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HomeMy WebLinkAbout2022-104 PO 20230179- Tony Roth Appliance Technician • Purchase Order rift cry wc} �>D4m. , Fiscal Year 2023 Page: 1 of: 1 g�.e J 5" Y 3 y �9 .t3 L L ."1 e 6 Ver s ANVIII B City of Ashland L 20 E. Main Accounts Payable Purchase 20230179 L 20 E. Ashland, OR 97520 Order* T, Phone: 541/552-2010 • • 0 Email: payable@ashland.or.us • V • H C/O Facilities Maintenance Div E TONY ROTH AP_PLIANCE TECHNICIAN I90 North Mountain Ave N 864 FOSS RD p Ashland, OR 97520 O TALENT, OR 97540 Phone: 541/488-5358 R T Fax: 541/552,2304 • amts it2Wha--sriAbe ='AtleaVe urnliil • David Arnold 11/29/2022 2473 FOB ASHLAND OR/NET30 City Accounts Payable — On-call Appliance Repair 0 1 On-call appliance repairs 1.0 $5,000.00 $5,000.00 • Goods and Services Agreement($35,000 or Less) Completion date: 06/30/2023 Project Account: • *************** GL SUMMARY*************** ' 088400-602400 $5;000.00 • • BDate: By: (41/ti � C � Authorize• i• ature5 000.00 ica4 F o-VA-A6A2t:r GL ORM CITY OF '`r . ® ( 7 ASHLAND A _` A f'c�x��t.lt,�6��for "i Purchasefl: ��0 v REQUISITE,! N l Dateofrequest: 91/1/2022. Required d for dei ry: Vendor Name Tony Roth Appliance Repair 6,4 ,11(1 Address,City,State,Zip 864 Foss Road.Talent.OR 97540 Contact Name&Telephone Number Tony Roth 541-6216530 tonyroth911@hotmall.com Email address SOURCING METHOD ❑ Exempt from Competitive Bidding '❑ Invitation to Bid ❑ Emergency ❑ Reason for exemption: Date approved by Council: ❑ Form#13,Written findings and Authorization : ❑ AMC 2,50 _(Attach copy of council communication) ❑ Written quote or proposal attached i ❑ Written quote or proposal attached . _(If council approval required,attach copy of CC) ® Small Procurement 0 Request for Proposal Cooperative Procurement • Not exceeding$5,000 Date approved by Council: 0 State of Oregon ® Direct Award _(Attach copy of council communication) Contract# ❑ Verbal/Written quote(s)or proposal(s) ❑ Request for Qualifications(Public Works) 0 State of Washington Date approved by Council: . Contract# : (Attach copy of council communication) ❑ Other government agency contract Intermediate Procurement C( Sole Source Agency GOODS&SERVICES ❑ Applicable Form(#5,6,7 or 8) Contract# • Greater than$5,000 and less than$100,000 ❑ Written quote or proposal attached Intergovernmental Agreement ❑ (3)Written bids and solicitation attached ❑ Form#4,Personal Services$5K to$75K Agency : PERSONAL SERVICES Date approved by Council: 0 Annual cost to City does not exceed$25,000, Greater than$5,000 and less than$75,000 Valid until: (Date) Agreement approved by Legal and approved/signed by O Less than$35,000,by direct appointment ❑ Special Procurement City Administrator.AMC 2,50,070(4) ❑ (3)Written proposals&solicitation attached ❑ Form#9,Request for Approval ❑ Annual cost to City exceeds$25,000,Council ❑ Form#4,Personal Services$5K to$75K ❑ Written quote or proposal attached approval required,(Attach copy of council communication) Date approved by Council: Valid until: (Date) Description of SERVICES Total Cost Appliance re airfor FY2 3 Item# Quantity Unit Description of MATERIALS Unit Price Total Cost 1 • $0 • $0,00 . $0 $0.00 $0 $0.00 O Per attached quote/proposal : :TOTAL COST; . 0:0.. Project Number: - _ _ Account Number: 088400-602400 ; �:,°`: <;;60::::.::.:::::::::::.:::: ::: 'Expenditure must be charged to the appropriate account numbers for the financials to accurately reflect(he actual expenditures. IT Director in collaboration with department to aovd all hardware and software purchases: IT Director Date Support-Yes/No By signing this requisition form,I cer ifthat the my Cffy' pubfjc contracting requirements have been satisfied. Employee: fyy t Department H:- `�� l 1.`r•to7-7 iI or greate than$5,000) Department Manager/Supervisor: City Manager: d a e (Greater than$3 ,000) Funds appropriated for current fiscal yea ' YES NO �� � r Fr -nce , e' •r-(Equal to or greater than ;5,000) Dale Comments: • Form 43-Requisition Firefox about:blank Firefox about:blank Z GOODS AND SERVICES AGREEMENT($35,000 OR LESS) "Y.) PROVIDER: Tony Roth Appliance Repair CITY OF PROVIDER'S ASHLAND CONTACT: Tony Roth 20 East Main Street Ashland,Oregon 97520 ADDRESS: 864 Foss Road Telephone: 541/488-5587 Talent,OR 97540 Fax: 541/438-600( PHONE: 541-621-6530 This Goods and Services Agreement (hereinafter "Agreement") is entered into by and between the City of Ashland, an Oregon municipal"corporation (hereinafter "City") and Tony Roth Appliance Repair. (a domestic/foreign business corporation)("hereinafter"Provider"),for appliance repairs. 