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HomeMy WebLinkAboutAgreement_General_2/13/2020_TRB Management, Inc.Memorandum To: Jeremy Allen, Village Manager Cc: Honorable Mayor and Village Council From: Jose Rodriguez, Building Director Date: January 7, 2020 Subject: Building Inspections and Plan Review Services Contract with TRB Management, Inc. on As -Needed Basis This agenda item is for the provision of Building Inspection and Plan Review Services by TRB Management, Inc. on an as -needed basis. Attached, for your review, is the contract between the Village of Tequesta and TRB Management, Inc. The Building Official is in favor of the approval of this contract. VILLAGE OF TEQUESTA CONTRACT FOR BUILDING INSPECTION AND PLAN REVIEW SERVICES THIS CONTRACT FOR BUILDING INSPECTION AND PLAN REVIEW SERVICES is entered into and effective this day of December, 2019 (the "Effective Date"), by and between the VILLAGE OF TEQUESTA , a Florida municipal corporation with offices located at 345 Tequesta Drive, Tequesta, Florida 33469-0273, organized and existing in accordance with the laws of the State of Florida, hereinafter "the Village"; and TRB MANAGEMENT, INC., a Florida corporation with offices located at 19005 Talon Way, Jupiter, Florida 33458, hereinafter "the Contractor" and collectively with the Village, "the Parties". WITNESSETH The Village and the Contractor, in consideration of the mutual covenants contained herein and for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged by both Parties, hereby agree as follows: 1. SCOPE OF SERVICES: The Parties hereby agree to enter into this Contract -whereby the Contractor shall provide an individual plans examiner licensed in all residential and commercial disciplines (i.e., building, electrical, plumbing, and rnecha.nical) and individual inspector licensed in all residential and comi-nerc cal disciplines (i.e., building, electrical, plumbing, and mechanical) for inspection and plan review services pursuant to all applicable statutory, licensing and Village code requirements. Services shall be rendered on an as needed basis when requested by the Village. The Parties agree to enter into this pursuant to the Contractors Pricing Proposal, hereby fully incorporated into this Contract and attached hereto as Exhibit "A". 2. COMPENSATION: In consideration for the above Scope of Services, pricing shall be fixed at Seventy -Five Dollars ($75.00) per hour for the Individual Plans Examiner and Seventy Dollars ($70.00) per hour for the Individual Inspector pursuant to Exhibit "A". 3. LICENSING, INSURANCE AND INDEMNIFICATION: The Contractor shall provide proof of all current and required state, county and other applicable licensing. The Contractor shall also provide proof of workman's compensation insurance and liability insurance in such amounts as are acceptable to the Village and shall name the Village as an "additional insured" on the liability portion of the insurance policy. The Contractor shall at all times indemnify, defend and hold harmless the Village, its agents, servants, and employees, from and against any claim, demand or cause of action of whatsoever kind or nature, arising out of error, omission, negligent act, conduct, or misconduct of the Contractor, its agents, servants, or employees in the performance of services under this Contract. Nothing contained in this provision shall be construed or interpreted as consent by the Village to be sued, nor as a waiver of sovereign immunity beyond the waiver provided in Section 768.28, Florida Statutes. 