Item G3
BOARD OF GOVERNORS
FIRE AND AMBULANCE DISTRICT 1
AGENDA ITEM SUMMARY
Meeting Date: September 15,2004
Bulk Item: Yes No -X-
Division: County Administrator
Department: Fire Rescue
AGENDA ITEM WORDING: Approval of Renewal Agreement effective from October 1,2004
through September 30, 2005, between Board of Govemors of Fire and Ambulance District 1 of Monroe
County Florida and Roy Khanna for maintenance of Fire Rescue vehicles (Ambulances) including
inspections, preventative maintenance, and unscheduled maintenance and repairs resulting from failure
or malfunction.
ITEM BACKGROUND: The original agreement provides for annual renewals for up to three (3)
one-year periods, with approval of the District's governing Board. We are requesting approval to
exercise that renewal clause for the second one-year period, commencing on October I, 2004 and
ending on September 30,2005.
PREVIOUS REVELANT BOG ACTION: On March 19, 2003, the Board approved an agreement
with Roy Khanna for maintenance of Fire Rescue vehicles (Ambulances) including inspections,
preventative maintenance, and unscheduled maintenance and repairs resulting from failure or
malfunction. On September 17, 2003, the Board approved a renewal agreement to extend the contract
with Roy Khanna for the first one-year period, effective October 1,2003 through Septemeber 30, 2004.
CONTRACT/AGREEMENT CHANGES: Contract term has changed to provide service for the
period of October 1,2004 to September 30,2005.
ST AFF RECOMMENDATIONS: Approval.
TOTAL COST:
$80,000.00
BUDGETED: Yes -X- No
COST TO COUNTY: $80.000.00
141-13001-530-462
SOURCE OF FUNDS: Ad valorem taxes
REVENUE PRODUCING: Yes
No ---K- AMOUNT PER MONTH_ Year
DIVISION DIRECTOR APPROVAL:
ES
APPROVED BY: County Atty YES OM
.--------
--
FIRE CHIEF APPROVAL: --
James L. Roberts
DOCUMENT A TION:
Included X
To Follow Not Required
00
AGENDA ITEM # L;- ~
DISPOSITION:
Revised 1/03
MONROE COUNTY BOARD OF GOVERNORS
CONTRACT SUMMARY
Roy Khanna
Contract #_
Effective Date:
Expiration Date:
1 % 1/2004
09/30/2005
Contract with:
Contract Purpose/Description:
Renewal of agreement dated 3/19/2003 for maintenance of Fire Rescue Vehicles
(Ambulances) including inspections. preventative maintenance. and unscheduled
maintenance and repairs resulting from equipment failure or malfunction.
Contract Manager: Susan Hover
(Name)
6088
(Ext. )
Fire Rescue / Stop 14
(Department/Stop #)
for BOCC meeting on
09/15/2004
Agenda Deadline: 08/31//2004
CONTRACT COSTS
Total Dollar Value of Contract: $ 80,000.00
Budgeted? Yes[8] No D Account Codes:
Grant: $
County Match: $
Current Year Portion: $ 80,000.00
13001-530462-_-_-_
- - - -
-----
- - - -
-----
- - - -
-----
ADDITIONAL COSTS
Estimated Ongoing Costs: $~yr For:
(Not included in dollar value above) (eg. maintenance, utilities, ianitorial, salaries, etc.)
CONTRACT REVIEW
Date In
Division Director 1-><"-"1
Changes
Needed
YesDN
Date Out
Risk Management ~ ' d 7-0 ~
O.M.B./Purchasing ~/01YesD No
County Attorney 3IZ4()~ YesD No
Comments:
OMB Form Revised 2/27/01 MCP #2
RENEWAL AGREEMENT
This AGREEMENT dated the day of , 2004, by and between
the Board of Governors of Fire and Ambulance District 1 of Monroe County, Florida, hereinafter called the
"District" and Roy Khanna., whose mailing address is 3117 Carol Avenue, Palm Springs, FL 33461,
hereinafter called the "Contractor".