1. PROVIDER'S OBLIGATIONS 1.1 Provide appliance repairs for FY23 as set forth in the"SUPPORTING DOCUMENTS"attached hereto and,by this reference,incorporated herein. Provider expressly acknowledges that time is of the essence of any completion date set forth in the SUPPORTING DOCUMENTS,and that no waiver or extension of such deadline may be authorized except in the same manner as herein provided for authority to exceed the maximum compensation. The services defined and described in the. "SUPPORTING DOCUMENTS"shall hereinafter be collectively referred to as"Work." 1.2 Provider shall obtain and maintain during the term of this Agreement and until City's final acceptance of all Work received hereunder,a policy or policies of liability insurance including commercial general liability insurance with a combined single limit, or the equivalent, of not less than S2,000,000 ilwo SI I ,ono(a million dollars)per occurrence for Bodily Injury and Property Damage. 1.2.1 The insurance required in this Article shall include the following coverages: • Comprehensive General or Commercial General Liability, including personal injury, contractual liability,and products/completed operations coverage; and • Automobile liability. 1.2.2 Each policy of such insurance shall be on an"occurrence"and not a"claims made"form.and shall: • Name as additional insured "the City of Ashland. Oregon, its officers, agents and employees" with respect to claims arising out of the provision of Work under this Agreement; • Apply to each named and additional named insured as though a separate policy had been issued to each,provided that the policy limits shall not be increased thereby; • Apply as primary coverage for each additional named insured except to the extent that two or more such policies arc intended to "layer"coverage and, taken together,they provide total coverage from the first dollar of liability: • Provider shall immediately notify the City of any change in insurance coverage • Provider shall supply an endorsement naming the City,its officers,employees and agents as additional insureds by the Effective Date of this Agreement: and • Be evidenced by a certificate or certificates of such insurance approved by the City. Pape 1 of 6: Goods and Services Agreement between the City of Ashland and Tony Roth Appliance Repair 1 of 6 11/1/2022.8:00 AM • 1 of 1 11/8/2022.6:37 PM Firefox about:blank 1.3 Provider shall,at its own expense,maintain Worker's Compensation Insurance in compliance with ORS 656.017, which requires subject employers to provide workers' compensation coverage for all of its subject workers. 1.4 Provider agrees that no person shall, on the grounds of race, color,religion, creed,sex, marital status, familial status or domestic partnership, national origin,'age, mental or physical disability, sexual orientation, gender identity or source of income, suffer discrimination in the performance of this Agreement when employed by Provider. Provider agrees to comply with all applicable requirements of federal and state civil rights and rehabilitation statutes,rules and regulations. Further,Provider agrees not to discriminate against a disadvantaged business enterprise;minority-owned business,woman-owned business, a business that a service-disabled veteran owns or an emerging small business enterprise certified under ORS 200.055,in awarding subcontracts as required by ORS 279A.110. 1.5 In all solicitations either by competitive bidding or negotiation made by Provider for work to be performed under a subcontract, including procurements of materials or leases of equipment, each potential subcontractor or supplier shall be notified by the Providers of the Provider's obligations under this Agreement and Title VI of the Civil Rights Act of 1964 and other federal nondiscrimination laws. 1.6 Living Wage Requirements: If the amount of this Agreement is $22,310.46 or more, Provider is required to comply with Chapter 3.12 of the Ashland Municipal Code by paying a living wage,as defined • in that chapter,to all employees performing Work under this Agreement and to any Subcontractor who performs 50%or more of the Work under this Agreement. Provider is also required to post the notice attached hereto as"Exhibit A"predominantly in areas where it will be seen by all employees. 