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09/18/1991 Contracti 10 CONTRACT "9l .JAN 2 ( 11 :3 f HURRICANE SHUTTERS M NRC a r i.r THIS AGREEMENT, made and entered into this 18th day of September, 1991, A.D., by and between Monroe County, Florida, party of the first part (hereinafter sometimes called the "Owner"), and R. K. Exteriors & Aluminum Products party of the second part (hereinafter sometimes called the "Con- tractor"). WITNESSETH: That the parties hereto, for the consideration hereinafter set forth, mutually agree as follows: 1.01 SCOPE OF THE WORK The Contractor shall furnish all labor, materials, equipment, machinery, tools, apparatus, and transporta- tion and perform all of the work described in the Request for Bid entitled: HURRICANE SHUTTERS MONROE COUNTY, FLORIDA and shall do everything required by this Contract, other Contract Documents, and the Request for Bid. 1.02 THE CONTRACT SUM The Owner shall pay to the Contractor for the faithful performance of the Contract, in lawful money of the United States, as follows: A. The lump sum prices for each location as stated in the Contractor's proposals, attached hereto and incorporated herein as part of this agreement. B. The total amount of the contract shall be Thirty Nine Thousand Three Hundred Fifteen Dollars and Ei cents as more particularly U-escribed in each proposal. 1.03 CONTRACTOR'S ACCEPTANCE OF CONDITIONS A. The Contractor hereby agrees that he has carefully examined the sites and has made investigations to fully satisfy himself that such sites are correct and suitable ones for this work and he assumes full responsibility therefore. The provisions of the Contract shall control any inconsistent provisions contained in the specifications. All Specifications have been read and carefully considered by the Contractor, who understands the same and agrees to their sufficiency for the work to be done. Under no circumstances, conditions, or situations shall this Contract be more strongly construed against the Owner than against the Contractor and his Surety. B. Any ambiguity or uncertainty in the Specifications shall be interpreted and construed by the Owner, and his decision shall be final and binding upon all parties. C. The passing, approval, and/or acceptance of any part of the work or material by the Owner shall not operate as a waiver by the Owner of strict compliance with the terms of this Contract, and Specifications covering said work; and the Owner may require the Contractor and/or his surety to repair, replace, restore, and/or make to comply strictly and in all things with the Contract and Specifications any and all of said work and/or materials which within a period of one year from and after the date of the passing, approval, and/or acceptance ofany such work or material, are found to be defective or to fail in any way to comply with this Contract or with the Specificaiions. This provision shall not apply to materials or equipment normally expected to deteriorate or wear out and become subject to normal repair and replacement before their condition is discovered. Failure on the part of the Contracoor and/or his Surety, immediately after Notice to either, to repair or replace any such defective materials and workmanship shall entitle the Owner, if it sees fit, to replace or repair the same and recover the reasonable cost of such replacement and/or repair from the Contractor and/or his surety, who shall in any event be jointly and severally liable to the Owner for all damage, loss, and expense caused to the Owner by reason of the Contractor's breach of this Contract and/or his failure to comply strictly and in all things with this Contract and with the Specifications. 