Loading...
Insurance - Kasprzyk, Theresa R. - 2012-07-20r '0 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDNYYY) 0,/23/2012 CATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ILr� U"A E DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES lS 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(les) 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 endomement(s). PRODUCER STATE FARM INSURANCE 8130 McFADDEN AVE SUITE 205 WESTMINSTER, CA 92683 aINSURERS NAME, PHONE .714 -8 5 -3 22 No: EMAIL ADDRESS: AFFORDING COVERAGE NAIC q INSURER A:State Farm General Insurance Company 25151 INSURED THERESA R KASPRZYK DBA TERRASTAR MEDIA 13861 JASPERSON WAY WESTMINSTER, CA 92683 INSURERS: 07123/2012 INSURER C: EACH OCCURRENCE INSURER D: INSURER E: A TO RENTED PREMISES Ea occurrence INSURER F: MED EXP (Anyone person) 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 REOUIREMENT, 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 LTR TYPE OF INSURANCE DDL 5 BR POUCY NUMBER POLICY EFF MMIDOIYYYY POUCY EXP MMIDD/YY1'Y LIMITS GENERAL UABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx—I OCCUR ❑ 92- CF- N648 -5 07123/2012 07123/2013 EACH OCCURRENCE $ 1,000,000 A TO RENTED PREMISES Ea occurrence a MED EXP (Anyone person) a PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE S 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: X POLICY PRO- Z LOC PRODUCTS - COMP/OP AGG S 2,000,000 S AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDALJTOS AUTOS ❑ XXXXXX OM81NE0 INGL LIMIT Ea accident a BODILY INJURY (Per person) a BODILY INJURY (Per accident) S lrIPE demDAMAGE S S UMBRELLA LIAB EXCESS UAB OCCUR CLAIMS -MADE El XXXXXX EACH OCCURRENCE S AGGREGATE S DIED I I RETENTIONS S WORKERS COMPENSATION AND EMPLOYERS' UABILFTY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICEIMEMBER EXCLUDED7 F (Mandatory In NHI tf yes, do under NIA XXXXXX VC STATU- OTH- T M ' E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE S E.L, DISEASE - POLICY LIMIT a ri D� XXXXXX DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) WEB DESIGN AND BUSINESS DEVELOPEMENT 13861 JASPERSON WAY WESTMINSTER, CA 92683 CERT ADDITIONAL INSURED: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN COSTA MESA SANITARY DISTRICT ACCORDANCE WITH THE POLICY PROVISIONS. 628 W 19TH STREET COSTA MESA, CA 92627 AUTHO EPRESENTA 198812010 ACID CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACOR 1001486 132849.7 03 -01 -2012 IN State Farm® State Farm Mutual Automobile Insurance Company 900 Old River Road Bakersfield CA 93311 -9501 AT2 4 M -1121 A 008808. 0008 KASPRZYK, THERESA 8 LEONARD, THOMAS 13861 JASPERSON WAY WESTMINSTER CA- 92683 -4012 0 aco �s AUTO RENEWAL ❑ POLICY:- NUMBER `;0685582 A08 -75D ,,, JUL 08 2012 to JAN 08 2013 DATE DUE PLEASE$PAY!' iiS AMOUNT JUL <08 2012: $309.35 Yourpremw.m is based on the following.... ,Itnot,correct,,contact your agent. 2005 SUBARU FORESTER VIN JF1 SG63625H713682 cia$w __�663HGV Superior Driver Rate Level {See descriptiori on back). . Driven over 7,500 miles annually. (National average is 12,000 miles annually.) A principal driver has between 34 -48 years of driving experience and there are no unmarried drivers with less than 9 years experience assigned to this car. As of JUL 08 2012 our =records show the rated driver of this vehicle will have 37 years driving experience. Pleasure use or commuting to and from work or school. Coverages and Limits Premium: A Liability Bodily.injury 251000/50,000:. . Property Damage -25,000 - 129. 31 C Medical Payments .5,000 16.24 D 100 Deductible Comprehensive. 29.6; G 250 Deductible Collision 115.31. U Uninsured Motor Vehicle Bodily Injury 25,,000/50,000 15.51 U1 Uninsured Motor Vehicle Property Damage 1 .2, S. Death Indemnity 1 . 9; Your premium has already been` adjusted by the following: ` Premium Reductions Multiple Line Multicar - Vehicle Safety - Driving SafetyRecord ` California Good. Driver. Loyalty 62. 