Okaloosa County BOCC — May 6, 2014 — Finalpmtdocs — reading text

CONTRACT/LEASE PAYMENT APPROVAL FORM COMPLETE AND FORWARD TO THE NEXT DEPARTMENT COMPLETED BY DEPARTMENT DATE: 4/14/2014 VENDOR NAME: Gum Creek Farms, Inc VENDOR #: CONTRACT/LEASE#: C14-2101-PW VENDOR TASK COUNTY/FEMA BUDGET INVOICE # ORDER # PROJECT # DEPARTMENT | ACCOUNT # AMOUNT $ (If Applicable) (ff Applicable) # 3 (final) 3202 563161 $ 1,900.00 302 2051100 12,547.50 Total | $ 14,447.50 APPROVED FOR PROGRESS PAYMENT (lease sign, as applicable and date) CONTRACTOR'S ENGINEER/ARCHITECT/PROJECT MANAGER: ATE: ° enBroeck COUNTY SUPER VISOR/PROJECT MANGER Sf A or = DATE: Lf DEPARTMENT DIRECTOR: _ fo P , of » a DATE: 27 (A/S OF a“ J ohn H Ziad CONTRACTS & GRANT MANA DATE: COUNTY ADMINISTRATOR: DATE: (Payments> $25,000.) Ff 7] Ic iH] FINAL PAYMENT FINAL PAYMENT YES no _ Of "Yes", forward to Purchasing Services Coordinator for Close-Out) DATE: PURCHASING DIRECTOR: (Per Initial Agreement) DATE! .4-/-/Y CONTRACTS & GRANTS MANAGER: Aifeccll . LAM - (All Contracts) DATE: cw) /, LY COUNTY ADMINISTRATOR APPROVAL; (Per Initial Agreemeni) DATE: BOARD APPROVAL: (Per Initial Agreement) COMPLETED BY FINANCE - ACCOUNTS PAYABLE ONLY FISCAL YEAR: DATE RECEIVED: REVIEWD BY: CONTRACT CLOSE-OUT CHECKLIST (To Be Prepared by the Contracts and Lease Coordinator) DATE: 4-28-14 TO: Contracts & Grants Manager, Finance Department Contracts & Grants Office SUBJECT: Contract No. C14-2101-PW MANAGING DEPARTMENT: PUBLIC WORKS CONTRACTOR'S NAME: GUM CREEK FARMS, INC. PROJECT TITLE: FOXWOOD DRAINAGE IMPROVEMENTS PHASE II The attached has met the final payment contract requirement in subject contract. Yes No 1. Final Invoice x] LI 2. Completed Contract/Lease Payment Approval Form x] im 3. Close-Out Documents Yes No N/A a. Signed Release of Lien x] [| C] b. Proof of Completion Advertisement [ ] | c. Certificate of Insurance x] [J L] d. Consent of Surety to Final Payment x] LC] [| e. Proof of Performance/Payment Bond x] L] LC] Continuation 12 Months Following Final Payment Yes No 4. Agenda Request x] | 5. Remarks Seif 4-AB-1Y {onfracianc Ledse C64 dinator DATE Project Title: Foxwood Drainage Repairs Project Number: PW 39-13 Purchasing Contract No.: C14-2101-PW Gum Creek Farms, Inc. Expires: 04-06-2044 3/24/2014 3/28/2014 3202- TOTAL 302-2051100 563161 COST 5% Amount Date Inv# Cost to date Withheld Paid Paid 1 90,340.00 90,340.00 (4,517.00) 85,823.00 02/13/14 2 160,610.00 160,610.00 (8,030.50) 152,579.50 03/06/14 3 1,900.00 1,900.00 12,547.50 14,447.50 4 . - - 5 - - - 6 - - . 7 - - - g - - . 9 - - - 10 - - - ie - - - 252,850.00 252,850.00 - 252,850.00 Contract Total Change Order #1 Change Order #2 Change Order #3 Change Order #4 New Contract Total Balance to finish w/o retainage 259,850.00 14,000.00 (21,000.00) 252,850.00 w/ 4 add'l days Check Number 1403088 1403683 3/19/2014 Application for Payment Gum Creek Farms, Inc. 1097 Hwy 83 North DeFuniak Springs, Fla, 32433 Page 1 SOLD TO: Richard Brannon, Purchasing Director Okaloosa County 602-C North Pearl St. Crestview, Florida 32536 Job Description Foxweod Drainage Repairs-Phase 2 Original Contract $259,850.00 |For Work Performed Project ID # C14-2101-PW Change Orders & Adj. ($7,000.00) |From: 21-Feb-14 Estimate # 3 & Final Purchase Order # Revised Contract $252,850.00 |To: 19-Mar-14 {pate 19-Mar-14 tiem Description of Work Unit | Estimated Unit Previous To Date Current Period Job To Date Number Meas{| Quantity Price Quantity | Amount Quantity | Amount Quantity | Amount >a Foxwood Drainage Repair PH2 1 10" ADS N-12 Perforated Pipe w/Sock LF 2,618.00 $15.00 |2,618.000 $39,270.00 0.000 $0.00 }2,618.000 $39,270.00 2 10" Cleanout Assembly EA 13.00 $700.00 13.000 $9,100.00 0.000 $0.00 13.000 $9,100.00 3 Nyloplast