1.04 LIQUIDATED DAMAGES Time is of the essence of this Contract and should the Contractor fail to complete the emergency repairs within the specified time, or any authorized extension thereof, there shall be deducted from the compensation otherwise to be paid to the Contractor, and the Owner will retain the amount of Fifty dollars ($50.00) per calendar day as fixed, agreed, an iqui at�mages for each calendar day elapsing beyond the specified time for completion or any authorized extension thereof, which sum shall represent the actural damages which the Owner will have sustained by failure of the Contractor to complete the work within the specified time; it being further agreed that said sum is not a penalty, but is the stipulated amount of damages sustained by the Owner in the event of such default by the Contractor. 1.05 PAYMENTS In accordance with the provisions fully set forth in the General Conditions, and subject to additions and deductions as proved, the Owner shall pay the Contractor as follows: The OWNER shall, within thirty (30) days after receipt of each monthly Application for Payment, either make payment to the contractor or return the Application to the CONTRACTOR indicating in writing the reasons for refusing payment. However, the owner will require sixty (60) days to process the Final Application for Payment. 1.06 TERMINATION A. The performance of work or provision of goods under this agreement may be terminated, delayed, or temporarily suspended by the County, in whole or in part, from time to time, whenever the County shall determine that such termination is in the best interest of the County. The County shall pay all reasonable costs incurred by the contractor up to the time of termination, and all reasonable costs to the contractor shall not be reimbursed for any anticipatory profits which have not been earned up to the date of termination. B. If the contractor fails to fulfill the terms of this agreement, or attachments, properly or on time, or otherwise violates the provisions of the agreement or of applicable laws or regulations governing the use of funds, the County may terminate the contract by written notice. The notice shall specify cause. All finished or unfinished supplies or services shall, at the option of the County, become property of the County. The County shall pay the contractor fair and equitable compensation for expenses incurred prior to termination of the agreement, less any amount of damages caused by the contractor's breach. If the damages are more than compensation payable, the contractor will remain liable after terminaiion and the County can affirmatively collect damages. 1.07 INDEPENDENT CONTRACTOR At all times and for all purposes under this agreement the contractor is an independent contractor and not an employee of the Board of County Commissioners for Monroe County. No statement contained in this agreement shall be construed so as to find the contractor or any of his/her employees, contractors, servants, or agents to be employees of the Board of County Commissioners for Monroe County. 1.08 DISCRIMINATION Contractor shall not discriminate against any person on the basis of race, creed, color, national origin, sex, age, or any other characteristic or aspect which is not job related, in its recruiting, hiring, promoting, terminating, or any other area affecting employment under this agreement or with the provision of services or goods under this agreement. 1.09 ASSIGNMENT Contractor shall not assign this agreement, except in writing and with the prior written approval of the Board of County Commissioners for Monroe County, which approval shall be subject to such conditions and provisions as the Board may deem necessary. This agreement shall be incorporated by reference into any assignment and any assignee shall comply with all of the provisions of this agreement. Unless expressly provided for therein, such approval shall in no manner or event be deemed to impose any obligation upon the Board in addition to the total agreed -upon price of the services/goods of the contractor. 1.10 1.12 COMPLIANCE In providing all services/goods pursuant to this agreement, the contractor shall abide by all statutes, ordinances, rules and regulations pertaining to, or regulating the provisions of, such services, including those now in effect and hereinafter adopted. Any violation of said statues, ordinances, rules and regulations shall constitue a material breach of this agreement and shall entitle the Board to terminate this contractor immediately upon delivery of written notice of termination to the contractor. NOTICE AND SERVICE Any notice required or permitted under this agreement shall be in writing and hand delivered or mailed, postage prepaid, to the other party by certified mail, returned receipt requested, to the following: For County: EngineeringDepartment College5100 a Tt—o--cTc Island Key West, 71orida 33040 PROFESSIONAL RESPONSIBILITY For Contractor: R.K. Exteriors & Aluminum Products 89 Overseas Hi hwa Tavernier, Florida The contractor warrants that it is authorized by law to engage in the performance of the work encompassed by the project herein described, subject to the terms and conditions set forth in the specifications set forth in the Request for Bid for Hurricane Shutters. The provider shall at all times exercise independent, professional judgment and shall assume professional responsibility for the services to be provided. Continued funding by the Board is contingent upon retention of appropriate local, state, and/or federal certification and/or licensure of contractor. 1.13 FUNDING SOURCE In the event that County funding is partially reduced or cannot be obtained or cannot be continued at level sufficient to allow for the purchase of the services specified herein, this agreement may then be terminated immediately at the option of the Board by written notice of termination delivedred in person or by mail to the contractor. The Board shall not be obligated to pay for any services provided by the contractor after the contractor has received written notice of termination. 1.14 INSURANCE Contractor shall furnish all insurances as required by Monrore County Code, Monroe County Public Works Manual, all state and Federal Statutes. The Contractor shall furnish the Owner with certificates of insurance indicating current coverage in the minimum amounts herein stated. Minimum limitations of required insurances are: Public Liability $500,000.00 Property Damage $300,000.00 Workers Compensation $100,000.00 1.15 IMDEMNIFICATION The Contractor shall defend, indemnify and hold harmless the County, its officials, employees and agents from any and all claims, liabilities, losses and causes of action which may arise because of the Contractor's negligent actions or omissions. Compliance with the insurance requirements shall not relieve the Contractor from the obligations imposed by this Article. IN WITNESS WHEREOF the parties hereto have executed this Agreement on the day and date first above written in four (4) counterparts, each of which shall, without proof or accounting for the other counterparts, be deemed an original Contract* Monroe County Board of County Commissioners Party of the First Part By: Signed, Sealed and Witnessed the presence of:** t,jy Crl"y pi a nuy. 13. A993 Ponded Tnru troy F..in; Insurance Inci Attest: ANNY Iw YQhrSAGF� 0e. Atte t: c. tt (Seal) (*) In the event that the Contractor is a Corporation, there shall be attached to each counterpart a certified copy of a resolution of the Board of Directors of the Corporation, authorizing the officer who signs the Contract to do so in its behalf. (**) Two witnesses are required when Contractor is sole ownership or partnership. APPROVED AS TO FOAM _ . _.