HomeMy Public PortalAboutC-23-037 - CARL D ANDERSON- 55TH ANNIV. GALA- Photography SPACity of Carson
Community Services Department
Service Provider Application
On behalf of the City of Carson, I would like to thank you for taking the time to explore business
opportunities with the City by applying to provide services for an event at a City facility. As part
of our application process, you must complete, sign, and return the following forms. Submission
of these forms does not guarantee that you will be provided the business opportunity you seek.
Your prompt assistance in submitting the requested documentation to the City staff member listed
below will be appreciated and will help expedite the application process. Please send your
completed application and attachments directly to the following address:
City of Carson
Attn: Bobby Grove
801 E. Carson Street, Carson, CA 90745
Email: bgrove@carsonca.gov
Should you have any questions, please feel free to contact the staff member listed below .
Truly,
Bobby Grove
Community Services Superintendent
PAAR AD eee
Before submitting your application packet make sure each of the below
indicated items have been attached or completed.
_w__ Service Provider Application Agreement
__t—__ Invoice for Future Event Date!
__N/A | Business License (if applicable)
_ wv __ Proof of Insurance/Certificate of Insurance
Waiver, Release, Hold Harmless, Agreement Not to
Sue, Indemnification, and Photo Release
~~ Current Copy of W-9 Form (if not on file already)
* The date of the Event shall be listed on the Invoice for Future Event Date (IFED). if the Service Provider Application is
approved, then the IFED will be processed as an invoice for services rendered for the Event. No payment will be made until
the conclusion of the Event, at earliest.
532227.5 CFN
uo
[Enter Date]
[Enter Company Name]
[Enter Company Address]
[Enter City, State ZIP]
Insurance Requirements
Dear [Enter Provider’s Name]:
Please be advised pursuant to your desire to work with the City of Carson, you are required to
submit the following:
¥ Compliant Certificates of Liability Insurance (to be maintained for the duration of services
against claims which may arise from or in connection with the services), evidencing the
coverage(s) as indicated below.
Certificates of insurance, as well as additional insured and waiver of subrogation
endorsements in favor of the City, must be submitted in their entirety before any services
are provided or the event takes place. Failure to submit such required forms shall be cause
for City of Carson to reject or terminate any service provider application agreement.
The City of Carson reserves the right to modify these requirements based on the nature of the
risk, prior events, insurance coverage, or other special requirements.
MINIMUM SCOPE AND LIMIT OF INSURANCE
General Liability Insurance: Coverage shall be at least as broad as Insurance Services Form CG
00 01 covering CGL on an “occurrence” basis, including property damage, bodily injury and
personal & advertising injury with limits no less than $1,000,000 per occurrence and $2,000,000
aggregale.
Additional Insured Status
The City of Carson, and its elected and appointed officials, employees, volunteers and agents, are
to be covered as additional insureds with respect to liability arising out of their work or operations
performed at or on behalf of the City-sponsored event including materials, parts, or equipment
furnished in connection with the event.
§32227.5 CFN
City of Carson
Community Services Department
Service Provider Application Agreement
Check one (staff use):
_X Carson Event Center__ Human Services Recreation _ Transportation
Event:Gala_ Ball Event Location: Carson Event Center Event Date:February 25, 2023
Name of Service Provider : CDA PHOTOGRAPHY /Triple T Photography
Business Form/Entity Type (if individual, sole proprietorship, corporation, or limited liability
company, specify here): Individual
Business Form/Entity Type (if general partnership, limited partnership, limited liability partnership,
or other, specify here):
Business Entity State of Incorporation (if applicable):
Type of Service: Photography and video services
Contact Person: Carl Anderson Phone #; (310) 293-2647
Emer. Contact: Rendell Peart Phone #: ( 962) 833-1097
Billing Address: 501 S Taper Ave
Number Street
Compton Ca 90220
City State ZIP
Proof of Insurance (circle one)
If no, would you like to purchase special event insurance through the City (circle one)? Yes No
Special Instructions / Notes:
532227.5 CFN
If Service Provider wishes to request any special accommodation needed to facilitate provision of the
services, please identify it here or contact the staff member referenced on page 1 of this application:
Total Service F ee l[éab. 6 0
NOTE: If service provider is unable to provide the services as proposed or requested or the City
of Carson cancels the service for any reason, the associated fees will not be paid.
[remainder of page intentionally left blank]
532227.5 CFN
Further Terms of Service Provider Application Agreement:
The undersigned signatory of Service Provider (Service Provider being the above-referenced person or
entity seeking to provide services at the above-referenced event, including all its officers, agents,
employees and volunteers) hereby represents and warrants that he or she is duly authorized by Service
Provider to execute and deliver this application on behalf of Service Provider, and that by so executing
this application, and in consideration for the City’s review of this application, Service Provider is bound
by these terms.
