05/18/1994 Install Channel Markers, Indian Key
jIlannp lL. Itolbage
BRANCH OFFICE
3117 OVERSEAS HIGHWAY
MARATHON, FLORIDA 33050
TEL. (305) 289-6027
CLERK OF THE CIRCUIT COURT
MONROE COUNTY
500 WHITEHEAD STREET
KEY WEST, FLORIDA 33040
TEL. (305) 292-3550
BRANCH OFFICE
88820 OVERSEAS HIGHWAY
PLANTATION KEY, FLORIDA 33070
TEL. (305) 852-7145
MEMORANDUM
TO:
Peter Horton, Director
Division of Community Services
~.
Isabel C. DeSantis, Deputy Clerk ~~.
May 31, 1994
FROM:-
DA TE:
At the May 18, 1994 meeting, the Board granted approval and authorized execution of a
Contract Agreement between Monroe County and A.S.A.P. Marine Contractors, for the
installation of 18 channel markers in Indian Key Channel.
Attached hereto for forwarding to the Contractor, is a duplicate original of the subject
document.
Should you have any questions concerning the above, please do not hesitate to contact
me.
cc: County Attorney
County Administrator, w/o document
Finance
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AGREEMENT, MADE THIS
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day of ~
9.994~
by
and between,
A ~ A P M~Tinp ~on~T~r~nTg
("Con-
tractor"), and the BOARD OF COUNTY COMMISSIONERS OF MONROE COUN-
TY, FLORIDA, of the County of Monroe, State of Florida ("Board").
1. The contractor shall furnish all the materials and per-
form all the work as required by the attached Specifications for
the installation of 18 Channel Markers in Indian Key Channel.
2. The work to be performed under the contract shall com-
mence immediately from the date the Marine Projects Coordinator
provides the Notice to Proceed and shall be completed by July
19, 1994.
3. If the Notice to Proceed has not been given by the Ma-
rine Projects Coordinator to the contractor on or before June 1,
1994 then this Agreement shall be null and void.
4. The work to be performed under the contract is contin-
gent upon receipt of appropriate grant monies from the State
Department of Environmental Protection, Boating Improvement Fund
Program.
If this grant is denied, this Agreement shall be null
and void. The contractor understands the rules of the Depart-
ment of Natural Resources and shall comply with said rules,
along with the rules and procedures instituted by the Board to
ensure an orderly progress to the project. Both the intent and
the requirements of the Specifications are understood by the
contractor.
5. The Board shall pay the contractor the total sum of
$15,640.00 for the installation of 18 Channel Markers in Indian
Key Channel. Payment for the work shall be upon completion by
the contractor and acceptance by the Board, subject to the terms
and conditions of the Specifications (attached as Exhibit A) and
this contra~t. A final payment will be made when all of the
work under the contract is complete.
6. The attached Specifications, Plans, and other documents
together with this Agreement, form the contract. They are fully
a part of this contract as if repeated herein verbatim.
7. The contractor shall indemnify the Board from and
against any and all claims, demands, actions, proceedings, damag-
es, liabilities, costs and expenses, including attorney fees,
arising out of, connected with, or resulting from this Agreement.
8. The contractor acknowledges his/her intention to comply
with the need to coordinate all work with the appropriate envi-
ronmental agencies, the u.S. Coast Guard, and the County.
9. The contractor agrees to supply the County with a photo-
graph of each installed marker along with a letter certifying
completion of work. The contractor will be responsible for the
camera, film, and development costs. The contractor also agrees
to provide transportation for Marine Projects Coordinator to
inspect completed project.
DV Contract--pagc 2
10. The contractor understands and agrees that no payment
will be forthcoming for this project without required photo-
graphs and written certification of completion.
11. The contractor understands and agrees that receipt of
Notice to Proceed from the County does not relieve his responsi-
bilities to obtain any appropriate permits. The contractor must
inform and advise the appropriate permitting authorities prior
to the replacement of this channel marker.
12. The contractor understands that he is to install eight-
een Channel Markers in Indian Key Channel.
13. The work must be completed by July 19, 1994.
14. Due to the use of heavy equipment and, at times, danger-
ous work environment, the contractor understands and agrees to
maintain an alcohol and drug free work environment.
15. The contractor will provide general liability insurance
in the amount of $ 500 000 workers compensation
I
as required by Chapter 440, Florida Statutes, Watercraft Liabili-
ty in the amount of $ 'iOO,OOO and automobile
insurance in the amount of $ 100,000
16. The Board may terminate this agreement without cause at
anytime upon giving the contractor up to 10 days notice in writ-
ing. Upon receipt of this termination notice all work must
cease. The Board shall pay the contractor the percentage of the
contract sum which is proportional to the amount of work per-
formed by the contractor in a manner satisfactory to the Board
up to the date the contractor received notice of termination.
DV Contract--page 3
IN WITNESS WHEREOF the parties hereto have executed this
Agreement the day and year
BY:
Yb/7/lt().
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Title:
(Seal)
Firm:
Attest
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Witness
(Seal)
Attest: DANNY L. KOLHAGE, Clerk
~aLd C. ~ ~~
Clerk I
AP~~ A ~\ TO FORft '
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AttornO'(s OfficF:
DV Contract--page 4
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SPECIFICATIONS FOR THE INSTALLATION OF AIDS TO
NAVIGATION IN INDIAN KEY CHANNEL, MONROE COUNTY, FLORIDA
Sealed bids will be received by the Board of County Commission-
ers, Monroe County, Key West, Florida. All bids will be opened
at a meeting between the County Attorney, County Administrator,
Clerk of Courts, and Marine Projects Coordinator or their repre-
sentatives, for the above referenced project.
Specifications for installation of treated wood piles complete
with U.S Coast Guard approved Daybeacons, in the locations indi-
cated are in the enclosed materials.
A. DAYBEACON PILES:
1. Pile shall be of timber treated with chromated copper
aresenate (C.C.A.).
2. Pile shall be of timber which will stand the driving for
which they are intended.
3. A straight line drawn from the center of the butt to the
center of the tip shall not at any point face further
away from center of the pile than a distance equal to 1%
of the length of the pile.
4. Minimum butt diameter = 12" measured 3' from end.
Minimum tip diameter = 8".
5. Piles to be sufficient length to provide a mlnlmum of
four feet penetration into existing sea floor and the
base of the dayboards must be eight feet above mean high
water.
6. Pile shall be driven or best installation practices used.
B . DAYBEACONS:
Daybeacons to be constructed and erected as indicated on the
enclosed sketches and documents. There are two dayboards per
daybeacon.