�rc7ClENCY _ DuIJ MONROE COUNTY EMERGENCY MANAGEMENT BOARD OF COUNTY COMMISSIONERS MONROE COUNTY, FLORIDA REQUEST FOR BID JULY 9, 1991 PROJECT: HURRICANE SHUTTERS TO BE INSTALLED ON SECTIONS OF STANLEY SWITLIK ELEMENTARY SCHOOL, MARATHON, FL, SUGARLOAF ELEMENTARY SCHOOL, SUGARLOAF KEY, FL, AND GLYNN ARCHER ELEMENTARY SCHOOL, KEY WEST, FL SCOPE: This project consists of the provision and installation of Panel Hurricane Shutters to be installed at Stanley Switlik Elementary School and Sugarloaf Elementary School and Accordion Hurricane Shutters at Glynn Archer Elementary School according to the specifications herewith enclosed. DOCUMENTS: All work specified herein shall be performed in accordance with the latest industry standards, the Standard Building Code, all applicable Federal, State, County and Local Codes, Laws, Ordinances, Rules and Regulations. EXECUTION: Bids to be considered shall be submitted to the Monroe County Clerk of Courts in accordance with the Notice of Calling for Bids announcement attached herewith. All bids shall be submitted on the attached bid form. Four complete copies of the bid shall be submitted with original signatures on each copy. Work shall commence within ten (10) days after the Notice to Proceed, and shall be completed within sixty (60) days of commencement of work. PERMITS AND Prior to commencement of the work, the contractor LICENSES: shall obtain all required permits. The contractor shall furnish copies of all current licenses as a part of the proposal. INSURANCE: Contractor shall furnish all insurances as required by Monroe County Code, Monroe County Public Works Manual, all State and Federal Statutes. The Contractor shall furnish the Owner with certificates of insurance indicating current coverage in the minimum amounts herein stated. Minimum limitations of required insurances are: Public Liability $500,000.00 Property Damage $300,000.00 Workers Compensation $100,000.00 INDEMNIFICATION The Contractor shall defend, indemnify and hold AND HOLD harmless the County, its officials,employees and HARMLESS: agents from any and all claims, liabilities, losses and causes of action which may arise out of the performance of the Contract except such claims, liabilities, losses and causes of action which may arise because of the County's negligent actions or omissions. Compliance with the insurance requirements shall not relieve the Contractor from the obligations imposed by this Article. PUBLIC The Contractor shall furnish the attached sworn ENTITY statement, fully complete and notarized, as CRIMES: required by law, as a part of his bid. NON -COLLUSION Any person submitting a bid or proposal in AFFIDAVIT: response to this invitation must execute the enclosed NON -COLLUSION AFFIDAVIT. If it is discovered that collusion exists among the bidders, the bid or proposals of all participants in such collusion will be rejected, and no participants in such collusion will be considered in future proposals for the same work. CONDITIONS: This project requires Contractor to furnish all labor, materials, tools, equipment, and machinery necessary for a complete installation of Hurricane Shutters on specified portions of all three schools. The following specifications/requirements shall apply to the shutters as minimum requirements: PANEL SHUTTERS: Storm Panels: Constructed of 20 gauge galvanized steel. Hurricane Clips: Stainless steel. Header and Sill: Constructed of extruded aluminum with wall thickness of .064. Removable Sills: All sills must be removable and will be fastened down with 1/4 - 20 stainless steel bolts with 5/8" flat slotted head that is fastened into a sleeve inserted into surface both during and after storage. Numbered System: Storm panel system to be numbered. ACCORDION SHUTTERS: Shutter components are of all extruded aluminum constructipn and exceed Coastline requirements. Test results from testing lab required. Shutters are hung in header with stainless steel wheel assembly for ease of opening and closing. Shutters are closeable from the inside of the building with inside locking capability. All fastenings to be stainless steel every 12" and sealed with silicone. All shutters are sealed across header and down sides with silicone. Header, centermates, sill sections and angles are 1/8" in thickness. Blade wall is 1/16" and blade nose is 3/8" and solid for full length of blade. Shutters shall be electrostatically painted with modified acrylic/polyester enamel applied over properly pretreated aluminum and baked at 