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HomeMy WebLinkAbout2021-134 PO 20220180- Rogue Boiler Works 1 _ A 1 4 ` Purchase Order ris Fiscal Year 2022 Page: 1 of: 1 , . B City of Ashland �0 ,a�IOtslC6 17,tm � 20 E. Main ATTN: Accounts Payable Purchase L Ashland, OR 97520 0 Order# 20220180 T Phone: 541/552-2010 0 Email: payable@ashland.or.us V H C/O Facilities Maintenance Div E ROGUE BOILER WORKS 1 90 North Mountain Ave N 936 PARKDALE AVE p Ashland, OR 97520 MEDFORD, OR 97501 Phone: 541/488-5358 O R T Fax: 541/552-2304 ^ �fi +-.�.a- -...^adti(� �l L_9ET.:a,-..5-r- 31fi \ __ _s —`.F_ '_}_ �"''c.Tc_ .- '.�..]4ri3.._ --u-.. -" - -- _•_ �'"- _ _ DavidArnold _ �I� Yt]YTiI� .��g .= _-.2'',---2--r- __ 2A_ A iTi J--l7_ ;-R , _=�d_e:e _�2 ., -frg-e= ...1,7H--,,i--t—z-, 11/01/2021 _ 4420 FOB AS_HLAND,OR/NET30 _ City Accounts Payable _1-.--L--7-----=-----7-7-1--- MAW On-call Boiler Services I 1 On-call Boiler Services - 1.0 $3,500.00 $3,500.00 Goods and Services Agreement($35,000 or Less) Completion date: June 30, 2022 Project Account: ********,.****** GL SUMMARY*,k************* 088400-602400 $3,500.00 I. I I I I , - lk By. .��_ 1_.>-..zDate: \ /0"--W _: _- Au honzed Signature ®� _ ,3 500.00 FORM #3CITY OF , , -a ( P er REQUISITION Pate of request: 10/26/2021 Required date for delivery: Vendor Name Rogue Boiler Works Address,City,State,Zip 2105 Corey Road.Central Point.OR 97502 Contact Name&Telephone Number Matt Smith 541-613-5457 roqueboiler anoutlook.com Email address SOURCING METHOD ❑ Exempt from Competitive Bidding ❑ Emergency ❑ Reason for exemption: ❑ Invitation to Bid - ❑ 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 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) 0 Request for Qualifications(Public Works) 0 State of Washington Date approved by Council: Contract# (Attach copy of council communication) 1 0 Other government agency contract Intermediate Procurement 0 Sole Source Agency GOODS&SERVICES 0 Applicable Form(#5,6,7 or 8) Contract# Greater than$5,000 and less than$100,000 0 Written quote or proposal attached Intergovernmental Agreement ❑ (3)Written quotes and solicitation attached 0 Form#4,Personal Services>$5K&<$75K Agency , PERSONAL SERVICES 0 Special Procurement 1 ❑ Annual cost to City does not exceed$25,000. Greater than$5,000 and less than$75,000 0 Form#9,Request for Approval 1 Agreement approved by Legal and approved/signed by ❑ Direct appointment not to exceed$35,000 0 Written quote or proposal attached City Administrator.AMC 2.50.070(4) ❑ (3)Written proposals/written solicitation Date approved by Council: I 0 Annual cost to City exceeds$25,000,Council ❑ Form#4,Personal Services>$5K&<$75K Valid until: (Date) 1 approval required.(Attach copy of council communication) Description of SERVICES , Total Cost As Needed Boiler service for FY22 $.3,500:00 Item# Quantity Unit Description of MATERIALS Unit Price Total Cost El Per attached quotelproposal TOTAL',COST `• Project Number _ _ _ Account Number 088400-6024010 r - 1 *Expenditure must be charged to the appropriate account numbers for the financials to accurately reflect the actual expenditures. 1 IT Director in collaboration with department to approve all hardware and software purchases: i IT Director Date Support-Yes/No By signing this requisition form,I c ' that the City's pu c c racting requirements have been satisfied. Employee: Department Head �� drai 1616 2 ri $5,000 Department Manager/Supervisor: City Administrator: (Equal to or greater than$25,000) Funds appropriated for current fiscal year: YES /NO Deputy Finance Director-(Equalto orgreaterthan$5,000) Date Comments: i Form#3-Requisition j 1 • GOODS AND SERVICES AGREEMENT($35,000 OR LESS) PROVIDER: Rogue Boiler Works CITY OF PROVIDER'S AS H LAN D CONTACT: Matt Smith 20 East Main Street Ashland,Oregon 97520 ADDRESS: 936 Parkdale Avenue Telephone: 541/488-5587 Medford,OR 97501 Fax: 541/488-6006 PHONE: 541-613-5457 This Goods and Services Agreement (hereinafter "Agreement") is entered into by and betweentheCity of Ashland, an Oregon municipal corporation (hereinafter "City") and Rogue Boiler Works, (a domestic/foreign business corporation)("hereinafter"Provider"),for boiler service. Y. PROVIDER'S OBLIGATIONS I ; 1,1 Provide boiler service for FY22 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 $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: • 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; l