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HomeMy WebLinkAbout2020-075 PO 20200308- Completely Floored Inc Purchase Order CITY T ' RECDO rs,O grar� Fiscal Year 2020 Page: 1 of:B City of Ashland • ATTN: Accounts Payable Purchase 20 E. Main Order# 20200308 Ashland, OR 97520 T Phone: 541/552-2010 O Email: payable@ashland.or.us ✓ H CIO Public Works Department E COMPLETELY FLOORED INC. i 51 Winburn Way N 1125 S HOLLY ST p Ashland, OR 97520 MEDFORD, OR 97501 Phone: 541/488-5347 O T Fax: 541/488-6006 R Paula Brown 3 -=R' 45--_SAT i - ?- 9. 3 - r= F` I4 1 =�'--�a[e(sl� §„u Z1; Z ;;mss -�3 ,_7 I --d i:3c- -..a-�, [l[A �1-[ S:� � -.��tr, ? �� 37 [eE 01/24/2020 5166 11111.11111111111111111111111.111111111111111111111111 City Accounts Payable Repace restroom floor 1 Restroom floor replacement, JLC Hangar at Ashland Airport 1 $548.0000 $548.00 Goods and Services Agreement(Less than $25,000) Completion date: 02/29/2020 Project Account: • ***le***********GL SUMMARY*************** 085700-704100 $548.00 I I I , 1, By: 814 Date: I I X (01-ti' - s Authorized Signature yez %_— $548.00 - f/ -1 /// ' rei. /c?, 2 FORM #3 �e. 5fa II" CITY OF W: - a' - ASHLAND A request fora Purchase Order 4. REQUISITION „1---D7—.° e ' � O A'e of request: la..i 11c1 Required date for delivery: Vendor Name Completely Floored Inc. ` Address,City,State,Zip 1125 S Holly Street Medford,OR 97501 Contact Name&Telephone Number Peggy Scott Email address SOURCING METHOD ❑ Exempt from Competitive Biddies 0 Emergency ) ❑ Reason for exemption: ❑ Invitation to Bid 0 Form#13,Written findings and Authorization ❑ AMC-2.50 Date approved by Council: ❑ Written quote or proposal attached ❑ Written quote or proposal attached _(Attach copy of council communication) (If council approval required,attach copy of CC) - 0 Small Procurement 0 Request for Proposal 1 Cooperative Procurement Not exceeding$5,000 Date approved by Council: 0 State of Oregon 0 Direct Award _(Attach copy of council communication) Contract# 0 Verbal/Written bid(s)or proposal(s) 0 Request for Qualifications(Public Works) 0 State of Washington Date approved by Council_ - Contract# _(Attach copy of council communication) ' 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 bids&solicitation attached 0 Form#4,Personal Services$5K to$75K1 Agency PERSONAL SERVICES 0 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 0 Written quote or proposal attached City Administrator.AMC 2.50.070(4) ❑ (3)Written proposals&solicitation attached Date approved by Council: ' 0 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- Restroom Floor Replacement, JLC Hangar at Municipal Airport 33:51414M_____1_,:' __ .__, ..___,` Item# Quantity Unit Description of MATERIALS Unit Price Total Cost ❑ Per attached quotelproposal i 1 r Troil AL,C sT 085700 704100 4' Project Number _ _ Account Number t=_ ,. 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: /T Director Date Support-Yes/No By signing this requisition form,I certify that the City's public contracting requirements have been satisfied. °4 Employee:����J�1j� % ,11' r epartment Head: , '� , 1� ___c qual to or gre ter 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 0-DS_21D SERVICES AGREEMENT (LESS THAN $25,000) PROVIDER: Completely Floored, Inc. CITY O F PROVIDER'S CONTACT: Peggy Scott ASHLAND -20 East Main Street ADDRESS: 1125 S. Holly Street Ashland, Oregon 97520 Medford, OR 97501 Telephone: 541/488-5587 PHONE: 541-779-2175 Fax:,541/488-6006 This Services Agreement (hereinafter "Agreement") is entered into by and between the City of Ashland, an Oregon municipal corporation(hereinafter"City")and Completely Floored,Inc.,a domestic business corporation ("hereinafter"Provider"), for Restroom Floor Replacement,JLC Hangar at Ashland Municipal Airport. 