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1596* SE Drilling Services Ch Order 2 t 5 gio _ C ri 970: NJOT1) ' t Rib Thursday, December 12, 2013 —1877-4 C'`,i CN PURCHASING DEPARTMENT L.! TRANSMITTAL. MEMORANDUM To: City Clerk RE: Hidden Lakes Well 7 Replacement IFB 11/12-17 Change Order No.2 The item(s)noted below is/are attached and forwarded to your office for the following action(s): Development Order Mayor's signature Final Plat (original mylars) Recordin. ❑ Letter of Credit ' - s ering 6,11 ((0 ❑ Maintenance Bond Safe keeping (Vault) ❑ Ordinance ■ Deput • ►4 . - -r Performance Bond ❑ Payment Bond ❑ Resolution City Manager Signature City Clerk Attest/Signature Once completed, please: Return originals to Purchasing I Return copies Special Instructions: Attest signature; From •ate T:\Dept_forms\City Clerk Transmittal Memo-2009.doc DATE: 01/17/13 PURCHASE ORDER PO NUMBER 033258 CITY OF SANFORD CHANGE # : 2 P.O. BOX 1788 DATE CHG: 07/09/13 PURCHASING OFFICE:407.688.5030 (300 NORTH PARK AVENUE) SUBMIT INVOICES TO:ACCOUNTS PAYABLE ACCOUNTS PAYABLE:407.688.5020 SANFORD, FLORIDA 32772 FINANCE DEPT. FACSIMILE:407.688.5021 FLORIDA TAX EXEMPT NO.:858012621681C-8 X 1788 P.O.P.O.BOX SANFORD, FL 32772 VENDOR NO.: 11855 TO: SHIP TO: SOUTHEAST DRILLING SERVICES, I CITY OF SANFORD 10614 E US HIGHWAY 92 300 N. PARK AVENUE TAMPA, FL 33610 SANFORD, FL 32771 DELIVER BY TERMS F.O.B.DESTINATION BID OR QUOTATION NO. REQUISITION NO. UNLESS OTHERWISE INDICATED 09/30/13 NET/30 63587 ACCOUNT NO.: 452-4530-536 . 63-03 PROJECT NO.: DW 11 O 6 NO DEVIATION FROM THIS PURCHASE ORDER WILL BE ALLOWED UNLESS AUTHORIZED BY THE PURCHASING MANAGER-CITY OF SANFORD UNIT OF ITEM NO. DESCRIPTION QUANTITY ISSUE UNIT COST EXTENDED COST **********************************,, * * * CHANGE ORDER * * **********************************i 1 HIDDEN LAKES WELL 7 REPLACEMENT 327200 . 00 NA 1 . 00 327200 . 00 SRF DW 590120 Increase PO changed the pump size from 1, 500 gpm to 2 , 000 gpm change the days in contract add 115 days total of 235 days. . . 2 INCREASE PO CHANGE ORDER FOR 7341. 00 NA 1 . 00 7341 . 00 ADDITIONAL SERVICES 3 UPGRADE FENCE TO ACCOMODATE SCADA 43905 . 00 NA 1 . 00 43905 . 00 & ELECTRIC GENERATOR. COMPLETE NECESSARY ELECTRICAL WORK TO ACCOMMODARE NEW CONSTRUCTION INCLUDING ADDITION AL SET UP FOR A PORTABLE GENERATOR. EMERGENCY REPAIRS. . . CHANGE ORDER NO. 3 INCREASE PO SUB-TOTAL 378446 . 00 TOTAL 378446 . 00 APPROVED : . _.,AM APPROVED BY: AOLAN, ,A / PURCH. 'G Ac ' CITY M," •GER ALL PACKAGES AND INVOICES ASSOCIATED WITH THIS P.O.MUST BEAR THIS PURCHASE ORDER NUMBER. THE VENDOR IS RESPONSIBLE TO CAREFULLY READ AND COMPLY WITH ALL OF THE STANDARD TERMS AND CONDITIONS PROVIDED ON THE REVERSE SIDE OF THIS PURCHASE ORDER AND AT HTTP://WWW.SANFORDFL.GOV/DEPARTMENTS/PURCHASE/TERMS.HTML COPIES TO: VENDOR ORIGINATING DEPARTMENT PURCHASING PROJECT NO. IFB 11/12-17 SECTION 00850 CHANGE ORDER FORM Change Order No. 2 Project Title Hidden Lakes Well 7 Replacement Bid No. IFB 11/12-17 Owner: City of Sanford Contractor: Southeast Drilling Services, Inc. Agreement Date: October 24, 2012 This Change Order is necessary to cover changes in the work to be • performed under this Agreement. The GENERAL CONDITIONS, SUPPLEMENTARY CONDITIONS, and STANDARD SPECIFICATIONS apply to and govern all work under this Change Order. THE FOLLOWING CHANGES ARE MADE TO THE CONTRACT DOCUMENTS: (1) Original Contract Price $ 327,200 (2) Current Contract Price (Adjusted by Previous Change Orders) $ 334,541 (3) Total Proposed Change in Contract Price $ (4) New Contract Price (Item 2 + Item 3) $ 334,541 (5) Original Contract Time 120 Days (6) Current Contract Time (Adjusted by Previous Change Orders) 235 Days (7) Total Proposed Change in Contract Time 90 Days (8) New Contract Time (Item 6 + Item 7) 