1. Construct all daybeacons as noted in the u.s. Coast Guard
Specifications enclosed.
Nav. Aids Specs.--Page 1
GENERAL CONTRACT SPECIFICATIONS FOR
INSTALLATION OF AIDS TO NAVIGATION
1. SCOPE OF WORK: The Contractor shall be reponsible for
providing all supervision, labor, equipment, tools, fees
and taxes required to complete this project to the
satisfaction of the County.
2. MATERIALS AND WORKMANSHIP: The Contractor shall provide
the necessary materials and equipment to safely complete
the job. The contractor agrees that all work shall be
performed by competent employees who are experienced and
qualified to do the work specified, and that all work will
be performed in accordance with the best commercial
practices. A list of equipment to be used and a
description of the installation procedures to be followed
must be provided to the County at the Prework Conference
described below.
Precaution shall be exercised at all times for the
protection of persons and property. The safety provisions
of the Occupational Safety and Health Act of 1970 (Public
Law 91-596) and other applicable laws, including building
and construction codes shall be observed. Machinery,
equipment and other hazards shall be guarded in accordance
with safety provisions of the "Manual of Accident
Prevention in Construction", published by the Associated
General Contractors of America, to the extent that such
provisions are not in contravention of applicable law.
The Contractor shall store materials and shall be
responsible for and shall maintain partly or wholly
finished work during the continuance of the Contract and
until the final acceptance. If any materials or part of
the work becomes lost, damaged, or destroyed by any cause or
means whatsoever, the Contractor shall satisfactorily
repair and replaces or not receive payment for the
unaccomplished work. The Contractor shall maintain
suitable and sufficient guards and barriers, and at night,
suitable and sufficient light or other appropriate security
or protection for the prevention of accidents.
3 · ASSIGNMENT OF CONTRACT AND SUBCONTRACTS: It is expressly
understood that the Contractor is in all respects an
independent Contractor for this work, not withstanding under
certain conditions he is bound to follow the directions of
the County, and is in no respect an agent, servant, or em
ployee of the County. Neither the Contract, nor any part
thereof, nor any monies due or to become due thereunder, may
be assigned by the Contractor without the prior written
approval of the County.
The Contractor is fully responsible to the County for the
acts and omissions of his subcontractors and of persons ei-
ther directly or indirectly employed by said subcontractor,
as he is for the acts and omissions of persons directly or
indirectly employed by him. Nothing contained in the Con
tract Documents shall create any contractual relations be
tween any subcontractor and the County. All subcontractors
shall abide by the terms, conditions, and requirements of
this Contract. It is the responsibility of the Contractor
to pay all debt obligations incurred with subcontractors in
an expedient manner.
4. LEGAL RESTRICTIONS, PERMITS AND TRAFFIC PROVISIONS: The
Contractor shall comply with all applicable local, State and
Federal requirements pertaining to the terms of this Con-
tract. The Contractor will be responsible for obtaining, at
his own expense, any licenses or permits that may be re-
quired and should inquire about permit requirements with the
appropriate agencies. The Contractor shall comploy with all
the requirements of the Federal Pollution Control Act.
The Contractor shall conduct his operations fo that he
shall not close any thoroughfare nor interfere in any way
with traffic on highways, or on water, without the written
consent of the proper authorities. Work shall be done at
any time that shall not interrupt or distrub members of the
public. Consideration should be given at all times to the
welfare of the public.
5. INSURANCE: The Contractor must obtain all insurance
required by the County and submit proof of same to the Coun-
ty prior contract approval by the Board of County Commission-
ers but no later than five working days after notice of low
bidder. All insurance shall be maintained until work has
been completed and accepted by the County.
The Contractor shall furnish the following certificates of
insurance for review by the County's Risk Management
Division (Attahced):
Certificates of Insurance provide proof that the
Contractor has obtained the insurance coverage required in
paragraphs a,b,c, and d below.
The Contractor hereby certifies that no modification or
change in insurance shall be made without (3) days written
advance notice to Monroe County, c/o the Director of the
Risk Management Division.
a. Worker's Compensation Insurance as in the amount of
$500,000.00.
b. General Liability Insurance on a comprehensive basis,
Gen. Spccs.--Page 2
in an amount not less that $500,000.00 per occurrence
for Bodily Injury and Property Damage combined, to
include contractual liability.
c. Water Craft Liability Insurance in the amount of
$500,000.00.
d. Automobile Liability Insurance covering all owned,
non-owned and hired vehicles used in connection with the
work, in an amount not less that $300,000.00 per
occurrence for Bodily Injury and Property Damage
combir1ed.
All insurance policies required above shall be issued by
companies authorized to do business under the laws of the
State of Florida. A Monroe County Insurance Checklist and
Monroe County Certificate of Insurance is enclosed for your
convenience.
6. COMMENCEMENT, DELAYS AND COMPLETION OF WORK: After
receiving Board of County Commission approval of the Con-
tract, and after reconciliation of any details or conditions
which may directly or indirectly interfere or conflict with
work of the Contract, the County will issue a "Notice to
Proceed with Contract Work" officially authorizing the Con-
tractor to commence. The Contractor shall commence work on
said date.
If the Contractor should be delayed in the progress of the
work included in the Contract by unforeseeable causes beyond
his control, the time for the completion of the work may be
extended upon agreement of the County representative. Re-
quests for extension of time must be submitted in writing to
the County representative. Extensions of time cannot legal-
ly be approved unless the written request is submitted in
time to permit it to be acted upon before the Contract
expiration date. To allow sufficient time for administra-
tive procedures required to obtain action by the County
Corr~ission, a requrest for time extension must be received
by the County representative at least sixty (60) calendar
days prior to the contract expiration date.
Liquidated damages resulting from factors beyond the
control of the Contractor which occur too late to allow time
for action by the Board of County Commissioners approving a
time extension may be waived by the County Commission. Such
waiver shall be granted only when the County representative
determines that the delay is beyond the control of the
Contractor, and in this event the Contractor shall not be
charged with liquidated damages or any excess cost when the
delay in the completion of the work is due:
Gen. Specs.--Page 3
a. To any duly issued order by the County or the State
Department of Natural Resources changing the
Contractor's approved work schedule;
b. To unforeseeable cause beyond the control and without
the fault or negligence of the Contractor.
c. To any delays of subcontractors or suppliers occasioned
by any of the causes sepcified in subparagraphs (a) and
(b) above.