as run • Apply y p ' ary 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; • 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 tliis Agreement; and • Be evidenced by a certificate or certificates of such insurance approved by the City. Page 1 of 6: Goods and Services Agreement between the City of Ashland and Rogue Boiler Works I _ • • 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.I 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 relation between the assignee or subcontractor and the City. 2, CITY'S OBLIGATIONS 2.1 City shall pay Provider the hourly rates effective 8/6/2021 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$3,500 (this is maximum, not to exceed amount lof 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 Rogue Boiler Works • • 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,negotiation's,and representations between the parties, whether written or oral. 3.5 This Agreement may be amended only by written inst ument;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 venue. 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. - 110 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 la 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 tr�ansfer all warranties to the City. ji f, Page 3 of 6: Goods and Services Agreement between the City of Ashland and Rogue Boiler Works _ • • • 4. SUPPORTING DOCUMENTS 43 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 August 6,2021. 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'•elated to termination of this Agreement or for anticipated profits.If previous amounts paid to Provideriexceed the amount due,Provider shall pay immediately any excess to City upon written demand provided. 6. TERM AND TERMINATION 6.1 Terni • 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, 2022, 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 Rogue Boiler Works 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: i i . Rogue Boiler Works ' Attn:Matt Smith 1 541-613-5457 i I 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. I 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: 1 (i) All tax laws of the State of Oregon, including but not limited to ORS 305.620 and ORS chapters 316,317,and 318; 1 K (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 taxi 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: 1 (i) All tax Iaws of the State of Oregon, including'but not limited to ORS 305.620-and ORS chapters 316,317,and 318; I o R (ii) Any tax provisions imposed.by a political subdivision of the State of Oregon applicable to Provider; and i ; (iii) Any rules,regulations, charter provisions,or ordinances that implement or enforce any of F 5 the foregoing provisions. i I I) t 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 inaterial breach of this Agreement. Further, any violation of Provider's warranty, as set forth in this 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. . J P 1 Page 5 of 6: Goods and Services Agreement between the City of Ashland and Rogue Boiler Works . i 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: Rogue Boiler Works(PROVIDER): By: By: 2— CEO__ Signature &orc--LE0e-y Mikir ,S-r1 Printed Name Printed Name PUe:u L t,XZrs tJl 2Fc Title Title to(224 f D I MI zc Date 1 Date (W-9 is to be!submitted with this signed Agreement) Purchase Order No. • Page 6 of 6; Goods and Services Agreement between the City of Ashland and Rogue Boiler Works ' I • • • iii "� "" "" .' ".:. r ► - '-: 8/6/2021 Invoice# Pot Customer: City of Ashland. Job Location: Services to be Provided: Hourly rates. Lead Mechanic per hour. $115.00 � I Lead Mechanic overtime per hour. $172.50 Mechanic and helper per hour. $185.00 Mechanic and helper overtime per hour. $277.50 �t1 Total. $0 A Terms Net15. *Credit cards accepted. CSLB#1007364 DIR#1000029463 CCB#200332 6 I € I - • State Farm at CityLine PO Box 853922 Richardson, IX 75085-3922 G State !i Farnr State Farm Mutual Automobile Insurance Company ROGUE BOILER WORKS PO BOX 809 SHADY COVE OR 97539-0809 { I j IMPORTANT NOTICE Policy information Policy number: 3864337-B12-37 June 7,2021 We're contacting you about the above State Farm®policy. We're enclosing your Declarations for the above policy for the period August 12,2021,to February 12, 2022. Please keep it for your records. • This is not a bill.The policy premium is being added to your new billing account. Your premium may be