Okaloosa County BOCC — February 18, 2014 — Reroofing TDD Welcome Center - Documents — reading text

[% Limited liability company. Enter the tax classification (D=disregarded entity. Gocorneration, Paparmersiiin) ® .. 22... [7] Other (eee Insiucdons: > Address inurndar, street, and ant. or suite no) 108 Estes Place City. sizie, and ZIP code Panama City Beach, Florida 32413 List account numberis} haré feplionah c Exemsi navies pays Requasier’s name and address icaional Print or type See Specific instructions on page 2. Taxpayer Identification Number {TIN} , Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 io avoid { Sootal security number backup withholding. For individuals, this is your social security number (SSN). However, for a resident i ; alien, sole proprietor, ar disregarded entity, see the Pari t instructions on page 3. For other antities, it is your employer identification number (EIN). if you do not have a number, see How to ge? a TIN on page 3. or Note. if the account is in more than one name, see the chert on page 4 for guidelines on whose number ta anter. Employer identification number 20 ? 8925851 Under penalties of perjury, | certify that: 7. The number shown on this form is my correct taxpayer identificatian number (or | em waiting for a number to bs issued to mej, and 2. lam not subject io backup withholding because: (a)! am exempt from backup withholding, or {b} ] have not been notified by the Internal Revenue Service (IRS) that | arn subject to backup withholding as a result of a failure to report all interest or dividends, or {c) the IRS has notified me that | am no longer subject to backup withholding, and 3. tama U.S. citizen or other U.S. person (defined baloys- Certification instructions, You must cross aut withholding because you have failed to report For mortgage interest paid, acquisition or arrangement (IRA), and generally, paymi provide your correct TIN. See the i DBI, eé if you have been notified by the IRS that you are currently subject to backup resi and dividends on your tex retum. For real estate transactions, ttem 2 doas not apply. ent of secured property, canceliation of debi, contributions to an indiviclual retirement er than interest and dividends, you are not required to sign the Certification, but you must Sign i ; noe | Sweet, Lz pate > 1/20/2014 (4 General Instructions Section references are to the intemal Revenue Code uniess otherwise noted. Purpose of Form A person who is required to file an information retum with the IRS must obtain your correct taxpayer identification number {TIN} to report, for example, income paid to you. real-estate transactions, mortgage interest you paid, acquisition or ‘ abandonment of secured property, cancellation of debt, or contrioutions you made io an IRA. Uss Form W-9 only if you are a U.S. person {including 2 resident alien), to provide your correct TIN to the person requesting it (the requester} and, when applicable, to: 1. Gerttiy that the TIN you are giving is correct for you ara waiting for a number to be issued}. 2. Certify that you are not subject to backup withheiding, or 3. Ciaim exemption from backup withholding tf you are a U.S. exempt payee. If applicable, you are aisc certifying that as a U.S. person, your elliocabie share of any partnership Income from a U.S. trade or business is not subject to the withhelding tax on foreign partners’ share of eifectively connected income. Note. if a requester gives you a form other than Form W-9 te request your TIN, you must use the requester’s form Ff it is substantially similar to this Form W-3. Definition of a U.S. person. For federal tax purposas, you ars considered a U.S. person if you are: @ An individual who is a U.S, citizen or U.S. resident alien, © A parinesship, corporation, company. or association created or organized in the United States or uncer the laws of the United States, 2 An estate (other than a foreign estate), or ® A domestic trust (as defined in Regulations section 301.7761-7}. Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners’ share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a pariner in a partnership conducting a trade or business in the United States. provide Forrn W-9 to the parinership to establish your U.S. status and avoid withholding on your share of parinership income. The person who gives Form V¥-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share o7 net income from the parinership conducting 4 trade or business in the United States is in ihe following Cases: ¢ The U.S. owner of a disregarded entity and not the entity, Cat, No. 1G231X Foon VWieS Rev. 10-2007) 13 ——, ACCORD CERTIFICATE OF LIABILITY INSURANCE AMERROO-01 CLINDNER DATE (MMIDDIYYYY) 1/28/2014 REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. 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 IMPORTANT: certificate holder in lieu of such endorsement(s). 