Okaloosa County BOCC — December 18, 2012 — Bob Sikes Airport Taxiway A - Change Order #5, Close-out docs, Final Payment form — reading text

being first duly sworn, on oath deposes and says: 1. That Gulf Coast Utility Contractors is/are a/an corporation hereinafter called “Subcontractor”. (Individual/Partnership/Corporation) 2. That affiant is the President of Subcontractor and is authorized to make this affidavit. (Owner/Officer) 3, That Subcontractor heretofore entered into a subcontract with Anderson Columbia Company, Inc., hereinafter called “Gencra! Contractor,” under Subcontract No. AG 61201, on the 18th day of March, 2011 for Bob Sikes Airport Taxiway Rehabilitation in the amount of $1,254,083.56 to furnish material, labor or services for the construction of a certain building, or repairs, or alterations specifically described in said subcontract, as amended. 4, Subcontractor has fully completed all work and furnished all materials in accordance with the terms of said subcontract and all amendments thereto; that all lienors, including, but not limited to all laborers, materialmen and taxes, have been paid in full, except: (List names of lienors and amounts owed.) 5. Receipt by the Subcontractor of the final payment, under the aforementioned subcontract, shall constitute a full release and discharge by the Subcontractor to the General Contractor of all claims of the Subcontractor against the General Contractor, arising out of, connected with, or resulting from performance of the obligations of the Subcontractor pursuant to said subcontract and all amendments thereto. Gulf Coast4Jtility opfrtractors-"” “ee (SEAL) Mike's fgton, President By Sworn t [ bscribedpeford the this 3rd day of October, 2012. = NN HUDSON AM nx ‘ DON pale eect a No Puhlic Gonimission No. toy D2) My Commission expires M SUBCONTRACTOR’S SWORN STATEMENT TO GENERAL CONTRACTOR ON REQUESTING FINAL PAYMENT STATE OF EL QAO COUNTY OF AWC BSON Before me, the undersigned authority, personally appeared WELEM OHxe Q__ who, being first duly sworn, on oath deposes and says: 1. That Qoarra Coosxascreanls. is/are alan _( eocgacodc sn_ hereinafter called “Subcontractor”. (Individual/Partnership/Corporation) 2. That affiant is the Pegs Near of Subcontractor and is authorized to make this affidavit. (Owner/Officer) 3. That Subcontractor heretofore entered into a subcontract with Anderson Columbia Company, Inc., hereinafter called “General Contractor,” under Subcontract No bl201-4437, on the = day of Ms. , 20 \ for Soerraw + Seek Les, in the amount of $ Ss to furnish material, labor or ee services for the construction of a certain building, or repairs, or alterations specifically described in said subcontract, as amended. 4, Subcontractor has fully completed all work and furnished all materials in accordance with the terms of said subcontract and all amendments thereto; that all lienors, including, but not limited to all laborers, materialmen and taxes, have been paid in full, except: (List names of lienors and amounts owed.) 5. Receipt by the Subcontractor of the final payment, under the aforementioned subcontract, shall constitute a full release and discharge by the Subcontractor to the General Contractor of all claims of the Subcontractor against the General Contractor, arising out of, connected with, or resulting from performance of the obligations of the Subcontractor pursuant to said subcontract and all amendments thereto. Roose: © Sec (SEAL) Subcontractor y O . _ (SEAL) By Sworn to and subscribed before me this yu day of SeOreengea 2012. KATHY WYMAN 2, NOTARY PUBLIC Ris STATE OF FLORIDA oa Comm# EE036931 Expires 11/28/2014 Daily News Published Daily Fort Walton Beach, Florida Distributed in Okaloosa, Santa Rosa & Walton Counties State of Florida, County of Okaloosa Before the undersigned authorized personally appeared M CULL vo \iilfse ; who on oath says that (s)he is C Lap Adu whsi i Meet. of the Northwest Florida Daily News, a daily newspaper published at Fort Walton Beach, in Okaloosa County, Florida; that the attached copy of advertisement, being a l é bat 3 O35" N abice Dro Syke 5 Kun bolt in the Q5k- County Court, was published in said newspaper in the issues of Oka lo Suoptimbu {15 22.29 Jop— in the matter of Affiant further says that the said Northwest Florida Daily News is a newspaper published at Fort Walton Beach, in said Okaloosa County, Florida, and that the said newspaper has heretofore been continuously published in said Okaloosa County, Florida, each day, and has been entered as second class mail matter at the post office in Fort Walton Beach, in said Okaloosa County, Florida, for a period of one year next preceding the first publication of the attached copy of advertisement; and affiant further says that (s)he has neither paid nor promised any person, firm or corporation any discount, rebate, commission or refund for the purpose of securing this advertisement for publication in the said newspaper. STATE OF FLORIDA COUNTY OF OKALOOSA Subsgribed and sworn to (or affirmed) before me this l Otel bu & Old- (Date) by Cita een hi jpbtac , who is/are personally known to me or has/have produced brs ally ho tv) _as identification. (Type of identification) — otary Public, Commission No. (Signatur ame of Notary typed, printed or stamped) typed, p p' ELEANOR HYPES Notary Public - State of Florida My Comm. Expires Jul 30, 2015 » Commission # EE 116319 CaTAR SS Bonded Through National Notary Assn Legal 3035 ADVERTISEMENT OF COMPLETION Anderson Columbia Co., Inc. 1301-6 w. Hwy 90, Holt, FL 32448 Gives notice of completion of Bob Sikes Airport Taxiway A Rehabilitation and sets 10/5/12 as the date of final settlement. All per- sons and firms should file all claims for pay- Ment to the below ad- dress prior to the set- tlement date: Okaloosa County ATTN: . Contracts and pes Coordinator q North era Pearl Crestview, FL 32536 By: Bobby Braun Project Manager eels iz ept. 8, 15, 22 2012 Tee eI Se a November 19, 2012 RE: _ Taxiway A Rehabilitation, Bob Sikes Airport, Contract No: C11-1852-PW General Liability - Policy No. A-4DG-003212-01 Dear Sir/Madam: This is to confirm that the above referenced General Liability policy written by Old Republic is written on an occurrence form. The policy declarations are attached. If you have any questions, please contact me directly. Sincerely, Katie Wright, CIC Account Executive PentaRisk Associates « 3715 Northside Parkway, Bldg 400, Ste 550 « Atlanta, GA 30327 « ph: 404.809.2530 + f: 404 809.2531 + pentarisk.com OLD REPUBLIC GENERAL INSURANCE CORPORATION GENERAL LIABILITY RENEWAL DECLARATION ACCOUNT NUMBER: ED00331 NAMED INSURED AND MAILING ADDRESS POLICY NO. A-4DG-003212-01 ENDOR 000 RENEWAL OF A~4DG-003211-00 AGENCY AND MAILING ADDRESS 7004 ANDERSON COLUMBIA CO., INC. P.O. BOX 1829 / 2 GUERDON RD. LAKE CITY FL 32056 OLD REPUBLIC CONSTRUCTION INSU RANCE AGENCY, INC. 3333 PIEDMONT ROAD NE, STE 775 ATLANTA GA 30305 POLICY PERIOD: THE NAMED INSURED IS = CORPORATION BUSINESS DESC : From 05/01/2022 to 05/01/2013 12:01 A.M. STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE STREET & ROAD CONTRACTOR IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE INSURANCE AS STATED IN THIS POLICY. LIMITS OF INSURANCE GENERAL AGGREGATE EACH OCCURRENCE MEDICAL EXPENSE DAMAGE TO PREMISES RENTED TO YOU PRODUCTS-COMPLETED OPERATIONS AGGREGATE PERSONAL INJURY & ADVERTISING INJURY $ 2,000,000 § 2,000,000 $ 1,000,000 $ 1,000,000 $ 100,000 $ 10,000 ANY ONE PREMISES ANY ONE PERSON LOCATION OF ALL PREMISES YOU OWN, RENT OR OCCUPY: AS PER SCHEDULE ON FILE WITH THE COMPANY. Loc CLASSIFICATION PMS PDTS CODE PREMIUM BASIS RATE RATE SEE FORM CGENGNOO26(09/06) - COMPOSITE RATING PLAN PREMIUM ENDORSEMENT FLORIDA HURRICANE CATASTROPHE FUND SURCHARGE TERRORISN EXCLUSION APPLIES ~ TERRORISM INSURANCE ACT REJECTEN 06-22-12 ve KTONG Page 1 of CONSENT OF SURETY OWNER is TO FINAL PAYMENT SRT . AIA Document G707 SERRE o Bond No. 248000540 OTHER 0 TO OWNER: ARCHITECT'S PROJECT NO.: (Name end address} Board of County Commissioners of Okaloosa County, FL 602-C North Pearl Street Crestview, FL 32536 PROJECT: CONTRACT DATED: January 11, 2011 (Name and address) CONTRACT FOR: Taxiway A Rehabilitation at Bob Sikes Airport In accordance with the provisions of the Contract between the Owner-and the Contractor as indicated above, the Onsert name and address of Surety) Liberty Mutual Insurance Company 175 Berkeley Street Boston, MA 02116 , SURETY, on bond of (Insert name and address of Contractor) Anderson Columbia Co., Inc. 2316 Highway 71 Marianna, FL 32448 , CONTRACTOR, hereby approves of the final payment to the Contractor, and agrees that final payment to the Contractor shal! not relieve the Surety of any of its obligations to Clasert name and address of Oterer) Board of County Commissioners of Okaloosa County, FL 602-C North Pearl Street Crestview, FL 32536 , OWNER, as set forth in said Surety’s bond. IN WITNESS WHEREOR, the Surety has hereunto set its hand on this date: October 25, 2012 Unsert in weviting the month followed by the maneric date and year.) Liberty Mutual Insurance Company _— air aatise of auborized representative) Kevin Wojtowicz Attorney-in-Fact {Printed nenae and tide) G707—1994 ) ANDERSON COLUMBIA CO., INC. P.O. Box 1829 ¢ Lake City, FL 32056 - 1829 (386) 752-7585 e (386) 755-5430 FAX October 22, 2012 Okaloosa County Board of County Commissioners 602 N. Pearl St. Crestview, FL 32536 RE: Taxiway A Rehabilitation, Bob Sikes Airport, Contract No.: C11-1852-PW Dear Sirs: Please accept this correspondence as confirmation that Anderson Columbia Co., Inc., will provide Okaloosa County with insurance certificates covering the Taxiway A Rehabilitation, Bob Sikes Airport project for two years. The certificates will be issued to the County as our insurance policies renew annually, and will be sent to the County in a timely manner. If there any questions, please feel free to call. Sincerely, Mark C. Resler, CPCU, AIC Risk Manager (386) 752-7585, ext. 252 CC: PentaRisk Insurance Specialists (electronically) ANDERSON COLUMBIA CO., INC. 1301-C Highway 90 West ° Holt, FL 32564 (850) 537-9074 ° Fax (850) 537-9072 October 6, 2012 John Collins Project Engineer AVCON 320 Bayshore Dr. Ste. A Niceville, FL 32578 RE: DBE Statement Bob Sikes Airport TW — A Rehabilitation Okaloosa Contract No. C11-1852-AP Dear Mr. Collins, Anderson Columbia Co., Inc. is pleased to make the following report of DBE usage on the above referenced project. The following summarizes their earnings and percentage of contractual work that was performed based on the Final Contract Amount: Emerald Coast Milling Services $ 46,216.22 45% Big Island Construction $ 114,909.54 1.12% Tom Hammonds Enterprises, LLC $ 33,676.00 33% Porter Construction Co., Inc. $ 806,184.06 71.87% $1,000,985.82 9.77% Please refer any questions or concerns to our office, 850-537-9074. Sincerely, S Bobby Braun Project Manager Anderson Columbia Co., Inc. Main Office: PO. Box 1829 * Lake City, FL 32056-1829 NIELSON, WOJTOWICZ, NEU & ASSOCIATES November 5, 2012 Okaloosa County Board of County Commissioners 101 East James Lee Boulevard Crestview, FL 32536 RE: Anderson Columbia Co., Inc. Bond #24S000540 TAXIWAY a Rehabilitation at Bob Sikes Airport To Whom it May Concern: WUTION We have executed the requested Consent of Surety to Final Payment dated 10/25/12. Upon acceptance of the completion of the project a one year maintenance period shall commence in JFET accordance with the contract terms. Respectfull Kevin Wojtowicz Attorney-in-Fact bd KRW/cmk ‘ Het MEL ST PETE S 1000 Central Avenue, Suite 200, St. Petersourg, FL 33705 P: 727.209.1803 F: 727.209.1335 ASHEVILLE 210 Westover Drive, Asheville, NC 28801 P: 828.505.7431 Not valid for mortgage, note, loan, letter of credit, bank deposit, currency rate, interest rate or residual value guarantees. TH'S POWER OF ATTORNEY IS NOT VALID UNLESS IT IS PRINTED ON RED