influenced by the drivers shown below and the other individuals permitted to drive your vehicle(s).This list does not extend or expand coverage beyond that contained in this automobile policy.The drivers listed below are the drivers reported to us that frequently drive vehicles in your household. Genevieve v Cutts, MATTHEW SMITH When you buy an additional car or one that replaces a car already on your policy, you need to report the change to your State Farm agent promptly.Even though the dealership you purchased the car from may offer to notify your State Farm agent or insurance company,you,as the named insured,are responsible for reporting all changes to your auto policy.By contacting your State Farm agent,you can help: • avoid any complications or lack of coverage in the event of an accident or loss, • avoid insurance verification problems with a lienholder,the police,or the department of motor vehicles,and • ensure that you receive any new discounts you may be entitled to. Prepared:June 4,2021 — Page 1 of 2 1 I 151511.5 10-17-2020 4 I ,05 6' t,to F., f t d f3 Your current State Farm policy automatically provides certain coverages for a new or replacement car for up to a specified, limited number of days after you take possession of the car. Please refer to your policy for the number of days that applies in your state. THANK YOU FOR CHOOSING STATE FARM.WE APPRECIATE YOUR BUSINESS. ' If you have any questions,call your State Farm Agent Russell Brown at 541-776-8466.If you are deaf,hard of hearing,or do not use your voice to communicate,you may contact us via 711 or other relay services. cc:Russell Brown 37-2275 DISCLAIMER: This message is provided for informational purposes only and does not grant any insurance coverage. The terms and conditions of coverage are set forth in your State Farm Car Policy booklet, the most recently issued Declarations,and any applicable endorsements. Page 2 of 2 00 tteFar ,i • State Farm Mutual Automobile Insurance Company State Farm at CityLine PO Box 853922 Richardson TX 75085-3922 Your State Farm Agent Russell Brown - Russell P Brown Ins Agcy Inc 2581 W Main St Medford OR 97501 Bus:541-776-8466 Email:russell.p.brown.jtl7@statefarm.com Declarations Policy number:3864337-B12-37 Named Insured: ROGUE BOILER WORKS Policy period:August 12,2021 to February 12,2022 The policy period begins and ends at 12:01 am standard time. BUSINESS CAR POLICY Policy address: • PO Box 809 Years in business: 8 , Shady Cove OR 97539-0809 Business description: Plumbing-Commercial. Business owner(s): AUTOMATIC RENEWAL This State Farm®policy will be renewed automatically subject to the rates,in effect,the coverages carried,the applicable limits, deductibles, and other elements that affect the premium that apply at the time of renewal. ENTITY Partnership POLICY PREMIUM This is not a bill.If an amount is due, then a separate statement will be sent prior to the due date. The premiums shown in the table(s)below are the 6-month premiums for the characteristics of the policy as described in this Declarations. 55 ;, TOTAL P.R0MIUM.-. . x. ERIESSelelematt gal $7 Coverage Symbols Vehicle 001 Premium $182.65 Included $19.59 $1.74 002 Premium $25.58 Included 003 Premium $175.72 .Included $18.60 j • $1.65 Policy Number:3864337-1312-37 Page 1 of 3 Prepared:June 4,2021 fi C10085990R-CV , 1008599 2005 15]5]0 205 03-20-2021 h { • • ® ® StateFarrrr ......:.... . Covera a ,.y bol D:;>:; ;i:: ;: .. Vehicle �.; :::'::... ...:.... ........ . .......::::....G:.:�:::':::':-,! :;::;.::::,;:- H _-.:: .. .. .... .. .... .. . Total premium by car 001 Premium $53,27 $118.07 $4.80 $380.12 Deductible $1,000 $1,000 002 Premium $25.58 Deductible 003 Premium $55.29 $123.79 $4.80 $379.85 Deductible $1,000 $1,000 VEHICLE SCHEDULE VEHICLE 001 Vehicle year:2015 Gross vehicle weight(lbs):12300 j Garaged address: Make:DODGE Total MSRP:$48,737 ! 