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HomeMy Public PortalAboutWL Lawrence Addendum #1 to Continuing Services ContractCITY OF CRESTVIEW Director Department of Public Services Telephone No. (850) 682-6132 Brona D. Steele 715 Ferdon Boulevard North Fax No. (850) 682-7359 E-Mail: steele@citvofcrestview.orq Crestview, Florida 32536 E-Mail: oublicservices@cvflora.accoxmail.com ADDENDUM NO. 1 to Underground Utility Continuing Services Contract RFB No.13-0110 City of Crestview, Florida 01-08-2013 • Delete "Total Base Bid" from page 7 of the Proposal. Acceptance and evaluation of the bid will be based on the individual line items and not on a total of base prices. Signature " Date CITY OF CRESTVIEW, FLORIDA REQUEST FOR BIDS RFB No. 13-0110 UNDERGROUND UTILITY CONTINUING SERVICES CONTRACT BID FORM PART I Bid submitted by: Company: L • � ��Ll-�i ! L L C Address. 30 y_ /'7-q9 2-- City & State: a f �l,Edi � I Telephone: ( ) .J D75 3 7 2- Number of Years in Business: / b Zip Code: .3 25 3 Fax:( ) ?SD-620— µ-S9 D PART II Bidding RFB No. , Underground Utility Continuing Services Contract as follows: ITEM UNIT PPRICE 1. Hourly cost associated with sewer and water utility installation $ 5 g• 13 L A IY:i2 ply 2. Materials and Supplies: Mater Is and supplies will be billed at contractor's wholesale price or contractors wholesale price plus %. Preference may be given to contractors providing materials at cost. The contractor shall supply materials invoices upon request. 3. Equipment c sts, if any: a t FAGk Hoe 'T R k s $ 4/6. $ z 9 .q,�i $ 4/-6/ $ 4. City owned property and right of ways are not authorized for storage without the Public Services Director's written authorization. 5. Any modifications to specified work must be authorized in writing by the Public Services Director. 6. Please list any additional costs associated with the above services and materials: 5 PROPOSAL BIDDERS NAME: PROJECT: UNDERGROUND UTILITY SERVICES CONTRACT #13-0110 for the City of Crestview, Florida The Bidder proposes (to furnish all Tools, machines, equipment and labor, and perform all Work for the following price: Item No. Pipe Size Description Quote per foot/hour/each Quote GRAVITY SEWER (New Construction) 1 12" 8' TO 10' CUT per foot $ ! 3. en 2 6' TO 8' CUT per foot $ 1 Z. 451g 3 0' 0 6' CUT per foot $ 1 D. 4 10" 8' TO 10' CUT per foot $ ( 3.6213 5 6' TO 8' CUT per foot $ I Z, 6 0' 0 6' CUT per foot $ / p, 7 8" 8' TO 10' CUT per foot $ / 3. °-- 8 6' TO 8' CUT per foot $ 11 , e- 9 0' 0 6' CUT per foot $ if. cg 10 6" or less 8' TO 10' CUT per foot $ / 3 . 19 11 6' TO 8' CUT per foot $ 9 , °= 12 0' 0 6' CUT per foot $ 01 , o 0 WATER & FORCE MAINS (New Construction) 13 12" PVC per foot $ 7, 14 12" GATE VALVES Each $ ?5, '' ° 15 12" FITTINGS Each $ '] D.�- Page I 1 6 Item No. Pipe Size Description Quote per foot/hour/each Quote WATER & FORCE MAINS (New ConstructIon) 16 10" 10" PVC per foot $ 1 °� 17 10" 10" GATE VALVES Each $ % p,425) 18 10" 10" FITTINGS Each $ b S• e-5-) 19 8" 8" PVC per foot $ (17).1-- 20 8" 8" GATE VALVES Each $ (p D. 21 8" 8" FITTINGS Each $ G 0. 29 22 6" 6" PVC per foot $ (0. e- 23 6" 6" GATE VALVES Each $ (o 0,°-9 24 6" 6" FITTINGS Each $ (p0, 25 4" or less 4" PVC AND UNDER per foot S'a $ 5, -- MISCELLANEOUS SERVICES 26 Fire Hydrant Removal and Install New Hand Dug/EACH $ `%SO S' 27 Fire Hydrant Removal and Install New backhoe/EACH $ 6, 5D 28 Tapping Sleeves and Valves All sizes/EACH $ 3 SO 29 Tie-ins All sizes/EACH $ 3 5 O, "= 30 Dozier Work per hour $ ifk 0. 51-0 31 Water Meter Removal and Install New All sizes/EACH $ q J. `i/ EMERGENCY SERVICES 32 Mobilization Charge with Track Hoe $ $00, 33 Mobilization Charge with Back Hoe, Mini Misc. tit:,Excavator, $ ,3543. $ (l S, 34 With Trackhoe per hour 35 Backhoe, Mini Excavator, Misc. per hour $ $ 5'. TOTAL BASE BID S(Numernls) (Written) AVQ To ensure responsiveness, you must submit this form and the mandatory information listed in Sections III and IV. 7 PART III Certifications: In accordance with your request for Bids, instructions and specifications, attached hereto, and subject to all conditions thereof, I(we), the undersigned, hereby propose and agree if this Bid is accepted, to contract with the City of Crestview, Florida to construct