4. PUBLIC ENTITIES CRIMES ACT: As provided in Sections 287.132-133, Florida Statutes, by entering into this Contract or performing any work in furtherance hereof, the Contractor certifies that it, its affiliates, suppliers, subcontractors and consultants who will perform hereunder, have not been placed on the convicted vendor list maintained by the State of Florida Department of Management Services within thirty-six (36) months immediately preceding the date hereof. This notice is required by Section 287.133(3)(a), Florida Statutes. 5. TERM • TERMINATION• NOTICE: This Contract shall be for a term of one year commencing on the Effective Date, and shall renew for additional annual one-year terms until and unless either party terminates this Contract. This Contract may be terminated by either party upon thirty (30) days written notice to the other party. Notice shall be considered sufficient when sent by certified mail or hand delivered to the Parties during regular business hours at the following addresses: Village Contractor Village of Tequesta TRB Management, Inc. 345 Tequesta Drive 19005 Talon way Tequesta, FL 33469-0273 Jupiter, FL 33458 Attn: Village Building Official Attn: Robert Duplessis, President 6. INDEPENDENT CONTRACTOR: It is specifically understood that the Contractor is an independent contractor and not an employee of the Village. Both the Village and the Contractor agrees that this Contract is not a contract for employment and that no relationship of employee —employer or principal —agent is or shall be created hereby, nor shall hereafter exist by reason of the performance of the services herein provided. 7. ATTORNEY'S FEES: In the event a dispute arises concerning this Contract, the prevailing party shall be awarded attorney's fees, including fees on appeal. 8. FORCE MAJEURE: The Contractor shall not be considered in default by reason of any failure in performance under this Contract if such failure arises out of causes reasonably Page 2 of 5 beyond the control of the Contractor or its subcontractors and without their fault or negligence. Such causes include, but are not limited to: acts of God; acts of war; natural or public health emergencies; labor disputes; freight embargoes; and abnormally severe and unusual weather conditions. 9. CHOICE OF LAW; VENUE: This Contract shall be governed and construed in accordance with the laws of the State of Florida, and venue shall be in Palm Beach County should any dispute arise with regard to this Contract. 10. AMENDMENTS & ASSIGNMENTS: This Contract, all Exhibits attached hereto, and required insurance certificates constitute the entire Contract between both parties; no modifications shall be made to this Contract unless in writing, agreed to by both parties, and attached hereto as an addendum to this Contract. The Contractor shall not transfer or assign the provision of services called for in this Contract without prior written consent of the Village. 11. INSPECTOR GENERAL: Pursuant to Article XII of the Palm Beach County Charter, the office of the Inspector General has jurisdiction to investigate municipal matters, review and audit municipal contracts and other transactions, and make reports and recommendations to municipal governing bodies based on such audits, reviews, or investigations. All parties doing business with the Village shall fully cooperate with the inspector general in the p g exercise of the inspector general's functions, authority, and power. The inspector general has the power to take sworn statements, require the production of records, and to audit, monitor, investigate and inspect the activities of the Village, as well as contractors and lobbyists of the Village in order to detect, deter, prevent, and eradicate fraud, waste, mismanagement, misconduct, and abuses. 