1 1. PROVIDER'S OBLIGATIONS 1.1 Provide Restroom Floor Replacement, JLC Hangar at Ashland Municipal Airport 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; • 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; • 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. Page 1 of 6: Agreement between the City of Ashland and Completely Floored,Inc. 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 $21,507.75 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. 2. CITY'S OBLIGATIONS 2.1 City shall pay Provider the sum of$548.00 as provided herein as full compensation for the Work 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$548.00 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 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. 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. Page 2 of 6: Agreement between the City of Ashland and Completely Floored,Inc. • 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 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, arisingout 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. 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 Estimate dated 12/19/2019. Page 3 of 6: Agreement between the City of Ashland and Completely Floored,Inc. • • 5. REMEDIES 5.1 In the event Provider isin default of this Agreement, Citymay, 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 February 29,2020,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. 6.2.2 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: City of Ashland—Public Works Department Attn: Kaylea Kathol • 20 E. Main Street Ashland, Oregon 97520 Phone: (541)488-5587 With a copy to: City of Ashland—Legal Department 20 E. Main Street Ashland, OR 97520 Phone: (541)488-5350 Page 4 of 6: Agreement between the City of Ashland and Completely Floored,Inc. If to Provider: Completely Floored, Inc. Attn: Peggy Scott 1125 S. Holly Street Medford, OR 97501 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 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. 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. Page 5 of 6: Agreement between the City of Ashland and Completely Floored,Inc. . • • CITY OF ASHLAND: COMPLETELY FLO D,INC. (PROVIDER): By: '11A\ By: igna re Sinature U fizuLy / f' e -Or-‘" Printed Name Printed Name 9e.Pu6 D om. tV/tir Title Title Date Date (W-9 is to be submitted with this signed Agreement) Purchase Order No.) i • • Page 6 of 6: Agreement between the City of Ashland and Completely Floored,Inc. COMPLETELY FLOORED, INC. CCB 175628 Page 1 1125 S. HOLLY ST CCB 1756285cn MEDFORD,OR 97501 Telephone: 541-779-2175 Fax: 541-772-4803 01 eo ESTIMATE Sold To Ship To CITY OF ASHLAND, KAYLEA KATHOL 403 DEAD INDIAN RD. ASHLAND, OR 97520 ASHLAND, OR 97520 Quote Date Tele#1 PO Number Quote Number 12/19/19 541-552-2419 ES900587 Inventory Style/Item Color/Description Quantity Units Price Extension LVS PLATINUM CAPRI 12' BASALT 60.00 SF 3.45 207.00 MAMT7111 MT-711 PRESSURE SEN ADH 1 GAL 150 SF/GAL 1.00 EA 55.42 55.42 UZ88810 UZIN#888 EXTREME PATCH 10# GRAY 54791 1.00 EA 31.08 31.08 VINYL CUT VINYL CUT CHARGE 1.00 EA 4.50 4.50 CHARGE MINIMUM CHARGE 1.00 EA 250.00 250.00 Quotes are good for 30 days —12/20/19 10:08AM— Sales Representative(s): Sub Total: 548.00 PEGGY SCOTT Sales.Tax: 0.00 Misc. Tax: 0.00 ESTIMATE TOTAL: $548.00 12/20/2019 Business Registry Business Name Search Business Registry Business Name Search 12-20-2019 New Search Business Entity Data 15:27 Entity_ Entity Next Renewal Registry Nbr Type Status Jurisdiction Registry Date Date Renewal Due? 407403-91 DBC ACT OREGON 01.-19-2007 01-19-2020 YES Entity Name (COMPLETELY FLOORED, INC. 