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Addendum 02/19/1992ADDENDUM TO AGREEMENT (Public Service Building Sewage Treatment Plant) THIS ADDENDUM TO AGREEMENT is made and entered into this 19th day of February, 1992, between the COUNTY OF MONROE and DAVIS WATER ANALYSIS, INC in order to amend that certain agreement between the parties dated January 30, 1991, as follows: 1. In accordance with Paragraph VI of aforementioned agreement, the County and Contractor hereby exercises its option to renew said Agreement and hereby amend paragraphs VI and VII to read as follows: "V.) The Owner and Contractor, upon mutual consent, shall have the option to renew this agreement after the second year, for one (1) additional year. The contract amount agreed to herein may be adjusted annually in accordance with the percentage change in the Consumer Price Index (CPI) for Wage Earners and Clerical Workers in the Miami, Florida area index, and shall be based upon the annual average CPI computation from January 1 through December 31 of the previous year. VII). Payment by the County to the Contractor for performance of said service on a per month in arrears basis on or before the 15th day of the following month in each of twelve (12) months. The Contractor shall invoice the County monthly for sewage treatment plant operation and maintenance performed under the Specifications contained herein. The Contract amount shall be at a rate of $2467.20 per year to be paid $205.60 per month." 2. In all other respects, the agreement between the parties r_- dated January 30, 1991, remains in full force and effect. IN WITNESS WHEREOF, the parties have hereunto set their hams and seal, the day and year first written above. LL , a BOARD OF COUNTY COMMISSIONERS `'- OF MONROE COUNTY, FLORIDA (Seal) Attest: DANNY L. KOLHAGE, CLERK By: � Deputy Clerk Witness fitness By: DAVIS WATER ANA YSIS, INC. By: AP D �S�FFIC TO FORM AN*7 L CY. By Al:orney`s O,` C0 Date ���I'w CERFIVATE OF INSURANCE ISSUE DATE (MM/DD/YY) ! 2120/92 I PRODUCER _ _ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND I CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE Southernmost Insurance Agency DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE 1104 Truman Avenue POLICIES BELOW. P.O. Box 323 COMPANIES AFFORDING COVERAGE Key West, F1. 33041 COMPANY A LETTER United States Fidelity & Guaranty Company COMPANY B INSURED LETTER Davis Water Analysis, Inc. COMPANY C P.O. Box 2584 LETTER aQ� Key West, Fl. 33045 COMPANY � D LETTER COMPANY E LETTER COVERAGES 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. CO TYPE OF INSURANCE POLICY NUMBER LTR POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE (MM/DD/YY) DATE (MM/DD/YY) GENERAL LIABILITY GENERAL AGGREGATE $ 100,000. A X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ 100 000. CLAIMS MADE X OCCUR. 1CP30005858300 12128191 12128192 PERSONAL & ADV. INJURY ) $ 100, 000.. OWNER'S & CONTRACTOR'S PROT. EACH OCCURRENCE $ 100,000. FIRE DAMAGE (Any one fire) $ 50,000. MED. EXPENSE (Any one person) $ 5,000. AUTOMOBILE LIABILITY COMBINED SINGLE ANY AUTO LIMIT $ 100,000. ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS 1CP30005858300 (Per person) $ 12/28/91 12/28/92 X HIRED AUTOS BODILY INJURY X NON -OWNED AUTOS (Per accident) $ GARAGE LIABILITY PROPERTY DAMAGE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM WORKER'S COMPENSATION STATUTORY LIMITS EACH ACCIDENT $ AND DISEASE —POLICY LIMIT $ EMPLOYERS' LIABILITY DISEASE —EACH EMPLOYEE $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS CERTIFICATE HOLDER CANCELLATION The Monroe Cou .ty Building Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Public Service Building - Wing 11 EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO 5100 College Road MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE Stock Island, Fl. 33040 LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR ATTN: WENDY LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTA E ACORD 25-S (7/90) CACORD CORPORATION 1990 COUNTY OCCUPATIONAL LICENSE 1 991-1 9 92 M 0 N R O E COUNTY -STATE OF FLORIDA TAX 2 [. c0 THIS LICEN'lE EXPIRES S EP T'EM 471— `3—oa E E R 30 i 1992 COST AND �y� UNIE PENALTY RENTTNUri3ER OF UNITS HERE: TRANSFER FEE �I TOTAL DUE D Zm m z STATE CERTIFICATE NUMBER Ocn M m ^ WF °^' NARhY F. KRIGHTo C.F.C. r T TAX COLLECTOR 294-8403 a P.I.SOX 1129 KEY WEST. FL 33041-1129 