HomeMy WebLinkAbout001326 Original Contract City of Port Angeles
C���
City ofPPort Angeleort AngelesRecord #001326
Public Works&Utilities Dept.
Engineering
ts,WA 8362 LIMITD EPUBLIC WORKS PROCE9Tel:360-417-4541
Fax: 360-417-4709 D Request for Quotation
M Contract
Contract Title: Lincoln and Whidby Street Roadway Repair Project Number: CON-2017-57
THIS CONTRACT is entered into the date last below written between the CITY OF PORT ANGELES, WASHINGTON
("City")AND Lakeside Industries, Inc ("Contractor").
1. WORK BY CONTRACTOR
The Contractor shall perform the work as described in Attachment"A"(Attachment"A"may include Contractor's
Proposal, Scope of Work, Statement of Work, Plans, Specifications, and any other related Contract Documents)
which is attached hereto and by this reference is incorporated herein.
2. TERM OF CONTRACT
All work under this Contract is to be completed as indicated (check one):
All work under this Contract is to be completed by this date:
All work under this Contract is to be completed 3jQ days from the Notice to Proceed. No work is
to be performed prior to written Notice to Proceed by the City.
The performance period under this Contract commences 10 calendar days after notice to proceed
and ends (20 davs thereafter or after contract award).
3. PAYMENT
A. The City shall pay the Contractor for the work performed under this contract(check one):
E] Force Account-Time and material, not to exceed: $
F-1 Force Account-Time and actual expenses incurred, not to exceed:
D Force Account- unit prices set forth in the Contractor's bid or quote, not to exceed:
E Firm Fixed Price set forth in Contractor bid or quote in the amount of: $46,341.00
The Contractor shall do all work and furnish all tools, materials, and equipment, in accordance
with and as described in the Attachment "A",
The Contractor shalt provide and bear the expense of all equipment, work and labor of any sort
whatsoever that may be required for the transfer of materials and for constructing and completing
the work provided for in this contract and every part thereof; except as are mentioned in the
specifications to be furnished by the City of Port Angeles.
B. The Contractor shall maintain time and expense records, which may be requested by the City. The contractor
shall submit invoices to the City for payment for work performed. All invoices must reference the City's contract
number. Invoices shall be in a format acceptable to the City.
C. The City shall pay all invoices from the Contractor by mailing a City warrant within 30 days of receipt of a
properly completed invoice.
D. All records and accounts pertaining to this Contract are to be kept available for inspections by representatives
of the City for a period of three (3)years after final payment. Copies shall be made available to the City upon
request.
Project CON-2017-57 Page 1 [FORM REVISED 7/20171
E. If during the course of the Contract, the work rendered does not meet the requirements set forth in the
Contract, the Contractor shall correct or modify the required work to comply with the requirements of this
Contract., The City shall have the right to withhold payment for such work until it meets the requirements of the
Contract Documents.
4. RESPONSIBILITY OF CONTRACTOR
A. Safety. Contractor shall take all necessary precautions for the safety of employees on the work site and shall
comply with all applicable provisions of federal, state and local regulations, ordinances and codes. Contractor
shall erect and properly maintain, at all times, as required by the conditions and progress of the work, all
necessary safeguards for the protection of workers and the public and shall post danger signs warning against
known or unusual hazards.
B. Correction of Defects. Contractor shall be responsible for correcting all defects in workmanship and/or
materials discovered within one year after acceptance of this work. When corrections of defects are made,
Contractor shall be responsible for correcting all defects in workmanship and/or materials in the corrected work
for one year after acceptance of the corrections by the City. The Contractor shall start work to remedy such
defects within seven (7) days of mailing notice of discovery thereof by City and shall complete such work within a
reasonable time. In emergencies where damage may result from delay or where loss of service may result, such
corrections may be made by the City, in which case the cost shall be borne by the Contractor. In the event the
Contractor does not accomplish corrections at the time specified, the work will be otherwise accomplished and
the cost of same shall be paid by the Contractor,
C. Warranty, Contractor shall be liable for any costs, losses, expenses or damages including consequential
damages suffered by the City resulting from defects in the Contractors work including, but not limited to, cost of
materials and labor expended by the City in making emergency repairs and cost of engineering, inspection and
supervision by the City. The Contractor shall hold the City harmless from any and all claims which, may be made
against the City as a result of any defective work and the Contractor shall defend any such claims at its own
expense. Where materials or procedures are not specified in the Contract Document, the City will rely on the
professional judgment of the Contractor to make appropriate selections,
D. Nondiscrimination/Affirmative Action. Contractor agrees not to discriminate against any employee or applicant
for employment or any other persons in the performance of this Contract because of race, creed, color, national
origin, marital status, sex, age, sexual orientation, genetic information, or handicap, or other circumstances as
may be defined by federal, state or local law or ordinance, except for a bona fide occupational qualification.
Contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices
to be provided by Contractor setting forth the provisions of the nondiscrimination clause.
E. Employment. Any and all employees of the Contractor, while engaged in the performance of any work or
services required by the Contractor under this Contract, shall be considered employees of the Contractor only and
not of the City. Any and all claims that may arise under the Workers Compensation Act on behalf of said
employees, while so engaged, and all claims made by a third party as consequence of any negligent act or
omission on the part of the Contractor's employees, while so engaged on any of the work or services provided or
rendered herein, shall not be the obligation of the City.
S. COMPLIANCE WITH LAWS
The Contractor shall comply with all federal, state and local laws and regulations applicable to the work done
under this Contract. Any violation of the provisions of this paragraph shall be considered a violation of a material
provision of this Contract and shall be grounds for cancellation, termination or suspension of the Contract by the
City, in whole or in part, and may result in ineligibility for further work for the City.
6.TERMINATION OF CONTRACT
A. This Contract shall terminate upon satisfactory completion of the work described in Attachment "A" and final
payment by the City.
B. The City may terminate the Contract and take possession of the premises and all materials thereon and finish
the work by whatever methods it may deem expedient, by giving 10 days written notice to the
Project CON-2017-57 Page 2 [FORM REVISED 7/20171
[L I OZIL 09SINIS WSO-41 E 05vd LS-L[OZ-NOD 133101d
stql 'uot4eDijiuwaputsiqljosasodjndaq4jojAlalos 'AADdTS@IILL 'a:)uejnsujleiiisnpuliapunA4!unwwijojaAiem
s,io:pei4uo:) aq4 sa4njqsuo:) uiaj@4 pap!AOjd uoi eDU!uwapui aq4 4eqj poolsiapun Aissajdxa pue Alle:)ij!Dads ja4:pnj
si 1I -a:)ua6q6au s,jo:pejjuo:)aqj jo 4ua4xa aq4 of Aluo aq Ile4s japunajaq A41I!qeil s,io:pej4uoD aq4 'sj@a4unjOA
pue 'saaAoldwa 'sleio!jjo IsiaDigo sj! '/%4!:)aq4 pue iopsiluoD a jo aoual5qbau 4uajjn:)uo:) aq4 wojj 6upinsaj
jo Aq pasne:) r4 atloid of sabewep jo suosiad of Ainfui Appoq to 4no 6uppe sa6ewep.sol A4!1!qeil To Juana 944
ui lua44 'sTT,i7Z*t, A/od of pafqns si 4u@waajbV siql jap aupiapp uoilaipsi.tnl jua4adwoo jo:pno:) e pinoqS 'q
-A4!D aqj to amabij6au
alos aq4 Aq pasneo sa6ewep pue saunfui joj 4daoxa 1juawaaj5V siq4 To wuewjojjad aq4 ql!m U014Dauuo:)
ul jo To Ino Wspe Isaaj Aaujo:ae Butpnloul sl!ns jo sassol 'sa6ewep Isapnfui 1swiep lie pue Aue wojj ssalwie4
sjaalunloA pue saaAoldwa Islepgo Isia:)U4o s4! 1/4!:)aq4 ploy pue Ajluwapui 'pualap lleqs jopeiluoo a4_L -V
ssnwim aioH / NOI1V:)I:IINIW3(]NI *OT
,pejjuo:)siq4 japun 'SaDIOAUI lie aAoidde pue maiAaj pue
'suoqe:munwwo:)a1pupow 'pawjojjad aq c4 Niom lie aAoidde pue aasjaAo Ile4s pue pej4uoD si44 japun A4!:) aq4
joj/4!l!q!suodsai /jewud aAeq lleqs aau61sap ja,q/siq jo juaw:pedao sappn pue qjoM :)Ilqnd a44 JO iopailcl a4i
IN3W39VNVW aNV Nouvujismiwav 1"3N39 '6
-wiep vans saq!j:)sap
Allnj pue wiep jeuopppe jo wi4ou sapnl:)ui 4uawAed leuU joj wiep vans ssalun 'apew uaaq lou se4 uoijeoildde
pi4m joj sa6ewep jaq4o Aue jo' wiep of lq6lJ S4! PaAiem aAeq 04 pawaap aq lleqs '4uawAed leuU joj uopeotldcle
6uijew uodn 'jopej4ucrj -4uawAed leuU and/q!:)aqj Aq leAoidde jo aw4 a44 ueqj.tale)Juana OU U1 pue Issol
.to asuadxa 'a6ewep vans jo AJaAO:)SIP aqj Ja:g2 sAep kpq4 utql.!m/,4!:)a44 of 6uptim w apew aq jsnw ppjjuo:)
siq4 jo aDuewjojjad aqj jo 4no 6utsije sei4xa jo s1soD 'sasuadxa 'sabewep and A4iD aqj Isuie6e pep AuV
SWI113Is
-japio pno:) Aq jo A4!:)aq4 jo leAoidde ua:n!jm joijd popm jo4:)ej4uoD aq4 Aq uoileziue6jo
jo lenp!Alpui Aue of alqel!eAe apew aq jou lleqs pue le!luapUuoo jdaN aq 1pm pej4uo:) siql japun jo:pej4uo:)aqj
Aq palqwasse jo pajeclaid jo of uaAj6 slepa4ew.to s4uawn:)op jaq4o jo e4ep 'uopewiojut 's:podai IspioDai AuV -9
•jsanbaj s4! uodn A4!:)aq4 of papieNuol aq Ileqs pue A4!:) aq4 jo A:padoid aqj awo:)aq lleqs peiluo:)
siq4 japun A4!:) aqj Aq pled spunj pm jopej4ucr) aq4 Aq pajeclaid lepa4ew pue sluawn:)op paqs1u1jun
Jo paqsiuU Ile 'peiluo:)si44 japun anp uoi4esuadww lie jo/4!:) aqj Aq jopei4uoD aq4 of 4uawAed uo 'V
SIN3wn:)oa :10 dIHSH3NMO 'L
-alqeuoseaj aq Ilei4s s4soo lebal vans pap!Aoid ':pej4uo:) aq4 japun A4!:)aqj jo s4saja4ui
pue sjq6u aqj haloid of A4!:) aqj Aq pajimm s4soD le6al Ile apnl:)ui lleqs sa6ewep pue asuadxa pnS -A4!:)aLI4
of a:)u;ajajj!p vans Aed lleqs pue A4!:) aq4 of ajopiat44 alqeil AllejaAas pue Aijujo(aq lleqs /qajns siq pue jopejjuo:)
'a:)ueleq peclun aqj paa:)xa sa6ewep pue asuadxa sA4!:)aq4 ji 'jopej4uo:)aq4 of/qD aqj Aq pled aq lleqs
ssa:)xa q:)ns 14uawAoldwa jo a:)uenuiluo:)sip jo ;ajnl!ej 'palf)au Ilesnjaj vans jo uoseaj Aq pauiqsns aq Aew pi4m
jo A4!D aq4 Aq pauie4sns sa6ewep Ile, pue 'Niom a44 6uipug ui A4!:) aqj Aq pajinDui asuadxa aqj spaua pel4uOD
si4l japun ped aq of 4unowe a4l jo aoueleq p!edun aqj jl lawp vans 4V -uotleumial jo a4ep aq4 of do 'painpaps
se 'pajaldwoo Al!jopejs!4es si ,V,, 4uawpepV ui paUpads Niom a4l pun peiluoD siq japun anp s4unowe
jaq4inj Aue aAI,9DaJ of paplua aq jou liet4s jopej4uo:) 'A4!:) aq Aq pajeuiwja4 si pei4uoD siq Juana aL44 ul -D
-joj papeilum)
)Ijom a4i jo uoilaldwa) punct of alqel!eAe lou aje spunj 6upejado 4uapWns 4eqj saupia4ap A4!D aqj_
-:peiluoo siq jo swial aLp sa4elOIA Alleguelsqns
aslmjaq4o jo 'jojej4spwpV pej4uoD aq jo suoi:pnj4sui spie6aisip Apua4sisjad jopej4uoD -9
-sa:)ueutpio pue suoileln6ai le:)ol jo a4els 11exapaj spie6aisip Allua4sisiad jopej4uoz) S
-joqel io letia4ew and siopej4uo:)qns of juawAed 4dwojd aNew of shed jo:peiluo:) -J7
-uit-)jaq paiinbai liom aq a4aldwm of shed jo sasnjai Alpa4eadaj jo Agualsisiad jopei4uo:) a4i -C
�jopej4uco aqj jo ADuaAlOSUI aq jo 41nsai e se pa4utodde si jaAlwaj V -Z
,sjol!paj:)qi jo juauaq aq4 joj juawu61sse jejauaI5 e saNew jopeiluoD @LtL -T
-pa!j!:)ads ia:4eajaq s4uaAa a4l jo ajow jo auo Aue jo aouaiinmo aql uodn liopej4uo:)
waiver has been mutually negotiated by the parties. The provisions of this section shall survive the expiration or
termination of this Agreement.
11. INSURANCE
The Contractor shall maintain insurance as set forth in Attachment B.
12. PREVAILING WAGE
This Contract is subject to Chapters 39.12 and 49.28 RC , amendments thereto and regulations issued
thereunder, relating to prevailing wages, benefits and other requirements. Workers shall receive no less than the
prevailing rate of wage. Bidders shall examine and be familiar with such requirements. No claim for additional
compensation will be allowed which is based upon a lack of knowledge or a misunderstanding of any such
requirements by the Bidder or a failure to include in Bidder's price adequate increases in such wages during the
performance of this Contract. The Contractor is advised to consult the Washington State Department of Labor
and Industries to determine the prevailing wages that must be paid.
This public works project is being done in Clallam County. Washington State wage determinations for Clallam
County Journeymen and Apprentices can be found at:
httt)s:Zlfortress,wa,gov/lnilwagelookupZprvWagelookup.as
px
htto://fortress.wa.gov/lni/wagelookup/ApprenticeWageLookup,aspx
Use the applicable wage determinations effective on the bid due date.
A copy of the applicable wage rates is available for viewing at the Port Angeles Public Works and Utilities
Contracts Office. In addition, this agency will mail a hard copy of the applicable wage rates upon request.
For a contract award under $2,500, and in accordance with RCW 39.12.040(2), the contractor or subcontractor is
authorized to submit a combined Statement of Intent to Pay Prevailing Wages &Affidavit of Wages directly to the
City of Port Angeles at final invoicing. Submission shall be made on the form developed by the Washington State
Department of Labor and Industries and available from the City of Port Angeles Public Works and Utilities
Department.
In case any dispute arises as to what are the prevailing rates of wages for a specific trade, craft or occupation
and such dispute cannot be adjusted by the parties in interest, including labor and management representatives,
the matter shall be referred for arbitration to the Director of the Department of Labor and Industries, and his
decision shall be final, conclusive, and binding on all parties involved in the dispute,
13. INTERPRETATION AND VENUE
This Contract shall be interpreted and construed in accordance with the laws of the State of Washington. The
venue of any litigation between the parties regarding this Contract shall be Clallam County, Washington.