350 degrees F. Finish must comply with ASTM and AAMA 603.8 standards. Shutters shall be erected in accordance with manufacturers' shop drawings. Any proprietary shutter system specified by the bidder must have been previously approved by the SBCCI, the Metro -Dade Products Control or any other similarly approved products control agency; bidder shall identify products control agency. Site visits are required and shall be arranged by phoning the Emergency Management Department at (305) 289-6018. SUGARLOAF ELEMENTARY SCHOOL, SUGARLOAF KEY, FL Furnish and install 20 gauge galvanized storm panels on the following areas of school: A. Seven (7) windows plus two (2) openings on back of cafeteria forming a hallway. B. Seventeen (17) windows of "L" shaped bldg for additional shelter. STORM PANEL SPECIFICATION Storm Panels: Constructed of 20 gauge galvanized steel. Hurricane Clips: Stainless steel. Header and Sill: Constructed of extruded aluminum with wall thickness of .064. Removable Sills: All sills must be removable and will be fastened down with 1/4 - 20 stainless steel bolts with 5/8" flat slotted head that is fastened into a sleeve inserted into surface both during and after storage. Numbered System: Storm panel system to be numbered. Panel Shutters for Sugarloaf Elementary School, Sugarloaf Key, Florida; Bid Price: $5, 932. 80 It is agreed by the undersigned Bidder that the signing and submittal of this Bid represents the Bidder's acceptance of the Terms and Conditions of the Specifications. Company Name: R.K. Exteriors & Alumiun Products (SP 1277) Address: 170 Overseas Hsghway City and State: Tavernier, o. • l o r t a Telephone Np Code: Zip � 3070 •1�251 852-1544 / 852 4229 By: (Authorized Signature) 8 / 9! 91 (Date) GLYNN ARCHER ELEMENTARY SCHOOL, KEY WEST, FL Furnish and install Accordion Shutters on twenty-three (23) windows of school with inside locking and all stainless steel fasteners every 12" and sealed with silicone. ACCORDION SHUTTER SPECIFICATIONS Shutter components are of all extruded aluminum construction (see attached component sheet) and exceed Coastline requirements. Shutters are hung in header with stainless steel wheel assembly for ease of opening and closing. All fastenings to be stainless steel. All shutters are sealed across header and down sides with silicone. Header, centermates, sill sections and angles are 1/8" in thickness. Blade wall is 1/16" and blade nose is 3/8" and solid for full length of blade. Accordion Shutters for Glynn Archer Elementary School, Key West, Florida; Bid Price: $ j4 _484 00 It is agreed by the undersigned Bidder that the signing and submittal of this Bid represents the Bidder's acceptance of the Terms and Conditions of the Specifications. Company Name: R.K. Exteriors & Alumiun Products (SP 1277) Address: verseas Hi hwa City and State:_ • Tavernier, Florida p 33070 Tele hone No.: Zip Codei2ntt 4229 By: ( Authorized Signature ) - R I ° 1g 1 (Date) STANLEY SWITLIK ELEMENTARY SCHOOL, MARATHON, FL Furnish and install 20 gauge galvanized storm panels on eighteen (18) openings on first floor of school, also panels to secure outside areas of school between stairwells and school building to allow movement from inside to second floor during a hurricane. STORM PANEL SPECIFICATION Storm Panels: Constructed of 20 gauge galvanized steel. Hurricane Clips: Stainless steel. Header and Sill: Constructed of extruded aluminum with wall thickness of .064 and stainless steel fasteners. Removable Sills: All sills must be removable and be fastened down with 1/4 - 20 stainless steel bolts with 5/8" flat slotted head that is fastened into a sleeve inserted into surface both during and after storage. Numbered System: Storm panel system to be numbered. Panel Shutters for Stanley Switlik Elementary School, Marathon, Florida; Bid Price: $ 8.899.00 It is agreed by the undersigned Bidder that the signing and submittal of this Bid represents the Bidder's acceptance of the Terms and Conditions of the Specifications. Company Name: R.K. Exteriors & Alumiun Products Address:g 1 (SP 1277 ) 70 Overseas Htghwau City and State Telephone No.