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HomeMy WebLinkAbout2017-175-E AMS - Roof Control Services of NC, Inc. to repair, replace shingle portion of roof at Millhouse Rd. DocuSign Envelope ID:7AE8A4FO-DD4C-48AF-9407-33164957C9A2 NORTH CAROLINA CONSTRUCTION SERVICES AGREEMENT UNDER$50,000 ORANGE COUNTY THIS CONSTRUCTION AGREEMENT (hereinafter "Agreement"), is made and entered into this 22nd day of May, 2017 by and between Orange County, North Carolina (hereinafter the "Owner") party of the first part; and Roof Control Services of NC, Inc (hereinafter the "Contractor"),party of the second part; WITNESSETH: For the purpose and subject to the terms and conditions hereinafter set forth, the Owner hereby contracts for the construction services of the Contractor, and the Contractor agrees to provide the construction services to the Owner in accordance with the terms of this Agreement. 1. TERM AND MAXIMUM AMOUNT PAYABLE Beginning and ending dates of contract: May 22, 2017 through August 31, 2017. The Project Commencement Date shall be May 22, 2017. Dollar Amount Not to Exceed: Eight Thousand Six Hundred Seventy Dollars ($8,670.00) 2. SERVICES Contractor agrees to provide the following construction services (the "Work"): Re-roof existing EPDM roof portion of the Orange County Parks Operation Base located at 6823 Millhouse Road, Chapel Hill NC and make repairs to the shingle portion of the roof per plan (1.01 Roof Plan, dated 2/2017 Job no. 16-179). Scope and pricing are based on proposal dated 04/20/17. Contractor shall not sub-contract all or any part of the construction services provided for in this Agreement without prior written approval of the Owner. Contractor shall be responsible for all errors or omissions, in the performance of the Agreement. Contractor shall correct any and all errors, omissions, discrepancies, ambiguities, mistakes or conflicts at no additional cost to Owner. 3. PAYMENT Contractor shall submit an invoice for construction services provided. The invoice shall contain Contractor's name and federal tax identification number and shall be signed and dated by an officer of Contractor. It shall detail all construction services provided in payment requests. The Owner will make payments to Contractor within thirty (30) days after receipt of and approval of the invoice by the contracting department. In the event the amount stated on an invoice is disputed by Owner, then Owner may withhold payment of all or a portion of the amount stated on an invoice until the parties resolve the dispute. In addition, should Contractor fail to perform its duties under the terms of this Agreement, Owner may, without fault or penalty, withhold any payment associated with the Work to be performed until such time as said work is completed. 4. RELATIONSHIP OF PARTIES Revised 2/17 1 DocuSign Envelope ID:7AE8A4FO-DD4C-48AF-9407-33164957C9A2 Contractor is an independent contractor of the Owner. Contractor represents that it has or will secure, at its own expense, all personnel required in performing the construction services under this Agreement. Such personnel shall not be employees of or have any contractual relationship with the Owner. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized or permitted under state and local law to perform such construction services. It is further agreed that Contractor will obey all State and Federal statutes, rules and regulations which are applicable to provisions of the construction services called for herein. Neither Contractor nor any employee of the Contractor shall be deemed an officer, employee or agent of the Owner. 5. SUSPENSION AND TERMINATION This Agreement may be terminated by Contractor upon thirty (30) days' written notice to the Owner, and the Owner may terminate this Agreement upon thirty (30) days' written notice to Contractor. Owner may suspend the Work at any time for Owner's convenience and without penalty to Owner upon three (3) days' notice to Contractor. Upon any suspension by Owner Contractor shall discontinue the Work and shall not resume the Work until notified to proceed by Owner. The notice required by this section or any other notice shall be delivered via certified mail, return receipt requested to the parties at the addresses as shown on the signature page to this Agreement. Such notice is deemed given upon its delivery to, or deposit in a receptacle of, the United States Post Office. 6. INSURANCE REQUIREMENTS Contractor shall obtain, at its sole expense, Commercial General Liability Insurance, Automobile Insurance, Workers' Compensation Insurance, and any additional insurance as may be required by Owner's Risk Manager as such insurance requirements are described in the Orange County Risk Transfer Policy and Orange County Minimum Insurance Coverage Requirements (each document is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing division/contracts.php). If Owner's Risk Manager determines additional insurance coverage is required such additional insurance shall be designated here N/A (if no additional insurance required mark N/A as being not applicable). Contractor shall not commence construction work until such insurance is in effect and certification thereof has been received by the Owner's Risk Manager. 7. INDEMNIFICATION Contractor agrees to defend, indemnify, save, and protect Owner and Owner's lender, if any, harmless from and against any and all claims, liens, liabilities, losses, damages, causes of action, and expenses (including court costs and reasonable attorney's fees related thereto) arising out of, in connection with, or resulting from any negligence, act or failure to act by the Contractor, the Contractor's agents, assigns or employees resulting in property damage or personal injury, including death, or other loss related to the Work. Contractor is responsible for all errors or omissions caused by its agents, contractors, employees, or assigns in the performance of this Agreement. It is the intent of this section to require Contractor to indemnify the Owner to the full extent permitted under North Carolina law. 8. NON-ASSIGNMENT Contractor shall not assign all or any part of this Agreement, including rights to payments, to any other party without the prior written consent of the Owner. Revised 2/17 2 DocuSign Envelope ID:7AE8A4FO-DD4C-48AF-9407-33164957C9A2 9. NON—APPROPRIATION Contractor acknowledges that Owner is a governmental entity, and the validity of this Agreement is based upon the availability of public funding under the authority of its statutory mandate. In the event that public funds are unavailable and not appropriated for the performance of Owner's obligations under this Agreement, then this Agreement shall automatically expire without penalty to Owner immediately upon written notice to Contractor of the unavailability and non-appropriation of public funds. It is expressly agreed that Owner shall not activate this non- appropriation provision for its convenience or to circumvent the requirements of this Agreement, but only as an emergency fiscal measure during a substantial fiscal crisis. In the event of a change in the Owner's statutory authority, mandate and/or mandated functions, by state and/or federal legislative or regulatory action, which adversely affects Owner's authority to continue its obligations under this Agreement, then this Agreement shall automatically terminate without penalty to Owner upon written notice to Contractor of such limitation or change in Owner's legal authority. 10. DISPUTE RESOLUTION Any dispute with respect to any provision of, or the performance or non-performance of, this Agreement shall be subject to the Dispute Resolution Rules and Procedures for Orange County Design, Building Construction, Renovation, and Repair Projects. The policy is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing division/contracts.php). 