Okaloosa County BOCC — December 31, 2012 — APAC Final Payment — reading text

EXHIBIT H CONTRACT CLOSE-OUT CHECKLIST (To Be Prepared by the Contracts & Leases Coordinator) DATE: nlele TO: Contracts & Grants Manager, Finance Department Contracts & Grants Division SUBJECT: Contract No. C/2-/4%9-AW MANAGING DEPARTMENT: _/Ud/t. bdo ks CONTRACTOR'S NAME: ALAC Mid-South , Ine. PROJECTTITLE: = Sy/vania Heiphts AO3372 The attached has met the final payment contract requirement in subject contract. Yes No 1. Final Invoice ay O 2. Completed Contract/Lease Payment Approval Form a oO 3, Close-Out Documents Yes No N/A a. Signed Release of Lien ap O O b. Proof of Completion Advertisement ea oO O c. Certificate of Insurance ag O O d. Consent of Surety to Final Payment “Pg im O e. Proof of Performance/Payment Bond ia O O Continuation 12 Months Following Final Payment Yes No a 4. Agenda Request 5: Remarks LAL f- wal Contracts and Lease Coordinator DATE EXHIBIT I CONTRACT/LEASE PAYMENT APPROVAL FORM COMPLETE AND FORWARD TO THE NEXT APPROVING DEPARTMENT COMPLETED BY DEPARTMENT DATE: 11/5/2012 VENDOR NAME: APAC Mid-South Inc. VENDOR #: COUNTY AGREEMENT # (Contact Contract/Lease Coordinator, if unknown) PW 33-12 Sylvania Heights TASK COUNTY/FEMA VENDOR ORDER # PROJECT # BUDGET INVOICE # (if applicable) (if applicable) DEPARTMENT # ACCOUNT # AMOUNT 002 $28,774.22, TOTAL $28,774.22 APPROVED FOR PAYMENT (please initial, as applicable and date): ENGINEER/ARCHITECT/PROJECT MANAGER caer a DATE: 5-Nov-12 COUNTY PROJECT a DATE: _ Wtofzore 1G, DEPARTMENT HEAD: DATE: “ADA FINAL PAYMENT: YES = O CONTRACTS & GRANTS DATE: CONTRACTS & GRANTS MANAGER: DATE: COUNTY ADMINISTRATOR APPROVAL : (Only Payments $25,001 - $50,000) FINAL PAYMENT APPROVAL (if needed): PURCHASING DIRECTOR: (Only Contracts < = $25,000) COUNTY ADMINISTRATOR : (Only Contracts between $25,001 to $50,000) Contracts Over $50,000 — BCC Approved COMPLETED BY FINANCE - ACCOUNTS PAYABLE ONLY FISCAL YR: DATE RECEIVED: Form revised 1-20-2011 APPLICATION FOR PAYMENT PERIODIC ESTIMATE NO.: an PROJECT NO.: PW. 33-12, WORK PERIOD BEGIN DATE: Det. |, 261 enn vate: _Oet. 10, 212 ROAD NAME: Sy Vania. Heights ORIGINAL CONTRACT SUM $_315, 152.% NET CHANGE BY CHANGE ORDERS $_Z£ 14, 08 |. 90> CONTRACT SUM TO DATE $_24], bb. 10 ANALYSIS OF WORK PERFORMED 1. Value of original contract work performed previously: $ atl 4f SOD, 93 2. Work performed this month: $ ) 1 BLY LT 3y Total value of work performed to date: $ T6./0 4. Less: Amount retained at five (5%) percent: $ oO. 66 5. Net amount earned on contract work to date: $ b./0 6. Less: Amount of previous payment: $ aA ie, g qs. 88 7, AMOUNT DUE THIS PAYMENT $ AS Z Zt. ey) a 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 Periodic Estimate are correct; that all work has been performed and/or materials su PA? full accordance with the terms and conditions of the contract between Okaloosa County and yi CG , and that the items for which payment is requested have been paid and that there are no vendors-mechanics, or other liens or conditional sales contracts which should be satisfied or ‘discharged before such payment is made. APAG Mid-Smucbh, Tne, By: watt x as Hobe. (Firm Name) (Name ‘of Authorized Officer & Title) CERTIFICATION OF ENGINEER I certify that I have verified this Periodic Estimate and that to the best of my knowledge and belief, it is a true and correct statement of work performed and materials supplied by the Contractor; and that the Contractor's ede we xs account and the amount due him is correct. —Grne Chal be Lease” Date: November E MMs Project Manager UY C C7 ° Sylvania Heights Resurfacing App. For Payment MI ee vLL'sz $ qunowy ad10Au] So’S0z‘ LL $ aBeurejay eseajoy ZV69S‘ZL $ PeWOpeg YOM LL69S°ZL $ [YUOIN Sy} PeULOLEd YOM 00'rre'2 $ 00°21 $ dt Z8L ISL SUUM ve ‘PIS ‘ONSe|doueYL 00°90'S| $ 00°r$ AS 6SZE ooge pos‘pn] soueuopeg : $ 00°e$ AS 008 HN] soueUOpeg * $ 00'S Les va s ysnipy