Provided further that the Contractor shall within ten
,10) days from the beginning of such delay notify the
County, in writing, of the causes of the delay. The County
representative will ascertain the facts and the extent of
the delay and notify the Contractor within a reasonable time
of his decision in the matter.
If the Contractor fails to complete the work within the
time limit, and if the County should nevertheless permit the
Contractor to continue and complete the same without offi-
cial extension of time in writing, such permission shall not
modify nor waive any liability of the Contractor for damages
arising from non-completion of work within the time limit,
but all such liabilities shall be subject to continuation in
full force against the Contractor.
7. CHANGES AND INSPECTION: The aids to navigation herein
considered are to be installed for the County by the Con
tractor in accordance with the Specifications. The County
may give instructions or directions to supplement the Speci-
fications. These shall be binding upon the Contractor and
upon all his subcontractors, employees and agents of every
kind.
All work and every process and operation shall be subject
to inspection at all times, and the County and their
representatives shall have free access to all aspects of the
work. The Contractor shall remove and make good, as may be
directed, without charge, any defective work. Oversight or
error of judgement of inspectors, or previous acceptance,
shall not relieve the Contractor from the obligation to make
good any defect whenever discovered.
The right is reserved to change the Specifications
consistent with regard to the general intention of the Con-
tract for any part of the work or materials, whether before
or after work has begun. Notice of such changes shall be
given in writing to the Contractor; such changes are not to
be grounds for any claim by the Contractor for damages, nor
for the forfeiture of the Contract_
Gen. Specs.--Page 4
Except when otherwise specified, the expense of all tests
requested by the County will be borne by the County.
8. AUDIT RIGHTS: As a provision of the grant from the State
of Florida to the County, as if so requested by the State,
the successful bidder agrees to provide access to all
records and allow the audit of any books, documents and pa-
pers related to this project for a period of up to one year
during and after termination of the contract.
9. CONTRACT AWARD: The County reserves the right to
evaluate the submitted bids and to award a contract to a
bidder other than the bidder submitting the lowest bid.
10. PREWORK CONFERENCE: A meeting will be necessary
involving a representative of the County, the Contractor and
other parties with direct involvement prior to the siging of
the contract. The time and place of this Conference will be
set by the County representative. At this time the Contrac-
tor shall provide the County with a schedule as to the order
in which he proposes to install the listed aids to
navigation.
11. CONTRACT SECURITY: The Contractor agrees to execute and
deliver simultaneously with the executed contract, a
Contractor's Performance and Payment Bond. This must be
in the form of a Surety Bond written through an approved,
reputable and responsible company authorized to do business
under the laws of the State of Florida. This Performance
Bond shall be in the amount of five thousand dollars
($5,000.00) to guarantee the delivery of a completed
project under this Contract, in strict accord with these
Specifications and accompanying Permits. The contractor is
expected to act and deliver in good faith all work, at the
agreed price, in the allowed time. Failure to do so, could
jeopardize the contractor's reputation with the County and
potentially influence any future contracts with Monroe
County.
12. EXECUTION OF CONTRACT DOCUMENTS: Due to the time frame
illvol ved wi th this proj ect, the Contractor upon
notification that he is to be awarded the contract
documents for execution, shall return said documents
properly executed along with any necessary bond and
insurance with TEN WORKING DAYS. With the Contractor's
cooperation, if this period can be reduced, it will assist
irl acceleration the executi.on of the contract documents.
The Contractor, by virtue of signing the Contract,
acknowledges that he and all his subcontractors have
satisfied themselves as to the nature and location of the
Gen. Specs.--Page 5
work, the general and local conditions, including, but not
restricted to, those bering upon transportation, handling,
access to the pick-up and disposal sites; and the character
of equipment and facilities needed to perform the work.
Failure on the part of the Contractor to completely or
properly evaluate any factors of his costs prior to bidding
shall not form a basis for additional compensation if he is
awarded the Contract.
If for any reason, not acceptable to the County, the Contrac-
tor does not perform, the County shall have the right to
levy liquidated damages against the Contractor. Liquidated
damages shall be assessed against the Contractor for any
bid item awarded to him which is not completed and accepted
by the County within the number of calendar days specified
in the Contract. Liquidated damages are accumulative.
13. NOTICE TO PROCEED: The Contractor shall commence work
upon this project on the effective date of the Notice to
Proceed and perform in a continuous manner until
completion and acceptance by the County. For Contracts
wherein a specified number of days for completion is stated
in the Contract, the effect.ive date of the "Notice to
Proceed with Contract Work" will establish the "beginning
date" of the project.
14. TERMINATION OF CONTRACT: This Contract may be terminated
by the County, giving up to ten (10) days written notice to
the Contractor; said notice shall be sufficient if
delivered to the party personally or mailed by certified
mail to his mailing address as specified on the accepted
Bid.
If the Contractor fails to begin the work under contract
within the time specified, or fails to perform the work
with sufficient workmen and equipment or with sufficient
materials to insure the prompt completion of said work, or
shall perform the work unsuitably or cause it to be
rejected as defective and unsuitable, or shall discontinue
the prosecution of the work, or commit any act of
bankruptcy or insolvency, or allow any final judgment to
stand against him unsatisfied for a period of 48 hours, or
shall make an assignment for the benefits of creditors or
from any other cause whatsoever shall not carryon the work
in an acceptable manner, the County may give notice in
writing to the Contractor.
If the Contractor, within the period specified in such
notice, does not proceed in accordance therewith, then the
County shall have full power and authority, without
violating the Contract, to take the prosecution of the work
Gen. Specs.--Page 6
out of the hands of said Contractor, to appropriate or use
any or all materials and equipment as may be suitable and
acceptable, and may enter into an agreement for the
completion of said Contract according to the terms and
provisions thereof, or use such other methods as shall be
required for completion of said contract in an acceptable
manner. .
15. FINAL CLEAN-UP: Upon completion of the work specified
herein and before acceptance and final payment shall be
made, the Contractor shall remove from the sites all machin-
ery, equipment, surplus and discarded materials and
temporary structures. All disposal of materials, rubbish
and debris shall be made at a legal disposal site.
16. CERTIFICATION: Bidder must also certify, upon completion
of the project, all installations are in accordance with
these specifications, the Florida Department of Environmen-
tal Protection, Marine Patrol and the Coast Guard permit
requirements as specified in the "Specifications for the
Installation of Aids to Navigation." and associated
attachments.
