HomeMy WebLinkAbout2021-166 PO 20220169- Polaris Land Surveying LLC Purchase Order
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B City of Ashland
I20 E. Main ATTN: Accounts Payable Purchase
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Ashland, OR 97520 Order# 20220169
T Phone: 541/552-2010
O Email: payable@ashland.or.us
V H C/O Public Works Department
E POLARIS LAND SURVEYING LLC I 51 Winburn Way
N PO BOX 459 p Ashland, OR 97520
O ASHLAND, OR 97520 Phone: 541/488-5347
R T Fax: 541/488-6006
/sa' rPrT1E D- 1 =
(541)482-5009 _ Ch_ance Metcalf
10/18/2021 604 FOB ASHLAND OR City Accounts Payable
—__— $ rc = :_ �. yf -, IINNA
Airport Approach Tree Survey
1 Airport Approach Treet Obstruction Survey 1.0 $10,000.00 $10,000.00
Personal Services Agreement ($35,000 or less)
Completion date: March 31, 2022
Project Account:
***************GL SUMMARY***************
085700-604100 $10,000.00
— 1a
By: /P---/P---/ ".. (/Da /P---/ ".. (/A thorized Signature .10 000.00
FORM #3 CITY OF
A request for Purchase ®r ' rr ��� (6o ASH LAN D
REQUISITION Date of request: 10/1112021
Required date for delivery: 10/1-1/2021
Vendor Name Polaris Land Surveying,LLC
Address,City,State,Zip PO BOX 459,Ashland,Or 97520
Contact Name&Telephone Number Shawn Kampmann, (541)482-5009
Email address
shawn@polarissurvey.com
SOURCING METHOD
❑ Exempt from Competitive Bidding ❑ Invitation to Bid 0 Emergency
O Reason for exemption: Date approved by Council: ❑ Form#13,Written findings and Authorization
O AMC 2.50 _(Attach copy of council communication) ❑ Written quote or proposal attached
❑ Written quote or proposal attached (If council approval required,attach copy of CC)
❑ Small Procurement ❑ 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) ❑ 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 ❑ Written quote or proposal attached Intergovernmental Agreement
❑ (3)Written bids&solicitation attached ❑ Form#4,Personal Services$5K to$75K Agency
PERSONAL SERVICES Date approved by Council: ❑ Annual cost to City does not exceed$25,000.
Greater than$5,000 and less than$75,000 Valid until: (Date) Agreement approved by Legal and approved/signed by
0 Less than$35,000,by direct appointment ❑ Special Procurement City Administrator.AMC 2.50.070(4)
❑ (3)Written proposals&solicitation attached 0 Form#9,Request for Approval ❑ Annual cost to City exceeds$25,000,Council
❑ Form#4,Personal Services$5K to$75K ❑ Written quote or proposal attached approval required.(Attach copy of council communication)
Date approved by Council:
Valid until: (Date)
Description of SERVICES Total Cost
Airport Tree Obstruction Survey,tag trees within survey&contractor quality control.
Item# Quantity Unit Description of MATERIALS Unit Price Total Cost
❑■ Per attached quote/proposal ; 'TOTALCOST ,
Project Number Account Number 0 8 5 7 0 0- 6 0 4 1 0 0 $ 10-000.0a
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 requisition form,I certify that the City's public contracting requirements have been satisfied.
Employee: eia- I2 7/'22&-ld Department Head: ��isomek. 10
org eat.rthan$5,000)
Department Manager/Supervisor: City Manager:
(Equal to or greater than$25,000)
Funds appropriated for current fiscal year: YES / NO f --/ -1)(
Finance Director-(Equal to orgreaterthan$5,000) Dale
Comments:
Form#3-Requisition
•
PERSONAL SERVICES AGREEMENT($35,000 OR LESS)
CONSULTANT: Polaris Land Surveying,LLC
CITY OF ADDRESS: PO BOX 459
�S H LAN D Ashland,Or 97520
20 East Main Street
Ashland,Oregon 97520 TELEPHONE: 541-482-5009
Telephone: 541/488-5587
Fax: 541/552-6006 EMAIL: shawn@polarissurvey.com
This Personal Services Agreement(hereinafter"Agreement")is entered into by and between the City
of Ashland,an Oregon municipal corporation(hereinafter"City")and Polaris Land Surveying,LLC,,a domestic
limited liability company "hereinafter"Consultant"),for a tree obstruction survey at the Ashland Airport.