9! 73.1. 8.34 293. 8! 77 . 3: 67.4. The premium on the expiring policy term was based on this vehicle having been. driven. over:7500,miles, per year. The premium on the renewal policy term is based on estimated mileage of over 7500 in the next year` The claim experience on your make and model of vehicle has resulted in a reduction to your vehicle rating group for collision coverage. The "cl 'aim experience on your make and model 'of vehicle has resulted in an increase to your I�abiiity rating group for` bodil Y ` inju rY' and/or property "p dama 9 e`:covera es­ Please see the premium adjustment message 6n4he back of this ricticel for an_explanation; --- u'@ KV1r �tENT-€' AYidtE1�TOPfil�1 ':�'Y��rrray =z"�e one= cfiS'Eat�Fa'rm�`�`atterr" fete` p�' yi�zrt- pE-ati-s:whrch�cliviirfe� our- pi�s�it_ premium into two separate payments. You may pay one half of the amountdue, $154:67, plus a handling charge of,$ma T 6e amount due on "JUL 08'2012 will be $156.67. The remaining half will be due on SEP 06 2012. We'll send you a reminder notice. 79 7493 5661 See reverse side for important information Agent MARK- :REESE,CLU Please keep :thispart for your-record. Telephone (714)895 -3022 Prepared JUN 042012 POLICY NUMBER 068 5582- A08.75D YR 2005 MAKE SUBARU JUL082012 TOOTIJAN082013 MODEL FORESTER VIN JF1SG63625H713682 AGENT MARK REESE PHONE 141895 -3022 NAIC 25178 1121.790 COVERAG PR VIDED BY THE POLICY MEETS THE MINIMUM LIABILITY OMITS PRESCRIBED BY LAW COVERAGES A C D105 G250 U Ui S SEE REVERSE SIDE FOR AN EXPLANATION. AIR:= MV POST OFFICE BOX 238 SANTA ANA, CA 92702-0238 Recorded in.Official Records, Orange County Tom 02 Clerk- Recorder 11mil l 111 buillijusul 20106238823 23.00 08/0512010 11:49:00 92 97 F01 23.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 FICTITIOUS BUSINESS NAME STATEMENT THE FOLLOWING PERSON(S) IS {ARE} DOING 13US.I,NES'S,AS: 1 ( Fictitious Business Name(s) TERRASTAR MEDIA optional) Business Phone No. 1AI [:] New Statement Re I file =list previo"us'No. 20056041694 Change Street Address, City & State of Principal place of Business city State Zip Code County 2.1 (Do not use P.O. box or P.M. B.) 13861 JASPERSON WAY WESTMINSTER. CA 92683 ORANGE Full name of Registered Owner (if Corporation, enter corporation name) If Corporation LLC 3, , THERESA ROSE KASPRZYK State of Incorporation or organization Res. / Corp. Address (Do NOT use a P.O. Box or P.M.B) city State Zip Code 13861 JASPERSON WAY WESTMINSTER CA 92683 (CHECK ONE ONLY) This businesses conducted by: F] a trust Fla state or local registereddomestic partnership 4, F—X] an individual a general partnership a limited partnership an unincorporated association other than a partnership F] y Partnership co- partners a husband and wife a joint venture Limited Liability Co, F] a corpom a Limited Liability El !0 D 1. 7 Have you started doing business yet? Notice: This Fictitious Business Name Statement expires five years from the date it was filed in the Office of the County Clerk-Recorder, The statement expires 40 days after any change in the facts is made other than F-1 Yes Insert Date: a change in the residences address of the registered owner. A new Fictitious Business Name Statement , must be filed before eithe r expiration, When ceasing to transact business under an active Fictitious Business Name Statement, Abandonment shall be filed. The filing of this statement does not of itself 5. No authorize the use in this state of a Fictitious Business Name in violation of the. rights of another under federal, state or common law (see section 14411 et sei:I- Business and Professions Code), If the registered owner is NOT a corporation, sign below: If the registered owner is: (See Instructions on the reverse side of this form) a corporation, an officer of the corporation signs