17. PAYMENT: Contractor may request one partial payment by
submitting an invoice and appropriate documentation that at
least half (9) aids to navigation have been properly
installed, providing the Contract agreement does not
explicitly prohibit partial payment. Contractor must
submit complete documentation, including the required
photographs for the work for which payment is being
requested. The Contractor must provide transportation,
upon request by the County representative, to the
installation site for review of work either in progress or
completed.
In addition, property, public or private, if damaged during
the work or removed for the convenience of the work, shall
be repaired or replaced at the expense of the Contractor in
a manner acceptable to the County prior to final payment
for contracted work.
18. PUBLIC ENTITIY CRIMES: Acceptance of the Bid is
contingent upon receipt of the signed and endorsed Public
Entity Crimes form (attached).
19. NON-COLLUSION AFFIDAVIT: Acceptance of the Bid is
contingent upon receipt of the signed and endorsed
Non-Collusion Affidavit form (attached)
70. ETHICS CLAUSE: Acceptance of the Bid is contingent upon
receipt of the signed and endorsed Ethics Clause form
Gcn~ Specs4--Page 7
(attached) .
21. DRUG FREE WORK PLACE FORM: Acceptance of the Bid is
contingent upon receipt of the signed Drug Free Work Place
fornl (attached).
Gen. Specs.--Page 8
SEVENTH COAST GUARD DISTRICT
PRIVATE AIDS TO NAVIGATION STANDARDS
DAYBEACONS (UNLIGHTED BEACONS)
AND LIGHTS (LIGHTED BEACONS)
SHAPE:
Dayboards on lights have the same shapes as those on
daybeacons.
Starboard hand dayboards have a triangular shape.
Port hand dayboards have a square shape.
Safe water dayboards have an octagonal shape.
COLOR OF DAYBOARDS:
Starboard hand, triangular dayboards are red.
Port hand, square dayboards are green.
Safe water, octagonal dayboards are red on the right half and
white on the left half.
see "RETROREFLECTIVE MATERIALS" for colors of letters and
borders.
CHARACTERS:
See "DIMENSIONS" for the correct size and distance from the
base or lower apex of the dayboard.
Red starboard hand triangular dayboards have even numbers.
Green port hand square dayboards have odd numbers.
Safe water dayboards are not numbered but may be lettered for
identification purposes. Letters should be sized and placed in
the same way as numbers. However, letters on safe water
dayboards should be centered in the red, right half.
FLUORESCENT AND RETROREFLECTIVE MATERIALS:
Fluorescent background material and retroreflective numbers,
letters, and borders, although optional, should be used on
dayboards. Retroreflective numbers, letter, and borders should
be the same color but a contrasting darker shade) as the
background material; alternatively, numbers and letters may be
white.
The signal characteristics of paint are relatively poor, but
use of paint is not prohibited. If paint is used, then numbers
and letters are white.
o I ME NS ION 5 :
OAYBOARDS: The minImum acceptable dlaenslons are for e no.lnal range ot 1/2 nautical mIle
(nml). ApplIcants -ay establish larger .Izes If they .ISh. Optional fluorescent background end
retroretlectlve numbers. letters. and borders ere encoureged. All dimensIons are In Inches.
t<<)M I HAL
RAKiE
( n. 1 )
TYPE
SIZE
o AYBOAPD
· NUN3ER/
LETTER SIZE
(single) (double)
D I STANCE DAYSON{)
BASE TO NUMBER BASE
(slngl.) (double)
RETROREFLECTIVE
BORDER SIZE
(opt lone I)
PORT
HAt()
1/2 Squzsre side length-18 e 6
Square side length-36 12 12
2 Squere sIde length-48 16 16
3 Square side I ength-72 24 24
STARBOARD HAND
1/2 Trlengle helght-24 8 6
width- -24
Tri~r.gie heigr.t-48 12 12
wldth* -48
2 Trlengle helght-72 16 16
width. -72
3 Trlengle helght-96 24 24
width. -96
SAFE W^TER
Octagon helgh't..-48 12 8
width.. -48
side length-20
3 Octogon helgh1..-96 16 12
w'dtn.. -96
side length-40
. ~Idth at base of the trlangl.
.. Width/height from side ~o the opposite sid.
... o I stance f rom the f ower apex to the latter bese
5
4
1.5
12
12
2
16
16
3
24
24
4
5
4
1.5
10
7
2
16
12
,
20
14
4
21... 21... j
42-.. 42... 6
(DIMENSIONS continued)
STRUCTURES: There are not required dimensions" materials,
fastenings, or designs for structures supporting dayboards and
associated lights. No particular height above mean high water is
mandated.
Permitees should insure all aids to navigation are established
consistent with prudent, sound engineering practice and the harsh
nature of the marine environment. The following sketches are
for general reference and should be modified to suit the
circumstances.
LIGHTING EQUIPMENT ON LIGHTS (LIGHTED BEACONS):
COLOR:
Lights on starboard hand lighted beacons are red.
Lights on port hand lighted beacons are green.
Lights on safe water beacons are white.
LIGHT NOMINAL (VISUAL) RANGE:
The minimum visual range of a light is one nautical mile.
Depending on the circumstances a greater range may be permitted,
required, or prohibited.
FLASH CHARACTERISTICS:
Red and green flashing lights are laterally significant and
usually flash (light off longer than on) regularly with a
frequency of not more than 30 flashes per minute. When special
caution is necessary, such as sharp turns, obstructions, wrecks,
etc., quick flashing lights (60 flashes per minute) may be used.
White lights on safe water beacons flash in a Morse Code "A"
rhythm (short-long flash).
~ED D~IONS
These are ge~ral reccmrendations and may be adapted to s~cific
circunstances. They should also be modified as necessary to rreet the
requirerrents of prooent sounc1 engineering practice am the demands of the
marine environment.
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MATERIAL LIST
Item QUllntl'ty Mllterl~ls Size
lll-l 2 6061 ^'umlnum elloy bolts, nuts, & washers 17i-' X ~2"
lll-2 1 ( op t I onl) I ) Concrete, prestresed lenjlth es r&qulred 10" X 10"
ll'-,3 2 _~boerd Size IlS needed
L I 1-4 2 ~O~minum~~__~f1S!_~~& "lSS~~ 1/2" X 1 4"
---- -------
L I 1-5 1 WOOd , pr(jssure tre/3ted, le~th es rOQuire<1 12" dIe.
Note 1:
All ~Iumlnum bolts meet recognized s1end~rds for ~8rlne use.
Note 2:
Plnce ~ 2" X ~" 11 Iler wi II be plbcod between deymerks end the pi Ie
n1 the upoor bolt conntic11on 10 provide tJ five degree outboard tl 11..