NOW THEREFORE, in consideration of the mutual covenants contained herein,the City and
Consultant hereby agree as follows:
1. Effective Date and Duration: This Agreement shall become effective on the date of execution on
behalf of the City,as set forth below(the"Effective Date"),and unless sooner terminated as specifically
provided herein,shall terminate upon the City's affirmative acceptance of Consultant's Work as
complete and Consultant's acceptance of the City's final payment therefore,but not later than March 31,
2022.
2. Scope of Work: Consultant will provide a tree obstruction survey at the Ashland Airport as more fully
set forth in the Consultant's Proposal dated October 1,2021,which is attached hereto as"Exhibit A"
and incorporated herein by this reference. Consultant's services are collectively referred to herein as the
"Work."
3. Supporting Documents/Exhibits; Conflicting Provisions: This Agreement and any exhibits or other
supporting documents shall be construed to be mutually complementary 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 exhibits or supporting documents.
4. All Costs Borne by Consultant: Consultant shall,at its own risk,perform the Work described above
and,unless otherwise specified in this Agreement,furnish all labor,equipment,and materials required
for the proper performance of such Work.
5. Qualified Work: Consultant has represented,and by entering into this Agreement now represents,that
all personnel assigned to the Work to be performed under this Agreement are fully qualified to perform
the service to which they will be assigned in a skilled and worker-like manner and, if required to be
registered, licensed or bonded by the State of Oregon,are so registered, licensed and bonded.
Pace I of 6: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND POLARIS LAND SURVEYING,LLC.
6. Compensation: City shall pay Consultant the sum of$10,000.00(ten thousand dollars)as full
compensation for Consultant's performance of all Work under this Agreement. In no event shall
Consultant's total of all compensation and reimbursement under this Agreement exceed the sum of..
$10,000.00(ten thousand dollars)without the express,written approval from the City official whose
signature appears below,or such official's successor in office. Payments shall be made within thirty
(30)days of the date of receipt by the City of Consultant's invoice. Should this Agreement be
terminated prior to completion of all Work,payments will be made for any phase of the Work completed
and accepted as of the date of termination.
7. Ownership of Work/Documents: All Work,work product, or other documents produced in
furtherance of this Agreement belong to the City,and any copyright,patent,trademark proprietary or
any other protected intellectual property right shall vest in and is hereby assigned to the City.
8. Statutory Requirements: The following laws of the State of Oregon are hereby incorporated by
reference into this Agreement: ORS 279B.220,279B.230 and 279B.235.
9. Living Wage Requirements: If the amount of this Agreement is$22,310.46 or more, Consultant 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. Consultant is also
required to post the notice attached hereto as"Exhibit B"predominantly in areas where it will be seen
by all employees.
10. Indemnification:Consultant hereby agrees to defend, indemnify,save,and hold City, its officers;
employees,and agents harmless from anyand all losses,claims,actions,costs,expenses,judgments,or
other damages resulting from injury to any person(including injury resulting in death),or damage
(including loss or destruction)to property,of whatsoever nature arising out of or incident to the
performance of this Agreement by Consultant(including but not limited to,Consultant's employees,
agents,and others designated by Consultant to perform Work or services attendant to this Agreement).
However,Consultant shall not be held responsible for any losses,expenses,actions,costs,or other
damages,caused solely by thegross negligence of City.
11. Termination:
a. Mutual Consent. This Agreement may be terminated at any time by the mutual consent of both
parties.
b. City's Convenience. This Agreement may be terminated by City at any time upon not less than
thirty(30)days' prior written notice delivered by certified,mail or in person.
c. For Cause. City may terminate or modify this Agreement, in whole or in part,effective upon
delivery of written notice to Consultant,or at such later date as may be established by City under
any of the following conditions:
i. If City funding from federal,state,county or other sources is not obtained and continued at
levels sufficient to allow for the purchase of the indicated quantity of services;
ii. If federal or state regulations or guidelines are modified,changed,or interpreted in such a
way that the services are no longer allowable or appropriate for purchase under this
Page 2 of 6: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND POLARIS LAND SURVEYING,LLC.
Agreement or are no longer eligible for the funding proposed for payments authorized by this
Agreement;or
iii. If any license or certificate required by law or regulation to be held by Consultant to provide
the services required by this Agreement is for any reason denied,revoked,suspended,or not
renewed.
d. For Default or Breach.
i. Either City or Consultant may terminate this Agreement in the event of a breach of the
Agreement by the other. Prior to such termination the party seeking termination shall give to
the other party written notice of the breach and its intent to terminate. If the party
committing the breach has not entirely cured the breach within fifteen(15)days of the date of
the notice,or within such other period as the party giving the notice may authorizein writing,
then the Agreement may be terminated at any time thereafter by a written notice of
termination by the party giving notice.
ii. Time is of the essence for Consultant's performance of each and every obligation and duty
under this Agreement., City,by written notice to Consultant of default or breach,may at any
time terminate the whole or any part of this Agreement if Consultant fails to provide the
Work called for by this Agreement within the time specified herein or within any extension
thereof.
iii. The rights and remedies of City provided in this subsection(d)are not exclusive and are in
addition to any other rights and remedies provided by law or under this Agreement.
12. Independent Contractor Status: Consultant is an independent contractor and not an employee of the
City for any purpose.
13. Assignment: Consultant shall not assign this Agreement or subcontract any portion of the Work
without the written consent of City. Any attempted assignment or subcontract without written consent
of City shall be void.
14. Default. The Consultant shall be in default of this Agreement if Consultant: commits any material
breach or default of any covenant,warranty,certification,or obligation under the Agreement;institutes
an action for relief in bankruptcy or has instituted against it an action for insolvency;makes a general
assignment for the benefit of creditors;or ceases doing business on a regular basis of the type identified
in its obligations under the Agreement;or attempts to assign rights in,or delegate duties under,this
Agreement.
15. Insurance. Consultant shall,at its own expense, maintain the following insurance:
a. Workers'Compensation. Consultant shall obtain and maintain Workers'Compensation insurance in
compliance with ORS 656.017,which requires subject employers to provide Oregon Workers'
Compensation coverage for its subject workers,unless such employers are exempt under ORS
656.126. If exempt under ORS 656.126,Consultant shall certify such exemption to the City.
b. Professional Liability insurance with a combined.single limit,or the equivalent,of not less than
$2,000,000(two million dollars)per occurrence. This is to cover any damages caused by error,
omission or negligent acts related to the Work to be provided under this Agreement.
Page 3 of 6: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND POLARIS LAND SURVEYING;LLC.
c. 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,Death,and Property Damage.
d. Automobile Liability insurance with a combined single limit,or the equivalent,of not less than
$1,000,000(one million dollars)for each accident for Bodily Injury and Property Damage,
including coverage for owned,hired or non-owned vehicles,as applicable.
e. Notice of cancellation or change. There shall be no cancellation,material change,reduction of limits
or intent not to renew the insurance coverage(s)without thirty(30)days' prior written notice from
the Consultant or its insurer(s)to the City.
f. Additional Insured/Certificates of Insurance. Consultant shall name the City of Ashland,Oregon,
and its elected officials, officers and employees as Additional Insureds on any insurance policies,
excluding Professional Liability and Workers'Compensation,required herein,but only with
respect to Consultant's services to be provided under this Agreement.The consultant's insurance is
primary and non-contributory.As evidence of the insurance coverages required by this Agreement,
the Consultant shall furnish acceptable insurance certificates and endorsements prior to commencing
the Work under this Agreement.
16. Nondiscrimination: Consultant agrees that no person shall,on the grounds of race,color,religion,
creed,sex,marital status,familial status or domestic partnership,nationalorigin,age,mental or physical
disability,sexual orientation,gender identity or source of income,suffer discrimination in the
performance of any Work under this Agreement when employed by Consultant. Consultant agrees to
comply with all applicable requirements of federal and state civil rights and rehabilitation statutes,rules
and regulations. Further,Consultant 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.
17. Consultant's Compliance With Tax Laws:
17.1 Consultant represents and warrants to the City that:
17.1.1 Consultant 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 Consultant;and
(iii) Any rules,regulations,charter provisions,or ordinances that implement or enforce any
of the foregoing tax laws or provisions.
17.1.2 Consultant, 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 Consultant;and
(iii) Any rules,regulations,charter provisions,or ordinances that implement or enforce any
of the foregoing tax laws or provisions:
Page 4 of 6: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND POLARIS LAND SURVEYING,LLC.
18. Governing Law;Jurisdiction: This Agreement shall be governed and construed in accordance
with 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.
