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17-001 Madhu Marathe 4 i NO. %)A " 132. FY 17-18 AGREEMENT BETWEEN THE CITY OF CUPERTINO AND MADHU MARATHE FOR CONTRACT SERVICES THIS AGREEMENT,for reference dated WEDNESDAY,APRIL 26,2017, is by and between CITY OF CUPERTINO, a municipal corporation(hereinafter referred to as "City"),and MADHU MARATHE,a CALIFORNIA SOLE PROPRIETORSHIP,whose address is (hereinafter referred to as"Consultant"),and is made with reference to the following: A. SCOPE OF SERVICES. Contractor shall provide or furnish the following specified services and/or materials:YOUTH CLASSES.Services are further described in Exhibit"A". B. TERM. The term of this Agreement shall commence on 7/1/2017,and shall terminate on 6/30/2018,unless terminated earlier as set forth herein. C. COMPENSATION. Consultant shall be compensated for services performed pursuant to this Agreement in the amount set forth below and as described in Exhibit"A"which is attached hereto and incorporated herein by this reference.Compensation shall consist of the following:70%or resident fee for each participant,based on the final roster,minus a$10 administrative fee per participant.The total compensation to the Consultant shall not exceed$4,999. D. EXHIBITS. The following attached exhibits hereby are made part of this Agreement: �7 EXHIBIT A-Scope of Services EXHIBIT B-Acknowledgement of Mandated Reporting Requirements, Receipt of Training,and Receipt of Penal Code Statutes.Required for any consultant working with minors. 6� EXHIBIT C-City of Cupertino, Consultant Declaration.Required for any consultant working with minors. GENERAL TERMS AND CONDITIONS 1. HOLD HARMLESS: Consultant shall,to the fullest extent allowed by law,with respect to all services performed in connection with the Agreement, indemnify, defend,and hold harmless the City and its officers,officials, agents, employees and volunteers from and against any and all liability,claims,actions,causes of action or demands whatsoever against any of them,including any injury to or death of any person or damage to property or other liability of any nature,whether physical, emotional, consequential or otherwise,arising out,pertaining to,or related to the performance of this Agreement by Consultant or Consultant's employees,officers,officials,agents or independent contractors. Such costs and expenses shall include reasonable attorneys'fees of counsel of City's choice,expert fees and all other costs and fees of litigation. In addition to the obligations set forth above,Consultant shall indemnify,defend,and hold the City,its elected and appointed officers,employees,and volunteers,harmless from and against any Claim in which a violation of intellectual property rights, including but not limited to copyright or patent rights, is alleged that arises out of,pertains to,or relates to Consultant's negligence,recklessness or willful misconduct under this Agreement. Such costs and expenses shall include reasonable attorneys'fees of counsel of City's choice,expert fees and all other costs and fees of litigation. 2. SUBCONTRACTING: Consultant has been retained due to their unique skills and Consultant may not substitute another,assign or transfer any rights or obligations under this Agreement. Unless prior written consent FY 2017/2018 Short Form Agreement less than$5,000 1 Z 000'S$uega ssaj auauiaaxSy u1103;zogs 8I0Z/LIOZ m •eiuzolilpO Io a4elS au;Aq pazinbaz sp a2ezaAoa X.io4n4e}S:uoliesua uto',szaxzoM •i :a2ezanoa aaueznsui 2uiMollol ago uie;uieui Ileus 4ue4lnsuoD :39V2IHAOJ •V •sajuxjgjaa az)uuznsui agp q4!m pa14iuugns aq Ileus paznsui Ieuoi4ippe se fq!D ago Suiwuu s}uauuaszopuH •eiuzoj!ILD 3o ajujS aq4 ui ssauisnq aaueznsui op o4 pasuaail pup A4iD of alqu4daaau si 4eg4 Xueduuoa aaueznsui ue g;rM 4uauuaaj2V sig4 liq paunbaz aaueznsui }o a2ezanoa a4midozddu Ile 4uauuaaz2V sigl 3o aaueuzzo;zad aq4 2uiznp sauzi4 Ile Ju aazo3 ui uivauiuuu Ilpgs 4uu4insuoJ je144 paaz2u si}I „•za2uuuw/4rJ:uoijua4jV'lieuu pagipaa Xq ouiPadnO;o fqiJ aq4 of ax4ou ua44izM aaupnpe sXup(O£)X;z1g4 apinozd Ilpgs a2ezanoa 2u1pzolle zaznsui aqj'Ioazau4 a4up uoi4ezidxa aq4 azo;aq paanpaz 02ezaAoD zo palaaupa aq a4mi3i}zaa siu}Aq pazanoa aauuznsui anoge ago jo Xue pinogS„ :4uauuawjs 2uiMoiio3 aq}Xllunuuasgns uiquoa osle llegs'uou4uailiuwapui s juvjInsuoD 41uuil 4ou op gaiqM'sa4uai3ijzaa qmS •Molaq sgdpz2ezud aq4 g4jm a:)ueulduuoz)ui a2pzanoa aauuznsui 3o uoiIezidxa 3o sa4pp pue sa4ep an14aal3a'pazanoa suoilezado 3o ssela 14unouup'addj agp 2uiMogs sa4eaijpjaa gjIm A41:)usiuzn;Ileus 4uejInsuoD'juauuaaz2V sigh Io uuzal agp Io juawaauauiuzoa agj azo;ag zo uO -dJNVHfISNI •9 Wuazalaz siu}Aq uiazaq pa;ezodzoaui pue o4azaq pagm1w si gaiqM ,D,}igigxH ui g4zo3 has su quauuazinbaz aqj o4 4uensznd'i?uivaazas qL Io s4lnsaz pup sasodznd 4sal punoz2jaeq Iuuiuziza zo3 s4uizdza$uiI apinozd llegs 4uauuaaz2V sig;zapun pazanoa sienpiAipui Ile jug4 saaz2u 4uPjInsuoJ :NOIIVUV'IJHQ INVIlfISNOJ SZ SISO'IfIJ2IH M V INR H39NI3 S (lw4q•xapui nsppa AO 'JpJ•MMM :S 4Tq •uoi;uanazd 2Y lozjuoD aseasiQ zo3 za4uaJ aq4 4e algelienu am saaznosaz guiuiezZ) •siseq AlzuaA p uo zoje4siuiuupe jup4Insuoa gaua o4 g4oq zo'sluiza;euu lumpuanpa 12uiuiezi zallo llegs 4up4InsuoD •4updoilzed u 2uisinzadns azo;aq'uoszad ui.To auiluo zau;ia aauo 4seal 4e uoi4e:)npa Xin[ui peaq pue uoissmuoa aq4 alaldwoa Xllnjssaaans o4 szo4ez4siuiuupu puu sagapoa Ile azinbaz Ilegs 4uujInsuoJ •Z puu'S£ZfZI uoPaaS aPOD fAa3uS pue g}IuaH Xq pazinbaz se ouzo;aq4 suzmaz pue sudis 4uedimpud gaga aznsua Ileus Iuu4lnsuoD •I-D 4igigxH se pagaulle se uuzo;aqj ui aq Xeuu gaiqM';sags uoijuuuojuu uoissnauoa u g4lm luediai4zed gaua apinozd llugs 4uellnsuoO •I ' (lw4q•xapui nspua Ao •JpJ•MMAm :s 4}g•uoi4uanazd ag Ioz;uoD asuasiQ zol zaluaD ago;e alquliune aze saz)znosag) •sloao4ozd Aeld o4 uzn}az pue'Meld uuozl Ienouuaz'uoi4enlena uoissnauoa 2uipnlaui-bas ja'S£ZtZI uoi4aaS apoO A4ajuS pue tpluaH ui pauipno asogp 2uupnlaui'ZOOZgV Io s4uauuazinbaz Ile g}iM Xlduuoa llegs 4ue4InsuoO :I0ao10zd uoissnauOD •g •aauaza;az siT Xq uiazaq pa4uzodzoaui pue olazag pagmpu su gaiqM..S„}igigxH ui gpzo3;as se pue£•tLili-:v9III apoO leuad eiuzolileJ Io quauuaunbaz a1441441M Xlduuoa Ileus juejInsuoJ pue'2ui4uizdza2ui j pue 2ui4zodaH fzo;upueW •V :ONINIVIU QNV S'IOJO.LOHd NOISSfIJNOJ QNV S.LN3WgHlf1 dH ONI.LHOdgH QH.LVQNVW JO 1N3W39a31MONXDV •:P •X40 30 4uasu0a ua4lizM zoizd 4nog4!m '}oazag4 suoiPod Xue zo juawaaz2V sill pv i4uoagns zo'zajsupz}'u2issu;ou Anil 4uullnsuoJ :LNaWNOISSV •£ quauuaaz2V sigh 3o aoueuzzoyad agp ui pasn aq Ileus}uauuaaz2V sigh pa4sil aze sauueu asogm aldoad asogp Aluo'pauie;go si,,�iO uuozl ii. Liabili :Commercial general liability coverage,including sexual abuse and molestation coverage,in the following minimum limits: 1. Bodily Injury: $500,000 each occurrence $1,000,000 aggregate-all other 2. Property Damage: $100,000 each occurrence $250,000 aggregate If submitted,combined single limit policy with aggregate limits in the amounts of$1,000,000 will be considered equivalent to the required minimum limits shown above. iii. Automotive:Proof of automobile insurance required at the California statutory minimums. 7. SUBROGATION WAIVER: Consultant agrees that in the event of loss due to any of the perils for which he/she has agreed to provide comprehensive general and automotive liability insurance, Consultant shall look solely to his/her insurance for recovery. Consultant hereby grants to City,on behalf of any insurer providing comprehensive general and automotive liability insurance to either Consultant or City with respect to the services of Consultant herein,a waiver of any right to subrogation which any such insurer of said Consultant may acquire against City by virtue of the payment of any loss under such insurance. 8. TERMINATION OF AGREEMENT: In the event Consultant fails or refuses to perform any of the provisions hereof at the time and in the manner required hereunder,Consultant shall be deemed in default in the performance of this Agreement. If Consultant fails to cure the default within the time specified and according to the requirements set forth in City s written notice of default,and in addition to any other remedy available to the City by law,the City Manager may terminate the Agreement by giving Consultant written notice thereof,which shall be effective immediately.The City Manager shall also have the option,at its sole discretion and without cause,of terminating this Agreement by giving seven(7)calendar days'prior written notice to Consultant as provided herein. Upon receipt of any notice of termination,Consultant shall immediately discontinue performance. 9. NON-DISCRIMINATION: Contractor shall not discriminate against a job applicant,employee,City employee, or a citizen on the basis of race,color,national origin, ancestry,religion,gender,sexual orientation or other protected class of such person. 10. INTEREST OF CONSULTANT: It is understood and agreed that this Agreement is not a contract of employment and,at all times, Consultant shall be deemed to be an independent Consultant and Consultant is not authorized to bind the City to any contracts or other obligations in executing this Agreement. Contractor certifies that no one who has or will have any financial interest under this Agreement is an officer or employee of City. City shall have no right of control as to the manner Consultant performs the services to be performed. Nevertheless,City may,at any time,observe the manner in which such services are being performed by the Consultant.Consultant shall comply with all applicable Federal,State,and local laws and ordinances including,but not limited to,unemployment insurance benefits,FICA laws,and the City business license ordinance. 11. PERMITS AND LICENSES: FY 2017/2018 Short Form Agreement less than$5,000 3 000'S$ueul ssal luautaa SV uizo3 IJOgS SIOZILIOZlu •luauilzudaQ aainzaS Aliunwu.ToD 28 uoiluazaaH?IO.LVNICIX00D NOLLVRUDd2I ,VlfaYq flglNVW:aq hues kUD zo3 anileluasazdaz pup zoleuipzoo:)4uatuaaz2V au I. ?I IVNIGHOOJ 1N3Nid3?IOV 'SI •G£•£zalduu:)apoD IudiaiunW ouilzadnJ ui into}las se aaueuipz0 a2eM wnuliuiW sAli:)aur aline Aldwoa zaulzn}pue asuaai7 ssauisng ouilzadnJ e uielgo Ileus zolaezluoD •X110 Xq panssi zo palauua suol4elri2az pup saint'saaueulpzo Ile pup sMel Ipzapa3 zo aluls Ile uliM Xlduloa Ileus lupllnsuoD :SaDNV1'1dW0D •XliD aur 3o luasuoa uappm aur InouliM pamoulne ate puri Xue 3o suoilulzun zo sa2ueua ON :SdONVHJ •£i •IuaulaazBe sial zapun pazinbaz saainzas Ile zo;X40 ruoz3 IuaiuXed leui;saniaaaz zolauzluoD zal3p szuaX(£)aazul;o poizad u zo3 pauieluiuul aq Ileus pup spzoaaz pup sluaulnaop zaulo uzoz3 aluzedas Ida�l aq ileus'sluaulnaop 2uilzoddns Aline zaula2o4'spzoaaz uanS •luauzaaz$V sial of