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Home My WebLink About2011-283 CONT Addendum - Polaris Land Surveying ADDENDUM TO_CITY OF ASHLAND CONTRACT FOR PERSONAL SERVICES LESS THAN $35,000 Addendum made this 27th day of September 2011, between the City of Ashland ("City") and Polaris Land Surveying. Inc. ("Consultant'). Recitals: A. On (January 22. 2009) City and Consultant entered into a "City of Ashland Contract for Personal Services Less than $35,000" (further referred to in this addendum as "the agreement'). B. The parties desire to amend the agreement to extend the contract by one year as part of the two, one-year contract extensions as allowed for in the original contract. City and Consultant agree to amend the agreement in the following manner: 1. The date for completion as specified in Paragraph 3 of the agreement is extended to October 1, 201.Y. �,- 2. The maximum price as specified in Paragraph 4 of the agreement is changed to $5,000. 3. Except as modified above the terms of the agreement shall remain in full force and effect. CONSULTANT: sz � CITY OF ASHLAND: BY BY Department Head Its M Date Vo (gL(. it DATE Purchase Order# Acct. No.: (For City purposes only) t-CITY OF ASHLAND,ADDENDUM TO CONTRACT FOR PERSONAL SERVICES LAND OURVEYINO , L L C it EXHIBIT"A" FOLAR15 LAND SURVEYING LLC FEE SCHEDULE (EFFECTIVE JANUARY 1.2008) PRINCIPAL LAND 5UKVEY0K................................$120.00 hour PKOFE55IONAL LAND 5URVEYOR..........................$100.00/hour SENIOR 5URVEY TECHNICIAN ...............................$55.00 1 hour SURVEY TECHNICIAN ........................................$75.00/hour DRAFTING TECHNICIAN .....................................$70.00./hour 5URVEY FIELD CREW(5TANDAPD) .......................$150.00/hour SURVEY FIELD,CREW(w/GP9) ............................$175.00/hour DOCUMENT PROCESSING.................................... $00.00/hour MILEAGE (out;of town prqjcct5)............................ $ 0.555/mile OUT-OF-POCKET EXPEN5E5 .................................ACTUAL C05T P. 0. Vex 459, Ashland, Oregon 97520 Phone: (541) 462-5009 • Fax: (541) 466-0797 mo&116: (541) 601-3000 " www.polarissurvey.com e Farm YY'7 Request for Taxpayer Give form to the (Rev.October 2007) Identification Number and Certification requester. I not mtmW ev ofthem,aay send to the IRS. Internal kevenue ae�ece ' Name(as shown on your income tax return m D s:v•'S �cae1 Ste,-ire- ,�. L1� M &um name,if different from above c 0 0p Check appropriate box: El Indeidud/Sole proprietor 11 carn El PmtnacWp F o united(lability company.Enter the tax dassificadon(p=disregarded entity,C=corporation,P=p r arship)►F_-- ❑ Exee apt Pa `off 'LJ Other(see imtruciiw) Z5 Address(number,street,and apt.a sake no.) Requestels name arM address(optional) a. o m City,state,and ZIP code + �r N, List account number(s)here(offanall Taxpayer Identification Number(TIN) Enter your TIN In the appropriate box.The TIN provided must match the name given on Une 1 to avoid Social aecmity number backup withholding. For Individuals,this is your social security number(ISSN).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 71N on page 3. or Note.If the account Is In more than one name,see the chart on page 4 for guidelines on whose Emfm !a?mfifi q y.n/beer number to enter. [�'UJ Certiflcation 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 number to be issued to me),and 2. 1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Intsmal Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am no longer subject to backup withholding,and 3. 1 am a U.S.citizen or other U.S.person(defined below). Certification 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 you have failed to report all interest and dividends on your tax return. For real estate transactions,item 2 does not apply. For mortgage Interest paid,acquisition or abandonment of secured property,cancellation of debt, contributions to an Individual retirement arrangement(IRA),and generally,payments other than Interest and dividends,you are not required to sign the Certification,but you must provide your correct TIN.See the instructions on page 4. Sign Sierature of / Here uS.pernan /�--9 ; L pats 0- General Instructions Definition of a U.S. person.For federal tax purposes, you are Section references are to the Internal Revenue Code unless considered a U.S.person ti you are: otherwise noted. a An individual who is a U.S.citizen or U.S.resident alien, e A partnership, corporation,company,or association created or Purpose of Form organized In the United States a under the laws of the United A person who Is required to file an information return with the States, IRS must obtain your correct taxpayer Identification number(TIN) •An estate(other than a foreign estate),or to report,for example.Income paid to you,real estate e A domestic trust(as defined in Regulations section transactions,mortgage Interest you paid,acquisition or 301.7701-7). abandonment of secured property, cancellation of debt, or Special rules for partnershl &Partnerships contributions you made to an IRA P g that conduct a Use Form W-9 only if you are a U.S. person(Including a trade or business t the United States are generally required e resident alien),to provide your correct TIN to the person Pay a withholding tax on any foreign partners'share of Income requesting it(the requester)and,when applicable,to: from such business. Further, in certain cases where a Form W-9 has not been received,a partnership is required to ld ng grin he that i. Certify that the TIN you are giving is correct(w you are a partner Is a foreign person, and pay the withholding tax waiting for a number to be Issued), Therefore, if you are a U.S. person that is a partner in a 2.Certify that you are not subject to backup withholding,or partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. 3.Claim exemption from backup withholding if you are a U.S, status and avoid withholding on your share.of partnership exempt payee.If applicable,you are also certifying that as a income. U.S, person,your allocable share of any partnership Income from The person who gives Form W-9 to the partnership for a U.S.trade or business is not subject to the withholding tax on purposes of establishing its U.S.status and avoiding withholding foreign partners' share of effectively connected income. on its allocable share of net income from the partnership Note.If a requester gives you a form other than Form W9 to conducting a trade or business in the United States Is in the request your TIN,you must use the requester's form if it Is following cases: substantially similar to this Form W9' •The U.S.owner of a disregarded entity and not the entity, . Cat No.10231X Form vhf-9 (Rev.10-2007) G:\pub-wrks\eng\dept-admin\SURVEYOR\Polaris 2009\Polaris Surveying contract Jan 09.doc Page 5 of 9 Uct Ub 11 U9:b3a JUN SNUWULN S I A I t FARM 5414524951 p.2 CERTIFICATE OF INSURANCE �..., This certifies that STATE FARM FIRE AND CASUALTY COMPANY,Bloomington,Illinois ❑ STATE FARM GENERAL INSURANCE COMPANY,Bloomington,Illinois ,. t ❑ STATE FARM FIRE AND CASUALTY COMPANY,Scarborough,Ontario ❑ STATE FARM FLORIDA INSURANCE COMPANY,Winter Haven,Florida ❑ STATE FARM LLOYDS,Dallas,Texas insures the following policyholder for the coverages indicated below: Policyholder Polaris Land Surveying Address ofpoficyholder P.O. Box 459 Ashland, OR 97502 Location of operations 151 CLEAR CREEK RD ASHLAND OREGON 97520 Description of operations Land surveying The policies listed below have been issued to the policyholder for the policy periods shown. The insurance described in these policies is subject to all the terms,exclusions, and conditions of those policies.The limits of liability shown may have been reduced by any paid claims. POLICY PERIOD LIMITS OF LIABILITY POLICY NUMBER TYPE OF INSURANCE Effective Date : Expiration Date (at beginning of policy period) Comprehensive BODILY INJURY AND 97-BG-L806-0 Business Liability _ _ __05-07-11 05-01-12---- PROPERTY DAMAGE .___________________------------------___________ This insurance includes: ®Products-Completed Operations ®Contractual Liability Each Occurrence $1000000 Personal Injury ❑Advertising Injury General Aggregate $2000000 ❑ Products-Completed 51000000 ❑ Operations Aggregate POLICY PERIOD BODILY INJURY AND PROPERTY DAMAGE EXCESS LIABILITY Effective Date : FxpIraf ri Date (Combined Single Limit) - ❑Umbrella Each Occurrence - $ ❑Other Aggregate $ POLICY PERIOD Part I-Workers Compensation - Statutory Effective Date ; Expiration Date 97-BG---783-9 Workers'Compensation 05/05/11 05/05/12 Part fl-Employers Liability and Employers Liability Each Accident S 5001000 Disease-Each Employee $500.000 Disease-Policy Limit $500,000 POLICY PERIOD LIMITS OF LIABILITY POLICY NUMBER TYPE OF INSURANCE Effective Date ; Expiration Data (at beginning of policy period) THE CERTIFICATE OF INSURANCE IS NOT A CONTRACT OF INSURANCE AND NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS,EXTENDS OR ALTERS THE COVERAGE APPROVED BY ANY POLICY DESCRIBED HEREIN. Name and Address of Certificate Holder If any of the described policies are canceled before CITY OF ASHLAND ITS OFFICERS, their explration date,State Farm will try to mail a EMPLOYEES 6 AGENTS written notice to the certificate holder 30 days before 20 E MAIN ST cancellation.H however,we fait to mail such notice, ASHLAND OR 97520-1850 no obligation or Gabilfty will be im 05ed on State Famr)or its ents o repres ' PA J Sig lure of ftwrizad Repres tativ Ag t 10/057011 Title Date Jon Snowden Agent Name Telephone Number 541-482-2461 Agent's Code Stamp Agent Cade 3719A13 AFO Coda F473 55&999&5 Rev.11-0e-2004 Printedn U.SA Page 1 / 1 �. CITY O F CITY RECORDER ASHLAND � DATE 'z�:-` IPO NUMBER'4^i 20 E MAIN ST. 10/31/2011 10532 ASHLAND, OR 97520 (541)488-5300 VENDOR: 008064 SHIP TO: Ashland Public Works POLARIS LAND SURVEYING INC (541)488-5587 PO BOX 459 51 WINBURN WAY ASHLAND, OR 97520 ASHLAND, OR 97520 FOB Point: Req.No.: Terms: Net Dept.: Req.Del.Date: Contact: Jim Olson special lnst Confirming? No .., Quaritify..' Unit ., �_ l'..:, .,., .Description Unit Price, ,-Ezt:Price, .` Contract for primary flexible general 5,000.00 surveying services to be provided on an as-needed basis. Street 260 08 12 Storm Drain 260 08 17 Water Dist 670 08 18 . Water Supply 670 08 15 WW Collections 675 08 17 Engineering 710 08 11 Contract Amendment-September 27, 2011 Date of original contract: January 22, 2009 The date for completion is extended to October 1, 2012 and maximum price is changed to$5,000.00. Insurance required/On file SUBTOTAL 5.000.001 BILL TO:Account Payable TAX 0.00 20 EAST MAIN ST FREIGHT 0.00 541-552-2028 TOTAL 5,000.00 ASHLAND, OR 97520 ,j_, Aciount Number,:. :''.Project Numti'er _ t.:'' Amount ': Aciount Number :.':;P,rolect Number ,. �„ ';Amount E 260.08.12.00.70410 1,500.00 E 260.08.17.00.70420 500.00 E 670.08.15.00.70420 500.00 E 670.08.18.00.70420 500.00 E 675.08.17.00.70420 500.00 E 710.08.11.00.60410 1,500.00 n� - -- �-'--y �� AUthO ¢d S18nature VENDOR COPY CITY OF ASHLAND REQUISITION No. P W FY 2011 Department PUBLIC WORKS Date September 26,2011 Vendor Polaris Land Surveying - Requested Delivery Date ASAP PO Box 459 Deliver To JIM OLSON Ashland,OR 97520 Via Item No. Quantity Unit Description Use of Pon;hasing Office only Unit Price Total Price PO No. Contract for primary flexible general surveying services to be provided on an as-needed basis. Street 260.08.12.00.704100 $ 1,500.00 Storm Drain 260.08.17.00.704200 $ 500.00 Water Distribution 670.08.18.00.704200 $ 500.00 Water Supply 670.08.15.00.704200 $ 500.00 WW Collections 675.08.17.00.704200 $ 500.00 Engineering 710.08,.23.0.00.604100 $ 1,500.00 It TOTAL $ 5,000.00 for Kari: BID /RFP/EXEMPT: RFP Contract Start Date: 441gust 3 1,20 11 Contract Completion Date: I-Oct-12 . Insurance on file: yes NO Project No: N/A Job No. Unit N0. I hereby certify that the above items are necessary for the operation of this department and ere budgeted Department Head or Authorized Person Issued By . Date Received By Ir, G:\pub-wrks\eng\dept-admin\SURVEYOR\Polaris 2011\2011 Polaris Flexible Sery Req.xls