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03/28/2023 Agreement Monroe County Purchasing Policy and Procedures COUNTY ADMINISTRATOR CON TRACT SUMMARY FORM FOR CONTRACTS LESS THAN $50,000.00 _.. f oratl'act w tll:KQ9I Cuqtom Metals, t6__C,. tjtrac;l Effective Date: Expiration Date: Contract Purpose/Description: Fabrication and Installment of African Memorial Aluminum Rail'n at Higgs Beach African emete Memorial Contract is Original Agreement Contract Amendment/Extension Renewal Contract Manager: William DeSantis 4307 Facilities anle N " I; t. Dcalt nt Slo # CONTRACT COSTS Total Dollar Value of Contract: $ Current Year Portion: $ (must be less than$50,000) 16,500 00 (rf multiyear agreement then requires BOCC approval,unless the l"I'd I Innt.11tla una.uli 1 �5 tilt 1 l) l n nn7 Budgeted? Yes* No ❑ Grant: $ N/A County Match: $ Fund/Cost Center/Spend Category: 117,-77n 11 -410n ADDITIONAL COSTS Estimated Ongoing Costs: $ /yr For: (Not included in dollar value above) (e.g.maintenance,utilities,janitorial,salaries,etc.) Insurance Required: YES ❑NO ❑ CONTRACT REVIEW Reviewer Date In Department Head Willie DeSantis Digitally signed by Willie DeSanlis p Si-nature: Dale:2023,022109:24:47-05'00' County Y Signature:Attorney g Patricia Eables Digilally signed by Patricia Eables Date:2023032110:07:36-04'00' Risk Management -' Signature: PurchasingLisa Abreu Digitally signed by Lisa Abreu Signature: Date:2023.03 20 09:56:50-04'00' OMB Digitally signed by John Quinn Signature: John Quinn Dale:2023.03281126:33-04'00' Comments: Revised BOCC 2/15/2023 Page 85 of 106 11 ONF OE COUNTY BOARD OF COUNTY COMMISSIONERS REQUEST FOR SERVICES FOR FABRICATION ICATION AND INSTALLATION OF AFI ICA I MEMORIAL ORIAL ALUMINUM AILING AT HIGGS BEACH AF ICAN CEMETERY MEMORIAL IAL m BOARD OF COUNTY COMMISSIONERS Mayor Craig Cates, District 1 Mayor Pro Tem Holly Merrill Raschein, District 5 Michelle Lincoln, District 2 James K. Scholl, District 3 David Rice, District 4 COUNTY ADMINISTRATOR Roman Gastesi Clerk of the Circuit Court Facilities Maintenance Director Kevin Madok William DeSantis JANURARY 2023 PREPARED BY: Monroe County Facilities Maintenance Department Page 1 of 28 Monroe County Facilities Maintenance General Scope of Work Job Name: Fabrication and Installation of Aluminum Railing Job Location: 1074- 1094 Atlantic Blvd.,Key West, FL 33040 (African Cemetery Memorial) Contact: Willie DeSantis Willie DeSantis 305-797-1250 Chrissy Collins 305-304-9711 PROJECT OVERVIEW PROJECT INTENT AND SCOPE GENERAL REQUIREMENTS 1. Project Overview A) Enter into a contract with a qualified Contractor fabricate and install aluminum railing at Higgs Beach African Cemetery Memorial. The term of this contract shall commence upon the date of issuance to the undersigned by Owner of the Notice to Proceed/Purchase Order/Task Order. Once commenced, the undersigned shall diligently continue performance until completion of the Project. The undersigned shall accomplish Final Completion of the Project within Sixty (60) days, thereafter. The Contractor shall be required to secure and pay for all required permits and approvals to perform the work which may include: City of Key West Building Department,Monroe County Building Department and any other permitting or regulatory agencies, if applicable. Contractor shall include those permit fees as a part of the Contractor's bid. B) All quotes are due by Wednesday, February 8,2023, at 12:00 P.M., via email to Page 2 of 28 Collins-chrissy@monroecounty-fl.gov. All Quotes must state they will be good for one hundred twenty (120) calendar days from submittal due date. 2. Project Intent and Scope Scope of Work: The Contractor shall provide the following Scope of Work and provide all labor and materials to complete the fabrication and installation of aluminum railing at Higgs Beach African Cemetery Memorial: • Materials to match existing design • 2x2 posts with pyramid cap • lx2 horizontal rails • '/2 pickets • 4" CC Sun ornament through sections • CNC cut ornament on bar between middle and bottom rail • 42" high sections for openings: • 3@ 123" • 1 @48" • 2@ 153" • Black powdercoat, demo and installation by core drill included 3. General Requirements A) The Contractor shall coordinate all activities with the Monroe County Facilities Maintenance Department contact: Willie DeSantis at 305-797-1250 B) The Contractor is required to provide protection for all existing surfaces including, but not limited to: i. Existing fixtures ii. Personal Items iii, Floors iv. Vehicles and Personal Property V. Landscaping C) The Contractor shall ensure that all non-exempt employees for this effort are compensated in accordance with all State and Local Laws. D) The Contractor shall load, haul, and properly dispose of all construction debris and materials. Page 3 of 28 E) The Contractor shall provide and maintain appropriate (OSHA required) construction warning signs and barriers. F) The Contractor shall furnish all required work site safety equipment. G) The Contractor shall furnish and maintain on-site material safety data sheets (MSDS) for all materials used in the construction. H) Construction work times shall be limited to: Specified by the County I) All materials must be approved by submittal prior to commencement of work. .n The Contractor shall provide a lump sum price by February 8,2023,at 12:00 p.m., via email as noted herein. K) The Contractor needs to be aware of weather and location and plan accordingly. L) The Contractor needs to be aware of the facility, its residents, and staff with unusual schedules and plan accordingly. NI) The Contractor shall provide a schedule for all phases of the project. N) The Contractor shall coordinate all activities with concurrent site work being performed, if any. O) Insurance Requirements: Workers Compensation Statutory Limits Employers' Liability $100,000 Bodily Injury by Accident $500,000 Bodily Injury by Disease, policy limits $100,000 Bodily Injury by Disease, each employee General Liability $200,000 per Person $300,000 per Occurrence $200,000 Property Damage or $300,000 Combined Single Limit Vehicle: $200,000 per Person (Owned, non-owned, $300,000 per Occurrence and hired vehicles) $200,000 Property Damage or $300,000 Combined Single Limit