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HomeMy WebLinkAbout2013-097 Contract - Brothers Custom Cabinets Contract for GOODS AND SERVICES Less than $25,000 CITY OF CONTRACTOR: Brothers Custom Cabinets and Furniture ASHLAND CONTACT: Carl Peugh 20 East Main Street Ashland, Oregon 97520 ADDRESS: 4619 Table Rock Road, Central Point, OR 97520 Telephone: 541/488-6002 Fax: 541/488-5311 TELEPHONE: (541) 664-5550 DATE AGREEMENT PREPARED: 04108/2013 FAX: (541) 665-0929 BEGINNING DATE: 04/08/2013 COMPLETION DATE: 06/30/2013 COMPENSATION: Time and materials not to exceed (NTE) $6,122 GOODS AND SERVICES TO BE PROVIDED: as per attached Exhibit C: Bid proposal dated April 4, 2013 for Custom front reception desk at Ashland Municipal Courthouse ADDITIONAL TERMS: NOW THEREFORE, pursuant to AMC 2.50.090 and after consideration of the mutual covenants contained herein the CITY AND CONTRACTOR AGREE as follows: 1. All Costs by Contractor: Contractor shall, provide all goods as specified above and shall at its own risk and expense, perform any work described above and, unless otherwise specified, furnish all labor, equipment and materials required for the proper performance of such work. 2. Qualified Work: Contractor has represented, and by entering into this contract now represents, that any personnel assigned to the work required under this contract are fully qualified to perform the work to which they will be assigned in a skilled and worker-like manner and, if required to be registered, licensed or bonded by the State of Oregon, are so registered, licensed and bonded. Contractor must also maintain a current City business license. 3. Completion Date: Contractor shall provide all goods in accordance with the standards and specifications, no later than the date indicated above and start performing the work under this contract by the beginning date indicated above and complete the work by the completion date indicated above. 4. Compensation: City shall pay Contractor for the specified goods and for any work performed, including costs and expenses, the sum specified above. Payments shall be made within 30 days of the date of the invoice. Should the contract be prematurely terminated, payments will be made for work completed and accepted to date of termination. Compensation under this contract, including all costs and expenses of Contractor, is limited to $25,000.00, unless a separate written contract is entered into by the City. 5. Ownership of Documents: All documents prepared by Contractor pursuant to this contract shall be the property of City. 6. Statutory Requirements: ORS 279B.220, 279B.225, 279B.230, 2796.235, ORS Chapter 244 and ORS 670.600 are made part of this contract. 7. Living Wage Requirements: If contractor is providing services under this contract and the amount of this contract is $19,494 or more, Contractor is required to comply with chapter 3.12 of the Ashland Municipal Code by paying a living wage, as defined in this chapter, to all employees performing work under this contract and to any subcontractor who performs 50% or more of the work under this contract. Contractor is also required to post the notice attached . hereto as Exhibit B predominantly in areas where it will be seen by all employees. 8. Indemnification: Contractor agrees to defend, indemnify and save City, its officers, employees and agents harmless from any and all losses, claims, actions, costs, expenses, judgments, subrogations, or other damages resulting from injury to any person (including injury resulting in death), or damage (including loss or destruction) to property, of whatsoever nature arising out of or incident to the performance of this contract by Contractor (including but not limited to, Contractor's employees, agents, and others designated by Contractor to perform work or services attendant to this contract). Contractor shall not be held responsible for any losses, expenses, claims, subrogations, actions, costs, judgments, or other damages, directly, solely, and proximately caused by the negligence of City. 9. Termination: a. Mutual Consent. This contract may be terminated at any time by mutual consent of both