06/06/2019 Agreement I
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ATTACHMENT-D.6 .
j COUNTY ADMINISTRATOR
CONTRACT SUMMARY FORM FOR CONTRACTS LESS THAN$50,000.00
Contract with: .Know-A-Fence Co_ . _ Contract If ,
Effective Date:
Expiration Date:
Contract Purpose/Description:
Removal of fencing damaged during Hurricane Irma and replacement of 320ft of chain
link fence at Rowell's Waterfront Park.
Contract is Original Agreement Contract Amendment/Extension Renewal
Contract Manager: Breanne Erickson X 4427 Project Mgmt/#1
(Name) (Ext.) (Department/Stop#)
r
CONTRACT COSTS
Total Dollar Value of Contract: $ 6,400.00 Current Year Portion:$ 6,400.00
(must he less than$50,000) (if multiyear agreement then
requites DOCC approval,unitss the
total wuudtuitc arruurtt t%its ticut
S50 3100 IH1)
Budgeted? YesD No® Account Codes: 125-0459110-IRMONRGI-530460-
Grant:$ Yes - - - -
County Match:$ 800.00
75% Federal, 12.5% State, 12.5% County -
ADDITIONAL COSTS
Estimated Ongoing Costs:$ /yr For:
(Not included in dollar value above) (c. maintenance.utilities'janitorial.salaries.etc.)
CONTRACT REVIEW
Changes Date Out
Df� Needed i er
•
Department Head G(5 // YcsD Ng 6/C./Xi
Risk Management L -9-11 Yes[] Nog -ly
O.M.B./Purchasing WWII YesU NoM 77
,„
County Attorney 0 /U "1 YesD NV
it
Comments:
`
{ t Monroe County Engineering
" 1100 Simonton Street,2-216
7 I Key West,FL 33040
' •�+ is r-r Project Management
_ PROPOSAL TO: _Monroe County Project Management _
1100 Simonton St., Room 2-216
Key West, FL 33040
PROPOSAL FROM: g litnd -A- 'Ne-LC CO •
Vigil Du -ste- -s I-eM+Y
tih .a . F - 3;031-
The undersigned, having carefully examined the Work and reference Drawings,
Specifications, Proposal, and Addenda thereto and other Contract Documents for
the construction of:
ROWELL'S WATERFRONT PARK FENCING
HURRICANE REPAIRS
and having carefully examined the site where the Work is to be performed, having
become familiar with all local conditions including labor affecting the cost thereof,
and having familiarized himself/herself with material availability, Federal, State,
and Local laws, ordinances, rules and regulations affecting performance of the
Work,does hereby propose to furnish all labor, mechanics,superintendents,tools,
material, equipment, transportation services, and all incidentals necessary to
perform and complete said Work and work incidental hereto, in a workman-like
manner, in conformance with said Drawings, Specifications, and other Contract
Documents including Addenda issued thereto.
The undersigned further certifies that he/she has personally inspected the actual
location of where the Work is to be performed, together with the local sources of
supply and that he/she understands the conditions under which the.Work is to be
performed. The proposer shall assume the risk of any and all costs and delays
arising from the existence of any subsurface or other latent physical condition •
which could be reasonably anticipated by reference to documentary information
provided and made available, and from inspection and examination of the site.
The undersigned agrees to commence performance of this Project within ten (10)
calendar days after the date of issuance to the undersigned by Owner of the
Purchase Order. Once commenced, undersigned shall diligently continue
performance until completion of the Project. The undersigned shall accomplish
Substantial Completion of the Project within Thirty (30) calendar days. The
undersigned shall accomplish Final Completion of the Project within Thirty (30)
calendar days thereafter.
Page 18 of 29
a--.<r.4
1Ii!..
1 Monroe County Engineering
' • 1100 Simonton Street.2-21G
Key West.FL 33040
Project Management
The Base Proposal shall be furnished below in words and numbers. If there is an
Inconsistency between the two, the Proposal In words shall control.
a0
5,X 1 a ,t-mb Pow- ,HuNr'iCb io0 — Dollars
(Total Base Proposal-words)
$ fe,'100.00 Dollars
(Total Base Proposal—numbers)
I acknowledge Alternates as follows:
Alternate#1
Dollars
(Alternate#1-words)
$ Dollars
(Alternate#1—numbers)
I acknowledge receipt of Addenda No.(s)or None
No. Dated
Page 19 of 29
Monroe County Fnginoatng
1100 Simonton Sltaet,2-216
Kay West,FL 33040
< ;" Project Management
In addition, Proposer states that he/she has included a certified copy of Contractor's
License, Monroe County Occupational License, and Certificate of Liability showing the
minimum Insurance requirements for this project.
Execution by the Contractor must be by a person with authority to bind the entity.
IN WITNESS WHEREOF, the parties have caused this Agreement to be executed by
their duly authorized representatives, as follows:
Contractor: -4 - A cAr co.
