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HomeMy WebLinkAbout2017-097 CONT Addendum - Jefferson State Fire Sprinkler ADDENDUM TO CITY OF ASHLAND CONTRACT FOF~ GQODS AND SERVICES LESS THAN $~5,~D0 Addendum made this 31st day of March, 2x17, between the City of Ashland ("City"} and Jefferson State Fire Sprinkler LLC ("Contractor"). Recitals: A. 0n 01123/017, City and Contractor entered into a "City of Ashland Contract for Goods and Services Less than $25,000" further referred to in this addendum as "the agreement"). g. The parties desire to amend the ~~reement (Fire Sprinkler Retrofit at ~2~4 Auburny Medford, Adult Footer Care1P0 537) as follows: City and Contractor agree to amend the agreement in the following manner: 1. The date for compieiion is expended to May 31, 20~ 7. 2. Workers' Compensation is no longer being waived. Contractor has employees and has provided a certii;cate of insurance for Workers' Compensation. Fxcept as modified above the terms of the agreement shall remain in full force and effect.. CONTRACTC}R: CITY OF A LAND: ~ p, BY r---r°'`' BY Vic, ''t :Dep ir►ent Head , Its Date - ~ . j' , ~ DATE I ~ ~ Purchase Order ~ r?,~ Acct. No.: (For City purposes only} ~I-CITY 4F ASHLAND, ADDENDUM TO CONTRACT FCR GOADS AND SERVICES ~$25,U00 Policy Number: Date Entered: 2./21/2017 ~ DATE (MMIDDIYYYY) '4~ 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 coNTACr Jennifer Butler WCFL Insurance Services NAME: _ 700 Mistletoe Rd Ste 206 PH°NE . (541) 488-4014 a!c No: (541) 488-4017 E-MAIL ennifer@workcom forless . com Ashland, OR 97520 ADDRESS: ~ p INSURERS AFFORDING COVERAGE NAIC # INSURER A ;preferred Contractors Ins Co INSURED Jefferson State Fire Sprinkler LLC INSURER B ;Berkshire-Hathaway Travis Jackson INSURER C ; 221 N Central Ave #316 INSURER D: Medford, OF, 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 SUER POLICY NUMBER MMIDDYYYYY MMIDDYYYYY LIMITS LTR A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1 , OOO , OOO 05/11/2016 05/11/2017 DAMAGE TO RENTED 5O OOO CLAIMS-MADE OCCUR PC107823 PREMISES Ea occurrence $ ~ MED EXP (Anyone erson) $ 5, OOO J 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 LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION $ ~ $ WORKERS COMPENSATION PER OTH- ANDEMPLOYERS' LIABILITY STATUTE ER B ANY PROPRIETOR/PARTNERlEXECUTIVE Y! N E.L. EACH ACCIDENT $ 5OO , OOO OFFICER/MEMBER EXCLUDED? ❑ N!A JEWC83468 2/14/2017 2/14/2018 (Mandatory in NHI 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 I LOCATIONS !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 Ashland OR 97520 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ~ 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 - ° ~ - ~ =~_'--I~---sue=:=- _ ATTN: Accounts Payable L 20 E. Main Purchase L Ashland OR 97520 Order # ~ ~ / T Phone: 541/552-2010 O Email; payable@ashland.or.us ~ S CIO Fire and Rescue De artment E JEFFERSON STATE FIRE SPRINKLER LLC H 455 Siskiyou Blvd P p 221 N CENTRAL AVE #318 P Ashland, OR 97520 O MEDFORD, OR 97501 Phone: 5411482-2770 R ~ Fax:5411488-5318 - - _ - r. Vendor=Phony Number 1~en~s~~T~~n~~:~ ~ : _ . ~ = - Mar ueritte Hickman - - - - . Qate_Qr~sr~d V~ndQr Num~~r~ ~a~e=.qp:~~~~ - _ . = V_ _ : a~aL~~atrn~ - _ 02/02/2017 2981 Cit Accounts Pa able _ _ _ _ _ ~ a Fire Sprinkler Retrofit 1 Fire Sprinkler Retrofit at 3204 Auburn, Medford 1 $9,303.0000 $9,303.00 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: 03/3012017 Processed change order 04!2412017 Completion date extended to: 05/31/2017 Workers' Compensation no Iongerwaived. Contractor has employees and has provided Workers' Compensation insurance certificate. Project Account: E-000480-999 GL SUMMARY ~ 075100 - 610300 $9,303.00 ~ 'f _ _ ~ ; m~, Date: _ Authorizec~Signature . = ~ - ~ a_v___. $9 303.00