HomeMy WebLinkAbout01/21/2004 ContractDANNY L. KOLHA GE
CLERK OF THE CIRCUIT COURT
DATE:
February 27, 2004
TO:
Dent Pierce, Director
Public Works Division
A TTN:
Beth Leto, Administrative Assistant
PubBc Works Division
FROM:
Pamela G. Hancoc~''~
Deputy Clerk L.J
~//At the January 21, 2004, Board of County Commissioner's meeting the Board granted
approval to award bid and authorized execution of a Contract between Monroe County and
Culvers Cleaning Company for the janitorial services, opening and lock up of Veteran's Memorial
Park restrooms.
At the February 18, 2004, meeting the Board granted approval and authorized execution
of a Renewal Agreement between Monroe County and Barnes' Alarm Systems, Inc. for alarm
system certification, maintenance, and monitoring.
Enclosed is a duplicate original of each of the above-mentioned for your handling. Should
you have any questions please do not hesitate to contact this office.
CC:
County Administrator w/o documents
County Attorney
Finance
File ./
SECTION THREE
CONTRACT
THIS AGREEMENT, made and entered into this 21st day of January. 2004 AD., by and
between MONROE COUNTY, FLORIDA, party of the first part (hereinafter sometimes called
the "OWNER"), and Culvers Cleaning Company, part of the second part (hereinafter sometimes
called the "CONTRACTOR")
WITNESSED:
agree as follows:
That the parties hereto, for the consideration hereinafter set forth, mutually
3.01 SCOPE OF WORK
The contractor shall provide janitorial and opening and lockup services, including all
necessary supplies and equipment required in the performance of same, and perform all
of the work described in the Specifications entitled:
Monroe County Public Works
Contract Specifications
Janitorial Service Specifications
Veterans Memorial Park Restrooms
A/K/ A Little Duck Key
Monroe County, Florida
And his bid dated December 3. 2003, each attached hereto and incorporated as part of
this contract document. The manual shall serve as minimum contract standards, and shall
be the basis of inspection and acceptance of all the work.
3,02 THE CONTRACT SUM
The County shall pay to the contractor for the faithful performance of said service on a
per month in arrears basis on or before the 30th day of the following month in each of
twelve (12) months. The contractor shall invoice the County monthly for services
performed under the Specifications contained herein. The Contract amount shall be as
stated by the contractors bid as follows: $1.360.00 per month.
3.03 CONTRACTOR'S ACCEPTANCE OF CONDITIONS
A The contractor hereby agrees that he has carefully examined the sites and has
made investigations to fully satisfy himself that such sites are correct and suitable
ones for this work and he assumes full responsibility therefore. The provisions of
the Contract shall control any inconsistent provisions contained in the
specifications. All Specifications have been read and carefully considered by the
contractor, who understands the same and agrees to their sufficiency for the work
to be done. Under no circumstances, conditions, or situations shall this Contract
be more strongly construed against the owner than against the contractor and his
Surety.
B. Any ambiguity or uncertainty in the Specifications shall be interpreted and
construed by the owner, and his decision shall be final and binding upon all
parties.
C. The passing, approval, and/or acceptance of any part of the work or material by
the owner shall not operate as a waiver by the owner of strict compliance with the
terms of this Contract, and Specifications covering said work. Failure on the part
of the contractor, immediately after Notice to Correct workmanship shall entitle
the owner, if it sees fit, to correct the same and recover the reasonable cost of such
replacement and/or repair from the contractor, who shall in any event be jointly
and severally liable to the owner for all damage, loss, and expense caused to the
owner by reason of the contractor's breach of this Contract and/or his failure to
comply strictly and in all things with this contract and with the Specifications.
D. Contractor recognizes that time is of the greatest importance and agrees to
reimburse County $50.00 per day for each day of delay in providing the services
under this Agreement unless said delay is caused by acts or omissions of the
County or Acts of God. The County shall have sole authority to determine if a
condition for non-payment under this paragraph has occurred.
3.04 TERM OF CONTRACT/RENEW AL
A. This Contract shall be for a period of one (1) year, commencing on February 1,
2004, and shall terminate on January 31, 2005. This Contract shall be renewable
in accordance with Article 3.04 B.
B. The owner shall have the option to renew this agreement after the first year, and
each succeeding year, for two additional one year periods. The contract amount
agreed to herein will be adjusted annually in accordance with the percentage
change in the Consumer Price Index for all urban consumers (CPI-U) for the most
recent 12 months available. Increases in the contract amount during each option
year period shall be extended into the succeeding years.
3.05 CANCELLATION
A. The County may cancel this contract for cause with seven (7) days notice to the
contractor. Cause shall constitute a breach of the obligations of the contractor to
perform the services enumerated as the contractor's obligations under this
contract.
B. Except for the County's termination because of non-appropriation (Article 3.12),
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.
3.06 HOLD HARMLESS
The contractor shall defend, indemnify and hold the County, its officials, employees, and
agents harmless, from any and all claims, liabilities, losses and causes of action which
may arise out of the performance of the Contract except such claims, liabilities, losses
and causes of action which may arise because of the County's negligent actions or
omissions. Compliance with the insurance requirements shall not relieve the contractor
from the obligations imposed by this article.
3.07 INDEPENDENT CONTRACTOR
At all times and for all purposes under this agreement the contractor is an independent
contractor and not an employee of the Board of County Commissioners for Monroe
County. No statement contained in this agreement shall be construed so as to find the
contractor or any of hislher employees, contractors, servants, or agents to be employees
of the Board of County Commissioners for Monroe County.
3.08 ASSURANCE AGAINST DISCRIMINATION
The contractor shall not discriminate against any person on the basis of race, creed, color,
national origin, see, age, or any other characteristic or aspect which is not job related, in
its recruiting, hiring, promoting, tenninating, or any other area affecting employment
under this agreement or with the provision of services or goods under this agreement.
3.09 ASSIGNMENT
The contractor shall not assign or subcontract this agreement, except in writing and with
the prior written approval of the Board of County Commissioners for Monroe County and
contractor, which approval shall be subject to such conditions and provisions as the
owner and contractor may deem necessary. This agreement shall be incorporated by
reference into any assignment or subcontract and any assignee or subcontractor shall
comply with all of the provisions of this agreement. Unless expressly provided for
therein, such approval shall in no manner or event be deemed to impose any obligation
upon the owner in addition to the total agreed-upon price of the services/goods of the
contractor.
3.10 COMPLIANCE WITH LAW
In providing all services/goods pursuant to this agreement, the contractor shall abide by
all statutes, ordinances, rules and regulations pertaining to, or regulating the provisions
of, such services, including those now in effect and hereinafter adopted. Any violation of
said statutes, ordinances, rules and regulations shall constitute a material breach of this
agreement and shall entitle the owner to terminate this contract immediately upon
delivery of written notice of termination to the contractor.
3.11 INSURANCE
Prior to execution of this agreement, the contractor shall furnish the owner Certificates of
Insurance indicating the minimum coverage limitations as indicated by an "X" on the
attached forms identified as INSCKLST 1-4, as further detailed on forms WC1, GL1,
VL 1, ED 1, each attached hereto.
3.12 FUNDING AVAILABILITY
In the event that funds from Parks and Beaches Unincorporated Contractual Services are
partially reduced or cannot be obtained or cannot be continued at level sufficient to allow
for the purchase of the services/goods specified herein, this agreement may then be
terminated immediately at the option of the owner by written notice of termination
delivered in person or by mail to the contractor. The owner shall not be obligated to pay
for any services provided by the contractor after the contractor has received written
notice of termination.
3.13 PROFESSIONAL RESPONSffiILITY
The contractor warrants that it is authorized by law to engage in the performance of the
activities encompassed by the project herein described, subject to the terms and
conditions set forth in the Public Works Manual entitled "Monroe County Public Works
Contract Specifications/Janitorial Service Specifications/V eteran' s Memorial Park
Restrooms/ A/KJ A Little Duck Key", which is attached hereto and incorporated herein as
a part of this contract/agreement. The provider shall at all times exercise independent,
professional judgment and shall assume professional responsibility for the services to be
provided. Continued funding by the owner is contingent upon retention of appropriate
local, state, and/or federal certification and/or licensure of contractor.
3.14 PERFORMANCE AND OBLIGATION
Monroe County's performance and obligation to pay under this contract is contingent
upon an annual appropriation by the Board of County Commissioners.