parties. b. City's Convenience. This contract may be terminated at any time by City upon 30 days' notice in writing and delivered by certified mail or in person. C. For Cause. City may terminate or modify this contract, in whole or in part, effective upon delivery of written notice to Contractor, or at such later date as may be established by City under any of the following conditions: i. If City funding from federal, state, count or other sources is not obtained and continued at levels Contract for Goods and Services Less than $25,000, Revised 06/30/2012, Page 1 of 5 sufficient to allow for the purchase of the indicated quantity of services; ii. If federal or state regulations or guidelines are modified, changed, or interpreted in such a way that the services are no longer allowable or appropriate for purchase,under this contract or are no longer eligible for the funding proposed for payments authorized by this contract; or iii. If any license or certificate required by law or regulation to be held by Contractor to provide the services required by this contract is for any reason denied, revoked, suspended, or not renewed. d. For Default or Breach. i. Either City or Contractor may terminate this contract in the event of a breach of the contract by the other. Prior to such termination the party seeking termination shall give to the other party written notice of the breach and intent to terminate. If the party committing the breach has not entirely cured the breach within 15 days of the date of the notice, or within such other period as the party giving the notice may authorize or require, then the contract may be terminated at any time thereafter by a written notice of termination by the parry giving notice. ii. Time is of the essence for Contractor's performance of each and every obligation and duty under this contract. City by written notice to Contractor of default or breach, may at any time terminate the whole or any part of this contract if Contractor fails to provide services called for by this contract within the time specified herein or in any extension thereof. iii. The rights and remedies of City provided in this subsection (d) are not exclusive and are in addition to any other rights and remedies provided by law or under this contract. e. Obligation/Liability of Parties. Termination or modification of this contract pursuant to subsections a, b, or c above shall be without prejudice to any obligations or liabilities of either party already accrued prior to such termination or modification. However, upon receiving a notice of termination (regardless whether such notice is given pursuant to subsections a, b, c or d of this section, Contractor shall immediately cease all activities under this contract, unless expressly directed otherwise by City in the notice of termination. Further, upon termination, Contractor shall deliver to City all contract documents, information, works-in-progress and other property that are or would be deliverables had the contract been completed. City shall pay Contractor for work performed prior to the termination date if such work was performed in accordance with the Contract. 10. Independent Contractor Status: Contractor is an independent Contractor and not an employee of the City. Contractor shall have the complete responsibility for the performance of this contract. 11. Non-discrimination Certification: The undersigned certifies that the undersigned Contractor has not discriminated against minority, women or emerging small businesses enterprises in obtaining any required subcontracts. Contractor further certifies that it shall not discriminate in the award of such subcontracts, if any. The Contractor understands and acknowledges that it may be disqualified from bidding on this contract, including but not limited to City discovery of a misrepresentation or sham regarding a subcontract or that the Bidder has violated any requirement of ORS 279A.110 or the administrative rules implementing the Statute. 12. Asbestos Abatement License: If required under ORS 468A.710, Contractor or Subcontractor shall possess an asbestos abatement license. 