Mailing Address: gt a• Lam}-ntcr L444
litt.--V �- p1-- S'303q
Phone Number: er x .13 to •$ tl
E.I.N.: 12-34$1, t43ti
Email: 1>3e. ow ay-c A u'/, tom•
Date: ram-3 CIA Signed: ,4r,e1A(A------"
(Name)
,tom ttti1'
(Title)
Contractor's Witness signat e:
772/ 2 -
Witness name: .0. .14- john$o '
Date: i:� - 3--
M n N OE COU
44 Date: 1 ' /5,
C ry Kit g It- Director of Project Management
MONRO COUPP1EY
(VS7- S FORM
I,
CHRIS AMBROSIO
AS T.9(NT, LINTY ATTORNEY
Date: L l g
� !` Monroe County Engineering
g fir' 1100 Simonton Street,2.216
Key Wert,FL 33040
J •
S'€Q_, ., _ 5,6 ne.„, Project Management
__ _ Minority.Owned Business Declaration _ _
`G r -A-- ivt-e ,a sub-contractor engaged by Monroe County during the
comple 'on of work associated with the below indicated project
(.heck one)
is a minority business enterprise,as defined in Section 288.703, Florida Statutes
or
✓ is of a minority business enterprise,as defined in Section 288.703,Florida Statutes.
F.S. 288.703( "Minority business enterprise"means any small business concern as defined in
• subsection(6)(s,e below)which is organized to engage in commercial transactions,which is
domiciled in Flo a, and which is at least 51-percent-owned by minority persons who are
members of an ins ar group that is of a particular racial,ethnic,or gender makeup or national
origin,which has be, subjected historically to disparate treatment due to identification in and
with that group result',g in an underrcpresentation of commercial enterprises under the group's
control,and whose man,gement and daily operations arc controlled by such persons.A minority
business enterprise may t 'manly involve the practice of a profession. Ownership by a minority
person does not include os► ership which is the result of a transfer from a nonminority person to
a minority person within a rt. ated immediate family group if the combined total net asset value
of all members of such family soup exceeds S l million. For purposes of this subsection,the
term"related immediate family ,.roup"means one or more children under 16 years of age and a
parent of such children or the spit).se of such parent residing in the same house or living unit.
F.S 288.703(6)"Small business"m ans an independently owned and operated business concern
that employs 200 or fewer permanen full-time employees and that,together with its affiliates,
has a net worth of not more than$5 m lion or any firm based in this state which has a Small
Business Administration 8(a)certificati 61.As applicable to sole proprietorships, the$5 million
net worth requirement shall include both ersonal and business investments.
Contractor may refer to F.S. 288.703 for m.re information.
Coat ctor Sub-Recipient: Monroe County
S. t ignature
Print Name: 2:) -yjp /',{R i t K- Pri ted Name:
Title: p yt Title/ • B Department:
Verified ia:
https://osd. ms.mvllorida.com/directories
Address: qa it ovtivsca�
DEM Contract. Z0002
City/State/Zip Wit/ l.A um, (t-33or
Date: Sit//q FEMA Project Numb :
Page 21 of 29
'7 Mauve County Cn I:aia
t. . �7 1100 Simonton Street,2.2t6
+� f Key West,FL 33040
Project Management
Minority Owned Business Declaration
/LNUw-h--N.t co. ,a sub-contractor engaged by Monroe County during the
completion of work associated with the below indicated project
(Check one)
is a minority business enterprise,as defined in Section 288.703,Florida Statutes
or
✓ is not a minority business enterprise,as defined in Section 288.703,Florida Statutes.
F.S.288.703(3) "Minority business enterprise"means any small business concern as defined in
subsection(6Xsee below)which is organized to engage in commercial transactions,which is
domiciled in Florida,and which is at least 51-percent-owned by minority persons who arc
members of an insular group that is of a particular racial,ethnic,or gender makeup or national
origin,which has been subjected historically to disparate treatment due to identification in and
with that group resulting in an undcrreprescntation of commercial enterprises under the group's
control,and whose management and daily operations are controlled by such persons.A minority
business enterprise may primarily involve the practice of a profession.Ownership by a minority
person does not include ownership which is the result of a transfer from a nonminority person to
a minority person within a related immediate family group if the combined total net asset value
of all members of such family group exceeds S l million.For purposes of this subsection,the
term"related immediate family group"means one or more children under 16 years of age and a
parent of such children or the spouse of such parent residing in the same house or living unit.
F.S 288.703(6)"Small business"means an independently owned and operated business concern
that employs 200 or fewer permanent full-time employees and that,together with its affiliates,
has a net worth of not more than S5 million or any firm based in this state which has a Small
Business Administration 8(a)certification.As applicable to sole proprietorships,the S5 million
net worth requirement shall include both personal and business investments.
Contractor may refer to F.S.288.743 for more information.
Sub-Recipient: Monroe County
ittotC‘ 64,t'%•64.0
S' t ignature
Print Name:_,7"L1-vTh at,t i&,c.- Printed Name: J14,11 C64.✓'e 4
ma ac1ev t,er ‘-• y.4l r`Qss Se�'�aCAS
Title: pwuacn- Title/OMB D'cpartmcnt: fkdywrty;t1s5cra r
Verified via:
biwzfigglAniumyllorkinsondireciptio.