3.15 NOTICE REQUIREMENT
Any notice required or pennitted under this agreement shall be in writing and hand
delivered or mailed, postage prepaid, to the other party be certified mail, return receipt
requested, to the following:
FOR COUNTY
FOR CONTRACTOR
Monroe County Public Works
Facilities Maintenance Department
3583 S. Roosevelt Boulevard
Key West, FL 33040
Culvers Cleaning Company
P.O. Box 500761
Marathon, FL 33050
, ~ WHEREOF the parties hereto have executed this Agreement on the day and date
'. en in four (4) counterparts, each of which shall, without proof or accounting for
\.
arts, be deemed an original Contract.
+' L. KOLHAGE, Clerk
"
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY FLORIDA
By:
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CONTRACTOR
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MONROE COUNTY, FLORIDA
RISK MANAGEMENT
POLICY AND PROCEDURES
CONTRACT ADMINISTRATION MANUAL
Indemnification and Hold Harmless
For
Other Contractors and Subcontractors
The Contractor covenants and agrees to indemnify and hold harmless Monroe County Board of
County Commissioners from any and all claims for bodily injury (including death), personal
injury, and property damage (including property owned by Monroe County) and any other
losses, damages, and expenses (including attorney's fees) which arise out of, in connection with,
or by reason of services provided by the Contractor or any of its Subcontractor(s) in any tier,
occasioned by the negligence, errors, or other wrongful act of omission of the Contractor or its
Subcontractors in any tier, their employees, or agents.
In the event the completion of the project (to include the work of others) is delayed or suspended
as a result of the Contractor" failure to purchase or maintain the required insurance, the
Contractor shall indemnify the County from any and all increased expenses resulting from such
delay.
The first ten dollars ($10.00) of remuneration paid to the Contractor is for the indemnification
provided for above.
The extent of liability is in no way limited to, reduced, or lessened by the insurance requirements
contained elsewhere within this agreement.
MONROE COUNTY, FLORIDA
INSURANCE CHECKLIST
FOR
VENDORS SUBMI1TING PROPOSALS
FOR WORK
To assist in the development of your proposal, the insurance coverage's marked with an "X" will
be required in the event an award is made to your firm. Please review this form with your
insurance agent and have him/her sign it in the place provided. It is also required that the bidder
sign the form and submit it with each proposal.
WORKERS' COMPENSATION
AND
EMPLOYERS' LIABILITY
WC1
WC2
WC3
WCUSLH
X
X
Workers' Compensation
Employers Liability
Employers Liability
Employers Liability
US Longshoremen &
Harbor Workers Act
Federal Jones Act
Statutory Limits
$100,000/$500,000/$100,000
$500,000/$500,000/$500,000
$1,000,000/$1,000,000/$1,000,000
Same as Employers'
Liability
Same As Employers'
Liability
WCJA
GENERAL LIABll..ITY
As a minimum, the required general liability coverage will include:
· Premises Operations
· Blanket Contractual
· Expanded Definition
Of Property Damage
.
Products and Completed Operations
Personal Injury
.
Required Limits:
GLl
x
$100,000 per Person; $300,000 per Occurrence
$50,000 Property Damage
or
$300,000 Combined Single Limit
GL2
$250,000 per Person; $500,000 per Occurrence
$50,000 Property Damage
or
$500,000 Combined Single Limit
GL3
$500,000 per Person; $1,000,000 per Occurrence
$100,000 Property Damage
or
$1,000,000 Combined Single Limit
GL4
$5,000,000 Combined Single Limit
Required Endorsement:
GLXCU
Underground, Explosion and collapse (XCD)
GLLIQ
Liquor Liability
GLS
Security Services
All endorsements are required to have the same limits as the basic policy
VEHICLE LIABILITY
As a minimum, coverage should extend to liability for:
· Owned; Non-owned; and hired Vehicles
Required Limits:
VLl
x
$50,000 per Person; $100,000 per Occurrence
$25,000 Property Damage
or
$100,000 Combined Single Limit
VL2
$100,000 per Person; $300,000 per Occurrence
$ 50,000 Property Damage
or
$300,000 Combined Single Limit
VL3
$500,000 per Person; $1,000,000 per Occurrence
$100,000 Property Damage
or
$1,000,000 Combined Single Limit
VL4
$5,000,000 Combined Single Limit
MISCELLANEOUS COVERAGES
DRI Builders' Limits equal to the
Risk completed project
MVC Motor Truck Limits equal to the maximum
Cargo value of any one shipment
PRO I Professional $ 250,000 per Occurrencel$ 500,000 Agg.