12. PUBLIC RECORDS: In accordance with Sec. 119.0701, Florida Statutes, the Contractor must keep and maintain this Contract and any other records associated therewith and that are associated with the performance of the work described in the Proposal or Bid. Upon request from the Village's custodian of public records, the Contractor must provide the Village with copies of requested records, or allow such records to be inspected or copied, within a reasonable time in accordance with access and cost requirements of Chapter 119, Florida Statutes. A Contractor who fails to provide the public records to the Village, or fails to make them available for inspection or copying, within a reasonable time may be subject to attorney's fees and costs pursuant to Sec. 119.0701, Florida Statutes, and other penalties under Sec. 119.10, Florida Page 3 of 5 Statutes. Further, the Contractor shall ensure that any exempt or confidential records associated with this Contract or associated with the performance of the work described in the Proposal or Bid are not disclosed except as authorized by law for the duration of the Contract term, and following completion of the Contract if the Contractor does not transfer the records to the Village. Finally, upon completion of the Contract, the Contractor shall transfer, at no cost to the Village, all public records in possession of the Contractor, or keep and maintain public records required by the Village. If the Contractor transfers all public records to the Village upon completion of the Contract, the Contractor shall destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. If the Contractor keeps and maintains public records upon completion of the Contract, the Contractor shall meet all applicable requirements for retaining public records. Records that are stored electronically must be provided to the Village, upon request from the Village's custodian of public records, in a format that is compatible with the Village's information technology systems. IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, PLEASE CONTACT THE VILLAGE CLERK, RECORDS CUSTODIAN FOR THE VILLAGE, AT (561) 768-06859 OR AT 1m.cwi11iams to uesta.or , OR AT 345 TEQUESTA DRIVE, TEQUESTA, FLORIDA 33469. 13. HEADINGS: The headings contained in this Contract are provided for convenience only and shall not be considered in construing, interpreting or enforcing this Contract. 14. SEVERABILITY: The invalidity or unenforceability of any provision of this Contract shall not affect the validity or enforceability or any other provision of this Contract and shall be construed and enforced in all respects as if the invalid or unenforceable provision is not contained herein. 15. WAIVER: No waiver by the Village of any provision of this Contract shall be deemed to be a waiver of any other provisions hereof or of any subsequent breach by the Contractor of the same, or any other provision or the enforcement hereof. The Village's Page 4 of 5 consent to or approval of any act requiring the Village's consent or approval of any act by the Contractor shall not be deemed to render unnecessary the obtaining of the Village's consent to or approval of any subsequent consent or approval of, whether or not similar to the act so consented or approved. 16. 'ENTIRE CONTRACT: This five (5) page Contract constitutes the entire contract between the parties; no modification shall be made to this Contract unless such modification is in writing, agreed to by both parties and attached hereto as an addendum to this Contract. IN WITNESS WHEREOF, the parties hereto have executed this Contract on the date and year first above written. WITNESSES: Fv�. G TRB MANAGEMENT, INC. 7 essis, Ayv:-.R o 6 e rrO uDplessis,President �w (Corporate Seal) VILLAGE OF TEQUESTA k I OF..rL ATTEST- ..... .... �9,yo 11;i:kQ P 0 jr•V �Seal) AL Lori McWilliams, MMC INCORPORATED:: Village Clerk VOF ....... ........ ;'N/41� OF F Page 5 of 5 Exhibi+ /Q TRB MANAGEMENT, INC 1.9005 TALON WAY JUPITER, FL 33458 Phone: 56 1-935-7355 email: FLINSPECTGRBN3459- UOTE Please provide a quote for the below listed services, sign and return to the Village of Tequesta at lbritt@tequesta.org no later than Dezember 1, 2019. DESCRIPTION FIXED HOURLY RATE Individual Plans Examiner licensed in all $ 75 residential and commercial disciplines (i.e., building, electrical, plumbing and mechanical). This quote is valid until September 30 2022. Individual Inspector licensed in all residential and 70 commercial disciplines (i.e., building, electrical, plumbing and mechanical). This quote is valid until September 30 2022. NAME: Robert Duplessis TITLE: COMPANY: ADDRESS: CITY/STATE/ZIP: TELEPHONE NO.: EMAIL: President TRB Management, Inc. 19005 Talon Way Jupiter, FL 33458 (561)935-7355 flinspectorbn3459 SIGNATURE: DATE: November 24, 2019 Page 1 of I DocuSign Envelope ID: 5C556OA4-4439-49E1-B4B6-EB98926FD492 ACORP. FLORIDA WORKERS COMPENSATION APPLICATION DATE (MMIDDIYYYY) 12/10/2019 PRODUCER PHONE A/C, No. Ext): (855) 465�8 8� COMPANY UNDERWRITER -- -- ^� FAx TechnologyInrCn Inc. suance orn a�� Kellie Jamieson (A/C, No): APPLICANT NAME - INCLUDE ALL SUBSIDIARIES & DBA'S TO BE INCLUDED IN COVERAGE, ALONG WITH THEIR FEIN CoverHound lnc.dba CoverHound Insurance Solution TRB Management Inc. 5655 Llndero Canyon Rd. Suite 420 MAILING ADDRESS (INCLUDING ZIP CODE) - INCLUDE CHECK HERE IF LIST OF 101 PRINCIPAL PHYSICAL LOCATION AND ALL INSURED ENTITIES ADDITIONAL LOCATIONS ATTACHED 19005 Talon Way Jupiter FL Westlake Village CA 9� 362 33458 LICENSE #: YRS IN BUS SIC CODE INDIVIDUAL PARTNERSHIP CORPORATION ^ E OTHER: SUBCHAPTER'S" CARP Other CODE: SUB CODE: AGENCY CUSTOMER ID _ FEDERAL EMPLOYER ID NUMBER NCCI ID NUMBER OTHER RATING BUREAU ID NUMBER 52038 1 650044437 5 I A I U5 C]F 5UbMI55IL)N BILLINGIAUDIT INFORMATION smej QUOTE ❑ ISSUE POLICY BILLING PLAN PAYMENT PLAN AUDIT AGENCY BILL ANNUAL PREM FINANCED AT EXPIRATION MONTHLY Quote#: 6483153 DIRECT BILL SEMI-ANNUAL ✓ OTHER: Monthly In SEMI-ANNUAL OTHER: QUARTERLY % DOWN: QUARTERLY a.iv I f1G1.. rl i I VIVRG Gva,.r� I IVi�V, I{7L3.,V 1J1{■ V G.7f lYnG 1 17GR 4V YGf[H<iC i.7 1'iCI�lJC�7 1 CU Vl'C {rkJ 1 . 11� 1'if-1—L14I1iM 1 la7 M - �C31'1 CCt`Q1^' 10 Al CRanI ^%In 1 l7 r"_ A LIN7 ATill►I 1172 P►liCA11i'li r►vr' i r^ A [.glair+ J+P%Rerh ► ■Iv I ir.r A I I - ir-a- r. r.Aar%A ■Ili-f% A al� r. ar-irl I r A r.N aLl + # STREET, CITY, COUNTY, STATE, ZIP CODE 19005 Talon Way Jupiter FL 33458 POLICY INFORMA I IUN PROPOSED EFF DATE PROPOSED EXP DATE NORMAL ANNIVERSARY RATING DATE PARTICIPATING 12/11 /2019 12/1 1 /202Q NUN -PARTICIPATING PART 1 - WORKERS PART 3 - OTHER STATES INS DEDUCTIBLE COMPENSATION (States) PART 7 - EMPLOYER 5 LIABILITY $ 100000 EACH ACCIDENT $ 500000 DISEASE -POLICY LIMIT COINSURANCE LIMIT _ $ 100000 DISEASE -EACH EMPLOYEE DIVIDEND PLAN/SAFETY GROUP I ► DDITI'ONAL COMPANY INFORMATION PATIMr. IAIFr]RMATInhI 1 ik f'_14PrLC 1- P09Z IG 114ZT ng; AnnITiIIAIAI r'1 AQQ rnnIPQ ATTArW=n RETRO PLAN OTHER COVERAGES U.S.L. & H. VOLUNTARY COMPENSATION LOC CLASS CODE COM- Y PUSS CATEGORIES, DUTIES, CLASSIFICATIONS # OF PL OYEES 1 ACTUAL REMUN- ERATION PAST 12 MONTHS ESTIMATED REMUNERATION FOR NEXT POLICY PERIOD $46800 RATE 0.27 ESTIMATED ANNUAL PREMIUM $126 FL 8721 Real Estate Appraisal Company----- SPECIFY ADDITIONAL COVERAGES/ENDORSEMENTS M