19. 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,by mailing using registered or certified United States mail,return receipt requested,postage
prepaid,or by electronically confirmed at the address or facsimile number set forth below:
If to the City:
City Department—Public Works
Attn:Chance Metcalf
20 East Main Street
Ashland,Oregon 97520
With a copy to:
City of Ashland-Legal Department
20 East Main Street
Ashland,Oregon 97520
If to Consultant:
Polaris Land Surveying,LLC—Shawn Kampmann
PO BOX 459
Ashland,Or 97520
20. Amendments. This Agreement may be amended only by written instrument executed by both parties
with the same formalities as this Agreement.
21. THIS AGREEMENT AND THE ATTACHED EXHIBITS CONSTITUTE THE ENTIRE
UNDERSTANDING BETWEEN THE PARTIES. THERE ARE NO UNDERSTANDINGS,
AGREEMENTS,OR REPRESENTATIONS,EITHER ORAL OR WRITTEN,NOT SPECIFIED
HEREIN REGARDING THIS AGREEMENT. CONSULTANT,BY SIGNATURE OF ITS
AUTHORIZED REPRESENTATIVE,HEREBY ACKNOWLEDGES THAT HE/SHE HAS READ
THIS AGREEMENT,UNDERSTANDS IT,AND AGREES TO BE BOUND BY ITS TERMS AND
CONDITIONS.
22. Certification. Consultant shall execute the certification attached hereto as"Exhibit C"and incorporated
herein by this reference.
Page 5 of 6: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND POLARIS LAND SURVEYING,LLC.
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: POLARIS LAND SURVEYING,LLC(CONSULTANT):
By: �� �Fftit' By:
Signature
Scar Fc.qu2y I p i Vi.R• yr
Printed Name Printed Name
Title Title
lot124 2.1 vc- 12-cv- 7 2.4 .2 I
Date Date
Purchase Order No. O ° W-9 is to be submitted with this signed Agreement)
Page 6 of 6: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND POLARIS LAND SURVEYING,LLC.
PO L- .4 £ J .5 LAND S URVEY/ NG , LLC
October 1,2021
City of Ashland Engineering Dept.
51 Winburn Way
Ashland Oregon 97520
Attn: Chance Metcalf,Project Manager
Re: Airport Approach Tree Obstruction Survey
401 Dead Indian Memorial Road,Ashland,Oregon
Assessor's Map No.39 1E 12,Tax Lot 301
Chance,
Per your request,the following is a proposal for surveying services to perform the annual
Ashland Airport Tree Obstruction Survey of the above referenced properties located at
401 Dead Indian Memorial Road in Ashland,per the scope of services outlined below:
SCO,P_E_OESERVICES:
♦ Field survey to re-establish project survey control network by this office
during the performance of previous surveys conducted to for the Runway 30
centerline alignment of the extended Approach Zone southeast of the runway.
♦ Office calculations,analysis and computations of field survey data previously
utilized to establish the centerline alignment and stationing in preparation of
the tree survey to identify and tag trees in the FAA restricted area and
compile a permanent,digital inventory and expandable database file.
• Field survey to identify and tag trees in the obstruction area with an
identifying number,tree diameter and species number for each tree and enter
in a database the alignment and stationing from the baseline to include the
maximum tree and cut height at each station.
• Prepare the Approach Zone Tree Survey site Map from the southerly
monument for the airport runway centerline and approach zone with the
staked points denoted and marked on the map at the corresponding station,
overlaid on G15 aerial imagery.Also to compile a master database file that
can be utilized in the field with GIS mapping Imagery to identify each tree and
cut/trim parameters.
• Contractor Quality Control sample plots to ensure compliance with tree
trimming maximum cutheightsand City/Contractor pre-work consultations.
P. 0. Box 459. Ashland, Oregon 97520 It, Phone: (541) 492-500.9_,A Fax: (541) 408-0797
MobJle:. (541) 6.01.5000 n www.polarinnurrey.com
•
Chance Metcalf
Survey Proposal
Page 2
FEES:
Fees will be paid on a Fixed Fee Basis of Ten Thousand Hundred Dollars($10,000.00).
Any additional work that is outside the scope of services as described shall be paid for
at the hourly rate schedule enclosed as Exhibit A. Polaris Land Surveying LLC will
endeavor to keep the actual cost of the work as low as may be consistent with the
purpose of the project and with proper workmanship and materials._Any fees required by
City of Ashland,or other quasi-governmental agencies are not included in the surveying
costs outlined above and shall be the responsibility of the owner.