PR02 Liability $ 500,000 per Occurrencel$I,OOO,OOO Agg.
PR03 $1,000,000 per Occurrence/$2,000,000 Agg.
POLl Pollution $ 500,000 per Occurrencel$ 1,000,000 Agg,
POL2 Liability $1,000,000 per Occurrence/$ 2,000,000 Agg.
POL3 $5,000,000 per Occurrence/$IO,OOO,OOO Agg.
EDl X Employee $ 10,000
ED2 Dishonesty $100,000
GKI Garage $ 300,000 ($ 25,000 per Veh)
GK2 Keepers $ 500,000 ($100,000 per Veh)
GK3 $1,000,000 ($250,000 per Veh)
MEDl Medical $ 250,000/$ 750,000 Agg.
MED2 Professional $ 500,000/$ 1,000,000 Agg.
MED3 $1,000,000/$3,000,000 Agg.
MED4 $5,000,000/$10,000,000 Agg.
IF Installation Maximum value of Equipment
Floater Installed
VLPl Hazardous $ 300,000 (Requires MCS-90)
VLP2 Cargo $ 500,000 (Requires MCS-90)
VLP3 Transporter $1,000,000 (Requires MCS-90)
BLL Bailee Liability Maximum Value of Property
HKLl Hangarkeepers $ 300,000
HKL2 Liability $ 500,000
HKL3 $1,000,000
AIR 1 Aircraft $ 1,000,000
AIR2 Liability $ 5,000,000
AIR3 $50,000,000
AEOl Architects Errors $ 250,000 per Occurrence/$ 500,000 Agg,
AE02 & Omissions $ 500,000 per Occurrence/$I,OOO,OOO Agg.
AE03 $1,000,000 per Occurrence/$3,000,000 Agg.
EOl Engineers Errors $ 250,000 per Occurrencel$ 500,000 Agg.
E02 & Omissions $ 500,000 per OccurrencelSl,OOO,OOO Agg.
E03 $1,000,000 per Occurrencel$3,OOO,OOO Agg.
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 property to 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, for
CA TEGOR Y TWO for a period of 36 months from the date of being placed on the
convicted vendor list. "
~ CERTIFICATE OF LIABILITY INSURANCE I DATE (MMIDDIYYYY)
11/13/2003
RODUCER (305) 743-0494 FAX (3 743-0582 THIS CERTIFICATE I, 3UED AS A MATTER OF INFORMATION
(eys Insurance Services, Inc, ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. Box 500280 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Marathon, FL 33050-0280
INSURERS AFFORDING COVERAGE NAIC#
lSURED Anthony Culver INSURER A: Bankers Insurance Company
DBA: Culver's Cleaning CO INSURER B: Western Surety Company
P,o. Box 500761 INSURER c:
Marathon, FL 33050-0761 INSURER D:
INSURER E:
;OVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINI
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
~ ~~'l;~ TYPE OF INSURANCE POLICY NUMBER POLICY EFFECllVE POLICY EXPIRATION UMrrs
GENERAl LIABIUTY 090004892905300 08/30/2003 08/30/2004 EACH OCCURRENCE $ 300,000
X COMMERCIAl GENERAl LIABILITY DAMAGE TO RENTED $ 50,OO(
I CLAIMS MADE []J OCCUR MED EXP (Anyone person) $ 5,OOC:
A PERSONAL & AOV INJURY $ 300 , OOCJ
-
GENERAL AGGREGATE $ 600,00(
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 300,00(]
"I 'nPRO- n
POLICY JECT LOC
AUTOMOBILE LlASIUTY COMBINED SINGLE LIMIT
- (Ea accident) $
MlY AUTO
-
ALL OWNED AUTOS BODILY INJURY
- $
SCHEDULED AUTOS (Par person)
-
HIRED AUTOS BODILY INJURY
- $