WITNESSETH
WHEREAS, the parties hereto did enter into an agreement dated March 19, 2003 for scheduled general
and preventative maintenance of all Monroe County Fire Rescue ambulances, and for unscheduled maintenance
and repairs resulting from equipment failure or malfunction; and
WHEREAS, said agreement provided an option to the District to renew the contract for three additional
one year terms; and
WHEREAS, the DISTRICT has elected to exercise said option for the continuation of scheduled general
and preventative maintenance of all Monroe County Fire Rescue ambulances, and for unscheduled maintenance
and repairs resulting from equipment failure or malfunction; now therefore
IN CONSIDERATION ofthe mutual convenants and obligations contained herein, the parties agree as
follows:
1. The District elects to renew the contract for an additional year pursuant to paragraph 1 of the
agreement entered March 19,2003.
2. The effective date of this amendment is October I, 2004 and shall extend through September
30, 2005, under the same terms and conditions of the contract dated March 19, 2003.
3. All other terms and conditions of the contract dated March 19,2003 shall remain in full force
and effect.
Attest: DANNY L. KOLHAGE, CLERK
BOARD OF GOVERNORS,
FIRE AND AMBULANCE DISTRICT 1
By:
Deputy Clerk
By:
Mayor/Chairman
ROY KHANNA
WITNESS:
Authorized Representative
- ,~<
. : '-.J i \~ "
~l"1l' :c,
4IA7-~1I
RENEW AL AGREEMENT
This AGREEMENT dated the /7 ~day of ~J>ll"gFve , 2003, by and between
the Board of Governors of Fire and Ambulance District 1 of Monroe County, Florida, hereinafter callell the
"District" and Roy Khanna., whose mailing address is 3117 Carol Avenue, Palm Springs, FL 33461,
hereinafter called the "Contractor".
WITNESSETH
WHEREAS, the parties hereto did enter into an agreement dated March 19, 2003 for scheduled general
and preventative maintenance of all Monroe County Fire Rescue ambulances, and for unscheduled maintenance
and repairs resulting from equipment failure or malfunction; and
WHEREAS, said agreement provided an option to the District to renew the contract for three l:l..9ditional
one year terms; and
WHEREAS, the DISTRICT has elected to exercise said option for the continuation of scheduled general
and preventative maintenance of all Monroe County Fire Rescue ambulances, and for unscheduled maintenance
and repairs resulting from equipment failure or malfunction; now therefore
IN CONSIDERATION of the mutual convenants and obligations contained herein, the parties agree as
follows:
1. The District elects to renew the contract for an additional year pursuant to paragraph 1 of the
agreement entered March 19, 2003.
2. The effective date of this amendment is October 1, 2003 and shall extend through September
30,2004, under the same terms and conditions of the contract dated March 19,2003.
3. All other terms and conditions of the contract dated March 19,2003 shall remain in full force
and effect.
Attest: DANNY L. KOLHAGE, CLERK
BOARD OF GOVERNORS,
FIRE AND AMBULANCE DISTRICT 1
By: ~ o..L.J C. !flv %~
Deputy Clerk
'i-- ., J1t~
By:
Mayor/Chairman
WITNESS: .ALA..a::2"l'\. ~
epresentative
MAINTENANCE OF FIREIRESCUE VEHICLES
AGREEMENT is made and entered into by the Board of Governors of Fire and Ambulance
District I of Monroe County, Florida, hereinafter referred to as "DISTRICT", and Roy Khanna,
hereinafter referred to as "CONTRACTOR".
RECIT ALS
A. The DISTRICT advertised a notice of calling for bids for MAINTENANCE OF
FIRE/RESCUE VEHICLES, which were opened on the ih day of January 2003;
B. The successful bidder was Roy Khanna;
C. The initial contract provides for a renewal of the contract for three additional one-year
terms.
D. This contract is an agreement between parties.
NOW, therefore, the parties agree as follows:
1. CONTRACT PERIOD AND RENEWAL - The first contract term is a period from the
date on which it is signed by the last of the two parties and will expire on September 30,
2003. This contract may be renewed, at the option of the DISTRICT, upon giving at least
30 days notice to CONTRACTOR. The option for renewal shall be for three additional
one-year terms conditioned upon annual appropriation of funds.