13. Assignment and Subcontracts: Contractor shall not assign this contract or subcontract any portion of the work without the written consent of City. Any attempted. assignment or subcontract without written consent of City shall be void. Contractor shall be fully responsible for the acts or omissions of any assigns or subcontractors and of all persons employed by them, and the approval by City of any assignment or subcontract shall not create any contractual relation between the assignee or subcontractor and City. 14. Use of Recyclable Products: Contractor shall use recyclable products to the maximum extent economically feasible in the performance of the contract work set forth in this document. 15. Default. The Contractor shall be in default of this agreement if Contractor: commits any material breach or default of any covenant, warranty, certification, or obligation it owes under the Contract; if it loses its QRF status pursuant to the QRF Rules or loses any license, certificate or certification that is required to perform the work or to qualify as a QRF if Contractor has qualified as a QRF for this agreement, institutes an action for relief in bankruptcy or has instituted against it an action for insolvency; makes a general assignment for the benefit of creditors; or ceases doing business on a regular basis of the type identified in its obligations under the Contract; or attempts to assign rights in, or delegate duties under, the Contract. 16. Insurance. Contractor shall at its own expense provide the following insurance: a. Worker's Compensation insurance in compliance with ORS 656.017, which requires subject employers to provide Oregon workers' compensation coverage for all their subject workers b. General Liability insurance with a combined single limit, or the equivalent, of not less than Enter one: $200,000, $500,000, $1,000,000, $2,000,000 or Not Applicable for each occurrence for Bodily Injury and Property Damage. It shall include contractual liability coverage for the indemnity provided under this contract. C. Automobile Liability insurance with a combined single limit, or the equivalent, of not less than Enter one: $200,000, $500,000, $1,000,000, or Not Applicable for each accident for Bodily Injury and Property Damage, including coverage for owned, hired or non-owned vehicles, as applicable. d. Notice of cancellation or change. There shall be no cancellation, material change, reduction of limits or intent not to renew the insurance coverage(s) without 30 days' written notice from the Contractor or its insurers to Contract for Goods and Services Less than $25,000, Revised 06/30/2012, Page 2 of 5 the City. e. Additional Insured/Certificates of Insurance. Contractor shall name The City of Ashland, Oregon, and its elected officials, officers and employees as Additional Insureds on any insurance policies required herein but only with respect to Contractor's services to be provided under this Contract. As evidence of the insurance coverages required by this Contract, the Contractor shall furnish acceptable insurance certificates prior to commencing work under this contract. The contractor's insurance is primary and non-contributory. The certificate will specify all of the parties who are Additional Insureds. Insuring companies or entities are subject to the City's acceptance. If requested, complete copies of insurance policies, trust agreements, etc. shall be provided to the City. The Contractor shall be financially responsible for all pertinent deductibles, self-insured retentions and/or self- insurance. 17. Governing Law; Jurisdiction; Venue: This contract shall be governed and construed in accordance with the laws of the State of Oregon without resort to any jurisdiction's conflict of laws, rules or doctrines. Any claim, action, suit or proceeding (collectively, "the claim") between the City (and/or any other or department of the State of Oregon) and the Contractor that arises from or relates to this contract shall be brought and conducted solely and exclusively within the Circuit Court of Jackson County for the State of Oregon. If, however, the claim must be brought in a federal forum, then it shall be brought and conducted solely and exclusively within the United States District Court for the District of Oregon filed in Jackson County, Oregon. Contractor, by the signature herein of its authorized representative, hereby consents to the in personam jurisdiction of said courts. In no event shall this section be construed as a waiver by City of any form of defense or immunity, based on the Eleventh Amendment to the United States Constitution, or otherwise, from any claim or from the jurisdiction. 18. THIS CONTRACT AND ATTACHED EXHIBITS CONSTITUTE THE ENTIRE AGREEMENT BETWEEN THE PARTIES. NO WAIVER, CONSENT, MODIFICATION OR CHANGE OF TERMS OF THIS CONTRACT SHALL BIND EITHER PARTY UNLESS IN WRITING AND SIGNED BY BOTH PARTIES. SUCH WAIVER, CONSENT, MODIFICATION OR CHANGE, IF MADE, SHALL BE EFFECTIVE ONLY IN THE SPECIFIC INSTANCE AND FOR THE SPECIFIC PURPOSE GIVEN. THERE ARE NO UNDERSTANDINGS, AGREEMENTS, OR REPRESENTATIONS, ORAL OR WRITTEN, NOT SPECIFIED HEREIN REGARDING THIS CONTRACT. CONTRACTOR, BY SIGNATURE OF ITS AUTHORIZED REPRESENTATIVE, HEREBY ACKNOWLEDGES THAT HE/SHE HAS READ THIS CONTRACT, UNDERSTANDS IT, AND AGREES TO BE BOUND BY ITS TERMS AND CONDITIONS. 19. Nonappropriations Clause. Funds Available and Authorized: City has sufficient funds currently available and authorized for expenditure to finance the costs of this contract within the City's fiscal year budget. Contractor understands and agrees that City's payment of amounts under this contract attributable to work performed after the last day of the current fiscal year is contingent on City appropriations, or other expenditure authority sufficient to allow City in the exercise of its reasonable administrative discretion, to continue to make payments under this contract. In the event City has insufficient appropriations, limitations or other expenditure authority, City may terminate this contract without penalty or liability to City, effective upon the delivery of written notice to Contractor, with no further liability to Contractor. 20. Prior Approval Required Provision. Approval by the City of Ashland Council or the Public Contracting Officer is required before any work may begin under this contract. 21. Certification. Contractor shall sign the certification attached hereto as Exhibit A and herein incorporated by reference. Contractor: 9 City of Ashland By ( ` ' r ` l- By t~ u~ a, Signature Department Hea W L 19P1136 µ ~C 1 t A r Q_ ~Ar Print Name Print Name ~Mf~er y~j2 /i3 Title Date W-9 One copy of a W-9 is to be submitted with / / the signed contract. Purchase Order No. ` Ar ROV D rSr 0 FORM Si lure Date Contract for Goods and Services Less than $25,000, Revised 06/30/2012, Page 3 of 5 EXHIBIT A CERTIFICATIONS/REPRESENTATIONS: Contractor, under penalty of perjury, certifies that (a) the number shown on the attached W-9 form is its correct taxpayer ID (or is waiting for the number to be issued to it and (b) Contractor is not subject to backup withholding because (i) it is exempt from backup withholding or (ii) it has not been notified by the Internal Revenue Service (IRS) that it is subject to backup withholding as a result of a failure to report all interest or dividends, or (iii) the IRS has notified it that it is no longer subject to backup withholding. Contractor further represents and warrants to City that (a) it has the power and authority to enter into and perform the work, (b) the Contract, when executed and delivered, shall be a valid and binding obligation of Contractor enforceable in accordance with its terms, (c) the work under the Contract shall be performed in accordance with the highest professional standards, and (d) Contractor is qualified, professionally competent and duly licensed to perform the work. Contractor also certifies under penalty of perjury that its business is not in violation of any Oregon tax laws, and it is a corporation authorized to act on behalf of the entity designated above and authorized to do business in Oregon or is an independent Contractor as defined in the contract documents, and has checked four or more of the following criteria: (1) 1 carry out the labor or services at a location separate from my residence or is in a specific portion of my residence, set aside as the location of the business. (2) Commercial advertising or business cards or a trade association membership are purchased for the business. n (3) Telephone listing is used for the business separate from the personal residence listing. (4) Labor or services are performed only pursuant to written contracts. (5) Labor or services are performed for two or more different persons within a period of one year. (6) 1 assume financial responsibility for defective workmanship or for service not provided as evidenced by the ownership of performance bonds, warranties, errors and omission insurance or liability insurance relating to the labor or services to be provided. ~ ?~-1213 Contractor (Date) Contract for Goods and Services Less than $25,000, Revised 06/30/2012, Page 4 of 5 ' CXN\g\T L CUSTOM CABINETS AND FURNITURE 541-664-5550 Fax: 665-0929 Mailing Address: 4619 Table Rock Road Central Point, OR 97502 April 4, 2013 Customer: City of Ashland Job site: Ashland Municipal Court House 1175 East Main Street Ashland OR 97520 Project: Custom front reception desk. We will provide the materials and labor required to fabricate and install the above mentioned cabinets. The cabinet style will be our European (faceframe less) look. The exterior of the cabinets will be covered with any standard Wilsonart laminate color (wood grain). The door style will be our standard slab door with a 'the same laminate face. The drawer fronts will be of the same design as the doors. The interior of the cabinets will be constructed out of white melamine with adjustable shelving throughout. Some of the features of the cabinets are: frame around glass panel, 42" height of desk, spot for trash can, spot for cutting board, open shelving, two cash drawers w/locks, and a stainless scoop under the glass wall. We will also provide a large piece of 1/2" tempered glass above the desk, there will be two 4" round cutouts for the speakers (provided by customer). Our standard concealed European hinges and heavy duty, full extension drawer slides will be used. We will supply and install our standard 3" stainless wire pull on the drawers. We will also supply and install a countertop on the desk unit. Any standard Wilsonart laminate color may be selected. The front edge detail of the countertop will be square. This bid is valid for 45 days y -,z-r3 We will provide all of the above mentioned services for a sum of $6,122. (this price is for a non- Davis-Bacon Act project) (5% more for credit cards). A down payment of $3,061 will be made at the time of signing and the balance is due upon completion of the project and will become overdue after 10 days. Acceptance of proposal: The above price and specifications are satisfactory and are hereby accepted. Brothers Custom Cabinets is now authorized to do the work as specified. Payment will be made as outlined above. Customer signature: Date: . s www.salf.com OREGON WORKERS COMPENSATION + SaIF CERTIFICATE OF INSURANCE ,corporatlon The policy of insurance listed below has been Issued to the Insured named below for the policy period Indicated. The Insurance afforded by the policy described herein is subject to all the terms, exclusions and conditions of such policy. POLICY NO. POLICY PERIOD ISSUE DATE 964175 04/01/2013 to 04/01/2014 04/09/2013 INSURED: BROKER OF RECORD:. BROTHERS CUSTOM CABINETS AND FURNITURE LLC BROTHERS CUSTOM CABINET DOORS 4619 TABLE ROCK RD CENTRAL POINT, OR 97502-3151 _ LIMITS OF LIABILITY: Bodily Injury by Accident $500,000 each accident Bodily Injury by Disease $500,000 each employee Body Injury by Disease $500,000 policy limit DESCRIPTION OF OPERATIONS/LOCATIONS/SPECIAL ITEMS: IMPORTANT: The coverage described above is in effect as of the Issue date of this certificate. It Is subject to change at any time in the future. This certificate Is issued as a matter of Information only and confers no rights to the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policies above-This certificate does not constitute a contract between the Issuing Insurer, authorized representative or producer and the certificate holder. AUTHORIZED REPRESENTATIVE 3r6?C!?>. `P R President and CEO 400 High Street SE Salem, OR 97312 P: 800.285.8525 F: 503.373.8020 Pollcy_Batch Celt1rcate0f[nwrance OP ID: JG ACO/?O' DATE (MM1OnIYYYY) CERTIFICATE OF LIABILITY INSURANCE 09107112 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND. THE CERTIFICATE-HOLDER. IMPORTANT: If the Certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER .541.479-2667 CONTACT NAME: Redwoods Leavitt Ins. Agency PHONE FAX CA Lic #OC66788 (Ac. No. F X): : YUC, No): 122 NE Beacon Dr. - E-MAIL Grants Pass, OR 97526 ADDRESS: Samantha Fedosky ToMERID$:BROTH-3 _ INSURER(S) AFFORDING COVERAGE NAIC$ INSURED Brothers Custom Cabinets INSURER A:Liberty Northwest Ins. Or p. 41939 & Furniture, LLC INSURER B: 4619 Table Rock Rd INSURERC: Central Point, OR 97502 INSURER D: INSURER E : INSURER PC COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: -THIS-IS-TO CERTIFY THAT SHE POLICIES-OF-INSURANCE USTED_BELOW HAVE.BEENJSSUED 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 POLICY NUMBER MID EFF M POLICY EXP LTR YY LIMITS GENERAL UABILITY EACH OCCURRENCE $ 1,000,00( A X COMMERCIAL GENERAL LIABILITY BKS54909216 09101112 09101113 PREMISES Ea etcMreecx $ 60,00( CLAIMS-MADE OCCUR MED EXP(Any One person) S, 5,00( PERSONAL&ADV INJURY $ 1,000,00( GENERAL AGGREGATE $ 2,000,00( GENL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO $ 2,000,00( POLICY PRO:' LOG S 1-1 'F JFQ.T AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT ANY AUTO - BODILY INJURY(Perperson) $ ALL OWNED AUTOS' BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accdent) $ NON-OWNED AUTOS S $ UMBRELLA LUUJ OCCUR EACH OCCURRENCE S EXCESS LIIB CL UMS# E AGGREGATE $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUDVE ❑ NIA E.L. EACH ACCIDENT $ OFFICERAtEMBER EXCLUDED? (Mandatory in NH) EL DISEASE - EA EMPLOYE $ Nyyeess IPTIOe CRIPTON OF F OPERATIONS below EL DISEASE - PODGY LIMB $ DES DESCMPTKIN OF OPERATIONS I LOCATIONS I VEHICLES (ADacb ACORD 101, AddKional Remarks Scha % If more space Is mcPd ed) Th is certificate is issued as proof of coverage. CERTIFICATE HOLDER - CANCELLATION - SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Insured: copy ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORUED REPRESENTATIVE Samantha Fedosky X ©1988-2009 ACORD CORPORATION. All rahts reserved. °t CERTIFICATE OF INSURANCE SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE CANCELED OR OTHERWISE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM THE DATE WRITTEN. THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED BELOW. This certifies that: ® STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois ❑ STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois ❑ STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas, Texas ❑ STATE FARM INDEMNITY COMPANY of Bloomington, Illinois, or ❑ STATE FARM GUARANTY INSURANCE COMPANY of Bloomington, Illinois has coverage in force for the following Named Insured as shown below: NAMED INSURED: BROTHERS CUSTOM COUNTER TOPS ADDRESS OF NAMED INSURED: 4619 TABLE ROCK RD CENTRAL POINT OR 97502-3151 POLICY NUMBER 134 6776-D21-37 134 6773-D21-37 134 6774-D21-37 150 8150-E02-37 EFFECTIVE DATE OF POLICY 10/21/12-04/21/13 10/21/12-04/21/13 10/21/12-04/21/13 11/02/12-05/02/13 DESCRIPTION OF 99 FORDE150 Van 95 FORD CLUBNAGON 97 MERCURY SABLE 1994 FORD ESCORT VEHICLE (Including VIN) 1FTRE1429XHC31551 1FBJS31H9SHB18366 1MELM55U3VA612476 3FARP15J1RR102288 LIABILITY COVERAGE ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO LIMITS OF LIABILITY a. Bodily Injury Each Person 100000 100000 100000 100000 Each Accident 300000 300000 300000 300000 b. Property Damage Each Accident 100000 100000 100000 100000 c. Bodily Injury & Property Damage Single Limit Each Accident PHYSICAL DAMAGE COVERAGES ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO a. Comprehensive $ Deductible $ Deductible $ - Deductible $ Deductible ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO b. Collision $ Deductible $ Deductible $ Deductible $ Deductible EMPLOYERS NON-OWNED CAR LIABILITY COVERAGE ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO HIRED COVERAGELIABILITY ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES - ❑ NO ❑ YES ❑ NO FLEET-COVERAGE FOR ALL ORHCLLICENSED ❑ YES MOTv IicLES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO Agent Staff 37-2165 11/13/2012 Signature of Authofized Representative Title Agent's Code Number Date Name and Address of Certificate Holder Name and Address of Agent Mark McUne State Farm 341 E Pine St Central Point, OR 97502 541-664-1252 INTERNAL STATE FARM USE ONLY: ❑ Request permanent Certificate of Insurance for liability coverage. 122429.3 Rev. 07-26-2005 ❑ Request Certificate Holder to be added as an Additional Insured. Page 1 / 1 PW. CITY OF CITY RECORDER 11 ASHLAND DATE PO NUMBER 20 E MAIN ST. 4/22/2013 11555 ASHLAND, OR 97520 (541) 488-5300 VENDOR: 017710 SHIP To: Ashland Public Works BROTHERS CUSTOM CABINETS (541) 488-5587 4619 TABLE ROCK ROAD 51 WINBURN WAY CENTRAL POINT, OR 97502 ASHLAND, OR 97520 FOB Point: Req. No.: Terms: Net Dept.: Req. Del. Date: Contact: Rob Morris Special Inst: Confirming? NO Ouariti:;UniG'e Descrip tion Unit Price 'Ext. Price Materials and labor to fabricate and 6,122.00 install new service counter and window at Ashland Municipal Court. Contract for Goods & Services Beqinninq date: 04/08/2013 Completion date: 06/30/2013 Insurance required/On file I I l SUBTOTAL 6122.00 BILL TO: Account Payable TAX 0.00 20 EAST MAIN ST FREIGHT 0.00 541-552-2010 TOTAL 6,122.00 ASHLAND, OR 97520 Account Number•> .C , Project Number Amount AccountNumliei" Project Nurriber_ E 410.08.24.00.70420 E 000345.999 6,122.00 1 Aut rized Signature VENDOR COPY FORM #3 CITY OF A request for a Purchase Order ASHLAND REQUISITION Date of request: 4/15/13 Required date for delivery: ASAP Vendor Name Brothers Custom Cabinets and Furniture Address, City, State, Zip 4619 Table Rock Road, Central Point, OR 97520 Contact Name & Telephone Number Cad Peugh (541) 664-5550 Fax Number (541) 665-0929 SOURCING METHOD ❑ Exempt from Competitive Bidding ❑ Emergency ❑ Reason for exemption: ❑ Invitation to Bid (Copies on file) ❑ Form #13, Written findings and Authorization ❑ AMC 2.50 Date approved by Council: ❑ Written quote or proposal attached ❑ Written quote or proposal attached ❑ Small Procurement Cooperative Procurement Less than $5,000 ❑ Request for Proposal (Copies on file) ❑ State of Oregon ❑ Direct Award Date approved by Council: Contract # ❑ Verbal/Written quote(s) or proposal(s) ❑ State of Washington Intermediate Procurement ❑ Sole Source Contract It GOODS & SERVICES ❑ Applicable Form (#5,6, 7 or 8) ❑ Other government agency contract $5.000 to $100,000 ❑ Written quote or proposal attached Agency ® (3) Written quotes attached ❑ Form #4, Personal Services $5K to $75K Contract # PERSONAL SERVICES ❑ Special Procurement Intergovernmental Agreement $5,000 to $75.000 ❑ Form #9, Request for Approval ❑ Agency ❑ Less than $35,000, by direct appointment ❑ Written quote or proposal attached Date original contract approved by Council: ❑ (3) Written proposals attached Date approved by Council: (Date) ❑ Form #4, Personal Services $5K to $75K Valid until: Dale Description of SERVICES Total Cost Materials and labor to fabricate and install new service counter and window at Ashland Municipal Courthouse. $6,122:00 Item # Quantity Unit Description of MATERIALS Unit Price Total Cost TOTAL COST ® Per attached quotelproposal $6;12100, Project Number 000345.999 Account Number 410.08.24.00.704200 Account Number Account Number 'Expenditure must be charged to the appropriate account numbers for the financials to accurately reflect the actual expenditures. IT Director in collaboration with department to approve all hardware and software purchases: IT Director Date Support -Yes/No By signing this requisition farm, I certify that the City's public contracting requirements have been satisfied. Employee Signature: - ' Department Head Signature: N'ALk),A ,SZ~ 1 ~f~ (Equal to or greater than $ , 00) City Administrator: (Equal toorgr terthan$25,000) Funds appropriated for current fiscal year. 9 I NO ,l9d~ f</ /JIZoL 3 i Finance Director- (Equal to orgreater tnan $5,000)/ Date Comments: Q/~u~*'A-, t.•.. Fa.J..~ (1 - C~,~.eti.f• d.,,,e.~Qy(,•C.~ I Form #3 - Requisifion .