HomeMy WebLinkAbout2008-074 Contract - Pacific Paving
P.O. Box 2370. White City, Oregon 97503-0370
Office 541-772-4616. Fax 541-830-4612
PROPOSAL SUBMITTED TO:
PHO
D
City of Ashland/W ~tewater Department
90 N Mountain Ave
Ashland ST&{E97520
552-2335
JOB NAME
June 13,2008
N
STREET
Herbert St
CITY
Ashland
STATE
We hereby submit specifications and estimates for:
Commercial Patching
1. Furnish and install 4" of asphalt over an area approximately 1 ,650sf and compact to
maximum density.
TO ACCEPT SIGN &
RET~~ TOP OOpy
We hereby propose to furnish the above labor and materials in accordance with the above specifications, for the sum of:
***Six Thousand One Hundred Seventy One and 00/100***
dollars ($ ***$6..171.00***)
TERMS: Cash on completion of job, unless other arrangements are made in writing. A 2% per month FINANCE CHARGE will be added on all past due accounts,
an ANNUAL PERCENTAGE RATE OF 24%. In the event any balance is turned over to an attorney for collection, or if a lawsuit is filed to collect any balance,
including appeals from trial, the prevailing party shall be entitled to his reasonable attorney fees and reasonable expenses of litigation, such as investigation,
deposition, provisional process and other like expenses. All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according
to standard practices. Any alteration or deviation from above specifications involving additional work and extra costs will become an extra charge over and above
the estimate. If subbase and/or base is prepared by o~ers, then guarantee is limited by workmanship. The normal soil sterilization process will not kill all types of
vegetation and we will not be responsible for any damaged pavement due to the growth of vegetation. All agreements contingent upon strikes, accidents or delays
beyond our control. If this contract exceeds $1,000, the owner acknowledges receipt of the "Information Notice to Homeowners about Construction Liens." This
proposal may be withdrawn by us if not accepted within 30 days. CCB #50835
Estimator
//4/
Paul Hildebrand
IWSA-I.
Acceptance of Prop,osal
The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do all of the work as specified.
Payment will be made as outlined above.
Signature
Date
Contract for GOODS AND SERVICES Less than $25,000
CITY OF
ASHLAND
20 East Main Street
Ashland, Oregon 97520
Telephone: 541/488-6002
Fax: 541/488-5311
CONTRACTOR: Pacific Paving, Inc.
CONTACT: Paul Hildebrand
ADDRESS: PO Box 2370, White City, OR 97503-0370
TELEPHONE: 541-772-4616
DATE AGREEMENT PREPARED: 06/18/2008 FAX: 541-830-4612
BEGINNING DATE: OGl2:;/2008 to / ~/;1aoe/~'COMPLETION DATE: 06/30/2008
COMPENSATION: $6,171.00 - Per attached proposal dated June 13, 2008
GOODS AND SERVICES TO BE PROVIDED: Furnish and install 4" asphalt over an area approximately
1 ,650sf and compact to maximum density. Location: Herbert Street
ADDITIONAL TERMS:
NOW THEREFORE, pursuant to AMC 2.50.090 and after consideration of the mutual covenants contained herein the
CITY AND CONTRACTOR 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 proper performance 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 and worker-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. Completion Date: Contractor shall provide all goods in accordance with the standards and specifications, no later
than the date indicated above and start performing the work under this contract by the beginning date indicated
above and complete the work by the completion date indicated above.
4. Compensation: City shall pay Contractor for the specified goods and for any work performed, including costs and
expenses, the sum specified above. Goods shall be paid for within 30 days of an invoice after delivery of goods
conforming to the standards and specifications. Once work commences, invoices shall be prepared and submitted by
the tenth of the month for work completed in the prior month. Payments shall be made within 30 days of the date of
the invoice. Should the contract be prematurely terminated, payments will be made for work completed and accepted
to date of termination. Compensation under this contract, including all costs and expenses of Contractor, is limited to
$25,000.00, unless a separate written contract is entered into by the City.
5. Ownership of Documents: All documents prepared by Contractor pursuant to this contract shall be the property of
City.
6. Statutory Requirements: ORS 279B.220, 279B.225, 279B.230, 2798.235, ORS Chapter 244 and ORS 670.600 are
made part of this contract.
7. Living Wage Requirements: If contractor is providing services under this contract and the amount of this contract
is $17,342 or more, Contractor is required to comply with chapter 3.12 of the Ashland Municipal Code by paying a
living wage, as defined in this chapter, to all employees performing work under this contract and to any subcontractor
who performs 500/0 or more of the work under this contract. Contractor is also required to post the notice attached
hereto as Exhibit B predominantly in areas where it will be seen by all employees.
8. Indemnification: Contractor agrees to defend, indemnify and save City, its officers, employees and agents harmless
from any and all losses, claims, actions, costs, expenses, judgments, subrogations, 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 contract by Contractor (including but not limited
to, Contractor's employees, agents, and others designated by Contractor to perform work or services attendant to this
contract). Contractor shall not be held responsible for any losses, expenses, claims, subrogations, actions, costs,
judgments, or other damages, directly, solely, and proximately caused by the negligence of City.
9. Termination:
a. Mutual Consent. This contract may be terminated at any time by mutual consent of both parties.
b. Citv's Convenience. This contract may be terminated at any time by City upon 30 days' notice in writing
and delivered by certified mail or in person.
c. For Cause. City may terminate or modify this contract, in whole or in part, effective upon delivery of
written notice to Contractor, or at such later date as may be established by City under any of the following
Contract for Goods and Services Less than $25,000, Revised by Legal 06/30/2007, Page 1 of 9
- 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 contract or are
no longer eligible for the funding proposed for payments authorized by this contract; or
iii. If any license or certificate required by law or regulation to be held by Contractor to provide the
services required by this contract is for any reason denied, revoked, suspended, or not renewed.
d. For Default or Breach.
i. Either City or Contractor may terminate this contract in the event of a breach of the contract by
the other. Prior to such termination the party seeking termination shall give to the other party
written notice of the breach and intent to terminate. If the party committing the breach has not
entirely cured the breach within 15 days of the date of the notice, or within such other period as
the party giving the notice may authorize or require, then the contract 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 Contractor's performance of each and every obligation and duty under
this contract. City by written notice to Contractor of default or breach, may at any time terminate
the whole or any part of this contract if Contractor fails to provide services called for by this
contract within the time specified herein or in 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 contract.
e. Obliaation/Liabilitvof Parties. Termination or modification of this contract pursuant to subsections a, b, or
c above shall be without prejudice to any obligations or liabilities of either party already accrued prior to such
termination or modification. However, upon receiving a notice of termination (regardless whether such notice is
given pursuant to subsections a, b, c or d of this section, Contractor shall immediately cease all activities under
this contract, unless expressly directed otherwise by City in the notice of termination. Further, upon termination,
Contractor shall deliver to City all contract documents, information, works-in-progress and other property that are
or would be deliverables had the contract been completed. City shall pay Contractor for work performed prior to
the termination date if such work was performed in accordance with the Contract.
10. Independent Contractor Status: Contractor is an independent Contractor and not an employee of the City.
Contractor shall have the complete responsibility for the performance of this contract.
11. 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.
Contractor further certifies that it shall not discriminate in the award of such subcontracts, if any. The Contractor
understands and acknowledges that it may be disqualified from bidding on this contract, including but not limited to
City discovery of a misrepresentation or sham regarding a subcontract or that the Bidder has violated any
requirement of ORS 279A.11 0 or the administrative rules implementing the Statute.
12. Asbestos Abatement License: If required under ORS 468A.710, Contractor or Subcontractor shall possess an
asbestos abatement license.
13. Assignment and Subcontracts: Contractor shall not assign this contract 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. Contractor 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 City of any assignment or subcontract shall not create any
contractual relation between the assignee or subcontractor and City.
14. 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.
15. Default. The Contractor shall be in default of this agreement if Contractor: commits any material breach or default of
any covenant, warranty, certification, or obligation it owes under the Contract; if it loses its ORF status pursuant to
the ORF Rules or loses any license, certificate or certification that is required to perform the work or to qualify as a
ORF if Contractor has qualified as a ORF for this 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 Contract; or attempts to assign rights in,
or delegate duties under, the Contract.
16. Insurance. Contractor shall at its own expense provide the following insurance:
a. Worker's Compensation insurance in compliance with ORS 656.017, which requires subject employers to
provide Oregon workers' compensation coverage for all their subject workers
b. General Liabilitv insurance with a combined single limit, or the equivalent, of not less than Enter one:
$200,000, $500,000, $1,000,000, $2,000,000 or Not Applicable for each occurrence for Bodily Injury and Property
Damage. It shall include contractual liability coverage for the indemnity provided under this contract.
c. Automobile Liabilitv insurance with a combined single limit, or the equivalent, of not less than Enter one:
$200,000, $500,000, $1,000,000, or Not Applicable for each accident for Bodily Injury and Property Damage,
including coverage for owned, hired or non-owned vehicles, as applicable.
Contract for Goods and Services Less than $25,000, Revised by Legal 06/30/2007, Page 2 of 9
d. Notice of cancellation or chanae. There shall be no cancellation, material change, reduction of limits or
intent not to renew the insurance coverage(s) without 30 days' written notice from the Contractor or its insurer(s) to
the City.
e. Additional Insured/Certificates of Insurance. Contractor shall name The City of Ashland, Oregon, and its
elected officials, officers and employees as Additional Insureds on any insurance policies required herein but only
with respect to Contractor's services to be provided under this Contract. As evidence of the insurance coverages
required by this Contract, the Contractor shall furnish acceptable insurance certificates prior to commencing work
under this contract. The certificate will specify all of the parties who are Additional Insureds. Insuring companies
or entities are subject to the City's acceptance. If requested, complete copies of insurance policies, trust
agreements, etc. shall be provided to the City. The Contractor shall be financially responsible for all pertinent
deductibles, self-insured retentions and/or self-insurance.
17. Governing Law; Jurisdiction; Venue: This contract shall be governed and construed in accordance with the laws
of the State of Oregon without resort to any jurisdiction's conflict of laws, rules or doctrines. Any claim, action, suit or
proceeding (collectively, lithe claim") between the City (and/or any other or department of the State of Oregon) and
the Contractor that arises from or relates to this contract shall be brought and conducted solely and exclusively within
the Circuit Court of Jackson County for the State of Oregon. If, however, the claim must be brought in a federal
forum, then it shall be brought and conducted solely and exclusively within the United States District Court for the
District of Oregon filed in Jackson County, Oregon. Contractor, by the signature herein of its authorized
representative, hereby consents to the in personam jurisdiction of said courts. In no event shall this section be
construed as a waiver by City of any form of defense or immunity, based on the Eleventh Amendment to the United
States Constitution, or otherwise, from any claim or from the jurisdiction.
18. 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 EITHER PARTY UNLESS IN WRITING AND SIGNED BY BOTH PARTIES. SUCH WAIVER, CONSENT,
MODIFICATION OR CHANGE, IF MADE, SHALL BE EFFECTIVE ONLY IN THE SPECIFIC INSTANCE AND FOR
THE SPECIFIC PURPOSE GIVEN. THERE ARE NO UNDERSTANDINGS, AGREEMENTS, OR
REPRESENTATIONS, ORAL OR WRITTEN, NOT SPECIFIED HEREIN REGARDING THIS CONTRACT.
CONTRACTOR, BY SIGNATURE OF ITS AUTHORIZED REPRESENTATIVE, HEREBY ACKNOWLEDGES THAT
HE/SHE HAS READ THIS CONTRACT, UNDERSTANDS IT, AND AGREES TO BE BOUND BY ITS TERMS AND
CONDITIONS.
19. Nonappropriations Clause. Funds Available and Authorized: City has sufficient funds currently available and
authorized for expenditure to finance the costs of this contract within the City's fiscal year budget. Contractor
understands and agrees that City's payment of amounts under this contract attributable to work performed after the
last day of the current fiscal year is contingent on City appropriations, or other expenditure authority sufficient to allow
City in the exercise of its reasonable administrative discretion, to continue to make payments under this contract. In
the event City has insufficient appropriations, limitations or other expenditure authority, City may terminate this
contract without penalty or liability to City, effective upon the delivery of written notice to Contractor, with no further
liability to Contractor.
20. Prior Approval Required Provision. Approval by the City of Ashland Councilor the Public Contracting Officer is
required before any work may begin under this contract.
21. Certification. Contractor shall sign the certification attached hereto as Exhibit A and herein incorporated by
reference.
CONTRA CITY OF ASHLAND:
BY ~
TITLE
Print Name
~)r ~ '
I
(()' ?O .D~
DATE
DATE
CONTRACT AWARD AND F.\N N[D.. INGS DETERMINED BY:
By:.' ~~
City Department Head
FederallD#
C\ ~- lO(o%<f\
ACCOUNT #
Date: 1,( ~ lo'?)
b~0C8'1'7 tf2&yt:'P~t?t:?