FACTOR FACTORED PREMIUM $ 126 TOTAL Credits/Debits $ 0 $0 EXPERIENCE MODIFICATION 1.00 $ 0 MODIFIED PREMIUM $ 126 PREMIUM DISCOUNT 0.00% $ 126 EXPENSE CONSTANT N/A $ 160 TOTAL ESTIMATED ANNUAL PREMIUM $ 291 MINIMUM PREMIUM $ 187 DEPOSIT PREMIUM $ 0 ACORD 130 FL (2002/07) PLEASE COMPLETE REVERSE SIDE @ ACORD CORPORATION 1991 DocUSign Envelope ID: 6C5666A4-4439-49EI-B4B6-EB98926FD492 INDIVIDUALS INCLUDEDIEXCLUDED PARTNERS, OFFICERS, OWNERS TO BE INCLUDED OR EXCLUDED. (REMUNERATION TO BE INCLUDED MUST BE PART OF RATING INFORMATION SECTION.) ATTACH LIST OF ADDITIONSIEXEMPTIONS, IF ANY. PROVIDE COPIES OF EVIDENCE OF EXCLUSIONS/]NCLUSIONS. DISCLOSURES OF THE SOCIAL SECURITY NUMBERS IS VOLUNTARY AS AN ALTERNATIVE ATTACH A COPY OF EXEMPTION OR INCLUSION FORM FILED WITH THE STATE OF FLORIDA_ # NAME DATE OF BIRTH SOCIAL SECURITY # TITLE/ RELATIONSHIP OWNR- H DUTIES INC/ EX CLASS CODE REMUNERATION 1 2 3 PRIOR CARRIER INFORMATION/LOSS HISTORY PROVIDE INFORMATION FOR THE PAST 5 YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS LOSS RUN ATTACHED YEAR CARRIER & POLICY NUMBER ACTUAL/AUDITED PREMIUM MOD # CLAIMS AMOUNT PAID RESERVE CO: POL #: CO: POL #: CO: POL #: CO: POL #: CO: POL #: NATURE OF BUSINESSMESCRIPTION OF OPERATIONS GIVE COMMENTS AND DESCRIPTIONS OF ALL BUSINESSES, OPERATIONS AND PRODUCTS (INCLUDING OTHER STATES): MANUFACTURING— RAW MATERIALS, PROCESSES, PRODUCT, EQUIPMENT; CONTRACTOR— TYPE OF WORK, SUB -CONTRACTS; MERCANTILE-- MERCHANDISE, CUSTOMERS, DELIVERIES; SERVICE-- TYPE, LOCATION; FARM— ACREAGE, ANIMALS, MACHINERY, SUB -CONTRACTS. IF CONTRACTOR, PROVIDE LICENSE NUMBER. PROFESSIONAL EMPLOYER ORGANIZATION (PEO)/EMPLOYEE LEASING COMPANY 0 TEMPORARY EMPLOYMENT SERVICE EMPLOYEES - ATTACH A LIST OF ADDITIONAL EMPLOYEE NAMES NAME CLASS CODE SOCIAL SECURITY # NAME CLASS CODE SOCIAL SECURITY # ATTACH THE LAST FOUR (4) UNEMPLOYMENT COMPENSATION EMPLOYER QUARTERLY TAX REPORTS - UCT-6 OR IRS FORM 941. PLEASE EXPLAIN IF UCT-6 OR 941 IS NOT AVAILABLE. DISCLOSURE OF THE SOCIAL SECURITY NUMBERS IS VOLUNTARY, AS AN ALTERNATIVE, THE LATEST UCT-6 FORM WITH CLASS CODES ADDED CAN BE USED IN LIEU OF A SEPARATE LISTING OF EMPLOYEE NAMES, SOCIAL SECURITY NUMBER AND CLASS CODE. ANY EMPLOYEES NOT ON THE UCT-6 FORM SHOULD BE SHOWN SEPARATELY. GENERAL INFORMATION EXPLAIN ALL "YES" RESPONSES YES NO EXPLAIN ALL "YES" RESPONSES YEt- 1. DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT/WATERCRAFT? ✓ 16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE? 2. ❑O/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVED) STORING, TREATING, ❑ISCHARGING, APPLYING, ❑ISPOSING, OR TRANSPORTING HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc) OF 17. ANY OTHER INSURANCE WITH THIS INSURER? ✓ 18. ANY PRIOR COVERAGE DECLINED/CANCELLED/NON-RENEWED (Last 3 years)? 3. ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET? ✓ 19. ARE EMPLOYEE HEALTH PLANS PROVIDED? ✓ 4. ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER? ✓ 20. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS/SUBSIDIARY? ✓ 5. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS? ✓ 21. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? ✓ 6. ARE SUB -CONTRACTORS AND/OR INDEPENDENT CONTRACTORS USED? ✓ 22. ❑O ANY EMPLOYEES PREDOMINANTLY WORK AT HOME? ✓ 7. ANY WORK SUBLET WITHOUT CERTIFICATES OF INS.? ✓ 23. WHAT ARE YOUR ESTIMATED ANNUAL REVENUES? $ ✓ 8. 15 A FORMAL SAFETY PROGRAM IN OPERATION? �/ 24. IS THERE ANY CURRENT OR ANTICIPATED DEBT FOR UNPAID PREMIUMS OWED TO ANY PREVIQUS WORKERS' MPENSATI N PROVIDER? ✓ 9. ANY GROUP TRANSPORTATION PROVIDED? ✓ CONTACT INFORMATION 10. ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE? ✓ IN- PHONE: SPECTION NAME: 11. ANY PART TIME OR SEASONAL EMPLOYEES? ✓ 12. IS THERE ANY VOLUNTEER OR DONATED LABOR? ✓ I ACCTNG PHONE: RECORD NAME: 13. ANY EMPLOYEES WITH PHYSICAL HANDICAPS? i/ 14. ❑O EMPLOYEES TRAVEL OUT OF STATE? CLAIMS PHONE: INFO NAME: 15. ARE ATHLETIC TEAMS SPONSORED? REMARKS ACORD 130 FL (2002107) DocuSign Envelope ID: 6C5660A4-4439-49El-B4B6-E'B98926FD492 ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE OR AS OTHERWISE PUNISHABLE AS PROVIDED UNDER THE LAW. UNDERSTAND THAT AS THE EMPLOYER, MUST UPDATE THE APPLICATION MONTHLY TO REFLECT ANY CHANGE IN THE REQUIRED APPLICATION INFORMATION; (THE FLORIDA WORKERS COMPENSATION CHANGE SHEET WILL BE USED FOR THIS PURPOSE.) IF I FILE AN APPLICATION OR APPLICATION UPDATE CONTAINING FALSE, MISLEADING, OR INCOMPLETE INFORMATION WITH THE PURPOSE OF AVOIDING OR REDUCING THE AMOUNT OF PREMIUMS FOR WORKERS COMPENSATION COVERAGE IT IS A FELONY OF THE THIRD DEGREE OR AS OTHERWISE PUNISHABLE AS PROVIDED UNDER THE LAW. SHALL SUBMIT TO THE CARRIER, A COPY OF THE QUARTERLY EARNINGS REPORT AND SELF -AUDITS SUPPORTED BY THE QUARTERLY EARNINGS REPORTS, AS REQUIRED BY CHAPTER 443, AT THE END OF EACH QUARTER, IF I OMIT THE NAME OF AN EMPLOYEE FROM THIS QUARTERLY EARNINGS REPORT, FLORIDA STATUTES STATE THAT I WILL REMAIN LIABLE AND WILL REIMBURSE THE CARRIER FOR ANY WORKERS COMPENSATION BENEFITS PAID TO THIS OMITTED EMPLOYEE; I AGREE TO MAKE AVAILABLE, ALL RECORDS NECESSARY FOR THE PAYROLL VERIFICATION AUDIT AND PERMIT THE AUDITOR TO MAKE A PHYSICAL INSPECTION OF OUR OPERATIONS. I UNDERSTAND FAILURE TO DO THIS SHALL RESULT IN A $500 PAYMENT TO THE CARRIER TO DEFRAY THE COST OF THE AUDITS; THAT, IN ACCORDANCE WITH FLORIDA STATUTES 440.381(6), IF I (WE) UNDERSTATE OR CONCEAL PAYROLL, OR MISREPRESENT OR CONCEAL EMPLOYEE DUTIES SO AS TO AVOID PROPER CLASSIFICATION FOR PREMIUM CALCULATIONS, OR MISREPRESENT OR CONCEAL INFORMATION PERTINENT TO THE COMPUTATION AND APPLICATION OF AN EXPERIENCE RATING MODIFICATION FACTOR, I (WE) SHALL PAY A PENALTY OF TEN (10) TIMES THE AMOUNT OF THE DIFFERENCE IN PREMIUM PAID AND THE AMOUNT I (WE) SHOULD HAVE PAID, AND REASONABLE ATTORNEYS FEES. FORMER NAMES AND OWNERS FOR THE LAST 5 YEARS, LIST THE CURRENT BUSINESS NAME AND ANY FORMER NAMES OR PREDECESSOR COMPANIES FOR ALL COMPANIES TO BE COVERED BY THE POLICY. INCLUDE THE FEIN FOR EACH COMPANY. FOR EACH COVERED COMPANY, LIST ANY CURRENT OWNER WHO HAS MORE. THAN 5% OWNERSHIP INTEREST, FOR EACH COVERED COMPANY OR PREDECESSOR COMPANY, LIST ANY OWNER WHO HAD MORE THAN 5% OWNERSHIP INTEREST IN THE LAST 5 YEARS. OW N ERS H I P/COMB I NAB[ L ITY DOES THIS BUSINESS OR ANY OF THE OWNERS OF THIS BUSINESS, EITHER INDIVIDUALLY OR IN COMBINATION WITH OTHER OWNERS OF THIS BUSINESS, OWN MORE THAN 50% OF ANY OTHER BUSINESS, WHICH OPERATED AT ANY TIME DURING THE FIVE YEARS PRIOR TO THIS APPLICATION? 0 YES NO OR, DOES THIS BUSINESS OWN A MAJORITY INTEREST IN ANOTHER ENTITIY, WHICH IN TURN OWNS A MAJORITY INTEREST IN ANY ENTITY THAT OPERATED AT ANY TIME IN THE FIVE YEARS PRIOR TO THIS APPLICATION? �-- YES NO l[....JI IF THE ANSWER TO EITHER OF THE ABOVE QUESTIONS IS YES, COMPLETE THE FOLLOWING SUPPLEMENTAL OWNERSHIPPCOMBINAB ILITY QUESTIONS: 1. IDENTIFY BY NAME, ADDRESS, AND FEIN EACH BUSINESS WHICH IS RELATED BY COMMON OWNERSHIP TO THE APPLICANT BUSINESS. 2. SET FORTH THE DATES EACH BUSINESS WAS IN OPERATION, THE INSURANCE COMPANY THAT PROVIDED WORKERS' COMPENSATION INSURANCE, THE POLICY NUMBER AND THE EXPERIENCE MODIFICATION FACTOR APPLIED TO EACH SUCH POLICY. 