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 PRODUCER CONTACT sentria. ing Panama City Office [Ale Wo, ext. (850) 257-2990 [TAS no}: (850) 257-2991 Panama City, FL 32401 BML oo. INSURER(S) AFFORDING COVERAGE NAIC # insurer a: First Mercury Insurance Company 10657 INSURED INsuRER B: Westfield Insurance Company 24112 Ameritech Enterprises LLC insureR c: Commerce & Industry Insurance Co. 19410 108 Estes Place insurer v : Bridgefield Employers Ins. Co. 10701 Panama City Beach, FL 32413 INSURER E: TRAVELERS INDEMNITY COMPANY 25658 INSURER E : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS {S$ 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. INSR TYPE OF INSURANCE SR el POLICY NUMBER naa aaron a9 LIMITS | GENERAL LIABILITY EACH OCCURRENCE $ 4,000,000 A | X | coMMERCIAL GENERAL LIABILITY NJCGL000001128102 05/23/2013 | 05/23/2014 | PAM AGE TO Nourence) _| $ 100,000 | CLAIMS-MADE OCCUR MED EXP (Any one person) | $ 0 |__| PERSONAL & ADVINJURY | § 1,000,000 | 4 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG | $ 2,000,000 | | poucy | X SRS mr $ | AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 4,000,000 B | XJ anyauto CWP7613204 05/23/2013 | 05/23/2014 | BODILY INJURY (Per person) | $ - WN ED ; |_| ALL QQNED SCHEDUL BODILY INJURY (Per accident) | $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (PER ACCIDENT) $ |__| UMBRELLALIAB | X | occur EACH OCCURRENCE $ 4,000,000 C | X | EXcess UAB CLAIMS-MADE BEO15820249 05/23/2013 | 05/23/2014 | accREeGaTE $ 4,000,000, veo |__| RETENTIONS $ WORKERS COMPENSATION Wo STATU- OTH. AND EMPLOYERS’ LIABILITY YI X | 1Ry LMits ER D | ANY PROPRIETOR/PARTNER/EXECUTIVE 0830-49584 12/01/2013 | 12/01/2014 | £1. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE] $ 1,000,000 If yes, describe under DESGRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | $ 1,000,000 E |Equipment Floater \QT6602D17535ATIL13 05/03/2013 | 05/03/2014 |Rented/lLeased 50,000 Job: Reroofing the Tourist Development Welcome Center DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION Okaloosa County Purchasing Department Joanne Kublik, Contracts and Lease Coordinator 602-C North Pearl Street Crestview, FL 32536 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 19 His./ ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Bid Bond CONTRACTOR: SURETY: (Name, keeal status and address) (Name, kal stains and principal place of business) Ameritech Enterprises, LLC The Guarantee Company of North America USA 108 Estes Place One Towne Square, Suite 1470 Squthfield Mi 48076 Panama City Beach, FL 32413 { Corporation This document-has important legal OWNER: ; consequences. Consultation with (Name, legat status and address) an attomey is encouraged with bose vale 3 respect to its: completion or - North Pearl St. modification. Crestview, FL 32536 Any singular reference to Contractor, Surety, Owner or . . . other party shall be considered BOND AMOUNT: Five Percent (5%) of Amount Bid plural where applicable. PROJECT: (Name, location or address, and Project number, if any) Project Number, if any: Reroofing of the Okaloosa County Tourist Development Welcome Genter, 1540 Miracle Strip Parkway S.E. (US Highway 98), Fort Walton Beach, FL 32458 The Contractor and Surety are bound to the Owner in the amount set forth above, forthe payment of which the Contractor:and Surety bind themselves, their heits, executors, administrators, successors arid assigns, jomtly and severally, as provided herein. The conditions of this Bond are such that if the Owner accepts the bid-of the Contractor within the time specified in the bid documents, or within such time period as may be agreed to by the Owner and Contractor, and the Contractor either (1) enters into a.contract with the Owner in accordance with the tenis of such bid, and gives such bond or bonds as may be specified in the bidding-or Contract Documents, with a surety admutted in the jurisdiction of the Project and otherwise acceptable to the Owner, for the faithful performance of such Contract and for the prompt payment of labor and material furnished in the prosecution thereof; or (2) pays to the Owner the difference, not to exceed the amount of this Bond, between the amount specified in said bid and such larger amount for which the Owner may in good faith contract with another party to perform the work covered by said bid, then this obligation shall be null and void, otherwise to remain im full force and effect. The Surety hereby waives any notice of an agreement between. the Owner and Contractor to extend the time in which the Owner may accept the bid. Waiver of notice by the Surety shall not apply to any extension exceeding sixty (60) days in the aggregate beyond the tume for aéceptance of bids specified in the bid documents, and the Owner and Contractor shall obtain the Surety's consent for an extension beyond sixty. (60) days. If this Bond is issued in connéction with a subcontractor's bid to'a Contractor, the tenn Contractor in this Bond.shall be deemed to-be Subcontractor and the term Owner shall be deerned to be Contractor. When this Bond has been furnished to comply with.a statutory or other legal requirement in the location of the Project, any provision in this Bond conflicting with said statutory or legal requirement shall be deemed deleted herefrom and provisions conforming to such statutory or other legal requirement shall be deemed incorporated herem. When so furnished, the