palelaz sapiAgm pup s�?uipaaaozd'sluaulnaop'ulup'�IzoM Ile 3o uoilaadsui Molle of pue'Xiussaaau se uloz}azaul sldizasuezl ajpul of pup 'aures 1pne pup auiu Lxa of 4u2iz aur XliD san12 pue'saulil zadozd Ile le saau2Isap sli zo Xli:)3o saniluluasazdaz aul of spzoaaz pup s�looq cans of ssaaae aaz3 apinozd lluus zolauzluo:) •algissaaae Xiippaz pup pai3i4uapi Xlzeala aq Ileus pue saldiaupd 2ullunoaae paldaaae XlluzauaS uliM aauppzoaae ui pauieluieul aq lleus spzoaaz urns IIV •saainzas Io uoilunlena up Iiulzad of lielap 4uaiai3lns ui'luauzaazi?V sial zapun saainzas Io aauewio3zad aur of alulaz leul XIiJ Xq pazinbaz uoileulzojui cans zaulo pup sldiaaaz 'sasuadxa'slsoa'sales of laadsaz ilpm spzoaaz aluznaae pup alalduloa uiuluiew Ileus zolapzluoJ •IuaulaaBv sial of luensznd XIiJ aur of pausiuzry Izodaz Xuu Io Xdoa e uiulaz Xeuz zolaezluo� 140 04 paezasaz ate s4u2iz uoileailgnd Ile pup'XI1D Io Xlzadozd aur auloaaq Ileus IuaulaaBV sial Xq pannbaz zo pazinbae elep pup uoi4pulzojui'Izoda21 XuV •luawaaBV sial of luensznd paluaza slzodaN of Iu2T.zXdoa aur Xli:)of aisse of sluaLunaop alpizdozdde alnaaxa lleus pue IuaulaaBV sial Xq pazinbaz IzodaH Xue Iu2izXdoa lou Ileus zolapzluOD •XlD;o Xlzadozd anisnlaxa aur aq lluus'4uawaaz2v sial uliM uoilaauuoa U1.10 of luensznd zolaezluoJ Xq pamdazd aq of pasnea zo pazedazd'paanpozdaz'„IzodaH„se of pazza;az Xlanllaalloa za43euiazau'Iuaulnaop zaulo pup pzoaaz'dual'lanpozd)IzoM'ljezp 'Izodaz Xzana pup uaeg :SaHOJd2I QNV SIHOdMd •ZZ zapunazau saainzas Io aauuuzzo3zad aur uliM uoilaauuoa ui pazmbaz aq Xeuz leul 'asuaai7 ssauisng Al!:)e 'ol paliUzil lou Inq'Suipnlaui sasuaail pup'saluaililzaa'sliulzad aluizdozddu Ile quawaaBV sial}o twal aur 2uiznp uiuluiew pup uiplgo lleus'asuadxa alos zau/siu le'luellnsuoD IN WITNESS,WHEREOF,the parties have caused the Agreement to be executed. MADHU MARATHE CITY OF CUP TIN Q� ,, A Municipal r o tion "/ By: MADHU MARATHE By: MEJIA Title: INSTRUCTOR Title: ftCR ION COORDINATOR Date: Date: 5/g/1--7. RECOMMENDED FOR APPROVAL: By: KIM CALptMr-- Title: RECREATION SUPERVISOR APPROVED AS TO FORM: )�V RANDOLPH STEVENSON HOM CITY ATTORNEY ATTEST: f GRACE SCHMIDT CITY CLERK EXPENDITURE DISTRIBUTION: Account No: 580-62-613-700-702 Amount: $4,999.00 FY 2017/2018 Short Form Agreement less than$5,000 5 g 000'4$ueg;ssaj}uauiaaisy ivaod a iogS SIOZ/LIOZ ki •Sui jnaao fanfui ails to sznoil IiZ uiuliM X4i:)aLp oI palliuigns aq isnuz podag Iuapiaul ail,L, •XIiD aui Aq panoadde w.To;auI ui podag Iuappul ue aialdwoz) pue znoq I unliiM A11J auI X3ilou Ipm iueilnsuo:)auI'Iuedoiped e of 2uiI.InDDo Ainfui ue 3o ivana auI ul •pani.ue seal ueipzunE IeSal 3o Iuaaed e Iiiun ssep xailu saouiui SutstAaadns zo}algisuodsaz am sluuilnsuoD •wLji?oad auI ui Lied Suilul of aoud uuol XIiliquFl to aaAMM sAiZ)auI aialdwoa of paau saaalunloA pue siuudixiaud IIV •Iuawllonza l0 3ooad mods uea ao aalsoi ssup aul uo paisil aju Aaill ssalun uieagoid ay ui lied ale;Iou Xuui siuedoplUd •alnpaqas uoiluazaaz ,(laal.zunb auI ui palsil se sainpamid uoiiezisi$ai of 2uiuiewad souiiap?nE Ile Mollo3 ileqs IuullnsuoJ atU •Iueilnsuoa ails Aq paw iopad Suiaq am saaiAzas dans uapinIi ui aauuuui auI anzasgo ';)Wll Xue Ie'Xeui A4j:)'ssaiaqlaaAaN •pauuo}aad aq oI saatAzas auI suuojiod IuullnsuoD aauuew aui oI su Ioaiuoa 3o IMSIJ ou Doul Ileus fgjD :saaiAaaS INVI ISNOJ to aauuuuoJxad •IuellnsuoD oI luau Aud ao aatlou leuoiltppe Inoul!m Iuawaai2v sial aleuiuual zo/pue ssep aulmiiaed auI laauea Xuw Xi!:)aqi 'ims oI palnpaips si ssup auk azolaq alnpaips auI ui pagguapi SLI ssep zulruilaed e zo3 Xud puu ui lloxua siuediaiVed