xoq eajen 2 $ 00'SLe$ Wa Se ysnipy ajoyueyy (00'0z6'e) $ | 00'0z¢"e$- $7 L L SUO} 000z JO %RE JOIORY Aeg aysoduioD (€9°0) $ 00'es$ NL L0‘0- OZ0¢ yeudsy eaegiedns 00°000'2 $ 00'0r$ AO os ost uoneaeoxy Jejnboy * $ | 00°000'¢$ $1 L Buiqqnidy pue buiuseala z $ os'e$ 41 000g JoLueg yUuaWIpas - $ 00'8$ AS 002 [O1U0D UOISOI pajjo1/SbulaA0D [elOWY 00°08 $ | 00°008'E$ $1 (xe) L oes] JO souBUalUIEL] 00°0Ee'L $ | 00°00E'21$ ial xe) L 1SO09 GSQNSLxX3 | 390ldd LINN | LINN | SLVIWILSS | ALLLNVNO SIHL XVIAl Buleynsay syy6ioy eiuealAs CONTRACTOR'S RELEASE OF LIENS STATE OF: _t lorida COUNTY OF: _FScamloia Before me, the undersigned Notary Public in and for the said County and State personally appeared Lysa_ S. Habec , representing the Contractor, . PAC Mid-Seith Tne. who being duly sworn according to law deposes and says that all labor, materials, and outstanding claims and indebtedness of whatever nature arising out of the performance of the Contract with OKALOOSA COUNTY BOARD OF COUNTY COMMISSIONERS the Owner, for Sy\anic. Ye aris , Contract No. , have been paid in full and that for the final payme in the amount of DU L(A1DAd , the Contractor releases and discharges the Owner and- his authorized ‘representatives from any liens or claims of any nature because of or arising from this contract and/or its performance, which it has had, has or May have in the future. oy, Mica SS. Heabren MINDY &. SMALLWOOD Sworn to and subscribed before me this Ic hy %, NOTARY PUBL STATE OF FLORIDA ad day of November, 2012 & HAGE Commit EEO17848 Mandy & Sonodttueod See Expires 8/16/2014 (Notary Public) My Commission Expires: LAle -AdIY Sylvania Heights Resurfacing Release of Liens Ol Page 4 of 1 10/16/2012 10:48:39 Ad Number : 34530734 Ad Key : Order Number: 34228561 Salesperson : 25 - Maureen Wiltse PO Number : Publication . Northwest Florida Daily News Customer : 33857108 APAC Mid-South Sectlon : Classified 2006 Contact y Mindy Smallwood Sub Soctlon 4 Classified 2006 Address1 : 4375 McCoy Drive Category : 4100 Legal Advertising Address2 ; Dates Run : 10/18/2012-1 1/08/2012 Clty St Zip ; Pensacola FL 32503 Days : 4 Phone 5 (850) 462-1337 Size : 1x 3.60, 34 lines Fax : (850) 434-8971 Words : 83 Credit Card : Sarseaeteseng {91 Ad Rate : Legals Rate Printed By : Maureen Wiltse Ad Price : 221.24 Entered By 3 Maureen Wiltse Amount Pald =: 221.24 AmountDue —: -0.00 Keywords 3 3239 Sylvania Heights Notes F Advertisement of Completion Zones F Legal 3239 AOVERTISEMENT OF COMPLETION APAC Mid-South, Inc. 4375 McCoy Drive, Pensacola, FL 32503 gives notice of compte thon of Syivania Heights Resurfacing Improve- ments and sets Novom- bor 6, 2012 as tho dato of final seltement All persons and = firms should file all claims for payment ta the below address prior to the setiiement dale: Okaloosa County (Owner) ATTN: Contracts and Leases Coordinator 602-C North Peart Street Crestview FL 32536 By: Lisa S. Haber Project Manager Legal 3239 Oct. 18, 25, Nov. 4, 8, 2012 MinSOUTH A SEMING. — 4375 wcCoy Drive Pensacola, FL 325034 (850) 433-3001 November 9, 2012 Mr. James R. VanSteenburg, P.E. Senior Project Engineer HDR Construction Control Corporation 4673 Highway 20 East Niceville, Florida 32578 RE: County: Okaloosa Project Description: Sylvania Heights Resurfacing Improvements Letter Description: Letter of Acceptance Dear Mr. VanSteenburg, Please find attached a copy of the current certificate of insurance for the above referenced project. APAC Mid-South, Inc. agrees to maintain said certificate of insurance for a period of two years from the date of acceptance which is October 9, 2012. Sincerely, Ya 2 Lisa S. Haber Project Manager APAC Mid-South, Inc. o Oldcastle’ Materials Certificate of Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER. THIS CERTIFICATE IS NOT AN INSURANCE POLICY AND DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED BELOW. POLICY LIMITS ARE NO LESS THAN THOSE LISTED, ALTHOUGH POLICIES