Port
r :T?;;~~~::--~~,~: ~.
-~_-.~._. .-."'~ ..-.....
..::~.:::". ~1'" '~:.;::~ ?~.
...::".-:-' \:"..:-- ~.-
f ,.. -
I.,I 2 ~ ;~~:~~:it~~i~;f:d-
n .. .-..
J .. 3' . I
-,
PORT AND STARBOARD MARKERS
(nominal range, 1 nmi)
2u GREEN
(OPTIONAL RETROREFLECTIVE)
BORDER
12" GREEN
(OPTIONAL RETROREFLECTIVE)
NUMBER
Starboard
GREEN 2" RED
(OPTIONAL (OPTIONAL RETROREFLECTIVE)
FLUORESCENT BORDER
FILM)
(n'r'~~()r~-: ~.
RED
12*' RED
(OPTIONAL RETROREFLECTIVE)
NUMBER
4'
:=- ..~ ~ 1 -.': ~.r: ~ ~ r ~ T
4'
.-1
t 1 Lh)
2" GREEN
(OPTIONAL RETROREFLECTIVE)
BORDER
:.......... GR EEN (OPT I ONAL
.; FLUORESCENT FIL"'
..
- au GREEN
.:---.... (OPT IONAL RETROREFLECT IVE)
. I NUMBERS
Jca- 3'
.
2" RED
(OPTIONAL RETROREFLECTIVE)
BORDER
12" RED
(OPTIONAL RETROREFLECTIVE)
NUMBERS
~.~
. '..
J :..< ". . . . '
... :...
~,-,:~:-~'~;~~.- ~.
"{:':~~;;;~ .~.....
/.:. ';:;:'~:t:.~:~:: ~:..~.....:..
:'/:~"'2 2..~r'''. -
.' ........" ~~ ; "-~.""'-" ~ ':C .
,'J__ .". ~. :;::..~, ..~~. ~<~:' :'.~'. :: .~~\, 7"
4'
RED
(OPTIONAL
F'~L10t\ESCFNT
PI LM)
. _...: ~ '- ':":;~ :~-l
-I,
- . -., '-..- -'..- ~- ... --
4'
..
*For 2 numerals. use 12" numbers at a height of 12" off base.
"*For 3 nurilerals J use 0" numbers at a height of 12" off base.
SEVENTH COAST GUARD DISTRICT
PRIVATE AIDS TO NAVIGATION STANDARDS
DAYBEACONS (UNLIGHTED BEACONS)
AND LIGHTS (LIGHTED BEACONS)
(SPECIAL PURPOSE SUPPLEMENT)
SHAPE:
Special purpose dayboards have a diamond shape.
COLOR OF DAYBOARDS:
Special purpose dayboards are yellow.
See 'fRETROREFLECTIVE MATERIALS" for colors of letters and
borders.
CHARACTERS:
Special purpose dayboards are not numbered but may be
lettered for identification purposed. Letters should be sized
and placed as described for numbers. \
See "DIMENSIONS" for the correct size and distance from the
lower apex of the dayboard.
RETROREFLECTIVE MATERIALS:
Retroreflective letters and borders, although optional,
should be used on dayboards. They should be the same color, (but
a contrasting darker shade) as the background material; letters
may be white.
The signal characteristics of paint are relatively poor, but
the use of paint is not prohibited. If paint is used, then
letters are black.
DIMENSIONS:
DAYBOARDS: The minimum acceptable dimensions are for a
nominal (visual) range of 1/2 nautical (nmi). Applicants may
establish larger sizes if they wish. Optional retroreflective
letters and borders are encouraged. All sizes are in inches.
DIMENSIONS (continued):
t<<)M I HAL
fWGE
(Mil)
TYPE
SIZE
OAYSON{)
NJf43ERI
LEnER Sllf
(alngl.) (~bt.)
OISTAtCE O~~
BASE TO ~ER BASE
(lingle) (double)
RETRoREFLECT f YE
8(R)ER SIZE
(OPtional)
SPEC. AI.. PURPosE
112 QJaa.onde sIde leng~la 8 6 ,.. 9 1.'
Ole~OOd. .Ide 'etlgth-36 12 12 20" 20 2
2 o I ~Ut'C)(' d · aide C.ngt~-48 16 16 26.. 26 3
3 o la.and- aide . ength-72 24 24 40" 40 4
. All .ngle, 900
.. OIAf.nee from the 'ow.r apex to the tetter bes.
STRUCTURES:
There are not required dimensions, materials, fastenings, or
designs for structures Supporting dayboards and associated
lights. No height above mean high water is mandated.
Permittees should insure that all aids to navigation are
established consistent with prudent, sound engineering practice
and the harsh nature of the marine environment. The enclosed
sketches are for general reference and should be modified to suit
the circumstances.
LIGHTING EQUIPMENT ON LIGHTS (LIGHTED BEACONS):
COLOR:
Lights on special purpose beacons are yellow.
LIGHT VISUAL RANGE:
The minimum visual range of a light is one nautical mile.
Depending on the circumstances a greater range may be permitted,
required, or prohibited.
FLASH CHARACTERISTICS:
Yellow lights on special purpose beacons are fixed or flash
(light off longer than on) regularly with a frequency of not more
than 30 flashes per minute.