325 Days (9) Original Ori inal Contract Substantial Completion Date 5/15/13 (10) New Contract Substantial Completion Date 12/06/13 00850-1 PROJECT NO. IFB 11/12-17 CHANGES ORDERED ITEM 1 Description of Change: Increase in contract time. Reason for Change: Column pipe was damaged upon receipt and returned. Change in Contract Price: $0 Change in Contract Time: 90 Days ITEM 2 Description of Change: Reason for Change: Change in Contract Price: Change in Contract Time: ITEM 3 Description of Change: Reason for Change: Change in Contract Price: Change in Contract Time: ITEM 4 Description of Change: Reason for Change: Change in Contract Price: 00850-2 PROJECT NO. IFB 11/12-17 Change in Contract Time: ITEM 5 Description of Change: Reason for Change: Change in Contract Price: Change in Contract Time: CHANGE ORDER SUMMARY Change in Change in No. Description Contract Price Contract Time 1 90 2 3 4 5 TOTAL 90 Days WAIVER This Change Order constitutes full and mutual accord and satisfaction for the adjustment of the Contract Price and Contract Time as a result of increases or decreases in cost and time of performance caused directly and indirectly from the change. Acceptance of this Waiver constitutes an agreement between OWNER and CONTRACTOR that the Change Order represents an equitable adjustment to the Agreement and that CONTRACTOR shall waive all rights to file a Contract Claim or claim of any nature on this Change Order. Execution of this Change Order shall constitute CONTRACTOR's complete acceptance and satisfaction that it is entitled to no more costs or time (direct, indirect, impact, etc.) pursuant to this Change Order. 00850-3 r PROJECT NO. IFB 11/12-17 APPROVAL AND CHANGE ORDER AUTHORIZATION ACKNOWLEDGMENTS The aforementioned change, and work affected thereby, is subject to all provisions of the original Agreement and specifically changed by this Change Order; and it is expressly understood and agreed that the approval of the Change Order shall have no effect on the original Agreement other than matters expressly provided herein. ATTEST: Southeast Drilling Services, Inc. Contractor W. B. Ziegler/President (Secretary) Printed Name and Ti le of Officer Date By (Signature 4. 3 9 ;Corporate Seal) Date ATTEST: City of Sanford Owner 96 To el to,e4 impo7y CiTy 1404.4 644 (Signatu ) Printed Name and Title Date By (Sig ture) (Seal) Date END OF SECTION 00850-4 • Saia, Inc. Page 1 of 3 • Tracing Results Tuesday - September 10, 2013 Pro # 00752570272 Current Status: Delivered Reference Numbers Bill of Lading # NS Purchase Order # NS Shipper's # NS Master Pro # 752570270 Pickup # N/A Reference # Shipper Consignee SAIA MOTOR FREIGHT O S & D XYLEM 9100 SIDNEY HAYES RD 4608 BRADLEY ST P O BOX 5487 ORLANDO, FL 32824 LUBBOCK,TX 79415 Origin Terminal: ORL Destination Terminal: LUB Delivery Information Shipment Information Pickup Date: 09/05/13 Shipment Type: NOC Expected Delivery Date: 09/10/13 Driver#9900087 Expected Delivery Time: Trailer#530319 Delivery Appointment Date: N/A Pieces: 5 Delivery Appointment Time: N/A Weight: 6505 Delivery Date: 09/10/13 Delivery Time: 11:22 Service Days: 3 Freight Received by-ANDREW Line Item Detail Pieces Code Hazardous Package Type Description Weight 5 PT PARTS, PIPE, PUMPS, SHAFT PIN 6505 RTS AUTH PER VERBAL FROM LEWIS CABALLERO W/XYLEM WATER 806 743 5767 http://wrvw.saiasecure.com/tracing/n_manifest.asp?m=2&UID=&PWD-&SID-=1N3 GY51... 