1.7 Assignment: Provider shall not assign this Agreement or subcontract any portion of the Work to be provided hereunder without the prior written consent of the City. Any attempted assignment or subcontract without written consent of the City shall be void. Provider 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 the City of any assignment or subcontract shall not create any contractual relationbetween the assignee or subcontractor and the City. 2. CITY'S OBLIGATIONS 2.1 City shall pay Provider the hourly rates effective 10/31/2022 as specified in the SUPPORTING DOCUMENTS. 2.2 In no event shall Provider's total of all compensation and reimbursement under this Agreement exceed the sum of$5,000(this is maximum, not to exceed amount of ENTIRE Agreement) without express, written approval from the City official whose signature appears below, or such official's successor in office. Provider expressly acknowledges that no other person has authority to order or authorize additional Work which would cause this maximum sum to be exceeded and that any authorization from the responsible official must be in writing. Provider further acknowledges that any Work delivered or expenses incurred without authorization as provided herein is done at Provider's own risk and as a volunteer without expectation of compensation or reimbursement. • 3. GENERAL PROVISIONS 3.1 This is a non-exclusive Agreement. City is not obligated to procure any specific amount of Work from Provider and is free to procure similar types of goods and services from other providers in its sole discretion. Page 2 of 6: Goods and Services Agreement between the City of Ashland and Tony Roth Appliance Repair /CN 2 of 6 11/1/2022,8:00 AM Firefox about:blank • 3.2 Provider is an independent contractor and not an employee or agent of the City for any purpose. 3.3 Provider is not entitled to,and expressly waives all claims to City benefits such as health and disability insurance,paid leave,and retirement. 3.4 This Agreement embodies the full and complete understanding of the parties respecting the subject matter hereof. It supersedes all prior agreements,negotiations,and representations between the parties, whether written or oral. 3.5 This Agreement may be amended only by written instrument executed with the same formalities as this Agreement. 3.6 The following laws of the State of Oregon are hereby incorporated by reference into this Agreement: ORS 279B.220,279B.230 and 279B.235. 3.7 This Agreement shall be governed by the laws of the State of Oregon without regard to conflict of laws principles. Exclusive venue for litigation of any action arising under this Agreement shall be in the Circuit Court of the State of Oregon for Jackson County unless exclusive jurisdiction is in federal court, in which case exclusive venue shall be in the federal district court for the district of Oregon. Each party expressly waives any and all rights to maintain an action under this Agreement in any other venue,and expressly consents that, upon motion of the other party, any case may be dismissed or its venue transferred,as appropriate,so as to effectuate this choice of venire. 3.8 Provider shall defend,save,hold harmless and indemnify the City and its officers,employees and agents from and against any and all claims, suits, actions, losses, damages, liabilities, costs, and expenses of any nature resulting from, arising out of, or relating to the activities of Provider or its officers, employees,contractors,or agents under this Agreement. 3.9 Neither party to this Agreement shall hold the other responsible,for damages or delay in performance caused by acts of God,strikes,lockouts,accidents,or other events beyond the control of the other or the other's officers,employees or agents. 