Okaloosa County BOCC — November 4, 2012 — Foxwood Drainage Closeout package — reading text

EXHIBIT H CONTRACT CLOSE-OUT CHECKLIST (To Be Prepared by the Contracts & Leases Coordinator) DATE: el. Whe TO: Contracts & Grants Manager, Finance Department Contracts & Grants Division SUBJECT: Contract No._C/2-/ 95 PW MANAGING DEPARTMENT: _/u d/ic. Wak CONTRACTOR'S NAME: Hero Ze evn and Revdels PROJECT TITLE: Aoxund Drains as ¢ [epa'es The attached has met the final payment contract requirement in subject contract. Yes No 1. Final Invoice ca | 2. Completed Contract/Lease Payment Approval Form oh LC] 3. Close-Out Documents Yes No N/A a. Signed Release of Lien La LJ CJ b. Proof of Completion Advertisement Ze C C] c. Certificate of Insurance i) L] L] d. Consent of Surety to Final Payment na L] L] e. Proof of Performance/Payment Bond [ye LC] LJ Continuation 12 Months Following Final Payment Yes No 4, Agenda Request Ee LJ 5. Remarks C a P va st $5 ) I2Lult2- DATE EXHIBIT I CONTRACT/LEASE PAYMENT APPROVAL FORM COMPLETE AND FORWARD TO THE NEXT APPROVING DEPARTMENT COMPLETED BY DEPARTMENT DATE: 12/12/2012 VENDOR NAME: Aero Training and Rental VENDOR #: COUNTY AGREEMENT # (Contact Contract/Lease Coordinator, if unknown) C12-1958-PW TASK COUNTY/FEMA VENDOR ORDER # PROJECT # BUDGET INVOICE # (if applicable) (applicable) DEPARTMENT# ACCOUNT # AMOUNT See Attached 302 2051100 $7,560.36 TOTAL $7,560.36 APPROVED FOR PAYMENT (please initial, as applicable and date) : ENGINEER/ARCHITECT/PROJECT MANAGER DATE: KK bth DATE: _]9~)9-12 DATE: (ef f/fe COUNTY PROJECT MANAGER: DEPARTMENT HEAD: FINAL PAYMENT. YES CONTRACTS & GRANTS IDATE: CONTRACTS & GRANTS MANAGER: DATE: COUNTY ADMINISTRATOR APPROVAL : (Only Payments $25,001 - $50,000) FINAL PAYMENT APPROVAL (if needed): PURCHASING DIRECTOR: (Only Contracts < = $25,000) COUNTY ADMINISTRATOR : {Only Contracts between $25,001 to $50,000) Contracts Over $50,000 — BCC Approved COMPLETED BY FINANCE - ACCOUNTS PAYABLE ONLY FISCAL YR: IDATE RECEIVED: Form revised 1-20-2011 APPLICATION FOR PAYMENT PERIODIC ESTIMATE NO.: 5/FINAL PROJECT NO.: C12-1958-PW WORK PERIOD BEGIN DATE: __ October 9, 2012 END DATE: November 10, 2012 ROAD NAME: _ Country Club Drive, Williams Way, Wedgewood Court ORIGINAL CONTRACT SUM $ 146,301.00 NET CHANGE BY CHANGE ORDERS $ 4,906.10 CONTRACT SUM TO DATE $ 151,207.10 ANALYSIS OF WORK PERFORMED 1. Value or original contract work performed previously: $ 151,207.10 2. Work performed this month: $ 0.00 3. Total value of work performed to date: $ 151,207.10 4, Less: Amount retained at five (5%) percent: $ 0.00 5. Net amount earned on contract work to date: $ 151,207.10 6. Less: Amount of previous payments: $ (143,646.74) 7. AMOUNT DUE THIS PAYMENT $ 7,560.36 CERTIFICATION OF CONTRACTOR According to the best of my knowledge and belief, I certify that all items and amounts shown on the face of the Periodic Estimate are correct; that all work has been performed and/or materials supplied in full accordance with the terms and conditions of the contract between Okaloosa County and Aero Training & Rental, Inc., and that the items for which payment is requested have been paid and that there are no vendors-mechanics, or other liens or conditional sales contracts which should be satisfied or discharged before such payment is made. © Aero Training & Rental, Inc. Gay __ Lewis Cooper, Presifent (Firm Name) (Name of Authorized Officer & Title) CERTIFICATION OF ENGINEER I certify that I have verified this Periodic Estimate and that to the best of my knowledge and belief, it is a true and correct statement of work performed and materials supplied by the Contractor; and that the Contractor's certified statement of this account and the amount due his is correct. p/m _ Date: _/2-/7*/2 Project Manager Foxwood Drainage Repairs — Phase I App. For Payment ML %00'001 ge'09g'2 00°0 Ob 2021S) 00'0 00'0 OL'20Z'494 | OL ZOZ'ESL %00'00L 69°26) 00'0 02'€96'e 00'0 00'0 00'0 OL'ES6'€ OL €S6'e 02°02 AS 00161 QATIVLSNI SNOLS 94] 2# O/D %00'001 SL Le 00°0 00°SE9'| 00'0 00'0 00'0 00°se9'L o0'SE9'L Ses d1 00°001 ddid dalva0suad 01] Z# O/O WALSAS %00'001 OS’ ZEL 00'0 00'°0S2'2 00'0 00'0 00'0 o0'0sz'e | 00°0S2'2 00'0S¢ wa 00'S JNM ANNYL NIVA LOANNOD OLSLNO ANLS! 