HomeMy WebLinkAboutKJB Industries
RESOLUTION 2007-767
ADOPTED
DOC ill: 3196
THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2007-767 WAS
ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON
SEPTEMBER 25,2007:
RESOLVED that the Town Board of the Town of Southold hereby authorizes aud directs
Supervisor Scott A. Russell to execute the Contractual Al!reement between the Town of
Southold and KJB Industries. Inc. in connection with the construction of a concrete slab
for the processinl! of C&D debris at the Cutchol!ue Transfer Station, subject to the approval
of the Town Attorney.
!'~..J.r;fa~- /11..
Elizabeth A. Neville
Southold Town Clerk
RESULT: ADOPTED [UNANIMOUS]
MOVER: William P. Edwards, Councilman
SECONDER: Albert Krupski Jr., Councilman
AYES: Krupski Jr., Edwards, Ross, Wickham, Evans, Russell
TOWN OF SOUTHOLD
Contractual Agreement
THIS AGREEMENT made this 21st day of September 2007 between the Town of
Southold, a municipal corporation of the State of New York, having its office and principal
place of business at 53095 Main Road, Southold, New York 11971 hereinafter called the
"Town" and KJB Industries, 14 Central Drive, Riverhead, NY 11901, herein
after called the "Contractor".
WHEREAS, the Town of Southo1d desires to engage the contractor to render certain
professional services herein described in connection with an undertaking.
NOW, therefore, the parties hereto mutually agree as follows:
1. The Contractor does hereby agree to perform all the work outlined in the
"Invitation to Bid And Specifications - For Construction of a Concrete Processing Slab" at
the Southo1d Town Solid Waste Transfer Station, Cox's Lane, Cutchogue, dated
July 13, 2007 as amended by letter to Mr. Jim Bunchuck dated August 22, 2007, each
annexed hereto and made part of this contract (Exhibit A).
2. The Town does hereby agree to pay the Contractor for the work, the total sum of
Thirty nine thousand one hundred eighty seven dollars ($39,187). The total sum
Is to be paid to the Contractor within forty-five (45) days of the completion ofthe
said work and the acceptance thereofby the Town.
3. The Contractor shall secure and maintain such insurance that will protect him/her
from claims under the Worker's Compensation Acts and from claims for bodily
injury, death or property damage that may arise from the performance of his /her
services under this Agreement, in limits of$I,OOO,OOO. and $2,000,000. aggregate
liability for bodily injury and property damage. The Contractor shall indemnify
and hold harmless the Town from and against all suits, claims, demands or actions
for any injury sustained or alleged to be sustained by any party or parties in
connection with the alleged negligent performance or negligent perfoIDlance by the
Contractor, his employees or agents or any subcontractor and in case of any such
action brought against the Town, the Contractor shall immediately take charge of and
defend the same at his own cost and expense. In addition, the Contractor will name
the Town as an additional insured on any applicable policies.
IN WITNESS WHEREOF, the parties hereto have set their hands and seals the day and
year first above written.
Towo "':2
By ~~
Scott A. Russell, Supervisor
:BI~t ~
Patricia Panchak
EXHIBIT 'A'
TOWN OF SOUTHOlD SOUD WASTE MANAGEMENT DISTRICT
INVITATION TO BID
AND SPECIFICATIONS
FOR
CONSTRUCTION OF A CONCRETE PROCESSING SlAB
A Public Works Project at the Southold Town Solid Waste Transfer Station
Co~slane.Cutchogue
Issued luh/ 13. 2001
Town of Southold Solid Waste Management District
Specifications for a CONCRETE SLAB
7/13/2007
Plof6
SOUTHOLD TOWN SOLID WASTE MANAGEMENT DISTRICT
SPECIFICATIONS FOR:
CONCRETE SLAB
I GENERAL DESCRIPTION
The Town of Southold Solid Waste Management District seeks bids for the construction of a
PQured outdoor reinforced concrete slab at the Cutchogue Transfer Station on Cox's Lane,
Cutchogue. The slab will be constructed on an existing surface of recycled concrete aggregate
(ReA) I foot thick. The slab must be capable of supporting the processing and/or crushing of
waste construction and demolition (C&D) debris through use ofa Caterpillar 816-B steel/spike
wheeled landfill compactor.
II SPECIFIC FEATURES
Specific features required for the slab are as shown on the attached drawing on page 2
of this specification, titled "Construction & Demolition Slab for Southold Landfill".
The slab is to be 50 ft x 75 ft in size, with a minimum thickness of 8", with the mix,
reinforcement, and additional dimensions as described on the attached.
ill CONTRACT CONDITIONS
Notwithstanding other provisions required under Federal and/or State Contract and
Labor law, all bidders agree herein to be bound by the attached General Conditions and
Contract Clauses, including applicable affirmative action and prevailing wage
requirements. Upon award of this bid by the Town Board of the Town of South old,
these conditions, together with the construction specifications, form the base contract
between the successful bidder and the Town of Southold.
IV PREVAILING WAGE REQUIREMENTS
The work described herein is an ARTICLE 8 PUBLIC WORK PROJECT under New
York State law, and is subject to New York State prevailing wage requirements.
The PREVAILING RATE SCHEDULE applicable to this project is attached. It is the
contractor's responsibility to apply these rates as appropriate, and to supply the Town
with a CERTIFIED PAYROLL to this effect (use payroll certification form attached to
Prevailing Rate Schedule).
- ,
Town of Southold Solid Waste Management District
Specifications for a CONCRETE SLAB
7/1312007
Page 2 of6
3
n;
0
::1
IT
III
0 1;,\
IT
..
n
0It..j III !ifli
::1
w..... !::I
.....8 tll
I (1)
-.Jtll m,
w~ 'tl !j
""::1 0
'I. 0 . ~ I~i '
,-.Ji:l' 11
,01 ~ (1) ~I
Cll 0, 0.
VI :<",
..... 01,/ ;~
::1 \J
---" en tiiJ5! en
(1) i n
0' ~~
rt en ~
~, i ~~ "r1 en
::s ~ 6!
ell ::oi llj
- en c::
i$I en n
0 ~
~' Sj 0
:J: z
. 0 tlo
~ 6 'il'
V1 i
'. ~
i,'j I:"'
0 H
!! ~
,.... H
,.... 0
Z
~
1"r1
(~
IS
~J
LJ
:YI
/
Town of Southold Solid Waste MaL)ment District
Specifications for a CONCRETE SLAB
7/13/2007
. I
- _ J of6
V BID PROPOSAL
Contractor's bid price for construction of a Concrete Slab as described in these
specifications (BIDS SUBMITTED MAY NOT BE CHANGED OR WITHDRAWN
FOR A PERIOD OF 30 DAYS).
AMOUNT - Written in Numbers:
AMOUNT - Written in Words:
Name of )(10 I
Bidder (print): , I ...;-p()
p;e~ iJtt
A) u t7L k ;4-#
:/"J C-.,
Bidder's
Address: I
Signature:
~~.$/--
~5.
Title:
Date:
7/
/07
I
" )
,
p. 4 of 6
NON-COLLUSIVE BID CERTIFICATE
The undersigned bidder certifies that this bid has been arrived at by the bidder independently and
has been submitted without collusion with any other vendor of materials, supplies or equipment
ofthe type described in the invitation for bids, and the contents of this bid have not been
communicated by the bidder, nor, to its best knowledge and belief, by any of its employees or
agents, to any person not an employee or agent of the bidder or its surety on any bond furnished
herewith prior to the official opening of the bid.
Signed:
Print :;::::?W'C-I ~
4-~M0~~
Corporate Title ~
(if any) ~~
ArE
Company Name
Mailing Address
;t/ffJ .
ILl C4t'/C
jfJ '0 t',(~ IfkJ
flit
.,7;</C
Phone Number
7d}-S000
BID ON Concrete Slab for SWTS
Town of South old Solid Waste Management District
Specifications for a CONCRETE SLAB
7/13/2007
P 5 of6
STANDARD CLAUSES FOR NYS CONTRACTS
The parties to the attached contract, license, lease, amendment or other agreement of any kind (hereinafter, lithe
contract" or "this contract") agree to be bound by the following clauses which are hereby made a part of the contract
(the word "Contractor" herein refers to any party other than the Town of Southold, whether a contractor, licenser,
licensee, lessor, lessee or any other party):
1. EXECUTORY CLAUSE. In accordance with Section 41 of the State Finance Law, the State shall have no liability
under this contract to the Contractor or to anyone else beyond funds appropriated and available for this contract.
2. WORKERS' COMPENSATION BENEFITS. In accordance with Section 142 of the State Finance Law, this
contract shall be void and of no force and effect unless the Contractor shall provide and maintain coverage during the
life of this contract for the benefit of such employees as are required to be covered by the provisions of the Workers'
Compensation Law.