Page 4 of 28 Builders Risk Not Required Construction Bond Not Required The Monroe County Board of County Commissioners, its employees and officials, 1100 Simonton Street, Key West, Florida 33040, shall be named as Certificate Holder and Additional insured on General Liability and Vehicle policies. A "Sample" Certificate of insurance is attached,which may not be reflective of the insurance amounts required for this project, but is provided for"informational purposes"only. P) The Contractor is required to have all current licenses necessary to perform the work and shall submit the Contractor's License and Monroe County Business Tax Receipt along with its Proposal. If the Contractor is not a current registered Monroe County Vendor, then it shall also submit a properly completed and executed W-9 Form. Q) INDEMNIFICATION, HOLD HARMLESS, AND DEFENSE. Notwithstanding any minimum insurance requirements prescribed elsewhere in this agreement, the Contractor shall defend, indemnify and hold the County and the County's elected and appointed officers and employees harmless from and against (i) any claims, actions or causes of action, (ii) any litigation, administrative proceedings, appellate proceedings, or other proceedings relating to any type of injury (including death), loss, damage, fine, penalty or business interruption, and (iii) any costs or expenses that may be asserted against, initiated with respect to, or sustained by, any indemnified party by reason of, or in connection with, (A)any activity of the Contractor or any of its employees,agents, contractors or other invitees during the term of this Agreement, (B) the negligence or recklessness, intentional wrongful misconduct, errors or other wrongful act or omission of the Contractor or any of its employees, agents, sub-contractors or other invitees, or(C)the Contractor's default in respect of any of the obligations that it undertakes under the terms of this Agreement, except to the extent the claims, actions, causes of action, litigation, proceedings, costs or expenses arise from the intentional or sole negligent acts or omissions of the County or any of its employees, agents, contractors or invitees (other than the Contractor). The monetary limitation of liability under this contract shall be equal to the dollar value of the contract and not less than $1 million per occurrence pursuant to Section 725.06, Florida Statutes. The limits of liability shall be as set forth in the insurance requirements included in Paragraph 3 O. herein. Insofar as the claims, actions, causes of action, litigation, proceedings, costs or expenses relate to events or circumstances that occur during the term of this Agreement,this section will survive the expiration of the term of this Agreement or any earlier termination of this Agreement. In the event that the completion of the project (to include the work of others) is delayed or suspended as a result of the Contractor's failure to purchase or maintain the required insurance, the Contractor shall indemnify the County from any and all increased expenses resulting from such delay. Should any claims be asserted against the County by virtue of any deficiency or ambiguity in the plans and specifications provided by the Contractor, the Contractor agrees and warrants that the Contractor shall hold the County harmless and shall Page 5 of 28 indemnify it from all losses occurring thereby and shall further defend any claim or action on the County's behalf. The extent of liability is in no way limited to, reduced, or lessened by the insurance requirements contained elsewhere within this Agreement. This indemnification shall survive the termination of this Contract. Nothing contained in this paragraph is intended to nor shall it constitute a waiver of the County's sovereign immunity. R) NON-COLLUSION. By signing this proposal, the undersigned swears, according to law on his/her oath, and under penalty of perjury, that their firm executes this proposal with prices 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. 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.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. The statements contained in this paragraph are true and correct, and made with the full knowledge that Monroe County relies upon the truth of the statements contained in this paragraph in awarding contracts for this project. S) EMPLOYMENT OR RETENTION OF FORMER COUNTY OFFICERS OR EMPLOYEES. By signing this proposal, the undersigned warrants that he/she/it has not employed, retained, or otherwise had act on his/hers/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 Agreement without liability and may also, in its discretion, deduct from the Agreement or purchase price, or otherwise recover, the full amount of any fee, commission, percentage, gift, or consideration paid to the former County officer or employee. T) CODE OF ETHICS. County agrees that officers and employees of the County recognize and will be required to comply with the standards of conduct for public officers and employees as delineated in Section 1 12.313,Florida Statutes,regarding,but not limited to, solicitation or acceptance of gifts; doing business with one's agency; unauthorized compensation; misuse of public position, conflicting employment or contractual relationship; and disclosure or use of certain information. U) DRUG-FREE WORKPLACE.By signing this proposal,the undersigned certifies that the contractor complies fully with, and in accordance with Florida Statute, Section 287.087, the requirements as follows: 1) They will publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance Page 6 of 28 is prohibited in the workplace and specify 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 1, 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 occurring 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, for 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. ADDITIONAL CONTRACT PROVISIONS I) Nondiscrimination/Ec uakl Employment Oj2portunity. The Contractor and County agree that there will be no discrimination against any person,and it is expressly understood that upon a determination by a court of competent jurisdiction that discrimination has occurred, this Agreement automatically