to aaguinu uznwiuiui pazinbaa auI ueg4 ssai 3I 81 :wnuiixLW J 6 :uinwiuiw 1 :sa:)iAzaS INVITISNOJ zo3 swnwixeW puu utnu miW iuedtapaud algisiIg •aSueqa Xew alnpauas ssep 'sapird gjoq;o Iuawaoi2e lenlnut auI Xg •suoiivaol ssep puu'sawil 'saiup uodn paaBL'aol STOZ ONIHdS HOfIOHH.L ZIOZ 2IdWWfIS paiup alnpaq:)S uoiiea.Da21 aui of aalag :saz)IAJaS INVEHISNOD JO alull puu uoiieaol H.LVW'IV1NHW/QdddS :stuezSoad duimollo3 aill'oi pa4!wil iou ing'ui S1SSd1J H.Lf1OA apinozd Ilio''J NVI-IfISNOJ aqj UaWHO!MRd da OZ SUTAH3S.LNVL1fISNOJ V.LISIHXd EXHIBIT B ACKNOWLEDGEMENT OF MANDATED REPORTING REQUIREMENTS,RECEIPT OF TRAINING,AND RECEIPT OF PENAL CODES STATUTES A mandated reporter is an individual who is obligated by law to report suspected cases of child abuse and neglect. In general, any individual who,in the ordinary course of their employment,has contact with children is a mandated reporter. Mandated reporters include child care workers,teachers and coaches. (California Penal Code 11165.7). If your job duties as an employee or an independent contractor of MADHU MARATHE include contact with children,you are a Mandated Reporter. Prior to commencing employment and as a prerequisite of that employment, California law requires that you sign a statement to the effect that you have knowledge of the provisions of the Mandated Reporter Law,and will comply with those provisions. (California Penal Code 11166.5). The following are the Mandated Reporter responsibilities under California law. You are also being provided with a separate informational document which includes the text of the California Mandated Reporter Law and contact information for Child Abuse and Neglect Reporting for the County of Santa Clara.Please review this information carefully and acknowledge your receipt and understanding where indicated. If you have questions or concerns about this form or your Mandated Reporter responsibilities, please contact the Recreation Supervisor at 408-777-3120. I understand that: • By virtue of my employment or independent contractor status with MADHU MARATHE,and because my employment requires me to have contact with children,I am a Mandated Reporter as defined by California Penal Code 11165.7. • The following situations trigger mandatory reports: a)Physical Abuse(willful harming of a child);b)Sexual abuse including sexual assault,child exploitation,pornography,and trafficking;c)Severe or General Neglect;and d)Extreme Corporal Punishment(resulting in injury). (Cal.Pen.Code 11165 et.seq.) I further understand that I may,but am not required to,report suspected Emotional Abuse. • If I reasonably suspect that a child is being abused,I must immediately make a telephone report. I must follow up with a written report within 36 hours. This report may be made to local law enforcement,or County Sheriff's Department,Probation Department or Child Welfare Agency. (Cal Pen.Code 11166(a)). • I am not required to,but I may,share information about suspected abuse with my supervisor or management or the parents of the alleged victim. • When I make a mandated report,I will be required to give my name. However,my identity will be kept confidential unless I either consent to disclosure or if the disclosure is made pursuant to a court order.Further,agencies investigating the mandated report may disclose my identity to one another. (Cal Pen.Code 11167(d)). FY 2017/2018 Short Form Agreement less than$5,000 7 g 000'S$uega ssal auauiaax$v uiio3 aiogs SIOZ/GIOZ m 2HOlDfI LLSNI :aI4ll ai-uv- vw f1Hclvw :Aq i HH.LV2IVW f lHCIVW ali3 lauuosaad Stu ui ida3l aq ll!m