11. ENTIRE AGREEMENT The parties have read this Agreement and agree to be bound by all of its terms, and further agree that it, together with specifically referenced documents, constitutes the complete and exclusive statement of the Agreement between the parties unless and until modified by a written amendment to this Agreement signed by the parties. Modifications may be evidenced by telefacsimile signatures. Should any conflict arise in the terms of any documents referenced herein and this Agreement the terms of this Agreement shall be given priority and shall control over all other such documents. Should a request for proposals and a proposal be referenced the terms of the request for proposals shall have priority over the terms of the proposal. 12. COMPLIANCE WITH LAW/GOVERNING LAW Both parties agree that this Agreement shall be governed by the laws of the State of North Carolina and any action brought under this Agreement shall be brought in the General Court of Justice of the State of North Carolina in Orange County. Contractor shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal non-discrimination laws,policies, rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy(each policy is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing division/contracts.php). Any violation of the Orange County Non-Discrimination Policy is a breach of this Agreement and County may immediately terminate this Agreement without further obligation on the part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Contractor affirms that Contractor and any subcontractors of Revised 2/17 3 DocuSign Envelope ID:7AE8A4FO-DD4C-48AF-9407-33164957C9A2 Contractor are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Contractor certifies that Contractor has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the consent of the Parties to utilize electronic signatures and intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. [SIGNATURE PAGE TO FOLLOW] Revised 2/17 4 DocuSign Envelope ID:7AE8A4FO-DD4C-48AF-9407-33164957C9A2 IN WITNESS WHEREOF Orange County and the Contractor have signed this agreement, effective as of the day and date first above written. ORANGE COUNTY CONTRACTOR ��Qp,,,,osyea��yL: �Q¢,,��_osge��Q¢,,,���__� BJ osnaorecnr... I By�,..,i-_-,, County Manager Roof Control Services of NC, Inc. 200 S. Cameron St. 104 Rand Park Drive P.O. Box 8181 Garner,NC Hillsborough,NC 27278 27529 Revised 2/17 5 DocuSign Envelope ID:7AE8A4FO-DD4C-48AF-9407-33 164957C9A2 COUNTY OF ORANGE FINANCIAL SERVICES— PURCHASING PO BOX 8181 HILLSBOROUGH, NORTH CAROLINA 27278 ORANGE COUNTY BID NO. April 5, 2017 ATTENTION: INTERESTED VENDORS Orange County requests your competitive quotation to furnish the item(s) listed below for Orange County Parks Operations Base, Chapel Hill, NC. A mandatory site visit is scheduled Tuesday, April 11, 2017 at 10:30 am at the site. We will meet at the Orange County Parks Operation Base located at 6823 Milihouse Road, Chapel Hill, NC. This is the only scheduled time for contractors to view the site By submission of a bid the contractor acknowledges he/she fully understands the extent of the project. Please transmit this quotation via facsimile or deliver by hand or U.S. Mail, to the Orange County Purchasing Agent-fax#(919)636-4913, via email to dcannellOoranciecounivnalov or by hand to 200 South Cameron Street, Hillsborough, NC 27278 by April 20, 2017 at 2:00 PM ITEM # COMMODITIES/GOODS OR SERVICES 1 ROOF REPAIR FOR THE PARKS OPERATION BASE PER DRAWING 1.01 DATED 2/2017 SUBMIT PRICING ON ATTACHMENT A PLEASE STATE FIRM DELIVERY TIME TO START AFTER RECEIPT OF PURCHASE ORDER: DAYS PLEASE STATE NUMBER OF DAYS TO COMPLETE THE PROJECT AFTER COMMENCEMENT: DAYS Will any people working on this job make less than $12.76 per hour YES NO If yes, the lowest hourly wage to be paid any employee shall be $ / HOUR **SEE ATTACHED INSTRUCTIONS TO BIDDERS** FIRM NAmE 0 , **Ws 51'111 411P License 2_0:,,,2 „,„,Of applicable) BY Proposal must be signed in wonting) ADDRESS Li-8 .,46 -0 FAX • " Ce 21529 TELEPHONE: gig Cri bc.3 EMAIL: ip dr,, MS rb• Kit Orange County Bid Page#1 DocuSign Envelope ID: 7AE8A4FO-DD4C-48AF-9407-33 164957C9A2 Attachment A Bid Proposal Form: Parks Operation Base Roof Repairs Contractor agrees to furnish all materials, labor,wood and any other supplies necessary to complete the above work,for the sum of: $ . 013 Total • All work must be completed within 60 days of the project start date(approx.July 15, 2017) • Contractor is willing to participate in the County's "Docusign"digital contracting process and enter into a standard contract with the County. 7.-C) (Signature of Contractor) (Date) Orange County Bid Page#3 DocuSign Envelope ID: 7AE8A4FO-DD4C-48AF-9407-33 164957C9A2 ete COMMERCIAL ROOF INSTALLATION, RCSMAINTENANCE & REPAIR oar cordiro srvce , nc, PROPOSAL County of Orange Financial Services Attn: David Cannel! RE: Orange County Parks Operations Base Thank you for selecting Roof Control Services to provide our professional recommendations on the above referenced project. Based on our recent site visit, we offer the following scope of work for your consideration Scope of Work: EPDM Repairs (As listed on plans provided by 5" Wall) 1. Load materials on to roof and set up necessary safety equipment (if needed) 2. Strip in edge metal along existing gutter 23ft+1- 3. Strip in edge metal without gutter on all remaining sides 25ft i-/- 4. Repairs holes in membrane at chimney and filed 12ea 5. Repair membrane flashing at door threshold 6. Repair membrane flashing at shingle tie in 10ft+1- 7. Repair membrane flashing at siding 20ft+1- 8. Clean and repair gutter and downspouts 23ft 9. Caulk counter flashing at chimney 10. Upon completion of repair remove all job related materials and debris *miscellaneous repair to other items not necessarily listed herein:NTE $500.00 Total .$4,465.00 *Alternate(re-roof EPDM portion): New cover board, .60m1 TPO, and flashings$5,690.00 104 Rand Park Drive • Garner, NC • 27529 919-441-7668 Phone 321.251.6543 Fax • www.roofcontrol.com DocuSign Envelope ID: 7AE8A4FO-DD4C-48AF-9407-33 164957C9A2 Scope of Work:Shingle Repairs (As listed on plans provided by 5th Wall) 1. Load materials on to roof and set up necessary safety equipment (if needed) 2. Seal exposed nail heads 3. Reseal pipe penetration flashing 2ea 4. Repair sheet metal edge flashing 10ft 5. Seal cracked shingles at ridge 30ft 6. Seal flashing at dormers 20ft 7. Clean and repair gutter and downspouts 47ft 8. Caulk counter flashing at chimneys 8ft 9. Upon completion of repair remove all job related materials and debris *miscellaneous repair to other items not necessarily listed herein: NTE $500.00 Total .$2,980.00 Should you have any questions regarding the above proposal, please feel free to contact me at your convenience. Thank you for your consideration of Roof Control Services, Inc., as your contractor of choice. Respectfully Submitted, Brian Burns NC Licence #67024 FL License # CC-0057884 '"+■ ,e u111,1 uVf RCS f rooF oar() DocuSign Envelope ID: 7AE8A4FO-DD4C-48AF-9407-33164957C9A2 ROOFC-1 OP ID:C5 ACC7R 1-3.. CERTIFICATE OF LIABILITY INSURANCE DATEIMMfDDIYYYY) 04120!2017 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 B EEN 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 NAME CT Cindy Smith Southeastern Agency Group,Inc. PHONE 232- 336- 0203 FAX 1501 Higghwoods Blvd.,St#301 f1 VC.NQ.EMI: _IA1c,No 336-218-7487 Greensboro,NC 27410 cross*csmith ce�sagnc.com Travis Ketron INSURER(S)AFFORDING COVERAGE NAIC INSURER A:Builders Mutual Insurance Co. 10844 INSURED Roof Control Services of INSURER B:Colony Insurance NC Inc INSURER C 104 Rand Park Dr - Gamer,NC 27529 INSURERD: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY 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 INSR I TYPE OF INSURANCE INSR I U6� PMID Y EFF i Pwoo YY INSR Wyp POLICY NUMBER fMMlOD1YYWl (MMlDOrYYYYI LIMITS GENERAL UABIUTY EACH OCCURRENCE S 1,000,000 A X COMMERCIAL GENERAL LIABILITY CPP0061584 01101/2017 01/0112018 DAMAGEC(RENTED PREM'SES(Ea occu co) $ 100,000 CLAIMS-MADE X J OCCUR MED EXP(Any one person) S 5,000 PERSONAL&ADV INJ,,IRY 5 1,000,000 GENERAL AGGREGATE S 2,000,000 GENL AGGREGATE LIMIT APPLES PER PRODUCTS•COMP/OP AGO S 2,000,000 POLICY X JE J I I LOC AUTOMOBILE LIABILITY COMBINED SINGLE L M T (Ea accident) S 1,000,000 A X ANY AUTO _ PCA0010375- 01/0112017 0110112018 BODILY INJURY(Per person ',. S — ALL OWNED SCHEDULED BODILY INJURY(Per acodenl' $ _ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS (PER ACCIDENT) S UMBRELLA LAB X OCCUR EACH OCCURRENCE 5 5,000,000 A EXCESS W1B ■' CLAIMS•MADE UMB0027820- 01/01/2017 0110112018 AGGREGATE S 5,000,000 DED X RETENTIONS 10,000 ++ p WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X 1TORY LIMITS I I ERI A ANY PROPRIETOR/PARTNER/EXECUTIVE Y f N WCP1030461- 01/0112017 0110112018 E L EACH ACC DENT s 1,000,000 OFFICER/MEMBER EXCLUDED? © N I A (Mandatory in NH) E L DISEASE=EA EMPLOYEE 5 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE POLICY LIMIT S 1,000,000 A 'Equipment CPP0061584.1 0110112017 01101/2018 B Pollution CSP306909 0313012017 03130/2018 Pollution 2,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,II more space Is required) See page 2 CERTIFICATE HOLDER CANCELLATION ORANGEC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 200 South Common St Hillsborough,NC 27278 AUTHORIZED REPRESENTATIVE Travis Ketron ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:7AE8A4FO-DD4C-48AF-9407-33 164957C9A2 HOLDER CODE ORANGEC ROOFC-1 INSURED'S NAME Roof Control Services of OP ID:CS PAGE 2 NOTEPAD: rvi °ate 04/20/2017 Certificate holder is automatically listed as additional insured for General Liability, according to the terms, conditions & exclusions within the policy with respects to work performed by the insured on behalf of the certificate holder as required by written contract signed by an authorized representative of the named insured and the certificate holder DocuSign Envelope ID: 7AE8A4FO-DD4C-48AF-9407-33 164957C9A2 Fenn Wil I.9 Request for Taxpayer Give Form to the (AM December 201q Identification Number and Certification requester.Do not Departrrant of the Treasury mend to ttie IRS. Internal Revenue Sunoco 1 Name las Worm on your Income tax return).Name Is required on trds Int do not leave this Ins blink. Roof Control Services of NC, Inc. . 2 Business name/disregenteol entity name,If(afferent from above N 1 c 3 Check appropriate brut for federal tax classlficalkno check only one of the Mowing sawn bons: 4 Exemptions(codes apply only to o 0 IndividtaVarde parolees or 0 C Corporation 12 S Corporation 0 Partnership 0 TrutrUestate rarbtihdotiono""litiol'ncit larldua4;see 1 0 Itltad lability ,cornU-Cpony.Enter the tax cleselflaition(C.0 corporation,S4 corporation,Pirpartnership)So Exempt payee code(If any) b Note.For a sinle-rnember MC that is dbregarded,do not check U.C;check the appropriate box In the Ina above for Exemption from"'Ma'mmt1119 the tax classification of the single-member owner. code al any) 0 011w,..instnoctlans)10 ow.owirgure munoirl nada DS u.s., a Address(number,Want and.pt.cr suit.no.) 114Ruasleee name and address(optional) 104 Rand Park Drive . 6 atty.state,and ZfP code t Gamer,NC 27529 7 east account numbercs)hens(optional) Part I Taxpayer Identification Number(flN) Enter your 71N In the appropriate box.The TIN provided must match the name given on line 1 to avoid I social a*cluttf number backup withholding.For individuals,this Is generally your social security number pm.However,for a ' resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other - - entitles,It is your employer Identification number(EIN).If you do not have a number,see Now to get a 77N on page 3. of Note.If the account Is In more than one name,see the instructions for line 1 and the chart on page 4 for I__ Idantificali"ina"bir guidelines on whose number to enter. 4 6 - 3 8 1 0 9 1 3 1 7 Part I I Certification Under penalties of perjury,I certify that; 1. The number shown on this form Is my correct taxpayer Identification number(or I am waiting for a number to be Issued to me);and 2. I am not subject to backup whhholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am no longer subject to backup withholdng;and 3. I am a U.S.citizen or other U.S.person(defined below):and 4.The FATCA code(s)entered on this form(if any)Indicating that I am exempt from FATCA reporting is correct. Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have felled to report al interest and dividends on your tax return.For real estate transactions,Item 2 does not apply.For mortgage interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to en Individual retirement arrangement(IRA),end generally,payments other than interest and dividends,you we not required to sign the certification,but you must provide your correct TIN.See the instructions on• •a 3. — _ Sign fLI ianniunglireilillellilifir, Here U.S.petters 11WW:77111111116110 Data IP 111 • , General Instructions •Form 1095(home mortgage Interest),1095-E(student loan Interest),10911-T (tuition) Section referent:85 ere to the Internal Revenue Code micas otherwise noted. •Form 1099-C @wooled debt) Fuhwe developments.Information sbout developments affecting Form W4(such •Form 1099-A(=mom or abandonment of sammd;moon) as legislation enacted altar we release It)is at ennv.irsgovilw9. Use Form W-9 only II you are a U.S.person(including a=Went Oen),to Purpose of Form provide your correct TIN. An indkfldual or entity(IForm W-9 requestan who is regrind to Me an information dim do not Mum Form W-9 to the requester with a TIN,you might be skied return with the IRS must obtain your correct taxpayer Idantiecation number(TIN) to hada*etthhoiding.See What Is bad oking7 on page 2. which may be your wall security number(5314),kdvfdual taxpayer identification By signing the filed-out form,you: number(ITINI,adoption taxpayer iderttillcation number(Alta,or employer 1.C,artfy that the TIN you are giving is correct(or you are waiting for a number identification number(E1N),lo report on an information return the amount pakt to to be issue* you,or other emount reportable on an Information Mum.Examples ol Information retina inckide,but we not Inked to,the folowing: 2.Certify that you are not subject to baclorp withhokling,or •Fenn 1099-INT(Interest earned or paid) 3.Claim exemption from backup withhoking If you we a U.S.exempt payee.U applicable,you are aiso certifying that as a U.S. ,your allocable share of • Form 1099-OW(dividends,Including those from shocks or mutual funds) err/partnership Income from a US.trade or b not subject to the •Fenn 1099-MISC(various types of income,prizes,swords,or gross proceeds) wIthhokiing tax on foreign prima'sham of effectively connected Income,and •Fawn 10994(stock or mutual fund sales and certain other transactions by 4.Candy that FATCA code(s)crewed on this form(If any)Indenting that you are brolurs) exempt horn the FATCA reporting,Is correct.See What b FATCA matting?on •Form 1099-S(proceeds from real estate tronsectons) page 2 for further Information. •Form 1099-K(merchant card and Ohl party network transactions) Cat.No.10231X Form W-9(Rev.12.2014) DocuSign Envelope ID:7AE8A4FO-DD4C-48AF-9407-33 164957C9A2 STATE OF NORTH CAROLINA AFFIDAVIT ORANGE COUNTY I, 6fI -rt************************** I"/LS (the individual attesting below),being duly authorized by and on behalf of 4701— e-r te c) (the entity bidding on project hereinafter"Employer") after first being duly sworn hereby swears or affirms as follows: 1. Employer understands that E-Verify is the federal E-Verify program operated by the United States Department of Homeland Security and other federal agencies, or any successor or equivalent program used to verify the work authorization of newly hired employees pursuant to federal law in accordance with NCGS §64- 25(5). 