terminates without any further action on the part of any party, effective the date of the court order. Contractor agrees to comply with all Federal and Florida statutes, and all local ordinances, as applicable, relating to nondiscrimination. These include but are not limited to: 1) Title VII of the Civil Rights Act of 1964 (PL 88-352) which prohibits discrimination on the basis of race, color or national origin;2)Title IX of the Education Amendment of 1972, as amended (20 USC ss. 1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; 3) Section 504 of the Rehabilitation Act of 1973, as amended (20 USC s. 794), which prohibits discrimination on the basis of handicaps; 4) The Age Discrimination Act of 1975, as amended (42 USC ss. 6101- 6107) which prohibits discrimination on the basis of age; 5) The Drug Abuse Office and Treatment Act of 1972 (PL 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; 6) The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (PL 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism;7)The Public Health Service Act of 1912, ss. 523 and 527 (42 USC ss. 690dd-3 and 290ee-3), as amended, relating to confidentiality of alcohol and drug abuse patient records; 8) Title VIII of the Civil Rights Act of 1968 (42 USC s. 3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; 9) The Americans with Disabilities Act of 1990 (42 USC s. 12101 Note), as may be amended from time to Page 7 of 28 time, relating to nondiscrimination on the basis of disability; 10) Monroe County Code Chapter 14, Article II, which prohibits discrimination on the basis of race, color, sex, religion, national origin, ancestry, sexual orientation, gender identity or expression, familial status or age; and 1 1) Any other nondiscrimination provisions in any Federal or state statutes which may apply to the parties to, or the subject matter of, this Agreement. II) Termination Provisions. A. In the event that the Contractor shall be found to be negligent in any aspect of service, the County shall have the right to terminate this agreement after five (5) days' written notification to the Contractor. B. Either of the parties hereto may cancel this Agreement without cause by giving the other party sixty (60) days' written notice of its intention to do so. C. Termination for Cause and Remedies: In the event of breach of any contract terms, the County retains the right to terminate this Agreement. The County may also terminate this agreement for cause with Contractor should the Contractor fail to perform the covenants herein contained at the time and in the manner herein provided. In the event of such termination, prior to termination, the County shall provide Contractor with five (5) calendar days' notice and provide the Contractor with an opportunity to cure the breach that has occurred. If the breach is not cured, the Agreement will be terminated for cause. If the County terminates this agreement with the Contractor, County shall pay Contractor the sum due the Contractor under this agreement prior to termination,unless the cost of completion to the County exceeds the funds remaining in the contract; however, the County reserves the right to assert and seek an offset for damages caused by the breach. The maximum amount due to Contractor shall not in any event exceed the spending cap in this Agreement. In addition, the County reserves all rights available to recoup monies paid under this Agreement, including the right to sue for breach of contract and including the right to pursue a claim for violation of the County's False Claims Ordinance, located at Section 2-721 et al. of the Monroe County Code. D. Termination for Convenience: The County may terminate this Agreement for convenience, at any time, upon seven (7) days' notice to Contractor. If the County terminates this agreement with the Contractor,County shall pay Contractor the sum due the Contractor under this agreement prior to termination, unless the cost of completion to the County exceeds the funds remaining in the contract. The maximum amount due to Contractor shall not exceed the spending cap in this Agreement. In addition, the County reserves all rights available to recoup monies paid under this Agreement, including the right to sue for breach of contract and including the right to pursue a claim for violation of the County's False Claims Ordinance, located at Art. IX, Section 2-721 et al. of the Monroe County Code. E. Scrutinized Companies: For Contracts of any amount, if the County determines that the Contractor/Consultant has submitted a false certification under Section 287.135(5), Florida Statutes or has been placed on the Scrutinized Companies that Boycott Israel List, or is engaged in a boycott of Israel, the County shall have the option of (1) terminating the Agreement after it has given the Contractor/Consultant written Page 8 of 28 notice and an opportunity to demonstrate the agency's determination of false certification was in error pursuant to Section 287.135(5)(a), Florida Statutes, or(2) maintaining the Agreement if the conditions of Section 287.135(4), Florida Statutes, are met. III) Maintenance of Records. The Contractor shall maintain all books, records, and documents directly pertinent to performance under this Agreement in accordance with generally accepted accounting principles consistently applied. Records shall be retained for a period of seven(7)years from the termination of this agreement or for a period of three (3) years from the submission of the final expenditure report as per 2 CFR §200.33, whichever is greater. Each party to this Agreement or its authorized representatives shall have reasonable and timely access to such records of each other party to this Agreement for public records purposes during the term of the Agreement and for seven (7) years following the termination of this Agreement. IV)Ri ght to Audit. Availability of Records. The records of the parties to this Agreement relating to the Project,which shall include but not be limited to accounting records(hard copy,as well as computer readable data if it can be made available; subcontract files (including proposals of successful and unsuccessful bidders, bid recaps, bidding instructions, bidders list, etc.); original