Standard 15" Steel H-20 Hinged EA 17.00 $500.00 17.000 $8,500.00 0.000 $0.00 17.000 $8,500.00 Grate Assembly With Collar 4 Type C Inlet FDOT Index 232 EA 3.00 $1,200.00 3.000 $3,600.00 0.000 $0.00 3.000 $3,600.00 5 Nyloplast 10" ADS STD 401 Drain Basin EA 4.00 $1,000.00 4.000 $4,000.00 0.000 $0.00 4.000 $4,000.00 6 210# SP-12.5 Asphalt Conc. Structural Cou TN 140.00 DELETE 0.000 $0.00 0.000 $0.00 0.000 $0.00 7 5" Thick ABC-3 Asphalt Base Material SY 1,164.00 $32.00 |1,164.000 $37,248.00 0.000 $0.00 11,164.000 $37,248.00 8 #57 Stone Installed 27" Thick SY 1,164.00 $61.00 |1,164.000 $71,004.00 0.000 $0.00 11,164.000 $71,004.00 9 D-2 Fabric Installed SY 1,164.00 $2.00 |1,164.000 $2,328.00 0.000 $0.00 |1,164.000 $2,328.00 10 Maintenance of Traffic LS 1.00 $7,000.00 0.900 $6,300.00 0.100 $700.00 1.000 $7,000.00 it Earthwork LS 1.00 $40,000.00 1.000 $40,000.00 0.000 $0.00 1.000 $40,000.00 12 Bonds LS 1.00 $4,800.00 1.000 $4,800.00 0.000 $0.00 1,000 $4,800.00 13 Mobilization LS 1.00 $12,000.00 0.900 $10,800.00 0.100 $1,200.00 1.000 $12,000.00 Change Order #1 6 Additional Work, Mob, Pipe, Asphalt Base, LS 1.00 $14,000.00 1.000 $14,000.00 0.000 $0.00 1,000 $14,000.00 >>> #57 Stone, Fabric and Earthwork GROSS EARNINGS PER CONTRACT $250,950.00 $1,900.00 $252,850.00 Less: Retainage @ 5% of contract. $12,547.50 ($12,547.50) $0.00 Less: Previous Payments $238,402.50 : . $238,402.50 Less: Account # $0.00 $0.00 $0.00 Less: Account # $0.00 $0.00 $0.00 Less: Account # $0.00 $0.00 $0.00 Less: Account # $0.00 $0.00 $0.00 Add: Account # $0.00 $0.00 $0.00 Add: Account # $0.00 $0.00 $0.00 NET DUE THIS REQUEST $0.00 $14,447.50 $14,447.50 Prepared By: Don Fife Don Fife Approved By: Perry H. Bell Perry H. Bell Distribution: Original - Owner Copy - Job File i | ACCORD Nema CERTIFICATE OF LIABILITY INSURANCE GUMC-01 OP ID: AW DATE (MMUDONY YYY) 10/14/2013 BELOW. THIS CERTIFICATE OF INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INF CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, FICATE HOLDER. ORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES -E DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTI certificate holder in leu of such endorsement(s). IMPORTANT: If the certificate holder Is an ADDITIONAL the terms and conditions of the polley, certain po INSURED, tho policy{les) must be endorsed. {f SUBROGATION licles may require an endorsement. A statement on this certificate does IS WAIVED, subject to not confer rights to the PRODUCER Phone: 880-581-4925] GONTACT Waldorff Ins & Bonding - FWB PHONE 45 Eglin Parkway NE, & 202 Fax: 850-581-4930] fio, ev: fae, No): Fort Walton Beach, FL 32548 ADRESS: n are :. wa y INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Travelers Indemnity Company 25658 INSURED ym Creek Farms, Inc. INSURER B: The Phoenix Insurance Co. 25623 r. Don Fife 1097 Highway 83 North INSURER C: Travelers Property & Casualty 25674 CERTIFICATE NUMBER: Defuniak Springs, FL 32433 INSURER O : ne See INSURER E : INSURER F : COVERAGES ADUCISUB ~ ; ~ TYPE OF INSURANCE bell POLICY NUMBER MAID (MWD) LIMITS | GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A |X | COMMERCIAL GENERAL LIABILITY DTCOS486P9491ND13 05/48/2013 | 05/18/2014 | Pages eee ence) [5 300,000 CLAIMS-MADE OCCUR MED EXP (Any one person) $ 5,000) | PERSONAL & ADV INJURY $ 1,000,000 = GENERAL AGGREGATE $ 2,000, 000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS. COMP/OP AGG | $ ____ 2,000,000) leoucr [X 1582 [roc E COMBINED SINGLE LIMIT | AUTOMOBILE LIABILITY (Ea accidenti $ 1,000,000 C {| X | any auto OT8109486PS49TIL13 05/1 8/2013 | 05/18/2014 | BODILY INJURY (Per person) | $ r | ALL OWNED SCHEDULED BODILY INJURY {Per acadent)| $ ly | NON-OWNED PROPERTY DAMAGE ee |X | HIRED AUTOS xX Roroe Per accident) $ PIP $ 10,009 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS.MADE AGGREGATE $ _ 0&0 |__| retentions $ WORKERS COMPENSATION WG STATU. OTH- AND EMPLOYERS" LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PAR TNERIEXECUTIVE £1. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA wee ee oe ee (Mendatory In NH) E.L DISEASE - EA EMPLOYEE] $ tf yas. descnbe under DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY LIMIT } $ B Scheduled Equip QT6609343P336PHX13 05/4 8/2013 | 05/18/2014 [Ded 2%-$2500MIN B Lease/Rented Equip QT6609343P336PHX13 05/18/2013 | 05/18/2014 |\Ded $5000 180,000 Re: Foxwood Drainage Repairs- Phase 2 OESCRIPTION OF OPERATIONS / LOCATIONS { VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space iz required) CERTIFICATE HOLDER CANCELLATION Okaloosa County Board of County Commissioners County Purchasing 602-C N. Peart Street Crestview, FL 32536 OKALPO5 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE eng Rare ACORD 25 (2010/05) ® 1888-2010 ACORD CORPORATION. All rights reaerved. The ACORD name and logo are registered marks of ACORD ACORIY DATE (MM/ODIYYYY) CERTIFICATE OF LIABILITY INSURANCE ronarz013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CE REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLOER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the polic to the terms and conditions of the Policy, certain policies may require an en to the certificate holder in lieu of such endorsement(s). y(les) must be endorsed. If SUBROGATION IS WAIVED, subject dorsement. A statement on this certificate does not confer rights PROOUCER CONTACT NAME: Risk Mar Oepai Aon Risk Services Northeast, Inc. PHONE FAX New York NY Office AIC, No, Ext}: (866) 443-8489 (A/C, No): (800) 889-0021 199 Water Street AOORESS: work.compGitrinat.com New York, NY 10038-3551 INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: Commerce & industry Ins Co 19410 TriNet HR Corporation and all its affiliates and subsidiaries* in . , wy SURER 8: Illinois National Ins Co 23817 Gum Creek Farms Inc (Endorsed as alternate employer) - 9000 Town Center Parkway INSURER C: Ins Co State of Penn 19429 Bradenton, FL 34202 INSURER D: Nat'l Union Fire Ins Co 19445 INSURER E: New Hampshire Ins Co 23841 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUME CERTIFICATE MAY BE ISSUED OR MAY PERTAIN BOVE FOR THE POLICY PERIOD NT WITH RESPECT TO WHICH THIS . THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as 5: 1NSR ADOL | SUBR POLICY EFF | POLICY EXP - Ha TYPE OF INSURANCE usr | wo POLICY NUMBER qumioorvyvyy | (umDowyvy) uMITS GENERAL LIABILITY EACH OCCURRENCE $ ) AMA N |_|COMMERCIAL GENERAL LIABILITY PREMISES (er oeesoen) $ ciams-mape [ Joccur MED EXP {Any ona parson) __[$ | PERSONAL & ADVINJURY |$ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG [$ poucy [| |prowect | |uoc ——_ AUTOMOBILE LIABILITY Each accent 5 | __}ANY AUTO BODILY INJURY (Per parson) 1 ALL OWNED SCHEDULED BODILY INJURY (Per | {AUTOS AUTOS accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per acadent) $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE s DED RETENTION $ x WORKERS COMPENSATION 39401238 (FL 07/01/2013 | 07/01/2014 WE STATU- | OTH- A ANO EMPLOYERS’ LIASILITY VIN 039401238 (FL) X [Tory uimits ER ANY PROPRIETOR/PARTNER/EXECUTIVE $2,000.000 OFFICER/MEMBER EXCLUDEO? Ll NIA E.L, EACH ACCIDENT {Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $2,000,000 H yes, describe undar 2000000 DESCRIPTION OF OPERATIONS below E.L. DISEASE-POLICY LIMIT inmate Re: Foxwood Drainage Repairs - Phase 2 ( ThiNet HR Il, Inc. and TriNet HR V, Inc. ESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required): 8658 / 7CB CERTIFICATE HOLDER CANCELLATION Okaloosa County Board of County