3.10 If any provision of this Agreement is found by a court of competent jurisdiction to be unenforceable, such provision shall not affect the other provisions,but such unenforceable provision shall be deemed modified to the extent necessary to render it enforceable,preserving to the fullest extent permitted the intent of Provider and the City set forth in this Agreement. 3.11 Deliveries will be F.O.B destination.Provider shall pay all transportation and handling charges for the Goods.Provider is responsible and liable for loss or damage until final inspection and acceptance of the Goods by the City. Provider remains liable for latent defects,fraud,and warranties. 3.12 The City may inspect and test the Goods. The'City may reject non-conforming Goods and require Provider to correct them without charge or deliver them at a reduced price, as negotiated.If Provider does not cure any defects within a reasonable time, the City may reject the Goods and cancel this Agreement in whole or in part. This paragraph does not affect or limit the City's rights, including its rights under the Uniform Commercial Code,ORS Chapter 72(UCC). 3.13 Provider represents and warrants that the Goods are new, current, and fully warranted by the manufacturer. Delivered Goods will comply with SUPPORTING DOCUMENTS and be free from defects in labor,material and manufacture.Provider shall transfer all warranties to,the City. Page 3 of 6: Goods and Services Agreement between the City of Ashland and Tony Roth Appliance Repair • 3 of 6 11/1/2022,8:00 AM Firefox about:blank • 4. SUPPORTING DOCUMENTS 4.1 The following documents are, by this reference, expressly incorporated in this Agreement, and are collectively referred to in this Agreement as the"SUPPORTING DOCUMENTS:" • The Provider's complete written Rate Sheet dated October 31,2022. 4.2 This Agreement and the SUPPORTING DOCUMENTS shall be construed to be mutually complimentary and supplementary wherever possible. In the event of a conflict which cannot be so resolved,the provisions of this Agreement itself shall control over any conflicting provisions in any of the SUPPORTING DOCUMENTS. In the -event of conflict between provisions of two of the SUPPORTING DOCUMENTS,the several supporting documents shall be given precedence in the order listed in Article 4.1. 5. REMEDIES 5.1 In the event Provider is in default of this Agreement, City may, at its option,pursue any or all of the remedies available to it under this Agreement and at law or in equity,including,but not limited to: 5.1.1 Termination of this Agreement; • 5.1.2 Withholding all monies due for the Work that Provider has failed to deliver within any scheduled completion dates or any Work that have been delivered inadequately or defectively; 5.1.3 Initiation of an action or proceeding for damages, specific performance, or declaratory or injunctive relief; 5.1.4 These remedies are cumulative to the extent the remedies are not inconsistent,and City may pursue any remedy or remedies singly,collectively,successively or in any order whatsoever. 5.2 In no event shall City be liable to Provider for any expenses related to termination of this Agreement or for anticipated profits.If previous amounts paid to Provider exceed the amount due,Provider shall pay immediately any excess to City upon written demand provided. 6. TERM AND TERMINATION 6.1 Term This Agreement shall be effective from the date of execution on behalf of the City as set forth below (the "Effective Date"), and shall continue in full force and effect until June 30, 2023, unless sooner terminated as provided in Subsection 6.2. • • 6.2 Termination 6.2.1 The City and Provider may terminate this Agreement by mutual agreement at any time. 6.2.2 The City may,upon not less than thirty(30)days'prior written notice,terminate this Agreement for any reason deemed appropriate in its sole discretion. 6.2.3.Either party may terminate this Agreement,with cause,by not less than fourteen(14)days'prior written notice if the cause is not cured within that fourteen(14) day period after written notice. Such termination is in addition to and not in lieu of any other remedy at law or equity. 