estimates; estimating work sheets; correspondence; change order files (including documentation covering negotiated settlements); back charge logs and supporting documentation; general ledger entries detailing cash and trade discounts earned, insurance rebates and dividends; any other supporting evidence deemed necessary by Owner or the Monroe County Office of the Clerk of Court and Comptroller(hereinafter referred to as "County Clerk") to substantiate charges related to this agreement, and all other agreements, sources of information and matters that may in Owner's or the County Clerk's reasonable judgment have any bearing on or pertain to any matters, rights, duties, or obligations under or covered by any contract document (all foregoing hereinafter referred to as "Records") shall be open to inspection and subject to audit and/or reproduction by Owner's representative and/or agents of Owner or the County Clerk. Owner or County Clerk may also conduct verifications such as, but not limited to, counting employees at the job site, witnessing the distribution of payroll, verifying payroll computations, overhead computations, observing vendor and supplier payments, miscellaneous allocations, special charges, verifying information and amounts through interviews and written confirmations with employees, subcontractors, suppliers, and contractors' representatives. All records shall be kept for ten (10) years after Final Completion. The County Clerk possesses the independent authority to conduct an audit of records, assets, and activities relating to this Project. If an auditor employed by the County or Clerk determines that monies paid to Contractor pursuant to this Agreement were spent for purposes not authorized by this Agreement, or were wrongfully retained by the Contractor, the Contractor shall repay the monies together with interest calculated pursuant to Sec. 55.03 of the Florida Page 9 of 28 Statutes, running from the date the monies were paid to Contractor. The right to audit provisions survive the termination or expiration of this Agreement. V) Payment of Fees i Invoices. County shall pay pursuant to the Florida Local Government Prompt Payment Act, Fla. Stat., Sec.218.70, upon receipt of a Proper Invoice from the Contractor. Payments due and unpaid under the Contract shall bear interest pursuant to the Florida Local Government Prompt Payment Act. The Contractor is to submit to the County invoices with supporting documentation that are acceptable to the Clerk. Acceptability to the Clerk is based on generally accepted accounting principles and such laws, rules, and regulations as may govern the Clerk's disbursal of funds. Invoices shall be submitted to Monroe County Facilities Maintenance Department, Attention Chrissy Collins, via email at collins- chrissy@monroecounty-fl.gov. The County is exempt from sales and use taxes. A copy of the tax exemption certificate will be provided upon request. Final payment shall be made by the County, as the Owner, to the Contractor when the Contract has been fully performed by the Contractor and the work has been accepted by the County. VI)l'ublic Records Compliance. The Contractor must comply with Florida public records laws, including but not limited to Chapter 119, Florida Statutes and Section 24 of article I of the Constitution of Florida. The County and Contractor shall allow and permit reasonable access to, and inspection of, all documents, records, papers, letters or other"public record" materials in its possession or under its control subject to the provisions of Chapter 119, Florida Statutes, and made or received by the County and Contractor in conjunction with this contract and related to contract performance. The County shall have the right to unilaterally cancel this contract upon violation of this provision by the Contractor. Failure of the Contractor to abide by the terms of this provision shall be deemed a material breach of this contract and the County may enforce the terms of this provision in the form of a court proceeding and shall, as a prevailing party, be entitled to reimbursement of all attorney's fees and costs associated with that proceeding. This provision shall survive any termination or expiration of the contract. The Contractor is encouraged to consult with its advisors about Florida Public Records Law in order to comply with this provision. Pursuant to Fla. Stat., Sec. 119.0701 and the terns and conditions of this contract, the Contractor is required to: (1) Keep and maintain public records that would be required by the County to perform the service. Page 10 of 28 (2) Upon receipt from the County's custodian of records, provide the County with a copy of the requested records or allow the records to be inspected or copied within a reasonable time at a cost that does not exceed the cost provided in this chapter or as otherwise provided by law. (3) Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law for the duration of the contract term and following completion of the contract if the contractor does not transfer the records to the County. (4) Upon completion of the contract, transfer, at no cost, to the County all public records in possession of the Contractor or keep and maintain public records that would be required by the County to perform the service. If the Contractor transfers all public records to the County upon completion of the contract,the Contractor shall destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. if the Contractor keeps and maintains public records upon completion of the contract, the Contractor shall meet all applicable requirements for retaining public records. All records stored electronically must be provided to the County, upon request from the County's custodian of records, in a format that is compatible with the information technology systems of the County. (5) A request to inspect or copy public records relating to a County contract must be made directly to the County, but if the County does not possess the requested records, the County shall immediately notify the Contractor of the request, and the Contractor must provide the records to the County or allow the records to be inspected or copied within a reasonable time. If the Contractor does not comply