- F l o r i d a Zip --� / 852 4229 By: (Authorized Signature) • JJV/ V ------------ -_919191 (Date) CASHIERS CHECK cgs® The Citizens and Southern Bank of Monroe County P.O. Box 278 Marathon, Florida 33050 ***R.K. ALUMINUM PRODUCTS*** REMITTER PAY 888BOARD OF COUNTY COMMISSIONERS*** TO THE ORDER OF' Notice to Customer: The purchase of an indemnity bond will be required before this check will be replaced or refunded in the event it is lost, misplaced or stolen. NO.011615 19 63-628 670 DOLLARS yy 1 AUTHORIZED SIGNATURE MCR164 1120 116 L SII' 1:06 7006 28 31: 00 7 70 2 SII' ----------------------------------------------.----------------------------------------- COUNTY OCCUPATIONAL LICENSE 1990-1991 009986 MONROE COUNTY-S1T#�bQ f f4TRIDA TAX THIS LICENSE EXPIRES SEPTEMBER 30,1991 COST AND PENALTY TRANSFER FEE__ SP 1277 (qualifier RICHARD KNODLE) TOTAL DUE STATE CERTIFICATE NUMBER MA11 ae"""' HARRY F KNIGHT TAX COLLECTOR TRIPLE K CANVAS/,AWNINGS P.O. BOX 1129 ZONIA GONZALEZ KEY WEST FL 33041 129 LAKE RD TAVERNIER FL 33070 PLEASE SEE BACK OF FORM ACCT 21539 LOC: 89170 OVERSEAS HIGHWAY MARINE CANVAS & AWNINGS & ALUMINUM PRODUCTS HFK/pja(�(,(��j((� 1) (} 3.00 CFI 01 / 1 �4/ 91 55f4 A417AQ,GMgppk� D41 t4Lq?7vHrGN vALIDATED DY ACCEIPTING MACHINE BHOWtNG TRAN$AC1I0N NUM6ER, DATE, AND AMOUNT PAID. ❑ COUNTY OCCUPATIONAL LICENSE iqq1992 11VV��� THIS LICENSE�RPP COUNT - E UFTEORIDA TAX 18.00 S SEPTEZEER 30,1992 COST AND 073412 PENALTY SP-1277 TRANSFER FEE STATE CERTIFICATE NUMBER TOTAL DUE 18.00 �m oN 1E "� 1 HARRY F KNI GIT TAX CX)IU CZC)R MITI R.K. EMERIORS & ALUMINUM PRODUCT'S T U P.O. BOX 1129 KI=LE RICHARD LEE DZI KEY WEST FL. 33041 183 ORLANDO DR :n4 TAVERNIER, FL. 33070' N Z `' PLEASE SEE BACK OF FORM ACCT 27664 IOC: 89170 OVERSEAS HIGHMY ALUNaNUM PRODUCTS 00NTRACTOR 1EX/pa A.LD*HARR'( F.KNIGHTak�>K '`~.'? C I2 / I5 '?; O �ri. �G,y �t yry. y�, ((��((��((��((}}��(ij� {{��((''�� qq `�'�TUIrrL'TFORIA 9E'�'OMES-A 17EIPT ONLV WHEN VALIDATED BV RECEIPTING MACHINE SHOWING TRANSACTION NUMBER. DATE. AND AMOUNT PAID. f THIS LICENSE MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS CASHIERS CHECK Cg$. The Citizens and Southern National Bank of Florida ***R.K. ALUMINUM PRODUCTS*** REMITTER PAY ***DAIM KOLHAGE CLERK M THE B.O.C.C.*** TO THE ORDER OF' C& �' 8, 6 8 6 Y1t 11"� 4 1 ct� Notice to Customer: The purchase of an indemnity bond will be required before this check will be replaced or refunded in the event it is lost, misplaced or stolen. 116y5U5U6114 1 U6'I'UU9U99':88 08944867711' No. 750506 19 JAN 2 4 1992 *$*8, 686.41*** DOLLARS .�- `' d b�4 AUTHORIZED SIGNATURE 10 +�11:. -CERTIFICATE OF INSURANCE ISSUE DFT ff/(u! 1Y) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS Mc.JG`1:1SOI7S Insurance A�jGI1Clr NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW 39015 Overseas Iiigiiway Tavernier, Fla. 33070 COMPANIES AFFORDING COVERAGE CODE INSURED SUB -CODE i'rl;'il% .:. Canvas AllouidffL II 163 Orive 's'avcrnier, ; la. 33,070 COMPANY A _ LETTER GraMada Insurance Coinpa.#y COMPANY B LETTER COMPANY C LETTER COMPANY D LETTER GJMPANY 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. O TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION ALL LIMITS IN THOUSANDS TR DATE (MM/DD/YY) DATE (MM/DD/YY) GENERAL LIABILITY .� X COMMERCIAL GENERAL LIABILITY GLO O O �% li 2 CLAIMS MADE OCCUR. OWNER'S & CONTRACTOR'S PROT. AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS GARAGE LIABILITY EXCESS LIABILITY OTHER THAN UMBRELLA FORM WORKER'S COMPENSATION AND o. EMPLOYERS' LIABILITY OTHER )ESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS GENERAL AGGREGATE $ 500 3/ 2 2/ 91 3/ 2 2/ 9 2 PRODUCTS-COMPIOPS AGGREGATE $ 13 a1�l0 PERSONAL & ADVERTISING INJURY $ nVIIC� EACH OCCURRENCE $ _50 0 FIRE DAMAGE (Any one fire) S i10110— MEDICAL EXPENSE (Any one person) $ COMBINED SINGLE $ LIMIT BODILY INJURY $ (Per person) BODILY INJURY $ (Per