any items or furnish any service requested herein and deliver same without additional cost to the City of Crestview at the specified location for the quotations listed above. The undersigned further declares that he/she has carefully examined the specifications referenced on this Bid Form and is thoroughly familiar with them and their provision(s) and further declares that no person or business entity other than the Bidder herein named has any interest in this Bid or in the contract to be executed, and that it is made without any connection with any other person or business entity making Bid for the same articles, and it is in all respects fair and without collusion and fraud. Signature and Certification: /- ,, / ,/ / Name and Title of Authorized Representative: 1 1 I IPI M E . Ligk IZE/t'c eWN ti (Print or Type) Signature: ,Lo .4611...." fi . Date of Bid: / --// —/ 3 Note: See RFB Section III, Bid Requirements, and attach all required information to Bid form. The City of Crestview reserves the right to reject any and all Bids or portions thereof, to waive minor defects in the process and to accept the Bid or any combination of Bid Items or take any other actions deemed by the City to be in the City's best interest. The City also reserves the right to assign additional work to the successful Bidder based upon their Bid proposal or negotiation as may be necessary to meet grant funding or completion requirements. END OF BID FORM 8 ATTACHMENT #1 CITY OF CRESTVIEW, FLORIDA REQUEST FOR BIDS RFB No. 13-0110 UNDERGROUND UTILITY CONTINUING SERVICES CONTRACT SWORN STATEMENT UNDER SECTION 287.133 (3) (A) FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. 1. This sworn statement is submitted with Bid, Proposal or Contract 2. This sworn statement is submitted Lo. C.c v u.c_-h.iy► (-Le_ _ whose � x business address is 6 Zp1 �49 a Or 4.,;4_ ,.a g"<. 34j 3(0 and (if applicable) Federal Employer Identification Number (FEIN) is 2 7- O 01024 Z(If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement: 3. My name is 1.-A-Di l l i A M W le Ac—t_ and my relationship to the entity named above is L��J/\ Lr 4. I understand that a "public entity crime" as defined in Paragraph 287.133(a)(g). Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any bid or contract for goods or services to be provided to any public entity or any agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. 5. I understand that "convicted" or "conviction" as defined in paragraph 287.133(a)(b), Florida Statutes, means finding of guilt or a conviction of a public entity crime with or without an adjudication of guilt, in any federal or state trial court of records relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, non jury trial, or entry of a plea of guilty or nolo contendere. 6. I understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes, means: 1. A predecessor or successor of a person convicted of a public entity crime; or 2. An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term "affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one of shares constituting a controlling income among persons when not for fair interest in another person, or a pooling of equipment or income among persons when not for fair market value under a length agreement, shall be a prima facie case that one person controls another person. A person who was knowingly convicted of a public entity crime, in Florida during the preceding 36 months shall be considered an affiliate. 9 City of Crestview, Florida RFB No. , Underground Utility Continuing Services Contract Page 2 of 2, Attachment #1, Public Entity Crimes Statement 7. I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of the state or of the United States with the legal power to enter into a binding contract for provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active n management of an entity. 8. Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement. (Please indicate which statement applies) / V Neither the entity submitting this sworn statement, nor any officers, directors, executives, partners, shareholders, employees, members, or agents who are active in management of the entity, nor affiliate of the entity have been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, s areholders, employees, members, or agents who are active in management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. (please attach a copy of the final order) The person or affiliate was placed on the convicted vendor list. There has been a subsequent proceeding before a h aring officer of the State of Florida, Division of Administrative Hearings. The final order entered by the hearing officer determined that it was in public interest to remove the person or affiliate from the convicted vendor list. (please attach a copy of the final order) gili The person or affiliate has not been placed on the convicted vendor list. (Please describe any action taken by, or ending with, the Department of General Services.) (Signature) Date: ( /J STATE OF FLORIDA COUNTY OF d1 4/[922s 4 PERSONALLY APPEARED BEFORE ME, the undersi n d authority, who, after first being sworn by me, affixed his/her signature at the space provided above on this _day of-5,c4Ada , 2013, and is personally known to me, or has provided Vors Li'c c.N s _t- as identification. My Commission expires: 45`"!:•:"°‘t, BARBARA A. MCKINNEY * _, , * MY COMMISSION f EE 044272 n EXPIRES: January 7,2015 �r124.0F F`oP\o� Bonded Thru Budget Notary Services 10 Notary Public k ATTACHMENT #2 CITY OF CRESTVIEW, FLORIDA REQUEST FOR BIDS RFB No. 03-0110, UNDERGROUND UTILITY CONTINUING SERVICES CONTRACT DRUG -FREE WORKPLACE CERTIFICATION The below signed Bidder certifies that it has implemented a drug -free workplace program. In order to have a drug -free workplace program, a business shall: 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. 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 occurring in the workplace no later than five (5) working days after such conviction. 5. Impose a sanction on, or require the satisfactory participation in drug abuse assistance or rehabilitation program if such is available in the employee's community, by any employee who is 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 this statement, I certify that this firm complies fully with the above drug -free workplace requirements. COMPANY: IA). L.• CO 41Z(A J�—�i- a N L L- (� ADDRESS: D, 6 K t' 2- CITY: eRE5I/ tA) STATE: n - ZIP CODE: 32. S 3 hp TELEPHONE NUMBER: g 5 D - 1 5 g' / 3 7 2- SIGNATURE: (.0 / C. �-C . DATE: NAME (TYPED OR PRINTED): Ufa./ I A 111 Lr I AvVR (Are-6 TITLE: OW/(iE/Z 11 STATE OF FLORIDA COUNTY OF d %f !J� IQv 5 Q PERSONALLY APPEARED BEFORE ME, the undersigned authority, who, after first being sworn by me, affixed his/her signature at the space provided above on this /Pe't day of , 2013, and is personally known to me, or has providedFMAD4vir,3Llceixts identification. My Commission expires: .1.?:(•!`. t, BARBARA A MCi4NNEY * MY COMMISSION A EE 044272 * Ti EXPIRES: January 7, 2015 .1l�rFOF F40F\�eBon Thru Budget Notary Services ATTACHMENT #3 12 Notary Public CITY OF CRESTVIEW, FLORIDA REQUEST FOR BIDS RFB No. 03-0110, UNDERGROUND UTILITY CONTINUING SERVICES CONTRACT NON —COLLUSION AFFIDAVIT STATE OF n D l2 c tJ Pt COUNTY OF C ICA (po SA W t LI:AM C. LAViRede c , being first duly sworn deposes and says that: l . He (it) is the ow Al etz, rYl A 14)t°►.9 C Z , of W • 1... 6nsiRtid1lmi LI- � , the Bidder that has submitted the attached Bid; 2. He is fully informed respecting the preparation and contents of the attached Bid and of all pertinent circumstances respecting such Bid; 3. Such Bid is genuine and is not a collusive or sham Bid; 4. Neither the said Bidder nor any of its officers, partners, owners, agents, representatives, employees, or parties in interest, including this affidavit, have in any way, colluded, conspired, connived or agreed, directly or indirectly, with any other Bidder, firm or person to submit a collusive or sham Bid in correction with the Contract for which the attached Bid has been submitted; or to refrain from bidding in connection with such Contract; or have in any manner, directly or indirectly. sought by agreement or collusion, or communication, or conference with any Bidder, firm, or person to fix the price or prices in the attached Bid or of any other Bidder, or to fix any overhead, profit, or cost elements of the Bid price or the Bid price of any other Bidder, or to secure through any collusion, conspiracy, connivance, or unlawful agreement any advantase against (Recipient), or any person interested in the proposed Contract; 16 5. The price or prices quoted in the attached Bid are fair and proper and are not tainted by any collusion, conspiracy. connivance, or unlawful agreement on the part of the Bidder or any other of its agents, representatives, owners, employees or parties in interest, including this affidavit. &AL- -67C?'64.,.