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HomeMy WebLinkAbout2011-320 Contract - JM Construction Inc Contract for the Installation of Electrical Conduit CITY OF CONTRACTOR: JM Construction, Inc. ASHLAND CONTACT: Jason Myers 20 East Main Street Ashland, Oregon 97520 ADDRESS: PO Box 1637, Shady Cove, OR 97539 Telephone: 541/488-6002 Fax: 541/488-5311 TELEPHONE: 541-878-7810 DATE AGREEMENT PREPARED: November 9, 2011 FAX: 541-878-7811 BEGINNING DATE: December 1, 2011 COMPLETION DATE: March 30, 2012 COMPENSATION: $28,680.00— Per proposal attached as Exhibit C. GOODS AND SERVICES TO BE PROVIDED: Contractor to dig and install conduit for Electric, AFN and Charter Communications per Oak Street UG Conversion plan attached as Exhibit D and contractor's proposal attached as Exhibit C. Conduit and related installation materials to be provided by the City, AFN and Charter Communications. 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. 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, 2798.230, 279B.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 $18,890 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 50% 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. City'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 the Installation of Electrical Conduit, Page 1 of 5 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. Obligation/Liability of 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.110 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 QRF status pursuant to the QRF Rules or loses any license, certificate or certification that is required to perform the work or to qualify as a QRF if Contractor has qualified as a QRF 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. C traeter-shell-at-if�sow� expense provide the following insurance: a. orker's Compensati�onjAsurance in compliance with ORS 656.017, which requires subject employers to provide on-wort mpensation coverage for all their subject workers b. General L. ' nsuCace with a combined single limit, or the equivalent, of not less than Enter one: $200,000, $500,000, 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 ' b' -insurance with a combined single limit, or the equivalent, of not less than Enter one: $200,000, $500,000, 1,000,000 Not Applicable for each accident for Bodily Injury and Property Damage, including coverage for owne hired or non-owned vehicles, as applicable. Contract for the Installation of Electrical Conduit, Page 2 of 5 d. 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 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 contractor's insurance is primary and non-contributory. 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, "the 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 Council or 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. Contractor: City of Ashland By By Sig a ure Department Head S LEA /�un/¢�S/z.2G Print Na Print Name �( P S" dq-;� 7 Z /Vol:y/ Title Date W-9 One copy of a W-9 is to be submitted with the signed contract. Purchase Order No. G -2 Contract for the Installation of Electrical Conduit, Page 3 of 5 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 ID (or is waiting for the number tote 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/: (1) 1 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 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. (6) 1 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. Contractor (Date) Contract for the Installation of Electrical Conduit, Page 4 of 5 r z P.O.Box 1637 m z Shady Cove,Oregon 97539 c (541)878-7810 Fax:(541)878-7811 0 � Email:jmconstructioninc @earthlink.net• imp ccb#162365 PROPOSAL & CONTRACT Date: September 28,2011 Proposal Submitted To: Dave Tygerson City of Ashland—Electric Department 90 North Mountain Avenue Ashland, Oregon 97520 Phone: (541) 488-5357 Fax: (541) 552-2436 Email: davet @ashland.or.us PROJECT SITE: Oak Street,Ashland, Oregon 97520 REFERENCE MATERIALS: Hand drawn sketch provided by Dave Tygerson (Ashland Electric). WE PROPOSE hereby to furnish labor and materials as detailed below: Road Crossing on Oak Street in accordance to plan sheet provided by Ashland Electric. 312 Excavator 60 hours @$120/hr $7,200.00 Truck Rental (2) 120 hours @ $75/hr $9,000.00 Labor 120 hours @ $45/hr $5,400.00 Saw Cutting of Asphalt $ 450.00 Steel Plates $1,400.00 Fill Sand . 30 tons @ $20/ton $ 600.00 Asphalt Patch $3,300.00 '/d' Minus Aggregate 120 tons @ $9.00/ton $1,080.00 Concrete Haul-off $ 250.00 "Total Cost $28,680.00 THIS PROJECT IS NOT BID AS A PREVAILING WAGE PROJECT. EXCLUSIONS: Engineering and Soil Testing Permits and Fees Surveys and Locates Barricades and Temporary Fencing Landscaping and Irrigation Topsoil Proposal-City of Ashland Elea-Oak St Road Crossing lof 3 September 27,2011 n �\ P.O.Box 1637 z b- 4 Shady Cove,Oregon 97539 a - (541)878-7810 Fax:(541)878-7871 J M i Email:imconstructioninc @ earthlink.net ccb#162365 PAYMENT TERMS: Progress invoices will be supplied by JM Construction Inc. at the end of each month and shall be paid by the customer no later than the 10th of the subsequent month. Any amounts and/or balances in arrears more than thirty(30)days will be subject to 2%per month interest. DISCLOSURES: 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 extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. However, JM Construction Inc. shall not be deemed to have waived its right to compensation for extra work if the extra work was not provided for in writing, but shall be paid the reasonable value for such work performed. All agreements contingent upon strikes, accidents or delays are beyond our control. Any dispute or controversy arising out of the terms, conditions, or requirements of this agreement which exceed $4,000.00 in possible damages shall be submitted to arbitration in accordance with the American Arbitration Association Construction Industry Arbitration Rules and judgment rendered by the arbitrator shall be entered into any court of competent jurisdiction. The prevailing party in any suit or action or arbitration or administrative proceeding(including Construction Contractors' Board Claims)brought under the terms of this agreement to enforce or interpret any provision herein, shall be awarded attoineys fees and costs as may be adjudged reasonable by the Arbitration panel, administrative authority, court, or appellate court. Owner to carry fire, earthquake and other necessary insurance. Our workers are fully covered by Workman's Compensation Insurance. Differing Site Conditions: Any undisclosed or unforeseen subsurface conditions that arise upon excavation that are not deemed"standard" shall be considered above the contract price and shall be converted to time and material for all extra conditions. (e.g. any soils unable to be excavated with a typical backhoe, excavator, etc.) Linear and/or Square Footage Totals: Actual quantities shall be verified between the customer and a JM Construction Inc. representative upon project completion if necessary. WARRANTY: Warranty and/or guarantee period shall be the standard one(1) year from the date of substantial completion of this project. This warranty is valid only when the property or its improvements are subject to normal use and care by the Customer and provided the Customer has fully complied with all the terms and payment provisions of this agreement. JM Construction Inc. reserves the right to repair, replace, or pay reasonable sum in order to affect any mutual acknowledged repairs or corrections both during the construction process and throughout the warrantee period. Proposal-City of Ashland Elect-Oak Sr Road Crossing 2of 3 September 27,2011 i P.O.Box 1637 a Shady Cove,Oregon 97539 c Q (541)878-7810 Fax:(541)878-7811 0 Email:imconstmctioninc @earthlink.net z � cclNi 162365 Note: This proposal may be withdrawn by us if not accepted within seven(7)days. JM Construction Inc./Authorized Signature ACCEPTANCE OF PROPOSAL --The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date of Acceptance , 2011 Customer/Signature Customer/Print Name and Title Proposal-City of Ashland Elea-Oak St Road Crossing JOE 3 September 27,2011 w Ay 553N NHA v < rt D 0 A o c O1 ort rt < I.Sn,. G m to r nom V1 JbO I NpA fl. .; o I/pl r+ rD d 3 f+ / • aa� In r S (D o N p, m m 1 I W < 0 1 • rD 1 I � C IA p 1 I a o 7 • r"1' 2 � I S UP A 1 I 1 i j 11GhI � i I 4 15 ° �i j aitl t aE - i ! 1 ' 1 v E}` ; •IS i�tl � 9 L£LEt'09 HL S£SEbOS-1 K` NI 0£SE409-3 _.. i.... • j � � is �•a0N33 _{1_ i . ' � I � s• �� I 0 �t' ... w 1 o tf Ee I� R� I�'P 4 51g1g71.i Ai of i tltfii3 � a v I 1 I 1 N www.saif.com OREGON WORKERS COMPENSATION SaIF CERTIFICATE OF INSURANCE f corporation CERTIFICATE HOLDER: CITY OF ASHLAND 90 N. MOUNTAIN AVENUE ASHLAND, OR 97520 The policy of insurance listed below has been issued to the insured named below for the policy period indicated. The insurance afforded by the policy described herein is subject to all the terms, exclusions and conditions of such policy. POLICY NO. POLICY PERIOD ISSUE DATE 948875 12/01/2011 to 12/01/2012 12/05/2011 INSURED: BROKER OF RECORD: JM CONSTRUCTION INC PO BOX 1637 SHADY COVE,,OR 97539-1637 LIMITS OF LIABILITY: Bodily Injury by Accident $1,000,000 each accident Bodily Injury by Disease $1,000,000 each employee Body Injury by Disease $1,000,000 policy limit DESCRIPTION OF OPERATIONS/LOCATIONS/SPECIAL ITEMS: OAK STREET ELECTRICAL CONDUIT INSTALLATION CONTRACT DATED NOVEMBER 9, 2011 IMPORTANT: The coverage described above is in effect as of the issue date of this certificate. It is subject to change at any time in the future. This certificate is Issued as a matter of information only and c6nfers no rights to the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policies above. CANCELLATION: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL MAIL 30 DAYS,WRITTEN NOTICE TO THE ABOVE NAMED CERTIFICATE HOLDER. AUTHORIZED REPRESENTATIVE 2rg?c1j. President and CEO 400 High Street SE Salem,OR 97312 P:800.285.8525 F:503.373.8020 Policy—Batt—aC ficateOflnsurance Ra® CERTIFICATE OF LIABILITY INSURANCE OP ID DS DATE / 12 os 05/11 11 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 ACONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT; If the Certificate,holders an ADDITIONAL INSURED,the policy es must be endorsed. If SUBROGATIOUIS 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 certiflcate holder In lieu of such endarsement(s). PRODUCER NAME: Insurance Marketplace, Inc. No Ezl: NC,NO: A/C 1998 Skypark Dr Suite 100 ADDRESS: Medford OR 97504 CUSTOMERIDN: JMCON-1 Phone:541-779-0177 Fax:FAX 772-8235 INSURER(S)AFFORDING COVERAGE NAIC0 INSURED INSURERA: Ohio Securit 24074 De Construction Inc. INSURERS: Deborah Mpere PO BOX 1637 INSURER C: j Shady Cove OR 97539 INSURER D: INSURER E: INSURER F: i 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS i 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. Mbm LTR TYPE OF INSURANCE BF POL INSR WVD POLICY NUMBER (MMIDD (MWDD/YYYY) LIMITS GENERAL LIABILITY EACHOCCURRENCE $1,000,000 A X COMMERCIAL GENERAL LIABILITY BKS54934538 09/15/11 09/15/12 PREMISES Eacccurtance $1,000,000 CLAIMSIAADE OCCUR MED EXP(My one person) $15,000 X PERSONAL 6 ADV INJURY 51,000,000 GENERAL AGGREGATE 52,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY X JECT LOG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 • X ANY AUTO BAA53704352 e9/13/11 09/15/12 BODILY INJURY IN,person) $ ALL OWNED AUTOS BODILY INIURY(Per accident) $ SCHEDULED AUTOS X PROPERTY DAMAGE HIREDAUTOS (Per ecdden0 $ NON WNEDAUTOS $ $ • UMBRELLALIAB OCCUR US053704352 09/13/11 09/15/12 EACH OCCURRENCE $1,000,000 X EXCESS UAB CLAIMS-MADE AGGREGATE $1,000,000 DEDUCTIBLE g X RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN TORY LIMITS Eft ANY PROPRIETOFUPARTNERIEXECUT E.L.EACH ACCIDENT $ j OFFICERJMEMBER EXCLUOEOY IA (MandeW,y m NH) - If E.L.DISEASE-EA EMPLOYEE $ vas,describe under O CRIPTgN OF OPETATIONS EeIaw E.L.DISEASE-POLICY LIMTT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is mclulme) The City of Aahla>;1d Dreg on and its elected officials, officers. and employees are additional insured pper the attached. Re: Contract for the Installation of Electrical ConduiC dated November 9, 2011 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 ACCORDANCE WITH THE POLICY PROVISIONS, Kari Olson Purchasing Representative AUTHORIZED REPRESENTATIVE 90 N Mountain Ave Ashland OR 97520 Insurance Marketplace Inc. ®1988.2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) - The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 88 11 10 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY EXTENSION (Oregon) This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART INDEX SUBJECT PAGE NON-OWNED AIRCRAFT 2 NON-OWNED WATERCRAFT 2 PROPERTY DAMAGE LIABILITY-ELEVATORS 2 EXTENDED DAMAGE TO PROPERTY RENTED TO YOU(Tenant's Property Damage) 2 MEDICAL PAYMENTS EXTENSION 3 EXTENSION OF SUPPLEMENTARY PAYMENTS-COVERAGES A AND B 3 ADDITIONAL INSUREDS-BY CONTRACT,AGREEMENT OR PERMIT 3 PRIMARY AND NON-CONTRIBUTORY-ADDITIONAL INSURED EXTENSION 5 ADDITIONAL INSUREDS-EXTENDED PROTECTION OF YOUR"LIMITS OF INSURANCE" 5 WHO IS AN INSURED-INCIDENTIAL MEDICAL ERRORS/MALPRACTICE AND WHO IS AN INSURED- 5 FELLOW EMPLOYEE EXTENSION -MANAGEMENT EMPLOYEES NEWLY FORMED OR ADDITIONALLY ACQUIRED ENTITIES B FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES 7 KNOWLEDGE OF OCCURRENCE,OFFENSE,CLAIM OR SUIT 7 LIBERALIZATION CLAUSE 7 BODILY INJURY REDEFINED 7 EXTENDED PROPERTY DAMAGE 7 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US- 7 WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU 02010 Liberty Mutual Insurance Company.All rights reserved, CG 88 11 10 09 includes copyrighted material of Insurance Services Office Inc.,with its permission. Page 1 of 7 With respect to coverage afforded by this endorsement, the provisions of the policy apply unless modified by the endorsement. A. NON-OWNED AIRCRAFT Under Paragraph 2. Exclusions of Section I - Coverage A - Bodily Injury And Property Damage Liability, exclusion g.Aircraft,Auto Or Watercraft does not apply to an aircraft provided: 1. It is not owned by any Insured; 2. It Is hired,chartered or loaned with a trained paid crew; 3. The pilot in command holds a currently effective certificate, issued by the duly constituted.authority of the United States of America or Canada,designating her or him a commercial or airline pilot; and 4. It is not being used to carry persons or property for a charge. However, the insurance afforded by this provision does not apply if there is available to the Insured other valid and collectible Insurance,whether primary, excess (other than insurance written to apply specifically in excess of this policy), contingent or on any other basis,that would also apply to the loss covered under this provision. B. NON-OWNED WATERCRAFT Under Paragraph 2.Exclusions of Section I-Coverage A-Bodily Injury And Property Damage Liability, Subparagraph (2)of exclusion g.Aircraft,Auto Or Watercraft Is replaced by the following: This exclusion does not apply to: (2) A watercraft you do not own that is: (a) Less than 62 feet long; and (b) Not being used to carry persons or property for a charge; C. PROPERTY DAMAGE LIABILITY-ELEVATORS 1. Under Paragraph 2. Exclusions of Section I - Coverage A - Bodily Injury And Property Damage Liabil- ity, Subparagraphs (3), (4) and (6) of exclusion j. Damage To Property do not apply If such "property damage" results from the use of elevators. For the purpose of this provision, elevators do no include vehicle lifts. Vehicle lifts are lifts or hoists used in automobile service or repair operations. 2. The following is added to Section IV - Commercial General Liability Conditions, Condition 4. Other Insurance,Paragraph b.Excess insurance: The insurance afforded by this provision of this endorsement is excess over any property insurance, whether primary,excess,contingent or on any other basis. D. EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) If Damage To Premises Rented To You is not otherwise excluded from this Coverage Part: 1. Under Paragraph 2. Exclusions of Section I-Coverage A-Bodily Injury and Property Damage Liability: a. The fourth from the last paragraph_of exclusion j. Damage To_Property.ls_replaced by the follow _ _.. _r.__ ._..___ . . __._.__ ing: Paragraphs(1), (3) and(4)of this exclusion do not apply to."property damage",other than damage by fire, lightning,explosion,smoke or leakage from automatic fire protection system)to: (1) Premises rented to you for a period of 7 or fewer consecutive days; or (ii) Contents that you rent or lease as part of a premises rental or lease agreement for a period of more than 7 days. Paragraphs (1), (3) and (4) of this exclusion do not apply to "property damage" to contents of premises rented to you for a period of 7 or fewer consecutive days. 02010 Liberty Mutual Insurance Company.All rights reserved. CG 88 11 10 09 Includes copyrighted materiel of Insurance Services Office Inc.,with its permission. Page 2 of 7 A separate limit of insurance applies to this coverage as described In Section III - Limits of Insurance. b. The last paragraph of subsection 2. Exclusions Is replaced by thefollowing: Exclusions c. through n. do not apply to damage by fire, lightning, explosion, smoke, or leakage from automatic fire protection systems to premises while rented to you ortemporarily occupied by you with permission of the owner. A separate limit of insurance applies to Damage To Premises Rented To You as described in Section ill-Limits of Insurance. 2. Paragraph 6. under Section III-Limits of Insurance is replaced by the following: 6. Subject to Paragraph 5. above, the Damage To Premises Rented To You Limit is the most we will pay under Coverage A for damages because of"property damage"to: a. Any one premise: (1) While rented to you; or (2) While rented to you or temporarily occupied by you with permission of the owner for damage by fire, lightning, explosion, smoke or leakage from automatic protection sys- tems; or b. Contents that you rent or lease as part of a premises rental or lease agreement. As regards coverage provided by this provision D. EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage)-Paragraph 9.a.of Definitions Is replaced with the following: 9.a. A contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire, lightning, explosion, smoke, or leakage from automatic fire protection systems to premises while rented to you or temporarily occupied by you with the permission of the owner, or for damage to contents of such premises that are included in your premises rental or lease agreement,is not an "insured contract". E. MEDICAL PAYMENTS EXTENSION If Coverage C Medical Payments Is not otherwise excluded,the Medical Payments provided by this policy are amended as follows: Under Paragraph 1.Insuring Agreement of Section 1 -Coverage C- Medical Payments,Subparagraph (b)of Paragraph a. is replaced by the following: (b) The expenses are incurred and reported within three years of the date of the accident; and F. EXTENSION OF SUPPLEMENTARY PAYMENTS-COVERAGES A AND B 1. Under Supplementary Payments-Coverages A and B, Paragraph 1.b. is replaced by the following: b. Up to $3,000 for cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have - to furnish these bonds. 2. Paragraph 1.d. is replaced by the following: d: Aff reasonable ezbenses lncurred by the Insured at our request to assist us in the investigation or defense of the claim or "suit", including actual loss of earnings up to $500 a day because of time off from work, G. ADDITIONAL INSUREDS- BY CONTRACT,AGREEMENT OR PERMIT 1. Paragraph 2. under Section II -Who Is An Insured Is amended to include as an insured any person or organization whom you have agreed to add as an additional insured in a written contract, written agreement or permit. Such person or organization is an additional Insured but only with respect to liability for"bodily Injury", "property damage" or"personal and advertising injury" caused by: 02010 Liberty Mutual Insurance Company.All rights reserved. Co 88 1110 09 Includes copyrighted material of Insurance Services Office Inc.,with its permission. Page 3 of 7 a. Your acts or omissions,or the acts or omissions of those acting on your behalf,in the performance of your ongoing operations for the additional Insured that are the subject of the written contractor written agreement provided that the "bodily Injury" or "property damage" occurs, or the "per- sonal and advertising injury" is committed, subsequent to the signing of such written contract or written agreement; or b. Premises or facilities rented by you or used by you; or c. The maintenance, operation or use by you of equipment rented or leased to you by such person or organization; or d. Operations performed by you or on your behalf for which the state or political subdivision has issued a permit subject to the following additional provisions: (1) This insurance does not apply to "bodily injury", "property damage", or "personal and ad- vertising injury" arising out of the operations performed forthe state or political subdivision; I (2) This insurance does not apply to "bodily Injury" or "property damage" included within the "completed operations hazard". i (3) Insurance applies to premises you own,rent, or control but only with respect to the following I hazards: j (a) The existence, maintenance, repair, construction, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, street banners, or decorations and similar expo- sures; or (b) The construction,erection,or removal of elevators; or (c) The ownership, maintenance,or use of any elevators covered bythis Insurance. With respect to Paragraph 1.a. above, a person's or organization's status as an additional insured under this endorsement ends when: (1) All work, including materials, parts or equipment furnished in connection with such work,on the project(other than service, maintenance or repairs) to be performed by or on behalf of the additional Insured(s)at the location of the covered operations has been completed; or . (2) That portion of "your work" out of which the Injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged In performing operations for a principal as a part of the same project. With respect to Paragraph 1.b.above,a person's or organization's status as an additional insured under this endorsement ends when their written contract or written agreement with you for such premises or facilities ends. With respects to Paragraph 1.c, above,this Insurance does not apply to any "occurrence" which takes place after the equipment rental or lease agreement has expired or you have returned such equipment to the lessor. The insurance provided by this endorsement applles onlyff the or written agreement is signed prior to the "bodily Injury"or"property damage". We have no duty to defend an additional insured under this endorsement until we receive written notice of a "suit" by the additional insured as required in Paragraph b. of Condition 2. Duties In the Event Of Occurrence, Offense, Claim Or Suit under Section IV - Commercial General Liability Condi- tions. 2. With respect to the insurance provided by this endorsement, the following are added to Paragraph 2. Exclusions under Section I-Coverage A-Bodily Injury And Property Damage Liability: 02010 Liberty Mutual Insurance Company.All rights reserved. CG 88 11 10 09 Includes copyrighted material of Insurance Services Office Inc.,with its permission. Page 4 of 7 This Insurance does not apply to: a. "Bodily injury" or"property damage" arising from the sole negligence of the additional Insured. b. "Bodily injury" or "property damage" that occurs prior to you commencing operations at the location where such "bodily injury" or"property damage" occurs, c. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the render- Ing of, or the failure to render, any professional architectural, engineering or surveying services, including: (1) The preparing, approving, or falling to prepare or approve, maps, shop drawings, opinions, reports,surveys,field orders,change orders or drawings and specifications; or (2) Supervisory, Inspection,architectural or engineering activities. d. "Bodily Injury" or"property damage"occurring after: (1) All work, Including materials, parts or equipment furnished In connection with such work, on the project (other than service, maintenance or repairs)to be performed by or on behalf of the additional Insured(s)at the location of the covered operations has been completed; or (2) That portion of "your work" out of which the injury or damage arises has been put to its Intended use by any person or organization other than another contractor or subcontractor engaged in performing operations fora principal as a part of the same project. e. Any person or organization specifically designated as an additional Insured for ongoing operations by a separate ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS endorsement is- sued by us and made a part of this policy. H. PRIMARY AND NON-CONTRIBUTORY ADDITIONAL INSURED EXTENSION This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this policy. Condition 4. Other Insurance of SECTION IV-COMMERCIAL GENERAL LIABILITY CONDITIONS is amend- ed as follows: a. The following Is added to Paragraph a.Primary Insurance: If an additional insured's policy has an Other Insurance provision making its policy excess, and you have agreed in a written contract or written agreement to provide the additional insured coverage on a primary and noncontributory basis,this policy shall be primary and we will not seek contribution from the additional insured's policy for damages we cover. b. The following is added to Paragraph b.Excess Insurance: When a written contract or written agreement, other than a premises lease,facilities rental contract or agreement, an equipment rental or lease contract or agreement,or permit Issued by a state or political subdivision between you and an additional Insured does not require this Insurance to be primary or primary and non-contributory, this Insurance is excess over any other insurance for which the addi- tional insured is designated-as a-Named Insured. - - - Regardless of the written agreement between you and an additional insured, this Insurance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional insured has been added as an additional insured on other policies. I. ADDITIONAL INSUREDS-EXTENDED PROTECTION OF YOUR"LIMITS OF INSURANCE" This provision applies to any person or organization who qualifies as an additional Insured under any form or endorsement under this policy. 1. The following is added to Condition 2. Duties In The Event Of Occurrence,Offense,Claim or Suit: ©2010 Liberty Mutual Insurance company.All rights reserved. CG 88 11 10 09 Includes copyrighted material of Insurance Services Office Inc.,with Its permission. Page 5 of 7 An additional insured under this endorsement will as soon as practicable: a. Give written notice of an "occurrence" or an offense,that may result in a claim or"suit" under this insurance to us; b. Tender the defense and indemnity of any claim or "suit" to all Insurers whom also have Insurance available to the additional Insured; and c. Agree to make available any other insurance which the additional insured has for a loss we cover under this Coverage Part. d. We have no duty to defend or Indemnify an additional Insured under this endorsement until we receive written notice of a "suit" by the additional insured. 2. The limits of insurance applicable to the additional insured are those specified In a written contract or written agreement or the limits of Insurance as stated in the Declarations of this policy and defined in Section III - Limits of Insurance of this policy, whichever are less. These limits are inclusive of and not in addition to the limits of insurance available under this policy. J. WHO[SAN INSURED-INCIDENTIAL MEDICAL ERRORS/MALPRACTICE WHO IS AN INSURED-FELLOW EMPLOYEE EXTENSION-MANAGEMENT EMPLOYEES Paragraph 2.a.(1)of Section II-Who Is An Insured is replaced with the following: (1) "Bodily injury" or"personal and advertising injury": (a) To you,to your partners or members(if you are a partnership orjoint venture),to your members(if you are a limited liability company),to a co-"employee" while In the course of his or her employ- ment or performing duties related to the conduct of your business, or to your other "volunteer workers" while performing duties related to the conduct of your business; (b) To the spouse, child, parent, brother or sister of that co-"employee" or "volunteer worker" as a consequence of Paragraph (1)(a)above; (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the Injury described in Paragraphs(1)(a)or(b) above; or (d) Arlsing out of his or her providing or failing to provide professional health care services. However, if you are not in the business of providing professional health care services or providing profes- sional health care personnel to others, or if coverage for providing professional health care ser- vices is not otherwise excluded by separate endorsement, this provision (Paragraph (d)) does not apply. Paragraphs(a)and (b) above do not apply to "bodily injury" or"personal and advertising injury"caused by an "employee" who is acting In a supervisory capacity for you. Supervisory capacity as used herein means the "employee's" job responsibilities assigned by you, Includes the direct supervision of other "employ- ass" of yours. However, none of these "employees" are insureds for "bodily Injury" or "personal and advertising injury" arising out of their willful conduct,which is defined as the purposeful or willful Intent to cause "bodily Injury" or "personal and advertising injury", or caused In whole or in part by their Intoxica- tion by liquor or controlled substances. The coverage provided by provision J.is excess over any other valid and collectable insurance available to our"em to es'. K. NEWLY FORMED OR ADDITIONALLY ACQUIRED ENTITIES Paragraph 3.of Section II-Who Is An Insured is replaced by the following: 3. Any organization you newly acquire or form and over which you maintain ownership or majority Interest, will qualify as a Named Insured If there Is no other similar insurance available to that organization. However: a, Coverage under this provision is afforded only until the expiration of the policy period in which the entity was acquired or formed by you: b. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the organization; and 82010 Liberty Mutual Insurance Company.All rights reserved. CG 88 11 10 09 Includes copyrighted material of Insurance Services Office Inc.,with Its permission. Page 6 of 7 c. Coverage B does not apply to "personal and advertising Injury" arising out of an offense committed before you acquired or formed the organization. d. Records and descriptions of operations must be maintained by the first Named Insured. No person or organization is an insured with respect to the conduct of any current or past partnership,joint venture or limited liability company that Is not shown as a Named Insured In the Declarations or qualifies for as an Insured under this provision L. FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES Under Section IV-Commercial General Liability Conditions,the following is added to Condition 8. Repr& sentations: Your failure to disclose all hazards or prior "occurrences" existing as of the inception date of the policy shall not prejudice the coverage afforded by this policy provided such failure to disclose all hazards or prior"occurrences" Is not Intentional. M. KNOWLEDGE OF OCCURRENCE,OFFENSE,CLAIM OR SUIT Under Section IV -Commercial General Liability Conditions,the following Is added to Condition 2. Duties In The Event of Occurrence,Offense,Claim Or Suit: Knowledge of an "occurrence", offense, claim or "suit" by an agent, servant or "employee" of any insured shall not in itself constitute knowledge of the insured unless an Insured listed under Paragraph 1. of Section II -Who Is An Insured or a person who has been designated by them to receive reports of "occurrences", offenses, claims or "suits" shall have received such notice from the agent, servant or "employee". N. LIBERALIZATION CLAUSE If we revise this Commercial General Liability Extension Endorsement to provide more coverage without additional premium charge,your policy will automatically provide the coverage as of the day the revision is effective in your state. O. BODILY INJURY REDEFINED Under Section V-Definitions, Definition 3, Is replaced by the following; 3. "Bodily Injury" means physical Injury, sickness or disease sustained by a person. This includes mental anguish, mental injury, shock, fright or death that results from such physical injury, sick- ness or disease. P. EXTENDED PROPERTY DAMAGE Exclusion a. of COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY is replaced by the following: a. Expected Or Intended Injury "Bodily injury" or "property damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury" or "property damage" resulting from the use of reasonable force to protect persons or property. O. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US - WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU Under-Section-IV--Commercial-GenerahLiability-Conditions;-the-following-is added to-Condition$:-Trans- far Of Rights Of Recovery Against Others To Us: We waive any right of recovery we may have against a person or organization because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included In the "products-completed operations hazard" provided: 1. You and that person or organization have,agreed in writing In a contract or agreement that you waive such rights against that person or organization; and 2. The injury or damage occurs subsequent to the execution of the written contract or written agree- ment, ®2010 Liberty Mutual Insurance Company.All rights reserved. . CG 88 11 10 09 Includes copyrighted material of Insurance Services Office Inc.,with its permission. Page 7 of 7 E:I I T F'�Cl►Il1P`[l.JCt'i Page 1 / 1 �. CITY OF _A CHLAAiD � DATE:.`.":;: .'.- !PO:NUMBER 20 E MAIN ST. 12/2/2011 10575 ASHLAND, OR 97520 (541)488-5300 VENDOR: 010109 SHIP TO: Ashland Electric Department JM CONSTRUCTION INC (541)488-5354 PO BOX 1637 90 N MOUNTAIN SHADY COVE, OR 97539 ASHLAND, OR 97520 FOB Point: Req.No.: Terms: Net Dept: Req.Del.Date: contact: Dave Tygerson Special Inst: Confirming? No =�Quariti ' •Unit; '� ;,-:•.•� ':_ _ ' •. Description - -- _ � � - -� � . . r.��[� "_Unit Price; Eiit. Price*, i Contractor to dig and install conduit 28,680.00 for Electric, AFN and Charter Communications per Oak Street UG Conversion Plan. Contract for the Installation of Electrical Conduit- Date of agreement Nov.9, 2011 Beginning date: December 1, 2011 Completion date: March 30, 2012 Insurance required/On file NOTE: Charter Communications to be billed for their portion of the contract-97,170.00. SUBTOTAL 28 680.00 BILL TO:Account Payable TAX 0.00 20 EAST MAIN ST FREIGHT 0.00 541-552-2028 TOTAL 28,680.00 ASHLAND, OR 97520 .Project Number f_ y' . Amount.l.: Account Number 'Fr6ject Number] .AmoiintL wi; B 110.21810 7,170.00 E 690.11.18.00.70410 E 000264.999 14 340.00 E 691.02.47.00.703000 E 000264.999 7,170.00 � V27 orized Signature / VENDOR COPY CITY OF A request for a Purchase Order ASHLAND REQUISITION Date of request: Required date for delivery: EEI Vendor Name 7-M -oM57RUC7-1dY INC . Address,City,State,Zip P.Q. 1?OX 1637 SHF}OY CnuP T OR • 975 39 Contact Name&Telephone Number 5-ql-878 -7e/0 Fax Number 879 - 78t1 SOLICITATION PROCESS ❑ Exempt from Competitive Bidding ❑ Emergency ❑ Written Findings(Form attached) ❑ Invitation to Bid (Copies on file) ❑ Written findings attached ❑ Quote or Proposal attached Date approved by Council: ❑ Quote or Proposal attached ❑ Small Procurement Cooperative Procurement Less than$5,000 ❑ Request for Proposal (Copies on file) ❑ State of Oregon Note:Total contract amount,including any Date approved by Council: Contract It amendments may not exceed$6,000 ❑ State of Washington Intermediate Procurement ❑ Sole Source Contract It GOODS&SERVICES ❑ Written Findings(Form attached) ❑ Other government agency contract BP5 0 0 to 100 000 El Quote or Proposal attached Agency (3)Written quotes attached Contract It PERSONAL SERVICES ❑ Special Procurement ❑ Intergovernmental Agreement $5,000 to$75.000 El Written Findings(Form attached) Agency El Less than$35,000,by direct appointment E] Quote or Proposal attached Contract# ❑ 3)Written proposals attached Date approved by Council: Date approved by Council: Description of SERVICES Total Cost 17/G !/✓SELL E«c7 tler4L EoKdUil OA-K .sT CdNV�JZS/ /✓ — TO rAAeLude- Furti2Tz e0rrclull- FOR gSAIL14"O Fibev I xl/2TuiOR1"C — CH142TF_2 CoMrrrc/rlleFlT/O/V $r Item # Quantity Unit Description of MATERIALS Unit Price Total Cost Elec77e1C*4- eontdul?- Z3y� f SEfL er F/Z�r L'ondue� 02 "/911c 7 /70 7/ / 70 n�rr yClzTloN e2 100 7 l70 7/ / 70 TOTAL COSTS ' [ Per attached QUOTE $ ,' :/ec. Project Number(20026y- 9$9 Account Number 690.1/-Z8.LUQ.70yf00 Account Number___-__-__-__-.______ 'FiV- PR01eCT1�-'0oo2.6v. 999 AccountNumber6?1-• 2•y1.00•7Q3Q20 Account Number 1LQ 'Expenditure must be charged to the appropriate account numbers for the financials to reflect the actual expenditures accurately. Attach extra pages if needed. By signing this requisition form,I certify that the information provided above meets the City's public contracting requirements,and the documentation can be provided upon request. n —1 Employee Signature: J JC�I ftA I C�J • ,JI LOAD& . Department Head Signature: 62y UU Additional signatures(if applicable): / Funds appropriated for current fiscal year. E -) NO /% Finance Director Date Comments: G:FlnanceTrocedure%AP1Forms%Form#3-Requisition.doc Updated on:1011412011