luautaSpalmomp V sial;o Ado:)a 4u-qI puelsiapun I -Alduxoa of alge pue Suillins uie puu aleis sial;o snlel zapoda-g palepueN aui zapun sapiligisuodsaz Sul pueiszapun puu Io ajume uie I uapodall palepueN illegal a uie I lull puelsiapun I •(AIL'I aalaodau palepueW)E-%rT.I-t9iii suopaas apoJ Ieuad eiuzolileJ Io Sdoa a uliM papinozd uaaq a"q I '((a)99III apoJ•uad •IeD)•laodaz of aanlie3 zoI algeil AIlinia aq pinoa I puelszapun i@gpnl I 'uloq jo 10001$ uelp ajouz lou 3o au13 e'lie[XlunoD ui sgluouz xis oI do si snll zopilleuad atU •asnge palaadsns Ixodaz of Suiliu;zo3 algr!l AIIeuimpa pla�l aq uea I pue snsel Suilzodau palepueW g4pA filduioa of Iiu3 04 zouuatuapsim a si li'aalzodau palepurw a sv . (ZGIIt apoD•uad IPD)podaa e Suieuz uaqm AliunLuwi Iuuiuziza pue Iinia aneq I'.zaizodag palupueW e sV . •asnqu pinla palaadsns Algeuoseaj Io podaz palepuew e 2uilew ao3 passeaeu zo lsuie2u paleuiuziaasip 14suie2e paleilulaa'passiuzsip'pauildiasip aq lou Arm I . (S'G9III apoJ•uad lug)•palaadsns Algeuoseaz si aaea aiuml-Io-Ino ui Iaal2au ao asnqu uagm tiaua2e 2uisuaail v o :apoJ suopniiisul pue aaeJlaM aui Io LIE uopaaS 30(a)uoisinipgns of luensand paluioddu lasunOD o 'asnqu plica pa2allu wOo J 2uisiae aPOD suoiln4i4sul pue azejlaM aui jo Z09 uoilaas zapun paleiliui uoilae uu ui ao 2ui4masoad leuiwiza e ui szoinaasoad o uauloue auo of AI!4uapi Xw asolasip Sum spodaz palepueui 2ui4e2ilsanui ao 2uwaaaa slunpinipui pue saiaua2e SuinAollo3 aILL EXHIBIT C CITY OF CUPERTINO CONSULTANT DECLARATION The undersigned does hereby certify that: 1. 1 am a representative of MADHU MARATHE;that I am familiar with the facts herein and am authorized and qualified to execute this declaration. 2. 1 declare that MADHU MARATHE has complied with fingerprinting and criminal background investigation requirements with respect to all Consultant's employees who may have contact with minors in the course of providing services pursuant to the Agreement,and the California Department of Justice has determined that none of those employees has been convicted of a felony,as that term is defined in California Penal Code Section 11105.3. 3. 1 declare that each coach and administrator shall be required to successfully complete concussion and head injury education at least once,either online or in person,before supervising a participant,as required by California Health and Safety Code Section 124235,et seq. 4. On a yearly basis,all participants shall be required to sign and return a concussion and head injury information sheet in compliance with California Health and Safety Code Section 124235, which may be in the form attached as C-1. 5. That a complete and accurate list of Consultant's employees,who may come in contact with minors during the course and scope of the Agreement,are included below. 6. All of the below mentioned employees have tested negative for TB,or X-ray results for TB,and have current documentation on file with Consultant. 7. All of the below mentioned employees have received training and understand their responsibilities under the Mandated Reporter laws of this state and are willing and able to comply. List of all Consultant Employees working for the City of Cupertino (if no Employees, identify"self"): FY 2017/2018 Short Form Agreement less than$5,000 9 OI 000'S$uega ssai}uauiaaziv uuo3 azogS SIOZ/ZIOZ Al i i :aIeQ NO.I.DII2I ISNI :0II11 dH.LVHVW fIHQVW :gig HHLV2IVW f1HQVW -pazzoz)pu-e arul si$uio2aio;DLII jrgj drnfiad jo X41ruad aapun ampap I outlzadn�Io 24D auI W 110m 2uluui2aq oI.ioiad Isll anogL,auI oI pappe aq Illm pue saaAolduza mau Xue jo 2uppm ui oullzadnJ Io SIJ aril AJtlou lUm IuEllnsuoJ ail,I, •8 Contractor/Consultant Affidavit of No Employees State of California County of Santa Clara City of Cupertino I, the undersigned, declare as follows: I am an independent MATH instructor. I wish to enter into a services contract with the City of Cupertino. I am fully aware of the provisions of section 3700 of the California Labor Code, which requires every employer to provide Workers'Compensation coverage for employees in accordance with the provisions of that Code. I am also aware that I must provide proof of workers' compensation insurance to the City of Cupertino for any and all employees I may have, pursuant to Section 12 of the City of Cupertino's contract. I hereby certify that I do not have any employees nor will I have any employees working for me or my business during the term of any service contract with the City of Cupertino. I am not required to have Workers' Compensation insurance. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on this � day of r ,2017, atCG.P�a , California. PRINT NAME SIGNATURE / AC W? CERTIFICATE OF LIABILITY INSURANCE D07/27/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT TINA LEDGER MIKE MYERS,AGENT LIC. #OG58440 NAME: 4855 ATHERTON AVE#150 PHONE NExt:408-550-7868 No: Statefarm E-MAIL SAN JOSE, CA 95130-1026 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:State Farm Fire and Casualty Company 25143 INSURED MADH URAN I MARATH E INSURER B: INSURER D: 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 INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADD 8R POLICY NUMBER MM POLICY DD/YYYY MM/DDPOLICY EXP LTR /YYYY LIMITS X COMMERCIAL GENERAL LIABILITY 97-CF-P283-1 G 09/24/2016 09/24/2018 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE F�l OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: LIAB AGGREGATE $ 2,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION CERTIFICATE HOLDER: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Cupertino, It's City Council, Boards and THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Commission, Officers, Employees,and Volunteers ACCORDANCE WITH THE POLICY PROVISIONS. 10300 Torre Ave Cupertino, CA 95014 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 1001486 132849.9 02-04-2014 Important Insurance Information `A' 07/10/2017 W wheels ����� AJAY MARATHE Vehicle Number: Welcome to the Wheels Insurance Card Program. Attached is your renewal Insurance Identification Card. This Insurance Card should be kept in your vehicle at all times. The card includes important insurance information you will need in the event of an accident; or to prove insurance coverage to a law enforcement officer. Failure to produce proof of insurance could lead to costly fines and/or more severe penalties. In the event of an accident, 1) Get the name and addresses of all involved drivers, passengers and witnesses. 2) Obtain the name of the Insurance Company and Insurance Policy Number for each involved vehicle. ;) Follow your company's policy for reporting accidents. If you have questions about your insurance card, please call 844-264-9323. California FLEET COMMERCIAL POLICY Fleet Auto Insurance Identification Card Company Number:NAIC 25682 Policy Number Effective Date Expiration Date company:Travelers Indemnity Co.of CT 810 51507644 07/01/2017 07/01/2018 Year Make/Model The policy meets the requirements of Section 16056 or Section 16500.5 of the California Vehicle Code and is a commercial or fleet policy. SEE IMPORTANT NOTICE ON REVERSE SIDE Agency/Company Issuing Card Insured