Loading...
HomeMy WebLinkAbout2017-096 CONT Addendum - Jefferson State Fire Sprinkler ADDENDUM TO CITY OF ASHLAND CONTRACT F4R GUaDS AND SERVICES LESS THAN $25,DDD Addendum made this 31st day of March, 2D17, between the City of Ashland {"City"} and _ Jefferson Stag Fire Sprinkler, LLC ~"Contractor"). Recitals: A. Gn 01123I2D17, City and Contractor entered into a "City of Ashland Contract #or Goods and Services Less than $25,000" {further referred to in this addendum as "the agreement"}. B. The parties desire to amend the agreement {Fire Sprinkler Retrofit at l~~ Glendale, Ashland, Adult Foster GarelP(~ 536} as follows: City and Contractor agree to amend the agreement in the follovuing manner: 1. the date for cornpleflon is extended fo May 3~, 2017. 2. Workers' Compensation is na longer being waived Contractor has employees and has provided a certificate of insurance for Vvorkers' Compensation. 2. Except as modified aba~ve the terms of the agreement shall remain in full force and effect, C~NTRAGTCR; CITY QF ASHLAND: ~ r~m~nt Head Its ~t:~~~t~-°~ Date F;~~~~.~~,~~ DATA ~ ~ ► ~ Purchase Order # 535 Acct. No.; (For City purposes only) 'I- CITY QF ASHLAND, ADDENDUM TO CONTRACT FOR GOODS AND SERV[CES <$25,404 Policy Number: Date Entered: 2/21/2017 ACIJI~iJo DATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 2/21/2017 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 have ADDITIONAL INSURED provisions or 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 Jennlfer Butler WCFL Insurance Services NAME: 700 Mistletoe Rd Ste 206 PHONE . (541)488-4014 FacNo; (541)488-4017 E-MAIL ennifer@workcom forless . com Ashland, OR 97520 ADDR S ; ~ p INSURER S AFFORDING COVERAGE NAIC # INSURER A :Preferred Contractors Ins Co INSURED Jefferson State Fire Sprinkler LLC INSURER 6 ;Berkshire-Hathaway Travis Jackson INSURER C 221 N Central Ave #318 INSURER D: Medford, OR 97501 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MMIDDYYYYY MMIDDYYYYY LIMITS LTR A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1, OOO , OOO CLAIMS-MADE ~ OCCUR PC107823 05/11/2016 05/11/2017 PREMISES Ea occur ence $ 5O, OOO _ MED EXP (An one erson) $ 5 r OOO PERSONAL & ADV INJURY $ 1 , OOO , OOO GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2 , OOO , OOO POLICY ❑ PRO ❑ LOC PRODUCTS - COMPIOP AGG $ 2 , OOO , OOO JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION PER OTH- ANDEMPLOYERS' LIABILITY STATUTE ER B ANY PROPRIETOR/PARTNERlEXECUTIVE Y 1 N E.L. EACH ACCIDENT $ 5OO , OOO OFFICERIMEMBEREXCLUDED? ❑ NIA JEWC83468 2/14/2017 2/19/2018 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 5OO , OOO If yes, describe under 500 000 DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ r DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Ashland, Oregon, and its elected officials, officers and employees are named as additional insured per the general liability. CERTIFICATE HOLDER CANCELLATION City of Ashland 20 East Main Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ashland, OR 97520 ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Margueritte Hickman, Fire Marshall email : margueritte . hickman@ashland. or. us AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Produced using Forms Boss Plussoftware. www.FormsBoss.com; Impressive Publishing800-208-1977 ~ Purchase order Fiscal Year 2017 Page: 1 of: 1 B City of Ashland - _S N: Accounts Payable ~ 20 E. Main Purchase Order # Ashland, OR 97520 T Phone: 5411552-2010 p Email: payable@ashland.or.us V H CIO Fire and Rescue Department N JEFFERSON STATE FIRE SPRINKLER LLC 1455 Siskiyou Blvd 221 N CENTRAL AVE #318 p Ashland, OR 97520 ~ MEDFORD, OR 97501 Phone: 5411482-2770 R O Fax:541/488-5318 -17~ndcar=Phon~Number =1~~~~~u~a _ _ Mar ueritte Hickman _ Dade ar_d~red _ _._~~of»vm _ _ urr : - : _ - _ - - - _ - - ~ - rQn'v 0210212017 2981 Cit Accounts Pa able Fire Sprinkler Retrofit 1 MODIFIEDe Fire Sprinkler Retrofit at 714 Glendale, Ashland 1 $7,813.0000 $7,813.00 Adult Foster Care Part of FEMA Fire Prevention & Safety Grant Contract for Goods and Services Less than $25,000 Beginning date: 01125/2017 Completion date: 0313012017 Processed change order 0412412017 Completion date extended to: 0513112017 Workers' Compensation no longer waived. Contractor has employees and has provided Workers° Compensation insurance certificate. Project Account: E-000480-999 GL SUMMARY 075100 - 610300 $7,813.00 - ,By~ i~~W Date: _ Authorized ignature ~ - $7 813.00