Name of aid
Daybeacon 1
Daybeacon 2
Daybeacon 3
Daybeacon 4
Daybeacon 5
Daybeacon 6
Daybeacon 7
Daybeacon 8
Daybeacon 9
Daybeacon 10
Daybeacon 11
Daybeacon 12
Daybeacon 13
Daybeacon 14
Daybeacon 15
Daybeacon 16
Position
24 52.536N
80 40.295W
24 52.584N
80 40.219W
24 52.822N
80 40.455W
24 52.887N
80 40.370W
24 53.II4N
80 40.7I6W
24 53.I46N
80 40.685W
24 53.38IN
80 4I.006W
24 53.4I6N
80 40.950W
24 53.579N
80 4I.025W
24 53.593N
80 40.968W
24 53.659N
80 41.2I0W
24 53.708N
80 41.185W
24 54.036N
80 41.321W
24 54.034N
80 41.251W
24 54.258N
80 41.447W
24 54.283N
80 41.382W
INDIAN KEY CHANNEL
Remarks
3' Square Green
(new establishment)
3' Triangle Red
(existing federal aid)
3' Square Green
(new establishment)
3' Triangle Red
(existing federal aid)
3' Square Green
(new establishment)
3' Triangle Red
(new establishment)
3' Square Green
(new establishment)
3' Triangle Red (existing federal
aid, Daybeacon 6, to be renumbered)
3' Square Green (existing federal
aid, Daybeacon 7, to be renumbered)
3' Triangle Red
(new establishment)
3' Square Green
(new establishment)
3' Triangle Red (existing federal
aid, Daybeacon 8, to be renumbered)
3' Square Green (existing federal aid,
Daybeacon 9, to be renumbered)
3' Triangle Red
(new establishment)
3' Square Green
(new establishment
3' Triangle Red (existing federal aid,
Daybeacon 10, to be renumbered)
PAGE TWO-POSITIONS ATTACHMENT
Daybeacon 17
Daybeacon 18
24 54.791N
80 41.581W
24 54.833N
80 41.518W
3' Square Green
(new establishment)
3' Triangle Red
(new establishment)
DRUG- FREE WORKPLACE FORM
The undersigned vendor in accordance with Florida Statute
287.087 hereby certifies that:
{l ~'A 'J ,-
r-I,::> . l. ~-~
(Name of Business)
1. Publish a statement notifying employees that the unlawful
manufacture, distribution, dispensing, possession, or use of a
controlled substance is prohibited in the workplace and
specifying the actions that will be taken against employees for
violations of such prohibition.
2. Inform employees about the dangers of drug abuse in the
workplace, the business's policy of maintaining a drug-free
workplace, any available drug counseling, rehabilitation, and
employee assistance programs, and the penalties that may be
imposed upon employees for drug abuse violations.
3. Give each employee engaged in 'providing the commodities or
contractual services that are under bid a copy of the statement
specified in subsection (1).
4. In the statement specified in subsection (I), notify the
employees that, as a condition of working on the commodities or
contractual services that are under bid, the employee will abide
by the terms of the statement and will notify the employer of
any conviction of, or plea of guilty or nolo contendere to, any
violation of Chapter 893 (Florida statutes) or of any controlled
substance law of the United States or any state, for a violation
occuring in the workplace no later than five (5) days after such
conviction.
5. Impose a sanction on, or require the satisfactory
participation in a drug abuse assistance or rehabilitation
program if such is available in the employee's community, or any
employee who is so convicted.
6. Make a good faith effort to continue to maintain a
drug-free workplace through implementation of this section.
As the person authorized to sign the statement, I certify that
this firm complies fully with the, a~~ "_____
---- .---~--..-._---- -;4~~---.-~--
MCP#5 REV. 6/91
NON-COLLUSION AFFIDAVIT
I , ,::;;; e-F,L;,-:r: F73" -,,-? 5?(
(
~Q~~~~- a~cording to law on my oath, and
~v,y-/y
, of the -eiLy ..
of
under penalty of perjury, depose and say that;
1 ) I am /I- ? ,t) · ~. , the bidder
making the Proposal for the project described as follows:
2) the prices in this bid have been arrived at independently
without collusion, consultation, communication or agreement for the
purpose of restricting competition, as to any matter relating to such
prices with any other bidder or with any competitor;
3) unless otherwise required by law, the prices which have been
quoted in this bid have not been knowingly disclosed by t'he bidder
and will not knowingly be disclosed by the bidder prior to bid
opening, directly or indirectly, to any other bidder or to any
competitor; and
4) no attempt has been made or will be made by the bidder to
induce any other person, partnership or corporation to submit, or not
to submit, a bid for the purpose of restricting competition;
5) the statements contained in this affidavit are true and
correct, and made with full knowledge that Monroe County relies upon
the truth of the statements contained in this affidavit in awarding
contra~ts for. said project.
STATE OF
F /()n ,-dA
~,('"71e>e
COUNTY OF
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
/} 1F:;r>1,,:r--: F-rJ/d' ~Who, after first being sworn by me,
(name of individual si ning)
affixed his/her signature in the space provided above on this
;2..r day of /1~n" 'j , 19 71'.
~.~~
NOTARY PUBLIC
My commission expires:
Noto,.)' Pill: ~[(1 ~ 1qi'~ n( nod~i! -....
My CHil'r:'..' '..:q ; 'd~ i'!. 1995"
b...;. , ;
C / "Pi I~ /-1. 73 MA('-t;
SWORN STATEMENT UNDER ORDINANCE NO. 10-1990
MONROE COUNTY, FLORIDA
ETHICS CLAUSE
;::;;;'0/1; ,.::r: F~/;Y-/ 0. warrants that he/it has not employed,
I
retained or otherwise had act on his/its behalf any former County officer
or employee in violation of Section 2 of Ordinance No. 10-1990 or any
County officer or employee in violation of Section 3 of Ordinance No.
10-1990. For breach or violation of this provision the County may, in
its discretion, terminate this contract without liability and may also,
in its discretion, deduct from the contract or purchase price, or
otherwise recover, the full amount of any fee, commission, percentage,
Date:
mployee.
gift, or consideration paid to the former
STATE OF
F/e,7?/'~
~ "/~"E
COUNTY OF
me on
Subscribed and sworn to (or affirmed) before
~-Lr:-?~
':::;;;~m.-::r: F73~W-7
f
(date) by
(name of affiant).
lie/She i? personally known to me or has produced
as identification.
(type of identification)
Notary Publir, ~fate of rrorida
My (omrni$~!v;1 r.~phe:; '~1:,;:d1 14, J995'
Ionded Thru Troy fain - Insurance 'oe.
~.x
NOTARY PUBLIC
C ,I, n' /1 /..{". ~.2S>~ ,-T'ro
MCP#4 REV. 2/92
SWORN STATEMENrr PURSUANrr l~O SECTION 287.133(3)(a),
FLORIDA srr A TUTES~ ON PUBLIC ENTITY CRIMES
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
OFFICIAL AUTHORIZED TO ADMINISTER OA~~
1. This sworn statement is submittcd to // /#N'"7?4c ~c:.//ij
by
~~rh?-: F/-r,~
(print individual's name and title) I
(print name of the public entity)
~7. ~t~/rnr,-p: ·
for
/I. >.,1?F.
[print name of entity submitting sworn statement)
whose business address is
/?1d7 ? /. 7
Q/795' 0/5
- / /( v~-rr #/~7) ,
/lwy
/
r~
.5' 30.3c::'
and (if applicable) its Federal Employer Identification Number (FEIN) is
.5"'7 - ~ 3to .3 .s-0/
(If the entity has no FEIN, include the Social Security Number of the individual signing this sworn
statement:
.)