2. Employer understands that Employers Must Use E-Verify. Each employer,after hiring an employee to work in the United States, shall verify the work authorization of the employee through E-Verify in accordance with NCGS§64-26(a). 3. Employer is a person,business entity, or other organization that transacts business in this State and that employs 25 or more employees in this State. (mark Yes or No) a,YES 9 or b.NO t4 4. Employer's subcontractors comply with E-Verify, and if Employer is the winning bidder on this project Employer will ensure compliance with E-Verify by any subcontractors subsequently hired by Employer. Tit This rZ.y day of 14- L., 2012. Si 0 1, A tant Print or Type Name: .6 4—t p istelinet _31 State of North Carolina Orange County -5; Signed and sworn to(or affirmed)before me, this the I 51 >4 mum oo , %,..4' '44t41\ / ç 5A/ ).. EP, My Commission E BOCJ ttt 04. N CCP," Notary Public IA tttttttttttttttt Orange County Bid Page#4 DocuSign Envelope ID: 7AE8A4FO-DD4C-48AF-9407-33164957C9A2 ROOFC-1 OP ID: CS A�CCAR© ID CERTIFICATE OF LIABILITY INSURANCE DATE 0412012017 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(fes)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 endorsements. CONTACT PRODUCER NAME: Cindy Smith Southeastern Agency Group,Inc. PHONE 33E-232-0203 FAX 1501 Highwoods Blvd.,St#301 lac,No.Ea11; lac,no 336-218-7487 Greensboro,NC 27410 EMAIL ADDRESS:csmith@sagnc,COm Travis Ketron INSURER(S)AFFORDING COVERAGE NAIC M INSURER A:Builders Mutual Insurance Co, 10844 INSURED Roof Control Services of INSURER a:Colony Insurance NC Inc 104 Rand Park Dr INSURER C: Gamer,NC 27529 INSURER 0: INSURERS: __.._. _.. ._.._ _... _,.,._._ _ _ , ........... INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY 4RIOD 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, INSR I TYPE OF INSURANCE ADDL.SUBR POLICY EFF 'POLICY EXP LTR INSR wvn POLICY NUMBER IIMMIODPYYYY) (MM!DDIYYYY1 LIMITS GENEtALUABIUTY EACH OCCURRENCE S 1,000,000 A X COMMERCIAL GENERAL LIABILITY CPP0061584 01/0112017 01/0112018 DAMAG es(es 7ED- PREM SES(Es oCCVrterice) s 100,000 CLAIMS-MADE OCCUR MED EXP(Any one person) S 5,000 ,,,_„,;_,•,,,,, _.:___„ PERSONAL EADVINJJRY S 1,000,000 — _ _,w GENERAL AGGREGATE 5 2,000,000 GENL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO. 5 2,000,006 POLICY I Jl jF a I-1 LOC 5 AUTOMOBILE UAeIUTY COMBINED SINGLE D:M•.T 1 000 [Eo ectldanll •S , ,000 A X ANY AUTO PCAOOi0375- 01/01/2017 01/01/2018 BODILY INJURY(Per pers n) S ALL OWNED SCHEDULED BODILY INJURY Per acC 0nt` S AUTOS AUTOS I V HIRED AUTOS AUTOS ED (PER PAC ICDENTMIGE 5 3 - UMBRELLA UAB X OCCUR EACH OCCURRENCE S 5,000,000 A — EXCESSLIAB CLAIMS-MADE UMB0027820- 01(01/2017 01/01/2018 AGGREGATE S 5,000,000 DED I X I RETENTIONS 10,000 p 5 AND EMPLOYERS'LIAEIUTY y I N X!TORY LIMITS I ER A YPROP ITCJRTNER/E ECUTVE © CP1030461- 01/01/2017 01/0112018 E.L,EACH ACCIDENT S 1,000,000 AF EREA NIA (Mandatory In NH) E DISEASE-EA EMPLOYEE 3 1,000,000 D SC RdPTaIlO uOF OP ERATIONS belay _ E.L.DISEASE•POLICY LIMIT S 1,000,000 A Equipment CPP0061584.1 01/01/2017 01/01/2018 B Pollution CSP306909 03/30/2017 03/3012018 Pollution 2,000,000 DESCRJPTON OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,AddlIlonal Rama,Schedule,H more span Is required/ See page 2 • CERTIFICATE HOLDER CANCELLATION ORANGEC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 200 South Common St Hillsborough,NC 27278 AUTHORED REPRESENTATIVE Travis Ketron 1 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: 7AE8A4FO-DD4C-48AF-9407-33164957C9A2 HOLDER CODE ORANGEC ROOFC-1 PAGE 2 NOTEPAD. HOLDER Roof Control Services of OP ID:CS 04/2012017 Certificate holder is automatically listed as additional insured for General Liability, according to the terms, conditions & exclusions within the policy with respects to work performed by the insured on behalf of the certificate holder as required by written contract signed by an authorized representative of the named insured and the certificate holder {