936 PARKDALE AVE Model:RAM 3500 Radius of operation(mi.):100 mi. MEDFORD OR 97501-1892 VIN:3C63RRGL0FG504194 Annual mileage(ml.):12000 mi. Territory:016 Vehicle use description:Service/Contractors Special equipment:Rack(miscellaneous)2015 Unknown$2,500 VEHICLE 002 Vehicle year:2015 Gross vehicle weight(lbs):7000 Garaged address: Make:INTERSTATE Total MSRP:$5,500 936 PARKDALE AVE Model:TRAILER Radius of operation(mi.):100 mi. MEDFORD OR 97501-1892 VIN:4RACS1423FN094859 Annual mileage(mi.): Territory:016 Vehicle use description:Service/Contractors VEHICLE 003 Vehicle year:2016 Gross vehicle weight(lbs):12500 Garaged address: Make:DODGE Total MSRP:$53,036 936 PARKDALE AVE Model:3500 Radius of operation(mi.):50 mi. MEDFORD OR 97501-1892 VIN:3C63RRGL5GG339549 Annual mileage(mi.):10000 mi. Territory:016 Vehicle use description:Service/Contractors Special equipment:Rack(miscellaneous)2016 Unknown$2,500 COVERAGES AND LIMITS This policy provides the following coverages to the vehicles for which the appropriate"Coverage Symbol"and a corresponding premium are shown in the"POLICY PREMIUM" schedules above. Coverage Symbol ,.,: ...Coverage. . [.imtt A Liability Coverage Bodily Injury Limit Each Person, Each Accident • $100,000 $300,000 Property Damage Limit • Each Accident . $100,000 D Comprehensive Coverage G Collision Coverage H Emergency Road Service Coverage P2 Personal Injury Protection Coverage See Policy Schedule for Limits U1 Uninsured Motor Vehicle Bodily Injury and Property Damage Coverage Property Damage Limit Each Accident $20,000 Policy Number:3864337-812-37 Page 2 of 3 Prepared:June 4,2021 • • oo S ateFa `i F Coverage Symbol, ., Coverage . ::..: Lima t U Uninsured Motor Vehicle Bodily Injury Coverage Bodily Injury Limit Each Person, Each Accident $100,000 $300,000 FORMS AND ENDORSEMENTS This policy consists of this Declarations, the policy booklet-Form 9637C,and any,endorsements that apply, including those listed below as well as those issued subsequent to the issuance of this policy. Endorsement(s) that apply only to VEHICLE(S)listed 4052G TRAILER ENDORSEMENT VEH002 IMPORTANT MESSAGES MUTUAL CONDITIONS Membership.While this policy is in force, the first insured shown on the Declarations is entitled to vote at all meetings of members and to receive dividends the Board of Directors in its discretion may declare in accordance with reasonable classifications and groupings of policyholders established by such Board. No contingent liability.This policy is non-assessable. Annual meeting.The annual meeting of the members of the company shall be held at its home office in Bloomington, Illinois,on the second Monday of June at the hour of 10:00 a.m.,unless the Board of Directors shall elect to change the time and place of such meeting, in which case, but not otherwise,due notice shall be mailed each member at the address disclosed in this policy at least 10 days prior to thereto. In Witness Whereof,the State Farm Mutual Automobile Insurance Company has 'Caused this policy to be signed by its President and Secretary at Bloomington, Illinois. 1 .y,A4tfit .fig *.vt ' . President Secretary it I It � I x � ie 1 � li I l Policy Number:3864337-B12-37 ! Page 3 of 3 Prepared:June 4,2021 # I • 10 A1co/ ® CERTIFICATE OF LIABILITY INSURANCE • DATE MM!DDI YY) V 1 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). PRODUCERg y CONTACT ' Russell P Brown Ins A c Inc NAME: Russell iP Brown 2681 W Main St (nuc No.Ext):541-776-8466 FAX No):541-776-8473 • EMAIL Stater-arm Medford,Or 97501 ADDRESS:russeII(irusaallbrown.blz INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:State Farm Fire and Casualty Company 25143 INSURED Rogue Boiler Works LLC INSURER B: Fa. 936 Parkdale Ave INSURER C) E - Medford,Or 97501 -1892 • INSURERD: ^r INSURERE: INSURERF: 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. LTR TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LIMITS ( INSR WVD POLICY NUMBER ommarYYYYI (MM/DOIYYYVI GENERAL LIABILITY A Y 97-CM-L796-1 0110212021 01/0212022 EACH OCCURRENCE $ 2,000,000 ENTED X COMMERCIAL GENERAL LIABILITY I PREMISES(Eaoccurrence) $ 100,000 CLAIMS-MADE I I OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ GENERAL AGGREGATE _S 4,000.000 • GEN'LAGGREGATE UM128,-.ITAPP�LIESPER: PRODUCTS-COMP/OP AGO $ 4,000,000 7 POLICY I I IfI LOC I Business Property $ 75000 AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT A Y u 3864337-612-37 08/12/2021 08/12!2021 IEa accident) S — X ANYAUTO BODILY INJURY(Per person) $ 100000_ X ALL OWNED — SCHEDULED BODILY INJURY(Per occident) AUTOS AUTOS $ 300000 NON-OWNED PROPERTY DAMAGE HIRED AUTOS _AUTOS (Peracctdent) $ 100000 S r UMBRELLA LIAB _OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTIONS _ $ WORKERS COMPENSATION TORYTAA177US T AND EMPLOYERS'LIABILITYER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN EA_EACH ACCIDENT $ OFFICE/MEMBER EXCLUDED? II N I A 1 (Mandatory in NH) EL.DISEASE-EAEMPLOYEE $ l If yes,describe under DESCRIPTION OF OPFRATIONS below E.L.DISEASE-POLICY LIMIT $ 1 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Sehodula,It more apace In required) iti Pr )' I CERTIFICATE HOLDER CANCELLATION Additional Insured: SHOULD AN SOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE i; 184.231.9 THE EXP1 TION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDd CE WITH THE POLICY PROVISIONS. IJ City of Ashland I I 20 East Main St AUTHORIZE REPRESEN E Ashland,Or 9752044-A.1 I 6/I I 1.1„,—--—_......