14. BRANDS OR EQUAL
When a special "brand or equal" is named it shall be construed solely for the purpose of indicating the standards
of quality, performance, or use desired. Brands of equal quality, performance, and use shall be considered,
provided Contractor specifies the brand and model and submits descriptive literature when available. Any bid
containing a brand which is not of equal quality, performance, or use specified must be represented as an
alternate and not as an equal, and failure to do so shall be sufficient reason to disregard the bid.
15. INSPECTION AND REJECTION
All goods, services, work, or materials purchased herein are subject to inspection and to approval by the City. Any
rejection of goods, services, work, or materials resulting because of nonconformity to the terms and specifications
of this order, whether held by the City or returned, will be at Contractor's risk and expense.
Project CON-2017-57 Page 4 [FORM REVISED 7/20171
16. SUBLETTING OR ASSIGNING OF CONTRACTS
Neither the City nor the Contractor shall assign, transfer, or encumber any rights, duties or interest accruing from
this Contract without the express prior written consent of the other.
17. INDEPENDENT CONTRACTOR
The Contractor is and shall be at all times during the term of this Contract an independent contractor and not an
employee of the City.
18. EXTENT OF CONTRACT/MODIFICATION
This Contract, together with the attachments and/or addenda, represents the entire and integrated Contract
between the parties hereto and supersedes all prior negotiations, representations, or agreements, either written
or oral. This contract may be amended, modified or added to only by written instrument property signed by both
parties hereto.
19. SUBCONTRACTOR RESPONSIBILITY
A. The Contractor shall include the language of this section in each of its first tier subcontracts, and shall require
each of its subcontractors to include substantially the same language of this section in each of their subcontracts,
adjusting only as necessary the terms used for the contracting parties. The requirements of this section apply to
all subcontractors regardless of tier.,
B. At the time of subcontract execution, the Contractor shall verify that each of its first tier subcontractors meets
the following bidder responsibility criteria:
- At the time of subcontract bid submittal, have a certificate of registration in compliance with chapter
18,27 RCW;
- Have a current state unified business identifier number;
- If applicable, have:
• Industrial insurance coverage for the subcontractor's employees working in Washington as required
in Title 51 RCW;
• An employment security department number as required in Tile 50 RCW; and
• A state excise tax registration number as required in Tile 82 RCW;
• An electrical contractor license, if required by Chapter 19.28 RCW;
• An elevator contract license, if required by Chapter 70.87 RCW.
- Not be disqualified from bidding on any public works contract under RCW 39.06.010 or 39.12.065(3).
Project CON-2017-57 Page 5 pFf7RM REVISED 7/20171
IN WITNESS S WHEREOF, the parties have executed this Contract as of the date of the Mast signature affixed
below.
LAKESIDE INDUSTRIES, INC. CITY OF PORT ANGELES
By: _ _ By:
Printed Name: i Printed Name:_,_
Cate: w_
Title:
Date:
Title:
Address: r»o. Zo.x 7ZT
City: r ..... L& � wA cite
Tax IC #: (00�
Phone Number: Z- 7 7
wwww
Project CON-2017-57 Pae 6 [FORM REVISED 7/20171
City of Port Angeles ATTACHMENT "A"
Engineering Office WORK BY CONTRACTOR
Public Works and Utilities Department
The contractor shall do all work and furnish all tools, materials, and equipment in order to accomplish the
project described below. Unless otherwise provided for in the Statement of Work, the Contractor will be
responsible for obtaining and paying for any and all permits required for this work.
General Scope: Subgrade and asphalt pavement replacement for roadway repairs
Location: Lincoln Street and Whidby Avenue
Site Point of Contact: Jason Hart, Water/Wastewater Field Superintendent at 360-417-4855
Work Hours and Schedule: The Contractor will be allowed to work from 7:30 AM to 3:30 PM, Monday
through Friday, excluding weekends and all legal holidays, Work outside of these hours may be requested
from and is at the discretion of the Deputy Director of Operations.
Permits: None Required
Specifications/Work Requirements:
This contract incorporates the current Washington State Department of Transportation's Standard
Specification for Road, Bridge, and Municipal Construction referred to herein as the Standard Specifications
(Current Edition).
Payment shall be"Lump Sum"for the entire work completed.
Special Provisions:
1-01.3 Definitions
(January 4, 2016 APWA GSP)
Delete the heading Completion Dates and the three paragraphs that follow it, and replace them with the
following:
Dates
Bid Opening Date
The date on which the Contracting Agency publicly opens and reads the Bids.
Award Date
The date of the formal decision of the Contracting Agency to accept the lowest responsible and
responsive Bidder for the Work.
Contract Execution Date
The date the Contracting Agency officially binds the Agency to the Contract.
Notice to Proceed Date
The date stated in the Notice to Proceed on which the Contract time begins.
Substantial Completion Date
The day the Engineer determines the Contracting Agency has full and unrestricted use and benefit of
the facilities, both from the operational and safety standpoint, any remaining traffic disruptions will be
rare and brief, and only minor incidental work, replacement of temporary substitute facilities, plant
establishment periods, or correction or repair remains for the Physical Completion of the total
Contract.
Project#CON-2017-57 Page 7
Physical Completion Date
The day all of the Work is physically completed on the project. All documentation required by the
Contract and required by law does not necessarily need to be furnished by the Contractor by this
date.
Completion Date
The day all the Work specified in the Contract is completed and all the obligations of the Contractor
under the contract are fulfilled by the Contractor. All documentation required by the Contract and
required by law must be furnished by the Contractor before establishment of this date.
Final Acceptance Date
The date on which the Contracting Agency accepts the Work as complete.
Supplement this Section with the following:
All references in the Standard Specifications, Amendments, or WSDOT General Special Provisions, to
the terms"Department of Transportation", "Washington State Transportation Commission",
"Commission", "Secretary of Transportation", "Secretary", "Headquarters", and "State Treasurer' shall be
revised to read"Contracting Agency".
All references to the terms"State" or"state" shall be revised to read "Contracting Agency" unless the
reference is to an administrative agency of the State of Washington, a State statute or regulation, or the
context reasonably indicates otherwise.
All references to"State Materials Laboratory" shall be revised to read"Contracting Agency designated
location".
All references to"final contract voucher certification" shall be interpreted to mean the Contracting Agency
form(s)by which final payment is authorized, and final completion and acceptance granted.
Additive
A supplemental unit of work or group of bid items, identified separately in the Bid Proposal, which may,
at the discretion of the Contracting Agency, be awarded in addition to the base bid.
Alternate
One of two or more units of work or groups of bid items, identified separately in the Bid Proposal, from
which the Contracting Agency may make a choice between different methods or material of construction
for performing the same work.
Business Day
A business day is any day from Monday through Friday except holidays as listed in Section 1-08.5.
Contract Bond
The definition in the Standard Specifications for"Contract Bond"applies to whatever bond form(s)are
required by the Contract Documents, which may be a combination of a Payment Bond and a
Performance Bond.
Contract Documents
See definition for"Contract".
Contract Time
The period of time established by the terms and conditions of the Contract within which the Work must
be physically completed.
Notice of Award
The written notice from the Contracting Agency to the successful Bidder signifying the Contracting
Agency's acceptance of the Bid Proposal.
Project # CON-2017-57 Page 8
Notice to Proceed
The written notice from the Contracting Agency or Engineer to the Contractor authorizing and directing
the Contractor to proceed with the Work and establishing the date on which the Contract time begins,
Traffic
Both vehicular and non-vehicular traffic, such as pedestrians, bicyclists, wheelchairs, and equestrian
traffic.
All references to "Engineer" and "Project Engineer" are redefined to mean City Engineer for the
City of Port Angeles.
The terms "Contract" and "Project Manual" are interchangeable.
1-04.1(2) Bid Items Not Included in the Proposal
Section 1-04.1(2)is replaced with the following:
"When the contract specifies Work that has no Bid item, and the Work is not specified as being included
with or incidental to other Bid items, payment for the Work shall be included in an appropriate unit price
or lump sum bid item in the Bid Form."
1-04.2 Coordination of Contract Documents, Plans, Special Provisions, Specifications,and Addenda
Revise the second paragraph to read:
Any inconsistency in the parts of the contract shall be resolved by following this order of precedence
(e.g., 1 presiding over 2, 2 over 3, 3 over 4, and so forth):
1. Addenda,
2. Proposal Form,
3. Special Provisions, including APWA General Special Provisions, if they are included,
4. Contract Plans,
5. Amendments to the Standard Specifications,
6. Current edition of the City of Port Angeles Urban Services Standards and Guidelines,
7. WSDOT Standard Specifications for Road, Bridge and Municipal Construction, and
8. WSDOT Standard Plans for Road, Bridge, and Municipal Construction.
1-04.4 Changes in Work
Section 1-04.4, Changes, of the Standard Specifications shall be supplemented with the following:
All revisions, clarifications, field requests and field authorizations for construction contracts shall be
documented using the "REQUEST FOR INFORMATION (RFI)"form. A construction contract change
order may be initiated by the Contractor, City Inspector, or Engineer by using the RFI form contained in
Contract documents.
1-05.7 Removal of Defective and Unauthorized Work
(October 1, 2005 A GSP)
Supplement this section with the following:
If the Contractor fails to remedy defective or unauthorized work within the time specified in a written
notice from the Engineer, or fails to perform any part of the work required by the Contract Documents,
Project # CON-2017-57 Page 9
the Engineer may correct and remedy such work as may be identified in the written notice, with
Contracting Agency forces or by such other means as the Contracting Agency may deem necessary.
If the Contractor fails to comply with a written order to remedy what the Engineer determines to be an
emergency situation, the Engineer may have the defective and unauthorized work corrected
immediately, have the rejected work removed and replaced, or have work the Contractor refuses to
perform completed by using Contracting Agency or other forces.An emergency situation is any situation
when, in the opinion of the Engineer, a delay in its remedy could be potentially unsafe, or might cause
serious risk of loss or damage to the public.
Direct or indirect costs incurred by the Contracting Agency attributable to correcting and remedying
defective or unauthorized work, or work the Contractor failed or refused to perform, shall be paid by the
Contractor. Payment will be deducted by the Engineer from monies due, or to become due, the
Contractor. Such direct and indirect costs shall include in particular, but without limitation, compensation
for additional professional services required, and costs for repair and replacement of work of others
destroyed or damaged by correction, removal, or replacement of the Contractor's unauthorized work.
No adjustment in contract time or compensation will be allowed because of the delay in the performance
of the work attributable to the exercise of the Contracting Agency's rights provided by this Section.
The rights exercised under the provisions of this section shall not diminish the Contracting Agency's right
to pursue any other avenue for additional remedy or damages with respect to the Contractor's failure to
perform the work as required.
1-05.10 Guarantees
Section 1-05.10 is supplemented with the following:
The Contractor shall guarantee all materials and equipment furnished and work performed for a period of
one (1)year from the date of physical completion. The Contractor shall warrant and guarantee for a
period of one(1) year from the date of physical completion of the system that the completed system is
free from all defects due to faulty materials or workmanship, and the Contractor shall promptly make
such corrections as may be necessary by reason of such defects including the repairs of any damage to
other parts of the system resulting from such defects. The City will give notice of observed defects with
reasonable promptness. In the event that the Contractor should fail to make such repairs, adjustments,
or other work that may be made necessary by such defects, the City may do so and charge the
Contractor the cost thereby incurred. All costs associated with this item shall be incidental to the contract
prices for the various bid items.
1-05.11 Final Inspection
Delete this section and replace it with the following:
1-05.11 Final Inspections and Operational Testing
1-05.11(1) Substantial Completion Date
When the Contractor considers the work to be substantially complete, the Contractor shall so notify the
Engineer and request the Engineer establish the Substantial Completion Date.The Contractor's request
shall list the specific items of work that remain to be completed in order to reach physical completion.
The Engineer will schedule an inspection of the work with the Contractor to determine the status of
completion.The Engineer may also establish the Substantial Completion Date unilaterally.
If, after this inspection, the Engineer concurs with the Contractor that the work is substantially complete
and ready for its intended use, the Engineer, by written notice to the Contractor, will set the Substantial
Completion Date. If, after this inspection, the Engineer does not consider the work substantially complete
and ready for its intended use, the Engineer will, by written notice, so notify the Contractor giving the
reasons therefore.
Project# CON-2017-57 Page 10
Upon receipt of written notice concurring in or denying substantial completion, whichever is applicable,
the Contractor shall pursue vigorously, diligently and without unauthorized interruption, the work
necessary to reach Substantial and Physical Completion. The Contractor shall provide the Engineer with
a revised schedule indicating when the Contractor expects to reach substantial and physical completion
of the work.
The above process shall be repeated until the Engineer establishes the Substantial Completion Date and
the Contractor considers the work physically complete and ready for final inspection.
1-05.11(2) Final Inspection and Physical Completion Date
When the Contractor considers the work physically complete and ready for final inspection, the
Contractor by written notice, shall request the Engineer to schedule a final inspection. The Engineer will
set a date for final inspection. The Engineer and the Contractor will then make a final inspection and the
Engineer will notify the Contractor in writing of all particulars in which the final inspection reveals the
work incomplete or unacceptable. The Contractor shall immediately take such corrective measures as
are necessary to remedy the listed deficiencies. Corrective work shall be pursued vigorously, diligently,
and without interruption until physical completion of the listed deficiencies. This process will continue
until the Engineer is satisfied the listed deficiencies have been corrected.
If action to correct the listed deficiencies is not initiated within 7 days after receipt of the written notice
listing the deficiencies, the Engineer may, upon written notice to,the Contractor, take whatever steps are
necessary to correct those deficiencies pursuant to Section 1-05.7. The Contractor will not be allowed an
extension of contract time because of a delay in the performance of the work attributable to the exercise
of the Engineer's right hereunder.
Upon correction of all deficiencies, the Engineer will notify the Contractor and the Contracting Agency, in
writing, of the date upon which the work was considered physically complete.That date shall constitute
the Physical Completion Date of the contract, but shall not imply acceptance of the work or that all the
obligations of the Contractor under the contract have been fulfilled.
1-05.13 Superintendents, Labor and Equipment of Contractor
(August 14, 2013 APWA GSP)
Delete the sixth and seventh paragraphs of this section.
1-05.15 Method of Serving Notices
(March 25, 2009 APWA GSP)
Revise the second paragraph to read:
All correspondence from the Contractor shall be directed to the Project Engineer. All correspondence
from the Contractor constituting any notification, notice of protest, notice of diSDute. or other
correspondence constituting notification reguired to be furnished under the Contract, must be in paper
format, hand delivered or sent via mail delivery service to the Project Engineer's office. Electronic copies
such as e-mails or electronically delivered copies Of correspondence will not constitute such notice and
will not comply with the requirements of the Contract.
Add the following new section:
1-05.16 Water and Power
(October 1, 2005 APWA GSP)
The Contractor shall make necessary arrangements, and shall bear the costs for power and water
necessary for the performance of the work, unless the contract includes power and water as a pay item.
Project 4 CON-2017-57 Page 11
1-07.1 Laws to be Observed
(October 1, 2005 APWA G SP)
Supplement this section with the following:
In cases of conflict between different safety regulations, the more stringent regulation shall apply.
The Washington State Department of Labor and Industries shall be the sole and paramount
administrative agency responsible for the administration of the provisions of the Washington Industrial
Safety and Health Act of 1973(WISHA).
The Contractor shall maintain at the project site office, or other well known place at the project site, all
articles necessary for providing first aid to the injured. The Contractor shall establish, publish, and make
known to all employees, procedures for ensuring immediate removal to a hospital, or doctor's care,
persons, including employees, who may have been injured on the project site. Employees should not be
permitted to work on the project site before the Contractor has established and made known procedures
for removal of injured persons to a hospital or a doctor's care.
The Contractor shall have sole responsibility for the safety, efficiency, and adequacy of the Contractor's
plant, appliances, and methods, and for any damage or injury resulting from their failure, or improper
maintenance, use, or operation. The Contractor shall be solely and completely responsible for the
conditions of the project site, including safety for all persons and property in the performance of the work.
This requirement shall apply continuously, and not be limited to normal working hours. The required or
implied duty of the Engineer to conduct construction review of the Contractor's performance does not,
and shall not, be intended to include review and adequacy of the Contractor's safety measures in, on, or
near the project site.
1-07.2 State Sales Tax
(June 27, 2011 APINA GSP)
The Washington State Department of Revenue has issued special rules on the State sales tax. Sections
1-07.2(1)through 1-07.2(3)are meant to clarify those rules. The Contractor should contact the
Washington State Department of Revenue for answers to questions in this area. The Contracting
Agency will not adjust its payment if the Contractor bases a bid on a misunderstood tax liability.
The Contractor shall include all Contractor-paid taxes in the unit bid prices or other contract amounts. In
some cases, however, state retail sales,tax will not be included. Section 1-07.2(2) describes this
exception.
The Contracting Agency will pay the retained percentage (or release the Contract Bond if a FHWA-
funded Project)only if the Contractor has obtained from the Washington State Department of Revenue a
certificate showing that all contract-related taxes have been paid (RCW 60,28.051). The Contracting
Agency may deduct from its payments to the Contractor any amount the Contractor may owe the
Washington State Department of Revenue, whether the amount owed relates to this contract or not. Any
amount so deducted will be paid into the proper State fund.
1-07.2(2) State Sales Tax—Rule 170
WAC 458-20-170, and its related rules, apply to the constructing and repairing of new or existing
buildings, or other structures, upon real property. This includes, but is not limited to, the construction of
streets, roads, highways, etc., owned by the state of Washington; water mains and their appurtenances;
sanitary sewers and sewage disposal systems unless such sewers and disposal systems are within, and
a part of, a street or road drainage system; telephone, telegraph, electrical power distribution lines, or
other conduits or lines in or above streets or roads, unless such power lines become a part of a street or
road lighting system; and installing or attaching of any article of tangible personal property in or to real
property, whether or not such personal property becomes a part of the realty by virtue of installation.
Project#CON-2017-57 Page 12
I 3Rvd L -LIOZ-NOD #I-)-)fOJd
-ale:)s of umeip lou sl molaq uoi4eiisnlli :@40N
:s6uimeja
-uoipni4suo-) builnp ueld juaujajdw! pue 'liom jo:gels of jotid leAoidde A4!:)joj
'ueld pace aA14NM '(dddMS) ueld UOIIU@AaJd MAN ja4emwjojS e ap!Aoid Reqs Jopeiluo:) aLtL -9
,1100i7 old qj!m bulAed ia)je sabpa aqj
5WleaS JOI pue binned aipjacl T-SS:) 41!m s4uiof aqj builoel joj apsuodsai aq lleqs jopeiluo:)aqj -S
-qjdap papedwo:) wnwiuiw,,Z 'VWH ,,z/t aq Reqs a4aj:)uo:)41eqdsv 'UO14eAala
asinoD aseq f5ui i4s,xa p4ew of pedwo:) pue asinm dol bui:)ejjns paqsnn q4!m apeJ5 ajolsai
pue laseq 6ui4s!xa pe,dwoD 'paiieclai aq of ease aqj uiq4!m lleqdse Ile aAOWaJ jIeqS JOPeJIUO:) aq 1 '17
-sa4e:)oj Ile joj 6uilleD joj alq!suodsai aq lleqs jo:pej4ucrj at4i -E
-15up4m) mines AaessaDau Ile wjopad II!m sala6uV:POd jo A4!:) a4.L -Z
-joijum :>L4ej4 jo4 lauumad pue sa:)tAap joijum:qJej4 Ile ap!Aoid Ipm sajabuV pod 10 All:)a41 -T
:molaq pap!Aoid spejap aqj jad palaidwo:)
aq Ile4s�Ijom IIv molaq 6uimeip uo umoqs eaje auo of juawamidwi aqj jol Pafojd wns dwnl e si s4i
uopcimmea potoid
,aouejnsul ,,e ju9wqoejjV,, qpm paoeldej s' 91,10'1, uOROOS
aoueinsul aBewea A:padOJd pue Al!l!qei-1 oilqnd BVLO-l.
'Aidde(,7)Z*,Lo-t uopoeS jo suoistAoid aqt *xe.L sales fed oj
joumo aqj sa;eAtlqo dugs sumo asoym spuel uodn powippod aq ol sji ;oejjuoo si14; uo )Ijom aq.L
.
pue 9C I, sojn�j anU9A9jo juawpedea a;ejS uol6uiqseAA ui pautlap se) saowas i9t4jo jo leuoissajoid
jol Alloqm joeiluoo due uo Aou96V 6utloeiluoo at4l wojj xel sales l!ejai joalloo jou Reqs joloeiluoo aq I
sODIAJOS WZ*L0-6
�junowe joeiluoo jaqjo
due ui jo saoijd wap pq pun aqj ui papnloui aq lleqs saxel sales L4onS �joafojd aqj olui palei6olui jou
saiIddns alqewnsuoo jo 'juawdinbe 'Ajaupqoew 'slool jo jejuai jo aset4oind aqj uo saNew joloeiluooqns
e jo joloeiluoo aqj juawAed e joj xel sales ui ppe jou ll!m Aou96V 6uiloeiluoo aqj :uotjd9Ox3
-uoqd9ox9 buimollol aqj qj!m 'OL 1, ajn�j of joafqns junowe joeiluoo i9qjo due ui io 'saoijd wal! pq
pun aqj ui xel sales I!elaj aqlapnioui jou lleqs joloeiluoo aqj 'uoseaj spqj jo-4 -joloejluoo aqj of juaw4ed
qoea of xel sales siql ppe Alleoijewolne Ipm AouabV 6upoeiluoo aqi aoijd joeiluoo jInj aqj uo xel
sales pejaj 'Aou96V builoeiluoo aqj wojj joapo lleqs joloeiluoo at4j 'saseo Bons ui powjopad�jom joj
!Em—
WE
* DRQ `+' !' fCr�K�• w� � �,
/
/r
ZZ
Of
✓ ;/ a ,„
! 1 /�!i !✓'�/ (lid r
/ 11
J
/ my ,// /r////o/�/a/%�o,
II` Jl,
lJ
gy
I
P'VU �j
Ito A Now AM,
n� �
/
410 ,,Jafi�r, r h7!✓�1 „,f%f ���1I, war � r ��
City of Port Angeles ATTACHMENT "B"
Engineering Office INSURANCE
Public Works and Utilities Department
INSURANCE REQUIREMENTS FOR
CONSTRUCTION AND SERVICE CONTRACTS
Includes construction and remodeling,janitorial service, tree inaintenance, road inaintenanev,
painting, electrical work-,plumbing, movers, and on site nivintenance agreements.
Insurance
The Contractor shall procure and maintain for the duration of the Agreement, insurance against
claims for injuries to persons or damage to property which may arise frorn or in connection with the
performance of the work, hereunder by the Contractor, their agents,representatives, employees or
subcontractors.
No Limitation
Contractor's maintenance of insurance, its scope of coverage and limits as required herein shall not
be construed to limit the liability of the Contractor to the coverage provided by such insurance, or
otherwise limit the City's recourse to any remedy available at law or in equity.
Minimum Scope of Insurance
Contractor shall obtain insurance of the types described below:
1. Automobile Liability insurance covering all owned, non-owned, hired and leased vehicles.
Coverage shall be written on Insurance Services Office (ISO) form CA 00 01 or a substitute
form providing equivalent liability coverage. If necessary, the policy shall be endorsed to
provide contractual liability coverage,
2. Commercial General Liability insurance shall be written on ISO occurrence form CG 00 01
and shall cover liability arising from premises, operations, independent contractors,
products-completed operations, stop gap liability, personal injury and advertising injury, and
liability assumed under an insured contract. The Commercial General Liability insurance
shall be endorsed to provide the Aggregate Per Project Endorsement ISO form CG 25 03 11
85 or an equivalent endorsement. There shall be no endorsement or modification of the
Commercial General Liability Insurance for liability arising from explosion, collapse or
underground property damage. The City shall be named as an insured under the Contractor's
Commercial General Liability insurance policy with respect to the work performed for the
City using ISO Additional Insured endorsement CG 20 10 10 01 and Additional Insured-
Completed Operations endorsement CG 20 3 7 10 01 or substitute endorsements providing
equivalent coverage.
3. Workers' Compensation coverage as required by the Industrial Insurance laws of the State
of Washington.
Minimum Amounts of Insurance
Contractor shall maintain the following insurance limits:
1, Automobile Liability insurance with a minimum combined single limit for bodily injury and
property damage of S1,000,000 per accident.
Project #CON-2017-57 Page 15
2. Commercial General Liability insurance shall be written with limits no less than $1,000,000
each occurrence, $2,000,000 general aggregate and $2,000,000 products-completed
operations aggregate limit.
Other Insurance Provision
The Contractor's Automobile Liability and Commercial General Liability insurance policies are to
contain, or be endorsed to contain that they shall be primary insurance as respect the City. Any
insurance, self-insurance, or insurance pool coverage maintained by the City shall be excess of the
Contractor's insurance and shall not contribute with it.
Acceptability of Insurers
Insurance is to be placed with insurers with a current A.M. Best rating of not less than A: VII.
E. Verification of Coverage
Contractor shall furnish the City with original certificates and a copy of the amendatory
endorsements, including but not necessarily limited to the additional insured endorsement,
evidencing the insurance requirements of the Contractor before commencement ofthe work.
F. Subcontractors
The Contractor shall have sole responsibility for determining the insurance coverage and limits
required, if any, to be obtained by subcontractors, which detennination shall be made in accordance
with reasonable and prudent business practices.
G. Notice of Cancellation
The Contractor shall provide the City and all Additional Insureds for this work with written notice
of any policy cancellation, within two business days of their receipt of such notice.
H. Failure to Maintain Insurance
Failure on the part of the Contractor to maintain the insurance as required shall constitute a material
breach of contract, upon which the City may, after giving five business days notice to the
Contractor to correct the breach, immediately terminate the contract or, at its discretion, procure or
renew such insurance and pay any and all premiums in connection therewith, with any sums so
expended to be repaid to the City on demand, or at the sole discretion of the City, offset against
funds due the Contractor from the City.
Project# CON-2017-57 Page 16
, ' CERTIFICATE OF LIABILITY INSURANCE DATE I@1d6w12017
1"YYYp
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed, If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s),
PRODUCER CONTACT
Parker,Smith 8 Feek,Inc. PHS .426-709-3600 FAX 425-709-7460
2233 112th Avenue NE (A1Cdtp
Bellevue„WA 98004 ADDRESS;
INSURE 5 AFFORDING COVERAGE NAIC
— INSURER A: Zurich American Insurance Co.
tNSURED ....... .. ........ .—..... ... INSURER p: American Guarantee&Liability Ins. .......... ._... _— ._
Lakeside Industries,Inc _. _ —.
P.O.Box 7016 ItpsURER C: -
Issaquah,WA 98027 INSURER D
ENSURER E
'INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CER'T'IFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED.1"0 TIME INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICA"T"E 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,
INSRFF
.. .... _.__ ... mDDti Stam-- .. ...... ___
LTR TYPE OF INS U_RANCE INSR WVD POLICY NUMBER dONIDCdYYYY) MtALI DYYYY_ ...._ LIMITS ,.._......_ ,
A GENERAL LIABILITY GLA399263013 61172017 611/2018 EACH OCCURRENCE $ 1,000,.000
. ......
.. .,.)
oOERCIAL GENERAL LIABELETY X X CAI&IAdE TO Rt4Tr
PREMISES Ta r y
300000en e s
c:LA MS-MADE X OCcuRvlEo EXP aAn, .one Pevlanp s '10,000
_
PER SCP9AL R ADV INJURY _s 1,000„000
GENERAL AGGREGATE S 2,000,000
GEN"L AGGREGATE LILIIT APRL.UES PER r>ROOCIC'TS-CeatWIPrOP AcrC s 2,000„000 .. ..._
PO UCY X PRC„, Xr L+7r` _— ... .._.. .. .. ............
A AUTOMOBILE LIAWLITY GLA399263013r O BUNEO&NCLE IIIAIT ,OOUOOfl
61172017' 61172.018 G,EMa,a ,
cggtrtl _ S .,.
X'*:ANY AUTO X X BODILY VNJURY IPer peTwnp
.._..,..
ALL OWNED uIaLLEC
AUTOS AJrosBODILY[NJURYiPar a
cccav%
HRED AUT„" DAMAdFCFvY
AUTOS "n
.......
,CPP?'.aaA'rc7errty,..,.. E
B UMBRELLA UAB X OCCUR SXS9379237136!1/2017 61'1!2018 EACL Caa;CURRENt E s 2 000,000
..
X EXCESSLIAS CLAWS-MADE.'X X bM', FCEa';A"rE...... 2,000,000
—. ...,.. .-.
DED X RETENTIONS 6 T
WORKERS COMPENSATION
A GLA399263013WC¢ Y1iTS._. �C
AND EMPLOYERS'LIABYt.1TY I
YIN »« 6/112017 :6/1720'I8
ANY PROPRIETCRtPARTNE.R/EXEC�UTNE Washington Stop Gap 1,.000,000
E.L EACH ACCti;Iq,EGaI"i S
CRrYd.;EIR!"tl-,mEluti®cR E."KCk.¢.JCEJ"r �I..rtl I A — ..
(Mandatory In NH)ff yes,desc"be under - E L..DISEASE•EA EMPLOYEE s 1.000,000
DESCRIPTION OF OPERATIONS Wow E.L.DaSFASE•POLICY LI MiT s 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required)
Ll Job No.0417345-CON 2017-57 Lincoln&Whidby Street Roadway Repair-The City of Port Angeles is included as Additional Insured and coverage is
primary and non-contributory oil the General Liability,Automobile,and Excess Liability policies per the attached endorsementsiforms.Waiver of Subrogation
applies on the General Liability,Automobile,and Excess Liability policies per the attached endorsementsiforms.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Port Angeles ACCORDANCE WITH THE POLICY PROVISIONS..
Atte:Teresa Reed-Jennings
3211 E 5th St AU'THORLZED REPRESENTATIVE
Pori Angeles,WA 9..8362
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
1 of 14 I;Cuilar 17}
wog qsqujjad sp 1,111M,,m r„ enuensul au;geijojemj poit46uAdc,,a sagmpu�
9 u0, ,;.ab d
Njom woij Ijo atuq jo esne3aq Aep
C, Oo04 dn SbLIIUICa 10 SSOp lenpe Nipripui 'Isanbai mo ;e painsm,,PL41 Aq pamiout sesuadxa apetiosew plea" (t)
SPUOq 9Saqj qSIUXWj u;aAep jou opaAA JOO 4M,JU9Pp00e,,
ue,jo asneoaq pajunbaj (,SUOIIqMA MJ2� Cfp P3pepal JOJ SPUOq bWpnp'IW) SPUOq Peq pO 4SOD 044 JO; DOO';$ of do (Z)
Zwmupop aqj/,q paDejdej Pie, a6ejaAoO
A4qjqqj sojnV pajoAo:D -- 11 uO1138S W LOISqAOICi SUOISUOIX3 06MA03 aLp!l jo (r)-e pue (Z)-e s4dc'BeJed
sluewAed AiquawalddnS-juawpuewV -13
WjDj abCJaAOO atip 10 SLJOuJtPUOO PUe SLUJaj 8qj
puOAPq pUQ4YA aftJ;MOO S$qj IgN,pUPAA OLI W 'J;MaMOP smeq ss;wa ue uo 4pdde fillM wPaVISUp,,JVU04PPB aLIJ Aq
pawe;umaw aoueinsu ALJC pue siseq AjoInqujuOD-tiou pue ketaid e uo Agddp gJwM ',jU,9j'M3DE,,,due yap joud palmaxp
noA'q,vm juaLuawEe uallPm, JO IOEAucy) U911pm Aq papnbei ajapM '(S)MIeZUE610 JO (S)UOSJRd ALle AOJ a6eJ8AO,,)
1J aotreinsul sse3xa Pue AJewlJd-aouainsul
LUJO-i 96CIaAO�)J;4111MC) 01(31N OL41 U U0111 PUOS
O UOISIAO d
A4,10 041 PLIe WJ04 a5eJaAOD 0111V SSOUMaqj ut wippuv) aweinsul ja4jo oqj ol pappe v butffiojjoj aql "t
jQAaq:)jqM'SUM4eXj')aO D4LA UMo4s a3uejnsup jo sigwrj aql joluaujeake uaUum ic,iDej;uO:)uDll!jm
tA jjj pOjpbaj juq,04;q on 4uO pue btu aajte 4o gmpj%) tpns M4 PawaAO6 SUORWado 40,1#101 sas'Ple
,Augpwv,014,paptAojd nO4 qjjA&VueW;;jbe OeUum jo j2v,4uoouajpm 4n$cl Wertsind Nso*JnOA bupailp
p
uapPOR,,, AUR 0;JO,I)d I)OMa)(0 nOA 4w lummos uawm
uajjpMAqpajfpb9j ajiw(S)OOPPANO JO(0mod Aue Im"1414 poultwed PiVe 9;,Pue 01)04M
lu,awas)opue sqj uu .q-p,V pause v-p.v sqdekejeci W PO'JUaJa;aJ,,Olrle,, UE SaLpSlUlnj Ok4M aSI,9 alUOAU'V 0
ssawsliq JnOA ol 4jesse3au SapmAae W suossad saqjo jo spiatp moApodsvejp ol N6ojjoq
JO aAq 'UMO ;,UOP rIOA PaJaA03 e 6uisn 9quLJM ,POJnSW,, ue v nrjol sa-xAjas &HAPIW1p0A quoAUV 'q
-mawsriq jnoA jo pripoo a4;01 pa;qaj sapp 6tuiuijjcwpod;?p#4m'uoiissliwiad
Inoi, qpm 4weu ,,s,,gaAotduja,, ue w IUOUJ4,31fle JO jOE'JjL*O E JOPUra P,9jU9J jo pami ,o;ne, ue 6uyjeiado
apt4m pairtm, ue ospe su sjnoA jo a;;Aqdu,w. AuV no Aq juauAojduj;4 jo adoos a4l ui4pm pawoped
spe jol moljcK4 jo jgq um) ;,urvoA ,olne,, P,',aJaAOO e Busn ap4m ,pajnstjt,, ue sp sumo~jo aaAqdwa,,,Auv -e
,,Spamsu4,,usge aje Bulmogpj ;aq.L
,96ej,oAoDAI!I!qel,lsoInVp4J$AOD-IIUOglaOSUmLSOII.;pAOJdPsJnsulUVS104Mi?L4lO;PaPPeslIBUumollola4i, 't,
Pairlsul Uxf Sl Oq,m Popuawv 'V
W104 86elOA03 JOWeO J*JOW
WJ04 OBOJOAO:)OjnV sseutsnq
,aql iapun papAojd aouemsuii saqpoui juawasiopue stql.
'Alln:138VO il UV3b 3SVR'ld 3HI S30NVHD INM3SHOUN3 SIHI
2 0 z/To-/9-0�— ZLOZ40/90 ETOE9Z66ZV'I5
--7(— -k, d
XN M pc�ld pu'--P 81VIC )d JO OWC '93 VN AWID
p—U,�07,
ItlaWaS.IOPU'
j UOISUaIX:4 a'jlVJaAOD
H:)Fdnz
au AS',.=,'4d% 14140 W31141() RWAWSUI JO W�'NMAJ POW6uAdoa sopn�,af@
9 jc�Z 01"c"i
4,n,toa
,Aq pasneo p sasuadxo asn;o ssq jo4 hid Him,
MA IUa3uJ0;DJ5E,' IOIUD, Ua"�UJV,JC JOE,?AUOD iU4A3J Uall!AN r!japun J,9AuJp e InOL11M PC4JI4 JO POIUOJ �4p0LJOA V 10 aVI JO SSC)p
)o4 Acd of apsuods;h 4 pe6au sawoo;4q j)@JriSLH,,Ue L4VL�M 10; sasuodxo Acid fpm am k5eumj jeojisA4d In ajq,4 )r)j
sasua,dx3 asn 10 sso-I
.buimqq
;A4j Aq pa:widaj ssn uoipo,F, 06LIJOA00 06ensue() fe:)MAM aqj w sostiodx3asn to-1 J04 u0fSu8lx3 0fiBj8A0:)aq,l
sesuodx:4osn jo sso-p posvaj,3ui—a6ewoo 1BOISA4d ojnV paiti-I -H
peoepdaj ue41 iaqjeu pp,pedpi
sr-'d6 ;941 6iiiiAP4 jo Li0qdo Pupj PAM,, 10, PgAiiPM ;4q 11W agqnInp,9;.) o4j 'pa3eldai ue41 Jaqlei pajiede.ji Aqerl,)e sa
pue pajaedoj aq uea sseg6 Ju JaAQMOq p A1dde "M SUOg4EJq:*(] 041 Ua UMC4�S aplonp9p 941 'peoqdej aq jsnuj send Ij
WiJIGEp 06eJOA03,86P,LUPO IPIIS44d eqj 4(.) vC-V 4driftied q p;;ppa j euumqcj 3q,L,
86MA03 SSelo Papt,481X-g E)
juawaglevp jo aoqd eqj JP pauuqpad aq Isru joqq a4; 'uaA4MOH Papesip
v adAp jaf)ua,.;c,,Pd ;;jviud aqj IO 011le,PW,)A0,D e, eUllj 4Oe4 J)aMlOul SISM,X)qPq Pue butmol jo; 9jT, o,, dn Aed gi!m ArA
twmoqol a44,Aq poeldai sil uoijoaE,o6ejoAoo ebeuieO leOIS44d a4l do Z-V kjdejbeie,j
joqt,-1 pue 6utmol -4
sueol jo sascal snolAa A ujoi;so:%wpq JaAO-AJJr')
pue "asra� )o ueol
;audj LJJW',paspLjoind AOUER)SW Alip4psp jo 4wep'ooe 441E04 'a,)UeJnSW C41[q JuPaJj- 'SallkJejjElM joa s1soo (t,)
')OSSPa44 Aq VOLUin;w jou slisodip Ajuni;�S (C)
,-)6P,'0uJ 01a4 JO A,;p PAR Xpm pujiouqr ^aaern 4NSS;.40X,9 JOp M-;uj e JOpLja) p)Sodii,jUa Spnpeu4d poueui2. (Z)
aql 10 awqat4l le sjuaujAed UU01 JO ISCDn aflplaAo (t)
AIV °q
PUE 'UVOj PbeJ;kA00,9L1j 10 J01;19S 669JOA03 06MB(I jeoisA4d a4l 19PUn ped junowe Aunt -p
SSAy 011E,,
P01aA00 E J01 UE01 JO aSPRp a41 UO Pnp jUnowe pedun Aue Aed ppm am%,olne.PIIOAO:)r 01 SSOJ,e gejOj e do 4UaAa ot4j Ul
96MA03 deE)ueo-I jo a,ses-I
.M�:�04,3 06MA03 0,610MIG jeaisA4d a4l JO U0IMA0J,,
j 06MA00 94101 PRPPE'53 GUMOClOj o41..
Qf)eJ,3A03 deo uLo-1 jo asee-I -3
suogjejjsuoujap Aly6e ndoru;jo ohne j,,)410 pue SOG,POJ XOnA JO olne "Op Pa;!LIJIIl
jou jnq 'Se 43rIS '4UaAa LUEJ60.id Alp;es jatup p w buqedco4jed ,SOInE,, PaJIGAM 01 Aldde jou soop uolsnp.-w; Snapp
:nuuuo,�l 06eJaAO')JaillP�j J01OVY Pql 10 06eJOA03
OfivuJeCl IMS 4d - Al uosloog p svolsnj=3 041 W Al tldekeie
d PUB LWO.4 06eJaA0-,p olnV mauisnje
at4j jo a6woAoC) o6ewe(I jeossA14d - III U01400S JO suojsnjox3 o41 w -Z 4deJ6cled 01 peppe sg 6LJIMoqf)j PLjj -Z
suormajisuowap kiipft, onjj jo olne jaqjo pue soapoj M3r,aI;jio ohne 01 p4pq
jou jnq `Sr L4'VIS ':�J@Ao tk)PJBOjd AjPJBS J;WJp 0 LH 6upedplied ,solne,, pajaA= of A�dde jou saop uoisnpYA sit4l
86LIJOA03 86ettleo peal 4d due 4;!Ilqet'l WEA01d AjojuS.nu AU0
'Aldde IOU SPorn aftJOA03 4)!j!(jP!j solnV pGJ0A03-11 uOFIDOS LO PPMeW03 u0'srVy.3 oo4oldtug molleA 1q.L
06MA03 eaAoldLug molle.q o
axwurlsuj Jo nvlwRIFnu palq bildw-,RJ:mptq
(P� tV i tzt,vo n
q,.ws ol Aldde lou 'aOp UOMIIAO-ld olqpwipa(3 06eJOA013 06PUle(3
pawls 4d' 0,41 009$ Sa S,'�40"P J;QJO JO S`Mp SPJ0')GJ 'sadej ol ,,ssol, qons joj And Ipm, am ISOW aLll.,
lsslo�,,;o ounj oql�e pine,,paiano e LH ZJV (q)
puna ,,pajnsUI,,Ue lo Aliadoid;?ql alt( (e)
:SanlAap NPOJpDaP WP 1EMSM °01)ne^jepwts�aqlo jo SOSP'SPio0ai sadktgL�J;p Allo Aed plm off", luewdmba
0Pu4Jjpojq ep jo WnsM °Olplle Ig111M PA,sn sA-wkop jequjns laqlo jo s.,!)sp spionai 'sadel ol ,ssq, jol Aad HIM ;4M
ucaPaS 06MA03 ObeweG IMS&4d
e4p JO UOISIAO'd 86MA00 Rtpl Ja°JPUln 06eJOA00 0AlsU04ajdwoC) ,w� L4dI?J6IRJed 01 PaPPe V 6ulmoIll0i ;kL41 "Z
41dde lou SOOP LLU0:J a5e)aAO'),
J010A OLIJ tlq 86WA00 af)PWe(3 l0UO430
o�skld - Al S P 'OTS 4deJ6cJEd w tjoIsnpx3- aq) PUP LUJO-4
,9 6 1 WPM-) olnV ssawsnq aW O6eJOA00 afttull!0 lv'31SAW- III 1,10!ltwa6 J0 T'VLpdehejec,4 Ull U0ISVlPx3 ap,1 1
a6elOA00 SOSIllo PUe SPJ0*,DtJ 'sodel
awes 041 Jc,J JqepeAe abejaACO 90UPASUIl JaP10 4UP JaAO SSalXe SIf UOQ SII SNI Aq PaPIAoid a6eimoo Auv
,juaujdnba 3wojpz@o EJEP J0 'OQIC 4.ll P;i?Sn Sa)Aw:PI JE'IILUIS Au:L410 JO GJSP SPJ030—i 'sadel (9)
,speil Jo uo4epodsuei p6app jo asmm a4l u Apjadojd jo pupqPuluoo (v)
I Ml 10 SXJCW JRqJ0 PJE'k0lle)S S6UIJ UWri (C)
sauow s snwaid-uas josriwaid
saiplem 'Ajpma� 's4uawie6 011 JO SAI; spa jo sAop snoioa,A JOA110 JO 'LUM1.1juld 'JlAJ!S, Pl06 uoqlnS Q)
aneA JO SlUaU'130P
ianjo jo jaded lensuowwoo Jo 'sa0W))aS 'SGIOLS AaIUOLU ';q-ap lo alouappoa 'Spgf?P kwaiinu qqq s4unoovv ft)
BUW,ClflOp aLJ4
p Aue jo spap leuosiad ol ,ssq, jol ked JoIll p M Pw 'JaAamOH abewv) slql ol saiildde RgplPaP ON ,olne,
PaJaAW e 10 1jadl JU101 e 10 PSAO a4l Usaildde Apo 'OAMle, '(1 pue 'e, s4deJOLJed up pap,wid aftJPAOD alLJ.L -3
,;qeA k4M IefljOe at4,t (Z)
as `aoqdaj ol lso, alqeuoseaj at4l, (0
�JO ASSal 441 LIO paseq aq Il!m,sp.,)olla pL-uosjad of P s sapm,jai ped eq o;4unoLue 941 'aAoqL, e qdejf)cJcd 01 l0a�qn(,� -q
PaJOA00 e UO JO Ul (Z)
pas,%painsui,,ue 4q paumo Apadwd WuOslad (0
,;je qoqm spap? Icuosiad ol,,ssoi,,jol 6 S ol do ked ppm aM v
66MA03 SP8143 leu0sJOd
:tlop Opp Mo
I g o6e,jaAoo o6eutea leossA4d a4l 10 UOMIAO)d 86eJOA00 84101 PaPPe SI!bu� PO;a4l
66MA03 S43843 IeUOSJOd -1
,0000S lo wnwxeuj e ol "keep).wad ooGS si asn lo ssojoi sasuadxe 4uE,JoJ ked Ipm am Isow e441 'JeAOMOH
,,,olne,,pojaA=AUe JOJ PUPACJCJ S@ a6eJ4Aoo uopjJo:D^1 0peopusuo;Ejepo]04p 0 4po uopqloo (C)
io ,olne,,PaJOAOD 4UL*JC;
Pap!A0Jd sl l 06PJaA0:) SSO-1 ;u�) SOSM") poIpoads le, pi alK51ut SuVlejepoc) e4lp Apo sso-1 Jo sasneo paypadS (Z)
'.olne,,
paiahoo Aue ioj pappAojd V G6eAJA0-,) aA I'S WaUwd LU00 Jetil Qle:XPUIl SUOUX13,K) aPI P ANO MSIPO Ue4l JP(4* 4)
Kairbag Coverage
The Exclusion in Paragraph B.3,a, of Section 111 -Physical Darnage Coverage in the Busnness,Auto Coverage Form
and the Exdusion in Paragraph BA,a, of Section IV - Physical Damage Coverage in the Motor Carrier Coverage
Form does not appy to the acckfertaI discharge of an airbag.
L. Two or More Deductibles
The fcHoMng is added to the Deduchole Provision of the Physical Damage Coverage Section,
If an accident is covered both by this poky or Coverage Form and by another poky or Coverage Form lssued to you
by US, the foilowng applies for each covered'auto"on a per vehicle basis;.
1. It the deductible on this pdicy or Coverage Form ms the smaHer(or sniaBfest)deduc-Vble, it,Mfl be waived" or
2. if the deduAtble on this poky or Coverage Form is not the srnafler(or srraflest) dedu0ble, it w0l be reduced by
the arnount of the smaller(or sniaUesl)deductible
M. Physical Damage-Comprehensive,Coverage-Deductible
rhe Vlowing is added to the Deductible Provsion of the Physical Darnage Coverage Secbon,
Regardless of the number of covered"autos"damaged or stolen, the maxirnurn deductible that will be,app4ed to
Cornprehensive Coverage for afl"'fos,s"fro am any one cause is$5,OCO or the dedurWe shown in the Dedarafior)s,
whichever is greater,
N, Temporary Substitute Autos-Physical Damage
1, The foflowing is added to Section I-Covered Autos
Temporary Substitute Autos - Physical Damage
if PhysncaJ Darnige Coverage us pio0ded by thus Coverage Form on your Owned covered "autos", the i'dio4rig
types of vehicles are also covered"autos"for Physical Damage Coverage�
Any "'auto YOU do not own when used with the perm'�ssiorr of its owner as a temporary substtutefor a covered
"auto"you do own but us out of mnv�ce because of uts,
1, Breakdcwn�
2. Repav,
3. serydng,
4. "Loss"', or
5Destnmtuon
2, The foHo4ng ds added to the Paragraph A. Coverage Provmion of the Physical Damage Coverage enon
remporary Substitute Autos-- Physical Damage
We wi3 pay the owner for"'loss" to the ten,mporary substitute"auto"uniess the"`boss""' results from fraudWent acts or
ufniss*nson your part ff we n,iake any payment to the owner, we wW obtam the owner's dg-ns against awry other
Party
The deducbbue for the temporary subst4ute "auto" mH be the same as the deduct We for the covered "auto" �t
replaces
0. Amended Duties In The Event Of Accident,CIaiir, Sult Or Loss
Paragraph a. of the Duties In The Evont OfAccident,Claim, Suit Or Loss Condftion is replaced by ffie f0owwg,
a, ln the event of"acodent", dairn, "suit" or 1oss" you mUS1 guvp us or our authortzed representatmvie prompt notice
of the "accident", dairn, "suit" or 1oss" However, these duties only apphy when the "'accident"', clairn "Suit" or
"dross"is known to you(if you are an indmduad), a patier("f
if you ase a partnership), a rnernber(mf you are as 1rnited
1uabflity company) or an executive officer or insurance manager (i( you are a corporation) The faflure of any
IJ ;,4-424 F CAMI t04 14y
ora'6
tm"Wes mpy"ghted iatateniV of ser vice:&Gfficp Inc,'math its pearmssc'm
)omskajod Q,41 qpm B'aJjc)vanvvo,,;,,rowwnsu ;o(oyogAv v�,pprqaiq
c
9 0)9 9bPd
(v t voq mo 4`vz's,vol
aspasvp it)ssaulqre pucpuja jo pejuaui jo adAq Aup sueaw qwnbue legu;w ;DLUQ 4ue;e vs,9L4 10 Aue LL104 15uppsai
qsafte pejUatU Jo 4jeOp &flpr)pOLH UO'Siad C, 4q PaWe;VIS 'OSLIOSIP JO SM)NOMAink'M Appoq sueatu ,)JrwV Appoo,,,
&,jimollq aq;Aq pooeldej sii kic"gineC, suop!upo a4l LA ,Aillus Appoq',in
paugsspas,d Ainful Alipog -j,
ssap jo sAep ocj jo polind L,)o; pamoijor4 to paju*j paliq 'paseaj Gu"Olne',PRJaA(),.�e p piom 1uuL;4 Lt$ ,)J AUNT (9)
&HAAOlpOj alt,gj Aiq P4sPpd;?J V UM;uPUO',)AJOI!JJOI OBVJOAO'�) 'POCAsd AaIlOd;?41 JO (9�*et t4debeJeci
8115eJaAGO apqM Ppa—0111V POAH 'S
Aoijod spqy jo aoueldo3oe 04104 joiA sn 01 F)gppAojd
JOLISLIM lib,444 UW4eUJJO;UII JOqp J�UL, jo TpjeZe4 AUie, JO AJDAGOSII[,,, aqj Ja;)v apssod se uoos se sn Apguu ISMil 110 ,,
ujoopeWjo,gW JO jUQUID;L'jSSIU) Ja410 Jo,,sap-iie,,jo uoqdp3S'4p 4a4doidwL UOIIVSuLUO'J,0194 UP eA (Z)
jo LUJOJ Pft)PAOD q144i gO;41ep UOqdv)DUt RLP is SWISXZ spit-,ppq Aue Qysopsp o4 Ve,� ( )
.A"eL0jU,ajLRRI VIOA gt LUJO,-j�OftjaAO,,")Sk4j udra6PJ,;Aoo Auap liou q!m omci,)Aamop-j
uJCMJwPUOO pnpjA jo uosiquas-aidAMW'WOWWOOLIOD 0444 04 PaPPe V BuW01101 041
sPJezeH asap st()ol airille:1 teuoituoimun ?i
PaJaAO.l C 4OU St WUP e LW,m pamoijoq jo pajua,tip pa,ulq'pase',-,q st gC�qj,,ojne,,Aup, ';aAamo4-j
'noA q suope6lljqo ilaqj p;#dsai ss,sapp sjelog4o pajuiodde jo pajoiqa jeqj jo noA Aq
yeqj jo adws pue asjIloo i14 1,n4pm fia;ejado bwaq apw LOSViuuad ow,uA LpJIAN psusupgo papodde jo pajo-ap
uo ,,aaAoidLua,, 111EP Aq OILQ r,)aJ4jIJa jupixpaAm uallpm m peJjUOrj LIAIJUM P itiptin P94UaJ 10;1a,ftq ojnppaAM01.)AUV (Z)
p1l AAOI.Joq jo juw wtj ase;)p noA ,qrke.paJQA03 4UV (p)
Lmox)no »,s u" p8jaA00 Oq O'�POUNa,ap uaJe bUMOfi0j;R11 kkeWVC] pBWSAPd ojnv pajpj4 asci
6umollo;aqj 4q
paoepdaj QJe LLUO:j OBPMAO.)JOUJeo JIOIO%04;Lill UOWPucO suO$SIAOJd ootteinsull SSOOX3 Pue AJcwfJd—ODueAsull
A1410 a4l JO -1 4dej6CJEd PLIe LUJO
OBEJOAO',) ojriV ssawsnH aqj uii uoujlpuo,) ooucjnsup jeLflo at4i jo-q 4dekeJed
Ofiett'00 Ie011skid-- sojnV pajiI4 ea,AoiduAia -t)
poilvoo at#vi paVw5jsuqqeziuebjo Jo posiod 041 41$940de
op,
Ajuo)oAttm sj,4,,j pelVioo qons Aq pe4oldunjum suo!'Twoldo jo Im sasiji."ot,40 jus'ploov"Q14"'pit"I paqAbjo",,S$04,
jo juaploop.Aup ol jopd painowo Iw u%pW a Aq noA jo pa4mbal)USIX0 ato OlAdde IOU MP U0114PU00's,141,
'I OUIM01101 041
uo"puS
cio" 'n 01 SU04*Isufoov)UOAOOOH 40 SAGIN 10 JOALIV1,041 01POPPOS
sn oi,mwo isotobv Asv io sa,jo Asks miLjojamem -,d
r°io4 Lug umukjsaujoaaq Appap pqq jo pej a4t ja4e Lal qua ogopjd se
uoos se aopou sn;M'iO noA papAoid sapp paptiawe asaql;o uo!1epA e se uaas aq jou ppw,sn ol podej al ajn[T;
jnoA 'sn o; popodej aAeq pnoqs no uq4m jajjisup jaqpue o; sso�,, jo jps,, juapap oc,, uepodoj no p1
-S88,SOUjlM PUe suosiod paxlw Aue jo sassaippe pue sakuetu Sugg'ajq!suod;ua;xa R41 oj (C)
PUB:SSaJppe ptge o4j, (Z)
�,,Jps,,Jo 'sing P',I%ltWp 4OU9U
Oat 0
'g4fmagq sq ,pnS,, J1D OPEW Sq LLHRpO C, F PLIP pwjn,.)',.)O "S'SOl" as ,jUOpl00rI, Gk4lj ;)JalqAr, PUE uR�4,m 'Moj.q
allqeopneid se uoos se'apnpq
A,ipd suing Aq pppjollr aouejnsuq iq;
RjepupMl;OU ppet4S ,SSDI,, 'wpLp ,,4uc4ppg )L,,Aue p sn 4ppu o4,,pajnstp,,eqj jo aaAoldjuja JO;LmAjas'Jua-ft-,
UOSSIaa~IWICI Sif UVM :AJ� s"INIPJut3 VOONMU�)0 jf�ua:ew poLi,.,,fo3k% sapnpul
'aLUeS 0f4p WFLU41 A01110d SKj JO SWNV)')X;� PUP SUqcMOjrJ 'SUOQPUOO SWJ@j AN.g10 ft
a6PJaAO,')SSO],40 SacMe'_)PAU!,"),;dS M AAJSU,3LpajdLuo,,)jatpa hin non tpqm jo; ,solne, paWapoo ascm.41 jq Apo
Jawad "a* �n°VnoA ol olne, aqj uinjau ol jjodsuejq p jso3 4qj Asad ppm am 'PeJZA(K.)GJ PUL- uapu;ugs ,0;
ne', paua�us pp
u00001Of5eJOA00 06etuca IMS44d CNI 10 UOMAOJd LAWSUD;X3O6L',JaAO:D app 01 PIPPO Sp 6WMOfOj J.
ej!qottjojnV tjopjS jo u.",ijs8 -X
,30jr)CaS pPnj;3MICUJPgpL'UC Aq pai,,wod ,olne,Ue JOU V 4OaJaqj pUap Aue jo pnj psaup jo guqosp.6'pnpq
4q paHaidoid Aplos ,Uq&T, uu a03UP PWJOSP6 PeLMIL19AUOD C Ueqi ja4jo jamod urjqndwd ;o j,;oxics e Aq pajamod
,Xj jSnLU ,01F)e, au.pp 'aninoor pPulj ;MJCLUDJpE UE Aq PaJaMOd ,ojnv,, laur se Apenb ol, popnbq io passaidwoo uatp;,
'sued pinlru jo jeps auedcud uaBojpAq 'ou4oajo aq lsnw jamod uoispdwd qo ;ojncvs vqqjcw aqj Jam od UMpdoid
jo 93inos AKp OLW P,UE aU6Ua atPpMb pM)OtjUaAUM C Aq PQJL4MOd ;,v4 ;snuj ,olne, @Ljj ,,ojnu, puclAq e se Appr& oj
-4w)waabe
OSeap 0p01uq�IA M,?u jo apes jo IINgq r Aq P;,MfapuAa rKle ,ssq,, aqjp juawAed eqj jo sAep jepuapeo r)q J� ali os p;�nj
, Lin;, m , n ,
GApJIPUJ,91pE u Aq paiwood Waryruaa, LW JO rMJCpAtp P Aq pooepdaj Pq isntu pjnp, ppjawo aqj 009Z�.,-jo umtWxew
e ol dru 'sap ebdn 01,'Mp@A ja�WWJP�JC AUC PUE Saa) JZ4410 'aSLSa311 'Z)jjq xej bupnpxa ,,alas,, vkaiu;anp,pdad ALI) JO
Isoo tnp)o %0� Neuo�jppc ure Ard pV!m am adAj jabuessed OjEtUA aq4 jO GJJcIOS panp eMWWZ41ge ueAq po.00mod pine,
JO ,aqua,, PNJqftN e q;iim poDeldej v jeqq c4dAl xa6upssed alvAud atp jo ,olne,,, ;M4AC') P, 01 ,SMO,, RF)Oj F,'JO JUC4Aa;,Ljj U�
LJOuJOGt,-, OBeIGAOC)86ME(I WOIS44d aq JO&6eAOAOo -V gdebeled 04 P,aPPe Sr BuIM0004 Gk4,1,
o4nV oajnoS jonj OA4CU1811V 10 PAAH c Om o1nV 406UOsscd WA e p luoujaouldob 'AA
"ss 0 p4
sju .oj Acrd am jo asci oq ppu;nlaj sN ,pjne,, PaJQAOZ oqq ua4m 'uopeAn s,Aoqod api p ssapieba; 16upua
PUe 4aL41 OL(j Ja4L' SVIOP RV BUIULHF)aq popad at4l Buunp pajinow sasuadxq uoqejjodsueA Ajejodwaj iol 4ed
pppmu OAA O5eJGAO:) ssol ;o sasneo pagpadc, io amstm4aidiLuo,)jaL41,ia 4jA'e:) noA 404M,JOJ Po.scupcaau PaJaA00
aSO41 JO; AILSO Awad ppm ;RIV,, ;)d4l ja�Buassed e;eAud 941 JO waOlne. PaJaAOC) e JO 40,441 MJPq i;ql jo 011;r1eoaq
noA Aq pajinzw asuidx,?uoqeWodsuejj 4jejodtual JOi 00,0'p$10 U)MUMeUS e 01 Aep,*d OgS ol dr Acrd ppm apA
sesuedX3 uoqepodsuujj, •c
SU*ISUOIXg OBLUSA03 �t
:BUW,OppOj app Aq paaqdaj SJI86MA00 06ewv-a 1u3!sA4d-ill uolpoS jo ,wtr-V L4dejbejej
GBV,JOAOO asuadx3 uopepodsuejj Ajejodujol leuo4!ppV-ofietueC]1VOM/Aid "A
'Apadoid
JO SUDSJod goaloid c; awol ppeuospaj jo Psn ai44 wojj Buqpsoj ,a6cuiep Ajjodojd,, jo .1un'U 4ppoq, ol Apdde pu
spop uvsnpxt; v4j. punsu ;4
i,, L41 jo jimodpuels aq; usoj; popualut jo pajoadxo ,,zBeLuep A4jodo,jdjo ,AinfW Appog,,
AinfUl popuejul jo pepo&3
ILHMOpJea;aqj Aq poelda)sp OBUJOA03
A411!qL"I'l 0111V POJOAOO-qj U01138S 40pun suo!snjoxa 'a 4dcj6eJed ut um,snpx-3 Ainful popuejul jo psjoedX3 OL41
Ainful popuoluq jo popodx3 'n
Additional Insures — Automatic — Owners, Lessees r ZURICH '
Contractors
Policy No Effff. (Date of Put Exp Date of PoL Eff Date off End, Producer No. Addl. Prem return r ren
G 3992630-13 06-012017 06-01.2013 0f-t't.,2o1"
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY,
ldamed lnsured: Lakeside :Tt'dListr .es„ Inc:..
"Address(including ZIP Code): P(D 2ox 701
Issaquah, WA 98027
This endorsement modifies insurance provided under the:
Commercial General Liability Coverage Part
A. Section! ll—Who Is An Insured is amended to include as an additional insured any person or organization whore you
are required to add as an additional insured on this policy under a written contract or written agreement executed by
you but only with respect to liability for"'bodily injury"" "'property damage" or""personal and advertising injury"
1.The written contract or written agreement specifically requires that you provide that the person or organization be
named as an additional insured under the Insurance Services Office (lSt) ISO CG20 10 10/01 edition or the ISO
CG20 37 10/01 edition, thea such party is an additional insured only to the extent that "bodily, injury" "property
damage" or "personal and advertising injury," arises out of your ongoing operations or "your work"', which is the
subject of the written contract or written agreernent; or
2. Except as provided in 1. above" it the written contract or written agreement require that you provide that the person
or organization be named as an additional insured such party is an additional insured only to the extent that
"bodily injury" "property damage" or"personal and advertising injury" is caused, in whole or in part by,
a. Your acts or omissions; or
b. The acts or omissions of those acting on your behalf,
in the performance of your ongoing operations or"your work"which is the subject of the written contract or written
agreement„ p
N
However, the insurance afforded to such additional insured:
1. Only applies to the extent permitted by law
2. Will riot be broader than that which you are required by the written contract or written agreement to provide for
such additional insured.-
3. Only applies if the"bodily injury"" "property damage" or"personal and advertising injury" occur subsequent to your
execution of the written contract or written agreement; and
4. Does not apply to `bodily injury" or "property damage" caused by "your work' and included within the "products-
completed operations hazard" unless the written contract or written agreement specifically requires that you
provide such coverage. If the minimum time period for providing such coverage in the written contract or written
agreement ends prior to or during the policy period, such coverage would not be available after that minimum time
period.
Pae I of 3
Includes copyrighted material of insurance Services Office, Bnc.,with its permission,
8 of 14 (CMBOO)
B. With respect to the insurance afforded to these additional insureds, the foHowring additional exclusion applies:
This insurance does not apply to:
"'Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or failure to
render, any professional architectural, engineering or surveying services including:
a. The preparing, approving or faihng to prepare or approve maps, shop drawings, opinions, reports, surveys,
field orders, change orders or drawings and specifications; or
b. Supervisory, inspection, architectural or engineering activities.
This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the
supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the
"bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the
rendering of or the failure to render any professional architectural, engineering or surveying services,
C. The foHowing is added to Paragraph 2. Duties In The Event Of Occurrence, Offense, Clairn Or Suit of Section IV —
Commercial General Liability Conditions:
The additional insured must see to it that:
1. We are notified as soon as practicable of an "occurrence"or offense that may result in a claim;
2. We receive written notice of a claim or"suit"as soon as practicable; and
1 A request for defense and indemnity of the claim or "suit" will promptly be brought against any policy issued by
another insurer Linder whlch the additional insured may be an insured in any capacity, This provision does not
apply to insurance on which the additionai insured is a Named Insured if the written contract or written agreement
requires that this coverage be primary and non-contributory,
D. For the, purposes of the coverage provided by this endorsernent:
1. The following is added to the Other Insurance, Condition of Section IV — Commercial General Liability
Conditions:
Primary and Noncontributory insurance
This insurance is primary to and will not seek contribution from any other insurance available to an additional
insured provided that.-
a, The additional insured is a Named Insured under such other inSUrartm and
b. You are required by written contract or written agreement that this insurance be primary and not seek
contribution from any other insurance available to the additional insured,
2. The folloMng paragraph is added to Paragraph 4,b, of the Other Insurance Condition of Section IV—Commercial
General Liability Conditions:
This insurance is excess over:
Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional
insured, in which the additional insured on our policy is also covered as an additional insured on another policy
providing coverage for the sarne"occurrence", offense, claim or "'suit". This provision does not apply to any policy
in which the additional insured is a Named Insured on such other policy and where our policy is required by a
written contract or written agreement to provide coverage to the additional insured on a primary and non-
contributory basis,
E. This endorsement does not apply to an additional insured which has beer) added to this policy by an endorsement
shoving the additional insured in a Schedule of additional insureds, and which endorsement applies specifically to
that identified additional insured,
F. With respect to the insurance afforded to the additional insureds under this endorsement, the following is added to
Section [it— Limits Of Insurance:
The most we wilt pay on behalf of the additional insured is the amount of insurance:
Page 2 of 3
Indudes copyrighted material of InSUrance Services Office,Inc,with its pem)ission.
of 14 (Cfvmoo�
1. That is the least amount minimally required by the written contract air written agreement referenced in paragraph
A. of this endorserment; or
2. Available under the applicable Limits of Insurance shown in the Declarations, whichever is less.
If the minimum amount of insurance required by the written contract or written agreement for General Liability
coverage is less than the Limits of insurance shown in the Declarations but the written contract or written agreement
requires umbrella or excess coverage, we wlii inciude that requirement in our assessment of the minimum amount of
insurance. This endorserrrent shall not increase the applicable Limits of lnsrurance shown in the Declarations.
All other terms and conditions of this policy remain unchanged.
-ACW 1002)
Page 3 of 3
Inckrndes copyrighted rnater4 of Insurance Services Office,Inc. with its permission.
10 of.94 (;;1v1B001
i
Waiver Of Subrogation ( Blunket) Endorsement
���I w, is �aai� as wva,.f0�6/01/2018
n�re aJ a aaa '��; a i w?w ,, P;,e,� �--;777 w"K NCH �� tai; �Mrrvw,,
LA3 9263 -13 06/01/201 � � Q6/01/2017
THIS N 1w1SE' lt. "a1' CIfAN(',1a, TFIR FU1,UM P1s1?;,ASE HMD IT 1KRE.FU1„LY
riris, �nu9awrsa,a cra t rUamaalnfua s insurance providcd under rhea
Commercial 1°/enea°aul 1jau�a fu1'y
19ham �60wrwaaug
is aaadala,al to the Trimster Of RihtsOf Recovery,�to iml /.ihera" wa us cc.uafififm
U'y(ks& arc, k r a,
a,a8a �. by a aawnUn 4.MW aW k4°d"�"�;Ba`4M."faY Ve icti as 1)cfire ,# 14"'s'»,[4n 0ji'e your rqghcs awf tti;ca;N" ry firom
aAhaaw, we apm: to wake hkU„p,r Hghs of a ama"v w„ay /Cada '4aa1'Vl„;"r of QWs WH mA hea':4 aM k^aN 7 cd, o 11he to k%wa@vcr vv ash rck spcct &"a�
Any aw her radaa:rarauns in vAgch the lanais awl has no a;awaouaal Maaem,
i
l
asr�any';"risw�r yw b ^w ars"'{
ot)Q I k)e',
U&0 p"All V-(Y"l-sy!"I B
013-M 01 UrIbOq SO:Lg JO PRJAO'N-1$WLI a5ewep Apadwd jo A�unk,ji Appoq JMJq SLJe@LAJ J0410 ALA-1 Aq 0JVMC SaUJO-)PO C
jo'aheujep AjjaWojd jo brifui Appoq aL41 jo asmnaq saftujq)JCJJ U.MfD JO PUU1.10P [CqJ,9A Xi W91JUM P 1;14AaaO448 -Z
:J0AISLA AGLIJO 4Ue J0 S11 01 OGLaWep Apodoid jo knl I LJp Aju,aOq m4l jo pled Auv jo pjv spudoH °1,
'umad pazpo4jne ALAI 10
noA u0qm ault) lsasgpue, at.11 le paj,jna'.po UAL-4 04 UAAOU)i UOOq PAPL4 01 p�'wjaap aq ppm waF.eujup Apodoid jo Ajrlkjp AppPOS
Pue pa POd 4090d a141)OIJE 85r?LAA?[)Ap4doid JO AXIfUl
Appoq 1eq1 jc) u()qdi.Ljnsw ji.) ubueqo 'uorlonuslum AUE Sapw°ut-)W uosied pavicti4lne Aue j(.,) noA Aq ;',)ajmfx)u eAeq ul
UANOWI, 'POP;4d 4040d OL11 01 Jopd IOU sum pue pouaj Aopj as 6upnp ssnoio q.m4m abewup Al,jadoid to Ajms uu Appo8
POP',) 4000d 941 cal jopd UMOU4 LJPC4qIAPk�OL Oq fluM POu,)Od ANg0(j
at4l jajjv jo buunp abewep Al.jadoid to kmtu Appoq Lja)M 10 Uol4dwrlsaj jo ahur?qo U0QeTRJ1jU0c D AM LJOLIJ 'P0JJr030
abpLuep ApAdoid jo 4jWw Appoq aql MW 'PO'Jad 4'040d C"a141 of jupd mau,j uosjad pa7poqjne Aue, Jo noA it ped
w J0 apqm'w `Pajin-xao peq aftwep Aljadwd Ajrpcq atil jewjj MaUuosiad parsiot4lne Aup Lou nof, J*LQ9kJ
'POPad AnuPd GLIJ M XJ�Jtd JR ApLW afiewup Apadoid jo fun.kn Appori el saqdde Aoqcd cAql jupun popolp,.a3uemsut aqj -3
1 juasuoo ino poLipm apew JLKEILLjapjas 4ue ol pudsw qpm k>JC"XJ SKJ1 gapur uoqPF)qqo ou oAvq oAA -(]
`33N'"nSNI -40 S11W 'It N01133S Ul Pqpnsap Sic pojamq se kApd SALjj )UrAm led fl/A GAA JLgnowe aq-L -3
-sa5euuep q�')ns ol Agide jou saop
Aiippd'Fwk,41 UaLJ4 Issol go puuwAud Aq numnsui;c sjpkuqj apeoqiddu JEJCl JU U01jS1K,qY,1 LAL'a.Ij.cFILk 10 PAJOSPE-41.10;SafPt.-%u(?p
ol Apdcp jcxj siaop eouunsus,BmApapun p 'aA()qe W PEAJ"e4u0:.)AJU)iUrCIZD 0141 cal bm.phje 13
,k)qod sqj o4 Apddv jpqj suoqipuc.) pue sulial aqj -Z
pue !mqaq Z qdcubPMW W 01 P,,)J)0l01 SUOQuPUOO PUC SWU01 8k.pl qjeOA j)kU1Jc'f) pli op,10
jucpjs&1jo'-)u1 tou aw, PUE,SWJ31 Gg,3rws pajxaaqcil eouwnsui Bus.Apepun p-ii SLJ4.Xj1XJ0,3,PUC SLUJC41 PLIJ �J,
sap ripw Aoqod sqj aDucinsui BupApapun jo
span I 9jqe--)qddV jt'4oj aqjr p sse-)xe uisoupjnsu�siql Aq PDA9A00 SC&MUQ�)DSOL4L PCIAIGUal,J)JC)J!PLJsq uo Aud ppm a/VN -V
30V83AOO 'I N01103S
sluawaajBV Bujinsul
-smqpI se a6CAMOD*PuA01d 0I noA qpm,aa A'ju,am 'Aoqod I.DLIJ JO SLJOIGpACJd DLjj LJJgOA 91UCP10a'.)E'
W PUL' su0QeXF'A4(3 OW W SWOwale;s eqj uodn 03ULNg,W LJL rXJP L1JnnA,o'ijd ;'Nt 10 ILKAUALId 041 10 U0QP1E1p!SU00 LjI
jeadde AAtgj PJPt;,M LIOMA,Ojd kwpd n!jpods @A41 up.pupa Aoqod','MI JO SNOLLINI-430 '1A
N0110.3S W tAMD; OR' SUOflJpLjj;ap OS144i koqcd vqj w paupp we adAj 00t;-PgOq W PCMEA *JP IPL41 spse.iLld ple spJoAA
'soveinsul 6u,1Ajjopun Lq aftuaAw jol Apjcnb,,(s),pamsul.q3ns 4afilm xy adais a4l uj4pm puvjuQjxa
*4; til 4juo jnq aweinsul Oul4papun ujp trins se BulAglerib uojjezjue6jo jo umad Aue sueaw ji�)peowsul. Wom aLl.1
'a
wLw,msuii sqj f5upAoid
AucNJujm aqj og jajai PLIL' SPJOM 3PJ '00LIMSUI BusApapun uu q0r)S SE 6LAApuJUra)U0QMLIC610 JO Uos.tad
jaqjo ALle pue ;4LIJ (Y� UAA0qS PWMW� POWUN 041 01 J9JRJ ,Jr'OApuce noA_ s,p.iom eqj 'Aallod suq11noq6noj4,L
JUJ Sa PUL'S1 JeL4AA
pup saqnp 'SJL�C'W DURUJUJUP cal 4ppico Aimlod GJQU9 Oill PP98 °05e)aAO�) '�DUISEU jCqj Ao4od csiq'1 u s'�moismcud ox ao4qj
A.1110�1 Xj!j!,qrrj ssa-ax,
HDranz j j tp� 1;'u1s,
Limited OtherInsurance Condition Amendment
ZURICH
Poky No. Ef.f.bate of 06 Exp IC ate of Poi. Eff.Date of End Producer Addi Prem Return Prem
Sxs. 06/01/2017
Named Insured and Mailing Address- Producer:
PARKER, SMITH ,& FEEK, lNC.
2233 112TH AVE NE
BELLEVUE, WA 98004-2936
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
Condition G. Other Insurance of SECTION V. CONDITIONS, paragraph G., Other Insurance is deleted and replaced
with the following:
G. Other Insurance
If other insurance applies to damages that are also covered by this policy, this policy will apply excess of the other
insurance, However, this provision will not apply:
1. If the other insurance is written to be excess of this policy; or
2. If you have agreed in a written contract to carry insurance to apply prlor to and be non-contributory with that of
another person or organization's insurance, but only as respects damages arising out of insured operations or
work on your behalf performed under such written contract However, the limits available to the other person or
organization wN be the lesser of our policy Limits of Insurance or the lirnits required by such written contract. In
that case, other insurance of that person or organization wfli apply as excess and not contribute prior to the
insurance afforded by this policy.
Nothing herein will be construed to make this policy subject to the terms, conditions and limitations of such other
insurance,
ALL OTHER TERMS AND CONDITIONS OF THlS POLICY REMAIN UNCHANGED.
U-EXS-420-A CW(03112)
Page I of I
Includes copy6ghted material Of IrISUrance services Office, 4ic.,witm its permission
0,jo c arjuc,
rfbw mo VGLwsxt;l
Ajppqcq jnoA ouiwialop gag no4 iswebe U0q,)c ur^w 41md i,?se"ri ppe(,.)p gqffij aLg;oucAtx aimb jou saop aouvinsm sq,j,
'Juawbpnf peug pue jriij pcnjDe Aq jo juaSU00,M0 Lp4pM 4UULUUjj,;w.;Aq powwjajap uaaq see amo no junoujo oL4,j Z
porus 'Aoijod stql 4o suijol oqj Ile qpm paqdwo.)rmpq no), j
�ss*juin eaue.msup SILgj *pun sr i ISMOP, Ljoupae jo 146ti ou aq pIpm Djoqj.
snISUIeBV U0117V IL601 A
sp.wpueps jo sop o�) 'suoqqnba.a 'smq qjjmAdwoo 4uqj jeqj
jo oie suoqejado jo sovwaid )L41 joqjupaijem loo op aA )qqnd aqj jo sjoap�jow,jo Alajes jo qjweoa4
041 JOJ OWOXI 01 uOWDue&* jo uosiad Aut,jo Ainp aqj wpojiad ol JOU 0p) OM 'sassq 9.,)npaj dpaLj Augur
qjodaj osoq4.aj!qM p)UgUAWOuaIJ OSnV AMU as 'PUI; OM SUCNJpPUOO OL4J UO sliodoi OPIAcid Auw oM 'pabjeqo
aq ol wntwaid oqI pue suoqiruodo rME S-RSuLWRAJ GLIJ JO AjppmqLwwsun*qj ol Ayuo pmsp a Aaq. suopo,,Agun Aptes jou a.m,
suoqiadsw jnC -o a
uolpedsul .o
Aaqod sp41 japur
eqe4ed aLuo:)oq MA swnnjj,,)jd uinjoi 4UR JO f3UIAIQ--k,9J a4LJ4 JOI PUe 'A:)qod SkL;j 10 lied P 5u"u,nq SjUOUJ9SJOPUO 4UC
pue Aaqod sp4j jo kme4d000e pue jdp000j oLfj jca 'kjoqejnf,5w jo a4njels Aq jo Aoqod stqj japu,m pajnnht-u a,)pu jotgo Aug
Jo UoljebpO')UEIO JO ODJOU JO PILA' butA!b 01.41 Jnj SPFUMV Ja410 Iilv apo 4peqoq uo In HIm pajmlp F)9LLWJSJU ;A�j
-sturuLtJoid pilus jo juawAred eqj jol aqnWoduoj sp suoquicloo(] ;)Ljj JO j Ulafl W PaILWU JSJgj UOuJEEZIUUbJO JO UOSAd aupl
poinsul POWON 4SX-1 N
loqod syqj jo lied e sowwaq tepi juoujosmpijo uallum e Aq pabueqo Aim Lwo k)qod snu,_IAoillod vqj jo lied Aup
Uw Ob0..IM40 C JO JaAleh% L'JOG)JO JOU pPAA UOSA)d Jat410 AUC JO putt 6V fkut,, Aq passassod ef)popmowj jo juabe Aue 01 POPON
SOBUe40 A
-4,mlod sn4j jo=jeupivol uo tjoijeAxe cqj ja;je sjeaA(C)o4ujql ol dri jol pue Aiijod
s@qt jo pouad ak4l buunp awq Aut?Ve Aoqud"upon ul o)upoj A@L4j sr spimaj pue s'upooq jnoA awwexo pue jpne Am oM
spJ0068 Pue SX002 10 Ppriv -1
fl'DpPd 5u41 JC GkUlaj GLIJ jopun pv'oJaACY,'I SSOJ.jo IWIOLUL,aRc j POOISLM aqj jo peniarl wo Aed ApdLuo.id a�m am 'tepi genjov, ujp
.ko4t*paLjmlqo pwnsut kie;suip6e,puaw6r.mf jukkq e Jo juvwogos powbe ue Aq POUN."COP S1 OI;0 lur')Owe a4l UNAA
-a:)ucjnsui BuiApopuna jospujij;,ipcjroqddV jejol Oe41 g()jUnowc Ipnj iqj Aed 01 pajebqqo Ap6o�
v jo p!vd SeLl Ja.MSUn BUp/,pJOPUVI S,pojnsup 041 JO PaPnSW F-141 MUn pue ssaptm Apddu JUU ppM kmpod SoL41 J9PLIII q6FRJGAnO
olquAcd S11 SSOI UOLIM 'Y
AJGACY)StpV'-Spw J04L? UpqLO�p,.)eid SE U00S, SW Auedwoo,;AJj 0)UOSI, 133LUO R.)JOJJD L40rIj liodai Isnw painsw F4141 'IAAF#MOH
,sosnwajd jo suowjado esoi4i JOI a6ieaZA03 Ow L41 )OG;Ir' 10 akPPpgIPAILH )OU pIC'k4S 'ADIpOd Vk4j Aq Pw o-A00 aq 0,1 POPIUA,JW
smjejado ic.)sasnujajd ALle Apajundujw aq!nsop 01, ainpej jcu 'I()uondposop oqj w uqssLuo jo joijo guoquojwun AuV
SUNSSIU40 Puc SJOJJ3ieuoouawun .r
'GMJaAO3OJ*0Jj00fJS9J JCW 0p1(-V ot4l w p4)umlioddv aq ppm sFnj!Poo,-)ojd A*WA(X,)UJ u4W's qu jo sosuadma U41 JUGUMed
p?nJoe jo juajxa4 aq; ol ssol jo ;uawled lC JOPJ0 OSJWWI GAII W JrPa"a110114(wdde Ckq flW, P,)JUAO'OUJ junowe Aw�� Z
'13WIUMI Ail AJOA03a)10 SJOU,po4 p*A!t,,m)ou s poinsui 041 4,014M 10j' suqgejodo
jaq,jo Auie al )oodsoj k;pm jotacm e asap ol pangsum oq joij tgm sjq6ij ;o jaMom v4 �, Jo jopu4uvu
1 'j, JUDWOOfop
U&IPJAN 0144 Aq paigiboi IVOIX0 04,1014JOA0091 1:0 54u46uJ Ino OA�OMOj 0 w6vom'sSol'o Diplaq PoInoexe
jag ),omquon uallpm e Aq SJ0410 woAp AooAooaj jo, sitl6p ji!;M41 9AjeM o; pombei w" pomsui Aue j! 'JOAaMOH
LLIOLgp a3'.IJOJUU VI CJI;,44 PUP a01 OgSJLp6i)aIGI(Xjj ua;SUPJJ JO
Oupq p6 poinsw atIl 'Isonbw ino gV Wek4l JoE(AW 04 SsOi 041 JN)Ijc bwqjou op isnui p,,;unstq ,-4qjL 'sumo ol
we slqf
5ij asoq ',rywcjinsu¢sR4 opun apew wi,eqam p,sawAvjJ Aue io;Jed JO ppU JOW)GJ 01 s1kibu sor,,q painsw PL41 fl j
snol sjoqjo jsu!e5V AjOA030)j JOSION JO JO;$UCJL *1
City of Port Ang6es ATTACHMENT "C'
Engineedng Office PERFORMANCE BOND, PAYMENT BOND,
Pubfic Works and Uflities Department &R-ETAINAGE
'Pt","RFORM20CE BOND
to('ity of:'Port Angeles, WA,
Pk,yndl No, 106805115
'rbe("ity of Port Angeles, Washington,has awarded tclakeside Industries(Pnncipaq),a o.m1ract fbr the
construction of the project designated as Lincoln and Whidby Street Roadway Repair,Pr( get No CON-2017-
57, in Pon Angeles, Washington,and said Principal is required to furnish a bond fo�r perfonnimce�of all
obligations under The Contract,
Travelers Casualty and Surety Company
1lie Principal,and_of Americander the Caws of the State of Connecticut
(Surety), a corporation,organized u
S
and licensed to do business inthe State of%Vasn as surety;and narned in the current list of"Surety
Companies Acxeptable in Federal Bonds"as published in tht Federal Register by die Audit Staff,Bureau of'
Accounts, DP
Dept., are joinfly,and severally held and Firnil r bound to the City in the surn of
*
E25y.§�I.X. —JJS Dollars(� 46,3jjQq 7ontn'tet Amount, sub ect to the provisions here-In.
_)Total J
*Thousand Three Hundred Forty One and no/100ths,
This statutory perft)rrziance bond shall bocorne null andvoid,if and when the Principal,its heirs,executors,
administraLors,succes&uv�,,or sssiwr is shall well uind fiuthfiffly perform all of the Principal's obligaLions under the
Contract and fulfill all the ternis and conditions of all duly authorizeNl modi Fications,additions,drid changes to
said Contract that may hereafter he made,at the time and in the manner therein specified;and if'such perf.brmance
obligations have not been fulfilled, thLs hnd shall remain in full force and effL-ct.
flie Surety for value received agees that no changc,extension of tirne,alteration or addition to the terins of the
Contract, dic specifications accompanying the Contract,or to the work to be Ix-rfort ned under the ContTact shall in
any way afft its obligation on this bond,and waives norice of any change,extension of time,alteration or
addition to the terms of the Ctract or the work perfonned, The SLTeagnes that modifications,,,Md changes to
the terms and conditions of theonContract that increase the total amount ty to bL paid thePtincipal shall automatically
increase the obligation of the Surery on this bond and notice to Sure* is not required for such increased
obligation.
This N)nd may be executed in two(2)original cotizilerparts,and shall be signed by, the parties"duly authorized
officers. This ba)nd will only be accepted if it is accompanied by,an fully executed and original jmwer of attorney,
for the officer executing on twhalf of the surety,
I I Travelers Casualty and Surety
PR kLI Lakeside Industries, Inc, SUREI'le Company of America
06V
-61f441t11/29/2017
Susan B. Larson
Attorney-in-Fact
Name,address,and telephone of local offlociagent of Suurety Company as
F pFer, Smith&Feek, Inc, (4251)709-36010-11,
2233 112th Ave�E
Pellevue, WA 98,0104
Project#CON-2017-57 Page 17
PAYMENTBOND
to City of Port Angeles,WA
Bond No 10680,5115
The Cicy of Port Angeics, aching ion, has awarded to Lakeside Industnes, Inc(Principal),a contractfair the
construction of the project designated ars.Lincoln and Wbidby Street Roadway Repair, Project No.CON-2017-
57,in Port Angeloi, Waihington, and said Principal is required under the tenns of that Contract to ftimish a
payrnent bond in accord with'rifle 39,,08 Revised CCode of Washington (RCW,)and (where applicable) 60.28
RCW,
Travelers Casualty and Surety Company
The Prin6pal,and of America (Surctly),a corporation, organized Lvider the laws of the fustic of Connecticutand
licensed to do busirums in the State of'Wasgrog tcm as sUrery and named in the mrTent list of"&Irety Companies
Acceptable in Federal Bonds"as published in the Federal Register by the Audit.Staff"Bureau ofAccounts, U &
Treasury Dept., arejointly and severnally:held and firunny boixid to dic it of Port Angeles in the sum
of FortSix*
y US DoUars (S46,,341 Mtr Amount,subject to the provisions herein,Con w
*Thousand Three Hundred Forty One and no/100ths
nis statutory payment bond shall become null and volid,if' and when true Principal,its,heirs,executors,
u1nninistrazon,successors,ar assigns shall pay all 1wrsons in accordance with Niles fig 0.28, 3908,and 39, 12 RC 1W
including aril workors, latx)rers,mechanics,subcontractors,and matenalmen,and all persons who shall supply
SUch conLraclor or subcontractor with prc%isions and supplies for the carnring on of such work,and all t!axes
iricurred i,)n said Contract tinder Title 50 and 51 R.CW and all Laxes imposed tin the Rrincipal under Title 82 R(`W;
and if such payment obligations hzvae not been fulfilled,this bend shall r-cmain in force and e6ect.
Thic,suret, ft,)r value received agrees that ne change,extiension of nine,a1wration or addition tir.)the terrris of the
Contract, the spccifications accompanying the Conti-act, or to the as to be perfomied under the Contract shall in
any way affect its obligation on this bond,and waives notice of any change,extension of time, alteration or
h ract or the wc�rk Ivxfomied, 111C SUret�,,agrees that modificadoni and changes to
addition to i e renns,of the Cont
the to ms and ca,,)nditiclns of the Contract that increase the total aniount to be paid die Principal shall automatieafly
increase the oblig
gation o f the Surety on this band and notice to Sore ry is not mquired for such increased
obligation,
This bond may be executed in M°o(2)onginal counterpams,and shall 1v signal by the parfies'duly aiahorized
officers, 1 his hondwillonly beaccegated if itisaccompaniedby a filfly extra uted and original po%vurofattorne,y
for dic officer exmuting on behalf of'die surety, Travelers Casualty and Surety
MINCIP2.ki, Lakeside Industnes, lno. SURETY Company of America
air
1,1/29/2017
Susan B. Larson
/-Rav,4 - Attorney-in-Fact
Narne,addres,and telephone of1ccal office/agent of Surety Company isw
Parker, Smith& Feek, Inc, (425)709-3600
2233112th Ave NE
Bellevue, WA 98004
'Project # CON-2lit 7- 7 I'lage 18
WARNING:THIS POWER OF ATTORNEY iS INVALID WITHOUT THE RED BORDER
Tins Power of Attorney is granted under and by the authority of the following resolutions adopted by the Boards cwt Directors of Famrington Casuafty Corripany,Fidelit'y,
and Guaianty Insurance Cornpmy,Fidelity and Guaranty, Insurance Underwrners, Inc.,Sd, Paul Fire and Marine Insurance Company,St. Paul Guardian Insurance
Company,St,Paul Mercury Insurance Company,'Travelers, Casualty and Surety Company, rravelers Casualty and Surety Company (ifArnerica,sand United States
Fidelity and Guaranty Company,which resolutions are now in full force and effect,reading its ftfflows:
RI'SOLVEW that the Chairman,the President,any Vice Chairman,any Execmive Vice President,any Sernor Vice President,any Vice President,city Second Vice
President, J,,r Freasurvr,any Assistant Treasurer,the Corporate Secretary or any Assisuant Secretary may appoint Attorneys in-Fact and Agents to act for and on behalf
of the Company and ruay give such appointee such authurity as his or her certificate of authority may prescribe to sign with die Con4xiny's name and seal with the
company's seal Iweanals,recogrfizaawrccs,ointracts of indemnity,and other writings obligirory in tire nature ofa bond,icccsgnazance,or conditional undertaking,and art)
of said officers or the Board of Directors at any there:may remove any such appointee and revoke the power given him or her,and it is
FURTFIER RESOLVED,that the Chairman,the President,any Vice Chairman,any EAccutive Vice President,any Senior Vice f1resident or any Vice President may
d0egate all or any part of the faregoing a"thority to one or rnore officers or ernployees of this Company,provided that each such delegation is in wrifing arid a copy
thcfeq)r is filed in the office of the Secretary;mid it is
FURTHER RESOLVED,that any bond,recognizance,contract of indennuty,or wfifing obligatory in the nature ofa hroad,recognizance,or conditional undertaking
9
upon the Companywhen(a)signed by the Priasident,any'Vice Chairman,any Executive Vice President,any Sentor Vice President or any Vice
Prestdcru,any Second Vice Presideni,the'rreasurer,any Assistant Treasurer,the Coqsorate Secretary or any Assistant Secretary and duIy a"ested and scaled with tht
onapany's seal by a Secretary,or Assistant Secretary,or(b)(July executed(under seat,if'required)by one or more Attorneys-f n-Fact and Agents IMSUant to the Power
J)res,Crilse,d in his or her certificate or th6r certificates of authority or by one or more, C'ornpany officers pursuant to as written dc⪚rtkin of authority, and it is
FUR I I"'HER RESOLVED,that the signature of each of the following officers. President,any Executive Vice President,any Senicu Vice President,any Vice President,
any Assistant Vice President,any Secretary,rwry Assistant Secretary,and the seal of the Company may be affixed by facsnnile to any flower of Auorney or to any
certificate relating thereto appointing Resident Vice Presidents,Resident Assisiant Secretaries or Auorneys-in-Fact for purposes onty of executing and attesting bonds
wul underiakrngs and other writings obligatory in the nature thereof,and any such Power ofAttorney or certificate hearing such ftwsjinfle signature or facsintile seat
)hall he valid and binding ujxnr the Company arid air),such 1rower so executed end certified by such facsindle signature and facsirnfle ieal sludl be valid and binding on
the Coaq)any in the future with respect to any bond or understanding to which it is attachest.
1,Kevin E,Hughes,the undersigned,Assistant.Secretary,of Farinington Casualty Company,Fidelity and Guaranty Insurance ompany,Fidelity and Guaranty Insurance
Underwfiters,Inc..St P,auC Frre and Marine Insurance Company,St.Paul Guardian Insurance Company,St.Paul Mercury Insurance Contpany,Travelers Casuafty arid
Surety Company,Travelers Casualty and Surety Company ofArnerica,arid Unded States Fidelity and Guaranty Company clo hereby certify that the above and foregoing
is a true and correct copy of are Power of Attorney executeAl by said Companies,which is in full force anal effeki and has not been revoked,
C144-)
day 01, 201.9
IN TESTIMONY IV HEREOF,I have hereunto set rny hand and affixed the seals of said Crimparfies fts _AJ4,Ck
,in E,I hildres,Assrsiran Sec tary
an,Se, t��,
1"o verity the audiernicity of this Power of Attorney,call 1-800-421-3880 or contact its at%wwrraveIctshond,corn.Please refer to the Attorney-In-Fact number,the
ahovcnamed indrvdduals and the details of the bond to Much the power is attached,
WARN!ING:Ti HfS POWER OF ATTORNEYdS INVALID WITHOUT THE RED BORDER
ESCROW AGREEMENT for RETAINED PERCENTAGE
Lincoln and Whidby Street Roadway Repair, Project No. CON-2017-57
Escrow
City of Port Angeles Contract No. CON-2017-57
Completion Date:
TO: reimburse yourself' rom such ninnies for the entire amount of
Your fee.
8, This agreentent shall not be binding until signed by both parties
and accepted by you.
9. This document contains the en ire agreement between you,the
Contractor,and the City,with respect to this Escrow,and you
THIS ES(,',ROW AGREENI ENT is for the investment of the retained arc not a party to,nor bound by any instrument or agreement
percentage of the above contract,in accordance with chapter 60,28 of other than this. You shall not be required to take notice of any
the Revised Code of Washington. It is fintited to FDICuisurcd default or any other matter,nor be bound by nor required to
Washington State Chartered Banks who are covered by the State of give notice or demand,nor required to take any action whatever
Washington Public Deposit Protection Act. except as herein expressly provided You shall not be liable for
any less or damage not caused by your own negligence or
The undersigned, (as"Contractor"),has willful misconduct,
directed the CITY OF PORI ANGELES(as"City"),to deliver to
you its warrants which shall be payable to you and;or the contractor. CONTRACTOR
The warrants are to be held and disposed of by you in accordance
with the following instruction: Federal Tax LD.No
INSTRUCTIONS By:
Upon delivery the warrants shall be endorsed by you and Title:
forwarded to the City for collection. You shall use the inornes
to purchase investments selected by the Contractor and AddrLw____
approved by the City. You may follow the last written
direction receiveil by you frons tire Contractor,for each
purchase,provided the direction otherwise confornis with this
agreement, Acceptable investments are: .....
A. Bills,certificates,notes or bonds of the United
States, DATE;
B. Other obligations of the United States or its
agencies;
C. Obligations(if any corporation wholly owned by the CITY OF PORT ANGELES
Government of the United States;
D. Indebtedness of the Federal National Mortgage By:
Association;
E. Time deposits in commercial banks; Title:
F. Other investments,except stocks,selected by the
Contractor,subject to express prior written consent
of the Cit v. DATE:
1 Fhe investments shall he,in a form which allows you alone to
reconvert,them into money if you are required to do so by the
City. THE ABOVE ESCROW AGREEMENT RECEIVED AND
3, The investments must mature on or prior to the data:set for the ACCEPTED on the day of 20__
completion of the contract,including extension there of or
thirty(30)days following the final acceptance of the work, BANK
4. When interest on tire investments accrues
and is paid,you shall collect the interest and forward By:__
it to the Contractor unless otherwise directed by the
Contractor.
5. You are not authorized to deliver to the Contractor all or any Title:
part of the investments held by you pursuant to this agivernent
(or any nionies derived from the sale of such investments,or
the negotiation of the City's warrants)except in accordance Address:
with the written instructions front the City, Compliance with
such instructions shall rcheve),on of any further liability
related thereto.
6. In the event the City orders you,in writing,to reconvert the
investments and return all monies,you shall do so within thin),
1 30)days of receipt of the order, DISTRIBUTION:
7. The Contractor agrees to compensate you for your services in City Clerk Contractor
accordance with your current published schedule of applicable Financial Institution File Copy
escrow fees. PaymLnt of all fees shall be the sole responsibility
ofthe Contractor and shall not be deducted from any monies
placed with you jiursuant to this agreement until and unless the
City directs,the release to the Contractor of the investments and
monies,held hereunder,whereupon you shall be entitled to
Project # CON-2017-57 Page 19
City of Port Angeles ATTACHMENT "D"
Engineering Office FORMS
Public Works and Utilities Department
REQUEST FOR INFORMATION (RFI) FORM
PROJECT`NAME: .............
PROJECT/CONI"RACI'NLJN4BER:—.-.-.,,,,-
ORIGINATOR: Owner Contractor
ITEM:
.................. .............--..................
REFERENCE DRAWING OR SPECIFICATION:_—. --—-----
DESCRIPI ION OI'CLARIFICA'I'ION/REQUEST:_,,,,,,,,
.............-
............................. ...........—............................--............
........... .........
................... ......
..........
............ ......
............ ........... ........... ...........---
DATE REPLY REQUESTED:_... CRITICALTO SCHEDULE: YES NO
ORIGINATOR SIG
COMMENTS:
RFI Number:
Project CON-2017-57 Page 20 [FORM REVISED 7/20171
City of Port Angeles
Public Works & tAilities
321 East 5th Street f Port Angeles, WA 98362
Contract No.&Title
Project Manager:
Date Charge Printer Order Nio.
Change Title:
Change Scope Justification:
...........
CONTRACT AMOUNT SCHEDULE
Original Contract Original Substantial Completion
Previous Time Extension by
Previous Change Orders I
Change Order(days)*
This Change Order
Amount(including Suspension of Work(days)
applicable taxes)
New Contract Amount Change Order#1 Time
Extension(days)
New,Substantial Completion
LAKESIDE INDUSTRIES, INC: CITY OF PORT ANGELES
Signature Signature
'—Name&Title Name&Title
Date:
This Change Proposal shall represent full and complete compensation and final settlement of all Claims for all(1)time;(2)direct,indirect,
and overhead costs;(3)profit;and(4)costs or damages associated with delay,inconvenience,disruption of schedule,impact,rippNe
effect,loss of efficiency or productivity,acceleration of work,lost profits,and/or any other costs or damages related to any work either
covered or affected by the Change Proposal,or related to the events giving rise to the Change Proposal,
Project CON-2017-57 Page 21 [FORM REVISED 7/21017]
CONTRACTOR'S APPLICATION FOR PAYMENT'
Page I of 2
PROJECT NAME:Lincoln and Whidby Street Roadway PROJECT NUMBER: CON-2017-57
Repair
TO:City of Port Angeles DATE:
Public Works&Utilities Department
321 E V1 Street
Port Angeles,WA 98362
FROM: PAYMEN'r REQUEST NO.
PERIOD From: d of period]:
STATEMENT OF CONTRACT ACCOUNT
I Original Contract Amount(Excluding Sales Tax) $
2 Total Value of'Approved Cliange Order No(s). (Excluding Sales Tax) $
3 Aqjusted Contract Amount[Line I+ Line 2] $
4 Total Retainage to be Withheld[5%of Line 3]
5 Value of Work Completed to Date (per attached breakdown)
6 Material Stored on Site(per attached breakdown and material receipts)
7 Subtotal [Line 5+ Line 6] S
8 8.4%Sales Tax [at 8.4%of Tine 7],As Applicable
9 Retainage for Work Completed to Date[5%of Line 7]
10 Subtotal[Line 7-�-Line 8 -Eine 91
11 Previous Retainage withheld(Line 9 from previous payment application)
12 Total Previously Paid([-me 10 from previous payment application)
13 RETAINAGE TO BEWITHHELD FOR THIS PAYMENT [Line 9—Line 11]
14 AMOUNTTO BE RELEASED TO CONTRACTOR [Line 10-Linel2l
WAIVER OF CLAIMS FOR EXTRA COST OR TIME: The undersigned Applicant waives and
releases, up through the date hereof, any and all claims for costs or item extensions arising out of or
relating to extra or changed work or delays or acceleration not specifically identified and reserved in the
amounts identified below or previously acknowledged in writing by the City of Port Angeles,
CERTIFICATE OF THE CONTRACTOR: I hereby certify that the work performed and the
materials supplied through the ending period date noted above represent the actual value of
accomplishment under the terms of the contract(and all authorized changes)between the Applicant and
the City of Poll Angeles, relating to the above referenced project, and that the remaining contract
balance is sufficient to cover all costs of completing the work in accordance with.the contract
documents.
Continued on Page 2
Project CON-2017-57 Page 22 [F'ORM REVISED 7/2017]
CONTRACTOR'S APPLICATION FOR PAYMENT
Page 2 of 2
1 also,certify that all lower-tier payments, less applicable retention, have been made by the Applicant for the
periods covered by previous payment(s)received by tile Applicant to(1)all lower-tier subcontractors/suppliers,
and(2) for all materials, equipment and labor used or in connection with the performance of this contract. I
further certify that I have complied with all federal, state and local tax laws, including Social Security laws and
Unemployment Compensation laws and Workmen's Compensation laws, insofar as applicable to the perfonnance
of this work, and]lave paid all such taxes,premiums and/or assessments arising out of the performance of the
work.
I further certify that, to the best of my knowledge, information and belief,all work for which previous payment(s)
have been received shall be free and clear of liens,claims, security interests and encumbrances in favor of the
Contractor, subcontractors,material suppliers, or other persons or entities making a claim by reason of having
provided labor, materials and equipment relating to the work.
Within seven(7)days of receipt of the payment requested herein,all payments, less applicable retention, will be
made through the period covered by this pay request to all my lower-tier subcontractors/suppliers and for all
materials, equipment, labor, taxes and assessments arising out of the perfonnance of all said lower-tire work.
DATED:
CONTRACTOR:
SIGNATURE.-
PRINTED NAME AND
SUBSCRIBED AND SWORN to before me this day of
Notary Public in and for the State of
residing at_................
My appointment expires
APPROVAL
Project Manager
Date
City Engineer
Date
Project CON-2017-57 Page 23 [FORM REV IS ED`x/201 7i
Afthk
str** Request ,to Sublet Work
Mil that ap*for State lomgram)
rl D�sadvantaged Busrr*ss(DBE) rl Veteran owned Business(VEE) 0 Wornar,Chvned Btmmess(WSE;l[
0 Mincrity Owned Busuress(MBE) [I State Small Business(SSE) 0 Federal SmaA Business(FEE((Federal Program)
Pmrne Cortractor Feder,ai ErTAoyer 1.D Number' State Contrad Nuntw
Job Desmpbon(7fbe) Request Number
Approval is Fie guested'to Stfttlet the Followina Described Work to:
Lower T*Su Suboontractor Umfsed Busir*ss Identifier(USO Feder&S IEntployer LO.Number
Lower Tier Suboantract/SubcorytracA, Name
Acktress Telephone Number
state zip Cock. Estmated Sterling Date
If Lower Tier Subcontractor,Name of Ccrrespcodng Sib. IF 10 of Cores pcndhV Sub ff no E Enpk7yer 10 Mimber
We Oww"s Sodai Sewity Number
IltemNo. PartW, Itern Oescmptmn
I undllt.-d ard mN emov Mat the sabimnifra-tor wit Nime Corma=sigm9iffe Date
wm#y f*wdh#*#am and Veorinafi�under
this mi*is beM peftm*d
Dep tit of TranWirtation Use Only
Percent V,Total Contract DBE Statri S Verification
7fus Request %
Prevxws Requests -%
Sublet to Li to %
Prcfec Ern 's Signature JDate JApproved-Regon Ccinsvixtm Er9neer 10ame
L1 Approved Wen Reamedl
COT F=421-C'12 D51rWOm Vftg�ngReg
e(Ori )- m Canmy(Copy)-ProtopyCon
jectEngneer Pink k- traLtor
ReMed(17Y2016
Project CON-2017-57 Page 24 [FORM REVISED 7/2017�
4" State
wro ==
or Transportation Request for Approval of Material
Coftad Number FA Number
Se d n d T-t a Pyoject Cosmo
Contractw tractor
This fora shah be compdetedl prior to submiftal, If this is not complete at time of For WSDOT Use Only l..
For t a ncnaaa a s ng,see Instructions asd Example RAM
hod MaWaor Namms and Loc3bom of IFa ,. r' speaIfamammvum PEtQPL Hdqtr,.m PL
hem No mW d"L * IA ammtaaamr tv or Pd Number R,s memms Coda Code
. Engineer v stme WeMtsEngine
Acceptance Achon Codes for Project Engnwer and Staft Materials Laboratory
1,Amelpdamt n tsmiva; acWammms basmmpsmm" aft a tory est Repv t Ibr samp4s of mm we6ads aro unccqwated imam as
2". orae >Via_ Mfg Ceit.of Compfiarwer"Aman m "prior to use.of maILW4,
Aueptmce Crter,4 Cataft u f dRma t ma use&materai. n Y em ONO
4. 9armmr Cnmsscaa Subm,4 Shop Dramsumi!s,'mm' vI'Igor to fabnr..,amPaami mmf ammamer&W.
5.AcaWamm Dh*na OftyA IGa for SNpmenf,WSD07 Wmsgpcaad am"Fabneatam am wa I rmmaa rW ehWa as mum.
8.baa aroma 0*ha Summa Cenficate of Materials,Orgm as Project m um m Office
7.Aw*ponce Craehai R ^sm Transnufted to State Poamamdals IL.; m, alar ApprwaLActmn.
.Source Ramp
kVivvai Wthheid, submt s as for prehmmmsmary saa amPam.
Wcomms " lams eWm
I I.M,,sc Aamma sous Accs am*Cnwa.
R*mmarkv
Project t ` o State Mgftriafs Engineer DisbiNfim
n cawada n Region n General Fie n ftpedio w
n Regwi CWabms Engnw El dals dalLab, CVW
0 Fardi - .. lrmrm WS 47W
DOT FwM)5D.071 lEf
fsa
Project CON-2017-57 Page 5 [FORM arEViSED7/20171 .
C-V
CERTIFICATION OF
WORK COMPLETION AND ACCEPTANCE
PROJECT: Lincoln and Whidby Street Roadway Renair
PROJECT NO.: CON-2017-57
All work on the above referenced project has been completed in accordance with the contract documents
and the final inspection and the warranty provision included therein or relating thereto.
The final estimate in the amount of$ , including any applicable taxes,has been
reviewed and is in agreement with our records. I further certify that the final estimate amount shown
above is a true and correct statement showing all the monies due me from the City of Port, Angeles for
work performed and material furnished under this contract. City Council acceptance and final payment,
including retained percentages, is hereby respectfully requested.
, Contractor, hereby releases the City of Port Angeles, Washington,
from any and all liens arising out of this Contract or is, herewith, providing a bond covering all unpaid
obligations for work,materials, equipment or any othcr liens outstanding on this Contract.
CONTRACTOR:
NAME AND TITLE:
ADDRESS:
AUTI-JORIZED OFFICIAL: DATE:
Project CON-2017-57 Page 26 [FORM REVISED 7/20171
City of Part Angeles ATTACHMENT '"E"
Engineering OfficeeAWARDED BID
Works and Utilities Department
Project CON-2012-57 Page 27 [FORM REVISED 7/2017]
WO""UOTATION FORM
Project Title: Lincoln and Whidby Street Roadway lie air Project Number: CON-2017"-57
The bidder hereby bide the following amounts for all work (including labor, equipment„ time and
materials) required to perform the work in the Statement of Work and this package.
_ .
1. Lump Sum S14 1.00
Please show your estimated amount of Pule 171 sales tax included in ali of the bid items above. Refer to
Section 1-07.2 in the Special Provisions. SSut
If you believe Rule 170 tax applies to any portion of this project, please identify and shown the calculated
amount of taxa
2. The bidder hereby acknowledges that it has received Addenda No(s)
(Enter"NBA if none were issued) to this Request for Quotation package.
. The name of the bidder submitting this bid and its business phone number and address, to which
address all communications concerned with this bid and with the contract shall be sent, are listed
below. Any written notices required by the terms of an awarded contract shall be served or mailed to
the following address:.
ContraqQr T r . n:
1. Company Name: " wn ,
2. Address: .a
3. City, State, Zip Code; 1- ,
. Phone Number: 066) 451-1103
5. Contractor Registration Number:
6IBI Number: ja 0 t 10 47
7. WA State Industrial Insurance Account Number.. o 0 ,?.L-7
. WA State Employment Security Dept Number: 4 K 4 ZZ -603
g. State Excise Tax Registration Number: l .
The bidder represents that it is qualified and possesses sufficient skills and the necessary capabilities
to perform the services set forth in this Contract.
Signed by
Printed Name: `t
Title: CIA
(4 194-
Date d' w
Project: CON-2017-57 Purge 3 [FORM REVusrD 7/2017]
Certification of Compliance
with Wage Payment Statutes
W
The bidder hereby certifies that, within, the three-year period immediately preceding the bid
solicitation date, October 31, 2017 the bidder is not a "willful" violator, as defined in RCW 49.4&082,
of any provision of chapters 49.46, 49.48,, or 49.52 RCW, as determined by a finial and binding citation
and notice of assessment issued by the Department of Labor and lndustries or through a civil judgment
entered by a court of limited or general jurisdiction.
I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true
and correct.
Lc-Kaw4,*J1- ZAJUS+66'
Bidder's Business Name
Signature of Authorized Official*
_31 0
Printed Name
Title
L0. 1_1 LAJ
Date City State
Check One:
Sole Proprietorship F1 Partnership El Joint Venture 0 Corporation Le
State of Incorporation, or if not a corporation, State where business entity, was formed:
............
If a co-partnership, give firm name under which business is transacted:
*If a corporation, proposal must be executed in the corporate name by the president or vice-president(or any
other corporate officer accompanied by evidence of authority to sign). if a co-partnership, proposal must be
executed by a partner,
Project: CON-2017-57 Page 4 [FORM REVISED 7/2017]