2. CONTRACT TERMINATION - This contract may be terminated for any reason by either
party on 30-day written notice without cause.
3. SUBJECT MATTER OF CONTRACT - This contract is for performing scheduled
general and preventative maintenance of all Monroe County Fire Rescue ambulances, and
for unscheduled maintenance and repairs resulting from equipment failure or malfunction.
4. RATES -The hourly rate shall be $65.00 per man-hour with no travel time or mileage
charge. Jobs requiring more than one technician will be charged at the rate of$35.00 per
man-hour for the second man. The charge for conducting an ambulance inspection with
each preventative maintenance performed will be $239.00.
5. WORK. SCHEDULE - Regularly scheduled inspections and preventative maintenance
shall be conducted at such intervals as are approved by the DISTRICT and by the Ford
Scheduled Maintenance Guide using "Special Operating Conditions" as the guide for the
Ford Maintenance. The modular portion of the vehicle shall be maintained in accordance
with the manufacturers recommendations.
6. PARTS, FLUIDS AND LUBRICANTS - All parts, fluids, and lubricants used for
maintaining and repairing vehicles shall be supplied by CONTRACTOR and billed to the
DISTRICT at cost plus 25%, with a copy of original parts supplier invoices for all parts
attached to the bill.
Page 10f3
7. ENGINE OIL AND FILTER CHANGE - CONTRACTOR shall complete drivetrain
lubrication and any other fluids and/or filter changes shall be performed as recommended
by Ford.
8. WEEKLY MAINTENANCE SCHEDULE - CONTRACTOR shall provide to the
DISTRICT a preventative maintenance schedule that can be performed weekly by
Monroe County Fire Rescue personnel.
9. MAINTENANCE LOG - CONTRACTOR shall maintain an inspection and maintenance
chart on each vehicle containing at least the following information:
(a) date of performance,
(b) apparatus serviced,
(c) service performed,
(d) parts used,
( e) name 0 f service person( s),
(f) total downtime of vehicle
A copy of this chart shall be supplied to the Fire Rescue Office within 30 days of the
servIce.
A computerized ambulance inspection form shall be developed by the Contractor and _
approved by the Monroe County Fire Rescue Support Services Manager. This form will
be completed by the Contractor and forwarded to the office of the Support Services
Manager so that it can part of the service record of the vehicle.
10. COMMUNICATION - CONTRACTOR shall maintain a telephone or paging device such
that prompt notification of request for service is possible at all times.
11. RESPONSE TO SERVICE REQUEST - CONTRACTOR shall have 120 hours to
respond if one ambulance goes' off line. If a second ambulance goes off line, the
Contractor must respond within 48 hours of notification to repair both vehicles. If a third
ambulance goes off line, the Contractor must respond immediately to get a minimum of
two ambulances back on line.
12. CERTIFICATION - CONTRACTOR shall provide evidence satisfactory to the
DISTRICT that its personnel who perform maintenance work are certified in general
mechanics and repair.
13. QUALIFICATIONS OF MAINTENANCE PERSONNEL - All personnel performing
maintenance, repairs, adjustments, and related work on the DISTRICT'S equipment shall
be certified or experienced in the work to be performed.
14. INDEMNIFICATION - CONTRACTOR shall indemnify and hold the DISTRICT and
Monroe County harmless for any negligence on its part, or faulty or improper
workmanship, for all work performed under this contract, including all costs of
collection, reasonable attorney fees, claim costs, and as per "Attachment A". All
property or equipment being directly maintained or repaired by CONTRACTOR shall be
considered in its care, custody, and control while such work is in progress and until
physical control of such property or equipment is restored to the DISTRICT.