below. any type of partnership, the general partner signs below, 6. a limited liability company, a manager or an officer signs below. Signature: Limited Liability Company/CorporationIPartnership Name Theresa Kasprzyk (Type or Print Name) Signature and Title of Officer/Manager or General Partner I declare that all information in this statement is true and correct. I declare that all information in this statement is true and correct. (A Registered owner who declares as true information which he or she (A Registered owner who declares as true information which he or she knows to be false is guilty of a crime.) knows to be fat . se is guilty of a crime,) Title of Officer/Manager or General Partner These fees apply at time of filing'. Filing fee $23.00 for one business name. $7.00 for each additional business name $7.00 for each additional partner after first two ws��'s►r h4 pa a n � ■ ` \, //,, District Costa Mesa Sanita �a ORAt� .. an Inbepenbent Special District Board of Directors Robert Ooten James Ferryman Mike Scheafer James Fitzpatrick Arthur Perry Staff Scott C. Carroll General Manager Joan Revak Office Manager Clerk of the District Robin B. Hamers District Engineer (949) 631 -1731 Alan R. Burns Legal Counsel Marcus D. Davis Treasurer Phone (949) 645 -8400 Fax (949) 650 -2253 Address 628 W. 19th Street Costa Mesa, CA 92627 -2716 40V %4 ;Printed on Recycled Paper NOTICE TO PROCEED August 7, 2012 Theresa R. Kasprzyk 13861 Jasperson Way Westminster, CA 92683 You are hereby notified to commence work on the 7th day of August, 2012, in accordance with our Agreement dated July 20, 2012 for website redesign services. The work shall be substantially completed on or about December 31, 2012. COSTA MESA SANITARY DISTRICT Protecting our community bealtl� anii the environment bN providing solib waste anb sewer collection services. www.crosbca.gov Theresa R. Kasprzyk Website Design — Graphic Design — Multimedia — Grant Writing — Publicist Services July 23, 2012 Costa Mesa Sanitary District Attn: Javier Ochiqui, Management Analyst 628 W. 19th Street Costa Mesa, CA 92627 Subject: Contracts for CMSDCA.GOV Website Dear Mr. Ochiqui, Enclosed are the signed contracts. No changes were made to your submission. I have enclosed the requested documents for liability and automobile insurance as well as a copy of my business license and dba for the City of Westminster. I am also enclosing a letter of sole proprietorship regarding workman's compensation as directed by Anna Sanchez, Administrative Service Manager at CMSD. I am looking forward to working with you and the District on the project. Sincerely, Theresa R. Kasprzyk 1-4zo?-�- Theresa R. Kasprzyk 1 13861 Jasperson Way, Westminster, CA 92683 1714.721.4535 1 trk7777 @gmail.com Theresa R. Kasprzyk Website Design — Graphic Design — Multimedia — Grant Writing — Publicist Services July 23, 2012 Costa Mesa Sanitary District Attn: Anna Sanchez, Administrative Service Manager 628 W. 19th Street Costa Mesa, CA 92627 Subject: Workers' Compensation Waiver for Consultant for CMSDCA.GOV Website SOLE PROPRIETOR WAIVER A sole proprietor with no employees is exempt from workers' compensation insurance. The following is a written waiver that provides that a Sole Proprietor may waive his/her rights to Workers' Compensation coverage and benefits. I am a sole proprietor and I am doing business as Theresa R. Kasprzyk, Terrastar Media • I agree to waive all rights of subrogation against the Costa Mesa Sanitary District, its directors, officials, officers, employees, agents and volunteers for losses which arise from work performed on the CMSDCA.GOV website. • I understand that if I have any employees working for me, I must maintain workers' compensation insurance on them. Theresa k. Kasp yk Date Theresa R. Kasprzyk 1 13861 Jasperson Way, Westminster, CA 92683 1714.721.4535 1 trk7777 @gmail.com