___ZA01/6( Sworn and subscribed to before me this �� day of,1gy nk,R , 20/3 , in the State of Q Q , County of ©ir ldv5 q . My Commission Expires: /f-� Notary Public 17 B� A. MCWNNEV o�• Pu• ,kCBAIOM MISSION EE044212. a �•My 1 2015 * L-�i * Boded hru %AO Sate{ SeMces Form W-9 (Rev. December2011) Department of the Treasury Internal Revenue Service 0 Request for Taxpayer Identification Number and Certification Check appropriate box for federal tax classification: Ul Individual/sole proprietor ❑ C Corporation ❑ S Corporation Partnershi ❑ P ❑ Trust/estate ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ► ❑ Other (see instructions) ► Give Form to the requester. Do not send to the IRS. Name (as shown on your income tax return) vvt L 6Jdo Business name/disregarded entity name, if different from above (A) kru_ cam. L_ L Address (number, street, and apt. or suite o.) 5 31 l„ ���otztE,dt'� DR. City, state, and ZIP code (f"es-fvteav r-L List account number(s) here (optional) ❑ Exempt payee Requester's name and address (optional) Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Part II Certification Social security number Employer identificat on number oV ri D Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S, person (defined below). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4. Sign I Signature of Here U.S. person ► General Instructions ( O Date ► /-// /3 Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S, person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income. Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W-9. Definition of a U.S, person. For federal tax purposes, you are considered a U.S. person if you are: • An individual who is a U.S. citizen or U.S. resident alien, • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, • An estate (other than a foreign estate), or • A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners' share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. Cat. No. 10231X Form W-9 (Rev. 12-2011) CITY OF CRESTVIEW, FLORIDA REQUEST FOR BIDS RFB No. 03-0110, UNDERGROUND UTILITY CONTINUING SERVICES CONTRACT INSURANCE REQUIREMENTS Contractor shall procure and maintain, for the duration of the contract, insurance against claims for injuries to persons or damages to property which may arise from or in connection with the performance of the work hereunder by the contractor, his/her agents, representatives, employees, or subcontractors. The cost of such insurance shall be borne by the contractor. A. Minimum Scope of Insurance: Coverage shall be at least as broad as: Workers' Compensation as required by the State of Florida and Employers' Liability insurance: B. Minimum Limits of Insurance: Contractor shall maintain coverage's and limits as follows: 1. General Liability: Aggregate Limit: $1.000,000. Products and completed operation aggregate limit: S500,000. Personal and advertising injury limit: N%A. Each occurrence limit: S500.000. Fire damage limit: S50.000 any one tire. Medical expense limit: $5.000 per person. Owner's and contractor's protective: Pollution - limited form: N/A. Pollution: N/A. Premises and Operations: N/A. Contractual Blanket: Designated contractors (specify): City of Crestview 2. Automobile Liability: (a) Business auto with symbol(s): one (1) (b) Limit per accident: S1.000.000. 3. Workers' Compensation as required by Florida laws, and Employer's Liability with the following minimum limits: (a) Each accident: S100,000. (b) Per employee disease: S100.000. (c) All claims disease: S500,000. 