9/10/2013 Sala, Inc. Page 2 of 3 OC XYLEM WATER SYSTEM REFUSED/SCRATCHED Shipment History Date Time Activity Location 09/10/13 11:22 am Delivered Lubbock, TX 08:07 am Dispatched for Delivery Lubbock, TX 11:07 am Load Trailer: 530319 Lubbock, TX 06:10 am Unload Trailer: 9915HETH Lubbock, TX 05:28 am Arrived at Destination Terminal Lubbock, TX 09/09/13 10:28 pm Departed from Terminal Dallas, TX 02:22 am Load Trailer: 9915HETH Dallas, TX 01:43 am Unload Trailer: 286751 Assigned Dallas, TX 09/08/13 02:46 pm Arrived at Breakbulk Terminal Dallas, TX 12:45 pm Departed from Terminal Tyler, TX 09/07/13 05:58 pm Arrived at Breakbulk Terminal Tyler, TX 12:24 pm Departed from Terminal Jackson, MS 05:15 am Arrived at Breakbulk Terminal Jackson, MS 09/06/13 04:31 pm Departed from Terminal Jacksonville, FL 10:10 am Load Trailer: 286751 Jacksonville, FL 01:24 am Load Trailer: 288403 Jacksonville, FL 12:04 am Unload Trailer: 286356 Assigned Jacksonville, FL 09/05/13 11:16 pm Arrived at Breakbulk Terminal Jacksonville, FL 08:16 pm Departed from Terminal Orlando, FL 06:52 pm Load Trailer: 286356 Orlando, FL hltp://www.saiasecure.com/tracing/n_manifest.asp?m=2&UID=&PWD=&SID=IN3GY51... 9/1 0/2013 PROJECT NO. IFB 11112-17 SECTION 00850 CHANGE ORDER FORM Change Order No. 3 Project Title Water Quality Improvement Project Bid No. RFQ 11/12-17, PO#33258 Owner: City of Sanford Contractor: Southeast Drilling Services, Inc. Agreement Date: October 24, 2012 • This Change Order is necessary to cover changes in the work to be performed under this Agreement. The GENERAL CONDITIONS, SUPPLEMENTARY CONDITIONS, and STANDARD SPECIFICATIONS apply to and govern all work under this Change Order. THE FOLLOWING CHANGES ARE MADE TO THE CONTRACT DOCUMENTS. (1) Original Contract Price $327,200.00 (2) Current Contract Price (Adjusted by Previous`Change Orders) $334,541.00 (3) Total Proposed Change in Contract Price $43,905.00 (4) New Contract Price (Item 2 + Item 3) $378,446.00 (5) Original Contract Time 120 Days (6) Current Contract Time (Adjusted by Previous Change Orders) 235 Days (7) Total Proposed Change in Contract Time 56 Days (8) New Contract Time (Item 6 + Item 7) 291 Days (9) Original Contract Substantial Completion Date May 15, 2013 (10) New Contract Substantial Completion Date February 27, 2014 • 00850-1 PROJECT NO. IFB 11112-17 CHANGES ORDERED ITEM 1 — Hidden Lake Well#7R Electrical work and fence modifications Description of Change: Upgrade fence to accommodate SCADA and electric generator. Complete necessary electrical work to accommodate new construction including additional setup for a portable generator. Reason for Change: Under the SRF Agreement No. 590120, the City requested funds to replace Hidden Lake wells as these wells are experiencing water quality challenges. Hidden Lake Well #7 construction did not include the electrical work as the well was already served by an old electrical service. The old electrical services collapsed and cannot be repaired. The City obtained easements and already placed a new electrical feed line. However, this new service will have to be connected to new well. This is an emergency work order and the City will issue a PO adjustment to existing contractor to perform the work to avoid any delay under their current contract. Change in Contract Price: 43,905.00 Change in Contract Time: 56 days CHANGE ORDER SUMMARY Change in Change in No. Description Contract Price Contract Time 1 Electrical and Fence Upgrades 43,905.00 56 days TOTAL 43,905.00 56 Days_ WAIVER This Change Order constitutes full and mutual accord and satisfaction for the adjustment of the Contract Price and Contract Time as a result of increases or decreases in cost and time of performance caused directly and indirectly from the change. Acceptance of this Waiver constitutes an agreement between OWNER and CONTRACTOR that the Change Order represents an equitable adjustment to the Agreement and that CONTRACTOR shall waive all rights to file a Contract Claim or claim of any nature on this Change Order. Execution of this Change Order shall constitute CONTRACTOR's complete acceptance and satisfaction that it is entitled to no more costs or time (direct, indirect, impact, etc.) pursuant to this Change Order. 