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HomeMy WebLinkAboutFormation Concrete & General Construction Inc t RECEIVE® ' J U L - 1 2021 AGREEMENT S011t1101d Town Clerk THIS AGREEMENT, entered into this' ay of June, 2021, by and between the Town of Southold, New York("the Town"), a municipal corporation organized and existing under the laws of the State of New York with offices at 53095 Main Road, Southold,New York, and Formation Concrete & General Construction Inc. (the"Contractor"),with an address of 4250 Veterans Memorial Hwy, Suite 304E,Holbrook,NY 11741; WITNESSETH, that the Town and the Contractor, for the consideration hereinafter named, agree as follows: ARTICLE 1. WORK TO BE DONE AND CONSIDERATION THEREFOR The Contractor shall install a concrete slab and footings for the Pavilion Project at Tasker Park for the Human Resource Center Freezer Pad located at Peconic Lane and Carroll Avenue in Peconic, NY as set forth in the Contractor Proposal Dated May 28, 2021 and the specifications of AMMTec Consultants PLLC dated April 7,2021 attached herewith as Exhibit A. The Contractor will furnish all labor, materials, supplies, equipment and other similar items necessary or proper for, or incidental to, the work contemplated by this Contract, as required by, and in strict accordance with the above drawings, and in strict accordance with such changes as are ordered and approved pursuant to this Contract. ARTICLE 2. TIME OF COMPLETION The services to be rendered under this Contract shall be completed no later than thirty (30) days from the date the contract is signed by all parties. Time of performance is of the essence of this Agreement. ARTICLE 3. ACCEPTANCE AND FINAL PAYMENT Upon receipt of written notice that the Contract has been fully performed and an inspection by the Town Engineer to certify that the work has been completed to the satisfaction of the Town, the Contractor shall file with the Town Comptroller an itemized voucher and the Town will pay the Contractor $30,531.00. Payments will be made on the basis of the actual work completed in accordance with the Contract. Contractor will be paid the total Contract amount after the project is completed and there will be no partial payments. The Town shall pay the Contractor upon the submission of a voucher at the conclusion of the contemplated project. Such voucher shall be due and payable within 45 days after receipt of such voucher, but such sum shall not be due and payable by the Town until the Town Board of the Town has received such a voucher and has audited and approved for payment the voucher to be submitted by Contractor in connection therewith. The Town Board shall process any voucher received from Contractor as expeditiously as possible. In the event that the Town disputes or objects to any portion of any voucher submitted by Contractor pursuant to this paragraph, the Town shall, within 30 days of the receipt of such voucher, notify Contractor in writing of such dispute or objection. Contractor acknowledges that Contractor is familiar with the requirements of section 118 of the Town Law which, in effect, prohibit payment of any of Contractor's claims against the Town unless an itemized voucher therefore shall have been presented to the Town Board or,Town Comptroller and shall have been audited and allowed by the Town Board or Town Comptroller. The acceptance by the Contractor of the final payment shall be, and shall operate as a release to the Town from all claims and all liabilities to the Contractor for all the things done or furnished in connection with this work and for every act and neglect of the Town and others relating to or arising out of, this Contract, except Contractor's claims for interest upon the final payment, if this payment be improperly delayed. No payment, however final or otherwise, shall operate to release the Contractor or its sureties from any obligations under this Contract. ARTICLE 4. CHANGES TO THE CONTRACT AND EXTRA WORK (a) The Town may at times, without notice to the Contractor's surety and without invalidating the Contract, order extra work or make changes by altering, adding to, or deducting from the work contemplated herein and may adjust the Contract price accordingly, pursuant to Paragraph (b) below. The Contractor shall not deviate from, add to, delete from, or make changes in the Work required to be performed hereunder unless so directed by a written Change Order. If the Contractor is directed by the Town to perform extra work prior to an agreement on costs or time, the Contractor shall promptly comply with the Change Order of the Town. No claim for extra work or any change in the work shall be allowed or made unless such extra work or change is ordered by a written Change Order from the Town. (b) The amount of compensation to be paid to the Contractor for any extra work, as so ordered, shall be determined as follows: 1. By a lump sum mutually agreed upon by the Town and the Contractor; or 2. Using the applicable price or prices within the Contract and/or Bid and approved by the Town and the Contractor. (c) Regardless of the method used by the Town in determining the value of a Change Order, the Contractor shall submit to the Town a detailed payment breakdown of the Contractor's estimate of the value of the omitted or extra work. (d) Unless otherwise specifically provided for in a Change Order, the agreed compensation specified therein for extra work includes full payment for extra work covered thereby, and the Contractor waives all rights to any other compensation for such extra work, damage or expense, including claims for delay, damage or expense. (e) The Contractor shall and hereby agrees to produce any and all data the Town may request, including but not limited to, time sheets, certified payrolls, foreman's reports, daily reports, bills and vouchers of Subcontractors, receiving documents, freight and trucking receipts, etc. ♦ f (f) All change orders shall be processed, executed and approved in the following manner: (i) if the estimated cost of the extra work is less than $1,000 in the aggregate, a Change Order Form must be processed and executed by the Supervising Department Head; (ii) if the estimated cost of the extra work is greater than $1,000, then a Change Order Form must be executed by the Supervising Department Head and submitted to the Town Board for consideration and approval by resolution. The Contractor must submit a detailed explanation of why the Change Order is needed and must also be submitted to the Town Board prior to its approval. The Change Order must also be approved by the Town Comptroller and the Town Attorney. Once this procedure is completed,the Contractor may proceed with the extra work. The Town will not accept any alteration to this form and no payment for Extra Work shall be due the Contractor unless it executes a Change Order on this Form. (g) If the Contractor claims that any work which the Contractor has been ordered to perform will be extra work, that the Contractor for any reason cannot comply with the terms and provisions of the Contract, or that any action or omission of the Town is contrary to the terms and provisions of the Contract and will require the Contractor to perform extra work,the contractor shall: 1. Promptly comply with the Town's direction to perform the work which the contractor claims will be extra work; and 2. Proceed diligently, pending and subsequent to the determination of the Town with respect to any said disputed matter, with the performance of the work in accordance with all the instructions of the Town. (h) No claim for extra work shall be allowed unless it was performed pursuant to change order duly approved by the Town Board. The Contractor's failure to comply with any part of this provision shall be deemed to be: 1. A conclusive and binding determination on the part of the Contractor that said change order, work, action or omission does not involve extra work and is not contrary to the terms and provisions of the Contract, and 2. A waiver by the Contractor of all claims for additional compensation, time or damages as a result of said change work, act or omission. (i) The value of claims for extra work, if allowed shall be determined methods described in the Contract including, but not limited to, section (b) immediately above. ARTICLE 5: CONTRACTOR'S OBLIGATIONS (a) The Contractor shall be responsible for the full and correct performance of the Work required by this Contract within the time specified herein, including work of the 1. 1 Contractor's Subcontractors, and any errors therein shall be corrected at the Contractor's own cost and expense. In addition, the Contractor shall indemnify the Town for any costs or expenses attributable to errors in performance by the Contractor or the Contractor's Subcontractors. (b) The Contractor agrees that the Contractor shall protect and shall be solely responsible for all labor and material provided for under this contract, whether or not the same may be erected in place, and for all its plans,tools, equipment, materials, tools of the Contractor's employees and agents, etc. for all adjoining private and public property, and all existing Work on the Project Site, which may be damaged by the Contractor's Work. In no event shall the Town be liable to the Contractor for loss of, pilferage, or damage to any of the same. In the event of,said labor and materials, plant, tools or equipment, etc., are damaged, lost or destroyed by reason of fire, theft (irrespective of the negligence of the parties hereto or others), civil commotion, riot, insurrection, violence, war, acts of God, etc., the Contractor's responsibility therefore shall be absolute, and the Contractor shall replace, repair, rebuild, and make good any and all said damage or loss of any and all kinds whatsoever. (c) Contractor shall be responsible for securing all permits required to perform the Work and/or required by the applicable laws, regulations, ordinances, etc., and maintain the validity of all such permits throughout the contract duration, if any. ARTICLE 6. CONTRACTOR'S INSURANCE The Contractor shall not commence work under this Contract until it has obtained all insurance required under this paragraph and such insurance has been approved by the Town. (a) Compensation Insurance: The Contractor shall take out and maintain during the life of this Contract Workers' Compensation Insurance for its employees to be assigned to the work hereunder. (b) Insurance: The Contractor shall take out and maintain during the life of this Contract such general liability, property damage, and commercial auto liability insurance as shall protect it from claims for damages for personal injury, including accidental death, as well as from claims for property damage which may arise from operations under this Contract. The amounts of such insurance shall be as follows: General liability insurance in an amount not less than $1,000,000 for injuries, including wrongful death to any one person and subject to the same limit for each person, in an amount not less than $2,000,000 on account of any one occurrence. Property damage insurance in an amount not less than $300,000 for damage on account of all occurrences. Commercial auto liability insurance in an amount not less than $500,000 for damage on account of all occurrences. r The Contractor shall furnish the above insurances to the Town and shall also name the Town as an additional named insured in said policies. (c) Any accident shall be reported to the office of the Town Clerk as soon as possible and not later than twenty-four (24) hours from the time of such accident. A detailed written report must be submitted to the Town as soon thereafter as possible and not later than three(3) days after the date of such accident. ARTICLE 7. REPRESENTATIONS OF CONTRACTOR The Contractor represents and warrants: (a) That it is financially solvent and that it is experienced in and competent to perform the type of work to be furnished by it; and (b) That it is familiar with all federal, state, municipal and department laws, ordinances and regulations which may in any way affect the work or those employed therein. ARTICLE 8. PERMITS AND REGULATIONS The Contractor shall comply with all permits issued to the Town in connection with the services furnished under this Agreement. ARTICLE 9. NO DAMAGES FOR DELAY The contractor agrees to make no claim for increased costs, charges, expenses or damages for delay in the performance of this Contract, or for any delays or hindrances from any cause whatsoever, and agrees that any such claim shall be fully compensated for by an extension in the time for substantial and/or final completion of the work. Should the Contractor be or anticipate being delayed or disputed in performing the work hereunder for any reason, it shall promptly, and in no even more than two (2) business days after the commencement of any condition which is causing or threatening to cause such a delay or disruption, notify the Town in writing of the effect of such condition stating why and in what respects the condition is causing or threatening to cause such delay or disruption. Failure strictly to comply with this notice requirement shall be sufficient cause to deny Contractor a change in Schedule and to require it to conform to the Schedule then in effect. ARTICLE 10. TOWN'S RIGHT TO STOP WORK OR TERMINATE CONTRACT The Town shall have the right to stop work or terminate the Contract if: (a) The Contractor is adjudged bankrupt or makes an assignment for the benefit of creditors; or (b) A receiver or liquidator is appointed for the Contractor or for any of its property and is not dismissed within 20 days after such appointment or the proceedings in connection therewith are not stayed on appeal within the said 20 days; or (c) The Contractor refuses or fails to prosecute the work or any part thereof with due diligence; or (d) The Contractor fails to make prompt payment to persons supplying labor for the work; or (e) The Contractor fails or refuses to comply with all applicable laws or ordinances; or (f) The Contractor is guilty of a substantial violation of any provision of this Contract; (g) The Town's execution and participation in this contract is found to be in violation of an existing collective bargaining agreement. (h) In any event, the Town, without prejudice to any other rights or remedy it may have, may, with our without cause, by seven (7) days' notice to the Contractor, terminate the employment of the Contractor and its right to proceed as to the work. In such case, the Contractor shall not be entitled to receive any further payment beyond what owed in quantum meruit. ARTICLE 11. DAMAGES It is hereby mutually covenanted and agreed that the relation of the Contractor to the work to be performed by it under this Contract shall be that of an independent contractor. As an independent contractor, it will be responsible for all damage, loss or injury to persons or property that may arise in or be incurred during the conduct and progress of said work, whether or not the Contractor, its agents, or employees have been negligent. The Contractor shall hold and keep the Town free and discharged of and from any and all responsibility and liability of any sort or kind. The Contractor shall assume all responsibility for risks or casualties,of every description, for loss or injury to persons or property arising out of the nature of the work, from the action of the elements, or from any unforeseen or unusual difficulty. The Contractor shall make good any damages that may occur in consequence of the work or any part of it. The Contractor shall assume all blame, loss and responsibility of any nature by reason of neglect or violation of any federal, state, county or local laws, regulations or ordinances. ARTICLE 12. INDEMNITY AND SAVE HARMLESS AGREEMENT The Contractor agrees to indemnify and save the Town, its officers, agents and employees harmless from any liability imposed upon the Town, its officers, agents and/or employees arising from the negligence, active or passive, of the Contractor and from and against any damages, claims, or expenses, including reasonable attorney's fees, arising out of Contractor's breach of the Agreement or from Contractor's acts or omissions outside the scope of the Agreement or arising out of claims or actions by third parties against Contractor by virtue of its performance of this Agreement. ARTICLE 13. NO ASSIGNMENT In accordance with the provisions of section 109 of the General Municipal Law, the Contractor is hereby prohibited from assigning,transferring, conveying, subletting or otherwise disposing of this Agreement, or of its right, title or interest in this Agreement, or its power to execute this Agreement, to any other person or corporation without the previous consent in writing of the Town. ARTICLE 14. REQUIRED PROVISIONS OF LAW Each and every provision of law and clause required by law to be inserted in this Contract shall be deemed to have been inserted herein. If any such provision is not inserted, through mistake or otherwise, then upon the application of either party, this Contract shall be physically amended forthwith to make such insertion. In particular,the Contractor shall, among other things, fully comply with: (a) Labor Law section 220-e and Executive Law sections 291-299 and the Civil Rights Law relating to prohibition against discrimination and providing equal opportunity. (b) Affirmative action as required by the Labor Law. (c) Prevention of dust hazard required by Labor Law section 222-a. (d) Preference in employment of persons required by Labor Law section 222. (e) Eight-hour workday as required by Labor Law section 220(2). ARTICLE 15. PREVAILING WAGE RATES REQUIRED BY LAW (a) The parties hereto, in accordance with the provisions of section 220(3) of the Labor Law, if applicable, hereby agree that there shall be paid each employee engaged in work under this Contract not less than the wage rate and supplements set opposite the trade or occupation in which he/she is engaged, which are the wage rates and supplements established as the prevailing rate of wages for the work covered by this Contract. (b) Labor classifications not appearing on the schedule of wages can be used only with the consent of the Owner and then the rate to be paid will be given by the Owner after being advised by the Department of Labor. (c) The Contractor shall post in a prominent and accessible place on the site of the work a legible statement of all wage rates and supplements, as specified in the Contract, for the various classes of mechanics,workingmen/women, or laborers employed on the work. ARTICLE 16. AUTHORITY FOR EXECUTION ON BEHALF OF THE TOWN The Supervisor has executed this Agreement pursuant to Resolution No. 2021-448 adopted by the Town Board of the Town 'of Southold, at a meeting thereof held on June 1, 2021. Scott A. Russell, Supervisor, whose signature appears hereafter, is duly authorized and empowered to execute this instrument and enter into such an Agreement on behalf of the Town. This instrument shall be executed in duplicate. At least one copy shall be permanently filed, after execution thereof, in the office of the Town Clerk, Elizabeth Neville. ARTICLE 17. NOTICES Any and all notices and payments required hereunder shall be addressed as follows, or to such other address as may hereafter be designated in writing by either party hereto: To Town: Elizabeth A.Neville, RMC, CMC Southold Town Clerk P.O.Box 1179 Southold,NY 11971-0959 With Copy To: Michael Collins, Town Engineer P.O. Box 1179 Southold,NY 11971-0959 To Contractor: Formation Concrete & General Construction Inc. 4250 Veterans Memorial Hwy Suite 304E Holbrook,NY 11741 ARTICLE 18. WAIVER No waiver of any breach of any condition of the Agreement shall be binding unless in writing and signed by the party waiving said breach. No such waiver shall in any way affect any other term or condition of this Agreement or constitute a cause or excuse for a repetition of such or any other breach unless the waiver shall include the same. ARTICLE 19. MODIFICATION This Agreement constitutes the complete understanding of the parties. No modification of any provisions thereof shall be valid unless in writing and signed by both parties. ARTICLE 20. APPLICABLE LAW This Agreement is governed by the laws of the State of New York. IN WITNESS WHEREOF, the Town of Southold has caused these presents to be signed by Scott A. Russell, its Supervisor, duly authorized to do so, and the Contractor has caused these presents to be signed by its President, the day and year first above written. Formation Concrete& General Constructio c. Town of Southo By: / By: uQ S'./y (Name) a- i Title Scott A.Russell, Supervisor STATE OF NEW YORK) ) ss.. COUNTY OF SUFFOLK) On this day of June in the year 2021 before me,the undersigned, personally appeared „5 N• i ' (Name)the h (title) and authorized agent of Formation Concrete& General Construction Inc., personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity and that by his signature on the instrument,the individual or the person upon whose behalf of which the individual acted, executed the instrument. Notary Public Mehta STATE OF NEW YORK) Notary Publ of New Yak No.01ME8231302 ss.: Qualifies in Suffolk County COUNTY OF SUFFOLK) Commission Exp m November 11,20:2Z On thisa day of June in the year 2021 before me, the undersigned, personally appeared SCOTT A.RUSSELL, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity and that by his signature on the instrument,the individual or the person upon whose behalf of which the individual acted, executed the instrument. r'7pLu/2 -M- jure D h Notary Public LAUREN M.STANDISH Notary Public-State of New York No.01 ST6164008 Qualified in Suffolk County Commission Expires April 9,2023 Exhibit A CONCRETE&GENERAL CONSTRUCTION,INC. PROPOSAL ATTN: Michael Collins LOCATION: Tasker Park-Peconic Lane& Carroll Avenue TO: Town of Southold Peconic, NY DATE: 5/28/2021 We propose to furnish all materials, equipment, and labor,subject to any exclusions listed below, required to complete the following: Our proposal is based on the following: American Recreational Sketches#4,5, 6, 12,all dated 4/11/2021 1. Scope of work $30,531.00 Description of Services: strip grass/dirt down approx. 10", load up to 42 cy of grass/dirt onto Town trucks for removal to town dump,excavate for 6 column footings, load town trucks with up to 3%cy of excess dirt for removal by town to the town dump, level slab on ground grade and furnish/spread/compact 6"thick of New York State DOT approved RCA, under the area covered by the 4"thick concrete slab on ground, install 6 concrete footings, per sketch#12, furnish/install up to 1,225 sf of 4"thick concrete slab on ground. Per instructions,but not shown on the sketches,we will provide 4—%"X 12"smooth dowels on each of the 6 concrete piers into the new slab on ground. We also assume that the owner will provide survey off-set stakes for each of the four corners of the slab on ground. We include one layer of 66-44 wire mesh in the new slab on ground. Finish of slab to be a light broom finish. Floor tolerance to be FF25/FL20. All concrete to be 4,000 PSI air entrained. Total Proposal Value: $30,531.00 Formation Concrete &General Construction Inc. •4250 Veterans Memorial Hwy,Suite 304E • Holbrook, NY 11741 Phone: 631-689-6809 Opt. 1- Email: infogformconst.com 1. Owner/contractor to provide protected access to all parts of the work areas. 2. We do not include any sales/use taxes or allowances (if any). 3. All work to be done during regular working hours. 4. We do not include any street barricades,traffic control or pedestrian control. 5. We do not include any final sealers as the Ashford Formula,Seal Hard,epoxy coatings, polished concrete, painted surfaces, colored/tinted concrete or similar applied applications. WE DO NOT INCLUDE ANY OF THE FOLLOWING: surveys/stake-out,testing/inspection of any work, winter concrete/winter protection/snow removal/frost removal, hot weather concrete/hot weather protection, protection of concrete from damage by others, or damage by the weather,set only of miscellaneous items to be embedded in the concrete as anchor bolts, plates, (WE DO INCLUDE TO SET THOSE ITEMS PROVIDED BY OTHERS),joint sealers/caulking,demolition/cutting/patching of any existing work, repair/fill any cracks in concrete (as we cannot anticipate same), provide or remove containers for concrete spoils, and truck wash-outs(contractor to provide an area for concrete truck wash-out,and spoils), pump/dewater any water condition,fences/fence post bases. Please do not hesitate to contact us with any questions that you may have. We also would welcome the opportunity to meet with you to go over a "scope of work"to be sure that we included all the items that you may require. Thank you,for your consideration of our firm for your requirements. Contractor: Sw'"-f?yZiFald 5/28/2021 Formation Concrete&General Construction Inc. Date ACCEPTANCE OF PROPOSAL: The above prices,scope,specifications and conditions are satisfactory and hereby accepted. You are authorized to do the work specified. ACCEPTED BY: Formation Concrete&General Construction Inc. •4250 Veterans Memorial Hwy,Suite 304E • Holbrook, NY 11741 Phone: 631-689-6809 Opt. 1• Email: infogformconst.com { DATE(MM/DD/YYYY) Ammo CERTIFICATE OF LIABILITY INSURANCE 06/18/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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 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 endorsement(s). PRODUCER CONTACT Kristin North-Hughes Cotgreave Insurance Agency,Inc PHONE N o.Ext (631)981-5400 FAX No: (631)981-5448 558 Portion Rd ADDRESS khughes@get-Insured com INSURER(S)AFFORDING COVERAGE NAIC# Ronkonkoma NY 11779 INSURERA: Ohio Security Ins Co 24082 INSURED INSURER B: West American Ins Co 44393 Formation Concrete&General Construction Inc INSURER C: The Ohio Casualty Ins Co 24074 4250 Veterans Memorial Hwy INSURER D: Ste 304e INSURER E. Holbrook NY 11741 INSURER F COVERAGES CERTIFICATE NUMBER: 20-21 Master REVISION NUMBER: THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 AVUL SUUK POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD MM/DD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTE15- CLAIMS-MADE �OCCUR PREMISES Ea occurrence $ 300,000 X Contractual Liability MED EXP(Any one person) $ 15,000 A BKS56376957 10/24/2020 10/24/2021 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER 2,000,000 GENERALAGGREGATE $ POLICY❑X JEa LOC �11 ODUCTS-COMP/OPAGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANYAUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED BAW56376957 10/24/2020 10/24/2021 BODILY INJURY(Per accident) $ AUTOS ONLYAUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 C EXCESS LIAR Hx CLAIMS-MADE ES056376957 10/24/2020 10/24/2021 AGGREGATE $ 5,000,000 DED I X RETENTION$ 10,000 $ WORKERS COMPENSATION X PEROTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER A ANY PROPRIETOR/PARTNEWEXECUTIVE EL EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? NIA XWS56376957 10/24/2020 10/24/2021 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY OMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Town of Southold Is included as additional insured subject to policy terms and conditions CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Main Road AUTHORIZED REPRESENTATIVE Southold NY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD •T YoRK Workers' CERTIFICATE OF STATE Compensation NYS WORKERS' COMPENSATION INSURANCE COVERAGE Board 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured Formation Concrete&General Construction Inc. (631)689-6809 4250 Veterans Memorial Highway Suite 304E 1c.NYS Unemployment Insurance Employer Registration Number of Insured Holbrook,NY 11741 Work Location of Insured(Only required if coverage is specifically limited to certain 1d.Federal Employer Identification Number of Insured or Social Security locations in New York State,i.e,a Wrap-Up Policy) Number 2.Name and Address of Entity Requesting Proof of Coverage(Entity 3a Name of Insurance Carrier Being Listed as the Certificate Holder) Ohio Security Ins Co 3b.Policy Number of Entity Listed in Box"1 a" Town of Southold XWS56376957 53095 Main Road Southold,NY 11971 3c.Policy effective period 10/24/2020-10/24/2021 3d.The Proprietor,Partners or Executive Officers are ❑ included.(Only check box if all partners/officers Included) ❑ all excluded or certain partners/officers excluded. This certifies that the Insurance carrier indicated above in box°3"insures the business referenced above in box"1 a"for workers' compensation under the New York State Workers'Compensation Law. (To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or Its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate.(These notices may be sent by regular mail.) Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. This certificate is Issued as a matter of Information only and confers no rights upon the certificate holder.This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy. This certificate may be used as evidence of a Workers'Compensation contract of insurance only while the underlying policy is in effect. Please Note:Upon cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers'Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. - Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: William Cotgreave (Print name of authonzed representative or licensed agent of insurance Amer) Approved by: 06/18/2021 (Signature) (Date) Title: Licensed Agent Telephone Number of authorized representative or licensed agent of insurance carrier: (631)981-5400 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2 (9-17) www.wcb.ny.gov Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-17) REVERSE ' r YERKworkers' e Compensation CERTIFICATE OF INSURANCE COVERAGE r Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier la Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured FORMATION CONCRETE&GENERAL CONSTRUCTION INC. 4250 VETERANS MEMORIAL HIGHWAY,SUITE 304E 6318752187 HOLBROOK,NY 11741 Work Location of Insured(Only required if coverage is specifically limited to 1 c.Federal Employer Identification Number of Insured certain locations in New York State,i e,Wrap-Up Policy) or Social Security Number 46-5200951 2 Name and Address of Entity Requesting Proof of Coverage 3a Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) Town of Southold Standard Security Life Insurance Company of New York 53095 Main Road 3b.Policy Number of Entity Listed in Box"1a" Southold, NY 11971 70957-00 3c.Policy effective period 10/24/2014 to 6/17/2022 4. Policy provides the following benefits Q A Both disability and paid family leave benefits. B Disability benefits only. ❑ C Paid family leave benefits only 5. Policy covers. Q A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. D B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as desc d above. Date Signed 6/18/2021 By Q�t (Signature of insurance carrier's authornz d representative or NYS Licensed Insurance Agent of that insurance carrier) Telephone Number (212) 355-4141 Name and Title SUPERVISOR-DBL/POLICY SERVICES IMPORTANT If Boxes 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mail it directly to the certificate holder If Box 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220, Subd.8 of the NYS Disability and Paid Family Leave Benefits Law. It must be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton, NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board (only if Box 4C or 5B of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only Insurance carriers licensed to write NYS disability and paid family leave benefits Insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120 1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) IIIII IIIIIIIIIIIIIIIIIIIIIIIIIIkIIIIoIlii1ll1lili111�1� Additional Instructions for Form D13-120.1 By signing this form, the insurance carrier identified in Box 3 on this form is certifying that it is insuring the business referenced in box"1 a"for disability and/or paid family leave benefits under the New York State Disability and Paid Family Leave Benefits Law. The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed as the certificate holder in Box 2 The insurance carrier must notify the above certificate holder and the Workers'Compensation Board within 10 days IF a policy is cancelled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from coverage indicated on this Certificate. (These notices my be sent by regular mail.) Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in Box 3c, whichever is earlier This certificate is issued as a matter of information only and confers no rights upon the certificate holder This certificate does not amend, extend or alter the coverage afforded by the policy listed, nor does it confer any rights or responsibilities beyond those contained in the referenced policy This certificate may be used as evidence of a Disability and/or Paid Family Leave Benefits contract of insurance only while the underlying policy is in effect. Please Note: Upon the cancellation of the disability and/or paid family leave benefits policy indicated on this form, if the business continues to be named on a permit, license or contract issued by a certificate holder, the business must provide that certificate holder with a new Certificate of NYS Disability and/or Paid Family Leave Benefits Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Disability and Paid Family Leave Benefits Law. DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW §220. Subd. 8 (a) The head of a state or municipal department, board, commission or office authorized or required by law to issue any permit for or in connection with any work involving the employment of employees in employment as defined in this article, and not withstanding any general or special statute requiring or authorizing the issue of such permits, shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits and after January first,two thousand and twenty-one,the payment of family leave benefits for all employees has been secured as provided by this article Nothing herein, however, shall be construed as creating any liability on the part of such state or municipal department, board, commission or office to pay any disability benefits to any such employee if so employed. (b)The head of a state or municipal department, board, commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in employment as defined in this article and notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair, that the payment of disability benefits and after January first, two thousand eighteen, the payment of family leave benefits for all employees has been secured as provided by this article. 1313-120.1 (10-17)Reverse STANDARD INSURANCE REQUIREMENTS TOWN OF SOUTHOLD CONTRACT INSURANCE REQUIREMENTS INSURANCE IDENTIFICATION: THE BID NUMBER IS TO APPEAR ON ALL INSURANCE CERTIFICATES INDEPENDENT CONTRACTOR: The Corporation/Contractor/Agency/Consultant, is an independent contractor and covenants and agrees that.it, its agents, servants and/or employees will neither hold itself/themselves out as, nor claim to be an employee, servant or agent of the TOWN OF SOUTHOLD, and that it, its agents and employees will not make claim, demand or application to or for any right or privilege applicable to an officer or employee of the TOWN OF SOUTHOLD including, but not limited to Worker's Compensation coverage, Unemployment Insurance benefits, Social Security coverage or retirement membership or credit. INSURANCE: Contractor/vendor shall not commence work under this contract until he has obtained all insurance required under the following paragraphs, and the Town of Southold has approved such insurance. WORKERS' COMPENSATION: Contractor/vendor shall take out and maintain during the life of this contract, such insurance as will protect both the owner and the contractor from claims under worker's compensation acts and amendments thereto and from any other claims for property damage and for personal injury including death, which may arise from operations under this contract, whether such operations by contractor or by any other party directly or indirectly employed by the contractor. Copy of Certificate to be provided to the Town of Southold. DISABILITY INSURANCE & UNEMPLOYMENT INSURANCE: Contractor/vendor shall take out and maintain during the entire term of the contract any disability benefits and unemployment insurance as required by law. Copy of Certificate to be provided to the Town of Southold. GENERAL LIABILITY INSURANCE: The contractor/vendor shall take out and maintain during the life of the contract, such bodily injury liability and property damage liability insurance as shall protect him and the Town from claims for damages for bodily injury including accidental death, as well as from claims for property damage which may arise from operations under this contract,whether such operations be by himself or by any subcontractor or by anyone directly or indirectly employed by either of them. It shall be the responsibility of the contractor/vendor to maintain such insurance in amounts sufficient to fully protect himself and the Town, but in no instance shall amounts be less than those set forth below. These amounts are specified only to establish the minimum coverage acceptable. Bodily injury liability and property damage liability insurance in an amount not less than $1,000,000 (one million dollars) for damages on account of anyone accident, and in an amount of not less than$1,000,000 (one million dollars) on account of all accidents (general aggregate). EXCESS/UMBRELLA INSURANCE: The contractor/vendor shall take out and maintain during the life of the project an excess/umbrella insurance policy in an amount of not less than $2,000,000 (Two million dollars) each occurrence and aggregate. SIR- I STANDARD INSURANCE REQUIREMENTS OTHER CONDITIONS OF COMMERCIAL GENERAL LIABILITY INSURANCE: 1. Coverage shall be written on commercial general liability form. 2. Coverage shall include: A. Contractual liability B. Independent contractors C. Products and completed operations AUTOMOBILE LIABILITY INSURANCE: Automobile bodily injury liability and property damage liability insurance shall be provided by the contractor/vendor with a minimum combined single limit(CSL) of$1,000,000(one million dollars). OTHER CONDITIONS OF AUTOMOBILE LIABILITY INSURANCE: 1. Coverage shall include: A. All owned vehicles B. Hired car and non-ownership liability coverage C. Statutory no-fault coverage OWNERS & CONTRACTORS PROTECTIVE LIABILITY: An OCP Policy shall be required by the Town of Southold in limits of $1,000,000 combined single limit, each occurrence, $1,000,000 General Aggregate. This insurance must fully cover the legal liability of the specific farm owner, as Owner, NAMING THE FARM OWNER AND TOWN OF SOUTHOLD AS INSURED. The contractor shall furnish the Town with the original insurance policy. ADDITIONAL CONDITIONS OF INSURANCE: 1. Contractor/vendor shall submit copies of any or all required insurance policies as and when requested by the Town. 2. If any of the contractor's/vendor's policies of insurance are cancelled or not renewed during the life of the contract, immediate notice of cancellation of non-renewal shall be delivered to the Town no less than 10 days prior to the date and time of cancellation or non-renewal. CERTIFICATE OF INSURANCE: The contractor/vendor shall.file with the Town of Southold prior to commencing work under this contract, a certificate of'insurance. 1. Certificate of insurance shall include: A. Name and address of insured B. Issue date of certificate C. Insurance company name D. Type of coverage in effect E. Policy number F. Inception and expiration dates of policies included G. Limits of liability for all policies on certificate. included on certificate SIR- 2 STANDARD INSURANCE REQUIREMENTS 'Description:of,opetations/locations/etc.Box musfiriclude,the statement: ,,.. . _ "THE TOWN I F,SOUTHOLD.-IS,LISTED:A`S ADDITIONAL INSURED" CERTIFICATE-HOL-DER'SHALL bE LISTED AS: TOWN'OF'SOUTiHOI;D ,53095,=MAIN20AD; SQUTHOLD NY,-T 7 2. If the contractor's/vendor's insurance policies should be non-renewed, cancelled or expire during the life of the contact, the Town shall be provided with a new certificate indicating the replacement policy information as requested above. Thirty days (30) prior written notice to the Town of Southold for cancellation is applicable. SIR- 3