with the County's request for records, the County shall enforce the public records contract provisions in accordance with the contract, notwithstanding the County's option and right to unilaterally cancel this contract upon violation of this provision by the Contractor. A Contractor who fails to provide the public records to the County or pursuant to a valid public records request within a reasonable time may be subject to penalties under Section 1 19.10, Florida Statutes. The Contractor shall not transfer custody, release, alter, destroy or otherwise dispose of any public records unless or otherwise provided in this provision or as otherwise provided by law. IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119 FLORIDA STATUTES TO THE CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT CONTACT THE CUSTODIAN OF PUBLIC RECORDS BRIAN BRADLEY AT PHONE NO. 305- 292-3470 BRADLEY-BRIAN ,MONROECOUNTY-FL.GOV. MONROE COUNTY ATTORNEY'S OFFICE 1.11.1 1.2T" Street SUITE 408 KEY WEST FL 33040. Page 11 of 28 VII) E-Verify System. Beginning January 1, 2021, in accordance with Fla. Stat., Sec. 448.095,the Contractor and any subcontractor shall register with and shall utilize the U.S. Department of Homeland Security's E-Verify system to verify the work authorization status of all new employees hired by the Contractor during the term of the Contract and shall expressly require any subcontractors performing work or providing services pursuant to the Contract to likewise utilize the U.S. Department of Homeland Security's E-Verify system to verify the work authorization status of all new employees hired by the subcontractor during the Contract term. Any subcontractor shall provide an affidavit stating that the subcontractor does not employ, contract with, or subcontract with an unauthorized alien. The Contractor shall comply with and be subject to the provisions of Fla. Stat., Sec. 448.095. VIII) Notice Requirement. Any written notices or correspondence given pursuant to this contract shall be sent by United States Mail, certified, return receipt requested, postage prepared, or by courier with proof of delivery. Notice is deemed received by Contractor when hand delivered by national courier with proof of delivery or by U.S.Mail upon verified receipt or upon the date of refusal or non-acceptance of delivery. The place of giving Notice shall remain the same as set forth herein until changed in writing in the manner provided in this paragraph. Notice shall be sent to the following persons: KUBI Custom Metals LLc For Contractor: ey West, FL. 33M- For Owner: Facilities Maintenance Department Attention: Willie DeSantis 123 Overseas Highway, Rockland Key Key West, FL. 33040 And Monroe County Attorney's Office 1111 12t" Street Suite 408 Key West, Florida 33040 IX) Uncontrollable Circumstance. Any delay or failure of either Party to perform its obligations under this Agreement will be excused to the extent that the delay or failure was caused directly by an event Page 12 of 28 beyond such Parry's control, without such Party's fault or negligence and that by its nature could not have been foreseen by such Party or, if it could have been foreseen, was unavoidable: (a)acts of God; (b) flood, fire, earthquake, explosion, tropical storm, hurricane or other declared emergency in the geographic area of the Project; (c) war, invasion, hostilities (whether war is declared or not), terrorist threats or acts, riot, or other civil unrest in the geographic area of the Project; (d) government order or law in the geographic area of the Project; (e) actions, embargoes, or blockades in effect on or after the date of this Agreement; (f) action by any governmental authority prohibiting work in the geographic area of the Project;(each, a "Uncontrollable Circumstance"). CONTRACTOR'S financial inability to perform, changes in cost or availability of materials, components, or services, market conditions, or supplier actions or contract disputes will not excuse performance by Contractor under this Section.Contractor shall give County written notice within seven (7) days of any event or circumstance that is reasonably likely to result in an Uncontrollable Circumstance, and the anticipated duration of such Uncontrollable Circumstance. Contractor shall use all diligent efforts to end the Uncontrollable Circumstance, ensure that the effects of any Uncontrollable Circumstance are minimized and resume full performance under this Agreement. The County will not pay additional cost as a result of an Uncontrollable Circumstance. The Contractor may only seek a no cost Change Order or Amendment for such reasonable time as the Owners Representative may determine. X) Ad'udication of Disputes or Disagreements. County and Contractor agree that all disputes and disagreements shall be attempted to be resolved by meet and confer sessions between representatives of each of the parties. If the issue or issues are still not resolved to the satisfaction of the parties, then any party shall have the right to seek such relief or remedy as may be provided by this Agreement or by Florida law. This Agreement is not subject to arbitration. This provision does not negate or waive the provisions of Sections I,Nondiscrimination, or Section II, concerning termination or cancellation. Page 13 of 28 PROPOSAL FORM PROPOSAL TO: Monroe County Facilities Maintenance 123 Overseas Highway,Rockland Key Key West,FL 33040 KUBI Custom Metals LLc PROPOSAL FROM: Key West, FL. 33040 The undersigned, having carefully examined the Work and reference Drawings, Specifications, Proposal, and Addenda thereto and other Contract Documents for the construction of: Fabrication and Installation of Aluminum Railing at Higgs Beach African Cemetery Memorial 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 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 Notice to Proceed/Purchase Order/Task Order. Once commenced, undersigned shall diligently continue performance until completion of the Project. The undersigned shall accomplish Final Completion of the Project within Sixty (60) days, thereafter. Page 14 of 28 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. sixteen thousand five hundred.00 Dollars. (Total Base Proposal-words) 16,500.00 $_ Dollars. (Total Base Proposal-numbers) I acknowledge Alternates as follows: N/A I acknowledge receipt of Addenda No.(s) or None No. Dated No. Dated Page 15 of 28 In addition, Proposer states that he/she has provided or will provide the County, along with this Proposal, a certified copy of Contractor's License, Monroe County Business Tax Receipt, and Certificate of Insurance showing the minimum insurance requirements for this project. Execution by the Contractor must be by a person with authority to bind the entity. By signing this agreement below, the Contractor has read and accepts the terms and conditions set forth by the Monroe County General Requirements for Construction found at the link on the Monroe County web page: Iittp.?1/11-�r,lioita'ciccotiiit v.civic)lus.corn/B ds.asLiN?C it1D—I g; AND accepts all of the terms and conditions and all Federal required contract provisions herein. IN WITNESS WHEREOF, the parties have caused this Agreement to be executed by their duly authorized representatives, as follows: KUBI Custom Metals LLc Contractor: Mailing Address: Key West, FL. 33040 305-842-1820 Phone Number: 83-2734037 E.I.N., Email: kubicustom@+gmail.com Date: 2/8/2023 Signed: - g W_ Jakub Blazek , Owner Name __... Title Contractor's Witness signature: Witness name: Ludek Koryta 2/8/2023 Date The County accepts the above proposal: MONROE COUNTY, FLORIDA B County A mnistrat Date: March 28 2023 Cou y°: y or or Designee MONROECouNWATTORVEYIS OFFICE. kP Eon T ,"c Page 16 of 28 PATRIC#A EAB S AS-SZT"_ 59_T_7 ATTORNEY DATE: NON-COLLUSION AFFIDAVIT Jakub Blazek Key West 1, of the city of according to law oonw��oath, and under penalty of perjury, depose and say that: 1. 1 am mjBi of the firm of the proposer making the Proposal for the project described in the notice for calling for proposals for: African Memorial Rails 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 knowledge that Monroe County relies upon the truth of the statements contained in this affidavit in awarding contracts for said project. 2/8/2023 (Signature of Proposer) (Date) STATE OF: , - COUNTY OF: .� . . ... Subscribed and sworn to (or affirmed) before me, by means of Pl�physical presence or ❑ online notarization, on :�M � (date) by name of affiant . ' /the Is personally known ( ) p y „ d me or has produced (type of identification) as identification, NOTARY PUBLIC My commission expires: `� '' (SEAL) 'A' 9� CHRISTINE E COLLINS Page 17 of 28 f. �';, Notary Public-State of Florica Commission=Ar+.2654 i 3 OF My Comm.Expires Jun 9,/3 Bonded through vationa:Notary Assr, LOBBYING AND CONFLICT OF INTEREST CLAUSE SWORN STATEMENT UNDER ORDINANCE NO. 010-1990 MONROE COUNTY, FLORIDA ETHICS CLAUSE KUBI Custom Metals LLc If (Company) warrants that he/she/it has not employed, retained or otherwise had act on his/her/ 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 County officer or employee". (Signature) 2/8/2023 Date: STATE OF: ° COUNTY OF- ...(0o(. ^��?'...... Subscribed and sworn to (or affirmed) before me, by means q aphysical presence or ❑ online notarization, on 20 _ (date) by (name of affiant). He/She is aro as ML-ntlfcatio (1-Vp of identification) ........... mW NOTARY PUBLIC My commission expires: " EBonded RISTINE E COLLINS(SEAL) ublicState of Floridaission HH 266973m.Expires Jun 9,2026h National Notary Assn. Page 18 of 28 DRUG-FREE WORKPLACE FORM The undersigned vendor in Wfftce vim MoofaTs SLalute, Sec. 287.087 hereby certifies that: (Name of Business) I. 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 requires the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community, for 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. 2/8/20�33-oposer's Signature Date STATE OF: Po V d e­ COUNTY OF:_.... r Subscribed and sworn to (or affirmed) before me, by means of El l ysical presence or ❑ online ,,; notarization, on-,�����. � �»� ......_ (date) by �.._ ����i���j �..,� � � . . ( t.nt). I ISIe persi�d6alt �owlta n or has produced name of affix ti _...m.. {=ice s identification. +"II Ad p NOTA `wPP I' ..f I1LIC SEAL My Commission Expires: CHRISTIN rD266973 COLLINS Page 19 of 28 t `; Notary Public•S 4� i Cmmmksslon qMy Comma.CxpirBonded through Natio .. 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, proposal, or reply on a contract to provide any goods or services to a public entity, may not submit a bid, proposal, or reply 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 property to a public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant 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 thirty-six (36) months from the date of being placed on the convicted vendor list." I have read the aBove and state that neither JaKUb Blaze (Proposer's name) nor any Affiliate has been placed on the convicted' vendor list within the last thirty-six (36) months. (Signature) 2/8/2023 Date: STATE OF: COUNTY OF: I Subscribed and sworn to (or affirmed) before me, by means of physical presence or ❑ online notarization, on the day of N e 3by roue (name of affiant). He/She is p..� r"sonal ly kn,ow,n-t w�r r►e: r s'p ed -- - (type of identification) as identification. My Commission Expires: �1,) " NOTARY PUB' IC (SEAL) Ay N • CHRISTINE EDNotaryAssn, '. Notary Public-S �I - Commission= * crr My Comm.Expire Bonded through Nation Page 20 of 28 VENDOR CERTIFICATION REGARDING SCRUTINIZED COMPANIES LISTS African Memorial Rails Project Description(s). Respondent Vendor Name: Vendor FEIN: 63-2734 Vendor's Authorized Representative Name and Title: Address: 5642 3rd Ave, Key West FL 33640 City: State: Zi one oeo 1820 p: Phone Number Email Address: KU131CU,5tolI . coff 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. understand that pursuant to Section 287.135, Florida Statutes,the submission of a false certification may subject company to civil penalties, attorney'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. Certified By: Jakub Blazek who is authorized to sign . Authorized Signatuir on behalf of the above referenced company iaktb Print Name: Title; Owner Note: The List are available at the following Department of Management Services Site: htt r°om�busuILP-,s ratnari �idor infbrrnatu n/co victert cusp ended disc rrnOatory comp-taints vendor 1.rst Page 21 of 28 INSURANCE REQUIREMENTS AND FORMS MONROE COUNTY, FLORIDA RISK MANAGEMENT POLICY AND PROCEDURES General Insurance Requirements For Other Contractors, Subcontractors and Professional Services As a pre-requisite of the work and services governed, or the goods supplied under this contract (including the pre-staging of personnel and material), the Contractor shall obtain, at his/her own expense, insurance as specified in any attached schedules, which are made part of this contract. The Contractor will ensure that the insurance obtained will extend protection to all Subcontractors engaged by the Contractor. Alternatively, the Contractor may require all Subcontractors to obtain insurance consistent with the attached schedules. The Contractor will not be permitted to commence work governed by this contract (including pre- staging of personnel and material) until satisfactory evidence of the required insurance has been furnished to the County as specified below. Delays in the commencement of work, resulting from the failure of the Contractor to provide satisfactory evidence of the required insurance, shall not extend deadlines specified in this contract and any penalties and failure to perform assessments shall be imposed as if the work commenced on the specified date and time, except for the Contractor's failure to provide satisfactory evidence. The Contractor shall maintain the required insurance throughout the entire term of this contract and any extensions specified in the attached schedules.Failure to comply with this provision may result in the immediate suspension of all work until the required insurance has been reinstated or replaced. Delays in the completion of work resulting from the failure of the Contractor to maintain the required insurance shall not extend deadlines specified in this contract and any penalties and failure to perform assessments shall be imposed as if the work had not been suspended,except for the Contractor's failure to maintain the required insurance. The Contractor will be held responsible for all deductibles and self-insured retentions that may be contained in the Contractor's Insurance policies. The Contractor shall provide, to the County, as satisfactory evidence of the required insurance, either: •Certificate of Insurance or •A Certified copy of the actual insurance policy. The County, at its sole option, has the right to request a certified copy of any or all insurance policies required by this contract. All insurance policies must specify that they are not subject to cancellation, non-renewal, material change, or reduction in coverage unless a minimum of thirty(30)days prior notification is given to the County by the insurer. The acceptance and/or approval of the Contractor's insurance shall not be construed as relieving the Contractor from any liability or obligation assumed under this contract or imposed by law. Page 22 of 28 The Monroe County Board of County Commissioners, its employees and officials, at 1100 Simonton Street, Key West, Florida 33040, will be included as "Additional Insured" on all policies, except for Workers' Compensation. Any deviations from these General Insurance Requirements must be requested in writing on the County prepared form entitled"Request for Waiver of Insurance Requirements"and approved by Monroe County Risk Management Department. Page 23 of 28 PROPOSER'S INSURANCE AND INDEMNIFICATION STATEMENT INSURANCE REQUIREMENTS Workers Compensation Statutory Limits Employers Liability $100,0005500,0001100,000 Bodily Injury by Accident/Bodily Injury by Disease, policy limits/Bodily Injury by Disease each employee General Liability $200,000 per Person $300,000 per Occurrence $200,000 Property Damage or $300,000 Combined Single Limit Vehicle $200,000 per Person (Owned, non-owned, and hired vehicles) $300,000 per Occurrence $200,000 Property Damage or $300,000 Combined Single Limit Builders Risk Not Required Construction Bond Not Required The Monroe County Board of County Commissioners, its employees and officials, 1100 Simonton Street, Key West, Florida 33040, shall be named as Certificate Holder and Additional Insured on General Liability and Vehicle policies. INDEMNIFICATION,HOLD HARMLESS,AND DEFENSE.Notwithstanding any minimum insurance requirements prescribed elsewhere in this agreement,Contractor shall defend, indemnify and hold the County and the County's elected and appointed officers and employees harmless from and against (i) any claims, actions or causes of action, (ii) any litigation, administrative proceedings, appellate proceedings, or other proceedings relating to any type of injury (including death), loss,damage, fine,penalty or business interruption, and(iii)any costs or expenses that may be asserted against, initiated with respect to, or sustained by, any indemnified party by reason of, or in connection with, (A) any activity of Contractor or any of its employees, agents, contractors or other invitees during the term of this Agreement, (B)the negligence or recklessness, intentional wrongful misconduct, errors or other wrongful act or omission of Contractor or any of its employees, agents, sub-contractors or other invitees, or(C) Contractor's default in respect of any of the obligations that it undertakes under the terms of this Agreement, except to the extent the claims, actions, causes of action, litigation, proceedings, costs or expenses arise from the intentional or sole negligent acts or omissions of the County or any of its employees, agents, contractors or invitees (other than Contractor). The monetary limitation of liability under this Page 24 of 28 contract shall be equal to the dollar value of the contract and not less than $1 million per occurrence pursuant to Section 725.06, Florida Statutes. The limits of liability shall be as set forth in the insurance requirements included in Paragraph 3.0. herein. insofar as the claims, actions, causes of action, litigation, proceedings, costs or expenses relate to events or circumstances that occur during the term of this Agreement, this section will survive the expiration of the term of this Agreement or any earlier termination of this Agreement. In the event that the completion of the project (to include the work of others) is delayed or suspended as a result of the Contractor's failure to purchase or maintain the required insurance, the Contractor shall indemnify the County from any and all increased expenses resulting from such delay. Should any claims be asserted against the County by virtue of any deficiency or ambiguity in the plans and specifications provided by the Contractor,the Contractor agrees and warrants that the Contractor shall hold the County harmless and shall indemnify it from all losses occurring thereby and shall further defend any claim or action on the County's behalf. The extent of liability is in no way limited to, reduced, or lessened by the insurance requirements contained elsewhere within this Agreement. PROPOSER'S STATEMENT I understand the insurance that will be mandatory if awarded the contract and will comply in full with all of the requirements herein. I fully accept the indemnification and hold harmless and duty to defend as set out in this proposal. Jakub Blazek , PROPOSER Signature Page 25 of 28 INSURANCE AGENT'S STATEMENT I have reviewed the above requirements with the proposer named above. The following deductibles apply to the corresponding policy. POLICY DEDUCTIBLES SCB-GL-000015217 No deductible- self-insured Retention (Per-occurrence)- $2,500 Liability policies are Occurrence X Claims Made E DO„GU,S'.igned by:Gaslamp Insurance services /ruu[ CAWu _ G83BE3SAD5E7'400._ Insurance Agency Signature Page 26 of 28 " DATE(MMIDDIYYYY) .Ak+C"R CERTIFICATE OF LIABILITY INSURANCE ih . 02/09/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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 is an ADDITIONAL INSURED,the policy(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 lieu of such endorsement(s). PRODUCER CONTACT Customer Service Department P PHONE No _ . . X _..... Gaslam Insurance Services PHONE (800)920 4125 A/ N� (800)920-4107 xtl)" 2244 Faraday Avenue,#125 ADDRESS: INSURERS)AFFORDING COVERAGE NAIC# Carlsbad CA 92008 INSORERA, Obsidian Specialty Ins Co 16871 _ .......... INSURED INSURER B Kubi Custom Metals,LLC INSURER C 30 Palm Drive INSURER D '..INSURER E Key West FL 33040 INSURER F; COVERAGES CERTIFICATE NUMBER: GL 22-23 Master REVISION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD ONDICATED, 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, TR ."."" INSD. O POLL Y POLICY EXP LIMITS TYPE OF INSURANCE V✓VD POLICY NUMBER MMIDD/YYYY !A I D/YYYY ,,,,,,,•,_, " ......_ X'.COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 �^ AMA 1 CLAIMS-MADE F OCCUR 0 PREMISES Ea occurrence) $ 50,00 MED EXP(Any one person) $ 5,000 q _ ... PERSONA-..._... _Y SCB-GL-000015217 08/24/2022 08/24/2023 �LaADvw 1,0 JURY $ 00,000 j ""ETJ"LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OPAGG $ 1,000,000 .`/ �.....POLICY �PRO- �LOG ..... AUTOMOBILE LIABILITY IT CIDMB REOaccident) IP�dGn_E LIMIT' $ .............. Ee ar.cirSecrG'. ANYAUTO BODILY INJURY(Per person) s OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS I ••"•"• HIRED NON-OWNED ""� r.. PROPERTY DAMAGE $... AUTOS ONLY AUTOS ONLY `""` Per a,cckjLnt�I 81 UMBRELLA LIAB OCCUR • 9 •2 3 EACH OCCURRENCE $ EXCESS LIAB - HCLAIMS-MADE w AGGREGATE $ DED RETENTION S WORKERS COMPENSATION PER OTH STATUTE ER AND EMPLOYERS'LIABILITY Y/N ...... ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) IE.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below IE..L.DISEASE POLICY LIMIT S ................ --......... .. ............... _•.. .......... _... DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101 Additional Remarks Schedule,may be attached if more space is required) Certificate Holder is named as Additional Insured,to the extent provided in the attached form(s) "Additional Insured status is subject to all policy terms,exclusions and conditions' CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Monroe County BOCC ACCORDANCE WITH THE POLICY PROVISIONS. 1100 Simonton street AUTHORIZED REPRESENTATIVE Key West FL 33040 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 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. c vveador: I EL DI CUSTOM, METALS V�' Project or Service . DS rq Contractov V endor Address&Phone0: 5642 3RD AVE 30S-842-1820 KEY WEST FL 33040 General Scope of Work: A„w . ......... Ressoo for Waiveror MONROE COUNTY WILL Modification: PICK UP AND D961VER Tl iEE R.041ANG; CLPS'7101,1 r Policies Waiver or JAKUB BLAZEK Modification will apply to: Signature of Contracw/Vendor; Daft: 2 . 9 .2 3 AppfOVed x Not Approved Risk Management Sipaw e: Jaclyn Flatt „a Daft: -- County Admintsuator appeal: Approved. . Not Approved: Dde .a _,... --.... Board ofCounty CommLsawee s appeal: Approved: Not Approved MceunQ Date ... _ Adoraistrinve laawcnm 7500 7 104 JIMMY PATRONIS CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION *' CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW NON-CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 2/17/2023 EXPIRATION DATE: 2/16/2025 PERSON: JAKUB BLAZEK EMAIL: KUBICUSTOM@GMAIL.COM FEIN: 832734037 BUSINESS NAME AND ADDRESS: KUBI CUSTOM METALS LLC 5642 3RD AVE KEY WEST, FL 33040 This certificate of election to be exempt is NOT a license issued by the Department of Business and Professional Regulation. To determine if the certificate holder is required to have a license to perform work or to verify the license of the certificate holder, go to www.myfloridalicense.com. IMPORTANT,Pursuant to subsectron 440,05(13),F S,an officer of a corporation who elects exempBuon from this chapter by Fdinig a certificate of election under his section may not recover benefils or compensation under this chapter.Pursuant to subsection 440 05(41) F 5.,.Certificates of election to be exempt issued under subsection(3)apply only to the Corporate officer roamed on the notice of election to be exempt Pursuant to subsection 440 05(`t2) F.S.notices of elecBion 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 cenifucate no longer meets the requirements of this section for issuance of a certufroate.The department shall revoke'a certificate at any time for failure of the person names on the certificate to meet the requirements of this section, DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT E01673074 QUESTIONS?(850)413-1609 RULE 69L-6.012, F.A.C.REVISED 01/2023