2. I understand that a "public entity crime" as dcfined in Paragraph 287.133(I)(g), Florida Statutes. means a
violation of any state or federal law by a person with respect to and directly related to the transaction of business
with any public entity or with an agency or political subdivision of any other state or of the United States, including,
but not limited to, any bid or contract for goods cr services to be provided to any public entity or an agency or
political subdivision 9f any other state or of the United States and involving antitrust, fraud, theft, bribery,
collusion, racketeerint, conspiracy, or material misrepresentation.
3. I understand that"convicted" or "conviction" as defined in Paragraph 287.133(1)(b), FlQrida Statute$, means a
finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or
state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result
of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.
4. I understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes, means:
I. A predecessor or successor of a person convicted of a public entity crime; or
2. An entity under the control of any natural person who is active in the management of the entity and who has
been con victed of a public entity crime. The term "affiliate" includes those officers, directors, executives, partners,
shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership
by one person of shares constituting a controlling interest in another person, or pooling of equipment or income
among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that
one person controls another person. A person who knowingly enters into a joint venture with a person who has
been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate.
S. I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural person
or entity organized under the laws of any statc or oHhc United States with thc I~al power to enter into a bindin2
contract and which bids or applies to hid on contracts for the provision of goods or services let hy a puhlic entity,
or which otherwise transacts or applics to transact husiness with a puhlic cntity. Thc ferm "person" includcs those
officers, directors, executives, partncrs, shareholders, employecs, memhers, and agents who are active in
mana~ement of an entity.
6. Based on information and belief, the statement which I have marked helm'V is true in relation to the entity
submitting f his sworn statement. [I ndicate \\'hich stafclncnt applies. J
A Neither the entity submitting this sworn statement, nor any of its officers, directors, executives, partners,
shareholders, employees, members, or agents who arc active in the management of the entity, nor any affiliate of
the entity has been charged with and co",'icted of a puhlic entity crime subsequent to July I, 1989.
- The entity submitting this sworn statement, nor any of its officers, directors, exectutives, partners,
shareholders, employees, members, or agents who are active in the management of the entity, nor an affiliah: of
the entity has been charged with and convicted of a public entity crime subsequent to July I, 1989.
- The entity suhmitting this sworn statement, or one or more of its officers, directors, executives, partners,
shareholders, employees, members, or agents who are active in the management o( the entity, or an affiliate of
the entity has been charged with and convicted of a public entity crime subsequent to July I, 1989. However, there
has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative
Hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to
place the entity submitting this sworn statement on the convicted vendor list. [attach a copy of the final order]
I UNDERSTAND THA TTHE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC
ENTITY IDENTIFIED ON PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS
FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO
UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A
CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA ST A TIITES
FOR CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM.
/.~
Personally known
'/
J'9pT=j/'/ ,19 ?(
~.~~
"
Notary Public - State of r ~ ~/CI;'
.. . tfotary Public, State of Florit!.
My Commission expires ... h 24 19'ft.f.I"
My (UHIH~:::)I\.I!I [~t'h~! r.lt.!fc , 7 ~
~ /"R':4 /{. ;?544';o;,ded Th,u Teul fa;n. Inwonce Inc.
(Printed typed or stamped
commissioned name of notary public)
Sworn to and subscribed before me this 2rday of
OR Produced identification
(Type of identification)
Form PUR 7068 (Rev. 06/11/92)
I~ "UHANGE: · ~: - _ '--~: "10'/12"l93)
· THis'CERTIF{CATE-islSS'UED As-,n,fATTER OF-iNFORMATION ONLVANo--"
CONFERS; NO RIGHTS; UPO,N T~. CERTIFICA T"i: HOL05iR. TWI, CkRT'FJcA T~
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
. ..rQ~~c~~_~_~~q_V!.._ _. ___-_ _
^';"I:I- ~ ~t:H.IIt:-I(';A,1 t:: U
'''OOUCEA
Regan Insurance Agency ~ Inc.
90144 OverpetlB HIghwny
Tavernier,!F1330iO
INSUREO
~ .
A.S.A.P., ~nc.
PO Box 8041
Tavenrier, r ~ 33070
: co
!lTR
GfHfRAL UA8'U-rr. .; . .
A x COMMERCIAl! GENERAL LlABIUTY .
CUJM~iUAOE X ~CUA. 93' HA. 3401
OVINER'S ~ fNTRACTOR'.,.PRO~.
i
.1
AUTO"O~lE LlAuiLm
ANY AUTO I
..
AU. ~o 1UT06
. ~J;nl.1I ~o .;t.'T~~
JiCf\eO AUTOS
t .
NO~w~t'F08
BARAQ E lu.a;lI!Y'
. :
. l
: I:
. !
. 1XClS$ UAIU.lTY " .
UlA8ASUA "tALC. .
OTHER THAN ,UMeRE~ fOAU :
,.
s
I
.
i
WOR6<fA'S ~"'.eHSA liON . .
, .
~O .;
UfPLOY!AS' UAa&UTY
.! . .
f .
~ .
OT"eR
· DESCRIPTION OF O'EMTIOHIILOCATIONSiVfHIClUIIPEClAl. fTQ
I . '-'barf Bui+~ing. : . .
Projact: .fmergency repair of
· Waterdraft . exclusion On " 11
CEflTIFICA TE HOrER :
Monroe C~ty Board of COur:tty.
Coamis6ion~rsl Addi ti9t181 In~ed
5100 Colle8cRd
Key West,. F1 33040
ACORD 25~S 7/90
COMPANIES AFFORDING COVERAGE
--- -I~-
GEKfR-'L.AGGREGATf C 600, ()(X) f. ~
PAOOUCTS-COMPIOP AGO. I.' 300, 000 .
'8/31/94 PE!\SOtW.. & ADV; INJURY . 300 , 000 ,
EACH OCCURAENCE S ~ t.~ .
FiRe =:M~_.IIrt) .: . . 5~,~. ;.1
hEO. ~~ ;Mf QM D<<lOnt '. . ~ I '-')'V ,
; .;
, .1
! ;;
. : j
t I'
COMPANY A
lElleR .
1 : .
COMPANY B
LETTeR:
: .
8/~1/9~
. ,
i
': .
I.
I
I.
i .
. ,
. !
I.
I.
i:
I
COOP A~Y C
lETTER. .