Service Provider understands and agrees to comply with the City’s “Service Provider Rules &
Regulations,” which are set forth below and incorporated herein by this reference.
Service Provider agrees to indemnify and release City in connection with its proposed services in
accordance with the “Waiver, Release, Hold Harmless, Agreement Not to Sue, Indemnification, and
Photo Release” submitted concurrently herewith.
Service Provider agrees to maintain all required insurance coverages and comply with all associated
insurance requirements as set forth on the above “Insurance Requirements” page, which is incorporated
herein by reference. Service Provider agrees that all required policies shall contain, or be endorsed to
contain, an agreement by Service Provider to waive all rights of subrogation and contribution against
the City, its elected or appointed officers, officials, employees and agents, for all losses and liabilities
paid under the terms of any policy which arise from the activities or operations of, or the services
performed by, Service Provider, regardless of any prior, concurrent, or subsequent non-active
negligence by the City.
In the event there is more than one person or entity named in this Service Provider Application
Agreement as the Service Provider, then all obligations, liabilities, covenants and conditions hereunder
shall be joint and several.
This Service Provider Application Agreement, unless and until accepted, approved, and executed by
the City Manager or designee, is only an application for provision of services to City, and does not
constitute an approval or authorization for Service Provider to perform or provide any service to City.
Neither Service Provider nor any of its agents or employees shall be deemed agents or employees of
the City, nor a member of a joint enterprise with the City. Neither Service Provider nor any of its agents
or employees shall at any time or in any manner represent that Service Provider or any of its agents or
employees are agents or employees of City, or that it is a member of a joint enterprise with City. Subject
to the requirements of this Service Provider Application Agreement, neither the City nor any of its
employees shall have any control over the manner, mode or means by which Service Provider, its
agents or employees, perform the services set forth herein.
In the event that part of this Agreement is 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
532227.5 CFN
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.
Service Provider acknowledges that the City of Carson’s consideration of Service Provider’s
application to provide the above-referenced services is on the express condition that Service Provider
represents and warrants that it is and will be in compliance with all applicable restrictions on the use
of intellectual property, including copyright laws, in connection with the services proposed to be
provided. Service Provider shall indemnify, defend, and hold harmless the City against any penalties,
claims, or liabilities arising from or in connection with Service Provider’s noncompliance with same.
The undersigned, on behalf of Service Provider, agrees that Service Provider seeks and is willing to
provide the above-referenced service(s) on the date and time of the above-referenced event.
This Service Provider Application Agreement has been executed on the dates written below.
APPLICATION SUBMISSION (wet signature required; no electronic signatures):
SERVICE PROVIDER: (o. orl AnderS0 1
oo ’ a <<,
-
Signature of Service Provider’s Authorized Representative Date
Len t A A nder s orr
Printed Name of Service Provider’s Authorized Representative
(space below this line for City use only)
APPLICATION APPROVAL:
CITY OF CARSON
Signature of City Manager or Designee Date
532227.5 CFN
February 13, 2023
Service Provider Rules & Regulations
1. SERVICE PROVIDER APPLICATION: Upon acceptance, approval, and execution of a service
provider application by the City of Carson (“City”), these rules and provisions shall become
binding and a part of the Service Provider Application Agreement between the applicant (being
the entity providing a service to City as specified in the service provider application), including its
officers, employees, agents and volunteers (“Provider”), on the one hand, and the City, on the other
hand. Any additions and amendments thereto that may be established or put into effect by the City,
and provided in writing to the Provider, shall also become binding and a part of the Service
Provider Application Agreement.
2. PAYMENT/CANCELLATION: If the Provider is unable to perform or cannot provide the
services as requested, or the City cancels the service for any reason, the associated fees for service
will not be paid.
3. CANCELLATION: No refunds will be given unless the subject event is cancelled by the City’s
Community Services Department. Applications may be denied or events cancelled in favor of City
programs.
4. PROPERTY LOSS OR DAMAGES: The City is not responsible for any damage to, loss or theft
of the Provider’s property, or that of Provider’s agents, employees or invitees.
5. CHARACTER OF ENTERTAINMENT: The Provider shall observe, obey and comply with all
applicable local, state and federal laws, and all applicable policies, rules, regulations and terms
and conditions governing use of City facilities. The Provider will forfeit all rents or other fees
paid if ejected from premises for violations of same. Ejection shall not release Provider from any
obligations for the payment of rents or other fees not yet paid under such permit or additionally
incurred. The policy of the City is to serve the public in the best possible manner. The Provider
shall at all times cooperate to this end.