3. IF THE POLICY WAS WRITTEN WITHOUT AN EXPERIENCE MODIFICATION FACTOR, PLEASE STATE. THE APPLICANT HEREBY AUTHORIZES AND REQUESTS EACH RATING ORGANIZATION WITH EXPERIENCE RATING INFORMATION RELATED TO THE APPLICANT AND THE BUSINESS SET FORTH ABOVE TO RELEASE SUCH INFORMATION TO THE INSURER, FWCJUA, OR OTHER RATING ORGANIZATION SO THAT THE CORRECT EXPERIENCE MODIFICATION FACTOR CAN BE DETERMINED, HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE STATEMENTS AND AS AGENT/PRODUCER, I HEREBY ATTEST THAT I HAVE GIVEN THE PERSONALLY SWEAR THAT THE INFORMATION CONTAINED IN THE APPLICANT/SIGNATORY THE OPPORTUNITY TO READ THE APPLICATION AND APPLICATION IS ACCURATE, THAT I, AS AN OWNER/OFFICER, AM FULLY HAVE EXPLAINED ANY AND ALL QUESTIONS REGARDING THE APPLICATION. I AUTHORIZED TO SIGN THIS APPLICATION ON BEHALF OF THE APPLICANT ALSO ATTEST THAT I HAVE EXPLAINED TO THE EMPLOYER OR OFFICER THE AND TO BIND THE APPLICANT. CLASSIFICATION CODES THAT ARE USED FOR PREMIUM CALCULATIONS PURSUANT TO SECTION 440.381 (2), FLORIDA STATUTES. NERWNOMMNATURE DATE PRC]DUC 'SSa GNAgneU E DATE rNtkl� � SSt� 12/10/2019 8:46 A PRM��� F192A94aF... 12/10/2019 � 8:45 Are S Pl#r� (,4� NOTARY PUBLIC SIGNATURE DATE NOTA Aq8%R8WfU7�E DATE PST ACORD 130 FL (2002/07) � D0 �+ DATE (MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 12/13/2019 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 GOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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 endorsements). PRODUCER NAME: CHUBB CUSTOMER SERVICE CENTER Coverhound, Inc P11614C No Ex# : 866-972-2727 (A/C, No 5655 Lindero Canyon Road, Suite 420 ADDRESS: CRU13I3CSC. @C 14UBD.0 0M. INSURER($) AFFORDING COVERAGE NAIC # Westlake. Village, CA 91362 INSURER A; Pacific: Indemnity Insurance Company 20346 INSURE© INSURER B TRB Management Inc. INSURER C : 19005 Talon Way INSURER D : INSURER E : Jupiter FL 33458 1 INSURER F : r1OVFRArtFS E'`.FPTIIPWAYI: IU! IIUIRI►-0- 1*C'k11Q1r%M AtI IItJ1MCD� .......... THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD - -------------- -- INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDfYYYY) (MM/0D1YYYY) LIMITS �..... COMMERCIAL GENERAL LIABILITY I----- EACH OCCURRENCE $ 1,QOQ,C3DQ ElCLAIMS -MADE 1:1OCCUR PREMISES SEa occurrence $ l U4,EIU0 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1)000)000 A Y SERFLF.147354555 02/07/2019 02/07/2020 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY OPRO- LO GENERAL. AGGREGATE $ 2,000,000 2,40,Qaa�J OTHER: $ AUTOMOBILE LIABILITY COMBINED accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NUN -OWNED AUTOS ONLY AUTOS ONLY PROPERTY I3TRTGr. Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAp CLAIMS -MADE AGGREGATE $ .DEC) RETENTION $ $ IORKERS COMPENSATION ND EMPLOYERS' LIABILITY NY PROPRIETORIPARTNERIEXECUTIVE Y J N FFICERIMEMBER EXCLUDED? N ! A STATUTE ER E.L. EACH ACCIDENT $ andatory In NH) ftiSCRIPTION yes, describe under E.L. DISEASE - EA EMPLOYEE $ EOF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The insurance: afforded by the policies described herein is subject to all terms, exclusions and conditions of'suell policies. The Village offequesta, is listed as Additional I.nStired, per the terms and conditions of the Chubb BLLSine&wwnem, .Liability ADDITIONAL INSURED -MANAGERS OR LESSORS OF PREMISES Endon. eme:nt (BIB 04 02 01 06, or its equivalent) included in the policy. CERTIFICATE HOLDER CANCELLATION 'rhe Village of Tequesta 345 Tecluesta .Drive: Tequesta, FL 33469 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered narks of ACORD PUBLIC RECORDS. |naccordance with Sec. ll9.O7Ol.Florida Statutes, CONTRACTOR must keep and maintain this Agreement and any other records associated therewith and that are associated with the performance of the work described in the Proposal or Bid. Upon request from the Village's custodian of public records, CONTRACTOR must provide the Village with copies of requested records, orallow such records tobeinspected orcopied, within a reasonable time in accordance with access and cost requirements of Chapter 119, Florida Statutes. AC(]NTRACTDR who fails to provide the public records to the Village, or fails to make them available for inspection or copying, within a reasonable time may be subject to ettornev's fees and costs pursuant to Sec. 119.0701, Florida Statutes, and other penalties under Sec. 119.10i Florida Statutes. Further,, CONTRACTOR shall ensure that any exempt or confidential records associated with this Agreement or associated with the performance of the work described in the Proposal or Bid are not disclosed except as authorized by law for the duration of the Agreement term, and following completion ofthe Agreement ifthe CONTRACTOR does not transfer the records tOthe Village. Finally, upon completion ofthe Agreement, CONTRACTOR shall transfer, at no cost to the Village, all public records in possession of the CONTRACTOR, or keep and maintain public records required by the Village. If the CONTRACTOR transfers all public records tothe Village upon completion ofthe Agreement, the CONTRACTOR shall destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. If the CONTRACTOR keeps and maintains public records upon completion of the Agreement,, the CONTRACTOR shall nlG8t all applicable requirements for retaining public records. Records that are stored electronically must be provided to the VILLAGE, upon request from the ViUaQe^s custodian of public records, in a format that is compatible with the Village's information technology systems. IF CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS AGREEMENT,� PLEASE CONTACT THE VILLAGE CLERK� RECORDS CUSTODIAN FOR THE VILLAGE, AT (561) 768'0440, OR AT 1mcwi11iams@tequesta,org,,OR AT 345 TEQUESTA DRIVE,� TEQUESTA~ FLORIDA 33469, Pursuant to Article XII of the Palm Beach County Charter, the Office of the Inspector General has jurisdiction to investigate municipal matters, review and audit municipal contracts and other transactions, and make reports and recommendations to municipal governing bodies based on such audits, reviews, or investigations. All parties doing business with the Village shall fully cooperate with the inspector general in the exercise of the inspector general's functions, authority, and power. The inspector general has the power totake sworn statements, require the production of records, and to audit, monitor, investigate and inspect the activities of the Village, as well as contractors and lobbyists of the Village in order to detect, deter, prevent, and eradicate fraud, waste, rnismmanegenmen�misconduct, and abuses. "The Village of Tequesta strives to be an inclusive environment. As such, it is the Village's policy to comply with the requirements of Title II of the American with Disabilities Act of 1990 ("ADA") by ensuring that the Contractor's [agreement /bid documents and specifications ] are accessible to individuals with disabilities. To comply with the ADA, the Contractor shall provide a written statement indicating that all [ agreement /bid documents and specifications], from Contractor, including files, images, graphics, text, audio, video, and multimedia, shall be provided in a format that ultimately conforms to the Level AA Success Criteria and Conformance Requirements of the Web Content Accessibility Guidelines 2.0 (Dec. 11, 2008) ("WCAG 2.0 Level AA"), published by the World Wide Web Consortium ("WK"), Web Accessibility Initiative ("WAI"), available at www.w3.org/TR/WCAG/.'l