00850-2 PROJECT NO. IFB 11/12-17 APPROVAL AND CHANGE ORDER AUTHORIZATION ACKNOWLEDGMENTS The aforementioned change, and work affected thereby, is subject to all provisions of the original Agreement and specifically changed by this Change Order; and It is expressly understood and agreed that the approval of the Change Order shall have no effect on the original Agreement other than matters expressly provided herein. ATTEST: vn A-ar- (/ pc., Contractor • C1/4/../3- grejZri-eX. /1k r.1 (Secretary)/ Printed Name and Title of Officer / AD Date By(Signatu /2l( /t3 (Corporate Seal) Date ATTEST: Owner eiVA4k-k-az-,04.%A 7-4/i NJ J �e (Signature) P rated Name and Title ( Z- 2ff' 3 Date By (S/nature) /a /A 13 (Seal) Date END OF SECTION 00850-3 Southeast Drilling Services, Inc. 119 Lucina Dove,Hypoluxo,FL 33462 (561)493-9832 FAX(561)493-5140 PROJECT: SANFORD WELL NO.7 REPLACEMENT SOUTHEAST DRILLING SERVICES,INC. SED CPR-3 SUBJECT:ELECTRICAL AND FENCE MODIFICATIONS UNIT EXTENDED ITEM DESCRIPTION QUANTITY UNIT PRICE COST COST Materials 1 1 LS $0 2 1 LS SO 3 Each $0 4 Each S0 5 Each $0 6 Each SO Subtotal Materials $0 Tax Total Materials $0 1 Project Supervisor 6 Hour $150 $900 2 Field Supervisor Hour $82 50 3 Project Labor Hour $45 $0 4 Perdiem Day $64 SO 5 Hotel Day $140 SO Subtotal Labor&Perdiem $900 Bonding $18 Subtotal SED Services $918 Administration&Overhead $138 Total SED Services 51,056 Subcontractor Work 1 Minner 6ft x 6 ft fence w/gates 1 LS ($1,945) 2 Minner w/fence modifiations 1 Each $4,975 3 Orange Electric(Standard starter and NEMA 3) 1 Each S33,500 - 4 Orange Electric(Adder for NEMA 4 SS$8,000) Each Total Subcontracts $36,530 Subtotal $36,530 Bonding $731 Subtotal $37,261 Overhead&Administration $5,589 Total Subcontract items $42,850 Total Change Proposal Request $43,905 Total Additional Time ¢$Calendar Days from NTP Note: 1 This CPR has been prepared at the request of the Owner to accommodate additional work area with the pump station and to expidite electrical service into the well site. 2 Note the starter will be a standard across the line starter. No soft start is included in the proposal. 3 6 to 8 Weeks to complete installation from a NTP CPR-3 Fence Mods 12-3-13.xls 12/3/2013 Page 1 P Proposal ' Date. August 20w 2013 MINER � �-�o����.������� � �m � m��K� ~~;~~ ' � ~ �~� .�' -�~ .~-.� ^. - Docks,Doors 4 Mars ~ ( 10� muil1() Dtive Right,Right how. . ' . .., .^ . PREPARED FOR: PREPARED - South Eas Drilling ' Dallas Powell Bart Ziegler . 3855 St. Johns Parkway Sanford, FL 32771 0: 407-210-6400 P: 813-390-0172 C- 407-948-7596 =bzkDsoutheastUri|Ung _ _ �n�d ��� con) Parts, Service or Accessories to be provided by Miner Florida Sanford Well#7 Furnish and install (1)rectangular chain link fence enclosure 43'x 30'. Fence includes double drive gates for a 14' opening. Fence will have galvanized finish and be 8' high. Fence will meet specs provided. Price:$4,875.00 Sanford Well#7 Furnish and install (1)square chain link fence enclosure 6'x 6'. Fence includes double drive gates for a 6' opening. Fence will have galvanized finish and be 6' high. Fence will be commercial Grade. Price:$2°946'00 The above pricing includes material and labor described above and all applicable sales tax. Work to be performed during regular business hours, Monday through Friday between aam and 4:30pm. Work required during hours other than normal business hours will include extra charges. CUSTOMER ACCEPTANCE Approval Signature Printed Name P0# Date xmww.rn/me,corp^com ~ ' ^ P � ~ 29* �O 3 ��| � �� ~������ Date: August . 1 �~���� ��N ~� '^ ~� - - �~- _-~�� ��� �, � MINER Pocks,Doors m Mono ~ (1':):" �xu �we�sx1«� Done . . .. Terms&Conditions: Unless otherwise stated in writing,the fol.owing terms and conditions of sale become a part of the proposal. -Company"refers to The Miner Corporation. 1. PRICES a.Are firm for acceptance within 30 days from toe date of quotation,provided Quotation is for production and far shipment of equipment within f6 weeks from the date of quotation. b Are subject to increase equal LP amount to any tax Company may be required to collect or pay on the sale. c.tee subject to any price increase resulting from Buyer requested changes in the equipment or changes in the prod Jc:ion schedule d.tipe subject to increase due to surcharges or price increases ny manutaclrrers prior to ship'r.ent c. SHIPMENT Shipment is F 0.a from place v,manufacture. Buyer shall bear all costs of freight and insurance in connection with delivery. Upon request of Buyer,Company may prepay freight and insurance charges on behalf of Buyer and bill such charges to Buyer. In either event,oak of toss or damage in transit passes to Buyer upon detivery to carrier. 3. DELIVERY a.Trw Conpanywili endeavor to secure shipment of orders as scheduled However,al shipment dates are approximate only,and the Company reserves the right to readjust shipment schedules. b Under no circumstances will the Company be responsible or incur any liability for costs or damages of any nature(whether general,consequent:a'as a penalty or liquidated damages,or otherwise)arising out of or owing to(1)delays in delivery or(2)failure to make delivery at agreed or specified times due to circumstances beyond its reasonable control. :Voolivery.,refused o,shipment is suspended uy Buyer,Buyer shall pay(:)Compaoy,invoice for Equipment as per payout terms,(2)Company's handling and storage charges.and(3)deniurrage charges. 4 CANCELLATION Buyer cannot cancel orders placed with the Company except wiwtxe Companys expressed written consent,and upon temis and payment to the Company indemnifying the Company against loss,including but not limited to expenses incurred and commitments made by the Company. Cancellation will be a minimum of 25%of the total Contract Sum. 5. CONCEALED OR UNKNOWN Concealed or unknown conditions below the surface of the ground or in an existing structure may be encountered that differ materially from those recognized as inherently pail of the contract. In the event,the Contract Sum she!'be equitably adjusted by Change Order upon claim by the Company. 6. pEnF0mu^wCsREQo|nEmENTS Tne equipment furnished under the contract will be as stated,and Buyer has selected same based on the specification(type,amount.source d prod ts and intended use of Buyer)of the material to be handled or processed by.Buyer and the Lotai,State and Federal Regulations in existence on the date of the Pro ed Contract Changes in the equipment requirements may result from matters determined by surveys,studies,approvals and permits or fro changes in the material specification by Buyer or from changes in the Local,State,and Federal Regulations. In this event.the Contract Sum shall be equitably adjusted by Cnarrge Order upon claim by the Company. 7. INFORhtATtON AND SERVICE REQUtRED OF THE BUYER a.The Buyer shall furnish all necessary surveys describing the physical charecteristes,legal limitations and utility locations for the site of the Project,and legal description of the site. e The Buyer shall secure and pay for all necessary surveys:studies,approvals,easements,assessmen:s,notices,and permts required for the construction and use of permanent structures or for permanent changes to existing facilities. c.Information or services under the Buyer's oontrol shall be furnished by the Buyer with reasonable promptness to avoid delay in the orderly progress of the work. d.Roof or wall openings.flashing,and counter flashing shall be furnished by the Buyer. e.Electric,water,steam,lol,compressed sir,storr'isanitary drain, or connections shall be turnushed by the Buyer. I Labor and material required to make connection between the equipment furnished under th contract and the utilities shall be provided by the Buyer. g.Labor and material mmu.':uto make field connections uvmeaoe«omm°ntcvmpvoonu(ao,pt reconnection of items dsmaatled foi ship,mer,f)snaIl be provided by the buyer. x Site access and site conditions to allow for unimpeded use of installation equipment is the responsibility of the Buyer, i The Buyer shall secure and pay for all testing requred by Local,Stafe,and Federal Regulations 8. SERViCE WARRANTY Company warrants all service performed hereeeder to be performed iv a workmanlike manner and free from defects in workmanship upon completion. Company's obligation and Buyers sole remedy,hereunder shalt be limited to repai'by Conaarry f any detects discovered and reported in writing to company within 90 nays after completion 01 services hereunder without oxp to Buyer,or(at Company's optlon)return of the contract price tar such defectve devices. 9. EQUIPMENT AND PARTS WARRANTY Company's obligation,and Buyers sole remedy relative to equipme t and parts warranty by nianulaclurers theeof,is to secure manufacturers warranty on behalf of Buyer and assnsf Buyer in the presentation of any warranty clam,but Company makes no warranty in additon thereto 10.ACCEPTANCE AND GOVERNING PROVISIONS This writing constitutes an offer by the Company to sell products andlor 5mi:es described herein and expires upon written notice cr thirty(30)days from this date.weidlever occurs first. This offer is,however,entirely comingont upon acceptance by Company's supplier of a corresponding nding purchase order from Company. Accep:ance of this otter is limited to the terms and conoitions hereof,aria any such other matter in buyers forms or correspondence shall not become pae hereof and same shall not be binding upon Company unless agreed to in writing,signed by an Officer of the Company, When accepted by Buyer,this writing shall constitute the enfire agreement between Company and Buyer on tire subject hereof,except as amended by a writing signed by Conrpany This offer arid any agreement asing Out of if shall be governed by and construed in accordance wfh the internal laws of the State of Texas vmxmv.m/ne000rp.conn 1035 Sunshine Lane Suite 108 Altamonte Springs, Fku. 32714 Date: 02/12/2013 Southeast brilling Services Inc. Attn: Bart Ziegler Ref: Sandford Weil #7 I'm pleased to quote the follow on the above ref: Job 1. Furnish & Install Conduit and Wire as required 2. Furnish & Install 75HP Nema 3 Well Pump Panel Part Wind Starter 3. Furnish &Install Meter Base and Grounding as required for 480v 3 PH service 4. Furnish & Install Equipment Racks 5. Furnish & Install 3R 300A Diyconnact, 3R 200A Main Breaker, 5KVA Min Power Center 3R 200A Manual Transfer 5witch WI 200amp Gen Recpt N3J And Light Fixture 6. Connect only Well Pump JQTU . Sol Valve Furnish by other • 7. Furnish & install Junction oxes and conduit for future Generator Quoted Price: «�^�3 %�[��� ���� -.�� Jerry Ornberg Orange Electric Co. DATE (MM/DD/YYYY) A`�o° CERTIFICATE OF LIABILITY INSURANCE 12/12/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 Phone: (813)988-1234 Fax: (813)988-0989 CONTACT NAME: Tracy ASSOCIATES AGENCY,INC. PHONE PA( 988-0989 (A/C,No.Eat): (813)988-1234 A/G,No): (813) PO BOX 16190 E-MAIL tracy@associatesins.com ADDRESS: y@ 11470 N.53RD ST. INSURER(S)AFFORDING COVERAGE NAIC# TEMPLE TERRACE FL 33687 Agency Lic#:L062850 INSURER A :OWNERS INSURANCE CO. 32700 INSURED INSURER B :AUTO OWNERS INSURANCE CO. 18988 SOUTHEAST DRILLING SERVICES INC. 10614 E US HWY 92 INSURER C :Star Insurance Co. TAMPA FL 33610 INSURER D: INSURER E : INSURER F COVERAGES CERTIFICATE NUMBER: 289921 