'Foreign Name Online Renewal: Renew Online Click here to generate and print an annual report. New Search Associated Names Type PPB PRINCIPAL PLACE OF BUSINESS Addr 1 1125 S HOLLY ST Addr2 CSZ IMEDFORD IOR 197501 1 I Country (UNITED STATES OF AMERICA Please clickIAGT here for general information about registered agents and service of process. Type REGISTERED AGENT Start Date 01-19- Resign Date 2007 Name ROBERT IE IWOOD I I Addr 1 594 HOLMES AVE Addr 2 CSZ IMEDFORD IOR 197501 1 I Country 'UNITED STATES OF AMERICA Type MALIMAILING ADDRESS I I Addr 1 1125 S HOLLY ST Addr 2 CSZ IMEDFORD TOR 197501 I I Country 'UNITED STATES OF AMERICA Type PRE (PRESIDENT 1 I Resign Date I Name (ROBERT 1 [WOOD I 1 Addr 1 594 HOLMES AVE Addr 2 CSZ I EDFORD OR 97501 Country ITED STATES OF AMERICA Type ISEC (SECRETARY I Resign Date I Name LESSLEE I TRIER I I Addr1 11816 HART ST egov.sos.state.or.us/br/pkg web_name_srch_inq.show detl?p_be_rsn=1224928&p_srce=BR_INQ&p print=TRUE 1/2 12/20/2019 Business Registry Business Name Search Addr 2 I CSZ EDFORD OR 97501 Country UNITED STATES OF AMERICA New Search Name History Business Entity Name Name Name Start Date End Date Type Status COMPLETELY FLOORED, INC. EN CUR 01-19-2007 Please read before ordering Copies. New Search Summary History ' Image Transaction Effective Name/Agent Available Action Date Date Status Change Dissolved By AMENDED ANNUAL 11 12-10-2018 FI` : !REPORT AMENDED ANNUAL 12-08-2017 FI REPORT _; AMENDED ANNUAL 02-07-2017 FI REPORT ...) REINSTATEMENT 106-02-2016 FI AMENDED ADMINISTRATIVE DISSOLUTION 03-17-2016 j SYS AMENDED ANNUAL REPORT 12-18-2014 I FI AMENDED ANNUAL ' (REPORT 12-12-2013 FI . ANNUAL REPORT 12-21-2012 SYS PAYMENT ANNUAL TREPORT 12-15-2011 , SYS PAYMEANNU N REPORT 12-17-2010 SYS ANNUAL REPORT PAYMENT 101-14-2010 SYS ANNUAL REPORT I01-13-2009 SYS PAYMENT AMENDED ANNUAL 12-28-2007 FI REPORT ARTICLES OF 01-19-2007 FI Agent INCORPORATION © 2019 Oregon Secretary of State. All Rights Reserved. egov.sos.state.or.us/br/pkg_web_name_srch_inq.show_detl?p_be_rsn=1224928&p_srce=BR_INQ&p print=TRUE 2/2 A� ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) O 1/10/2020 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 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: HANK RADEMACHER HANK RADEMACHER(15637) PHONE FAX 158 W MAIN ST STE 2 LAIC.No.Ext): 541-826-8900 (A/C,No):541-826-8908 PO BOX 255 E-MAIL SS: HANK.RADEMACHER@COUNTRYFINANCIAL.COM EAGLE POINT,OR 97524-0000 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: COUNTRY Mutual Insurance Company 20990 INSURED 9619202 INSURER B: COMPLETELY FLOORED INC INSURER C: 1125 S HOLLY ST MEDFORD,OR 97501 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MMIDDIYYYY) (MMIDD/YYYY) GENERAL LIABILITY AM9009980 2/10/2020 2/10/2021 EACH OCCURRENCE $2,000,000 A ✓ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) ,$_50,000 CLAIMS-MADE I OCCUR MED EXP(Any one person) $5,000 BUSINESSOWNERS PERSONAL&ADV INJURY $2,000,000 GENERAL AGGREGATE $4.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $4,000,000 71 POLICY JECT PRO- n LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT AV9185515 2/10/2020 2/10/2021 (Ea accident) $1,000 000 ANY AUTO BODILY INJURY(Per person) $ A ALL OWNEDSCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ ✓ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND,EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVEN/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 $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) JOB NAME: RESTROOM FLOOR REPLACEMENT,JLC HANGER AT ASHLAND MUNICIPAL AIRPORT. (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 STREET ASHLAND,OR 97520 AUTHORIZED REPRESENTATIVE ©1988-2010 A 4 RD C -ORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD • Accmci® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 1/10/2020 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 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 HANK RADEMACHER(15637) PHONE HANK RADEMACHER FAX 158 W MAIN ST STE 2 INC.No,Ext): 541-826-8900 (A/C,No):541-826-8908 PO BOX 255 E-MAIL S: HANK.RADEMACHER@COUNTRYFINANCIAL.COM EAGLE POINT,OR 97524-0000 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: COUNTRY Mutual Insurance Company 20990 INSURED 9619202 INSURER B: COMPLETELY FLOORED INC INSURER C: 1125 S HOLLY ST MEDFORD,OR 97501 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: • THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP/YLIMITS LTRINSR WVD POLICY NUMBER (MM/DD/YYYY) (MMIDDYYY) GENERAL LIABILITY AM9009980 2/10/2019 2/10/2020 EACH OCCURRENCE $2,000,000 DAMAGE TA COMMERCIAL GENERAL LIABILITY ✓ PREM SESO C (Ea occurrence) $50.000 CLAIMS-MADE I OCCUR MED EXP(Any one person) $5,000 BUSINESSOWNERS PERSONAL&ADV INJURY $2,000,000 GENERAL AGGREGATE $4.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $4,000,000 71 POLICY n JEOT 7 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT AV9185515 2/10/2019 2/10/2020 (Ea accident) $1,000,000 ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED , SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE 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 $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 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 20 EAST MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. ASHLAND,OR 97520 - AUTHORIZED REPRESENTATIVE j ©1988-2010 A •RD C•' 'ORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD • AGENCY CUSTOMER ID: LOC#: AR ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED COMPLETELY FLOORED INC POLICY NUMBER 1125 S HOLLY ST AM9009980 MEDFORD,OR 97501 CARRIER NAIC CODE COUNTRY Mutual Insurance Company 20990 EFFECTIVE DATE:.1/1 0/2020 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE ADDITIONAL INSURED(S): CITY OF ASHLAND,OREGON,IT'S OFFICERS,AGENTS AND EMPLOYEES 20 EAST MAIN STREET ASHLAND,OR 97520 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: AM9009980 BUSINESSOWNERS BP 04 51 07 02 EFFECTIVE DATE: 2/10/2020 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - WITH ADDITIONAL INSURED REQUIREMENT IN CONSTRUCTION CONTRACT This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM The following is added to Paragraph C. Who Is An Insured in Section II -Liability: 4. Any person or organization for whom you are performing operations is also an insured, if you and such person or organization have agreed in writing in a contract or agreement that such person or organization be included as an addi- tional insured on your policy. Such person or organization is an additional insured only with respect to liability arising out of your ongoing operations performed for that insured. A person's or organization's status as an insured under this paragraph ends when your operations for that insured are completed or the contractor's agreement is terminated. BP 04 51 07 02 ©ISO Properties, Inc., 2001 Page 1 of 1 • POLICY NUMBER: AM9009980 BUSINESSOWNERS BP 04 51 07 02 EFFECTIVE DATE: 1/10/2020 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - WITH ADDITIONAL INSURED REQUIREMENT IN CONSTRUCTION CONTRACT This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM The following is added to Paragraph C. Who Is An Insured in Section II -Liability: 4. Any person or organization for whom you are performing operations is also an insured, if you and such person or organization have agreed in writing in a contract or agreement that such person or organization be included as an addi- tional insured on your policy. Such person or organization is an additional insured only with respect to liability arising out of your ongoing operations performed for that insured. A person's or organization's status as an insured under this paragraph ends when your operations for that insured are completed or the contractor's agreement is terminated. BP 04 51 07 02 ©ISO Properties, Inc., 2001 Page 1 of 1