3. NON-DISCRIMINATION REOUIREMENTS. To the extent required by Article 15 of the Executive Law (also
known as the Human Rights Law) and all other State and Federal statutory and constitutional non-discrimination
provisions, the Contractor will not discriminate against any employee or applicant for employment because of race,
creed, color, sex, national origin, sexual orientation, age, disability, genetic predisposition or carrier status, or marital
status. Furthermore, in accordance with Section 220-e of the Labor Law, if this is a contract for the construction,
alteration or repair of any public building or public work or for the manufacture, sale or distribution of materials,
equipment or supplies, and to the extent that this contract shall be performed within the State of New York, Contractor
agrees that neither it nor its subcontractors shall, by reason of race, creed, color, disability, sex, or national origin: (a)
discriminate in hiring against any New York State citizen who is qualified and available to perform the work; or (b)
discriminate against or intimidate any employee hired for the performance of work under this contract. If this is a
building service contract as defined in Section 230 of the Labor Law, then, in accordance with Section 239 thereof,
Contractor agrees that neither it nor its subcontractors shall by reason of race, creed, color, national origin, age, sex or
disability: (a) discriminate in hiring against any New York State citizen who is qualified and available to perfonn the
work; or (b) discriminate against or intimidate any employee hired for the performance of work under this contract.
Contractor is subject to fines of$50.00 per person per day for any violation of Section 220-e or Section 239 as well as
possible termination of this contract and forfeiture of all moneys due hereunder for a second or subsequent violation.
4. WAGE AND HOURS PROVISIONS. If this is a public work contract covered by Article 8 of the Labor Law or a
building service contract covered by Article 9 thereof, neither Contractor's employees nor the employees of its
subcontractors may be required or permitted to work more than the number of hours or days stated in said statutes,
excep; as otherwise provided in the Labor Law and as set forth in prevailing wage and supplement schedules issued by
the State Labor Department. Furthennore, Contractor and its subcontractors must pay at least the prevailing wage rate
and payor provide the prevailing supplements, including the premium rates for overtime pay, as determined by the
State Labor Department in accordance with the Labor Law.
S. NON-COLLUSIVE BIDDING CERTIFICATION. In accordance with Section 139-d of the State Finance Law, if
this contract was awarded based upon the submission of bids, Contractor affirms, under penalty of perjury, that its bid
was arrived at independently and without collusion aimed at restricting competition. Contractor further affirms that, at
the time Contractor submitted its bid, an authorized and responsible person executed and delivered to the State a non-
collusive bidding certification on Contractor's behalf.
6. RE'CORDS. The Contractor shall establish and maintain complete and accurate books, records, documents, accounts
and other evidence directly pertinent to performance under this contract (hereinafter, collectively, "the Records"). The
Records must be kept for the balance of the calendar year in which they were made and for six (6) additional years
thereafter. The State Comptroller, the Attorney General and any other person or entity authorized to conduct an
examination, as well as the agency or agencies involved in this contract, shall have access to the Records during normal
business hours at an office of the Contractor
within the State of New York or, ifno such office is available, at a mutually agreeable and reasonable venue within the
State, for the term specified above for the purposes of inspection, auditing and copying. The State shall take reasonable
steps to protect from public disclosure any of the Records which are exempt from disclosure under Section 87 of the
Public Officers Law (the "Statute") provided that: (i) the Contractor shall timely inform an appropriate State official, in
writing, that said records should not be disclosed; and (ii) said records shall be sufficiently identified; and (iii)
desigEation of said records as exempt under the Statute is reasonable. Nothing contained herein shall diminish, or in
any way adversely affect, the State's right to discovery in any pending or future litigation.
'.
Town of Sonthold Solid Waste Management District
Specifications for a CONCRETE SLAB
7/13/2007
P 6 of6
7. EOUAL EMPLOYMENT OPPORTUNITIES FOR MINORITIES AND WOMEN. In accordance with Section
312 of the Executive Law, if this contract is: (i) a written agreement or purchase order instrument, providing for a total
expenditure in excess of $25,000.00, whereby a contracting agency is conunitted to expend or does expend funds in
return for laboT, services, supplies, equipment, materials or any combination of the foregoing, to be performed for, or
rendered or furnished to the contracting agency; or (ii) a written agreement in excess of $100,000.00 whereby a
contracting agency is committed to expend or does expend funds for the acquisition, construction, demolition,
replaCement, major repair or renovation of real property and improvements thereon; or (iii) a written agreement in
excess of $100,000.00 whereby the owner of a State assisted housing project is committed to expend or does expend
funds for the acquisition, construction, demolition, replacement, major repair or renovation of real property and
impr~ements thereon for such project, then:
(a) The Contractor will not discriminate against employees or applicants for employment because of race, creed, color,
national origin, sex, age, disability or marital status, and will undertake or continue existing programs of affirmative
action to ensure that minority group members and women are afforded equal employment opportunities without
discrimination. Affirmative action shall mean recruitment, employment, job assignment, promotion, upgradings,
demotion, transfer, layoff, or termination and rates of pay or other forms of compensation;
(b) at the request of the contracting agency, the Contractor shall request each employment agency, labor union, or
authorized representative of workers with which it has a collective bargaining or other agreement or understanding, to
furnish a written statement that such employment agency, labor union or representative will not discriminate on the
basis of race, creed, color, national origin, sex, age, disability or marital status and that such union or representative
will at1irmatively cooperate in the implementation of the contractor's obligations herein; and
(c) the Contractor shall state, in all solicitations or advertisements for employees, that, in the performance of the State
contract, all qualified applicants will be afforded equal employment opportunities without discrimination because of
race, creed, color, national origin, sex, age, disability or marital status.
Contractor will include the provisions of "a", "b", and lieu above, in every subcontract over $25,000.00 for the
constrUction, demolition, replacement, major repair, renovation, planning or design of real property and improvements
thereon (the "Work") except where the Work is for the beneficial use of the Contractor. Section 312 does not apply to:
(i) work, goods or services unrelated to this contract; or (ii) employment outside New York State; or (Hi) banking
services, insurance policies or the sale of securities. The State shall consider compliance by a contractor or
subcontractor with the requirements of any federal law concerning equal employment opportunity which effectuates the
purpose of this section. The contracting agency shall determine whether the imposition of the requirements of the
provi~ons hereof duplicate or conflict with any such federal law and if such duplication or conflict exists, the
contracting agency shall waive the applicability of Section 312 to the extent of such duplication or conflict. Contractor
will c"omply with all duly promulgated and lawful rules and regulations of the Governor's Office of Minority and
Women's Business Development pertaining hereto.
, .-
'.
l~
,-y;t~/
ell ~ f~ ~bJr
I} fUr.1( ? Ir,I)V
lL I l,.1C/~' iL (J- JtC''f
~ .Jl .AJJ- \1<ll/1
'~y 'f' ct
Dear Jim. /
As per our site meeting with Jamie Richter, the following quotes are for the optional alternates to
the base bid.
K.J.B. INDUSTRIES, INC.
14 CENTER DRIVE, RIVERHEAD, N.Y. 119'01
PHONE 631.727.~600 - FAX 631-717-4)577
NYS CERTIFIED WBE
August 22, 2007
TO\VTI of Southold Waste Management
Cox Lane
CU1chogue, NY 11935
o~
"
Art: Mr. Jim Bunchuk
Re; C&DSlab
Item 1 - Road mesh - replace the specified wire fabric (6 x6, 10 x 10) with road mesh (6 x 6, 6 x
6)
.
.",1
Add: $400.00
Item 2 - Extend rebar to adjoining slab at tapered apron to slab. Existing /15 bars to be extended
through to next section of slab. This extended section to be sleeved so slabs can move individual
horizontally, but not vertically (Note: #5 bar to protrude into next slab at 1 ')
Add: $300.00
Item 3 - Saw cut control joints.
Add $750.00
We look forward to working with you. Please feel free to cali if you have any questions.
Patricia Panehak
M, -((2/1
(;3 ('-77L{ - 7 '15,-~
Sincerely,
09/20/2007 16:00
16312345920
AJ BONOCORE AGENCY
PAGE 02
ACORDN CERTIFICATE OF LIABILITY INSURANCE I ll"TEIMMa>IVYYYJ
QJ~MJ':Inn.,
PRODUC&R TttIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMAnO/ll
A. J. Bonocore ~gency :Inc. ONLY AND CO/lIFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
1777-18 Veterans Memorial Highway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
:IslaDC!ia, NY 11749
631-234-5595 INSURERS AFFORDING COVERAGE NAIe.
INSURED KJB XNIltTSTlUI!lS IJIC. INSURER A: Pir.t Cardinal COrDOratiOD
I)BA !lAC..B ASPHALT IlAIl'l'1'BNANCB INSUREA. 8:
14 CEl'l'l'BR DRIVB INSURER c:
RXVBRHBAD, NY 11901 IN$UREftCl:
,0;", 727 "o;nn INeUMA E:
coveRAGES
THE POLICIES OF INSUlltAMCII.I$"eD .aow HAVE BEEN I$SUEO TO TM& lttSUREl;J NAMED ABOVE FOR THE POI.lCV PERIOD INDICATEO. NOTWITHSTANDING
I>>/V ReQUIREMENT. TERM OR CONDITION OP ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHCH THI$ CERTIFICATE MAY IE ISSUED OR
MAV PERTAIN. THE INSURANCE AFFORDED BV THE POLICIES DESCR.eD MEREIN IS SUBJECT TO ALL THE TeRMS, EXCLlISIONS AND CONDITIONS O' SUCH
POLICES. AGCREGATe LIMITS SHOWN MAYHAVEeeEN RIiC:UCEO BV P~ID CLAIMS.
1'0
POLICY NUMBER
yexPIRATION
GENEAII.L llABlLIn'
CO~"'l.G1NERAL I..IAIIILrry
CLAIM!JMASe: D OCCUR.
eAC~OCCUINNCE
UMlTS
S
S
S
S
S
S
PRE .o~
a.tED EXP one D8l'1Gn)
PERSON~ I ADV NJURY
GENERAl AGCREG\TE
PRODlJCTS. COMPIOP AGG
COG
AUTOt.IOIIllELlAlll.1TV
Atf'rAVTO
AlL OWNEDAUT')s
SQolEOUf.EDAU't05
HIREOAUTQS
NON-OWNEOAV"O$
OE:DUCTI8U;;
RETSNTION S
WORt(~C0MP5N511'nO"AND
EMPlOYER.S' LIABiliTY
""'" 1Ifl00000TO"'P~CVTI\E
A orrIClC~EII F.XCWOtCl'
l1yea, dllSCrlbtllfldw
SPEC~P~ONSBNOW
OTHER
004000351871107
5/2/07
COt-tBINEO SlNmIE LIMIT S
rEI.td_ftQ
BODilY fNJURY S
IP....lilhon)
IIODILVINJIJA'r S
(PllrKCfcMlr1l1
~PERTY DAMAGE S
('-'r.C'ClcHnl)
AUTOONLVeEAACCIDENT .
O'll<al THAN EA.CC ,
AllTOONl Y: AGG S
EAeH OCCU....ENCE S
AGGREGATE S
S
.
ou-
IMlT
1/1/08 E.L. EACH ACCDiNT S 000 000
E.l. DISEASE . E4 !MPlO S 1 000 0 0
E,L. OI6eA&E. POLICY UMIT S 000 00
GA.RAG; l.'AelL"'"
AHV AlITO
'iXee.SSo\JMBRiLLo\ LiA81LllY
OCCUR C] ClJIIMSW.ce
D~SCAIPTIONor; OPeRATIONS ILC'CATIONSlVEHIClt5t EXClUSIONSADDEI:l eVENOORSD.ENT l!PeCI"'L PROVl$rONS
:ERT'FICATE HOLDER
TOWN or SOUTBOLD
530!l5 Ret. 25
Southold, NY 11971
CANCELLAllON
'CORD2512001101)
Sep 20 2007 11:40AM
Ro~ H R@eve A~enc~
6312983850
p.2
ACORD CERTIFICATE OF LIABILITY INSURANCE I DATE CMWODIVYVY)
1M. 0912012007
PRODUCER PnOl'lll: (e31)211e-4Tm Fax: 8:11-28&-3850 ntlS CERnFICA1E IS 188U!O AS A NATTER OF NFORMAOON
ROY H REEVE AGENCY,INC. ONLY AND CONFERS NO RIGHTS UPON THE CEF TIFICATE
PO BOX 54 HOLOl!"- THIS l2ImFICA1E OOES NOT AMEND, EX1ENO OR
MAmTUCKNY11H2 ALTER THECOVEIU.GE AFFORDED BY THEPOLICES BELOW'.
INSURERS AFFORDING COVeRAGE NAlCII
INSURED INSURER A: 0.. Cas Co. orWIs (0310761) 24414
KJB INDUSTRIES INC. INSURER B:
DBA EAGL~ ASPHALT MAINTENANCE INSURER C.
14 CENTER DRIVE
RIV~HEAD NY 11101 INSURER. 0:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE lISTED BELOW HAVE BEEN ISSUEO TO THE INSURED NAMED ABOVE FOR. lHf POLICY PER!OD INDCATED, NOTWITHf TANDING
NN REQUIREMENT, TERM OR CONDITION OF AN'( CONTRACT O~ OlliER OOCUrENT WITH RESPECT TO WHICH nus CERTIFICATE MAY BE ISSUED OR
Mo\y PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEReiN IS 6U8JECT TO AlL THE TEFIIIS, EXCLUSIQH8 AND CONDITIONS C; SUCH
POLIUS. AGGREGATE LNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
... l;~ 'lYPEOFINBURANCE POLICY NUM89 ~~=-E ,"==-~N u.m -c
H.
~ERAL LIABIUTV CCX03t3OO1i OtlO2/07 01tlO2/08 EACH OCCURRENCE . ,000.000
X COMMeRCIAL GENERAL. UA8lLtTY ~=~~=_l . 100,000
l c~ MACE[!] OCCUR t.1ED. EXP (Anycrw person) . 5.000
A - PERSONAL & ArN INJURY' . 1,000,000
- GENERAL AGGREGATE . 2,000,000
~LA~nL~~Pn~R: PRODLJCTSCOMPfOPAGG. . 2,000,000
POLICY JEer Loe
~UTOI<<l"Ll UAl!lLITY COMBINED SINGL.E LIMIT
ANV AUTO {Ellaccidenll .
f--
~ AlLOWItEOAUTOS BODIL.Y INJURY
(P...penon) .
~ SCHEDULED AUTOS
f-- HIRED AUTOS SOOIL.Y INJURY
NON.OWNED AUTOS (~accidelnIl .
I--
f-- PROPERTY DNMOe .
[PIIl'"MlCidenl}
SMAQI! UMUTY AUTO ONLV. EAACCIDE:~T .
==i ANY AUTO OTtlER l'HAN EAACI; .
AUTO ONLY: AS" .
~E8S f UMBRE.L.LA UABlUTV EACH OCCURRf:NCE .
OCCUR 0 ClAIMS MADE AGGREGATE .
.
==l ~EDUCTIBlE .
RETENTKJN S .
WClAKEIl8 CO'-UTlON NoID I~T~~I IOllEl
EMPLOYERS" LIABLI'I'Y EL EACH ACel OEHT
ANt""'I~lITIVE .
ClfJ"1CER1MEMIHElICLUDm)'t ! E L DISEASE-fA EI.tPlOYEE .
1I,..,"g1I11~"r E.L DlSEASE.POlICYlIMIT .
.PliCW.I"ftCl'tlINON...._
OTHER:
DeSCRIPTION OF OPERATION8n.OCATlONSNEHlCLEBIEXCLUSIONS ADDm BY ENDORSe"~NTI SPECIAL PROVISION 5
~RTFlCATE HOLDER
CANCELLATION
SHOUlD AN'( OF THE ABOlle DESCRIBED POLICIES B! CANe :LLED B!FQRE THE
EXPAATtoN DATE THEREOF TtiE ISSUING INBURER. \\'1I..lENllE....YQRTO MAl110 DAYS
WRITTEN NOllCE TO THE CERTIFICATE HOLDER NAMED TO iHE LEFT, BUT FAILURE
T..... 01 Southold TO DO so SHIlLllMPOSe NO 08LIGATION OR IJABIUTY OF Nf'f tlJEI UPON THE INSURER,
53011 Roule 2S ITS AGENTS OR ~EPRESENTATlVES.
&outl1old, NY 11971 AUTHORIZED REPRESEMTATlVE ~~
Attention:
ACORD 25 (2001108)
Certificato. 10332
C ACO~D C )RPORATlON 1188
..>"'-
Sep 20 2007 11:40AM Ro~ H Reeve A;enc~
6312983850
p.3
. I
.. .
IMPORTANT
'fthe certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statelnent
on this certificate does not confer rights to the certificate holaer in lieu of such enaorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement A statement on this certificele does not confer rights to the certificete
holder in lieu of such enaorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not conslllule a contract betwE en
the issuing insurer{s), authorized representative or proaucer, ana the certificate hoider, nor does it
affirmatively or negatively amend, extena or a~er the coverage affordea by the policies listed the llOn.
ACORD 25-8 (2001/08)
Certlftcate,10332