MAY INCLUDE ADDITIONAL SUBLIMIT/LIMITS NOT LISTED BELOW. This is to Certify that APAC Mid South Inc 500 Riverhills Park Suite 590 e Birmingham AL 35242 ADDRESS. Liberty Mutual. OF INSURED INSURANCE is, at the issue date of this certificate, insured by the Company under the policy(ies) listed below. The insurance afforded by the listed policy(ies) is subject to all their terms, exclusions and Conditions and is not altered by any requirement, term or condition of any contract or other document with respect to which this certificate may be issued. EXP DATE CONTINUOUS TYPE OF POLICY Oo : POLICY NUMBER LIMIT OF LIABILITY EXTENDED [1 pouicy term WORKERS 9/1/2013 WAT-C8D-004095-022 Bae OCLOWING States, | EMPLOYERS LIABILITY ALL STATES EXCLUDING COMFENSSTION WG7-C81-004095-012 | MONOPOLISTICS STATES AND [Polly Hur by boric NY Each Accident! wi Bodily Injury By Disease $1,000,000 poticy tim! Bodily Injury By Disease $1,000,000 Fach Person COMMERCIAL General Aggregate GENERAL LIABILITY 9/1/2013 TB2-C81-004095-112 $2,000,000 MW occurrence Products / Completed Operations Aggregate $2,000,000 O1 crams Mabe Each Occurrence $2,000,000 RETRO DATE Personal & Advertising Injury $2,000,000 Per Person / Organization (Other Other FIRE DAMAGE $100,000 PER PROJECT AGGREGATE Medical Exp-$5.0! AUTOMOBILE Each ee Limit LIABILITY 9/1/2013 AS2-C81-004095-122 $2,000,000 B1. And P.D. Combined aw Each Person OWNED M1 noy-ownep Each Accident or Occurrence M1 rireo Each Accident or Occurrence OTHER Auto: Comp Ded $10,000/Coll Ded $10,000 EVIDENCE OF COVERAGE ADDITIONAL COMMENTS Okaloosa County, its respective agents, consultants, servants and employees of each and all other interests are listed as acoltona! ineured. Coverage is primary and non- “contributory. Includes a waiver of subrogation in favor of the additional insure * If the certificate expiration date is continuous or extended term, you will be notified if coverage is terminated or reduced before the certificate expiration date. NOTICE OF CANCELLATION: (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS ENTERED BELOW.) — BEFORE THE STATED EXPIRATION DATE THE COMPANY WILL NOT CANCEL OR REDUCE THE Liberty Mutual INSURANCE AFFORDED UNDER THE ABOVE POLICIES UNTIL ATLEAST 30 DAYS NOTICE Insurance Group OF SUCH CANCELLATION HAS BEEN MAILED TO: [ Okaloosa County ~] Yi Walyentis’ 602-C North Pearl Street Judith Balazentis bs Crestview FL 32536 Pittsburgh / 0387 AUTHORIZED REPRESENTATIVE Es 12 Federal Street, Ste. 310 2 Pittsburgh PA 15212-5706 412-231-1331 11/27/2012 OFFICE PHONE DATE ISSUED This certificate is executed by LIBERTY MUTUAL INSURANCE GROUP as respects such insurance as is afforded by those Companies NM 772 07-10 CERT NO.: 14780374 CLIENT CODE: LM 44 Christopher Herring - NE 11/27/2012 7:45:02 AM Page 1 of 1 BOND NO. 8229-91-83 Rule 14-24, FAC. STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 700-050-241 CONTRACTOR'S AFFIDAVIT AND SURETY CONSENT adnan (FORM 21-A) STATE OF FLORIDA countyor —fSCambia Before me, the undersigned Notary Public, personally appeared Tun sto\\ QB. Pe WN TV. to me well known er-who-has-produced KRY“ LLY LY. as identification, (Type of Identification) who being first duly sworn, deposes and says that he/she is: Nice Pres ident (Title of duly authorized person) of _ APAC MID-SOUTH, INC. a CORPORATION i (Contracting entity) (Type of entity) the Contractor on Financial Project |.D. * NIA , Road No. N/A in OKALOOSA County, Florida under Contract No. REB# PW 33-12 ; OLAS Count ; Dot with the State-of Florida- Department of Transportation-dated the i —_ day of duly . BOA; and that the Affiant based on his/her personal knowledge says that: 1, Said contract has been complied with in every particular by the Contractor and that all parts of the work have been approved by the District Director of Operations of the State of Florida Department of Transportation. 2. The Contractor has not offered or made