Okaloosa County BOCC — March 1, 2016 — TanglewoodCloseout

CONTRACT CLOSE-OUT CHECKLIST (To Be Prepared by the Purchasing Services Coordinator) DATE: February 9, 2016 TO: Contracts & Grants Manager, Finance Department Contracts & Grants Office SUBJECT: Contract No. C15-2238-PW MANAGING DEPARTMENT: Public Works CONTRACTOR'S NAME: H&T Contractors, LLC PROJECT TITLE: Overbrook/Tanglewood Stormwater Improvements The attached has met the final payment contract requirement in subject contract. Yes No 1. Final Invoice X O 2. Completed Contract/Lease Payment Approval Form X ] 8. Close-Out Documents Yes No N/A a. Signed Release of Lien X L] Ll b. Proof of Completion Advertisement X ] ] c. Certificate of Insurance ] L] d. Consent of Surety to Final Payment [] ] e. Proof of Performance/Payment Bond X ] ] Continuation 12 Months Following Final Payment Yes No 4, Agenda Request X ] 5: Remarks Purchasing Servicey Coordinator DATE CONTRACT/LEASE PAYMENT APPROVAL FORM COMPLETE AND FORWARD TO THE NEXT DEPARTMENT COMPLETED BY DEPARTMENT paTE: 12/08/2015 VENDOR NAME: H&T Contractors, LLC VENDOR #: 21500127 CONTRACT/LEASE#: C15-2238-PW (Tanglewood/Overbrook) TASK COUNTY/FEMA VENDOR BUDGET INVOICE # ORDER # PROJECT # DEPARTMENT #| ACCOUNT# ANKIUNT S (If Applicable) (If Applicable) 05 NA 8911 _XA 711431 563390 $ 12,006.80 05 NA 8911 U 101 2051100 $20,075.13 TOTAL $32,081.93 APPROVED FOR PROGRESS PAYMENT (please sign. as applicable and date) CONTRACTOR'S ENGINEER/ARCHITECT/PROJECT MANAGER:Z ¢~ __ | oz [ERIC BRAUE DATE: 2Jo4 ) 20/6 COUNTY SUPERVISOR/PROJECT MANAGER: ?4!(, g&‘/ DATE._Z_ g -/ DEPARTMENT DIRECTOR: 'fr\ DATE:'),_ Q “" \fi\ CONTRACTS & GRANT MANAGER: \ \ ‘ \-) DATE: COUNTY ADMINISTRATOR: \ k DATE: (Payments>$§25,000.) FINAL PAYMENT FINAL PAYMENT YESNOD (If "Yes", forward to Purchasing Services Coordinator for Close-Out) DATE: 2/9]) ¢ PURCHASING DIRECTOR: -/} 1L é(—{jewl t / ¥ (Per Initial Agreement) O ATE: A /Y)W CONTRACTS & GRANTS MANAGER: (1) il B Eulantss (All Contracts) DATE: g/fig{//‘ COUNTY ADMINISTRATOR APPROVAL: (Per Initial Agreement) / DATE: BOARD APPROVAL: (Per Initial Agreement) COMPLETED BY FINANCE - ACCOUNTS PAYABLE ONLY FISCAL YEAR: DATE RECEIVED: REVIEWD BY: APPLICATION FOR PAYMENT PBRIODIC BSTIMATENO.: ___° . PROJECTNO,; _C15-2238¥ N WORK PERIOD BEGIN DATRE; _°¢/25/2018 END DATE; _ 12/30/2035 ROAD NAME: TA-HGLEHOOD/OVBRBROOK STORMWATER MANAGEMENT PROJECT ORIGINAL CONTRACT SUM § donenso NBT CHANGE BY CHANGE ORDERS g memms CONTRACT SUM TO DATR : § 13,5030 ANALYSIS OF WORK PERFORMED 1. Valuse of original contract work performed previously: §1o%s02:90 2 Work performed this month: $ 12,006.80 3. Total value of work performed fo date: $ 413,509.30 4, Less: Amount retained at five (5%) percent: $_ 5, Net amount carned on contract work to date: § 413.509.30 6. Loss: Amount of previous payment: § 38142737 7. AMOUNT DUE THIS PAYMENT §_ s2om. 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 Periodio 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 _# & T fontractors, tLc , and that the ifems for which payment is requested have been paid and that there are no vendors-mechanios, or other liens or conditional sales contracts which should bo satisfied or discharged before such payment js mage. H & T Contractors, LLC By‘ aging Merber | (Firm Name) (Name of Authorlzed Officer & CERTIFICATION OF ENGINEER 1 certify that I have verified this Perlodlo Estimate and that to the best of my knowledgo and belief, it is a true and correct statement of work petformed and materials supplied by the Contractor; and that the Contractor’s certified statement of this account and the amount due him is correct, i:A/\\) 64&17\7/"“/ Date: Z _/03/20(6 Project Maunager ’ Tanglewood/Overbrook Stormwater Grant Agp. For Payment Ml Project Title: Tanglewood/Ove