_ ©1988-2010 ACORD CORPORATION. All rights reserved. ly. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1001486 132849.8 01-23-2013 Il I 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 ( ) • Contractoris a sole proprietor,and • Contra ctorhas no employees,and • Contractor will not hire employees or subcontractotsto perform this contract. I i 11 CORPORATION-FOR PROFIT (Initials) • Contractor's business is incorporated;and ■ All employees of the corporation are officers and directors andhavea substantial ownership interest*in the corporation,and • All work will be performed by the officers and directors;Contractorwill not hire other employees or subcontractors to perform this contract. CORPORATION-NONPROFIT (Initials) ■ ' Contractor'sbusinessisincorporated asanonprofit corporation,and . • Contractorhas no employees;all work is performedby volunteers,and ■ Contractorwill not hire employees or subcontractors to perform this contract. __ PARTNERSHIP (Initials) • Contractor is a partnership,and 67 Contractorhasno employees,and ■ All work will be performed by the partners;Contractorwill not hire;employees or subcontractors to perform this contract,and ■ Contractoris not engaged in work performed in direct connection with the construction,a Iteration,repair, improvement,moving or demolition of an improvement to real property or appurtenances thereto.** LIMITED LIABILITY COMPANY (Initials) • Contractoris a limited liability company,and • Contractorhasno employees,and ■ All work will be performed by the members;Contractorwill not hire employees or subcontractors to perform this contract,and - a If Contractor has m ore than one member,Contractoris not engaged in work performed in direct connection with the construction,alteration,repair,nnprovement,moving or demolition of an improvement to real property or q appurtenances thereto.** `'4/�- /a /o //2/2621 (Signature of Authorized Signer) (Date) ( (Sigter'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 shareholderhas 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 contractorwho will perform construction work. ( s I b , LB Policy No. 97 CML796 1 2275 LFAE6 CMP-4684.1 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CMP-4684.1 ADDITIONAL INSURED —OWNERS, LESSEES, OR CONTRACTORS (Scheduled) This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 97 CML796 1 Named Insured: ROGUE BOILER WORKS LLC • 936 PARKDALE AVE MEDFORD, OR 97501-1892 Name And Address Of Additional Insured Person OriOrganization: CITY OF ASHLAND 20 EAST MAIN ST ASHLAND, OR 97520 1. SECTION II — WHO IS AN INSURED of SECTION II — LIABILITY is amended to include, as an additional insured, any person or organization shown in the Schedule, but only: a. Ongoing Operations With respect to liability for "bodily injury", "property damage", or "personal and advertising injury" caused by your ongoing operations for that additional insured and only to the extent that such "bodily injury", "property damage" or "personal and advertising injury" is caused by your negligence or the negligence of those performing operations on your behalf; or b. Products-Completed Operations To the extent that the liability for "bodily injury" or "property damage" is caused by "your work" per- formed for that additional insured and included in the "products-completed operations hazard". 2. Any insurance provided to the additional insured shall only apply with respect to a claim made or a "suit" brought for damages for which you are provided coverage. 3. Primary Insurance. The insurance afforded the additional insured shall be primary insurance. Any insurance carried by the additional insured shall be noncontributory with respect to coverage provid- ed by you. All other policy provisions apply. CMP 4684.1 155600 04-09-2019 ©,Copyright,State Farm Mutual Automobile Insurance Company,2018 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. it � 1