Address: gee Kl/ w+wtit.a 113/
DEM Contract: Z0002
City/State/Zip Atc1/ r dttrno IL$So?1
Date: Sir /g FEMA_Project Number:
Page 21 of 29
eP 1 r 'h
Monroe County Engineering
t. r II00 Simonton Street.2.21G
;
KcyWest,FL 330,10
Project Management
Certification Regarding .. __ _
Debarment, Suspension, Ineligibility
And Voluntary Exclusion
Contractor Covered Transactions •
(1) The prospective contractor of the Recipient, lam, FT2LC co. , certifies, by
submission of this document, that neither it nor its principals is presently debarred,
suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from participation in this transaction by any Federal department or agency.
(2) Where the Recipient's contractor is unable to certify to the above statement, the
prospective contractor shall attach an explanation to this form.
CONTRACTOR:
JAL+•A--Pb'i lLtc co•
B
gnature Recipient's Name
2)1W 044u434' - o -
Name and Title . Division Contract Number
lVteIut ' ""- a
Street Address FEMA Project Number
ite-ei 3 07
City, Stat , Zip
6-- f-j t
Date
Page 22 of 29
•
• Monroe County Engineering
'4 IP I. 1100 Simonton Street.2-2 tO
y J Key West.FL 330-0
Project Mnnngement
VENDOR CERTIFICATION REGARDING SCRUTINIZED COMPANIES LISTS
Project Description(s): 12.411.4t'1.4•'S t.kre.-rNLP - .'v" P4'+C- l l ,l4 yr cr��-1ws
Respondent Vendor Name: pLArtrt.,-4 -FLc r et).
Vendor FEIN: '2 -3'f -4 3Vci
Vendor's Authorized Representative Name and Title: DA-vi D Wt I _t,l;'W - o wr+
Address: ¶'t' (1 ow+lcj4 >F{t
City: wry est-4-6 o State: Fe. Zip: 77071-
Phone Number f 3- Email Address: roil a it-Now A-Pr.wC.c6t '.twos.
Section 287.135, Florida Statutes prohibits a company from bidding on, submitting a proposal for, or
entering into or renewing a contract for goods or services of any amount if, at the time of contracting or
renewal,the company Is on the Scrutinized Companies that Boycott Israel List,created pursuant to Section
215.4725,Florida Statutes,or is engaged In a Boycott of Israel.
As the person authorized to sign on behalf of Respondent, I hereby certify that the company identified
above In the Section entitled"Respondent Vendor Name"Is not listed on the Scrutinized Companies that
Boycott Israel List or engaged in a boycott of Israel and for Projects of$1,000,000 or more is not listed on
either the Scrutinized Companies with Activities in Sudan List,the Scrutinized Companies with Activities In
the Iran Petroleum Energy Sector List,or engaged in business operations in Cuba or Syria.
I understand that pursuant to Section 287.135,Florida Statutes,the submission of a false certification may
subject company to civil penalties,attomey's fees,and/or costs.I further understand that any contract with
the COUNTY may be terminated,at the option of the COUNTY,if the company is found to have submitted
a false certification or has been placed on the Scrutinized Companies that Boycott Israel List or engaged
in a boycott of Israel or placed on the Scrutinized Companies with Activities In Sudan List or the Scrutinized
Companies with Activities in the Iran Petroleum Energy Sector List or been engaged In business operations
in Cuba or Syria.
Certified by: 2),It-v►D $'s4L4 "$— ,who Is authorized to sign
on behalf of the above refs c� any.
Authorized Signature: !cf
Print Name: Z r,
Title: 01.rw 5b%-
Note:The List are available at the following Department of Management Services Site:
http:/lwww.dms.myflorida.comlbusiness operations/state purchasinglvendor informationlconvicted susp
ended discriminatory complaints vendor lists
SCRUTINIZED COMPANIES LISTS Page 23 of 29
• :74 r .1").
Monroe County Engineering
1100 Simonton Street,2-216
.trKey West,FL 33040
Project Management
NON-COLLUSION AFFIDAVIT
I, pA-tn.be of the city ?-••(
according to law on my oath, and under penalty of perjury, depose and say that:
1. I am 6w14":10-
of the firm of 1LNow- LAC CD•
the proposer making the Proposal for the project described in the notice for
calling for proposals for:
V10 w tc L . w Mf tcwf-V-vN'r VI-CP PA-t rt-
and that I executed the said proposal with full authority to do so;
2. The prices in this proposal 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 proposer or
with any competitor; and
3. Unless otherwise required by law, the prices which have been quoted in this
proposal have not been knowingly disclosed by the proposer and will not knowingly
be disclosed by the proposer prior to proposal opening,directly or indirectly,to any
other proposer or to any competitor; and
4. No attempt has been made or will be made by the proposer to induce any other
person, partnership or corporation to submit, or not to submit, a proposal for the
purpose of restricting competition; and
5. The statements contained in this affidavit are true and correct, and made with full
kno ge f id p ' t.
ignature ro oser) (Date)
STATE OF: l!'�1 4/, AAA,-
COUNTY OF: 11 (
PERSONALLY APPEARED BEFORE ME, the undersigned authority, litt'a J P1tlt"'1Z
who, after first being sworn by me, (name of individual signing)affixed his/her
signature in the space provided above.
on this ' I day of L420 IQ .
�hIQ NOTARY P BLI
nn
My commission expires: Ub %6
f� '•, MARYRQGAN
t\•.( t Nc:aryPuDISC-5'd:cofFlond.t
• M CDT n sII.I'GG VAS
:O.