13 ACOREP DATE (e11 OOP/M) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO FUGHTS UPON THE CERTIFICATE HOLDER. TH2jS 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 holler is an ADDITIONAL INSURED, the policy(lss) must be endorsed. tf 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 ems), PRODUCER INSURED COVERAG CERTIFICATE OF LIABILITY INSURANCE Legacy Insurance of Northwest Florida LLC 301 N. Ferdon Blvd. Crestview, FL 32536 License #: A018115 W L CONSTRUCTION, L L C PO BOX 1492 CRESTVIEW, FL 32536-7492 CONTACT NAME: Pam Myers MOM yip. Em; (1150)6112-2619 I DM. Nor. (860)689 3375 ENIWL ADDRESS: allenelegaeylnsurancenwLeom INSURERS) AFFORDING COVERAGE NMC f INSURER A: SOUTHERN OWNERS INS CO MEURERa: AUTO OWNERS INSURER C: INSURER D : INSURER E : INSURER F : ........ ••••-•-•• ••••••macm. uvwrssu-iIMOD. ION NUMBER: 2 THIS INDICATED CERTIFICATE EXCLUSIONS N IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED ED ABOVE FOR THE POUCY PERIOD NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER * • . MENT WITH RESPECT TO WHICH THIS MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED REIN IS SUBJECT TO ALL THE TERMS, AND CONDITIONS OF SUCH POUCIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID C MS LTSR TYPE OF INSURANCE ADM MISR MR) POLICY NUM NUMBER POUCYYYT (MINDDl i , . UMIn A GENERAL UABIlTY COMMERGAL GENERAL LIABILITY N N 114622 78744149 02/16/20'12 16/2013 EACH OCCURRENCE $ 500,000 DAMAGE (�X f 50,000 CLAIMS -MADE X OCCUR PREMISFS Eaa OCfa) MED EXP (My ono parson) S 5,000 PERSONAL N1 ADV INJURY S 500,000 $ 1,000,000 GENERAL AGGREGATE ^GEEML AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG S 500,000 S B AUTOMOBILE - X ~ _ UAIMUTY ANY AUTOLLAR ADED ' AUTOS I HIRED AUTOS f —accxlinti SCHEDULED AUTOS ANOTN� ED N N 44-716466-01 tir 02/16/2012 02J16/2013 /CEOMeI � SINGLE OMIT S 1,000.000 BODILY IWURY(Ptxperson) f BODILY INJURY (Paraoddant) S (PROPERTY OrWAGE S f _ UwF• • • LABB EXCESSIJAB 1 OCCUR CLAIMS -MADE EACH OCCURRENCE S AGGREGATE S DED RETENTIONS S A WORKERS AND EMPLOYERS' U B UTY COMPENSATION ANY PROPRIETOR/PARTNERIFXECUTNE OFFICER/MEMBER EXCLUDED? In NIQ YIN N NIA N 7,125035 02H6/2012 02J16/2013 X LIMITS ER EL EACH ACCIDENT S 1 OO,000 E.L DISEASE - EA EMPLOYEES 100,000 (Mandatory If yes tieaaibra under DESCRIPTION OF OPERATIONS belowEL DISEASE - POLICY UNIT $ 500,000 °Q.% DESCRIPTION OF OPERATIONS / LOCA • 1 1 ACORD 101, AMR:1 rl Rtm ults Sandulf IF mom *pore RI (././.. ntRIRM CERTIFICATE BOLDER CANCELLATION CITY OF CRESTVIEW PO BOX 1209 32536 ACORD 25 (2010/05) SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTMDRGZD REPRESENTATIVE ' 'T- (Q (PPM) ®1966-201 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Printed by PPM on January OB, 2013 at 03:21 PM STATt OF FLORIDA DEPARTMENT OF BUSINE S AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD SEQ#L11090101549 DATE BATCH NUMBER LICENSE NBR 09/01/2011 118020357 RU11066569 The UNDERGROUND UTILITY & EXCAVATIONTCONTRACTOli Named below HAS REGISTERED Under the provisions of Chapter 489 FS. ; Expiration date: AUG 31, 2013 (INDIVIDUAL MUST MEET ALL LOCAL, LICENSING REQUIREMENTS PRIOR TO CONTRACTING IN' ANY, .,AREA) ,; LAWRENCE, WILLIAM EDWARD INDIVIDUAL P O BOX 1492 CRESTVIEW FL 32536 RICK SCOTT KEN LAWSON GOVERNOR - SECRETARY DISPLAY AS REQUIRED BY LAW 2012 - 2013 OKALOOSA COUNTY TAX COLLECTOR BEN ANDERSON OKALOOSA COUNTY LOCAL BUSINESS TAX RECEIPT STATE OF FLORIDA FA S/ 1 MA S ROOMS SEATS EMPLOYEES TYPE OF CONTRACTOR UNDERGROUND UTILITIES & EXCAVATION BUSINESS CONTRACTOR BUSINESS 5316 OPPORTUNITY DR ADDRESS CRESTVIEW, FL 32539 OKALOOSA COUNTY Tax Collector MAKE CHECKS PAYABLE TO: OkalOOSa County Tax Collector P.O Box 1387, Nlceville, FL 32588 W L CONSTRUCTION LLC WILLIAM E LAWRENCE 5316 OPPORTUNITY DR CRESTVIEW,FL 32539 102-12002411 01/10/2013 Paid 22.50 RECEIPT NO 3600100735202 EXPIRES SEPTEMBER 30, 2013 SUPPLEMENTAL RENEWAL NEW BUSINESS TRANSFER ORIGINAL TAX AMOUNT PENALTY COLLECTION COST TOTAL 0.00 18.00 0.00 4.50 0.00 22.50 11 )/tv-t- 62_ SIGN AND DISPLAY AS REQUIRED I SWEAR THAT THIS LOCAL BUSINESS TAX RECEIPT IS MADE, FOR THE BUSINESS OR PROFESSION INDICATED HEREON AND IS TRUE AND CORRECT. THE APPLICATION MUST COMPLY WITH STATE AND CITY OF CRESTVIEW COUNTY OF OKALOOSA LICENSE NO: 13-175 DATE: 9/21 /2012 CONTRACTOR REGISTRATION BUSINESS NAME WL Construction, LLC. COMPANY ADDRESS: P.O. Box 1492 CITY: Crestview STATE: FL Lip: 32536 BUSINESS TELEPHONE NO: 850 7581372 CLASSIFICATION: Underground Utility LICENSE EXPIRATION DATE: Sep 30 2013 COLLECT O RO A S