Page 2 of3
15. LOCATION OF WORK - This contract covers ambulances located at the following
stations:
a. Big Coppitt
b. Cudjoe
c. Big Pine
d. Conch Key
e. Tavernier
16. INSURANCE - As per Attachments "B" and "C".
1 7. PAYMENTS - Payments shall be made by the DISTRICT within 30 days of the
completion of the rendered services on each vehicle and proper invoicing by the
CONTRACTOR. All unscheduled maintenance and repairs resulting from equipment
failure or malfunction requiring service shall be billed by the CONTRACTOR at the
applicable rates as specified in Section four of this AGREEMENT. The CONTRACTOR
upon notification by the DISTRICT of an equipment failure or malfunction requiring
unscheduled maintenance shall, in a timely manner investigate the problem and provide
to the DISTRICT an estimate of the cost for repair and vehicle downtime. The
CONTRACTOR upon receiving authorization to proceed from the DISTRICT shall
effectuate .~uch repair; upon completion of same the contractor shall notify the DISTR!.CT
of the outcome and actual cost. The DISTRICT shall issue a separate purchase order for
each occurrence of unscheduled maintenance and repair.
18. This contract takes effect on the date of the last party to sign.
19. Monroe County's performance and obligation to pay under this contract is contingent
upon an annual appropriation by the B.O.C.C.
20. Venue for any litigation arising under this contract must be in a court of competent
jurisdiction in Monroe County, Florida.
IN WITNESS WHEREOF, each party hereto has caused this contract to be executed by its duly
authorized representative.
I .I'
BOARD OF GOVERNORS,
FIRE AND AMBULANCE DISTRICT 1
~ ._~ /1tJl-
Attest: DANNY L. KOLHAGE, CLERK
BY:~~C.. LQ.u~~ By:
Deputy Clerk APPROVED AS TO FOR~{ayerlChairman
AND 1-::. L SU"F_' ~ C '
~ v.If'A .
c/ S',; ANM A. HUTTON
D;:.T'" .:;J-. /~P3 ,_
R Y KHANNA
WITNESS: ~CL-A.- fbt.--elL
--
ve
Page 3 of3
199ti Edition
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 Conunissioners 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 \\iTongful act or 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'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.
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.
TCS
Administration Instruction
#4709.5
96
ATTACHMENT A
1996 Edition
RISK MANAGEMENT
POLICY AND PROCEDURES
CONTRo\CT ADMINISTRATION
MANU AL
General Insur.mce Requirements
for
Other Contractors and Subcontractors
As a pre-requisite of the work governed, or the goods supplied under this contract (including the
pre-staging of personnel and material), the Contractor shall obtain, at his/her OVt"TI 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. As an alternative, 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 (inc1udingpre-
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 penahies 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 shall provide, to the County, as satisfactory evidence of the required insurance,
either:
. Certificate 0 f Insurance
or
. A Certified copy of the actual insurance policy.
The County, at its sole optio~ 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.
Administration Instruction
1#4709.5
14
ATTACHMENT B (Page 1 of 2)
1996 Edition
The Monroe County Board of County Commissioners, its employees and officials 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 fonn entitled "Request for Waiver ofInsurance Requirements" and approved
by Monroe County Risk Management.
Administration Instruction
#4709.5
ATTACHMENT B (Page 2 of 2)
--
15
1996 EJilion
GENERAL LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN ..
l\'IONROE COUNTY, FLORIDA
AND
Prior to the commencement of work governed by this contract, the Contractor shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the contract and
include, as a minimum:
. Premises Operations
. Products and Completed Operations
. Blanket Contractual Liability
. Personal Injury Liability
. Expanded Definition of Property Damage
The minimum limits acceptable sball be:
$300,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$100,000 per Person
$300,000 per Occurrence
$ 50,000 Property Damage
.-
An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its
provisions should include coverage for claims filed on or after the effective date of this contract.
In addition, the period for which claims may be reported should extend for a minimum of twelve
(12) months following the acceptance of work by the County.
The Monroe County Board of County Commissioners shall be named as Additional Insured on all
policies issued to satisfy the above requirements.