; lJq[omn.6plrecaunC.W1
PUBLIC ENTITY CRIME STATEMENT Page 24 of 29
y } Monroe County EngineeringH,4,. , J 1100 Simonton Street.2-216
,, 1 r Key Welt,1 L 33040
Project Management
LOBBYING AND CONFLICT OF INTEREST CLAUSE
SWORN STATEMENT UNDER ORDINANCE NO. 010-1990
MONROE COUNTY, FLORIDA
ETHICS CLAUSE
" "A O-U— A- Ftc lr ib' "
(Company)
"... warrants that he/it has not employed, retained or otherwise had act on his/its behalf
any former County officer or employee in violation of Section 2 of Ordinance No. 010-
1990 or any County officer or employee 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 or
purchase price,or otherwise recover,the full amount of any fee, commission,percentage,
gift, or consideration paid to the former Count fficer or emp yee".
Si natur
Date: r - 3- /1
STATE OF: ((DNA
COUNTY OF: UYk•t l 4'10.1 Z t ���
Subscribed and sworn to (or affirmed)before me on
(date)
by 1&"1 ,1 akt1 1 (name of affiant). He/She is personally known
to me
or has produced 1)1-iitttioD POI ION) as dentifi ion. (Type of Identification)
NOTARY h
My commission expires: Deb OkklaPI
(SEAL)
muyRoGAN
y„.".1 'aatarytyr;,�.s..,trciik,,IL.,
k•".t } Ccmmst'a,a
i+ S: GGtitul5
414 G.iA71
PUBLIC ENTITY CRIME STATEMENT Page 25 of 29
- t
4 .*
Monroe County Engineering
it
1100 Simonton Street,2-216
'•� •` Key West.FL 33040
Project Management
DRUG FREE WORKPLACE FORM
The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies
that:
/L/VM e 4- per_ cc) .
(Name of Business)
1. Publishes 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. Informs 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. Gives each employee engaged in providing the commodities or contractual
services that are under proposal a copy of the statement specified in subsection
(1).
4. In the statement specified in subsection (1), notifies the employees that, as a
condition of working on the commodities or contractual services that are under
proposal, 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 occurring in the workplace no later than five (5)
days after such conviction.
5. Imposes 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. Makes 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 above requirements.
ro oser's Signature
s--i- n
Date
PUBLIC ENTITY CRIME STATEMENT Page 26 of 29
PUBLIC ENTITY CRIME STATEMENT
"A person or affiliate who has been placed on the convicted vendor list following a
conviction for public entity crime may not submit a bid on a contract to provide any goods
or services to a public entity, may not submit a bid on a contract with a public entity for
the construction or repair of a public building or public work, may not submit bids on leases
_ of real_propertyto public entity, may not be awarded or perform work as a contractor, - -
supplier, subcontractor, or CONTRACTOR under a contract with any public entity, and
may not transact business with any public entity in excess of the threshold amount
provided in Section 287.017, Florida Statutes, for CATEGORY TWO for a period of 36
months from the date of being placed on the convicted vendor list."
I have read the above and state that neither
A-L'riD KA1(-4.04_ (Proposer's name)nor any Affiliate
has been pl d21on t e co is d vendor list within the last thirty-six(36) months.
(Signatur
Date: s-3 -/1
STATE OF: rOriliaa-
COUNTY
OF: ,r e
22r`
Subscribed and sworn to (or affirmed) before me on the J ' day of Lk
20 ICI , by ' I4 \lk tl\erg c (name of affiant). He/She is
p rsonall known to me or has produced
L)L Mibo(7ocf i 0�b0 (type of identification)as
identification.
My Co i sf n ires: aJ 06 •
N T UBLIC
(SEAL) •
jj d. a %1AaYRCGAN
(` l !�OIary F}OIC-State o!'O'''
.`.e:P �; COrl:NISCr a
1G�i3d,5
PUBLIC ENTITY CRIME STATEMENT Page 27 of 29
Monroe County Engineering
avn w 1100 Simonton Street.2-216
Kcy West,FL 33040
Project Management
DISCLOSURE OF LOBBY ACTIVITIES
Certification of Contracts,Grants,Loans and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief,that:
(1) No Federal appropriated funds have been paid or will be paid by or on behalf of the
undersigned to any person for influencing or attempting to influence an officer or employee of any
agency, a member of Congress,an officer or employee of Congress or an employee of a member
of Congress in connection with the awarding of any Federal contract, the making of any Federal
Grant, the making of any Federal loan, the entering into of any cooperative agreements and the
extension,continuation,renewal,amendment or modification of any Federal contract,Grant, loan
or cooperative.agreement.
(2) If any funds other than Federal appropriate funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency,a member
of Congress, an officer or employee of Congress or an employee of a member of Congress in
connection with this Federal contract,Grant,loan,or cooperativd agreement,the undersigned shall
complete and submit Standard Form-LLL, "Disclosure of Lobby Activities", in accordance with
its instructions.
(3) The undersigned shall require that the language of this certification be included in the
award documents for all sub-awards at all tiers (including subcontracts, sub-grants and contracts
under Grants, loans and cooperative agreements) and that all sub-recipients shall certify and
disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making
or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who
fails to file the 1 uircd certifi•ation shall be subject to a civil penalty of not less than$10,000 and
not more th 'iO pit for / such failure.