7. NOTICE Whenever notice is required or permitted to be given under this Agreement, such notice shall be given in writing to the other party by personal delivery,by sending via a reputable commercial overnight courier, or by mailing using registered or certified United States mail,return receipt requested,postage prepaid,to the address set forth below: If to the City: Page 4 of 6: Goods and Services Agreement between the City of Ashland and Tony Roth Appliance Repair 41/4'1 4 of 6 11/1/2022,8:00 AM Fit`efox , about:blank • City of Ashland—Facilities Maintenance Department Attn: David Arnold 20 E.Main Street Ashland,Oregon 97520 Phone:(541)552-2292 With a copy to: City of Ashland—Legal Department 20 E.Main Street Ashland,OR 97520 Phone:(541)488-5350 If to Provider: Tony Roth Appliance Repair Attn:Tony Roth 541-621-6530 8. WAIVER OF BREACH One or more waivers or failures to object by either party to the other's breach of any provision,term,condition, or covenant contained in this Agreement shall not be construed as a waiver of any subsequent breach,whether or not of the same nature. 9. PROVIDER'S COMPLIANCE WITH TAX LAWS 9:1 Provider represents and warrants to the City that: 9.1.1 Provider shall, throughout the term of this Agreement, including any extensions hereof, comply with: (i) All tax laws of the State of Oregon, including but not limited to ORS 305.620 and ORS chapters 316,317,and 318; (ii) Any tax provisions imposed by a political subdivision of the State of Oregon applicable to Provider;and (iii) Any rules,regulations,charter provisions,or ordinances that implement or enforce any of the foregoing tax laws or provisions. • 9.1.2 Provider,for a period of no fewer than six(6)calendar years preceding the Effective Date of this Agreement, has faithfully complied with: (i) All tax laws of the State of Oregon, including but not limited to ORS 305.620 and ORS chapters 316,317,and 318; (ii) Any tax provisions imposed by a.political subdivision of the State of Oregon applicable to Provider;and (iii) Any rules,regulations,charter provisions,or ordinances that implement or enforce any of the foregoing tax laws or provisions. 9.2 Provider's failure to comply with the tax laws of the State of Oregon and all applicable tax laws of any political subdivision of the State of Oregon shall constitute a material breach of this Agreement. Further, any violation of Provider's warranty, as set forth in tliis Article 9,shall constitute a material breach of this Agreement. Any material. breach of this Agreement shall entitle the City to terminate this Agreement and to seek damages and any other relief available under this Agreement,at law,or in equity. • Page 5 of 6: Goods and Services Agreement between the City of Ashland and Tony Roth Appliance Repair 5 of 6 11/1/2022,8:00 AM ;.1• Firefox . about:blank • IN WITNESS WHEREOF the parties have caused this Agreement to be signed in their respective names by their duly authorized representatives as of the dates set forth below. • CITY OF ASHLAND: Tony Roth A ce Repair(PROVIDER): • By: i By: / !) i nature Signature 06 (� L Le�sa.c-� d�nr f I t- Printed Name Printed Name City tlllcth a_cv r GwiAe Title) Title / IV/S.72-2_ A [( Date Date (W-9 is to be submitted with this signed Agreement) p7 9 (7/ Purchase Oi'der No. • • • Page 6 of 6: Goods and Services Agreement between the City of Ashland and Tony Roth Appliance Repair 4) 6 of 6 11/1/2022,8:00 AM From the desk of Tony Roth Appliance Technician 864 Foss Road Talent, Oregon 97540 541,621.6530 CCB 197022 October 31, 2022 Nicole Graham, Office Assistant City of Ashland, Fleet Services/Facilities Maintenance 90 North Mountain Avenue, Ashland, Oregon 97520 Greetings from Talent, Oregon and thank you for your interest in my services. My rate is $125/hour and materials vary depending upon the situation and/if parts are required. I've done a few jobs for your fire department in the past and if I remember correctly they have Continental washers which are made in Spain. That means parts can be expensive compared to some of the American made brands — Unimac, Milnor, Dexter, etc. I hope for a long and successful relationship with the City of Ashland. Thank you again for your interest. Tony Roth 541.621.6530 • DATE(MMIDD/YYYY) A o® CERTIFICATE OF LIABILITY INSURANCE 11/2/2022 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 CONTNAME:ACT Shannon Abney Protectors Insurance, LLC i PHONE FAX P.O. Box 4669 (NC.No.Ext):541-842-2974 (A/c.No):541-772-1906 Medford OR 97504 ADDRess: shannona@protectorsins.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Am Hallmark Ins Co of Texas INSURED • ROTH-01 INSURER B Anthony Gilbert Roth Tony Roth Appliance Technician INSURERC: 220 W Rapp Rd#46 INSURER D: Talent OR 97540 • INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:1273715645 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 EFF POLICY EXP LIMITS LTR JN /Y SD WVD POLICY NUMBER (MM/DDYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY Y 44CL009007212 5/14/2022 5/14/2023 EACH OCCURRENCE __$1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $1,000,000 _ PRO POLICY X JECT LOC PRODUCTS-COMP/OP AGG $1,000,000 OTHER: $ A AUTOMOBILE LIABILITY N 44CL009007212 5/14/2022 5/14/2023 COMBINEDdentSINGLE LIMIT $300,000 (Ea acci ) ANY AUTO BODILY INJURY(Per person) $ OWNED X 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 AND EMPLOYERS'LIABILITY Y/N PER ER ANYPROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT -$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may he attached if more space is required) Certificate holder is listed as additional insured when required by written contract per MP9538 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Ashland 20 E Main St Ashland OR 97520 AUTHORIZED REPRESENTATIVE ia4V • ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED ENDORSEMENT This endorsement modifies the insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM A. SECTION II -WHO IS AN INSURED is amended to include as an insured any person or organization (referred to below as Additional Insured) whom you are required to add as an additional insured on this policy under: 1. A written contract or agreement; and 2. Where a certificate of insurance showing that person or organization as an additional insured has been issued; and 3. When the written contract or agreement and the certificate of insurance are currently in effect or becoming in effect during the term of the policy and executed prior to the"bodily injury,""property damage,"or"personal injury and advertising injury." B. The insurance provided to the Additional Insured(s) is limited as follows: 1. The Additional Insured(s) is only an additional insured for: a. "Bodily injury," "property damage," or"personal and advertising injury" caused in whole or in part by negligent acts or omissions of the Named Insured or anyone directly or indirectly employed by the Named Insured or for whose acts a Named Insured may be liable. b. Liability arising out of your ongoing operations for the Additional Insured(s) by or for you. A person's or organization's status as an insured under this endorsement ends when your operations for that insured are completed. 2. The Limits of Insurance applicable to the Additional Insured(s) are those specified in the written contract or agreement but not more than the Limits of Insurance specified in the Declarations of this policy. The Limits of Insurance applicable to the Additional Insured(s) are inclusive of and not in addition to the Limits of Insurance shown in the Declarations for the Named Insured. C. In addition to the other exclusions applicable to Coverages A, B, and C, the insurance provided to the Additional Insured(s)does not apply to: 1. "Property damage"to: a. Property owned, used, occupied by, loaned or rented to the Additional Insured(s); b. Property in the care, custody or control of the Additional Insured(s) or over which the Additionallnsured(s) are for any purpose exercising physical control; or c. "Your work"performed for the Additional Insured(s). 2. "Bodily injury," "property damage," or "personal and advertising injury" arising out of an architect's, engineer's or surveyor's rendering or failure to render any professional services for you,for the Additional Insured(s)or for others, including, but not limited to: a. The preparing, approving or failure to prepare or approve maps, drawings, opinions, reports, surveys, change orders, designs or specifications; or b. Supervisory, inspection or engineering services. 3. "Bodily injury"or"property damage" occurring after: a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s)at the site of the covered operations has been completed; or b. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. MP 95 38 03 05 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 1 of 1 CERTIFICATION OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE REQUIREMENTS Contractor is exempt from the requirement to obtain workers compensation insurance under ORS Chapter 656 for the following reason. Contractor is to initial the appropriate box as follows: ( ) SOLE PROPRIETOR (Initials) • Contractor is a sole proprietor,and • Contractor has no employees,and • Contractor will not hire employees or subcontractors to perform this contract. CORPORATION—FOR PROFIT (Initials) • Contractor's business is incorporated;and • All employees of the corporation are officers and directors and have a substantial ownership interest*in the corporation,and • All work will be performed by the officers and directors;Contractor will not hire other employees or subcontractors to perform this contract. CORPORATION-NONPROFIT (Initials) • Contractor's business is incorporated as a nonprofit corporation,and • Contractor has no employees;all work is performed by volunteers,and • Contractor will not hire employees or subcontractors to perform this contract. PARTNERSHIP (Initials) • Contractor is a partnership,and • Contractor has no employees,and • All work will be performed by the partners;Contractor will not hire employees or subcontractors to perform this contract,and • Contractor is not engaged in work performed in direct connection with the construction,alteration,repair, improvement,moving or demolition of an improvement to real property or appurtenances thereto.** LIMITED LIABILITY COMPANY (Initials) • Contractor is a limited liability company,and • Contractor has no employees,and • All work will be performed by the members;Contractor will not hire employees or subcontractors to perform this contract,and • If Contractor has more than one member,Contractor is not engaged in work performed in direct connection with the construction,alteration,repair,improvement,moving or demolition of an improvement to real property or appurtenances thereto.** ,111.1 (Signature of Authorized Signer) (Date) _Owner November 7,2022 (Signer'sTitle *NOTE: Under OAR436-50-050 a shareholder has a"substantial ownership"interest if the shareholder owns 10%of the corporation,or if less than 10%is owned,the shareholder has ownership that is at least equal to or greater than the average percentage of ownership of all shareholders. **NOTE: Under certain circumstances partnerships and limited liability companies can claim an exemption even when performing construction work. The requirements for this exemption are complicated. Consult with City Attorney's Office before an exemption request is accepted from a contractor who will perform construction work. Memo TO: Joseph L. Lessard, City Manager FROM: Tami De Mille-Campos, Administrative Analyst DATE: 11/9/2022 RE: City Manager Signature Needed for Tony Roth Appliance Repair Background: This item is coming to you as the vendor doesn't have the required insurance. Please see the attached letter requesting reduced insurance. Council Action: Signatures Re uired: ll D o t_vanager el5 term inance D irecto OilTani ' g, ovEmawan ,om . . 1 of Ma aoar 11l6cecontrac Other Relevant Information: Insurance waived or reduced? Mg, Who to return to if different from sender? Are all other signatures required collected? Yes If no,please collect before sending them to the City Manager. Are all attachments listed included? Yes Form3 City Standard contract • CITY OF ASHLAND 20 East Main Street Tel:541-488-6002 Ashland,Oregon 97520 Fax:541-488-5311 www.ashland.or.us TTY: 800-735-2900 Ir e Jac Tony Roth Appliance Technician 864 Foss Road Talent, Oregon 97540 541.621.6530 CCB 197022 November 7, 2022 To: City of Ashland To whom it concerns, Regarding the City of Ashland's Service Agreement General Liability Insurance requirement, I would like to request an exception. As the owner of Tony Roth Appliance Technician, my company currently carries $1,000,000 worth of Liability Insurance while providing appliance repair. During the process of performing these repairs or services, incidents are extremely rare and personal injury or property damage is almost unheard of. Please contact me if you have any questions or would like more information as you consider my request, Thank you, I ', Ifs?k Tony Roth Owner—Tony Roth Appliance Technician