUILDING REVIEW ALL DISCIPLINES 1,600 CONSTRUCTION PHASE SERVICES 4,700 Architectural. 3,800 Mechanical. 500 Electrical. 400 TOTAL CONTRACT COST NOT TO EXCEED $24,300 Progress payments may be made based on approved monthly invoices for services performed. EXHIBIT "C' SPECIAL REQUIREMENTS 1. Section 4.3, Performance Bond is hereby waived. Client#: 9627 JOHNRTRUE ACQEQM CERTIFICA' OF LIABILITY INSUF, )NICE o4;03,03°""' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dealey, Renton &Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P. 0. Box 10550 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES-BELOW. Santa Ana, CA 92711-0550 INSURERS AFFORDING COVERAGE 714 427-6810 , * � INSURED NsuRERa. United States Fidelity& Guaranty John R. Trueblood Architect INSURER B: Security Ins. Co. of Hartford Try 121 S. Palm Canyon Drive — INSURER C: Palm Springs, CA 92262 INsuRER D NSURER E COVERAGES 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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER POLICY—EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE MM/DD/YY DATE MM/DDNY A GENERAL LIABILITY BKO1370166 03/07/03 03/07/04 EACH OCCURRENCE $2 000 000 X COMMERCIAL GENERAL LIABILITY General Liability FIRE DAMAGE(Any one fire) s300000 CLAIMS MADE OCCUR excludes claims MED EXP(Any one person) $10000 rising from the PERSONAL&AOV INJURY $2,000,000 performance of GENERAL AGGREGATE s4,000,000 GEN'L AGGREGATE LIM ITAPPLIES PER: professional PRODUCTS COMP/OP AGO $4,000,000 POLICY PRO LOC services. ECT A 'AUTOMOBILE LIABILITY BKO1370166 03/07/03 03/07/04 COMBINED SINGLE LIMIT $2,000,000 ANY AUTO (Ea accident) ALL OWNED AUTOS ,- BODILY INJURY $ SCHEDULED AUTOS - (Per person) X HIRED AUTOS , BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT !$ ANY AUTO OTHER THAN EA ACC $ "11 AUTO ONLY: AGG $ E%CESS LIABILITY EACH OCCURRENCE S OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE _$ RETENTION S $ WORKERS COMPENSATION AND DRY LLIfA L WC I_1 IT OTH- s L_EP _—- EMPLOYERS'LIABILITY E L EACH ACCIDENT _5 EL DISEASE-EA EMPLOYEE $ EL DISEASE-POLICY LIMIT I$ B OTHER Prof I. Liab AEE0229591 04/11/03 04/11/04 $1,000,000 per claim Claims Made $1,000,000 annl aggr. Retro: 4/11/02 $5,000 Ded. Per Claim DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS City of Palm Springs is additional insured on General Liability policy for services provided by the above Named Insured. *Except if canceled for non payment of premium, 10 days notice given. CERTIFICATE HOLDER ADDITIONALINSURED;INSURERLETTER: CANCELLATION SHOULD ANVOFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of Palm Spings DATE THEREOF, THE ISSUING INSURER WILL%XRII34=X7P MAIL WJ* DAYS WRITTEN Attn: City Clerk NOTICETOTHE CERTIFICATE HOLDER NAMED TOTH E LEFT,B)OTAWMARMMxRARMXXX P O Box 2743 M18D6x79RX1WC1nAnpC4QBG tCEtlX4TxRR7tXR71RRkRRGU[b[4 R7ff1pARRJdfiXUCEA CJ RRX Palm Springs, CA 92263.2743 7 K13=XV076' X AUTHORIZED REPRESENTATIVE / /L ACORD 25-S(7/97)1 of 1 #S85900IM84694 j`I�'ZCAALBLC f/©C/fACO"`R',D`�000',RPORATION 1988 COMMERCIAL GENERAL LIABILITY Policy Number: PAS37648210 Named Insured: John R. Trueblood This endorsement changes the policy. Please read it carefully. ADDITIONAL INSURED—OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following— COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE: NAME OF PERSON OR ORGANIZATION: City of Palm Springs Office of the City Clerk 3200 Tahquitz Canyon Way Palm Springs, CA 92262 (If no entry appears above, information required to complete this endorsement will be shown in the declarations as applicable to this endorsement.) Who is an insured (Section II) 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 work" for that insured by or for you. CG20101185 Copyright Insurance Services Offices, Inc. 1984 AUG-22-2003 FRI 05: 16 PM FROM: JOHN TRUEBLOOD FAX: 7604162381 PAGE 2 JOHN R TRUEBLOOD August 22, 2003 Patricia A. Sanders, CMC City Clerk City of Palm Springs 3200 Tahquitz Canyon Way Palm Springs, CA 92263 Re: Workmens Compensation Insurance Dear Ms. Sanders: With regard to Workmens Compensation Insurance coverage I do not have employees and, therefore, do not have such insurance. K4 J hi# t R. rueblood rch 121 S. Palm Canyon Drlve, Suite 204 Palm Springs, Callfomia 92262 (760)416-1685