Signed: Dated: - / -'if
Co• sr'• 'ut iorizcd Representative
PUBLIC ENTITY CRIME STATEMENT Page 28 of 29
,Rc'*% ••!
At Mommc County fngmccong
. 11(10 Sinontun tilted.2-216
Kcy µ'clt.FL 11040
PIIIICtI Managcntcnl
EXHIBIT "A"
Site Ma 1 of Fencin 1 Re F airs
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•
4.. Fencing Area to Be Replaced
EXHIBIT "A" Page 29 of 29
CONTRACTOR ID 1 LICENSE M CERTIFICATE OF COMPETENCY NUMBER: CERTIFICATE TYPE:
15548 I AP18040008 SP4397 FENCE ERECTOR CONTRACTOR
MONROE COUNTY GROWTH MANAGEMENT -BUILDING DEPARTMENT
Middle Koys/Mein Office:2798 Overseas Highway.Marathon,FL(305)289-2501
Lower Keys Ot6ce:5503 College Road,Key West.FL(305)295-3990
Upper Koys Office: 102050 Overseas Highway,Key Largo,FL(105)453-8800
.1161)1 CR 905.Koy Largo,FL(305L 453-87¢5 -
CERTIFICATE OF COMPETENCY
I IMPORTANT:CONTRACTOR CERTIFICATE OF COMPETENCY ENCLOSED I
MILLER,DAVID JAMES
306 LANCE LANE
KEY LARGO FL,33037
Dear Certificate of Competency Holder:
Please find below your renewed Monroe County Certificate of Competency.
Please note:
• You have agreed to abide by the requirements found in Monroe County Code 6-234
• It is the certificate holder's responsibility to notify this office in writing of any legal name and/or address
changes by completing the Name and/or Address Change Form.(Obtained from our website at
wvnw,monroe county-fl.gov).
• Journeyman and Masters are NOT contractors,and therefore,are prohibited from contracting,and shall
only perform work in their trade while under the supervision and direction of a licensed contractor of same
category.
• Contracting shall only be done under the qualified business name. This license does NOT belong to the
Company and may NOT be renewed or used by another individual or company other than the license
holder named herein for any construction purposes
• If you are inactive, you may NOT contract to do work or pull a permit,and you do not need to have current
Insurances on file.
Thank you.
MONROE COUNTY GROWTH MANAGEMENT
BUILDING DEPARTMENT � <<
CERTIFICATE OF COMPETENCY
This Is to certify that the contractor
listed is in good standing. Issue date: 12/10/2018
This certificate according to law of Expiration date: 10131119
competency is valid and in force Qualifier: MILLER, DAVID JAMES
unless revoked until the noted Company name: KNOW A FENCE COMPANY
expiration date below.
License type: FENCE ERECTOR CONTRACTOR (SPs
Red 9itetlP County license: SP4397
BUILDING OFFICIAL
RECEIPT 10019076 Cont.1D: 16548 AMOUNT PAID $ 75.00
0:\GOCW91\MAR\PERMIT\COCREr1EWED.dot—Printed Monday, December 10,2018
co�a�ul' CERTIFICATE OF LIABILITY INSURANCE DATE
('°uosery")
05040018
MS CERTIFICATE IS ISSUED AS A MATTER OP INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
mow. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS).AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: IT the certificate holder is an ADDITIONAL INSURED,the pofey(les)mull be endorsed. It SUDROOATION IS WAIVED.subject to the
-- _. - _tams and conditions of the_polley.certain policies may requite an.endomsment. A statement on thls_oedflcats does not confer rights to the _
eatfleab holder In lieu of such sndorssmenl(s).
moons 'y Clwlpine ThIno Keys IIIltrrell0e 8eMnos a()Melon of IDA ttt &Inv'UM4e41444.5 I f rr
Wit-
'Ins
PO Box 370541 -/�s1.e
Key Largo FL 33037 etWeen)AnnORaerCOMMRAoa NAM
.IeuxaaLQranrda Irnursna Corpsnl team
HIUIID GOMA•
Waken Ink LLC ODA:Know a Fence Company
306 Lance Lane Owns e:
unumnO:
Key Limo FL 33037 mums;
axuter I:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POUCES 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 CR OTHFA DOCUMISNT 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 TER1rS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAM.
tar TM Of IMAMS m WM POUGY MAWR Mrs, wins
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tau UA arsY MN oa:tpolEwea s 1.000000
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1 CIAaaSAIADE Q Occurs r I ThTId►(M inspoia.I 15000
0165FLO0108030 0109/2018 01/290019 r NAL IAIOIAMINJURY $1.000.000
OQa M.AOOttEOATI $2.000.000
OEMAGYnIS ter.* P,t�,s.CO OPAGO I2.000.�
,U10a00La meant 1 r WOJABINGUI UMW I
ANY AUTO sOon.vINAMYRMMew) $
_ *Trio -ADM= OOa.Y MAY(Pao AaweO $
_ MEDAL —
10e ens li�ir0°arai.loAa 15 I
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sxcasl WI aAllrl•a uoa AOOAIOATO $
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OFFICSAIDALOI P�4,pNu.ry N Nos IL muss•EA EIaRATEL $
eRfe ORetiiutfeutWar /.I.OEEASU•MUM,L•UT $
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OesalrUONa°MMATIOILOCATION I MMUS pima cons e~Aidrislial R..e.rt:a i.' r&.w.e......le turir.n
CRIRTIFICATId HOLDER CANCELLATION
Monroe County Bldg Department Tits
ANY of THE Agave DISCRIUO POLICIES co CANCELLED WORE
SHE 11%!nlATION DATE THa50P, Henna WILL BE DAD IN
2793 Overact HIgHw„y ACCORDANCE WITH THE POLICY PROVIIIONs.
Ste 300
AtrlwOltQlD 'j� TNYa
Marathon FL 33050 �`` 1
w
1
1?
m • 0 ACORD CORPORATION. A0 rights rammed.
ACORD 25(2010105) The ACORD name and logo it.registers• arks of A9RD
2018 / 2019
MONROE COUNTY BUSINESS TAX RECEIPT
EXPIRES SEPTEMBER 30, 2019
RECEIPT# 30140-124419
Business Name: KNOW A FENCE COMPANY
DAVID JAMES MILLER,KRAKEN INK LLC99411 OVERSEAS HIGHWAY SUITE 1
Owner Name: Business Location: KEY LARGO,FL 33037
Mailing Address:
99411 OVERSEAS HIGHWAY SUITE 1 Business Phone: 833-336-2387
KEY LARGO,FL 33037 Business Type: CONTRACTOR(FENCE ERECTOR CONTRACTOR)
Employees 2
STATE LICENSE: AP18040008
Tax Amount Transfer Fee Sub-Total Penalty Prior Years Collection Cost Total Paid
20.00 0.00 20.00 0.00 0.00 0.00 20.00
Paid 404-18-00000110 12/07/2018 20.00
THIS BECOMES A TAX RECEIPT Danise D. Henriquez, CFC, Tax Collector THIS IS ONLY A TAX.
WHEN VALIDATED PO Box 1129, Key West, FL 33041 YOU MUST MEET ALL
COUNTY AND/OR
MUNICIPALITY PLANNING
AND ZONING REQUIREMENTS.
MONROE COUNTY BUSINESS TAX RECEIPT
P.O. Box 1129, Key West, FL 33041-1129
EXPIRES SEPTEMBER 30, 2019
Business Name: KNOW A FENCE COMPANY RECEIPT# 30140-124419
99411 OVERSEAS HIGHWAY SUITE 1
Business Location: KEY LARGO,FL 33037
Owner Name: DAVID JAMES MILLER,KRAKEN INK LLC Mailing Address: Ousiness Phone: 833 336 2387
99411 OVERSEAS HIGHWAY SUITE 1 Business Type: CONTRACTOR(FENCE ERECTOR CONTRACTOR)
KEY LARGO,FL 33037
Employees 2
STATE LICENSE:AP18040008
Tax Amount Transfer Fee Sub-Total Penalty Prior Years Collection Cost Total Paid
20.00 0.00 20.00 0.00 0.00 0.00 20.00
Paid 404-18-00000110 12/07/2018 20.00
........—.1.4 KRAKINK-01 CAPWBI,LC
ACOR®' DATE(41Mm0lYYYYI
`
CERTIFICATE OF LIABILITY INSURANCE 5/14/2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. - - -- -- - -- -- - -
IMPORTANT: If the certificate holder le en ADDITIONAL INSURED,the poilcy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
- If SUBROGATION-IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement-A statement on
this certificate does not confer rights to the certificate holder In Ileu of such endorsement(e).
PRODUCER CT Julie Broche
Keys Insurance Services a Division of 1OA PHO►e FAX
P.O.Box 370541 I g� WC,I C,NO.
Key Largo,FL 33037 ya;Julle.BrochectIoausa.com
INSURER®AFFORDING COVERAGE NAIC I
INSURER A:Granada Insurance Company 16870
INSURED INSURER a:
Kraicen Ink LLC DBA Know a Fence Company INSURER C:
306 Lance Ln INSURER 0:
Key Largo,FL 33037
IN348ER E: ,
INSURER F
COVERAGES CERTIFICATE NUMBER; REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY 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.
D TYPE OF INSURANCE �60DLSUDR �• -.—W.'"T POLICY EFF I POUCYHXP .'.'
p,sD1y PDUCYNUMBER lilayaxamryyll D Y 1 LIMITS
A X COMMERCIAL GENERAL LIASIUTY I I I 1,000,000
_...i CLAIMS MADE (--(OCCUR -EhCiiQ:,CJFR�Ed'Y:E IF f
I 1 X X 018SFL00106030 1f2812019 912912020 E t41 j s 100,000
! LIELIaosca2!1 iE 6,000
?cR_soriA:s AOV(*JURY (1 1,000,000
.Q TE UNIT APPLIES PER GENERAL A+ORECOT $ 2,000,000
X J I I we
OTHER: . PR4M?�5.41+ Pq ##
2,000,000
AUTOMOBILE LIABILITY j C-OMEINEOSINGLE UNIT s
tLEQt4" LI
I ANY AUTO 7 EOOd},Y IN)QRY(pprJerp it I_—
AUTO D SCHEDULED RC(F Y u.:IJNY�P4rCmN UI.5
AUppT��QE ONLY AUTOS p p��ppp�� ry�g
—., ANDS ONLY ._ WI/ (Per RA�dif(1 S
t RIS 5 �,
..� UMBRELLA LAB I OCCUR BY sC7UJ!;•EACHOCaRRZHCSI S
EXCESS LIMB CLAIMS-MADE. i - AGGREGATE S
DEO IJRETENTIONS 1 I DATE ,e '' {
J1INORKER8 COMPENSATION PFR 'OT}r.
ANO EMPLOYERS'LIABILITY YIN WAIVER Wk..,,, _ -__I.STATUTE . �a rdNt
7
1}Al�Y IETORIPARTNEA/EXECUTIVE C•L EACH 004-, 1 L
4 an ory mMBE`EXCLUDED? n N!A ' '�.a'_-.._.— --._
II re aairnbe under
C
T�'_RRTICN OF O:�ERATIpyt tL - E L V ASE-PP ',NIT IT!$
(DESCRIPTION OF OPERATIONS ILOCATiONS/VEHICLES(MORO TOL AddllIcsal Remarks Schedule,may be attached if mare space Is required)
Job:Rowell's Waterfront Park Hurricane Fencing Repairs
The certificate holder is a named Additional Insured with the Waiver of Subrogation on the General Liability policy when required by written contract per
forms CG 2010 07 04&CG 24 04 05 09 respectively.
j
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Monroe County BOCC -
1100 Simonton Street,Suite 2-216
(Kay West.FL 33040 (fit�` °"L
ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
{
DIVIDER
PAGE
Producer No: 74427 SAN: 64601160000000
Pol Eff Dt: 05-22-2019 Office: 99
Date Printed: 05-22-2019
Time Printed: 10:57:16
Trans Eff Dt: 05-23-2019
Insured Name: KRAKEN INK LLC DBA KNOW A FENC
Policy No: 9100253757
Trans Seq No: 004
Trans Type: Change Endorsement
Oper Init: A218099 _
Company Abbr: GK
Release Version: 19.02
User-Selected Sets Copies Printer
INSURED 01 RWPRINT8- HP LJ 9050
COMPANY 01 Don't print
CERTIFIED COPY 01 Don't print
CERTIFICATES 01 Don't print
...---1 •
,4CQRD� CERTIFICATE OF LIABILITY INSURANCE DATE(rrdJ/DDrnYYY)
�� 5/22/2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGfIS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
This CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEDREPRESENTATIVE
OR PRODUCER,AND THE CERTIFICATE HOLDER.
- IMPORTANT:II du fflceteholder is anADDmONALINSURED,tie policy(Ras)must have ADDMONALINSURED provisiaraor be endorsed. - -
II SUBROGATION IS WAIVED,aubjectlo the terns and conditkxeof the policy,aettain policies any log Wiean erEdormitent Astatenenton
this certificate does rot corder rights to the certificate holder in lieu of such endoraerre1R(s). . - . .
PRODUCER CONTACT GEICO
GBCO Naafi:
Ono GEICO Boulevard PHONE 1� I FAA
Fredericksburg,VA 22412 ( No Ea) for Not
EalI RICONNENVGBCOCOM
Address:
INSURERISI AFFORDING COVERAGE NAIL
INSLERERA.GOVERNMENT EMPLOYEES INSURANCE COMPANY 7.2063
INSURED INSURER B.
KRAKLN INK LLC MIA KNOW A FENC
306 LANCE :,N INSLFIERC:
KEY LARGO, FL 3303/ INSURER D:
INSLRER E.
INSURER F:
COVERAGES CERDFICATE NUMBER REVISION NUMBER
THIS IS TO CEEITIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT,TERM CR CONDITION OF ANY CONTRACT CR OTHER DOCUMENT WITI I RESPECT TO WI UCH THIS CERTIFICATE MAY BE
ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUEUECT TO ALL THE TEMS,EJ(CWSIONSAND CONDITIONS
OF SUCH FVUCIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. _
NSA TYPE OF INSURANCE ADM l SUER POLICY NUMBER POLICY EFF faICY DPWAITSLW INISIn WVO ru rmarYVS rtaliCrir en
`
COMMERCIAL GENERAL IMMITY EACH OCCURRENCE $
. j CIA/AS-MADE FlOCCUR DMIIAGETORENTED S.
FFtf74"`Y°C(Ea rm•geCel
_ MED,EJP(Anyoneperonl $
PERSONAL 6 AOV INJURY $
GEM AGGREGATE UNIT OFF S PER: GENERAL AGGREGATE $
1POLICY[PRDIECT I ---Aux PRODUCTS-COtaP/OPAL7C. $
OTHER S
AUTOMOBILE LIABILITY cgMBWED srIGIE UMfr $ 300,000 ,
_--_ (FA aJern1 ,
A ANY AUTO X 91CLyi 53757 O.?: 5/22120I5 S/22/2020 9001LY INJURY(Per perron) $
OWNED X SCE DRItEo x SOOLY INJURY(Ebiaaccident) $
„AUTOS ONLY _.--. AUTOS
HIRED NCN-OWNED x PROPERTY MACE $
AUTOS OPLY -AUTOS CNLY (Per azedand
$
U6SU31AUAB OCCUR EACH OCCURRENCE $
--- ' .e ‘''al BY FRK MEIN IAENT
EXCESS UPS CLAMS MADE E r4 AGGREGATE $
F -
ofc *Tenor S . BY - ,ryTIONt . -$
WOAND�EIAPID MUFTI' Y I N DATE. A-1�� - I STATUTE- OER . .