accident) PROPERTY $ DAMAGE EACH AGGREGATE OCCURRENCE a s installantion of aluminulli oroductsw<: nd canvas products STATUTORY $ (EACH ACCIDENT) $ (DISEASE —POLICY LIMIT) $ (DISEASE —EACH EMPLO) CERTIFICATE HOLDER CANCELLATION w __ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE nonroe C;eheay EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO Ke`iestE'11Fla Street3050 MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE IC`=j� '.'1eSt, Fla. 33GJ0 LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY,& ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. ACORD 25•S (3/11111!L ..L"A-, IN �/ w ©DACORD CORPORATION 1988 a CONSTRUCTION INDUSTRY NOTICE OF ELECTION TO BE EXEMPT FROM THE PROVISIONS OF THE FLORIDA WORKERS' COMPENSATION LAW MAIL TO-. Department of Labor & Employment Seitic tjr' �- �•.i.7 ' E� 1 -- - 6TATE US1l; ONLY - _ Bureau of W.C. Compliance POSTMARK DATE 2728 Centerview Drive, 100 Forrest Bid$. effect Tallahassee, Florida 32399.OMI This notice shall fbe in effect for two (2) yeArs from the AWJk T__.._ effective date otT C I until�' , PLEAS; TYPE r —1 4g or until revoked, whichever coams first, (Legal Bwinealt Namof Sole I'roprietnr;tlip, Paltottfttip, or Corporation) �ce m r rl Lf 1?1 �,eoti % T (UB/A If Ayplicapk) (Mailing Addtcll) (Street Addtc,e, it dirretent)— r) t e F 3 ?) 0 (City) Mate) (7Jp) (Feder■I Employer Idemiltentiwt Nutt _o . Nature of Buginc33 or 'Grade; � I tr(l � J r) U JY1 Q ,e fl qUG / S //)5 � ���� / ....As of 3t2.d4iiallowing the rintn ar.Lbs- railing of this f o�rre� Ift�rttta�t7 [t�ltpwing • ole Proprieicir; Partner or Corporate Officer of the above named business does ele to be ciu mp(` the pMvisionss t�f the:Plor Workeii' Compensation Law. I understand that by this action I am not entitl to. n fits in' tder chapter 440,, gf;da iS� "lRy filing this form I have not exceeded the exemption limit of three Partners or th o rate Officers. futtlw,c(o'tt any�employeL%; o, Vie business named above are covered by workers' compensation insure s"'a T1w. following are the certified or mgistcred licenses held by ute; pursuant to chapter 489 Florida Statultes TIf no+,•s�te): (1) 'rype=� G' Number: �%a r2 17 (2) Type: Number, INSURANCE CARRIER INFORMATION (If Applicable): A construction industry employer with one (1) or mote employees must maintain Workers' Compensation coverage. Niiure to comply will result in a five -hundred dollar ($SW) fine and a one -hundred dollar ($100) One for each day of noncompliance; (set: section 440.43, P.S.). Namc,of Carrier Carrier Arldrvss Policy Number EFE&CCi TIME DAT>v Insurance Agcnt (Agency).. Agency Addius ✓Signature Social S�Number "/Pttint Name eG %S%�I!m Position: Proprietor /Partner .. —/or/Officer (Title) n'(i IMPORTANT: Individual exemption filing fee, pursuant to Section 440,05, F.S., is seven dollars and. fifty cents ($7.50) and is Payable only by money order or eawhicr's check, to W.C. Administrative Trust Fund. WIure to enclose'fee will result in return of request and delay of certification. SWOR '10 AND SUBSCRIBED BEFORE MF THIS __ DAY OF L7'--' , AT �-�, FLORIDA _.., 1iureau of W.G. Compliance Null ry P�,:Gr: Sts"e of P.)ua �_. My 13, IM Lw"d Th.. Tmy r.t„- 1.,....... ., 11.y My Nmw�(o■�B Ndiei:� LF_S rnnm rwu 7m t%17I011 SWORN STATEMENT UNDER SECTION 287,133(3)(a), FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. 1. This sworn statement is submitted with Bid, proposal or Contract No. for t� (`S)U- CK C M miX 14 1 C ,-,_ tfG 1, e r"G �\ 1) Q-P �_- J 2. This sworn statement is Submitted by. to hca r)p4 I c­ whose business address is A, _ i_ C'a i0 t (a ll,c m in�tn _ Y(1 o cC . 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: 3. My name is 1ACILd E ei and my relationship to the entity named above (please print name ot individual signing is O(,yn4- 4. I understand that a 'public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a violation of an state or federal law by a person with respect to and directly fcjated to the transaction of business with any public entity or with an agency or political subdivision of other State or with the United- States including but not limited . an, 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, " tacketeedrig, °conspiracy, or material misrepresentation. 