Dm 50 DAVIS WATER ANALYSISPINC PLEASE SEE BACK OF FORM DAVISj,JOE PRESIDENT mz In THE AFOVE LICENSEE IS HEREBY PO 9CX 2584 LICiNS`tD TO ENCASE IN THE SUSINESS KEY WESTrFL 33040 PRIFESSION OR CCCUPATION OF TRiA+TMEyNyT SERVICE I�/�TT�SyE)WAr6�r_ /� (+ i pi ('_ 1 t11 L'Tflti Ft.Il1 F. K111 Vf1TTTT 2L.U'J l+K 10/10/71 �(�(�/�/j/�(�y(�(��(j�( 19TVl. T• 16 RMAI OOMB6'A TIE�CNVi 9►I11'M?IEN VALIDATED BY RECEIPTING dCCCUNT MUM3E:I I3 01060 MACHINE SHOWING TRANSACTION NUMBER, DATE. AND AMOUNT PAID LOCATION: bf 3c) FRONT ST STOCK ISLAND THIS LICENSE MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS STATE OF FLORIDA DEPARTMENT OF ENVIRONMENTAL REGULATION 10F �►VIROWAFF �\ t, -,fl StAtE OF FIOa�?P This acknowledges that JOE H. DAVIS has met the requirements of Chapter 403, Florida Statutes, and Chapter 17-602, Florida Administrative Code, and is licensed to perform the duties and responsibilities of a treatment plant operator. TYPE: CLASS B WASTEWATER LICENSE NO: 004504 ISSUED: 11 /27/89 - � cew.. Bureau Chief 4 ,1 — 4 - F�/w e�— Secretary of the Department SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a), FLORIDA STATUTES. 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 OATHS. 1. This sworn statement is submitted to Monroe Coun [print name of the public entity] by Joe Davis of Davis Water Analysis (President, Executive Director) [print individual's name and title] for [print name of entity submitting sworn statement] whose business address is P•0. Box 2584 Key WEst, FL and (if applicable) its Federal Employer Identification Number (FEIN) is (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 defined in Paragraph 287.133(1)(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 or services to be provided to any public entity or an agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. 3. I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes. 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: U 1. 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 convicted 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 a 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. 5. 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 state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of an entity. 7 6. Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement. [indicate which statement applies.] Neither the entity submitting this sworn statement, nor any of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to. July 1, 1989. The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 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 THAT THE SUBMISSION OF THIS FORM_ TO q!xyv OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABA!!, UBLIC FNTITY 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 STATUTES FOR CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. A. r- [signature] STATE OF [date] COUNTY OF PERSONALLY APPEARED BEFORE ME, the undersigned authority, [name of individual signing] who, after fast being sworn by me, affixed his/her signature in the space provided above on this day of , 19 My commission expires: NOTARY PUBLIC Form PUR 7068 (Rev. 04/10/91) STATE OF FLORIDA COUNTY OF MONROE SUBSCRIBED AND SWORN to ( ) before me on January 29, 1992 (date) by Joe Davis(name of affiant). He/ i�� ��ea�� -a never to -.me-- r.- has produced Florida Drivers License, D120-488-49-49 (type of identification) as identification. Wendy K Buxt Notary ldblic f AA681857 CERTIFICAT9 OF EXEMPTION FROM -COVERAGE UNDER WORKMEN'S COMPENSATION LAW TO; Bureau of Workmen's Compensation, Division of Labor, Department of Commerce, Tallahassee, Florida 32301 Fed. Emp. ID No. Re; Davis Water Analysis, Inc (Print Nome of Corporatlon) P.O. Box 2584 (Addrees) Key West, F1. 33040 (City) I/we, the undersigned officers) of the above named corporation, do hereby elect to be exempt from coverage under the Florida Workmen's Compensation Act. Type or Print each Officer's Name and Corporate Title Under Signature. i Signature: i c' .. �i !� 6 V Name and Title: Joe Davis — President Signature: Name and Title: Mark Burkemper — Treasurer/Secretary Signature: Name and Title-' (Send copy to insurance agent or carrier.) Name of Insurance Carrier Policy Number Effective Date Insurance Agent Southernmost Insurance Agent's Address 1104 Truman Ave.,Key West, Fl. 33040 Date jjf it. FDC Form WCF-207 (Rev. 4/78) 4377 &,j WC 677 (7.70) •a:.