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HomeMy WebLinkAbout2020-074 PO 20200307- Carlson Construction Purchase Order Fir41 CITYC® � Fiscal Year 2020 Page: 1 of: 1 �a pao=i3 :s_.ing B City of Ashland ATTN: Accounts Payable L 20 E. Main Purchase L Ashland, OR 97520 Order# 20200307 T Phone: 541/552-2010 O Email: payable@ashland.or.us V H CIO Electric Department E CARLSON CONSTRUCTION I 90 North Mountain Ave N PO BOX 1503 p Ashland, OR 97520 O MEDFORD, OR 97501 Phone: 541/488-5357 R T Fax: 541/552-2436 ter)€L-!6arj€ =e.-1=13 61Z�E Ali ct� . =- ._ E . {ei€ ) �E ;t-[Ee= Ma McCla — o- 01/21/2020 1669 Ci Accounts Pa able Conduit for charging stations 1 Directional drill from transformer in the parking lot to address 175 1 $4,500.0000 $4,500.00 Lithia Way under asphalt to a planter area about 90' away to install (1)4" conduit for additional charging stations. Contract for Carlson Construction Completion date: 07/01/2020 Project Account: ***************GL SUMMARY*************** 024700-704100 $4,500.00 K ,,jjam� By: r gt\' Date: ( 34 ao „<. Authorized Signature • 1 $4,500.00 aY' e FORM #3 (6144`.4At I Y F A request fbr a Purchase Order ASHLAND REQUISITION D j D g D,7Date of request: 01/13/2020 Required date for delivery: , Vendor Name CARLSON CONSTRUCTION Address,City,State,Zip PO BOX 1503 MEDFORD,OR 97501 2 , Contact Name&Telephone Number . Breant Carlson 541 773-3035(cell)541 601-3849 Email address CCB#173889 Email:bcarlsonconstruction@hotmail.com SOURCING METHOD ❑ Exempt from Competitive Bidding _ ❑ Emergency ❑ Reason for exemption: 0 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 a•'royal re,uired,attach co. 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 bid(s)or proposal(s) 0 Request for Qualifications(Public Works) ❑ State of Washington Date approved by Council: Contract# _(Attach copy of council communication) ❑ Other government agency contract Intermediate Procurement ❑ Sole Source - Agency GOODS&SERVICES ❑ 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 bids&solicitation attached 0 Form#4,Personal Services$5K to$75K Agency PERSONAL SERVICES - ❑ Special Procurement 0 Annual cost to City does not exceed$25,000. Greater than$5,000 and less than$75,000 0 Form#9,Request for Approval Agreement approved by Legal and approved/signed by ❑ Less than$35,000,by direct appointment ❑ Written quote or proposal attached City Administrator.AMC 2.50.070(4) ❑ (3)Written proposals&solicitation attached Date approved by Council: ❑ Annual cost to City exceeds$25,000,Council ❑ Form#4,Personal Services$5K to$75K Valid until: - (Date) approval required.(Attach copy of council communication) Description of SERVICES Total Cost Bid is to include directional drill from transformer in the parking lot next to address 175 Lithia • Way,under the asphalt to a planter area about 90'away to install(1)4"conduit for additional - •-• ' charging stations. Conduit and fittings will be supplied by city. Any concrete,asphalt,or landscape $4',500.00, repairs will be made by city. Permits supplied by city. Item# Quantity Unit Description of MATERIALS Unit Price Total Cost / ® Per attached quote/proposal •TOTAL COST Project Number _ _ _ Account Number _0 24 7 0 0 •_7 0 410 0 $4;500.00 • Account 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 r uisition form,I certify thattheCity's public contracting requirements have been satisfied. 7� Employee: `f.0 Department Head: �� G 7 1-I? 00 (Equal to or greater than$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-(Equal to or greater than$5,000) Date Comments: - Form#3-Requisition . Contract for Carlson•Construction - . - - CITY OF. - •. INDEPENDENT CONTRACTOR: Carlson Construction . • : • • ASHLAND -CONTACT: Brent Carlson - - - • - • - 20 East Main Street. -. - _ .ADDRESS:1234 Corona Avenue,Medford,OR 97504 - - - - : Ashland,Oregon 97520- TELEPHONE: 541 773;3035;.(ceil).541.601.3849 . FAX: Telephone:.:541/488-6002 Fax: .541/488-5311 . .' EMAIL:bcarlsonconstruction@hotmail:com . . " . . . . •EFFECTIVE DATE:.01/13/2020 . ' : • COMPLETION DATE: 07/01/2020 - . . • • . . . •• ' . " ' . -TOTAL COMPENSATION:$4,500.00 . . . . GOODS AND SERVICES TO BE PROVIDED: - . - 'Bid is to include_directional drill.from transformerin the parking lot next-to address 175 Lithia Way,-under the asphalt to a planter area about 90'away to install(1)4"conduit foredditional charging stations. Conduit and:fittings.will be supplied by - .city..Any concrete, asphalt, or landscape.repairs will.be made by city. Permits.supplied by city: . ADDITIONAL.TERMS: • • • • . • In the.event of a conflict or discrepancy among the Contract Documents,this City of Ashland Contract will be primary and take precedence,and any . :exhibits or.ancillary agreements having redundant or contrary.provisions will be subordinate to and interpreted in:a manner that will:not conflictwith:the • said primary City of Ashland Contract. .. ." - NOW THEREFORE;the CITY AND CONTRACTOR HEREBY AGREE as follows: . - . • . . . ' " " : 1. .All Costs by Contractor::Contractor shall;provide all goods as specified above and shall at its own risk and expense;perform any work . • described above:and,unless otherwise specified,furnish all labor,equipment and materials.required for the:properperformance of such:work. - 2: Qualified Work:- Contractor•has represented;and-by entering into this contract now represents,that any personnel assigned to the work required under this contract are fully qualified to perform the work to which•they will.be assigned in a skilled andworker-like manner and;if required to be • 'registered,.licensed or bonded•by the State of Oregon,are so registered,licensed and bonded.Contractor must also maintain a current City - , - business license. _ : • • • _ - 3.. Ownership of Production:All documents,materials or items produced by Contractor pursuant to this contract shall be the property of City.. • • • - 4: Statutory Requirements:ORS 2798.220,279B.225i 2798.230;279B.235,ORS Chapter 244 and ORS 670.600 are made part of this contract. . 5: . Indemnification:Contractor agrees to defend,indemnify and save City,.its officers,.employees and agents harmless from those losses," - expenses,or other damages resulting from injury.to any personor damege.to property.arising out.of or incident to the negligent performance of - : this'contractby Contractor its employees,or agents. Contractor shall not be held responsible for any losses,expenses,or other damages; : . directly,solely,_and proximately caused,by the.negligence.of.City. : . . . • : - 6.' Termination:. City's•Convenience. This contract may be.terminated-at any time'by the City. . • •. . "- 7: Independent Contractor Status:-Contractor is an.independent Contractor andnot an employee of the City. Contractor shall have the complete • . responsibility for the performance of this contract. . 8.- .Non-discrimination Certification:The undersigned certifies that the undersigned Contractor has not discriminated against.minority,women or • : - ' emerging small businesses enterprises in obtaining any required subcontracts. C_ontractor-further certifies that it shall not discriminate in the award"of such subcontracts,if any. . - . , . . . . . ." . . . . . . . . . . - 9: Asbestos Abatement License: If required under ORS 468A.710,Contractor or Subcontractor shall possess an asbestos abatement license.. 10. Assignment and.Subcontracts:.Contractor shall not assign this contract or subcontract any portion of the work.. - : 11-..Use of Recyclable Products:Contractor shall use recyclable products.to the maximum extent economically feasible in the performance of the - contract work set forth in this document - . - -12. Default: The Contractor shall be in default of this agreement if-Contractorcommits any'material breach or default of any covenant-warranty, . • . certification,or obligation it owes under the Contract. . 13. Insurance. Contractor shall at its.own expense provide the following insurance: , • . . . , •- a: a. Worker's Compensation insurance incompliance with ORS 656:017; hich•requires subject.employers to.provide-Oregon.workers'- - . compensation coveragefor all their-subject workers. Worker'scompensation insurance is required if work-is performed by employees,' . . • - . - . subcontractors,or volunteers. - BY INITIALING THIS SENTENCE,CONTRACTOR CERTIFIES UNDER PENALTY OF LAW THAT THE WORK REQUIRED BY THIS • -CONTRACT SHALL BE PERFORMED SOLELY BY THE UNDERSIGNED: - - - - - - • b, • General Liability insurance with a combined single limit or the equivalent,of not less than$1,000,000 for each occurrence for Bodily. Injury and Property Damage. . • c. • Automobile Liability insurance with a combined single:limit,or the equivalent;of not:less:than$1,000,000'for each accident for Bodily • . Injury and Property Damage;including coverage for-owned,hired or non-owned vehicles,as applicable. • "14. Governing Law;Jurisdiction;•Venue:This contract shall be governed and construed in accordance with.the laws of the State of Oregon - 15. THIS CONTRACT AND ATTACHED EXHIBITS CONSTITUTE THE•ENTIRE AGREEMENT BETWEEN THE PARTIES.-NO WAIVER,CONSENT, - -. " .MODIFICATION OR"CHANGE OF"TERMS'OF THIS CONTRACT SHALL BIND EITHERPARTY UNLESS IN WRITING AND•SIGNED BY BOTH PARTIES. . - - ' . . . . . . . -16. Certification. Contractorr shall sign-the certification attached-hereto as-Exhibit Nand'herein incorporated by-reference. 17. Consultant's compliance with.Oregon Tax Law: (1): Consultant represents and warrants to the City that,Consultant shell,.throughput.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 Consultant;and,• , - . (iii) Any rules,regulations,charter provisions,or ordinances that implement or enforce any of,the foregoing tax laws or provisions. (2) Consultant represents and warrants that,'for a period of.no fewer than six (6)Calendar years'preceding the Effective'Date'of this Agreement, it- : faithfully complied.with: _ . -: • • (i)-: All tax laws of the,State of Oregon,including but notlimited to ORS 305:620 and ORScChapters$16,:317,-and 318;_ - . Revised 10-28-14 Page 1"of 2- - (ii) Any tax provisions imposed by a political:subdivision of the State of Oregon applicable to'Consultant;and • : (iii) Any rules,regulations;charter provisions,or ordinances that implement or enforce any of the foregoing•tax laws or provisions: ' CONTRACTOR: CITYOF ASHLAND: By: Signature ,� Department Head ' • • ti •cc\aOYN /O- /er,6.4.z 7, '/r Print Name: Print.N me/ : Title ate. , (W-9 is to be submitted'with the signed contract.) Purchase Order No. 4 7 • EXHIBIT A ). : CERTIFICATIONS/REPRESENTATIONS: :Contractor,under penalty of perjury, certifies that.(a) the , numbershown on the attached W=9formis its:correct taxpayer ID (or is waiting for the number to be issued to it and(b)Contractor i,s not subject to backup withholding because (i) it exempt from backup Withholding or (ii) it has:not been notified by:the-Internal Revenue Service:.(IRS)that it:is subject to:backup:withholding as'a. result of a failure to report all interest or dividends,.or(iii)the IRS has notified it that it is no longer subject to backup:withholding. Contractorfurther represents and warrants to City that.(a) it has the,power and authority to -enter into and perforin the work, (b)the Contract,when executed and delivered,:shall be:a valid and binding . obligation of Contractor enforceable in accordance with its:terms, (c)_the.work under the Contract shall be performed in accordancewith the highestprofessional standards, and(d) Contractor is qualified, professionally '. competent and duly licensed toperform the work. Contractoralso:certifies under penalty of perjury that its business is not in violation of any Oregon tax laws,and it is a corporation authorized to act on behalf of the entity designated above:and authorized to do business in Oregon or is an independent Contractor as defined in the contract documents, and has checked four or more of the following criteria: (1)I carry out the labor or services at a location separate_from my residence or is in a specific- portion of my residence, set:aside as:the location of the business: : ✓ (2)Commercial advertising or business cardsor a trade associationmeinbership arepurchased for the business. (3) Telephone listing is-used for the business separate from the personal=residence listing. (4) Labor or services are performed only pursuant towritten contracts: ✓ (5) Labor or services:are performed for two or more differentpersonswithin a period of-one year. v" (6) I assume:financial responsibility for defective workmanship or for service not provided as . evidenced by the ownership of performance-bonds,warranties,errors:and omission insurance or. lia ' y insurance relating to the labOr or services to be provided:- . - i: /' ' \ V-50-09:7Qi - : : : • : Con ctor :. .(Date) : . • • Revised 10.28=14 'Page 2 of 2 - 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: bcarlsonconstruction@hotmail.com BID PROPOSAL DATE SUBMITTED: 1/6/20 CONTRACT AMOUNT:$4,500.00 Required Deposit: $ Signed bid& deposit due upon scheduling. Remaining balance due upon job completion. PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT: Owner: City of Ashland—Electric Address: Parking lot next to 175 Lithia Way Address: City:Ashland City: Phone: Phone: Dave • Email: Thank you for-allowing Carlson Construction the opportunity to bid this project for you. Our estimate is based on your plansand specifications. Please feel free to call and discuss this quote at any time. Bid is to directional drill from transformer in the parking lot next to address 175 Lithia Way, under the asphalt to a planter area about 90' away to install (1)4" conduit for additional charging stations. Conduit and fittings will be supplied by city.Any concrete, asphalt, or landscape repairs will be made by city.Any permits will be supplied 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. Liability 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 above prices,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_O Jf6QA,9..Q Date of Acceptance I - $ -ZO2_o Page 1 of 1 . Permit Fee* CITY OF Cost • .S H LA N D Sidewalk/Parking<72 hrs $16 Sidewalk>72 hrs $71 We, Parking>72 hrs $71 Street/Alley 1$216 Application For: Permit# *Acceptance of fee does not deem the • Right-of-Way Closure Permit permit approved. This permit covers the temporary closure of sidewalks,streets,alleys,parking spaces and paths within the City of Ashland public right-of-way. Closures on federal highways, state highways or county roads may require additional permits through ODOT or Jackson County.The applicant must submit this application along with the written temporary traffic control plan at least 48 hours prior to the proposed closure.All traffic control plans shall conform to the ODOT Temporary Traffic Control Handbook, City of Ashland Engineering Standards and the Ashland Municipal Code.The applicant is responsible for notifying the Fire Department 541-482-2770,the Police Department 541-482-5211, 911 Dispatch 541-488-2211 and the Ashland School District Transportation Department 541-482-3174 of all street closures.For more information call 541-488-5347. Owner Information Contractor Information Owner's Name BRiAIT C'y/ZL SON J Contractor's Name C!¢$LScWI/ CONST Mailing Address AD.Bt /563 f/ e,D, 072 Mailing Address ,°O.BOX/502 #1fOFa/2D. CR Phone Number 5'y/-60/385E'9 Office/Cell Phone Number 5V-773.3635 ber+'rtroN'Cv4/',S'TAue7t6elt //crdi igt-coni CCB Number /73889 Applicant shall,at the Applicant's own expense,at all times during the term of this Permit,maintain in force a comprehensive or commercial general liability policy including coverage for contractual liability for obligations assumed under this Permit. Applicant shall defend, indemnify and save City, its officers, agents, and employeesharmless from any and all claims, actions,costs,judgments, damages or other expenses resulting from injury to any person(including injury resulting in death,)or damage to property(including loss or destruction), of whatsoever nature arising out of or incident to the negligent activities covered under the terms of this Permit. Applicant Name DaV L,p' '(-Vq,aftSe f i Applicant Signature Dt3t0.icg losaLCLACYL Date l—I 3-ZLza Site Information Site Address /49 L.,rb Zl4 Inm Y Block(between X&Y Streets) Estimated Start Date/Time /-2 on-2 0 Estimated Closure Duration /—2 3-2 O -Proiect Information 0 Street 0 Sidewalk L1d'Parking Space 0 Sidewalk 0 Alley 0 Path 0 Other Purpose: D/2 ecriD#c D/tILL St*RUC i /2 O0W1-0)2VI¢774a/ petor TO /NSTi4L (5)Amw 0-aes RLC. CAM edzIOL91/1 5714 T/OMS 4,44o F/Pcr2r[ioczoFiL 5Ekv icE For Staff Use Only Received by: Approved by: Additional Conditions-of Approval: , 0 Pre-Qualified Provide traffic control plan per MUTCD standards 0 Active Business License` f DEPARTMENT OF PUBLIC WORKS - 20 East Main St Fax:541-488-6006- A Ashland,Oregon 97520 TTY: 800-735-2900 www.ashland.or.us G:Ipub-wrksleng101A Blank Forms\Current Permit Forms\July 2019 • ® DATE IMMIDDIYYYY) :AcoRE) • CERTIFICATE OF LIABILITY INSURANCE T (MMIDDIVY /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 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 tothe certificate holder in lieu of such endorsement(s). PRODUCER - CONTACT' NAME: LORI L MARTINEZ. ) LORI L MARTINEZ(19083), PHONEFAX 541-326-3049 227 S HOLLY STREET INC.No.Ea* 541-772-4092 INC.No): MEDFORD,OR 97501-0000 Ai MAIL ss: LORI.MARTINEZ@COUNTRYFINANCIAL.COM " INSURER(S)AFFORDING COVERAGE - NAIL# INSURER A:•COUNTRY Mutual Insurance Company 20990 INSURED 9795349 INSURERB: CARLSON BRENT AXEL DBA CARLSON CONSTRUCTION INSURER C: < .. ATTN.LAURIE STEVENS PO BOX 1503 INSURER D: " - •MEDFORD,OR 97501. INSURERE: ' INSURER F: . _ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT.THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED,TO THE INSURED NAMED ABOVE,FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING.ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH.THIS CERTIFICATE MAY BE ISSUED"OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE'TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES:LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. : . ILTR' TYPE OF INSURANCE ANER SWyt} POLICY NUMBER (MM OLIDDY ) IY EFF MMIDD I - . LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A ✓ AB9058957 10/6/2019 10/6/2020 DAMAGE TO RENTED 1 COMMERCIAL GENERAL LIABILITY 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 GEEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG• $2,000,000 .POLICY 1-7 JEC Ti LOC $ AUTOMOBILE LIABILITY. • COMBINED SINGLE LIMIT' I AB9058957 10/6/2019 10/6/2020 (Ea accident) $1.000.000 A - ANY AUTO BODILY INJURY(Per person) $ ALL OWNED / SCHEDULED BODILY INJURY(Per.accident) $ . AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $' 1 HIRED AUTOS I AUTOS (Peracddent) _ 'UMBRELLA LIAB f' OCCUR ✓ AU9274380 s 10/6/2019 10/6/2020 EACH OCCURRENCE $2,000,000 A EXCESS LIAB ,CLAIMS-MADE AGGREGATE $2,000,000 DED 1- RETENTION$ 10:000 ) $' WORKERS COMPENSATION- WC STATU- 0TH- AND EMPLOYERS'LIABILITY - TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y N N A 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 $' 1 • r 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 . ii, . " ©1988-2010 A •RD C k " ORATION. All rights reserved._: ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD • AGENCY CUSTOMER ID: LOC#: ACORD ADDITIONAL.REMARKS SCHEDULE Page I 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 ISA 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.I NS U RE D(S): CITY OF ASHLAND 20 EAST MAIN ST ASHLAND,OR 97520 • ACORD 101 (2008101). ©.2008 ACORD CORPORATION. All rights reserved: The ACORD name and logo are registered marks of ACORD U www.saif.com• . Oregon Workers' Compensation ' work. Certificate of Insurance SaI Life. Oregon. Certificate holder: , CITY OF ASHLAND 20 EAST MAIN ST ASHLAND,OR 97520 The policy of insurance listed below has been issued to the insured named below for the policy period indicated.Theinsurance 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 Laurie Stevens 541.772.4092 Tori.martinez@countryfinancial.com POBox1503 Medford,Or 97501-0112 Issued • 10/30/2019" Lim its 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 certificateis 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 affordedby the policies above.This • certificate does not constitute a contract between the issuing insurer,authorized representative or producer and the certificate holder. Authorized representative Kerry 13amett " President and CEO 400 High Street SE Salem,OR 97312 P:800.285:8525. F:503.584.9812 Policy_O LCA_CertificaleOfinsurance