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COOPER, PRESIDENT AERO TRAINING & RENTAL, INC. 537 GULFSHORE DRIVE DESTIN, FL. 32541 Phone (770) 560-8038 Fax (770) 573-4872 Email aerort@aol.com October 11, 2012 RE: Foxwood Drainage Repairs — Phase I, Contract #C12-1958-PW Robert VandenBroeck Okaloosa County Public Works Department 1759 South Ferdon Boulevard Crestview, FL 32536 Dear Mr. VandenBroeck, We hereby certify that we will provide insurance on this project for a two year period starting October 11, 2012 and ending October 11, 2014. An insurance certificate is attached that will expire on November 22, 2012. Coverage will be renewed annually at that date. If you need any additional information, please do not hesitate to contact me at (678) 227-8868 or Lewis Cooper at (770) 560-8038. It has been a pleasure working with you and your organization and look forward to the opportunity of working with you again in the future. Singerely, A Caughey Secretary/Treasurer AEROTRA-01 ROAN ACORP CERTIFICATE OF LIABILITY INSURANCE “sneizo12 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 Yates Insurance Agency (404) 633-4321 CONTACT NAME: PHONE {A/IC, No, Ext): | (ne, No}: 2800 Century Parkway NE E-MAIL Suite 300 ADDRESS: : Atlanta, GA 30345 INSURER(S) AFFORDING COVERAGE NAIC # insurer A :National Trust Insurance Company INSURED Aero Training & Rental, Inc. INSURER B :FCCI Insurance Company 902 Kendall Park Drive INSURER C: Winder, GA 30680 INSURER D: INSURER E : - _ | INSURER F : COVERAGES CERTIFICATE NUMBER: 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. ADDL|SUBRI ~~ ; - Nae TYPE OF INSURANCE Areal WED POLICY NUMBER [MMIDDIYYYY) | (MODY YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000; A |X | COMMERCIAL GENERAL LIABILITY X | X |CPP0007725 11/22/2011 | 11/22/2012 PRES E oo Coane] $ 300,000 | CLAIMS-MaDE | X | OCCUR MED EXP (Any one person) | $ 10,000 PERSONAL & ADVINJURY /j $ 1,000,000; _ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG | $ 2,000,000 pouicy | X | SRO: LOC $ AUTOMOBILE LIABILITY COMBINED INGLE LIMIT I 1,000,000 A |X | anyauto X | X (\CA0009716 11/22/2011 | 14/22/2012 | BODILY INJURY (Per person) | $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) | $ — NON-OWNED PROPERTY DAMAGE $ 4 HIRED AUTOS AUTOS (Per accident) b- : — X | UMBRELLA LIAB | X | occuR EACH OCCURRENCE $ 2,000,000, B EXCESS LIAB CLAIMS-MADE UMB0005973 11/22/2014 | 14/22/2012 | acorecate 5 2,000,000 DED al RETENTION $ 10,000 $ WORKERS COMPENSATION X | WG STATU- OTH AND EMPLOYERS’ LIABILITY YIN TORY LIMITS ER A | ANY PROPRIETOR/PARTNER/EXECUTIVE X |010WC11A58756 11/22/2011 | 19/22/2012 | EL. EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 500,000 if yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | $ 500,000 Re: Foxwood Drainage Repairs - Phase I. DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The County of Okaloosa, all entities names in and its respective agents, consuitants, servants and employees are additional insured in regards to the General Liability and Auto Liability as required by written contract. The insurances evidenced on this Certificate of Insurance are intended to be Primary & Non-Contributory with respect to The GL County of Okaloosa, all entities names in and its respective agents, consultants, servants and employees as an Additional Insured. Waiver of Subrogation in favor of The County of Okaloosa, all entities names in and its respective agents, consultants, servants and employees in regards to the General Liability, Auto Liability and Workers Compensation as required by written contract. Umbrella follows form, but subject to policy terms, conditions, forms, and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Okaloosa County ACCORDANCE WITH THE POLICY PROVISIONS. 602-C North Pear! Street Crestview, FL 32536- AUTHORIZED REPRESENTATIVE ae a ae Let EF mo. _L © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACORD