Loading...
HomeMy WebLinkAbout2019-302 PO 20200242- Carlson Corp. Purchase Order ,MaCT �'�� �fl _�,�a Fiscal Year 2020 Page: 1 of: 1 B City of Ashland �'�i` -' 4� 4-1 = - 1 ATTN: Accounts Payable � 20 E. Main •• Purchase 20200242 Ashland, OR 97520 Order# T Phone: 541/552-2010 • • - O .Email: payable@ashland.or.us • V • H iC/O Electric Department E CARLSON CORP I s90 North Mountain Ave N PO BOX 1503 P 'Ashland, OR 97520 O MEDFORD, OR 97501 7 Phone: 541/488-5357 R 0 Fax: 541/552-2436 _ 'r.._ r—r 1 t al [ _1 7 7 f t E (S V I IEal IF C �?L lVj7 =r J I"C Thomas McBartlett 10/30/2019 1669 • Cit Accounts Pa able — ' r iiaa �--^1E` °_ - _ i — Conduit Install 120 Clear Crk 1 Install(1)4" conduit from designated area at 120 Clear Creek 1 $4,850.0000 $4,850.00 Address to vault location across the street by means of directional drilling, conduit and fittings will be supplied by City, concrete and asphalt repairs will be performed by City. Goods and Services Agreement(Less than $25,000) Completion date: 02/28/2020 Project Account: ***************GL SUMMARY*************** 111800-602400 $4 850.00 - • • • • • ' t • • 1 f ' • 'By: C€Jv' Y°fi4 Date: I i az Authorized Signature iTT,_. ___ '.4 850.00 FORM #3 l_.. 0' f & d CITY OF A request for a Purchase Order ASHLAND REQUISITIONDate of request: 10/14/2019 Vendor Name Carlson Construction , Address,City,State,Zip PO Box 1503 Medford OR 97501 Contact Name Brent Carlson Telephone Number 541-773-3035 Cell:541-601-3849 • Email address - CCB#173889 Email:bcarisonconstruction@hotmail.com SOURCING METHOD ' ❑ Exempt from Competitive Bidding ❑ Emergency ❑ Reason for exemption: 0 Invitation to Bid (Copies on file) ❑ Form#13,Written findings and Authorization ❑ 'AMC 2.50 Date approved.by Council:_ 0 Written quote or proposal attached ' ❑ Written quote or proposal attached _(Attach copy of council communication) (If council approval required,attach copy of CC) ❑ Small Procurement Cooperative Procurement Less than$5,000 ❑ Request for Proposal (Copies on file) 0 State of Oregon 0 Direct Award Date approved by Council:_ Contract# 11Verbal/Written quote(s)or proposal(s) —(Attach copy of council communication) ❑ State of Washington Intermediate Procurement ❑ Sole Source Contract# _ GOODS&SERVICES ❑ Applicable Form(#5,6,7 or 8) 0 Other govemment 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 0 Special Procurement Intergovernmental Agreement $5,000 to$75,000 ❑ Form#9,Request for Approval- ❑ Agency ElLess 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) —(Attach copy of council communication) - Description of SERVICES Total Cost Bid is to install(1)4"conduit from designated area at 120 Clear Creek address to vault •-- - _ - _ location across the street by means of directional drilling,conduit and fittings will be supplied - '_- '' by city,concrete and asphalt repairs will be performed by city. -$$4,850:00' •- Item# Quantity Unit • Description of MATERIALS Unit Price Total Cost See Attached Quote&Submittal -`TOTAL.COST' ' . El Per attached quote/proposal '$, - l; Project Number •_ _ _ Account Number $_, 5$4 ^850^OO 1 1 1 8 0 0 .6 0 2 4 0 0 4 8 5 0 0 0 --- Project Number) -_ _ _ Account Number - $_,- - --- - - — T Project 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 re isition form,I certify the City's public contracting requirements have been satisfied. --�' Employee: f. Department Head: ``� l40,--- 0/Z l AA 1 �� (Equal to or greater than$5,0.07‘ Department Manager/Supervisor: City Administrator: (Equal to or greater than$25,000) Funds appropriated for current fiscal year: YES / NO Deputy Finance Director-(Equal to or greater than$5,000) Date Comments: Form#3-Requisition Carlson Construction Mailing: PO Box 1503 Medford OR 97501 Office: 1234 Corona Avenue Medford, OR 97504 541-773-3035 Cell: 541-601-3849 CCB# 173889 Email: bcarisonconstruction@hotmail.com BID PROPOSAL DATE SUBMITTED:10/10/19 CONTRACT AMOUNT:$4,850.00 . , Required Deposit:_ $ Signed bid& depositdueupon scheduling. Remainingbalance due upon job completion. , PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT: Owner: City of Ashland Address: 120 Clear Creek Dr . Address: City:Ashland City:. Phone: Phone: Dave Tygerson Email: Thank you for allowing Carlson Construction 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. Bid is to install(1)4"conduit from designated area at 120 Clear Creek address to vault location across the street by means of directional drilling,conduit and fittings will be suppliedby city,concrete and asphalt repairs will be performed by city. *Note:.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 as 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,this includes all city and or county inspection requirements. ILiability Disclaimer: Carlson Construction is not responsible for unmarked utilities,irrigation,private water, private power, landscape repairs,and/or unforeseens. Repairs will be completed at the owner's expense,and billed at time and material rates. . Reasonable access to be provided for equipment unless discussed prior to job. Extra cost to complete job due to verbal changes, adverse weather,ground condition,rock,and/or unforeseens will be billed at time and material rates. The prices quoted above are subject to change after 90 days of this proposal. ACCEPTANCE OF PROPOSAL The aboveprices,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 1 of 1 GOODS AND SERVICES AGREEMENT(LESS THAN$25,000) PROVIDER: Carlson Construction CITY O F, PROVIDER'S CONTACT Brent:Carlson ASHLAND bcarlsonconstruction@hotmail:com 20 East Main Street Ashland,Oregon 97520 . ADDRESS: 1234 Corona.Avenue, Medford,OR 97504 Telephone: 541/488-5587 Fax: 541/488-6006 PHONE: 541.773:3035; cell 541.601.3849 This Services:Agreement (hereinafter "Agreement") is entered into by and between the City of Ashland,:an Oregon municipal corporation (hereinafter "City") and Carlson Construction (a domestic/foreign.business) ("hereinafter"Provider"), for installation of conduit from 12.0 Clear Creek address to vault location across the ' street.:PROVIDER'S.OBLIGATIONS 1.1 Provide installation of (1) 4 conduit from .designated area at 120 Clear.Creek addressto vault location across the street by means of directional drilling. Conduit,and fittings will be supplied. bycity; and concrete and .asphalt repairs will be performed by city. See "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,::orthe equivalent,.of not less than $2,000,000 (two 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: 1 • Name asadditional 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 are intended to "layer" coverage.:and, taken together, they provide total coverage from the first dollar of liability;. Page 1 of 5: Agreement between the City of Ashland and:XXXXXX . . • Providershall 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. . 1.3 Provider shall, at- its own expense, maintain Worker's Compensation insurance :in compliance with. ORS 656.017, which. requires 'subject .employersto provideworkers' 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:partnershiip, 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 civilrights: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 is 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 amountof this. Agreement: is .$21,507.75: or more, Provider isrequired 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. CITY'S OBLIGATIONS 1.1 City shall pay.Provider the sum.of$4;850:00 as provided herein as:full':compensation for the Work as specified in the SUPPORTING DOCUMENTS. 1.2 In no event shall Provider's .totalof all "compensation .and' reimbursement under. this Agreement exceed the sum :of $4,850.00 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 toorder or authorize additional. Work which would cause this maximum sum to be exceeded and thatany 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: 2. GENERAL PROVISIONS 2.1. This is a non-exclusive Agreement. City is not:obligated to procure.any specific amount of Work from Providerand is freeto procure similar types of goods and services from other_ providers in its sole discretion. Page 2 of 5: Agreement between the City.of Ashland and:XXXXXX : . 2.2 Provider is an independent contractor and not an employee or agent of the City for any purpose:" J " " 2.3 Provider is not entitled to,:and expressly waives all claims to:City:benefits Such as health'and • disability insurance, paid leave; and retirement:. 2.4 This Agreement embodies the full and complete. Understandingof=the:parties respecting the subject matter hereof. It:supersedes all prior agreements, negotiations, and representations between the parties, whether written or oral. 2.5 This Agreement .may be amended only by written instrument executed with the. same formalities as this Agreement. 2;6 The following laws :of the State of Oregon are hereby incorporated by referenceinto this Agreement: ORS 2796.220, 2796.230 and 2796.235. - 3.7 This Agreement shall begoverned by the.laws of the State of Oregon without regard to conflict oflaws 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 infederal court, in which case exclusive venue,shall be in the federal district court forthe district of Oregon: Each"party expressly waives anyand allrights to maintain an action under this Agreementin any:other venue, and: expressly consents that, upon :motion of the otherparty, any case may_be dismissed or its venue-transferred, as appropriate, so as to effectuate this choice of venue. 3:8. Provider shall defend, save, hold harmlessand indemnify:the City and its:officers, employees and.agents from and against any and allclaims;. 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 bya court of competent "jurisdiction to be unenforceable; such provision shall not affect the :other provisions, but such unenforceable pr"ovision". 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.0,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 Page 3 of 5: Agreement between the City of Ashland and XXXXXX • 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. 4. SUPPORTING DOCUMENTS 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 Bid Proposal dated 10/10/19. 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; 5:1.2Withholding all moniesdue for the Work that Provider has failed to deliver within any scheduled completion dates .or. any.Work that have been delivered inadequately or defectively; 5.1.3Initiation of an action or proceeding for damages, specific performance, or declaratory or injunctive relief; 5;1.4These remedies are cumulative to the extent the remedies are not inconsistent, arid City may pursue any remedy or remedies singly, collectively, successively orin 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 anticipatedprofits.-.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 thedateof execution-on behalf of the City as set forth below (the "Effective_ Date"), and; shall continue in full force and effect until February 28, 2020, 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.- 6.2.2The City may, upon not less than thirty (30) days' prior written notice, terminate this Agreement for any reason deemed appropriate in its sole discretion: 6.2:3Either 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 Page 4 of 5: Agreement between the City of Ashland and.XXXXXX • 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: City of Ashland -Electric Department Attn: Dave Tygerson 20 E Main Street Ashland, Oregon 97520 Phone: (541)4882389 • With a copy to: = City.of Ashland Legal Department 20 E.-Main Street Ashland, OR 97520 Phone: (541.)488-5350 If to`Provider: Carlson Construction Attn;Brent Carlson PO Box 1503, Medford, OR 97501 8. WAIVER OF BREACH : One ormore 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 taxlaws of the Stateof Oregon, including:butnot 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. 9:1.2Provider, for a.period of na 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.provisionsimposed by a political subdivision of the: State of Oregon : applicable to Provider; and (iii) Any .rules, regulations, .charter.:provisions, or ordinancesthat implement or enforce anyof 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 subdivisionof the State of Oregon shall constitute a material breach of this-Agreement. Further, any violation:of Provider's.warranty, as set forth in this Article 9, shall constitute a materialbreach of this Agreement. Any material breach of this Agreement Page 5 64'5: Agreement between the City of Ashland and XXXXXX • 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. - IN WITNESS WHEREOF the parties have caused- this Agreement to be signed in their respectivenames by their duly authorized representatives as of.the datesset forth below. CITY.OF ASHLAND: Carlson Co � . "r `o (P' . D ): : By: , (ac0 By; ignature b'n Si, Tillfr Thomas McBartlett f !0"A JI :4 /,,,e;14 Printed Name . Printed Name Electric Department Director OWNif Title (// Tit October 25, 2019 1D .9q s Date . ate. (W-9 is to be submitted withthis signed Agreement)_ • Purchase Order No.. - 2 Page 6 of 5: Agreement between the City of Ashland and XXXXXX. ® DATE(MM/DDIYYYYI a►CoRI CERTIFICATE OF LIABILITY INSURANCE 10/30/2019 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 COVERAGEAFFORDEDBY 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 CONTACT NAME; LORI L MARTINEZ LORI L MARTINEZ(19083) . PHONE FAX 227 S HOLLY STREET INC.No.Ext): 541-772-4092 (NC.No):541:326 3049 E-MAIL LORLMARTINEZ COUNTRYFINANCIAL.COM MEDFORD,OR 97501-00.00 ADDREss: � ' INSURER(S)AFFORDING COVERAGE. . . NAIC# INSURER A COUNTRY Mutual Insurance Company 20990 INSURED 9795349 INSURER B CARLSON BRENT AXEL DBA CARLSON CONSTRUCTION INSURER C ATTN LAURIE STEVENS PO BOX 1503 INSURER D: MEDFORD,OR 97501 INSURER E INSURER F c 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 EFF POLICY EXP LIMITS - LTR INSR WVD 'POLICY NUMBER IMMIDD/YYYY) (MM/DD/ YYYY) - - GENERAL LIABILITY AB9058957 10/6/2019 10/6/2020 EACH OCCURRENCE $1,000,000 A ✓ DAMAGE TO RENTED ✓ COMMERCIAL GENERALLIABILITY - PREMISES(Ea occurrence) $100.000 • CLAIMS-MADE ✓ OCCUR MED EXP(Any one person) $25,000 PERSONAL&ADV INJURY. $1,000,000 -: GENERAL AGGREGATE $2.000.000 GEN L AGGREGATE LIMIT APPLIES PER PRODUCTS COMP/OP AGG $2,000,000 POLICY ri JEC 7 LOC. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1AB9058957 10/6)2019 10/6/2020 (Ea accident) $1.000.000 ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED AUTOS ✓ AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ • �/ HIRED AUTOS ✓_ AUTOS (Per accident) • • UMBRELLA LAB �/ " AU9274380 10/6/2019 " 10/6/2020 ✓ OCCUR EACH OCCURRENCE $2,000,000 A EXCESS LIAB" CLAIMS-MADE. AGGREGATE $2,000,000 DED ✓ RETENTION$ 10.000 $ WORKERS COMPENSATION - WC STATU- ' OTH- ' AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER 'ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT ' - $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ . If yes,describe under ' DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ . DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) JOB NAME: 120 CLEAR CREEK (CONTINUED).. CERTIFICATE HOLDER 'CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF ASHLAND . : . : THE EXPIRATION DATE'THEREOF," NOTICE .WILL' BE DELIVERED" IN ACCORDANCE WITH THE POLICY PROVISIONS: 20 EAST MAIN ST ASHLAND,OR 97520 AUTHORIZED REPRESENTATIVE ©1988-2010 A •-D ' • ORATION. All-rights reserved. ACORD 25(2010/05) The ACORD name and logo are.registered marks of ACORD AGENCY CUSTOMER ID: LOC#: ACCPRD ADDITIONAL REMARKS SCHEDULE Page . 1 of 1 AGENCY NAMED INSURED CARLSON BRENT AXEL DBA CARLSON CONSTRUCTION POLICY NUMBER ATTN LAURIE STEVENS AB9058957 PO BOX 1503 MEDFORD,OR 97501 CARRIER - - - - NAIC CODE COUNTRY Mutual.Insurance Company 20990 EFFECTIVE DATE: 10/30/2019 ADDITIONAL REMARKS • THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE REMARKS: . THE CITY OF ASHLAND,ITS ELECTED OFFICIALS,OFFICERS&.EMPLOYEES ARE INCLUDED AS ADDITIONAL INSUREDS. COVERAGE IS PRIMARY AND NON-CONTRIBUTARY. ADDITIONAL INSURED(S): CITY OF ASHLAND 20 EAST MAIN ST ASHLAND,OR 97520 • ACORD 101 (2008/01.) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • - COMMERCIAL GENERAL.LIABILITY CG 200104.13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY OTHER INSURANCE CONDITION This endorsement modifies insurance'provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART. . The following is added to the Other_Insurance - (2) You have agreed in writing in a contract or Condition and supersedes any provision to. the- agreement that this insurance. would be contrary: primary and would. not seek contribution Primary Arid Noncontributory Insurance _ from any other insurance available:to the additional insured. This,insuranceis primary to. and will not seek contribution from any other insurance available to an .additional insured .under your policy provided that: (1). The additional insured is a Named Insured under such other insurance; and • CG 20 01 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: AB9058957 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s)Or Organization(s): CITY OF ASHLAND Information required to complete this Schedule, if not shown above,will be shown in the Declarations.. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or. ' additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect toliability for"bodily injury", "property If coverage provided to the additional insured is damage" "personal personal and advertising injury" required by a contract or agreement, the most we caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the omissions or the acts or omissions of those'acting amount of insurance: on your behalf: 1. Required by the contract or agreement; or 1. In the performance of your ongoing operations; 2. Available under the applicable pPlicable Limits of 2. In connection with your premises owned by or Insurance shown in the Declarations; rented to you. whichever is less. However: This endorsement shall not increase the 1. The .in urance afforded to such additional applicable Limits of Insurance shown in the Declarations. insured only applies to the extent permitted by law; an 2. If coverage provided to,the additional insured is required by a, contract or agreement, the insurance afforded to such additional insured will not!be broader than that which you are required by the contract or agreement to provide!for such additional insured. CG 20 26 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 1 i • • HP LaserJet CM1415fnw Fax Confirmation City of Ashland - 5415522436 Oct-30-2019 2:48PM Job Date Time Type Identification Duration Pages Result 1984 10/30/2019 2:47:36PM Receive 0:36 0 No Fax Detected • www.saif.com Oregon Workers' Compensation Work: say Certificate of Insurance Life. Oregon. Certificate holder: CITY OF ASHLAND ' 20 EAST MAIN ST ASHLAND, OR 97520 • . I f The policy of insurance listed below has been issued to the insured named below for the policy period indicated.The insurance afforded by this policy is subject to all the terms,exclusions and conditions of such policy;this policy is subject to change or cancellation at any time. Insured Producer/contact • Brent Axel Carlson CC Services Inc Carlson Construction Lori Martinez U Laurie Stevens 541.772.4092;lori.martinez@countryfinancial.com PO Box 1503 Medford, Or 97501-0112 • • Issued 10/30/2019 Limits of liability Policy 878937 Bodily Injury by Accident $1,000,000 each accident Period 12/01/2019 to 12%01/2020 Bodily Injury by.Disease ' • $1,000,000 each employee Body Injury by Disease $1,000,000 policy limit Description of operations/locations/special items All operations Important • This certificate is issued as a matter of information only and confers no rights to the certificate holder.This certificate does not amend,extend or alter the coverage afforded by the policies above.This certificate does not constitute a contract between the issuing insurer, authorized representative or producer and the certificate holder. Authorized representative • )('2 _RasDC— Kerry Barnett President and CEO • 400 High Street SE Salem,OR 97312 P:800.285.8525 F:503.584.9812 Policy_OLCA Certificate0flnsurance