5. 1 understand that 'convicted" or 'conviction" as defined in Paragraph 287.133(1)(b)t Florida .Statutes, ttttr6tls I finding of guilt nr a crinvictinn of a pnhBr, n7rity crime., with nr kitl'in t An aration of guilt, in any federal or state trial court of record relating to charges brought by indictmcnt or information after July 1, 1989, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or polo contenders. 6. I understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes, meats: a. A predecessor or successor of a person convicted of a public entity crime: or or b. 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 controlled interest in another person, or a pooling of equipment or income among persona wI cn not for a 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. 1 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 t;tatc or of the toted 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. T"he term "person' includes those officers, directors, executives, partners, shareholders, employees, members and agents who are active in management of as entity, 8. Bascd on intormation and belief, the statement which ! have marked below in true in rclatidie to the entity submitting this swam statcmcnt, (Please indicate which statement applies.) Neither the entity submitting this swam statement, nor any officers, directors, axccutivcs, partners, shareholders, employees, members, or agents who are active in management of the entity, nor any affiliate of the entity have been cliargcd with and convicted of a public cntity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of (lie officers, directors, executives, partners shareholders, employees, members, or agents who are active in management of the entity, or an ahliate of the entity has been charSed with and convicted of a public entity crime subsequent to July 1, 1989► AND (Please indicate which additional statement applies). There has been a procecdinjconcerning the conviction before a hearing officer of the t5te of Florida, Division of Administrative fleaHri s. The final order entered- by the hearing officer did not place the person or affiliate on the convicted vendor list. (1111case attach a copy of the final order.) The person or affiliate was placed on the convicted vendor list, Tliere has been a su sequent proceeding before a hearing officer of the State of Florida, Division of Administrative Hearings. The final order entered by the hearing officer determined that it was in the public interest to remove the person or affiliate from the convicted vendor list. (Please attach a copy of the final order.) The person or affiliate has not been )laced on the convicted vendor list. (Please cii ri a any action taken by or pending with t9c Department of General Services,) signature FORM PUR 7068 (Rev. 11/89) Date:' pT � Gl SWORN STATEMENT UNDER ORDINANCE NO. 010-I990 MONROE COUNTY, FLORJDA E7MCS CLAUSE 41 L ' (— warrants that it has not employed, retained or otherwise hid act oa rta a any ormer County officer or employee subject to the prohibition of Sccdon 2 of Ordinance No. 010-IM or any County officer or en't loyee in violation of Section 3 of Ordinance No. 010.1990. 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 of purchase price, or otherwise , recover, the fall amount of anI fee, commission, percentage, gift, or consideration paid to the former County officer ar' 6416yce . signature Date:� STATE OF C COUNTY OF %%/Q,7 /tom PERSONALLY APPEARED BEVORE ME, the undersigned authority, who, after first being sworn by me, affixed his/her space provided above on tWs_ day of My commission expires: 11 `9 Benceu Tl— Troy Fzin - insurance Inc. signature (name ofBB individual signing) in the e rye_ 19"3 /L ROTARY PUJ31,5