NON-OWNED AUTOS (Par accident)
- ~()1:
~~ ~~lAN,:~1EI i PROPERTY DAMAGE
- , , 'iI. II. _/ (Par accident) $
GARAGE UABIUTY .', \ j-'\ -;Il rX107 AUTO ONLY - EA ACCIDENT $
R MlY AUTO ."n OTHER THAN EA ACC $
.,,...'" AUTO ONLY: AGG $
;oJ;' ., ,i r.'!!' ._, 5if '. (l
EXCESS/UMBRELlA LlASIUTY )(1_ EACH OCCURRENCE $
o OCCUR o CLAIMS MADE AGGREGATE $
~",J--'" $
R DEDUCTIBLE J/~~ Vi' $
RETENTION $ $
WORKERS COMPENSATION MlD C~'1~ l M (,~~,) I WC STATU- I IOgt-
EMPLOYERS' LlASIUTY E.L. EACH ACCIDENT
ANY PROPRIETORIPARTNERlEXECUTIVE $
OFFICERlMEMBER EXCLUDED? E.L. DISEASE. EA EMPLOYEE $
II yes, describe under E.L. DISEASE - POLICY LIMIT $
SPECIAL PROVISIONS below
F~ra~' i ty Bond 68634853 07/30/2003 07/30/2004 $10,000
B
DESCRIPTION OF OPERATIONS I lOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
:ertificateholder is additional insured with respect to liability, as their interest may appear,
I RErET'l"ED
CERT unlni=R , NO\I 1 9 7nn1 14TlnN
:
~ SHOULD ANY OF THE ABOVE O:1>OU.;:les BE CANCELLED BEFORE THE
\BY;~ EXPIRATION DATE THEREOF. THE ING INS.1eR WILL ENDEAVOR TO MAIL
L_~ -<-~.- ..JJL. OAYS WRITTE)HOTlCE TO l~Rll!FlCATE HOlDER NAMED TO THE LEFT,
Monroe County Board of County Commissioners BUT FAILURE TO MAIL UCH NOT: E LL IMPOSE NO OBlIGATION OR LIA8IUTY
\.su /
1100 Simonton Street OF ANY KIND UPON THE _ RE.... OR REPRESENTATIVES.
I Key West, FL 33040 AUTHORIZED REPRESENTATIVE \) \...
-
ACORD 25 (2001/08)
@ACORD CORPORATION 1988
BID FORM
Send Bid To:
Monroe County Board of County Commissioners
C/O Purchasing Department
Gato Building Room 2-213
1100 Simonton Street
Key West, FL 33040
~vPi,~1~~~f4!Jfl'Y'1
1',0. &)i .Su;~~~3
[Y\ Ar?q +h1Y\ P'\ (L.I '- ~ 0.1::\0- 0333
I .
BID FROM:
The undersigned, having carefully examined the work, specifications, proposal, and addenda
thereto and other Contract Documents for the services of:
RESTROOM JANITORIAL SERVICES, OPENING AND LOCK UP
VETERAN'S MEMORIAL PARK AlKJA LITTLE DUCK KEY
/>'C' .~/ A 'J .,..,
VA -tn~t:r...,f <<.c:.(!0
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DATE:
And 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 labor, tools, material, equipment, transportation services, and all incidentals necessary to
perform and complete said work in a workman-like manner, in conformance with specifi~ations,
and other contract documents including addenda issued thereto
thl /;ikft2n?{~rLr' A-i.rdrL~.I-S/~-h/ dtJ//~ ,4ne-l ~~a:>
Amount of bid in writing - per month /
/..3&0 tV
Amount of bid in numbers
Per Month
I acknowledge receipt of Addenda No. (s)
Checklist:
I have includ~ the Bid Proposal which entails the Proposal Form. /" . the Non-Collusion
Affidavit ~, the Lobbying and Conflict of Interest Clause~, the Drug Free Workplace
Form, and.:Jl a ?:t copy of my Monroe County Occupation Licens~ ~.