I. I
. COMPA~Y' 0
! LETTeR I .
i COMPANV E
~ : i LE TTER i . . . , :
icoVERA<ies-.-:'--';--.- . :., . I f:~.' .... .' ~~7'
: THIS IS TO CERllFY THA TTHE POLicIES OF INSUAA~CE IST~' BELOW H~Ve: BEE:N I~~~EO TO THE INS~REO NAMED ABOVE FOR THE POLlCY peRI~ :: ~
J INDICATED. NOtwITHSTA~OING ANY REOVIREJ.4ENT. TE M 0 ONOITICN OF ANY CONTRACT O~ OTHER DOCUMENT WITH RESPECT TO WHICH THIS :
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. T'iE IN URA ...E AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUGJECT TO ALL THE TERMs,
EXCLUSIONS A~D CONOITIONS OF SUCH POLICIES. LIlA S S I <:lWf4 MA. Y ~AVE 8~N AEouceQ BY PAlO CLAIMS. : ,:
l"YP( OF ~SUfWfCE . POLICY HU eA [ I'OL~v U.ieCTIVE POLICY PPlllATlOlI . UMITS i . j
D~ Te (N~/PONV): OA 1"( (MWODJYY)
: :' : : i
ker ~5, Taveriuer Creek. TavenU,er ,Fl ' .1
t>een delet~. Watercraft li~bility is incluled , .'
CANCelLATION' .' . ';; ". . ~I
SHO~lO AN'~ O~ TH~ ABOVE OESCRIBEO POLICIES BE CANCELLED !EFOAE THE: .
EXPIRATION '.DATE THfHEtY~ THE ISSUING COMPANY WILL ENOEAVOR TO ,!
UAI~ J.!L DAVS WRITTEN NOTICE TO THE CEP.TIFICATE HOUJE:R NAMEO TO THE . i
: j lEFT,: BUT FAIlURETO ~~..~llCE':;HALlI&APOSE NO OBLlGAnoN Of.. I
,I ltAetl'TY Of .ANY KI ~~O"'PA TS AGENTS OR REPRESENTATIvES. "'
I!, ~
,AUTHOA1UO RfPAU ~
i I
I . OACORD CORPORA TIOH 1990
. . . ;
,
Proforma c/o Hull & Company
. .
· I
i '
couelNeo Sl~ ,
UMIT
800lL Y IN.'URY I
. ~ef 1*1On)
IOOIL V INJUA Y .
(P.. ~ldtnt)
PROPERTY OAW.GE I
EACH oeCUA~E ,
.AGG~CI^lE .
aTATU1'OAv,-,...,,:.
EACH ACC()ENT $
DC:S~-"Ouey LIMI'r ..
DISEASe-EACH EMPLOYEE I
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Il-) ). 1 .:.,~L_,.l,. : I CONSTRUCTION 'INDUSTRY
l r -t - ,. J NonCE OF ELECTION 10 BE EXEMPT FROM
THE PROVISIONS OF THE FLORIDA WORKERS' COl\fPENSATION LAW
MAJLTO: DeJtlnmcnto(Lllhor&P.mpjOy'I!fI'I$~'\f! '.. "~~.l-q7-- ~. .-. .STATKUS&ONLY- ...... ·
Bu~au or w.e. CompUAEI4:t . ACKNOWlEDGED T . '" POSTMAAK DAT6 ~I 1_
2'28 Ccnll.lr\'iow Dd,'c, 100 Fc~_R . ',' 1111, nocloe Iha1l be in effDct lor two'(2,ii"1~
1illlh.,.oo. FIorjdn 323~.()66J. AG N 1/1.' (J~). . )" C':
E T etrOCiliI'O dIIe 0( ~ L' 1 1 Ulllil i
PLF..\S~lfRINT: :j)R II.. :(l 11 0: UIlIU <<wiled. wt.i~hcver OOln'" Ii,....
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. 1111>1"'161 'or~I'nlrwlf:arOlp.hinIlcnIt/p.C,Ir~).. _. q/'7 '.. .(D~~ / /..>> .,
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A-VeetJl.efC. R'* L33DJO
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AI of 12:01 8.m. :40 dr.y8 (ollo\lo'll1&: rhe dAle of themailingoflbh:fQrm.you.li · th · , 'or,
ranaer or Corporate Om~et of the abCJve ftamed b\l.lne5~ doC)~ elect to be .el III j
Cotr.p&m..tion Law. J understand lhe. by this lCtiOIlI8m not tIltitlod 10 bene h
form J have not exceeded the exemption limit 01 thn:" Partners or IhrM Corp ,
bu"lneai named -hove Ire cO\'crod by 'A'orten- cumpensation iftsurMnc.. .
The ~lIowin art tt>> ~i ed nf ~sJ'tcred licon_elt IlcJd by mc pW".'"ant to chlPtor 489 Florida StlUUtoI at nOAK'/Ilf"ltifA!)!'"
(I) 'J)pe: · · Number: ~ (2) 'IYpe; '~ Number:,
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INSl1RANCIt CAltRIER lNl'ORMATJON (If Applicable): A c:ormtllclion induSCIy emploYer with one (I) (jr ,",O!e'OInpJoyees nlu.1
nwlntain Wnrlcoc.' Cotnpcnlilltlon ~rlSc. Failure 10 comply wJU msull in I flve-htlndtea dollar ($500) fine and. cme-hundlWd
doJlar (SIOO) fine i>r each day of noACumpllllU;e (Ice liCCtioll.uo.43. RS.}
rumc cltClITlcr Se-e ~flC.H'iJ').
:miet AdchIc _ .
Polley Nun1b~
Jnlurance Alent (AaMC)J)
~,'ncy Add..... ~
En'~VE DATE
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Social SKUricy Number ~" 1':~1-q'lI2'
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'Q5lllon: PruprJecol ..--lPlInntr -K/nrlOftw (nIle) . <) ee. I ~e5 · · · . 0 · . :
MPOIrr.\NTr Individual exernptinn flUllg (eo, pursuant to Sactlon 440.05, F.S.. Is seven dClJlm and MI)' cents (~7.S0, Ind il
")I.ble only by mnney order or clWhler', chock, to w.e. Admini.trIltJve Trust fund. Pailu~ to enc!o$e fu wjJl ~uJt in return Qf'
~uea lAd delay of oertilicltlon,
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.WOttN ro AND SUBSCRIBBD BBPORE ME llllS
\T ~ 1 ~ AI.. =5 ~~ . F1.OJtIO..\
AccePTED ~
eureau oJ W.C. Comp1l1nce
as IOltM bCM.204 (~,?IP1)
3( ~ DAYOF ~~ \,cr3 . I
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f.t" . MY~~'CC21Z352 .
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