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Fort Walton Beach Resolution — 2023-08 FDOT Utility Work Agreement-Brooks Bridge Replacement — reading text
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800-305-7019 County and Slate last aforesaid.
“aon” Bonded Ineuraneh
: My Commission Expires:
* Serial No., if any:
RE
DocuSign Envelope ID: 13568854-D02E-4D60-A472-FA11EDE67AC6
BK: 3483 PG: 2821
IN WITNESS WREREOF, the City has caused these presenis lo be executed in its name by its
City Council nee by the Mayor of said Council, the day and year aforesaid.
ATTEST: via City of Fort Walton Beach
STATE OF FLORIDA
COUNTY OFC) Posen.
The foregoing instrument was acknowledged before me, by means of aphy sical presence
or 0 online notarization, this. day of Meg _. 202, ObyRichaal 4 Pir
personaily known to me or who has produced :
Notary Public in and for the
County and State last aforesaid.
My Commission Expires:
Seriai No., if any:
Notary Publis State of Florin
Laraine Van Elten
r My Commission GG IRRI7O
Expires OMS 2027
DocuSign Envelope ID: 13568854-D02E-4D60-A472-FA11EDE67AC6
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION COMPTROLLER
CONTRACT STATUS CHANGE/CHECKLIST 010s
[xo STATE COMPTROLLER USE:
Info Provider: Kathy Ozmore Received date:
Return to: Jenee Floyd Approved date:
Mail Station: D-3 Approved by:
Phone # of Info Provider: 850-466-4122
CONTRACT NUMBER: ASW58 SITE/DISTRICT: D-3
Total Executed Contract Amount: $ 916,345.24 ia)
To date This action
Status Code (choose one) XX] 10 = Executed Contract L] 4X or 6X = Audit Status (Indicate Year)
(] 20 = In Claims (_] 99 = Post Design Service (_] 50 = Complete/Terminated Contract
&X] Original Contract CO Amendment (Indicate #)_ C Renewal OO Addition (Indicate #)
OC Award CO Supplemental (Indicate #)_— C Letter of Authorization (Indicate #)_—
(] Time Extension (J Close Contract (J Other Changes (must include comments)
LETTING DATE: AWARD DATE:
06/02/2023 | 10:47 AM EDT
DATE OF CONTRACT EXECUTION (Last Signed Date):
If last date signed > contract start date you must submit emergency certification (287.059 F.S. (2) 1) or
Certificate of noncompliance (287.059 F.S. (2)) or settlement document (CM4(87-88) or CM11 (91-92)).
06/02/2023 | 10:47 AM EDT
CONTRACT BEGINNING DATE: ENDING DATE: 5/8/2027
06/02/2023 | 10:47 AM EDT
SERVICES BEGINNING DATE: SERVICES ENDING DATE: 5/8/2027
VENDOR NAME: City of Fort Walton Beach VENDOR NUMBER (FEID/SS): F596000323005
PROJECT NUMBER: 415474-2-56-02 PROJECT NUMBER:
PROJECT NUMBER: PROJECT NUMBER:
CAN THIS CONTRACT BE RENEWED? (1 YES JNO SERVICE TYPE: 72141121
PAGE NUMBER RENEWAL CLAUSE IN CONTRACT:
Comments:
Certification Statement: | certify that the above information is correct and a true reflection of information contained in the above
referenced contract.
Approved by: (Printed or typed) Title:
Approval Signature: Approval Date: