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HomeMy WebLinkAbout2015-330 Contract - Accurate Plumbing Solutions Contract for GOODS AND SERVICES Less than $25,000 ASN4 y '1~ CONTRACTOR: Accurate Plumbing Solutions, Inc. CONTACT: Greg Kuitert ADDRESS: 711 Medford Center PMB 211, Medford, OR 97504 340 S. Pioneer Street Ashland, Oregon 97520 TEL: 541-773-3035 FAX: 541-773-3980 Telephone: 541/488-5340 Fax: 541/488-5314 EMAIL: qpsincplumb mail. com DATE AGREEMENT PREPARED: 10/14/15 BEGINNING DATE: 10/26/15 COMPLETION DATE: 11/13/15 COMPENSATION: $710.00 GOODS AND SERVICES TO BE PROVIDED: Lower the existing side urinal to 17" off the floor. Includes labor and materials to lower the waste and water lines, reset the existing urinal (non-ADA) and flush the valve. Install cover over hole in tile at old water stub out. ADDITIONAL TERMS: In the event of conflicts or discrepancies among the contract documents, the City of Ashland Contract for Goods and Services will be primary and take precedence, and any exhibits or ancillary contracts or agreements having redundant or contrary provisions will be subordinate to and interpreted in a manner that will not conflict with the said primary City of Ashland Contract. 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, 2796.230, 27913.235, 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 $20,142.20 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 an time b mutual consent of both parties. Contract for Goods and Services Less than $25,000, Revised 07/08/2014, Page 1 of 4 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, county or other sources is not obtained and continued at levels 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 party 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 Contract for Goods and Services Less than $25,000, Revised 07108/2014, Page 2 of 4 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 insurer(s) to 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. Contra City of Ashland q~ u By By Signature Department Head /aft ~/e ~Sa~S - M rch At'-f t d31 ~ 11 ~jrmt Name Print Name Title I Date W-9 One copy of a W-9 is to be submitted with the signed contract. Purchase Order No. Contract for Goods and Services Less than $25,000, Revised 07/08/2014, Page 3 of 4 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: V (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. _ (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. Contractor (Date) Contract for Goods and Services Less than $25,000, Revised 07/08/2014, Page 4 of 4 Accurate Plumbing Solutions, Inc. 711 Medford Center PMB 211 Medford, OR 97504 541-773-3035 Fax: 541-773-3980 CCB# 177438 Email: apsincplumb@gmail.com BID PROPOSAL DATE: October 8, 2015 CONTRACT AMOUNT: See Prices Below Payment schedule as follows: Balance due upon job completion. PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT: Owner: Ashland Parks and Recreation Address: YMCA City Park -Restroom Building Address: 340 S. Pioneer St. Off Tolman Creek behind YMCA City: Ashland, OR 97520 City: Ashland Phone: 541-488-5340 Phone: 541-552-2252 Bruce Dickens Email: bruce.dickens@ashland.or.us Thank you for allowing Accurate Plumbing Solutions the opportunity to bid this project for you. Our estimate is based on your plans and specifications. Please feel free to call and discuss this quote at any time. SCOPE OF WORK: Bid 1 $710.00 This bid proposal is for lowering the existing right side urinal to 17" off the floor. Includes labor and materials to lower the waste and water lines, reset the existing urinal (non-ADA) and flush valve. Install cover over hole in tile at old water stub out. Restrooms will need to be closed while work is in progress. Relocating sink next to urinal not included. Bid 2 $970.00 Provide and install new wall hung urinal and flush valve. Note: Bid based on info provided by Parks and Rec department as to access to piping and piping materials. Any additional work due to unseen layout of piping will be at additional cost. *Note: A 3% charge will be added to all credit card payments over $300.00. Delinquent accounts will be charged a minimum of $25.00 or 3% per month on all past due invoices. All material is guaranteed to be a specified. Any alteration or deviation from above specifications involving additional extra costs will be executed only upon additional written orders and will become an additional extra on the project. All agreements are contingent upon accidents or delays beyond our control. Liability Disclaimer: APS, Inc. is not responsible for any unmarked utilities, irrigation, water, private power, and other. Repairs will be done at the owner's expense at time and material costs. Reasonable access to be provided for equipment unless discussed prior to job. Extra cost to complete job due to verbal changes, adverse weather, ground, or rock conditions will be billed out at time and material costs. Page 1 of 2 The prices quoted above are subject to change after 90 days of this proposal. ACCEPTANCE OF PROPOSAL The above prices, specifications, and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Signature Date of Acceptance Page 2 of 2 FromANSURANCE MARKETPLACE 10/115/201S 14:SS #746 P.006/006 ACCUR-2 OP ID: DR CERTIFICATE OF LIABILITY INSURANCE OATE(MMfDDIYYYY) 10116!2015 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 Phone; 541-779-0177 NAME: Insurance Marketplace, Inc. - 1998 Skypark Dr Suite 100 Fax: FAX 772$235 aHo N_Eri1 _ uc No Medford, OR 97604 E-MAIL _ Insurance Marketplace InC. ADDRE33: INSURER(S) AFFORDING COVERAGE NAIC p - INSURERA:Allled Insurance Group - _ _ , 26093 INSURED Accurate Plumbing Solutions, INSURER B: Inc. dba: Barnes Plumbing - - 711 Medford Center #211 rNSURER c : Medford, OR 97504 INSURER D_ INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS 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 IAD LISUBTiT T"`POLICY EFF 25CT Y P _ . . - - LTR TYPE OF INSURANCE I POLICY NUMBER M/D YYY MM/DDiYYVY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,D00,0O DAMA E T A I X COMMERCIALGENERALLIABILITY X `ACP7525855025 10/02!2015 10!02!2016 pREMISESSEaoccurrence) $ 100,00 1 CLAIMS-MADE L ^j OCCUR MED_EXP (Any one persor) 10.00 PERSONAL & ADV INJURY $ 1 ,000,00 GENERAL AGGREGATE $ __T 2,001),00 GEN'L AGGREGATE LIMIT APPLIES PER; PROD...TS - COMP/OP AGG $ 2,000.00 PRO- .._---_UC_. $ POLICY LOC f ALI OU091LE LIABILITY COMBINED SINGLE LIMIT Ea accidenlL__ ANY AUTO - BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON-OWNED PROPER?Y DAMAGE' MIRED AUTOS _ AUTUS Peraccidw I f ! i $ UMBRELLA LIAB OCCUR I EACH OCCURRENCE_ $ - EXCESS LIAB I CLAIM_S_-MADE AGGREGATE S _ DED RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY YIN TORY LIMIT R ANY PROPRIETORIPARTNER/EXECUTIVE ❑ E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA - (Mandatory in NH) I E,L. DISEASE - EA EMPLOYEE $ yes, describe untler DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY I IMIT ; S i I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, AddlUonal Remarks Schedule, Ir more space is rectulredl additional insured CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CI of Ashland, Park and THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN tY ACCORDANCE WITH THE POLICY PROVISIONS. Recreation Commission 340 S Pioneer St AUTHORIZED REPRESENTATIVE Ashland, OR 97520 Insurance Marketplace Inc. ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD t.15.2015 05:00 AM Robert Pinnell State Farm 541 826 6333 PAGE. 1/ 1 DATE t(M1NOaYYYY) AALLL/// CERTIFICATE OF LIABILITY INSURANCE 10/16/2015 THIS CERTIFICATE 18 138UED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MOLDER. 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: 11 the eertificste holder is an ADDITIONAL I LIED, the pollay(les) must be endorsed. If SUBROGATION 18 WAIVED, subject to the terms and conditions of the pulley, certain policies may require an endorsement A statement on this certificate doss not confer rights to the certificate holder In lieu of such endorsemen s . PRODUCER June Reece Robert Plnnell jT.61 b28 8333 541 26-5933 StateFarrn 10558 Highway 62, Suite C -AL Eagle Point OR 97524 . 1NSURR s AFFOROINO COVpRAOe NAIL _ - ►NSURERA:Stst4 Farm Mutual AutomoIMe Imsuranop Company 28178 INSURED Accurate Plumbing Solutions, Inc INSURERS: 711 Medford Center # 211 INSURER C: -1 - M Medford, OR 97504 INSURER D: INSURER E : COVERAGES CERTIFICATE NUMBER; REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE IN6URED 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. TYPE OF INSURANCE NUMBER LIMITS _jmma COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE OCCUR T1NI TCIRENT50 ~1d16 64EA9sou11amw..._...... „MEOEXP(Any one person) $ PkR§RNAL & ADV INJURY $ M` GdN'L AOOREOATE LIMIT APPLIES PER; GENERAL AOOREOAT@ 8 _ POLICY ❑ P~~T F-1 LOC PRODUCTS-COMP/OPAGG $ OTHER: E A AUTOMOBILE LIAawTY !Q. Q!]tE---- LIM IT ............._....5... , ANY AUTO 1501049 E14 37 0811412015 0511412019 BODILY INJURY (Per pereon) $ 11000,000 ALL OWNED SCHEDULED - AUTOS x AUTOS 2413 6629 FOa 87 0810312015 12/09/2014 BODILY INJURY (Per accident) $ 1,000,000 X HIREDAUTOS K AUT08E0 1,000,000 134 0303 D04 37 10/04/2015 04IU2016 $ UMDRELLA LU1B OCCUR EAgH OCCURRENCE: $ (Coss LIAO ClAIM8-MAO129 AGGREGATE $ D RETEN I N _ WORKBRG COMPENSATION A TE ANO PMPLOYeRS' LIAe1LI Y YIN ANY PRpoPRIETORIMARTNERIEXECUTIVII NIA ❑ E.L. EACH ACCIDENT_,.,,.,.,.,.,,,.-,,. OFPICBN/MeMSER eXCLUO!OI (Mandatory In NH) El DISEASE - EA EMPLOYE S If ea deacnbe under IPT ON OF OP RATI NS balow [.L. Mt:ASE - POLICY LIMIT S beSCRIPTION 01 OPBRA11IONS I LOCATIONS 1 VEMK:LES (ACORD 101, Additional Ramorke Bohedule, may be enached If more space Is required) 1601049 ENOL 246 5529 2007 IsuzU 134 0303 2007 Freightliner 3500 Boxtruck CERTIFICATE HOLDER CANCELLATION City of Ashland, Park and Recreation Commission SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 340 S Pioneer Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ashland, OR 97820 ACCORDANCri WITH THE POLICY PROVISIONS. Attn; Susan Dysseyard, Admin Supervisor A® 1986-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are re Mred marks of ACORD 1001486 132849.9 02-04-2014 rom-INSURANCE MARKETPLACE 10/15/2015 14:54 4746 P.001/006 OP ID: DR CERTIFICATE OF LIABILITY INSURANCE I ° 0;MM/DDnYYYI 0/1612015 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(les) 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 CONTACT Phone: 541-779-0177 NAMfi: Insurance Marketplace, Inc. Fax: FAX 772-8235 PHONE FAX 1998Skypark Dr Suite 100 A/c No Extl:__ AC No: Medford, OR 97504 E-MAIL Insurance Marketplace Inc. PRDRESStR_ CUSTOMER ID N: ACCUR-2 INSURER(S) AFFORDING COVERAGE ~AIC tI _ INSURED _ Accurate Plumbing Solutions, INSURER A: Saif Corporation Inc dba: Barnes Plumbing INSURER6: 711 Medford Center #211 Medford, OR 97504 INSURERC: INSURER D _ INSURER E : INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS 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 10 ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR T7LSDL' UB W-~ POUCY EFF ' POLICY EXP - T TYPE OF INSURANCE POLICY NUMBER IAMIDD/YYYY MM/DD/YYYY OMITS GENERAL LIABILITY EACH OCCURRENCE S -iSAFA E TO E Eb T _ COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) I CLAIMS-MADE I OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ _ t GENERAL AGGREGATE f $ - GEN L AGGREGATE LIMIT APPLIES PER: I PRODUCTS - COMP/OP AGG $ POLICY PRO- - LOC $ - - AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Eaaccident) y ANY AUTO i BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accidenl) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNEDAUTOS ~ i I $ UMBRELLA LIAB OCCUR EACH OCCUR_R_E_NCE EXCESS LAB - 1 CLAIMS-MADE f AGGREGATE $ ^ _ DEDUCTIBLE 'RETENTION $ $ WORKERS COMPENSATION WC S IMITS OTR _ AND EMPLOYERS' LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE Y!N I 1731841 02101/2015 02/0112016 EL EACH ACCIDENT S 1,000,00 UFFICER/MEMBER EXCLUDES? N/A, f 1 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE' S 1,000,00 If yes, describe urder DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,00 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Addlional Remarks Schedule, If more space lE required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Ashland, Park and THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Y ACCORDANCE WITH THE POLICY PROVISIONS, Recreation Comm Susan AUTHORIZED REPRESENTATIVE 340 S. Pioneer St Insurance Marketplace Inc. Ashland, OR 97520 I ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD From:INSURANCE MARKETPLACE 10/15/2015 14:55 #746 P-002/006 COMMERCIAL GENERAL LIABILITY CO 72 8811 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONTRACTORS ENHANCEMENT ENDORSEMENT This endorsement modules hunance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM LOST KEY COVERAGE 'Loss' means unintondonal damage or SECTION I - COVERAGES, OOVERA13E A destruction but does not Include disappearance, BODILY IIWURY AND PROPERTY DAMAGE then, or loss of use. LIABILITY, coverage Is extended b include the NON*WNEDWATERCRAFT following: SECTION 1 - COVERAGES, OOVERAGE A If a customers master or grand key, excluding BODILY INJURY AND PROPERTY DAMAGE eleoirork key card, b lost Whfle in your rare, LIABILITY, 2. 115tclustons is amended as follows: custody or corrbkoi we will pay the oost of ti, Akcridto Auto Or Walwai tt (2) (s) is replacing the keys, Including the master lock and roplaood WL all keys used In the same lock, the cost of (a) Less then Si foci fong; and adjusting kicks to accept the new keys, or the cost Io replace the logos, Wfthmr Is less, EXPANDED PROPERTY DAMA" DOV- Limit of lnsumnot • The most we vdl pay for ERAGE 'loss" arising out of any one 'occurrence' Is For the purposes of this andwwment aNy: Vow. SECTION I - COVERAGE% COVERAGE A SECTION V DEFINITIONS Is amended as BODILY INJURY AND PROPERTY DAMAGE follows: tIABL TTY, 2 Exclusions Is amended as follows: The following def Mon applies to Lost Key s• Exclusiono J.(9). J.(S), and J.(6) are Covergw: deleted In their entirety, 'Loss' means unlXe *mW physical damage or Ix. Exclusion J.(4) Is deleted In Its "rely de*MUM b ImVible properly, Including then or and replaced by the lot;ovVM., disappearance. Twgglble property does riot Personal property In the care custody or Include mor ey or securitles. c of*ol of be Insurect YOL,UNTARV PROPERTY DAMAGE 1. for storage or sale at premises you SECTION I - COVERAGES, COVERAGE A own, rent or occupy; or BODILY INJURY NO PROPERTY DAMA13E 2. whiie being transported by any LIABILITY. a wege lo wnanderi b Include the alrcr> k *vAo' or watercraft awned btwaVa or operated by or radecf to or loaned At yttu request we will pay fa 'property damage' to to arty Insured. - pnoperty of otme caused by you and while in your o. The fdlowg exduslons are added: possevalM raflalng out of your bwskwss ~Q #16 policy p~• 1. The coverage provided by this and ~ erwors~ does not Llu* of irmumnoe - The most we Witt pay for apply to t 'lase" arhdng out of any one `occurrence' is d"property damage loss g of out of use of d 8600 sappearance or lo loss Petsorld property SECTION V - DEFINITIONS Is amerxied as foilove: The folks deiiN6on applies to Voluntary Property Damage coverage: 007268111 it Inck des eopyrtMW material of Insurance Services Offba. Ma., Pa" 1 of 4 With its permtsslon. FromANSURANCE MARKETPLACE 1011512015 14*55 #746 P.003/006 CQ 72 8811 ti 2. The ooverage provided by this BUPPLEMSNTARY PAYMENTS endorsement does not a" to SECTION I - COVERAGE6, SUPPLEMEN- IxoparlY damW" trx*jded In the TARY PAYMENTS - COVERAGES A AND B IS roI>d operations amended as foilows: hazard-. 1. 1. b. replaced with: Lknit at insurance - The most we wig pay b. Up to $2.500 for cost of bell bords for "property damaW provided by this required because d uclderKs or traffic coverege in any am "occurrence" Is $5,000. law Oolatlorw aristrig out of the knee of OWLmtlble - Our obWon to pay for a any vehhkte ID which the Bodily Injury covered Ioss applies only to the amount of Llabillr Coverage apples. We do not low In excess of 6M. have to furnish these bond& This Insurance Is excess over any other valid 2 1. d. replaced with. and cdiedlbto insurance, d. All reasonable expenses Incurred by the DAMAGE TO PREM1$ES RENTED TO YOU insured at our request to assist us In the SECTION I - COVERAGES, COVERAGE A InvesiWWn or defense of the claim or BODILY INJURY AND PROPERTY DAMAGE `suit". IrA ding actual loss of earnings LIABILITY, the last paragraph of 2. Exokwkw s up m $SOD a day bacasme of time off of Is replaced by the following: from work. If Damn" to Pri9trim" fiattted to You Is NMY FORMER AND AOQWRi's:D not olhowtse excluded, aduslorm c. ORGANIZAIKM through e. do not apply to damage by fire, SECTION II WHO IS AN INSURED Is Iigitning, explosion, smoke or sprinkler wnnwKw as follows: leakage to premises vrhile rented to you or 1. 8. a. Is replaced with: temMwIly oomood by you vdih permladm of the owner. A separate IIm t of Insurance a. Coverage under this provision is applies to this coverage as described In afforded only until the ISO day alter you Section tl14,11mlfs of Insurance. acquire or form fie orMizalbn or ft SECTION III - LIMITS OF INSURANCE, end of the poiloy period' whtchcrvw is paragraph 0 Is replaced with: eaniiar' 8. Subject to & above, bte Damage To ADDITIONAL. UtSURtrD - WHEN REQUIRED Premises Rented To You Limit is the most IN AN AGREEMENT OR CDNTFU= WITH we will pay under CovereW A for damages YOU because d 'property darmge" to ary one The follotuing Is added to SECTION a -WHO 119 premises, while rented to you. or in the case AN INSURQD of damae by fire, RgMning, exploslom 4. Any person(s) or agw*doXs) with whorn smolw or sprlnider to e, while ranked to you have agreed In it valid written oohed or you or temporarily occupied by you with written agreement #19 such person or permission of the owner. The Ilmit Is organiz ion be added as an additional irmu"d to $300.000. Insured on your pollcy during the policy SECTION IV - COMMERCIAL. 604ERAL period stwvrn In the OeciaraWns. Such LIABILITY CONDtTIOI+IB, 4. Other inswence, pew or organization Is an addffornal b. Excess insurance (1) (a) (5) Is replaned insured arty with- respect to Ilabillly for with: '~N InW, prolarty damage- or 'personal and adm Ming Injury". (ti) That Is Fire. t ~ttrrirrg, FxDkusio~ The person or ownizatlon added as an Smoke or rider leaKege Irwrance for premises rented to you or temporarily only to" extent you kl liable dtuem to d occupied by you with permbslon d the owner. PaW 2 of 4 includes coppthted material of lnu ante Servbea Orrice, Ina., 0072881111 rdh As permWalon. From_INSURANCE MARKETPLACE 10/15/2015 14:55 #746 P.004/006 CQ 72 8011 11 a Lessors o'f L.eassd Equipment In the performance of your wWing Maintenance, operation or use of operations perforrnW for that adOStbrxll equipment teased to you by such person Insured, wt>eliar the work Is performed by or organl=&L This Insurance does rat you or on your behalf. apply to any 'ocaerence" which takes The Insurortce does not apply to: place after the equipment loess expires. (1) "bodily Injury, `property damage", or However, their status as addlbonai 'personal and advertising Injury ariskg Insured under this po" ends when their out d the rendering of or the fai4re to lease, contract or agreement with you render any protessionaf architectural, for such leased equipment expires. engineering or survey services. b. Mam Were at Lessors of PnmWv Indudirg: The ownership, maireenariae or use of (a) The preparing, approving, or falling that print of the premises you own, rent, to prepare or approve mom. shop [ease or occupy. drawl g% opinions, Isporfs, survey. This Insurance does not apply to: field orders, change orders or (1) Any 'bccurrence` which takes pace drawhtgs and specification: or after you cease to be a tenant in that (b) Supervisory, Inspection, ar- premises. tural or engineering aotM Wit (2) Structural Wileralions, new con- (2) "Bodtty lrfwf' or 'property dame' druction or de"Mon operations orxurting WW. performed by or on behal of the (e) All work, Including mafertats, parts or equipment fury shed in pennon or connedlon with such work, on tho However, that statue as additional K*d (other than service, Insured under Us policy ends when you mslraenance or rsphirs) to be cease to be a lament of such premises. performed by.or on behalf of the a Staffs or PoMkM Subdtyislon additional Insured(s) at the loea*m (trans of the covered operatons has been Operations performed by you or on your completed; or behalf for which the state or po&ilcal (b) That portion of 'our work" out of subdivision has Issued a permit. which ttre Injury or damage arises This Insurmce does not appyto. has been put to b b#eitded use by (1) 'Bodily Injury or 'Property damage" ban ~ranother o contractor oftr or or "personal or advertising Injury suboam actor engaged in arising oil of operations performed pedomwg operations for a Principal for the state or minicipailty; or as a print of the same project. (2) 13odfly injur' or 'property damn" However, a person or o%wi*adon's Included wrthtn the 'products- status as additional Insured under this completed operationn hazard". poky ~ Insured are operations Jor However, such state or polltlosl completed subdivision's status as aMitionat insured AGGREGATE LXAFT PER PROJECT wider this policy ends when the permit SECTION III - LIMITS OF INSURANCE The rands. foMOV,frg paragraph Is added to paragraph 2: d. Owners, Luse, or Conttactom The Gerwal Aggregate Limit under Section "sody injury". `property damage" or M Umds of Insurrance applies separately to "personal aryl advertising InJiryr' caused, In each d your construction projects away from whole or In part, by., premises awned by or rented to yen. (1) Your acts or omissbms; or (2) The acts or ornisstorre of those acting on your behalf: CG 72 881111 indundw oopfttded material of Inwwance Servicee OtOde Ina, Pago 9 of 4 with its permission. From-INSURANCE MARKETPLACE 10/15/2015 14:55 4746 P_005/006 CG 72 881111 MEDICAL PAYMENTS policy provided such failure to disclose all SECTION III - LIMITS OF INSURANCF, hazards or prim *oaxjrrwme or offenses is Paragraph 7. is replaced: not Intentional. TNs provision does not affect our right to coW additional premium 7. SubOd to 6. above, the higher oh or exercise our dgIA of canoeNatlon or rot- a $t0,00D;or renewal. b. The amount stwAn In the Declarations WAIVER OF SUBROGATION for Medical Expense Limn is the most SECTION IV - COMMERCIAL GENERAL we VAN pay under Coverage G for all UAB LITY CONDITIONS, 8. Tronsbr at Fjhts medical expenses because of "bodily of R wyv" Against Others to Us is amended INLW sust OW by one person. to Include: This eoverape does not apply If Owe-age C - If rectured by s wrllten contract executed Msdkal Perna ft is eWuded ether by the prior to loss, we waive any right of pnwisions of any couersoe forms attached to the subraCation was may have against Rae policy,or by endorsement. aontreoting person or organlzallon because KNOWLEDGE OF AN 000URREMCE of paymends we make for Ir`jury or damage SECTION W - COMMERCIAL GENERAL arWN out of your orgokV operations or LIABILITY CONDITIONS, The fotb" is added your worts' dune under a contract with M to 2. Dutlss In The Event Of Oveurr mo% person or erMnIzation and Included in the Offense, Ck*n Or SuR condition: "products-oompteled operations hazwW. e. KiaaWrkllge of an occurrence6 offense, claim LIBERALIZATIOM or suit by an agent or employee of any SECTION IV - COMMERCIAL GENERAL Insured shall not h itself eonstltde LIABILITY CONDITIONS, 10. U wralt ration is Mowiedge of the Inmrsd unless you, a added as follows: partner. II you are a pa*wshfp; or an if vole revise this coverage form to provide more exwAlvae oBloer or Insurance manager, It coverage without additional proms m daarge, you are a corporation receives such notice of your policy #All automatically provide the an occurrence, offense, claim or suit from ed itional eoverew as of the day the revision is the agent or employee. effective In your saw f. The requirements In Sectlon IV BROADENED BODILY INJURY D04NITION Condltkxas Psu+s*mph 2b. aril not be MENTAL. ANGUISH) coraWered breached unless there Is SECTION V - DEFINITIONS Is amnded as knosvledga of oc curny= as outlined in lcilows; paragraph s. above. 1. 3 "Bodfly Iryury' is deleted and replaced with UNKIIENTIONAL FAILURE TO DISCLOSE the following: HAZARD "idly Injury!' meats physlod Injury, SECTION IV - COMMERCIAL. GENERAL slobwoo or r come to a person and, If LIABILITY CONDITION$ 6. Representations is arlskV out of the fcregohV, mental anguish, amended to include: mental injury, shook or humfli , Inckrdkrg d. Your fallure to disclose all hazards or prior death at any tune reS A*V ftref ni 'commences" or olfemas exls frg as of the Inception date of the policy shell not prejudice the wvarage afforded by this All terms and avndltions of this potiay apply unless modlftd by this endorsement. Pegs 4 of 4 incWdes copyrighted material of Irwrance Services office, inn, 0072881111 vvdh its permission. m rn O ti CA a~0 o~m~ O A -n C v m > dC a m -49 22 ::E O n S c ~ za A r- . o zi O d n. z 2. Nrn co o0 o w ~Cl) m D fn Z ou m m O ~ rt1 m n o C- r m a cr) . t Page 1 / 1 ASHLAND PARK COMMISSION 20 E MAIN ST. DATE FPO NUMBER ASHLAND, OR 97520 11/9/2015 00517 (541) 488-5300 VENDOR: 004712 SHIP TJ: ACCURATE PLUMBING SOLUTIONS 711 MEDFORD CENTER PMB 211 MEDFORD, OR 97504 FOB Point: Req. N,-).: Terms: net Delit.: Req. Del. Date: Contact: Bruce Dickens Special Inst: Confirminia? NO Quantity unit Descri tion Unit Price Ext. Price Lower the existinq riqht-side urinal 710.00 (non-ADA) at the YMCA Park to 17" off the floor. per attached contract. Contract for Goods and Services Beqinninq date: 10/26/2015 Completion date: 11/13/2015 i SUBTOTAL 710.00 BILL TO: TAX 0.00 FREIGHT 0.00 TOTAL 710.00 Account Number Project Number Amount Account Number Project Number Amount E 211.12.02.06.60222 710.00 Author ed Signat re VENDOR COPY FORM #3~'~ CITY OF ,A., vezelpapast for a Purchase Order AS LAN D REQUISITION Date of request: 10/13/15 Required date for delivery: 10/28/15 Vendor Name Accurate Plumbing Solutions, Inc. ATTN: Greg Kuitert Address, City, State, Zip 711 Medford Center PMB 211, Medford, OR 97504 Contact Name & Telephone Number Fax Number TEL: 541-773-3035 FAX: 541-7733980 ansincolumb(a)gmail.com 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 FY 15-16 ❑ Direct Award Date approved by Council: Contract # ® Verbal/Written quote(s) or proposal(s) ❑ State of Washington Intermediate Procurement ❑ Sole Source Contract # 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 and solicitation attached ❑ Form #4, Personal Services $5K to $75K Contract # .PERSONAL SERVICES ❑ Special Procurement Intergovernmental Agreement $5,000 to $75,000 ❑ Agency ❑ Form #9, Request for Approval ❑ Less than $35,000, by direct appointment ❑ Written quote or proposal attached Date original contract approved by Council: ❑ (3) Written proposals/written solicitation Date approved by Council: (Date) ❑ Form #4, Personal Services $5K to $75K Valid until: _(Date) I Description of SERVICES Total Cost Lower the existing right-side urinal at the YMCA Park to 17" off the floor. Includes labor and materials to lower the waste and water lines, reset the existing urinal (non-ADA) and flush valve. $ 710.00 Install cover over hole in tile at old water stub out. Item # Quantity Unit Description of MATERIALS Unit Price Total Cost Materials and labor for lowering one urinal at YMCA Park in 1 1 ea Ashland. $710.00 $710.00 TOTAL COST ® Per attached quotelproposal $ 710.00 Project Number _ _ _ _ _ _ - _ _ _ Account Number _ 211 - _12_ - 02 - 06 - 602220 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 form, I certify tat the City's public contracting requirements have been satisfied. _t_1_ Employee: 'L +i J(. zl~ ti ~ Department Head: to or greater than $5,000) Department Manager/Supervisor: I ~~1,IJCity Administrator: (Equal (Equal to or greater than $25,000) Funds appropriated for current fiscal year: YES / NO Finance Director- (Equalto orgreaterthan $5,000) Date Comments: Form #3 - Requisition