(For City purposes only)
*Completed W9 form must be submitted with contract
PURCHASE ORDER # tJ @ ~ ? ~
Contract for Goods and Services Less than $25,000, Revised by Legal 06/30/2007, Page 3 of 9
EXHIBIT A
CERTIFICATIONS/REPRESENTATIONS: Contractor, under penalty of perjury, certifies that (a) the
number shown on the attached W-9 form is its correct taxpayer 10 (or is waiting for the number to be
issued to it and (b) Contractor 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. Contractor further represents and
warrants to City that (a) it has the power and authority to enter into and perform 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
accordance with the highest professional standards, and (d) Contractor is qualified, professionally
competent and duly licensed to perform the work. Contractor also 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:
~&~
it ~-S
~
~
(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 cards or a trade association membership are
purchased for the business.
(3) Telephone listing is used for the business separate from the person~1 residence listing.
(4) Labor or services are performed only pursuant to written contracts. \ ~ f-.)~S'\1l..V
(5) Labor or services are performed for two or more different persons within a period of (one
year.
(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 liability insurance relating to the labor or services to be provided.
Yo.c-~~ ?oi)\~ ~L-
Contractor
(g . 2t) . 0 ~
(Date)
~,~
Contract for Goods and Services Less than $25,000, Revised by Legal 06/30/2007, Page 4 of 9
Form W-g
Request for Taxpayer
Identification Number and Certification
Give fann to the
re.quester. 00 not
send to the IRS.
(Rev. QctQbet 2007)
Department of the Treasury
Internal Revenue Service
Name (EU! shown on your income tax return)
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Enter your TIN in theappropril;lte box. The TIN provided must match the name given on Une 1 to l;lvoid
backupwithholging.Forindividuals.this is your social security number (SSN). However. for a resident
alien. sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is
your employer identification number (EIN). If you do not have a number, see HoW to get a TIN on page 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
number to enter.
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a nurhber to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
RevenUe serviCe (IRS) that lam subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that lam no longer subject to backup withholding, and
3. lama U.S. citizen or other U.S. person (defined below).
Certlflcation instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because ydU have failed to report all interest and dividends on your tax return. For real estate transactions. item 2 does not apply.
For mortgage interestpaid.aoquisition or abandonment of secured property. cancellation of debt. contributions to an individual retirement
arrangement (IRA),ahdgenerally, payme other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. See the in io 0 page 4.
Taxpayer Identification Number (TIN)
o Exempt
payee
Requester's name and address (optiona~
I Social 887 num~r
or
Sign
Here
Signe1u~ of
U.S. person ....
Date ....
b.20.0&
General Instructions
Section references are to the Internal Revenue Code unless
otherwise noted.
PurpOS4! of Form
A person who is required to file an information return with the
IRS must obtain your correct taxpayer identification number (TIN)
to report, for example, in~ome paid to you, real estate
transactions, mortgage interest you paid, acquisition or
abandonment of secured property, cancellation of debt, or
contributions you made to an IRA
Use Form W-9 only if you are a U.S. person (including a
resident alien), to provide your correct TIN to the person
requesting it (the requester) and. when applicable, to:
1. Certify that the TIN you are giving is correct (or you are
waiting fora number to be issued),
2.. Certify that you are not subject to backup withholding, or
3. Claimaxemptionfrom backup withholding if you are a U.S.
eXElmpt payee. If applicable, you are also certifying that as a
U.S. person. your allocal:>le Share of any partnership income from
a U.S. trade or business is not subject to the withholding tax. on
foreign partners' share of effectively connected income.
Note. If a requester gives you a form other than Form W-9 to
request your TlN,You must use the requester's form if it is
substantially similar to this Form W-9.
eennlUon of a U.S. person. For federal tax. purposes, you are
considered a U.s. person if you are:
. An individual who is a U.S. citizen or U.S. resident alien,
. A partnarship, corporation, company, or aSSOciation created or
organized in the United States or under the laws of the United
States,
. An estate (other than a foreign estate), or
. A domestic trust (as defined in Regulations section
301.7701-7).
Special rule$ for pcJ1nerships. Partnerships that conduct a
trade or business in the United States are generally required to
pay awithholding tax. on any foreign partners' share of income
from such business. Further, in certain cases where a Form W-9
has not been received, a partnership is required to presume that
a partner isa foreign person, and pay the withholding tax..
Therefore, if you are a U.S. personthat is a partner ina
partnership conducting a trade or bU$in~ss in the United States,
provide Form W-9 to the partnership to establish your U.S.
status and avoid withholding on your share of partnership
income.
The person who gives Form W-9 to the partnership for
purposes of establishing its U.S. status and avoiding withholding
on its allocable share of net incol'l'l& frOm the partnership
conducting a trade or business in the United States is in the
following cases:
. The U.S. owner of a disregarded entity and not the entity,
Cat. No. 10231X Form W-9 (Rev. 10-2007)
Contract for Goods and Services Less than $25,000, Revised by Legal 06/30/2007, Page 5 of 9
Form W-9 (Rev. 10-2007)
Pag.2
. The U.S. grantor or other owner of a grantor trust and not the
trust, and
. The U.S. trust (other than a grantor trust) and not the
beneficiaries of the trust.
Foreign person. If you are a foreign person, do not use Form
W-9. Instead, use the appropriate Form W-8 (see Publication
515, Withholding of Tax on Nonresident Aliens and Foreign
Entities).
Nonresident alien who becomes a resident alien. Generally,
only a nonresident alien individual may use the terms of a tax
treaty to reduce or eliminate U.S,. tax on certain types of income.
Hpwever, mostt~ tr~aties contain a provision known as a
"saving clause." Exceptions specified in the saving clause may
permit an exemption from tax to continue for certain types of
income even after the payee has otherwise become a U.S.
resident alien for tax. purposes.
If you are a U.S. resident alien who is relying on an exception
contained in the. saving clause of a tax. treaty to claim an
exemption from U.S. tax on certain types of income, you must
attach a statement to Form W-9 that specifies the following five
items:
1. The treaty country. Generally, this must be the same treaty
under which you claimed exemption from tax as a nonresident
alien.
2. The treaty article addressing the income.
3..The.~icle number (or location) in the tax treaty that
contains the saving clause and its exceptions.
4. Toe type and amount of income that qualifies for the
exemption from tax.
5. Sufficient facts to juStify the exemption from tax under the
tElrms of the treaty article.
Qample. Article 20 of the U.S.-China inc;().me tax. treaty allows
an exemption from tax for $cholaf$hip income received by a
qhinese st.udent temporarily present in the United States. Under
U.s. law, this student will become a resident alien for tax.
purposes if his or her stay in the United States exceeds 5
calendar years. However, paragraph 2 of the first Protocol to the
U.S.-Chin~ treaty (dated April 30, 1984) allows the provisions of
Article 20 to continue to apply even after the ChinQse student
bec()fTl$sa resident alien of th$ United states. A Chinese
student who qualifie.Sfofthis exception (uncter paragraph 2 of
thefirst.protocoij and is relying on this exception to claim an
exemption from tax on his or her scholarship or fellowship
income would attach to Form W-9 a statement that includes the
information described above to support that exemption.
If you area nohr.esidentalien or a foreign entity not subject to
backup withholcting, give the requester the appropriate
completed Form W-8.
What .Is back\lPWlthholdlng? Persons making certain payments
toyou must under certain conditions withhold and pay to the
IR$ 2~% of such paYments. This is called "backup withholding."
Payments thatmay be subject to backup withholding Include
interest,.. tax-ex$mpt inter$st, dividends, broker and barter
excoange transactions, rents, royalties, nonemployeepay, and
certain payments from fiShing boat operators. Real estate
transactions are not subject to backup withholding.
You Will not be subject to backup withholding on payments
you re<;eiveif you give the requester your correct TIN, make the
proper certifications, and report all your taxable interest and
dividends on your t~ return.
Payments you receive will be subject to backup
withholding if:
1 . You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see the Part II
instructions on pag$3 for details),
3. The IRS tells the requester th~t you furnished an incorrect
TIN,
4. The IRS tells you that you are subject to backup
withholding because you did not report all your interest and
dividends on your tax return (for reportable interest and
dividends only), or
5. You do not certify to the requester that you are not subject
to backup Withholding under 4 abOVe (for reportable interest and
dividend accounts.opened after 1983 only).
Certain payees and payments are exempt from backup
withholding. See the instructions below and the separate
Instructions for the Requester of FormW-9.
Also see Speci8J rules for partnerships on page 1.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a
requester, you are subject to a penalty of$50 for each such
failure unless your failure is due to reasonable cause and not to
willful neglect.
CIvil penalty for false Infol1T1aUon VIIIh respect to
withholding. If you make a.false statement with no reasonable
basis that results in no backup withholding, you are subject to a
$500 penalty.
Crlml~lpenalty; for fal~ng lnfcum~lUon. WillfLJ11y falsifying
c.ertifications.or .affirmations may SUbject you to criminal
penalties including fine~ and/or imprisonment.
Misuse of TINs. Ifthe requester discloses or uses TINs in
violation of federal law, the requester may be subject to civil and
criminal penalties.
Specific Instructions
Name
If you are an individual, you mustg$nerally enter the name
shown on your income tax return. However, if you have changed
your last narTle, for instance, d.ue to marriage without informing
the Social Security Administration of the name change, enter
your first name, the last name shown on your social security
card, and your new last name.
If the account is in joint names, list first, and then circle, the
name of the person or entity whose number you entered in Part I
of the form.
Sole proprietor. Enter your. individual name as shown on your
inc.ome tax. return on the "Name" line. You may enter your
business, trade, or "doing business as (DBA)" name on the
"Business name" line.
Umlted llabllltycofnpany (LtC). ChecR the "Limited liability
company" boX only and enter the appropriate code for the tax
classification ("0" for disregarded entity, "c" for corporation, "P"
for partnership) in the space provided.
Fora single-member LLC(includinga foreign LLC with a
domestic owner) that is disregarded as an entity separate from
its owner under R$gulations section ~01.7701-3, enter the
owner's name on the "Name" line. Enter the LLC's name on the
"Business name" line.
For an LLC classified as a partnership or a corporation, enter
the LLC's name on the "Name" line and any business, trade, or
DBA name On the "Business name" line.
Other entitles. Enter your busin~sname as shown on required
federal tax documents on the "Name" line. This name should
match the name shown on the charter or other legal document
creating the entity. You may enter any business, trade, or DBA
name on the "Business name" line.
Nom. You are requested to check the appropriate box for your
status (individuaVsole proprietor, corporation, etc.).
Exempt Payee
If you are exempt from backup withholding, enter your name as
described above and check the appropriate box for your status,
then check the "Ex$mpt. payee" box in the line fOllowing the
business name, Sign and date the.form.
Contract for Goods and Services Less than $25,000, Revised by Legal 06/30/2007, Page 6 of 9
FOITl'1W.g (Rev. 10-2007)
Generally, individuals (including sole proprietors) are.notexempt
frombllckupwithholding. Corpprations are exempt from backup
withholding for certain payments, such as interest and dividends.
Note. If you are exempt from backup withholding, you should
still complete this form to avoid possible erroneous backup
Withholding.
The follOWing payees are exempt from backup withholding:
1. An org~niz~tion exempt from tax under section 501(a), any
IRA, or a custodial account under section 403(b)(7) if the account
satisfies the requirements of section 401 (f)(2) ,
2. Th~ united States or any of its agencies or
instrumentalities,
3. A state, the District of Columbia, a possession of the United
states, or any of their political Subdivisions or instrumentalities,
4. A foreign government or any of its political subdivisions,
ag~ncies, or instrumentalities, or
5. An international organization or any of its agencies or
instrumentalities;
Oth.er payees that may be exempt from baCkUp withholding
include:
6. A corporation,
7. AfOl'eign central bank of issue,
8. Adealer inseClJrities or commodities required to register in
the United~tates, the Oistrict of Columbia, ora possession of
the United States,
9. A futures commission merchant registered with the
Commodity Futures Trading Commission,
10. A real estate inve$tment trust,
11.An entity registered at all times during the tax year under
the Investment Company Act of 1940,
12. A common trust fund operated by a bank under section
584(a).
13. Afinancilll institution,
14. .Amiddleman known in the investment community as a
rlominee or custodian, or
15. Atrust exempt from tax under section 664 or described in
section 4947.
Ttlechart below shows types of payments that may be
exempt from backup withl1olding. Ttle chart applies to the
exempt payees listed above, 1 through 15.
IF thepaymentls for . . .
THEN the payment Is exempt
for. . .
All exempt payees except
for 9
Exempt pa.yees 1 through 13.
Also, a perl~on regi~ered under
the Investment Advisers Act of
1940 who regular1y acts as a
broker
Exempt payees 1 through 5
Interest.and dividend payments
Broker transactiol1s
Barter exchange transactions
and patrona.gedividends
Payments over $600 required
to be repQr'tedand direct
sales over $5,000 1
Generally, efempt payees
1 through 7
l~.l=orm 10Q9-fv1ISC, Mecellaneous Income, and itBinetruc1ions.
2Howel/er, the followinQ.peyments made to a CQl'poI'ation6nc;luding 9"088
pr~ed. paid tOlll'lattomey under section6045(f), 8V1IlO if theattomey Ie a
corporation) and reportable on Form 1099-MISC are not exempt from
backup Withholclil'lg: medical and health care payments, attomeys' fees, and
payments for servicea paid bya federal execo1ive agel"lCY.
Page 3
Part I. Taxpayer Identification
Number (TIN)
Enter your TIN In the appropriate box. If you are a resident
alien and you do not have and are not eligible to get an SSN,
your llN is your IRS individual taxpayer identification number
(ITIN). Enter it in the social security number box. If you do not
have an ITIN,seeHowto get a TIN below.
If you are a sole proprietor and you have an EIN, you may
enter either your SSN or EIN. However, the IRS prefers that you
use your SSN.
If you are.a single-member LLC that is disregarded as an
entity separatefrom its owner (see Limited liability company
(LLC) on page 2), enter the owner's SSN (or EIN, if the owner
has one). Do not enter the disregarded entity's EIN. If the LLC is
classified as a corporation or partnership, enter the entity'sEIN.
Note. SEl$. the chart on page 4 for further clarification of name
and TIN combinations.
How to get.a TIN. If you do not have a TIN, apply for one
immediately. To apply for an SSN, get Form SS-5, Application
for a Social Security Card, from your local Social Security
Administration office or get this form online at www.ssagov. You
may also get this form by calling 1-800..772..1213.. Use Form
W-7, Application for IRS Individual Taxpayer Identification
Number, to apply for an \TIN, or Form SS-4, Application for
Employer Identification Number. to applY for an EIN. You can
apply for an EINonline by accessing the IRS website at
www.irs.govlbusinesses and clicking on Employer Identificatiol1
Numb~r (EIN) under starting a Business; You can get FOl'ms W-7
and SS-4 from the I RS by visiting www:il'S:gov or by calling
1-800-TAX-FORM (1-800"'829"3676).
If you are as.ked to compl~te FormW-9 but do not l1avea TIN,
write "Applied ForI' inthe space for the TIN, sign and date the
form, and give it to the r~quest~r. FOl' lnter~st and dividend
payments,.and certain payments made with. respect to readily
tradable instruments, gener.ally you will have 60 days to get a
TIN and give it to the requester before you are subject to backup
withholding on payments. The 60-day rul~ does not aPply to
other types of payments. You will be SUbjeCt tobllCkup
withhOlding on all such payments until you prO\lide your TIN to
the requester.
Note. Entering "Applied For" means that you have already
applied for a TIN or that you intend to apply for one soon.
CautIon: A cJisregarded domestic entity that has a foreign owner
must use the appropriate Form W-8.
Part II. Certification
To establish to the withholding llgent that you area U.S. person,
or resident alien, sign Form W-9. You may be requested to sign
by the withholding agent even if items 1,4, and 5 below indicate
otherwise.
Fora joint account, only the person whose llN is shown in
Part I should sign (when required). Exempt payees, see Exempt
Payee on page 2.
Signature reqlilre....nts. Complete the certification as indicated
in 1 through 5 below.
1. Interest, dividend, and barter exchange accounts
opened before 1984 and. brok&r~CCC)Unts conslderedacUVe
during 1983. You must give yourcorreQt TIN, but you do not
have. to sign thecert ification.
2. Interest, dividend, broker, and barter exchange
accounts openedatter1983and. brour accounts<consIdered
Inactive during 1983. You must sign the certification or backup
withholding Will apply. If you are. subject to backup withholding
and you are merely providing your corr~ct TIN to th~ reguester,
you must .cross .out item2 in the certification before signing the
form.
Contract for Goods and Services Less than $25,000, Revised by Legal 06/30/2007, Page 7 of 9
Form VV-9 (Rev. 10-2007)
~. Real estate transactions. You must sign the certification.
You may cross out item2 of the certification.
4. . Other paymGnts. You must give your correct TIN, but you
do not have to sign the certification unless you have been
notified that you have previou~1y .given an incorrect TIN. "Other
paY01$nts" include payments made in the course of the
request~'s trade or.business for rents, royalties, goods (other
than b!lIs for merchandise), medical and health care services
(including payments to corporations), payments toa
nonempl6yee for services, payments to certain fishing boat crew
members and fishermen, and gross proceeds paid to attorneys
(including payments to corporations).
6. Mortgagelntel'estpaid by you, acquisition or
aballfjOmnent of secured property,. cancellation of debt,
quallftedtutuon prO{Jfal11 payments (under section 529), IRA,
Covel'dell ESA,ArCher MSA or HSAcontrlbutlons or
distribUtions, and pension distributions. You must give your
qorrect TIN, but you do not have to sign the certification.
What Name and Number To GiVe the Requester
For this type ofaccomt:
1. Individual
2. Two or more individualsOoint
account)
Give name and SSN of:
The individual
The actual owner of 'the account or,
if combined fUnda, the first
indiVidual on the account'
The minor ·
S. Custodian aCCOlJ'ltof a minor
(Unifcnn Gift to Minors Act)
4. a. The usual revocable savings
trust (grantor is also trustee)
b. SO-called trust account that is The actual owner'
not a legal or valid trust under
state law
5. SQfe.proprie..hip<< disregarded The owner ·
entity owned by an individual
For this typeohccoU"lt:
6. Disregarded enttty not owned by an The owner
individual
7. A vafJd trust, ea... or pension trust Legal entity .
~. Corporate or LLC ~eding The corporation
corporateatatuson FCltm 8832
Q.~cia'llon, club, r~i9i0U8,
chl:llitable, ed\JC8tional, or other
tax-exempt organization
10. Partnership ormulti-rnerni:)er LLC The partnership
11. A broker or registered nominee The broker or nominee
12. Acc.oontwith the Department of The public entity
Agricultu-ein the name of a plblic
erwtity($Ucheaa....te or loc:lll
govemment,schoc>ldiatrict, or
prison) that receives agricultural
progr.m payments
\ist firstEtldcirciethe hlif'ne of the persdn whose number you furnish. If ooly one persdn
on a Idnt accd\Jrlt 11-'ar1 ss.N, thatperson's number must I;>e furnished.
2Circlelhe minor's hameand furnish the minor's SSN.
3YOUmustshow YOJr indiyiql.laJ name and YOJ may also enter your I:)usineS$ or "DBA"
nfl/lleon the second name line: You may use either YOJr S$Nor EIN (if you have one),
I:XJt the IRS encOJrages ydJ to use your SSN.
4 Ust first ang circle the nfl/lleolthe trust, estate, or pension trust. (Do not fumish the TIN
of the personal representative or trustee unless the legal entity itself is not designated in
the account tiUel.AJsqsee S~ciaJ rulas for partnerships dn page 1.
Note. If no name is circled when more than one name is listed,
thednumber will be considered to be that of the first name liSted.
The grantor-trustee '
Give name and EIN of:
The organization
Page 4
Secure Your Tax. Records from Identity Theft
Identity theft occurs when someone uses your personal
information such as your name, social security number (SSN), or
other identifying information, without your permission, to commit
fraud or other crimes. An identity thief may use your SSN to get
a job or may file atax return using your SSN to receive a refund.
To reduce your risk:
. Protect your SSN,
. Ensure your employer is protecting your SSN, and
. Be careful when choosing a tax preparer.
Call the IRS at 1-800-829-1040 if you think your identity has
been used inappropriately for tax purposes.
Victims of identity theft who are experiencing economic harm
ora system problem, or are seeking help in resolving tax
problems that have not been resolved through normal channels,
may be eligible for Taxpayer Advocate.service (TAS) a.ssistance.
You can r~ch TAS by calling the TAS toll~frEM} case intai<$ line
at 1-877-777-4778 or TlYrrDD 1-800-829-4059.
Protect yourself from suspicious emalls or phlshlng
schemes. Phishing is the creation and us~ of emailand
websites designed tc) mimic legitimate bu~iness emailsand
websites. The most common act is sending.an email to allSer
falsely claiming to beanestabHshed I~gitimate~nterpris~ in an
attempt to scam the user into surrendering private information
that will be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails.
Also, the IRS does not request personal d~tailed informatiOn
through .email or ask. taxpayers for the PIN numbers, passwords,
or similar secret access information for their credit card, bank. or
other financial. accounts.
If you receive an unsolicited email claiming to be from the IRS,
forward this mesSage tophishing@it$.gov. You may alSQ report
misuseC)t the IRS name, logo, or other IRS personal property to
the Treasury Inspector G~neralfbr Tax .Admihistration at
1-800-366-4484. You can forward suspicious emails to th~
Federal Trade Commission at: spamOuce;govor contactthemat
www.consumer.govlidtheft or 1-877-IDTHEFT(438-4338).
Visit the IRS website at www.irs.govto learn more about
identity theft and how to reduce your risk.
PrIVacy Act NOtioe
Section 6109 of the Internal Revenue Code requiree you to provide your correct TIN to per80l'\8 who must file information returns with 'the IRS to report interest,
divittenda, ..,d .c.-tt\inother inc:cme paid to you, moog.geinter_you paid, the acquiaitiprl. or abendonrnent. of secured prOPerty,~t\I'lC.tlation of debt,Of'
contributionayoo made to an IRA, or Archer. MSA or HSA. The IRS us- the numbers for identification pLl'po8U and to help verify the a9CUf'acyof YOLl' tax retum.
The IRS mayal80 pl"()Vide this information to the DlilPartment of JustiCe for civil and criminal. litigation, af'ld tocitifl8, states, the. Distri~ of Columbia, t\r'ld. U.S.
P<*!f!88i()l'M!to oarryout~ir taxlaw~. We may also dis<:loee this infcnn,.tiontoother countries under a tax treaty, to federal and atate.agenciea to enforc:;8 fede~
nontax crirninallaws, . or to federal law enforcement and inteUigence agencies to combet terrorism.
You must provide YOLl' TIN whether or not you are. required .tofile a tax rilturn.Payere must generally withhold 28% of taxable interest, dividend,andcertain ather
paYrnents to a payee who doeanat gilte a TIN to a payer. Certain penal'llea may also apply.
Contract for Goods and Services Less than $25,000, Revised by Legal 06/30/2007, Page 8 of 9
CITY OF ASHLAND, OREGON
EXHIBIT B
City of Ashland
LIVING
~~,
Employees must be paid a
living wage:
~ For all hours worked under a
service contract between their
employer and the City of
Ashland if the contract
exceeds $17,342 or more.
~ For all hours worked in a
month if the employee spends
50% or more of the
employee's time in that month
working on a project or
portion of business of their
employer, if the employer has
ten or more employees, and
has received financial
assistance for the project or
business from the City of
Ashland in excess of $17,342.
~ If their employer is the City of
Ashland including the Parks
and Recreation Department.
~ In calculating the living wage,
employers may add the value
of health care, retirement,
401 K and IRS eligible
cafeteria plans (including
childcare) benefits to the
amount of wages received by
the employee.
~ Note: "Employee" does not
include temporary or part-time
employees hired for less than
1040 hours in any twelve.
month period. For more
details on applicability of this
policy, please see Ashland
Municipal Code Section
3.12.020.
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
Contract for Goods and Services Less than $25,000, Revised by Legal 06/30/2007, Page 9 of 9
III ,----
ACORD... CERTIFICA TE OF LIABILITY INSURANCE OP ID J~ DATE (MM/DDIYYYY)
PACI05W 08/31/07
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
KPD Insurance, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
PO Box 784 ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW.
Springfield OR 97477
Phone: 541-741-0550 Fax:541-741-1674 I
INSURERS AFFORDING COVERAGE NAIC#
----.-.--- -'-.-.---- ~--'-'-'---.__._- --. - -..--.--.-----.-.---------.---+-- _. -"-
INSURED ~I~URER A~ _ SAIF C~~orat~~ =- ~a-.!~__ _~.___ ._. _
- - -
INSURER B: I
-'- -.----------- -- ---------.---.--.- ---- -. - --
Pacific Paving, Inc. INSURER C
.---.-. ----------.- _.~- _.. '-..- '-'-"-' -- - -
PO Box 2370 INSURER D:
White City OR 97503 -'- ----------.------------ ----i--.-.- -. .-
, INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED_ NOT\I\1THSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VIIITH 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
INS~'--------- -. ---.---:--- ________.___
L TR INSRD TYPE OF INSURANCE . POLICY NUMBER
I GENERAL LIABILITY
I~ CO~MERCIAL GENE~~L LIABILITY ,
;- _~ __. CLAIMS MADE L _ OCCUR
;
---! -----'---._-
-. PJiVfr'::J~~P"Rl~ijX':brg~ ~-- --- - -~MITS- - --- -
, EACH OCCURRENCE : $
I-mMAGFTcrnENTEIJ -- --' - --- - ---
rPREMISES (~occurenceL -!...~ _ _ _ __ __
~EE..E~(~_~_?~~o'1. _$__ _ _ ._
PERSONAL & ADV INJURY : $
!GENERAL AGGREGATE ---+~-- -- .--
---.---.-------.- -- --
i PRODUCTS - COMP/OP AGG ! $
..---.--.-....---.-..- -'--..-
~-.J __________
~~N.L AGGR~GATE ;~~~ AP;':!.~S PER:
I POLICY · I JECT' LOC
I AUTOMOBILE LIABILITY
,-;
-.J ANY AUTO
! ALL OWNED AUTOS
,1 SCHEDULED AUTOS
~.J HIRED AUTOS
, . NON-OWNED AUTOS
'-1
r-j-----.- --
i fE~~~~~~t~'NGLE LIMIT ! $
1-----_-- _ __---'___ ____.
BODILY INJURY
j (Per person)
i$
i GARAGE LIABILITY
L-l ANY AUTO
II
I EXCESS/UMBRELLA LIABILITY
~J OCCUR '_-I CLAIMS MADE
I BODILY INJURY
; (Per accident)
-------.------+.- - -.----.. -
I PROPERTY DAMAGE ' $
: (per aCCIdent) i
! AUTO ONLY - EA ACCI DENT , $
r-.-.-.----t--------- -- -
I OTHER THAN ~~ AC_~ $____ __ __ _ _
I AUTO ONLY: AGG i $
! EACH OCCURRENCE S
i AGGREGAT;- -- ._- r; - - - - --
----------.-.-.-.- - --- -
: $
I DEDUCTIBLE
~ I RETENTION $
~ WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
A I ANY PROPRIETORlPARTNERlEXECUTIVE
; OFFICER/MEMBER EXCLUDED?
1 ~P~tl~pf!toVi~?O~s bell7N
OTHER
L-.__ __ ____ _~ _.._
812919
I
10/01/07 I
~-----.-- - - __.l...!. _ __ ___ __._ ._.
I S
! xiT~~l~~Ws._:O~~-: ______ .__.
10/01/08 E L EACH ACCIDENT . $ 500,000
1---------1-___ -- _
, E.L -'?!S~ASE - ~:"..E~L~V.E~_S~Q_q, OOQ
i E.L. DISEASE - POLICY LIMIT I S 500 000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
RE: Al~ Operations
I
CERTIFICATE HOLDER
CITAS02
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCElLED BEFORE THE EXPIRATIO~
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRllTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE lEFT, BUT FAILURE TO DO so SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTA TlVES.
~~
Ci ty of Ashland
90 N Mountain Ave.
Ashland OR 97520
ACORD 25 (2001/08)
@ ACORD CORPORATION 1988
"",t~" 8f:CORDER
ACORDTM CERTIFICA TE OF LIABILITY INSURANCE DATE (MMlDD/YYYY)
3/13/2008
PROOUCER (541)772-1111 FAX: (541)772-3785 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTlFICA TE
JBL&K Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
707 Murphy Rd ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Medford OR 97504 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A Travelers
Pacific Paving, Inc INSURER B: Developers Surety & Indem
PO Box 2370 INSURER c:
INSURER 0:
White City OR 97503 INSURER E:
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.
A - .-..- ,- . IMITS SHOWN MA Y I-tAVF= RF=F= J BY CAin ('I AIU~
INSR AOO'L TYPE Of INSURANCE POLICY NUMBER Pg.k+~~~:6g/~VF ~i!fJI~:~~J~N LIMITS
LTR INSRD
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
,.-- ~~~~~~J9E~~~~Pence)
X COMMERCIAL GENERAL LIABILITY $ 100,000
A ~ CLAIMS MADE [!] OCCUR O'COS26D8417TIL08 3/20/2008 3/20/2009 MED EXP IAnv one ""'rson\ $ 5,000
f--
PERSONAL & MJV INJURY $ 1,000,000
- 2,000,000
GENERAL AGGREGATE $
-
GEN'l AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000
I nPRO- n
POLICY JECT lOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000
- (Ea accident) $
X ANY AUTO
- 3/20/2008 3/20/2009
A ALL UWNI::U AU I U~ OT81052608417TIL08 BODilY INJURY
- (Per person) $
SCHEDULED AUTOS
-
- HIRED AUTOS BODILY INJURY $
(Per accident)
- NON-OWN EO AUTOS
- PROPERTY DAMAGE $
.. (Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
R ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY I=ACl-llV"rllDDI::Nrl:: $ 1,000,000
~ OCCUR D CLAIMS MADE AGGREGATE $ 1,000,000
$
A ~ DEDUCTIBLE DTSMCUP526D8417TIL 8 3/20/2008 3/20/2009 $
X RETENTION $ 10 000 $
WORKERS COMPENSATION AND I T~~tJIYS I IOJ~-
EMPLOYERS'LIABILlTY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.l. EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED? EL DISEASE - EA EMPLOYEE $
11 yes, describe under
SPECIAl ~()\/I<::I()N~ hAlnw EL DISEASE. POLICY LIMIT $
B OTHER Contractor's License 247088C 7/15/2005 7/15/2008 Limi t : $10,000
Bond
DESCRIPTION OF OPERA TIONS/LOCA TIONs/VEHICLESlEXCLUSlONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Certificate holder included as additional insured per attached endorsement #CGD246080S where required by contract.
Subject to policy terms, conditions and exclusions.
CERTIFICATE HOLDER
(541)488-5320
The City of Ashland, its officers, agents
a~d employees
90 North Mountain Avenue
Ashland, OR 97520
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL
~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT
FAILURE TO DO so SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE f IJ
S Wilson, AAI, AIC/SU S..,-.... ~. W~
@ ACORD CORPORATION 1988
Page1of2
ACORD 25 (2001/08)
INS025 (0108).08a
IMPORT ANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this
certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing
insurer(s), authorized representative or producer. and the certificate holder, nor does it affirmatively or negatively
amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 (2001/08)
INS025 (0108).08a
Page 2 of 2
II
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
BLANKET ADDITIONAL INSURED
(CONTRACTORS)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
1. WHO IS AN INSURED - (Section II) is amended
to include any person or organization that you
agree in a "written contract requiring insurance"
to include as an additional insured on this Cover-
age Part, but:
a) Only with respect to liability for "bodily injury",
"property damage" or "personal injury"; and
b) If, and only to the extent that, the injury or
damage is caused by acts or omissions of
you or your subcontractor in the performance
of "your work" to which the "written contract
requiring insurance" applies. The person or
organization does not qualify as an additional
insured with respect to the independent acts
or omissions of such person or organization.
2. The insurance provided to the additional insured
by this endorsement is limited as follows:
a) In the event that the Limits of Insurance of
this Coverage Part shown in the Declarations
exceed the limits of liability required by the
"written contract requiring insurance", the in-
surance provided to the additional insured
shall be limited to the limits of liability re-
quired by that "written contract requiring in-
surance". This endorsement shall not in-
crease the limits of insurance described in
Section III - Limits Of Insurance.
b) The insurance provided to the additional in-
sured does not apply to "bodily injury", "prop-
erty damage" or "personal injury" arising out
of the rendering of, or failure to render, any
professional architectural, engineering or sur-
veying services, including:
i. The preparing, approving, or failing to
prepare or approve, maps, shop draw-
ings, opinions, reports, surveys, field or-
ders or change orders, or the preparing,
approving, or failing to prepare or ap-
prove, drawings and specifications; and
ii. Supervisory, inspection, architectural or
engineering activities.
c) The insurance provided to the additional in-
sured does not apply to "bodily injury" or
"property damage" caused by "your work"
and included in the "products-completed op-
erations hazard" unless the "written contract
requiring insurance" specifically requires you
to provide such coverage for that additional
insured, and then the insurance provided to
the additional insured applies only to such
"bodily injury" or "property damage" that oc-
curs before the end of the period of time for
which the "written contract requiring insur-
ance" requires you to provide such coverage
or the end of the policy period, whichever is
earlier.
3. The insurance provided to the additional insured
by this endorsement is excess over any valid and
collectible "other insurance", whether primary,
excess, contingent or on any other basis, that is
available to the additional insured for a loss we
cover under this endorsement. However, if the
"written contract requiring insurance" specifically
requires that this insurance apply on a primary
basis or a primary and non-contributory basis,
this insurance is primary to "other insurance"
available to the additional insured which covers
that person or organization as a named insured
for such loss, and we will not share with that
"other insurance". But the insurance provided to
the additional insured by this endorsement still is
excess over any valid and collectible "other in-
surance", whether primary, excess, contingent or
on any other basis, that is available to the addi-
tional insured when that person or organization is
an additional insured under such "other insur-
ance".
4. As a condition of coverage provided to the
additional insured by this endorsement:
a) The additional insured must give us written
notice as soon as practicable of an "occur-
rence" or an offense which may result in a
claim. To the extent possible, such notice
should include:
CG 02 46 08 05
@ 2005 The St. Paul Travelers Companies, Inc.
Page 1 of 2
COMMERCIAL GENERAL LIABILITY
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I b) If a claim is made or "suit" is brought against
\ the additional insured, the additional insured
must:
I
How, when and where the "occurrence"
or offense took place;
ii. The names and addresses of any injured
persons and witnesses; and
iii. The nature and location of any injury or
damage arising out of the "occurrence" or
offense.
i.
i. Immediately record the specifics of the
claim or "suit" and the date received; and
II. Notify us as soon as practicable.
The additional insured must see to it that we
receive written notice of the claim or "suit" as
soon as practicable.
c) The additional insured must immediately
send us copies of all legal papers received in
connection with the claim or "suit", cooperate
with us in the investigation or settlement of
the claim or defense against the "suit" I and
otherwise comply with all policy conditions.
d) The additional insured must tender the de-
fense and indemnity of any claim or "suit" to
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any provider of "other insurance" which would
cover the additional insured for a loss we
cover under this endorsement. However, this
condition does not affect whether the insur-
ance provided to the additional insured by
this endorsement is primary to "other insur-
ance" available to the additional insured
which covers that person or organization as a
named insured as described in paragraph 3.
above.
5. The following definition is added to SECTION V.
- DEFINITIONS:
"Written contract requiring insurance" means
that part of any written contract or agreement
under which you are required to include a
person or organization as an additional in-
sured on this Coverage Part, provided that
the "bodily injury" and "property damage" oc-
curs and the "personal injury" is caused by an
offense committed:
a. After the signing and execution of the
contract or agreement by you;
b. While that part of the contract or
agreement is in effect; and
c. Before the end of the policy period.
@ 2005 The St. Paul Travelers Companies, Inc.
CG 02 46 08 05
II
rA'
CITY OF
ASHLAND
20 E MAIN ST.
ASHLAND, OR 97520
(541) 488-5300
OlfY RECORDER
I
Page 1 / 1
DATE
6/23/2008
I I
f?Qts!l4tMSER
08339
VENDOR: 000903
PACIFIC PAVING, INC
POBOX 2370
WHITE CITY, OR 97503
SHIP TO: Ashland WWTP
(541) 488-5348
1295 OAK STREET
ASHLAND, OR 97520
FOB Point:
Terms: Net
Req. Del. Date:
Speciallnst:
Req. No.:
Dept.: PUBLIC WORKS
Contact: David Gies
Confirming? No
Unit Price
THIS IS A REVISED PURCHASE ORDER
Furnish and install 4" asphalt over an
area approximately 1 ,650sf and compact
to maximum density. Location: Herbert
Street
6,171.00
Contract for Goods and Services
BeQinninQ date: 06/20/2008
Completion date: 06/30/2008
Insurance required/On file
BILL TO: Account Payable
20 EAST MAIN ST
541-552-2028
ASHLAND, OR 97520
SUBTOTAL
TAX
FREIGHT
TOTAL
i..,..... .:x> :> ..:;;....:, ,,'ii'; > .... lcc~;Numtift ~; .." .:'.' }\~P.,t
.. . .' .
E 675.08. 1 7.00.60240( 6,1 71 .00
I
~J-
1I-e:C~7
AlJtho . ActlSionatlJrp.
VENDOR COPY
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