The policies, rules, regulations and conditions governing use of City facilities are subject to change
without notice to Provider unless the change affects a permit already issued to Provider.
Provider shall be solely responsible for the orderly conduct of all persons using the premises by
its invitation, either expressed or implied, during all times covered by the Service Provider
Application Agreement. The City reserves the right to eject or cause to be ejected from the
premises any person or persons due to unlawful conduct.
6. RESPONSIBILITY: The Provider shall provide all material, equipment, and personnel
necessary for provision of the service described in this agreement.
7. MOVE-IN/MOVE-OUT: Move-in to the event area will be set for each venue. Unless otherwise
stated, Provider will be required to keep its area fully set up and manned until the event is officially
over. Please note that these times are subject to change.
8. SAFETY: Standing on chairs, tables or other rental equipment is prohibited. This equipment is
not engineered to support your weight. The City of Carson, its employees, agents, or officers will
not be responsible for injuries or falls caused by the improper use of furniture. Please assist in our
efforts to provide a SAFE WORKING ENVIRONMENT.
532227.5 CFN
9. VOLUME/LIGHT CONTROL: The City reserves the right to regulate the volume or intensity
of any and all noise or light generating mechanisms (including, but not limited to, loudspeakers,
radios, television sets, musical instruments, entertainers, or blinking or flashing lights) in the
reasonable judgment of the City.
10. FLAMMABLE MATERIALS — All decorations, props and electrical equipment must be
fireproof or of fire retardant materials, must meet City requirements and are subject to removal.
Candles and other open flame devices will not be permitted except as authorized on this agreement;
subject to Fire Department regulations.
11. COPYRIGHT INFORMATION: Provider is responsible for licensing fees as required by law.
Provider may be subject to legal action for the use, display or sale of any item using any
copyrighted and/or trademarked name or logo which has not been specifically authorized under
license from the trademark holder.
12. PERMITS AND LICENSE: Provider shall procure at its own cost and expense all the required
licenses and permits applicable to Provider’s use or activity .
13. OBLIGATION FOR CLEANLINESS: Provider agrees that the facility and any other
surrounding City property (including parking lots) used by the Provider must be left in a clean and
orderly condition (equal to or better than the condition existing prior to the event). If additional
maintenance is required, other than the normal cleaning process, the Provider will be charged
additional fees based on the cost of such maintenance.
14. DISPUTES: All points not covered by the Service Provider Rules & Regulations are subject
to the decision of the appropriate City representative.
15. FLOOR MANAGEMENT: The City will appoint a Floor Manager who is authorized to
enforce these rules and regulations.
16. SPACE ASSIGNMENT: Event space is assigned to providers at the sole discretion of the City.
Concerns regarding competitive or specific types of providers should be communicated to the City
at the time of application.
17. RULE CHANGES: The City reserves the right to make reasonable changes to the foregoing
rules, event hours and move-in/move-out arrangements at any time without notice to Provider,
unless the change affects a permit already issued to Provider.
532227.5 CFN
10
Waiver, Release, Hold Harmless, Agreement Not to Sue, Indemnification, and Photo Release
I, ; (“individual”) fon behalf of
(“Service Provider”), and as a bona fide agent of Service Provider
duly authorized to execute this Waiver, Release, Hold Harmless, Agreement Not to Sue and Indemnification
agreement (“Agreement”) on behalf of Service Provider] (individual and Service Provider hereinafter
collectively referred to as “Signatory,” and the term “Signatory” includes Service Provider’s officers, officials,
employees, agents and volunteers), seek acceptance by the City of Carson of an application to provide services
in/at (“Event”) on (“Date”).
Signatory understands that accidents and injuries can arise out of the Event; knowing the risks, nevertheless, and
in consideration of the acceptance of an application to provide a service at the Event on the Date, Signatory
hereby waives, releases and discharges any and all claims for damages for death, personal injury, or property
damage which Signatory may have, or which hereafter accrue to Signatory, against the City of Carson, its elected
and appointed officers, officials, employees, agents and volunteers (collectively “City”), and from and against
any and all liability arising out of or connected in any way with Signatory’s participation in or presence at the
Event, even though that liability may arise out of negligence or carelessness on the part of City. It is farther
understood and agreed that this Agreement is to be binding on Signatory’s heirs and assigns.
Signatory hereby grants City the right to photograph or video-record Signatory during or in connection with the
Event, and to use Signatory’s photographed or video-recorded likeness, and any image, silhouette, or
reproduction of the voice or appearance of Signatory taken during or in connection with the Event (“Likeness”),
for any purpose, including publicity and promotion of City and its events, and creation or production of materials
in any form for such purpose, with no claim of entitlement to any license fee or royalty of any kind from City.