Signed: -/.Id0t 4~ Name: 47//l,y Ik/.z.--
Title:~,~.e a.nK'L Mailing Address:' D.. JJtl1t. 0"Zi0::3.3
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Phone~ -Po{:):- ?/';-/}j~1 &- Fax: ;V#
10
NON-COLLUSION AFFIDAVIT
J, Aj~~ (J .h'er of the city of .#~//Jt.YJ /A"n'o{___
according to la on my oath, and under penalty of perjury, depose and say tha1:
L J am 1.14/J( rY'
of the firm of f'M-k--bC< [1/(~ ~d,?/
the bidder making the Proposal for the project described in the Notice for Calling for bids for:
J;Ln/k~J ,,-fer.n'{;t7 J ltlkl..--rK 4J:- /~h.?rn< g//J-ff/?J-.liY-;.2?-v~u;~_
and that J executed the said proposal with full authority t do so:
2. the prices in this bid have been arrived at independently without collusion, consultation,
communication or agreement for the purpose of restricting competition. as to any matter relating to
such prices with any other bidder or with any competitor;
3. unless otherwise required by law, the prices which have been quoted in this bid have not been
knowingly disclosed by the bidder and will not knowingly be disclosed by the bidder prior to bid
opening, directly or indirectly, to any other bidder or to any competitor; and
4. no attempt has been made or will be made b the bidder to induce any other person, partnership or
corporation to submit, or not to submit, a bid for the purpose of restricting competition;
5. the statements contained in this affidavit are true and correct, and made with full knowledge that
Monroe County relies upon the truth of the statements contained in this affidavit in awarding contracts
for said proj
4~~
...Ijt",[ 4<.J-J~___
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(Date)
STATE OF:
;;!o,e/!J#
#IC)/I~-C
COUNTY OF:
PERSONALLY APPEARED BEFORE ME, tho unde"ignod .uthority, Mxt//y d~/C
who, after ~rst being .1om by me~me ~vidual signing) .affixed hislher sigflature in the space provided
above on thIS ~ day of '~~ . .., / 20 c::;?p ,.
My Commission Expires:
-
- -
GRIMJLOA BETANCOURT ~
Nofay Public - S1ate of FIorfda
Myecm.,~ 8rpiIw May 25. DU
CammlssIan # c:c.'9>>a.,
I I
SWORN STATEMENT UNDER ORDINANCE NO. 10-1990
MONROE COUNTY, FLORIDA
E'IHICS CLAUSE
C1t ~z.-::f C / fA,7/;? C:n;,o/h /
/7JJ//;ry '~J/ Lv-
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. 10-1990 or any County officer or employee in violation of
Section 3 of Ordinance No. 10-1990. For breach or violation of this provision the County
may, in its discretion, terminate this contract without liability and may also, in its discretion,
deduct from the contract or purchase price, or otherwise recover, the full amount of any fee,
commission, percentage, gift, or consideration paid to the
f~
(signature) I. ~~d<.J::l.T
Date: 4~~'~/
STATE OF
;J;tC"/DA
IJt I)' ,e~/~
COUNTY OF
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
2~ .7
...' ,". i"~ ..~
.,;/- '7l '1/77 ( ~I ~ "<',,C who, after first being sworn by me, affIxed hislher
.--:> /
?4 day of
signature (name of individual signing) in the space provided above on this
.i>--6.?~.~
, 20 {) ~
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NOTARY PUBLIC
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My commission expires:
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OMB - MCP FORM #4
GR1MILDA BETANCOURT
Notary Public - State of Florlda
My Commlsslon &pires May 25. 2IXU
CommlssIon. CC9273BO
- -
12
DRUG-FREE WORKPLACE FORM
The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies that:
!~l,.h~,." C~t' M""7 L'<npan/
(Name of Business) !~
I. Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or
use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against
employees for violations of such prohibition.
2. Inform employees about the dangers of drug abuse in the workplace, the business's policy of maintaining a drug-
free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties
that may be imposed upon employees for drug abuse violations.
3. Give each employee engaged in providing the commodities or contractual services that are under bid a copy of
the statement specified in subsection (1).
4. In the statement specified in subsection (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, or any employee who is so convicted.
6. Make a good faith effort to continue to maintain a drug-free workplace through implementation of this section.
As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements.
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Date /
OMB - MCP#5
13
INSURANCE AGENTS STATEMENT
I have reviewed the above requirements with the bidder named below. The following
deductibles apply to the corresponding policy.
POLICY DEDUCTIBLES
09c7C10 ~f/ d- 705300
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Insurance Agency Signature
Claims Made
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BIDDERS STATEMENT
I understand the insurance that will be mandatory if awarded the contract and will comply in full
with all ~ re uirements.
kl ,~?
BidderSignature
25
MONROE COUNTY, FLORIDA
Request For Waiver
of
Insurance Requirements
Contractor:
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:
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Contract for:
Address of Contractor:
Phone:
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Scope of Work:
Reason for Waiver:
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bk//lLr- ,ovkhY'y /U/ ,(~~
Policies Waiver
will apply to:
Signature of Contractor:
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7;7~ ~otAPfKOVed
lis/oJ
.
Risk Management:
Date:
County Administrator appeal:
Approved
Not Approved
Date:
Board of County Commissioners appeal:
Approved
Not Approved
Meeting Date:
31
NOTICE OF ELECTION TO BE EXEMPT
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Effective/Issue Date:
Please refer to the written instructions prepared by the
Division of Workers' Compensation before completing this form.
Expiration Date:
By filing this application, you elect to be exempt from the provisions of Chapter 440,
Florida Statutes and waive any right you may have to workers' compensation benefits In Control Number:
the State of Florida should you become Injured on the job. Anv person who knowlnl!lv and
with Intent to Iniure, defraud, or deceive the Division or any emplover. emplovee, or Postmark Date:
insurance company or purposes prol!l"am. files a Notice of Election to be Exempt contalninl!
any false or mlsleadinl! information is 1!U1Itv of a felony of the third del!ree. Certain Received Date:
documentation Is required by law to be attached to this application-refer to the Instruction
sheet for more details.
I am applying for exemption as a (check only one box in this section):
~)lSTRUCTlON INDUSTRY ( S 50.00 FEE REQUIRED)
5J Sole Proprietor 0 Partner 0 Corporate Officer (your corp. title: ) -QR-
NON-CONSTRUCTION INDUSTRY ( NO FEE REQUIRED)
o Co rate Officer our co . title:
CORPORATE OFFICERS AND PARTNERS: List the registration number of your business on file with the Division of Corporations,
Department of State's Office (NOTE: our partnership may not have one, but all corporations must have one. If your partnership doesn't
have one, state UN/A"): .
3-14~Lt
Unemployment Compensation Date Business Established:
Tax. No: q- D-
Are you required to be registered or certified pursuant to Chapter 489, F. S.?
licenses issued .to you pursuant to Chapter 489, Florida ~tatues
Are you or a qualifier for your business required by the county or the municipality in which your business mailing address is
located to have an occupational license for the business which is the subject of this application? 0 No J:7l Yes:
YOU MUST ATIACH A COpy OF A CURRENT OCCUPATIONAL LICENSE ~
Are you e ployed by any sole proprietorship, partnership, corporation or business entity other than the business to which this application
applies? NO 0 YES list the name of all other businesses in which you are employed:
Yes: list all certified or registered
Has the above-referenced business entity been in 0 eration long enough to have filed with or be required to file by the IRS.
an annual Federal Income Tax Return? No Yes, You must attach tax records. See instruction sheet for details.
AFFIDA VIT OF APPLICANT: I hereby certify that the information contained herein is true and correct to the best of my
knowledge and belief; that this election does not exceed exemption limits for corporate officers or partners as provided in ~440.02
Florida Statutes; and that I will secure the payment of workers' compensation benefits, pursuant to Chapter 440, Florida Statutes,
for any employee I now have or may hereinafter acquire, for which my business is required by Florida law to secure such benefits.
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TYP' R NT NANlE PERSON PPLYING FOR EXEMPTION
d..'}.J I~/~
SOCIAL SECURITY NO.
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PLICA "S SIGNATURE !l1'
NOTARY STATE OF FLORIDA, COUNTY OF Dn({) f~
Sworn '''Ud'Ub''L~<"rn ~ duyof 51 O-:t , .i oca, by 0 fI IKjJYUvd!IJJ AK/
Pcrsonally Known OR reduced . IC n I Type of Idcmification Produced LINOA A. REGAN rida
Notary publlo. State vI Ro
Commission Expires ~ Commlt.lon =n9 8,2001
EVER FO~J. ~RMATION)
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DATE SIGNED
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mo. day yr.
DATE OF BIRTIt
ilLJ1_
NOTARY SIGNATURE
LES FORM BCM-2S0 Revl
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