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR WADD'L SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR wD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A GENERAL LIABILITY 20709632 07/01/13 07/01/14 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED $ 300 000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurence) CLAIMS-MADE I X OCCUR MED.EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000- 7 POLICY PRO- LOC $ AUTOMOBILE LIABILITY 4142994900 07/01/13 07/01/14 COMBINED SINGLE LIMIT 1,000,000 B CO accident) $ X ANY AUTO BODILY INJURY(Per person) $— ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ . AUTOS AUTOS PROPERTY DAMAGE $ X HIRED AUTOS ©NON-OWNED per accident) AUTOS $ B X UMBRELLA LIAB )( OCCUR 4346231701 07/01/13 07/01/14 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION$ WC WORKERS COMPENSATION WC0732469 07/01/13 07/01/14 X TORY LIMITS OR TORY LIMITS ER $ C' AND EMPLOYERS' LIABILITY Y/N E.L.EACH ACCIDENT $ 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.DISEASE-EA EMPLOYEE $ 500,000 (Mandatory In NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS(VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) The City of Sanford is an additional insured. CERTIFICATE HOLDER CANCELLATION City of Sanford SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn:Purchasing Manager THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O.Box 1788 ACCORDANCE WITH THE POLICY PROVISIONS. Sanford,Florida 32771 AUTHORIZED REPRESENTATIVE .��� +r`-.' Attention: hernandm @sanfordfl.gov/Tara.Lamoureux @Sanfordfl.g Mike Rogers ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DATE (MM/DD/YYYY) ACO o° CERTIFICATE OF LIABILITY INSURANCE 12/12/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 Phone: (813)988-1234 Fax: (813)988-0989 CONTACT racy ASSOCIATES AGENCY,INC. PHONE FAX (A/C.No,Ext): (813)988-1234 IIA/c,No): (813)988-0989 PO BOX 16190 E-MAIL tracy@associatesins.com ADDRESS: y@ 11470 N.53RD ST. INSURER(S) AFFORDING COVERAGE NAIC# TEMPLE TERRACE FL 33687 Agency Lic#:L062850 INSURER A :OWNERS INSURANCE CO. 32700 INSURED INSURER B :AUTO OWNERS INSURANCE CO. 18988 SOUTHEAST DRILLING SERVICES INC. 10614 E US HWY 92 INSURER C :Star Insurance Co. TAMPA FL 33610 INSURER D: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 289921 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR Wwo POLICY NUMBER (MMIDD/YYYY) (MM/DDIYYYY) A GENERAL LIABILITY 20709632 07/01/13 07/01/14 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED $ 300 000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurence) CLAIMS-MADE I X OCCUR MED.EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 PRO- -7 POLICY JJECT LOC $ AUTOMOBILE LIABILITY 4142994900 07/01/13 07/01/14 COMBINED SINGLE LIMIT 1,000 000 B CO accident) $ X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED -SCHEDULED BODILY INJURY(Per accident) $ AUTOS $ AUTOS PROPERTY DAMAGE —�NON-OWNED (per accident X HIRED AUTOS X (? ) _AUTOS $ B X UMBRELLA LIAB X OCCUR 4346231701 07/01/13 07/01/14 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION$ WORKERS COMPENSATION WC0732469 07/01/13 07/01/14 X TyORYTLIMTS OERH $ C' AND EMPLOYERS' LIABILITY YIN E.L.EACH ACCIDENT $ 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.DISEASE-EA EMPLOYEE $ 500,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) The City of Sanford is an additional insured. CERTIFICATE HOLDER CANCELLATION City of Sanford SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn:Purchasing Manager THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O.Box 1788 ACCORDANCE WITH THE POLICY PROVISIONS. Sanford,Florida 32771 AUTHORIZED REPRESENTATIVE ���� ir`+,/ Attention: hernandm@ sanfordfl.gov/Tara.Lamoureux @Sanfordfl.g Mike Rogers ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD