Okaloosa County BOCC — October 21, 2014 — BILL SMITH ELECTRIC FINAL PAYMENT — reading text

Stephen C. Ruschak, Sr. Vice President, COO Randall Musselman, Secretary County of Oakland On this 28rd day of February, 2012 before me came the individuals who executed the preceding instrument, to me personally known, and being by me duly sworn, sald that each is the herein described and authorized officer of The Guarantee Company of North America USA; that the seal affixed to said instrument is the Corporate Seal of said Company; that the Corporate Seal and each signature were duly affixed by order of the Board of Directors of Cynthia A. Takai IN WITNESS WHEREOF, | have hereunto set my hand at The Guarantee Notary Public, State of Michigan Company of North America USA offices the day and year above written. County of Oakland My Commission Expires February 27, 2018 Cy nthe a . Vafpat Acting in Oakland County renee |, Randall Musseiman, Secretary of THE GUARANTEE COMPANY OF NORTH AMERICA USA, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney executed by THE GUARANTEE COMPANY OF NORTH AMERICA USA, which is still in full force and effect. Randall Musselman, Secretary IN WITNESS WHEREOF, | have thereunto set my hand and attached the seal of said Company this 19th day of August , 2014 BILL SMITH ELECTRIC FINAL WAIVER AND PO BOX 1057, GONZALEZ, FL 32560 RELEASE OF BOND AND LIEN OFFICE (850) 968-6500 FAX (850) 937-8113 WAIVER OF RIGHT TO CLAIM AGAINST THE PAYMENT BOND UPON FINAL PAYMENT The undersigned, in consideration of the final payment in the amount of $ 201,207.00 herby waives its right to claim against the payment bond, liens, & lien rights for labor, services, or materials furnished to Okaloosa County Board of Commissioners on the following project: Owner Name: Okaloosa County Board of Commissioners Project Name: Russell Stephensen Electrical Manhole Rehab Project City/State: Okaloosa County, Florida Job Name & #: Russell Stephensen Electrical Manhole Rehab Subcontract or PO #: 03-2014 In addition, the undersigned herby releases Bill Smith electric, General Contractor and Owner, its successors and assigns, of all claims or demands of any kind whatsoever (contract or equitable), which the undersigned now has or might have against Bill Smith Electric, General Contractor, Owner, Bill Smith Electric’s surety, and/or insurance carriers on account of labor performed and/or materials furnished for the construction of any improvements for the described project or on account of any other costs incurred in the prosecution of the work on the described project. The undersigned further certifies that all labor and materials used by the undersigned in the construction of said improvements have been fully paid for. Please Type: Bill Smith Electric, Inc. Name of Sub or Supplier (hte rtd Title: Project Manager Date: 8/13/14 Authojized Signature~> State of: Florida County of:___ Escambia The foregoing instrument was acknowledged to be true and correct before me by Jake Smith . who certified under oath that he/she is the Project Manager, of Bill Smith Electric, Inc. , and has full, complete and unbridled authority to execute the foregoing instrument on behalf of Bill Smith Electric, Inc. and has executed the same on this 13 day of August, 2014 -— <p ote, LISA M. RIETZ ae bs . Seal/Stamp: J Notary Public - State of Florida i Pub My Comm. Expires Jan 22, 2017 4 es Commission # EE 867444 "Banded Through Nationat Notary Assn. My Commission Exptée: 7 Date CERTIFICATE OF LIABILITY INSURANCE 1/28/2014 Producer; Lion Insurance Company ‘This Certificate is issued as a matter of information only and confers no 2739 U.S. Highway 19 N. rights upon the Certificate Holder. This Certificate does not amend, extend Holiday, FL 34 691 or alter the coverage afforded by the policies below. (727) 938-5562 Insurers Affording Coverage NAIC # Insured: South East Personnel Leasing, inc. & Subsidiaries | "Ue _Hon Insurance Company 11075 2739 U.S. Highway 19 N. Insurer B: Holiday, FL. 34691 Insurer C: Insurer D: Insurer E: Coverages me policies of insurance Teled ta low hava been issued to the eure’ named above for te policy period mmarcatece Nowmtietenel Ing any requirement, tern or conaon o ‘any contract or oner 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 terme, exclusions, and conditions of such policies. Aggregate limits shown may have been reduced by paid claims. ae . Policy Effective Policy Expiration aot WSR) RD Type of Insurance Policy Number Date Date Limits (MM/DD/YY) (MIM/DDIYY) {GENERAL LIABILITY Each Occurrence 3 Commercial General Liability Tpamage to rented premises (EA } Claims Made Cl Occur eccurrenice) joued Med Exp fk ~ , Personal Adv injury f General aggregate {imlt applies per: General it | Policy oO Project oO Loc jeneral Aggragate i Products - Comp/Op Agg AUTOMOBILE LIABILITY Combined Single Limit (EA Accident} Bp Any Aste Bodily injur jt All Owned Autos iy inlay (Par Person) p Scheduled Autos Hired Autos Bodlly Injury Non-Owned Autos (Per Accident} B Property Damage (Per Accident} bk EXCESS/UMBRELLA LIABILITY Each Occurrence Occur Clalms Made Aggregate Deductible A {Workers Compensation and wc 71949 01/01/2014 01/01/2015 Xq WC Statu- OTH- Employers’ Liability tory Limits ER Any proprietor/partner/executive officer/member E.L. Each Accident $1,000,000 excluded? WO E.L. Disease ~Ea Employee § $1,000,000 If Yes, describe under special provisions below. ° . nee E.L. Disease - Policy Limits $1,000,000 Other Lion Insurance Company is A.M. Best Company rated A- (Excellent). AMB # 12616 Descriptions of Operations/Loecations/Vehicles/Exciusions added by Endorsement/Special Provisions: Client ID: 93-67-085 Coverage only applias to active employee(s) of South East Personnel Leasing, Inc. & Subsidiaries that are leased to the following “Client Company": Bill Smith Electric, inc. Coverage only applies to injuries incurred by South East Personnel Leasing, Inc, & Subsidiaries active employee(s}, while working in; FL. Coverage does not apply to statutory employee(s) or independent contractor(s) of the Client Company or any other entity. A list of the active employee(s) leased to the Client Company can be obtained by faxing a request to (727) 937-2138 or by calling (727) 938-5562. Project Name: ISSUE 01-28-14 (ND) _ Begin Date 4/1/2043 CERTIFICATE HOLDER CANCELLATION poomaseeemmatcmns BOARD OF COUNTY OMMISSIONERS OKALOOSA COUN Should any of the above described policies be cancelled before the expiration date thereof, the Issuing insurer will endeavor to mail 30 days written notice to the certificate holder named to the left, but fallure to da so shait impose no obligation or flability of any kind upon the Insurer, its agents or representatives. 302 N, WILSON ST. #203 CRESTVIEW, FL 32536 Let ME snae ACORIY ee” CERTIFICATE OF LIABILITY INSURANCE BILLS-4 OP ID: JT DATE (MMIDDIYYYY) 01/30/2014 THIS CERTIFICATE 1S 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: [f the certificate holder ls an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain poflcies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lleu of such endorsement(s). PRODUCER Fisher Brawn Div, Pensacola 1701 West Garden Street Pensacola, FL 32502 Alan D. Moore, CPCU Phone: 850-432-7474) Fax: 850-438-4678 CONTACT NAME: Lynne Teeu, CPCU, CIC TASTE, xy, 850-444-7624 [EAE ney, 850-458-4678 AbouEss; Itecu@fbbins.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Amerisure Insurance Company 19488 INSURED Bill Smith Electric, Inc. INSURER B: Laura Smith ” PO Box 1057 INSURER Gi Gonzalez, FL 32560 INSURER D : INSURER E: INSURER E COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS [8 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. BR Rae TYPE OF INSURANCE Noe POLIGY NUMBER (AMEE) | ENT) Lats | GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000) A. |X | COMMERCIAL GENERAL LIABILITY GL 2077896 07/24/2043 | 07/24/2014 | CREE eT ew |s 300,000) | CLAIMS.MADE occuR MED EXP (Any one person) | $ 10,000 |X {Pollution $100000 PERSONAL & ADVINJURY 1 $ 1,000,000 CI GENERAL AGGREGATE $ 2,000,000 | GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS - COMP/OP AGG | $ 2,000,000) ~_ Lroucy | x | BB Loc Emp Ben, $ 1,000,000 OMBINED SI | AUTOMOBILE LIABILITY COMBINED SINGLET MITT 1,000,000 A |X | any auto ICA 2077895 07/24/2013 | 07/24/2074. | BOOILY INJURY (Per person) | $ janet 1 agsguen Sn Ps |X | HIRED autos AUTOS (Pat accident) ¢ $ LX |UMBRELLALIAB | X | occur EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE ‘CU 2077898 07/24/2013 | 07/24/2014 | asorEGATE 4 1,000,000) pep [X | Rerenrions 0 $ WORKERS COMPENSATION Wo statu. Orn AND EMPLOY ERS' LIABILITY YIN TORY LIMIT: ER ANY PROPRIETOR IPARTNER/EXECUTIVE ELL, EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NEA (Mandatory in NH) E.L, DISEASE - EA EMPLOYEE] $ if yes, describe under DESCRIPTION OF OPERATIONS below E.L, DISEASE - POLICY LIMIT | $ A. |Equipment Floater IM 2077897 07/24/2013 | 07/24/2014 |LeaseRent 125,000) Ded 4,000] DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Project: Russell Stephenson Electrical Manhole Rehabilitation Ws03-14 Should any of the above policies cancel before the expiration date thereof, 30 days written notice will be mailed to certificate older. CERTIFICATE HOLDER CANCELLATION Board of County Commissioners Okaloosa County, FL 602-C North Pearl Street Crestview, FL 32536 OKALO01 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 ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD © 1988-2010 ACORD CORPORATION. All rights reserved. . HOLDERcopE }4©- OKAL.004 BILLS-4 NOTEPAD: iInsureo's NAME Bill Smith Electric, Inc. OP ID: JT PAGE 2 DATE 01/30/44 Certificate Holdex is Additional Insured in regard to General Liability, Auto Liability and Umbrella Liability if required by written contract. General Liabi ity is primary and non-contributory if required by written jcontractk. Waiver of Subrogation epplics in favor of Certificate Holder in regard to General Liability, Auto Liability and Umbrella Liability if required by written contract, General Liability Additional Insured Endorsement is attached. | . BILLSMI-01 JLTECU ALORP CERTIFICATE OF LIABILITY INSURANCE se eemone 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 pollcy(ies) must be endorsed. If SUBROGATION IS WAIVED, sublect to the terms and conditions of the policy, certain policies may require