GLl
Administration Instruction
1#4709.5
48
ATTACHMENT C (Page 1 of 3)
1996 Edition
VEHICLE LIABILITY
INSURANCE REQUlRE.MENTS
FOR
CONTRACT
BETWEEN
~IONROE COUNTY, FLORIDA
AND
Recognizing that the work governed by this contract requires the use of vehicles, the Contractor,
prior to the commencement of work, shall obtain Vehic1e Liability Insurance. Coverage shall be
maintained throughout the life of the contract and include, as a minirnwn, liability coverage for:
. Owned, Non-Owned, and Hired Vehicles
--
The minimum limits acceptable shall be:
$100,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$ 50,000 per Person
$100,000 per Occurrence
$ 25,000 Property Damage
The Monroe County Board of County Commissioners shall be named as Additional Insured on all
policies issued to satisfy the above requirements.
VLl
Administration Instruction
1#4709.5
80
ATTACHMENT C (Page 2 of 3)
1996 Edition
GARAGE LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Recognizing that the work governed by this contract involves the servicing and/or repair of
County-owned vehicles, the Contractor will be required to purchase and maintain a Garage Policy
"to include Garage Liability Insurance extending to vehicles, owned or leased by the County, left
with the Contractor for servicing, repair, storage, or safekeeping. Coverage should include, as a
minimum: .-
. Premises and Operations Liability
. Vehicle Liability
. Contractual Liability
. Products and Completed Operations Liability
. Garage Keepers' Legal Liability, to include:
Comprehensive and Collision
The Garage Keepers' Legal Liability shall extend to all County-owned/leased vehicles in the care,
custody, and control of the Contractor.
The Contractor's insurance shall be primary to any coverage maintained by the County.
The minimum limits acceptable shall be:
$300,000 Combined Single limit (CSL) for liability
$ 25,000 Garage Keepers' Legal Liability
The Monroe County Board of County Commissioners shall be named as Additional Insured on all
policies issued to satisfy the above requirements.
GKl
Administration lnstruction
1#4709.5
46
ATTACHMENT C (Page 3 of 3)
MONROE COUNTY FIRE RESCUE
AMBULANCES
VEHICLE LOCATION YEAR/MAKE/ MODEL VIN NUMBER COUNTY ID Prime or
Backup
BIG COPPITT 2002 FORD AMBULANCE 1 FDXF46F22ED14878 1416-215 Prime
BIG COPPITT 1995 FORD AMBULANCE 1 FDLF47FOSEA60715 1416-54 Backup
CUDJOE 2001 FORD AMBULANCE 1FDXF46F61 EC33364 1416-207 Prime
BIG PINE 2001 FORD AMBULANCE 1 FDXF46F61EC33365 1416-208 Prime
BIG PINE 1997 FORD AMBULANCE 1 FDLF47F8VEA7393 1416-059 Backup
CONCH KEY 2001 FORD AMBULANCE 1 FDXF46F41EC33363 1416-206 Prime
CONCH KEY 1997 FORD AMBULANCE lFDLF47F8VEA18040 1416-080 Backup
TAVERNIER 1999 FORD AMBULANCE 1 FDWF46F9XEB99283 1416-120 Prime
TAVERNIER 1984/94 FORD AMBULANCE 1 FDLF47M8REA52323 1417-151 Backup
Page 10 of 10
/...'....'.......
. ,. . ~
. ..;,
. ,
/
/;
//
/
"
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 CATEGORY TWO for a period of 36 months from the date of being placed on
the convicted vendor list."
Page 6 of 10
I, Roy
of k..F 'I L fl-vL 6-0
NON-COLLUSION AFFIDAVIT
IChA~,VA-
rL
, of the city
according to law on my oath. and under
penalty of perjury, depose and say that;
I) I am~L{\II,c", IT
the project described as ollows:
/)c'---
'v -
, the bidder making the Proposal for
f\ (01.... T eN F, cv~T7 j) ftw,S ~tL . (u~.,(( De Couv.---r-- FUh:. R €s t. j,/ e.
\J e h ic eJ
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 an~ 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 by 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 aftidavit in awarding
contracts for said project.
STATE OF fi8tl'1:>lf
'--'-- '- --
COUNTY OF (n~.p ~
I J - / c" C .. "7 --
Date
PERSONALL Y APPEARED BEFORE ME, the undersigned authority,
fl'frNII who. after first being sworn by me, (name of individual
affixed hislher signature in the space provided above on this
/~ d day of ])E~RJ11l3tL
'~Pfvt
. :2 w.;l..
My commission expirestJ....ll... 0 "
OMB - MCP FORM #1
~' '~ elizabeth EI Kowy
*1:*Mv COlMlisslon CC787397
't.::; EJlplres December 11. 2002
Page 7 of to
SWORN STATEMENT UNDER ORDINANCE NO. 10-1990
. MONROE COUNTY, FLORIDA
ETHICS CLAUSE
Ko'( lLhA-.-..- ~
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, per.centage, gift, or consideration paid to the former County ofticer'or employee.
9&~~
" (signature)
Date:
/,) -j 0 '-0;;-
,
COUNTY OF
n~ LlJ>f'r
.
tnb IJ~
STATE OF
PERSONALL Y APPEARED BEFORE ME, the undersigned authority,
KlJ'j KI4HA./1J A who, after first being sworn by me, affixed hislher
signature (name of individual signing) in the space provided above on this I tJ ct day of
:Y~e:R- , 20~
~~~k#t-
My commission expires:
/d. - /1- ();;..
OMS - MCP FORM #4
;~ ~to Elizabeth EI Koury
*J1J*My Commission CC787397
'\i;",,~. Expires December 11, 2002
Page 8 of 10
DRUG-FREE WORKPLACE FORM
The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies that:
R&'1 K!uw,-,vA-
(Name of Business)
1. 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. Infonn employees about the dangers of drug abuse in the workplace, tl1e business's policy of
maintaining a drug-free workplace, any available drug counseling, rehabiiitation, 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. 1n the statement specified in subsection (I), 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 tenns of the
statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere 1'0, 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 finn complies fully with the above
requirements.
fl~-~~
Bidd~rYs Signature
J J. -d-7-o A
Date
OMB - Mep FORM #5
Page 9 of 10
~t"'~~"'~"'."'B."~- )I'
Jot \"vn ~~ .:;~.B' ~ I . ,~. :Ei:E -atsn~I!,tj'J.r~n~' .~..
.....~~I~ll '!f;__lt!Ju('~~U~Hl1l1i~::;f,.!!,~"..};.,$~~~I~: '.'1 ,
ROOUC:EIl -"
ONLY AND CONFERS .NO RIGHTS UPON
HOLDER. THIS CER1IF.:A TE Does NOT Ar
ALTER THE COVERAGi AFFORDED BY THI
COMPANIES AFfORDING COVER
JOHNSON & MILLER INSURANCE
1225 N MILITARY TRAIL #2
w€ST PALM BEACH, FL 33409
561-640-4333
COM~ANY
A HERMITAGE INSURANCE co.
INSURtD'
COIA..ANV
B
ROY KHANN~
C:OIll~"NV
C
311"7 C1\.ROL AVE
PALM SPRINGS, FL 33461
(561)641-~360
lal~,,\>!"'r 0:'",,(, ;~"'!:IIl\"':V':: :i:1i;. "c,jl",,\ :. "'.1".1' "';;'".l''' ,'-',a' "I.":,,,.;. ".1 :,.:. ~;.. i'lj{ ~r'"''''''\''' '\.!,.1 ~~Il':~ulil: 1\~~rtl.i~'l';\f;'aI '.'. 1ll.;;~JlII,'l.iij~'~' . ',.
~..~~.l:i:4~"";j.;,,,;)i:. "'i;l'r~lo..i1ilj.\\rj(:;~~II~;;.:,\,.j.~~w.,~iii"!*lli;.:..",~:,\,;,~;,,'.:i:"'1;lJl:;(~';i.o:;j,"""'Jl!("..,II:,: 1l(,llllit:i'dlRoll . ~\Mil iil';
THIS l~ TO C~RTIFV THAT THE POUClES (S IN:llJft4NOE LllITED BELOW HAve BtCN IssuED TO THe INSURED NAMED Aoove fOR TH~ PO
INOlC,.TEO, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONOlTION Of NolV CONTRACT OR OTHJ:R DOCUMENT WITH REsPEOT TO
CEIUlFICATE MAY DE IS:lUED OR MAV PERTAIN, THE INSVAANCE AFFORDEO 8'1' THE PCR.ICIE$ DESCRIBED HEREIN IS ~UBJ1:CT TO ,AU
EXClUSIONS AND CONDITIONS OF SUCH POlIC1C~. lMTS SHOWN MAY HAVE efEN REDua;o BY PAlO CLAIMS.
COhll'ANY
o
CO
lTR
TYrc OF INaJ",,"CI
PO~'CV wu".~
,0UCV E"EC:TJl/E
01. TE IIllMlODI'fVl
,cuCV ElLPlIl" TION
OATE llllIllOD/T'f)
~IHlIH
GENtllAll~'TY
cO/lilMF.IlC....l GGNEIIAL ljA'ItLlTY
CUlIM" .~f 0 OCCUIl
OINH~'~ , CONTRIICTOR';o; ..ROT
#HGL41l3501
11/26/03
11/26/04
,"CNEIlAL ^COR'CATE
..RooUC;TS . COMP/OP ..(;C
r-I!RISOfolAl.. & ADV INJUR"I'
f:M:H OC:CUIIRF.t<CE
~IRE OMtAoe IMY on- "..I
IA(D EXI' (MY one pet_J
A
cOM8INF.O !l1l("1L' liMIT
A\lTOMoetL.E ~IllU1Y
Attf 10\11'0
SCH(DUU.D ^\/Too
HIRF.O AUTO:;
Il~OW""'O AIITOS
"'n( -
\~... I' I , '. ,.
. . I) I .:.
'~\t' __.\. _. .
, . .,
.. "l
'ATE
.. ....-.. '. .... ~,~..
800l~ Y INJUI<'"
(pe, pa...hl
ALl.. OWN'-O ~TC~
;, I f' ....
llOOIl V INJUIIV
(Pt. ,.,chlothtl
MlcPtRTV 0AMM'1:i
\'/"\ .
... 'I i:: :~; .
AI1TO ON\.. V - CA ACClOl:I'(f
OTHER Tt1AN AVfO ONLY:
f,ACri AQl;loClf
ACC,R'GA'
lOACH OCCURRENCf
....GReoATC
CAIUoGI1 UAellm'
AN" ..UTO
ElLC:EU UA..uTY
uloIllRElUl f01\1oI
oTlER TH,l\tI UMr.l'flL.A ro~1oI
wOIlKEllil COlllPIN,..TIOH AND
EIIlPl.O'nIlS' U,.,.IUTY
TI1" ~OI'k'~
I'AR'lNERSlCllf Cl./TIVE
OFFICeR!: AF<C
oYME'!
INCl
C:llCL
F,\. CIS"","' ' J'O\ICT l",r
Gl OIF:F..QE - f.'" CMPlOVl
L!!lCllltmON QF OPl!lV'TlON!o\.OCATlOflSIYEMICLEIISPEClAL lTP5
MONROE COUNTY BOARD OF COUNTR:l COMMISSIONERS SHALL BE LISTED AS
ADDITIONAL INSU'P.EDS ON POLICY ftHGL443501 WITH HERMITAGE INSURANCE C
"
MONROE COUNTY. BOARD OF COUNTY
COMMISSIONERS
ATTN: RISK MANAGEMENT
1100 SIMONTON STREET
KEY. WEST, FL 33Q10
... ..... _...... n r.-.., ~e::
st40UlD MY Of THI A,OVE O.BCIl.EO ,ouctaS .. I
EllI'IIlATIQH DATE TIKiIlIiOP, TtlE lS'UIIlG COlli''''''' WL
],.U- DAYS WRITTEN NOTIce TO 1>lE CEIlTlflCATE I<<'LD
IlUT , "' TO!l'" UCI< NO S"Al.l l1li"0. NO I)
1 . d
2~E"-S62 (SOE)
F\~uno:J ao..lUOW
dn :21 ..0 61 'n~