As compensation for services rendered,an invoice will be sent on the first day of each
month,or at the conclusion of the project,showing the hours and rates of the various
classifications of personnel working on the project.. Payment of the invoice amount must
be made within 30 days of the invoice date.
This letter is written as a Surveying Proposal and Agreement.An acceptance line Is
provided for your signature if you wish to engage us to perform the aforementioned
services.Please return one signed copy for our files.
Please don't hesitate to call if you have any questions.
Yours truly,
•
Shawn Kampmann
Professional Land Surveyor
S:\surveys\1058-16\Ashland Airport Tree Survey proposal 2021.docx
AU HORIZAT1011
Approved By Date
•
• P. 0. Box 459. Ashland. Oregon 97520 n Phone: (541) 482-5009 x Fax: (541) 480:979.7
�^ TM Mobile:. (541).601-3000 n www.polarlseurrey.eom
•
P O L A X I O LAND SURVEYING , LLC
rc
s7
EXHIBIT"A"
POLARIS LAND SURVEYING LLC
FEE_5-CHEDULE
(EFFECTIVE AUGUST 20.2021)
PRINCIPAL LAM)SURVEYOR 4160.001 hour
PROFESSIONAL LAND SURVEYOR ..$120.00/hour
SENIOR SURVEY TECHNICIAN $90.00!hour
SURVEY TECHNICIAN $80.00!hour
DRAFTING TECHNICIAN $80.001 hour
SURVEY FIELD CREW(STANDARD) $140.00/hour
SURVEY FIELD CREW(w/GPS) $160.001 hour
DOCUMENT PROCESSING.. $ 60.00/hour
MILEAGE(out of town projects only) ...$ 0.545/tulle
OUT-OF-POCKET EXPENSES ACTUAL COST
P. 0. Box 459. Anhland. Oregon 97520 a Phone: (541) 452-5009 x Fax: (54_1) 455_0797
Mobile: (541) 601-3000T x www.polarioourve.y.cent
EXHIBIT B
CITY OF ASHLAND, OREGON
City of Ashland
LIVING
ALL employers described WAG E
below must comply with City
of Ashland laws regulating
pa ment of a livin. wale.
$15.96 per hour;effective June 30,2021.
The Living Wage,is-adjusted:annually every
Val
June 30bylhei.Consumner Price Index.
Employees must be paid a portion of business of their 401K and IRS eligible
ivi ng wage: employer,if the employer has cafeteria plans(including
ten or more employees,and childcare)benefits to the
has received financial amount of wages received by
For all hours worked under a assistance for the project or the employee.
business from the City of
service contract between their Ashland in excess of ➢ Note: For temporary and
employer and the City of $22,310.46. part-time employees,the
Ashland if the contract Living Wage does not apply
exceeds$22,310.46 or more. ➢ If their employer is the City of to the first 1040 hours worked
For all hours worked in'a Ashland,including the Parks in any calendar year. For
and Recreation Department. more details, please see
month if the employee spends Ashland Municipal Code
50%or more of the > In calculating the living wage, Section 3.12.020.
employee's time in that month employers may add the value
working on a project or of health care,retirement,
For additional information:
Call the Ashland City Administrator's office at 541-488-6002 or write to the City Administrator,
City Hall,20 East Main Street,Ashland,OR 97520,or visit the City's website at www.ashland.or.us.
(Notice to Employers:This notice must be posted predominantly in areas where it can be
seen by all employees.
CITY OF
ASHLAND
Page I of 1: EXHIBIT B
EXHIBIT C
CERTIFICATIONS/REPRESENTATIONS: Consultant,by and through its authorized
representative,under penalty of perjury,certifies that(a)the number shown on the attached W-9
form is its correct taxpayer ID(or is waiting for the number to be issued to it and(b)Consultant
is not subject to backup withholding because: (i) it is 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. Consultant further represents and warrants
to City that: (a)it has the power and authority to enter into this Agreement and perform the
Work,(b)the Agreement,when executed and delivered,shall be a valid and binding obligation
of Consultant enforceable in accordance with its terms,(c)the work under the Agreement shall
be performed in accordance with the highest professional standards,and(d)Consultant is
qualified,professionally competent,and duly licensed(if applicable)to perform the Work.
Consultant also certifies under penalty of perjury that its business is not in violation of any
Oregon tax laws, it is an independent contractor as defined in the Agreement, it is authorized to
do business in the State of Oregon,and Consultant has checked four or more of the following
criteria that apply to its business.
{- (1)Consultant carries out the work or services at a location separate from a private
residence or is in a specific portion ofa private residence,set aside as the location of
/ the business.
V (2)Commercial advertising or business cards or a.trade association membership are
purchased for the business.
V (3)Telephone listing is used for the business separate from the personal residence
/ listing.
� (4) Labor or services are performed only pursuant to written contracts.
(/ (5)Labor or services are performed for two or more different persons within a period
/ of one year.
t/ (6)Consultant assumes financial responsibility for defective workmanship or for
service not provided as evidenced by the ownership of performance bonds,
warranties,errors and omission(professional liability)insurance or liability insurance
relating to the Work or services to be provided.
Consultant's signature
2024
Date
Page 1 of l: EXHIBIT C
J
1
45
A ARD CERTIFICATE OF LIABILITY INSURANCE DA'sDALVIR""'")
10107/2020 .
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 coKHicato holder Is an ADDITIONAL INSURED,the policy(los)must have ADDITIONAL INSURED provisions or be endorsed.•
if SUBROGATION IS WAIVED,subject to tho toms and conditions of tho policy,contain policies may roqulro an ondorsomont, A statement on
this cortificato does not confer rights to tho cortificato holdor in lieu of such ondorsomont(s).
PRomm=ERyE CT Ryan SChorovzky.
wh
StateFarm Jon Snowden insurance Agency,Inc. PHONE (541)482.2461 • I(lex (541)482.4957
0 420 Bridge SI • LAtc
.110.14: L(AIC.No1;
AIL
O.O. ADDRESS; ryan.schorovsky,szmr@statefarm.com
INSURERISIAFFORDINO COVERAGE HAIL a
Ashland OR 97520 WSURERA:Stale Farm FIR)and Casualty Company 25143
INSURED WsuRERs:Stale Farm Mutual Automobile Insurance Company 25178
Polaris Land Surveying.LLC INSURER C: '
PO Box 459 INSURER o:
INSURER E: . . .
Ashland OR 97520
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.
USSR TYPE AOOLMW SUPOUCY EFF POUCY EXP
LLA 1 LVED Wen POUCYNUYOER • (uPOI
MYYYYI (YWDPSWUNITS YYt _
X COMMERCIAL OENERALLIABIUTY EACH OCCURRENCE $ 1.000.000
wigwams
__ CLAMS-MACE n OCCUR
PRnE )_-S 300,000
• LIE EXP(My Dna person) $ 5.000
1. _ Y 97•CO-H089-5 05107/2020 05107/2021 PERSONAL a ADM INJURY S
GENT.AGGREGATE UMITAPPUESPER. GENERAL AGGREGATE ,S 2.000,000
1 POLICY n.7 ter n LOC PRODUCTS•COMP/OP AGO S
OTHER S
AUTOMOBILE UAIRLITY Y L23 4521-D30.37H 04/30/2020 10130/2020 .emBINE0 SINGLE uMIT S 1.000,000
ANY AUTO v L23 4521-D30-37H 1013012020 10130/2021 BODILY INJURY(Por parson) S
B ___^ O.IE ONLY SCHOS�ED BODILY INJURY(Per ocWCent) S
HIRED NON•OPOIED 0904953.809.37E 08109/2020 02109/2020 PROPERTY DAMAGE S
_ AUTOS ONLY AUTOS ONLY . (Per amdeml
$
'
CLAIMS-MADE I UMBRELLA LIAR OCCUR EACH OCCURRENCE S
EXCESS UAB AGGREGATE S
OED RETENTIONS S
;MUTE WORKERS COMPENSATION (S '
AND EMPLOYERS MEM/TYII W. .
Y
OFFFICEER/MEMBEERREEXCLUDE C� Y J NSA 97-CM•K359.3 05/05/2020 05/0512021 ELEACH AcaDENT s 500,000
(Mandatory In NH) E.LDISEASE•EAEMPLOYE S 500.000 •
It�o a,dosvao iwce,
OESCRIPTION OF OPERATIONS below E DISEASE-POl1CY LIMIT S 500.000
•
DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD 101.Additional Rsnurhs Schedule,maybe attached It mon spate Is rsqulted)
Land Surveying
On•call services •
The City of Ashland.its elected officials 8 employees are Included as additional insureds. Coverage is primary and non-contributory.
•
•
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED,POLICIES BE CANCELLED BEFORE
• THE .EXPIRATION DATE THEREOF, NOTICE WILL. BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
CITY OF ASHLAND OREGON AND ITS ELECTED
OFFICIALS.OFFICERS&EMPLOYEES MEOWED REPRESENTATIVE
20 E MAIN ST Completed by an authorized State Farm roprosontativo.If signature
ASHLAND OR 97520 Is required,please contact a State Farm agont.
®1988.2015 ACORD CORPORATION.'All rights iosorved.
ACORD 25(2016/03) Tho ACORD name and logo aro rogistarod marks of ACORD
1001486 132610.13 04.22.2029
ACD CERTIFICATEOF LIABILITY INSURANCE DATE(MIA°°""Y"'
oBr171202f . .
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 cortlficato holder Is an ADDITIONAL INSURED,the policy(IDs)must have ADDITIONAL INSURED provisions or he endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,curtain policies may require an endorsement. A statement on
this certificate dogs not confer rights to the certificate holder in lieu of such ondorsomont(s).
PRODUCER NaMEG} LoZotto Brewton •
Assurance Risk Managers.Inc. [PHONE�Ealr (303)454.9562 I FAX (303)454.9564
10651 East Bethany Drive Lss: lezelle.browton@aml.com
ADDRE
lAr�No)
Suite 300 WSURERIS)AFFORDING COVERAGE NAIC
Aurora CO 80014-2688 mum A: Hanover Insurance Company 22292
INSURED
INSURER 0:
Polaris Land Surveying,LLC.
mime c:
PO8ox459
NSURER D:
INSURER E: •
Ashland OR 97520.0016 =IAEAF•
COVERAGES CERTIFICATE NUMBER: 21-22 E&O 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 REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VYHICH THIS
CERTIFICATE MAYBE ISSUED OR(SAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLIHE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES:LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
151TYPE OF INSURANCE POLICY EFF POLICY 5*P
LTR Ivso YVvo 'POLICY NUMBER ,Yw00HYYY) (UMJDOIYYYYI, LIMITS
COMMERCIAL GENERALLYURUTY EACH OCCURRENCE S
DAMAGE TO HENIEO
I CLNUF.NADE El OCCUR mimes lea eemn...A S
•
LIED EXP(Ana on.Teruel S
• PERSONAL/LADYINJURY S •
GEM AGGREGATE LIVITAPPLIES PER: GENERAL AGGREGATE S
POLICY D jra [J LOC PRODUCTS.COMPCPAGG $
OTHER S
AUTOMOBILE WBAITY COMBINED SINGLE LIMIT S
(Ea accident)
ANY AUTO BODILY INJURY(Per pence) 5
OWNED �SCHEDULED BODILYI IURY(Pcraccidem3' S
AUTOS ONLY ,�,AUTOS '
HIRED NONLOYITIED PROPERTY DAMAGE S
AUTOS ONLY _ AUTOS ONLY (Par.endeet
S
UMBRELLAUAD OCCUR EACH OCCURRENCE S
EXCESS WO CLNMS.LUDE AGGREGATE S
DED I 1 RETENTIONS S
WORKERS COMPENSATION 16 ATUTE I I ERN`
AND EMPLOYERS'UAIIUTY YIN •
ANY PROPRIETORJPARTNERJEXECUTIVE ❑ NIA EL EACH ACCIDENT S
OFFICEWLUEMBER EXCLUDED?
tWadalecy MNli) EL DISFac, .EA EMPLOYEE S
Wel,desame!alder
DESCRIPTION OF OPERATIONS belsw _ EL DISEASE•POUCY LIMIT $
PROFESSIONAL LIABILITY EACH CLAIM: 1,000.000
A CLAIMS MADE POLICY LH4 A349055 08 082812021 0612812022 aggregate 21300.000
oescsuPnoN OF OPERATIONS 1 LOCATIONS/VEHICLES(ACORD 101.Additlo ui Rema,As Schedule.may be attached U mom space.Is requited) -
PSA(525.000 or less)
. CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED IN
City of Ashland Oregon&its Elected Officials it Employees • ACCORDANCE WITH THE POLICY PROVISIONS.
20 E Main St
AUTHORISED REPRESENTATIVE
Ashland OR 97520 YA c. .Q� ,n � •
._
•
®1988 2015 ACORD CORPORATION.AS Tights resoriOd.
ACORD 25(2016103) Tho ACORD namo and logo aro registered marks of ACORD.