Signatory hereby waives any right to the intellectual property of Signatory’s Likeness. The rights granted by
Signatory hereunder shall not expire.
Signatory further agrees to indemnify, defend and hold harmless City from and against any and all claims,
liabilities, losses, damages, expenses, and costs (including without limitation costs and fees of litigation) of every
nature (including, but not limited to, property damage, bodily injury, or death), whether imposed by law or
otherwise, sustained or alleged to be sustained by any person or entity (whether they be members of the public
visiting the Event, employees of the City, other service providers at the Event, or otherwise), occurring at, arising
from, or connected with Signatory’s preparation or performance of services at the Event, Signatory’s actions,
inactions, or use of facilities at the Event, or any equipment, machinery or items displayed or used by the
Signatory at or for the Event, except for such claim, liability, loss, damage, expense, or cost which was caused
by the sole negligence or willful misconduct of the City.
By signing below, I acknowledge and represent that I have read and understand the above, and that I
voluntarily agree to it me
Signed:
NAME: Lo al Anderset
ORGANIZATION:
Date: / —3 O A 3
532227.5 CFN
@MRCDAPHOTOS
BILL TO
Msanchez@carsonca.gov
3105477409
Item
Event Coverage 1
Candid photography coverage and group shots throughout the event for 6
hours 6pm-12am in a online album that can be downloaded to any device.
Additional Photographer
Additional photographer for 6 hours.
Event Videography
Candid video coverage throughout the event with multiple angles edited into
a 60-90 minute highlight reel for 6 hours of coverage from 6pm-12am in a
online album that can be downloaded to any device.
Payment Instruction
Payment can be made via Zelle or Google Pay using 310-293-2647 or
Cashapp $mredai
City of Carson's Gala Ball. February 25, 2023
6-12am
Invoice #
Date
Due date
Quantity
1
1
6
Subtotal
Amount Due
Invoice
CDA PHOTOGRAPHY
310-293-2647
Cdaphotos@hotmail.com
159
Feb 2, 2023
Feb 9, 2023
Price Amount
$475.00 $475.00
$250.00 $250.00
$150.00 $900.00
$1,625.00
$1,625.00
$1,625.00
om W-9
(Rev. October 2018)
Department of the Treasury InternalRevenue Service
Carl D Anderson
2 Business name/disregarded entity name, if different from above
Request for Taxpayer
Identification Number and Certification
» Go to www.irs.gov/FormW49 for instructions and the latest information.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
Give Form to the
requester. Do not
send to the IRS.
following seven boxes.
@] Individual/sole proprietor or OJ C Corporation
single-member LLC
Print
or
type.
[_] Other (see instructions) »
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
C] S Corporation
C Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) >
Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check
LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
C Partnership O Trust/estate
Exempt payee code (if any)
Exemption from FATCA reporting
code (if any) (Applies to accounts maintained outside the U.S.)
5 Address (number, street, and apt. or suite no.) See instructions.
501 S Taper Ave
See
Specific
Instructions
on
page
3.
Requester’s name and address (optional)
6 City, state, and ZIP code
Compton CA 90220 7 List account number(s) here (optional)
Taxpayer identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part |, later. For other 51518) -/4 11) -11 19 17 |4
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
| Social security number
or
[ Employer identification number |
aaa Certification
Under penalties of perjury, | certify that:
1. The number shown on this form is my correct taxpayer identification number (or | am waiting for a number to be issued to me); and
2. | am not subject to backup withholding because: (a) | am exempt from backup withholding, or (b) | have not been notified by the Internal Revenue
Service (IRS) that | am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that | am
no longer subject to backup withholding; and
3. lama U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that | am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part Il, later.
Sign Signature of
Here U.S. person LOSE
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www. irs.gov/FormW49.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
* Form 1099-INT (interest earned or paid)
2-8-2023
+ Form 1099-DIV (dividends, including those from stocks or mutual
funds)
+ Form 1099-MiSC (various types of income, prizes, awards, or gross
proceeds)
« Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
+ Form 1099-S (proceeds from real estate transactions)
« Form 1099-K (merchant card and third party network transactions)
* Form 1098 (home morigage interest), 1098-E (student loaninterest),
1098-T (tuition)
+ Form 1099-C (canceled debt)
+ Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withhoiding,
later.
Date
Cat. No. 10231X
Phone# 310-293-2647
Form W-9 (Rev. 10-2018)
Emait: Cdaphotos@hotmail.com