ANY PRCPRETOR/PARTNER/E]ECUTIVE El N/A WAIVER ' YES EL EACH ACCUENT $
OFFECERIMEM ER EXCLUDED?
(Mandatory In NH) EL DISEIISEEA EMPU7YEE $
If yes describe under
DFSCFIPTION OF OPERATIONS below , EL DtSEI�SEPOIICY MIT $
DESCRIPTION OF OPERATIONS f LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is mew tied)
MONROE COUNTY BOCC IS NAMED AS AN ADDITIONAI, INSURED
CERTIRCATE HOLDER GANCEUA11ON
MONROE COUNTY BOCC SHOULD ANY OF1HEABWE DESCRIBED POUCIESBE CANCELLED BEFORE
1300 S IMONTON Si 5'i'K 2-216 THE EJIPIRA71ON DATE THEREOF, NOTICE WILL BE DEUVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
KEY WEST, E'L 33040-3110 AUTHORED)REPRESENTATIVE
0198&2015ACORO CORPORATION.AN rlgtttsreserved.
ACORD25(2015I03) The ACORD name and logo are registered marks of ACORD
pis t•dnion
MONROE COUNTY,FLORIDA
REQUEST FOR WAIVER OF INSURANCE REQUIREMENTS
It is requested that the insurance requirements,as specified in the County's Schedule of Insurance
Requirements,be waived or modified on the following contract.
Contractor/Vendor: 1<Cno3m Xj! e CQ. ---
Project or Service: Rowell's Waterfront Park Fencing,Hurricane Repairs
Contractor/Vendor c.-s scs3'�-
Address a'.Phone I:: ___.n 7OLs__.La`_?_Cd:�___.._�r!-1--wC_-/__G C v___E�...
,'os - SSi-01 - Cos `(
General Scope of Work: Demolition of existing damaged fencing and installation of new
chain link fence. (_320ft total) __. _
Reason for Waiver or WoW _ cor > Lst C�&-';'»4. o?'-r
Modification: ct,'nr-t Ps c.4 -
Policies Waiver or
Modification will apply to: Workers Compensation
Signature of Contractor/Vendor:_ _
Date: S"• '1°t Approved Not Approved
Risk Management Signature:_---. .\\61-- --
-- . . �_.�.�. _._
Date: 5 I'IC(
County Administrator appeal;
Approved: Not Approved:
We:
Board of County Commissioners appeal:
Approved: Not Approved:
Meeting Date:
Administrative Instruction 7500.7 10 t
(4itP r
,41 r7:9
coo Ys 1
JIMMY PATRONIS
CHIEF FINANICAL OFFICER STATE OF FLORIDA
- DEPARTMENT OF FINANCIAL SERVICES -- - -
DIVISION OF WORKERS'COMPENSATION
"'CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW••
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law.
EFFECTIVE DATE: 3/5/2018 EXPIRATION DATE: 3/4/2020
PERSON: FERNANDEZ ROBERT K
FEIN: 823474389
BUSINESS NAME AND ADDRESS:
KRAKEN INK LLC
KNOW A FENCE COMPANY
306 LANCE LANE
KEY LARGO FL 33037
SCOPE OF BUSINESS OR TRADE:
Fence Installation and Repair-
Metal,Vinyl,Wood or
Prefabricated Concrete Panel
Ponce installed By Hand
IMPORTANT:Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under
this section may not recover benefits or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be exempt...apply
only within the scope of the business or trade listed on the notice of election to bo exempt Pursuant to Chapter 440.05(13).F.S.,Notices of election to be
exempt and certificates of election to be exempt shall be subject to revocation if,at any time after the filing of the notice or the Issuance of the certificate,the
person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate.The department shall revoke a
certificate at any time for failure of the person named on the certificate to meat the requirements of this section.
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609
•
y1•Y
JIMMY PATRONIS
CHIEF FINANICAL OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION
••CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW•'
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law.
EFFECTIVE DATE: 3/5/2018 EXPIRATION DATE: 3/4/2020
PERSON: MILLER DAVID J SR
FEIN: 823474389
BUSINESS NAME AND ADDRESS:
KRAKEN INK LLC
KNOW A FENCE COMPANY
306 LANCE LANE
KEY LARGO FL 33037
SCOPE OF BUSINESS OR TRADE:
Fence Installation and Repair-
Metal,Vinyl.Wood or
Prefabricated Concrete Panel
Fence Installed By Hand
IMPORTANT:Pursuant to Chapter440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate detection under
this section may not recover benefits or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be exempt...apply
only within the scope of tho business or trade listed on the notice of election to be exempt Pursuant to Chapter 440.05(13),F.S..Notices of election to bo
exempt and certificates of election to be exempt shall be subject to revocation if,at any time after the filing of the notice or the issuance of the certificate,the
person named on the notice or certificate no longer meets the requirements of this section for Issuance of a certificate.The department shall revoke a
certificate at any time for failure of the person named on the certificate to moot the requirements of this section,
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609