HomeMy WebLinkAboutAl Bosgraaf and Sons, Inc. Fire Station Number 26 -1994 09 23
Section 00681
CONTRACT CHANGE ORDER
Change Order No. 2
Engineer Project No. W0435.00
Project Title: Fire Station Number 26
Contractor: Al Bosgraaf and Sons, Inc.
Reason for Change: Time extension and carpet change.
Breakdown of Proposed Changes and Basis for Payment
(Includes pertinent drawings, specifications, and documentation where necessary)
Item No. and Description Change in Contract
Cost + (-)
Detailed descriptions are attached.
Time extension contract is amended as follows:
1. Temporary Certificate of Occupancy from the City Building
Department no later than November 21, 1994. Fire
Department must be able to move in on November 21, 1994.
2. Completion of miscellaneous items and punchlist items by
November 30, 1994.
3. Carpet upgrade.
$532.00
(1) Total Proposed Change in Contract Cost +(-)
$
532.00
(2) Original Contract Price
$ 329.000.00
(3) Total All Previous Change Orders (Change Order No.1 thru ~
$ 4.543.57
(4) New Contract Price (Total of Item 1 & Item 4)
$ 334.075.57
Accepted By Contractor:
Date:
Date:
Recommended By Engineer:
Accepted By Owner:
Date:
END OF SECTION
00681-2
00681.for
ITEM 1:
The previous change order covered rain and other delays through
July 13, 1994. Heavy rains this summer have made it difficult to
complete the project within the original time frame.
In addition, the contractor submitted the interior color and
finishes for approval by the Architect on August 4, 1994, and
final selection was verified on October 4, 1994. Delivery of
materials for the interior finishes was delayed beyond the
contract end date and the materials could not be installed by the
completion date.
ALBAS
AL BOSGRAAF & SON'S, INC.
441 Surrey Run
Casselberry, FL 32707-3135
(407) 695-3064
FAX: 695-6242
Terry Zaudtke
Conklin, Porter and Holmes
Engineers, Inc.
1104 E. Robinson st.
Orlando, FL 32801
11/08/94
RE: Winter Springs Fire Station #26
CPH Project No. W0435.0
Change Order #4 Proposal
PROPOSA4
The carpet that was originally specified for the above referenced
project is discontinued. The new carpet that was selected by the
architect is of a better quality and therefore more expensive, than
that originally specified.
Additional cost for supplying and installing of newly specified
carpet. (J .P. Stevens - Network 26 A/B S.D.)........ .$532.00
Respectfully Submitted,
Gerald Bosgraaf,
Vice President
COMMERCIAL LIABILITY
SCOTTSDALE INSURANCE COMPANY
8877 North Gainey Center Drive, Scottsdale, Arizona 85258
1-800-423-7675 or in AZ 1-800-225-9458
A STOCK COMPANY
NEW Renewal Number
Policy Number
CLS178176
Item 1. Named Insured and Mailing Address:
City of Winter Springs
11126 East State Road 434
Winter Springs, FL 32708
Southern Ins Und
P.O. Box 105609
Atlanta, GA 30348-5609
NO FLAT CANCELLATION
NOTICE: THIS POLICY
CONTAINS A MINIMUM EARNED
PREMIUM PROVISION,
(PLEASE READ YOUR POLICY)
"Subject to Audit"
Agent No. 10005
Item 2. Policy Period From: 03 /17 / 9 4 To: 03 /17 /95
12:01 A.M. Standard Time at your mailing address. :,i:i
Item 3. Retroactive Date: N / A
Item 4. Business Description: Vacant Land
Item 5. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide
the insurance as stated in this policy.
This policy consists of the following coverage parts for which a premium is indicated, Where no premium is shown, there is
no coverage. This premium may be subject to adjustment.
Coverage Part(s)
Form No. and Edition Date Premium
CG0001(11-88) $750.00
$Not Covered
$25 Fee
Commercial General Liability Coverage Part
Professional liability Coverage Part.
Total $ 750.00
Item 6.
Forms and endorsements applicable to all Coverage Parts: UTS - 128 g ( 11 - 92) I
SHOW NUMBERS
CLS-J-2(11-91), CLS-SD-l(02-92)
Countersigned
03/17/94
DATE
By
AUTHORIZED REPRESENTATIVE
THIS COMMERCIAL LIABILITY DECLARATIONS AND THE SUPPLEMENTAL DECLARATIONS,TOGETHER WITH THE COMMON POLICY CONDITIONS,
COVERAGE FORM(S) AND ENDORSEMENTS COMPLETE THE ABOVE NUMBERED POLICY,
CLS-D-1 (10-92)
ORIGINAL
.
Secretary
Gordon E
President
SCOTTSDALE INSURANCE COMPANY"
ENDORSEMENT
NO.
ATTACHED TO AND ENDORSEMENT EFFECTIVE
FORMING A PART OF (STANDARD TIME) INSURED AGENCY AND CODE
POLICY NUMBER MO. DAY VA. 12:01 NOON
A.M.
CLS178176
03 17 94
City of Winter Springs
10005
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
OPTIONAL PROVISIONS ENDORSEMENT
In consideration of the premium charged, it is agreed that the following special privisions (indicated by an
"X") apply to this policy.
SCHEDULE
Bodily Injury and Property Damage Liability Deductible Endorsement
C Amountand Ba.sls ofDeduetible
Bodily Injury Liability $ 500 . 00 per claimant
Property Damage Liability $ 500 . 00 per claimant
Service of Suit Clause
Service of Process will be made upon Southern Ins Und
P.O. Box 105609. Atlanta. GA 30348-5609
Minimum and Advance Premium Endorsement
Minimum Premium $ 7 5 0 . 00
Minimum Earned Premium
Minimum Earned Premium 2 5
% of the original premium.
BODILY INJURY AND PROPERTY DAMAGE LIABILITY DEDUCTIBLE ENDORSEMENT
APPLICATION OF ENDORSEMENT (Enter below any limi-
tations on the application of this endorsement. If no limita-
tion is entered, the deductibles apply to damages for all
"bodily injury" and "property damage," however caused.):
1. Our obligation under the Bodily Injury Liability and Prop-
erty Damage Liability Coverages to pay damages on your
behalf applies only to the amount of damages in excess
of any deductible amounts stated in the Schedule above
as applicable to such coverages, and the limits of insur-
ance applicable to "each occurrence" for such coverages
will be reduced by the amount of such deductible.
UTS-128g (11-92)
Page 1 of 2
ORIGINAL
"Aggregate" limits for such coverages shall not be
reduced by the application of such deductible amount.
2. The deductible amounts include all legal and loss adjust-
ment expenses.
3. The deductible amounts stated in the Schedule apply
under the Bodily Injury Liability or Property Damage
Liability Coverage, respectively, to all damages because
of "bodily injury" sustained by one person, or to all dam-
ages because of "property damage" sustained by one
person, any organization, or association or any individual
member of any organization or association as the result
of anyone "occurrence."
4. The terms of this insurance, including those with respect
to our right and duty to defend any "suits" seeking those
damages and your duties in the event of an "occurrence,"
claim or "suit," apply irrespective of the application of the
deductible amount.
5. We may pay any part or all of the deductible amount to
effect settlement of any claim or "suit" and, upon notifica-
tion of the action taken, you shall promptly reimburse us
for such part of the deductible amount as has been paid
by us.
SERVICE OF SUIT CLAUSE
It is agreed that in the event of the failure of the Company
and/or Underwriters to pay any amount claimed to be due
under this policy, the Company and/or Underwriters at the
request of the Insured (or reinsured), will submit to the
jurisdiction of any court of competent jurisdiction within the
United States of America and will comply with all require-
ments necessary to give the Court jurisdiction. All matters
which arise will be determined in accordance with the law
and practice of the Court.
It is further agreed that service of process in such suit may
be made upon the individual(s) listed in the Schedule
~ and that in any suit instituted against anyone of
them under this contract, the Company and/or
Underwriters agree to abide by the final decision of the
Court or of any Appellate Court in the event of an appeal.
The above-named are authorized and directed to accept
service of process on behalf of the Company and/or
Underwriters in any such suit and/or upon the request of
the Insured (or reinsured) to give a written undertaking to
the Insured (or reinsured) that it or they will enter a general
appearance upon the Company's and/or Underwriter's
behalf in the event a suit is instituted.
Pursuant to any statute of any state, territory or district of
the United States of America, which makes a provision, the
Company and/or Underwriters will designate the Superin-
tendent, Commissioner or Director of Insurance or other
officer specified for that purpose in the statute or his
succes- sor or successors in office, as their true and lawful
attorney upon whom may be served any lawful process in
any action, suit, or proceeding instituted by or on behalf of
the Insured (or reinsured) or any beneficiary arising out of
this contract of insurance (or reinsurance). The above
named is designated as the person to whom the officer is
authorized to mail the process or a true copy.
MINIMUM AND ADVANCE PREMIUM ENDORSEMENT
Item b. of the Premium Audit Condition (under SECTION IV-COMMERCIAL GENERAL LIABILITY CONDITIONS) is
changed to read:
b. Premium shown in this Coverage Part as advance premium is a deposit premium only. At the close of each audit
period we will compute the earned premium for that period. Audit premiums are due and payable to us on notice to
the first Named Insured. If the sum of the advance and audit premiums paid for the policy term is greater than the
earned premium, we will return the excess to the first Named Insured, subject to a minimum premium listed in
the Schedule above. For purposes of this policy, the terms advance premium, audit premium, earned premium,
and minimum premium are defined as follows:
Advance Premium - The premium that is stated in the policy declarations and payable in full by the first Named
Insured at the inception of the policy.
Audit Premium -The premium that is developed by calculating the difference between the Advance Premium and
the Earned Premium.
Earned Premium - The premium that is developed by applying the rate(s) scheduled in the policy to the actual
premium basis for the policy period.
Minimum Premium - The lowest premium for which this insurance will be written for the policy period.
MINIMUM EARNED PREMIUM
If this policy is cancelled at the request of the INSURED, the total retained by the Company shall not be less than the
percentage of the original premium listed in the Schedule above.
/
3/17/94
DATE
UTS-128g (11-92)
Page 2 of 2
AUTHORIZED REPRESENTATIVE
SCOTTSDALE INSURANCE COMPANY
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SUPPLEMENTAL DECLARATIONS
These Supplemental Declarations form a part of policy number
CLS178176
LIMITS OF INSURANCE
General Aggregate Limit (other than Products/Completed Operations) $1,000,000
Products/Completed Operations Aggregate Limit $ Excluded
Personal and Advertising Injury Limit $ Excluded
Each Occurrence Limit $1.000.000
Fire Damage Limit $ Excluded anyone fire
Medical Expense Limit $ Excluded anyone person
BUSINESS DESCRIPTION AND LOCATION OF PREMISES
Form of business:
o Individual o Joint Venture o Partnership [K] Organization (other than Partnership or Joint Venture)
Business description: Vacant Land
Location of all premises you own, rent or occupy: 850 Northern Way, Winter Springs, FL 32708
PREMIUM
Rate Advance Premium
Classification Code No. *Premium Basis PR/Co All Other Pr/Co All Other
Vacant Land 49450 u) 1 Incl 4.61 $Incl $650 MP
Additional Insured 100
EXTRA FORMS AND ENDORSEMENTS
FORMS AND ENDORSEMENTS (other than applicable forms and endorsements shown elsewhere in the policy)
Forms and endorsements applying to this Coverage Part and made part of this policy at time of issue:
UTS-182g(06-93), CG0041 (05-86), CG0001 (11-88), CG2104(11-85), CG2135(01-87), CG2138(11-85),
CG2145111-85\ GLS-83al03-92\
*(a) Area, (c) Total Cost, (m) Admission, (p) Payroll, (s) Gross Sales, (u) Units, (0) Other
THIS SUPPLEMENTAL DECLARATIONS AND THE COMMERCIAL LIABILITY DECLARATIONS, TOGETHER WITH THE COMMON POLICY
CONDITIONS, COVERAGE FORM(S) AND ENDORSEMENTS COMPLETE THE ABOVE NUMBERED POLICY.
CLS-SD-1 (2-92) OR I G I NAL
SCOTTSDALE INSURANCE COMPANY
ENDORSEMENT
NO.
ATTACHED TO AND ENDORSEMENT EFFECTIVE
FORMING A PART OF (STANDARD TIME) INSURED AGENCY AND CODE
POLICY NUMBER MO. DAY YA. 12:01 NOON
A.M.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
AMENDATORY ENDORSEMENTS
In consideration of the premium charged it is agreed that
the following special provisions apply to this policy.
A. COMMERCIAL GENERAL LIABILITY CONDITIONS
AMENDMENT
The Commercial General Liability Condition, When We Do
Not Renew, is deleted in its entirety.
B. ASBESTOS EXCLUSION
The coverage afforded by this policy does not apply to
Bodily Injury, Personal Injury or Property Damage arising
out of;
A. Inhaling, ingesting or prolonged physical exposure to
asbestos or goods or products containing asbestos; or
B. The use of asbestos in construction or manufacturing
any good, product or structure; or
C. The removal of asbestos from any good, product or
structure; or
D. The manufacture, sale, transportation, storage or
disposal of asbestos or goods or products containing
asbestos.
The coverage afforded by the policy does not apply to
payment for the investigation or defense of any loss, injury
or damage or any cost, fine or penalty or for any expense of
claim or suit related to any of the above.
C. LEAD CONTAMINATION EXCLUSION
This endorsement excludes occurrences at the insured
premises which result in:
A. Bodily Injury arising out of the ingestion, inhalation or
absorption of lead in any form;
B. Property Damage arising from any form of lead;
UTS-182g (6-93)
C. Personal Injury arising from any form of lead;
D. Advertising Injury arising from any form of lead;
E. Medical Payments arising from any form of lead;
F. Any loss, cost or expense arising out of any request,
demand or order that any "insured" or others test for,
monitor, clean up, remove, contain, treat, detoxify or
neutralize, or in any way respond to, or assess the effects
of lead; or
G. Any loss, cost or expense arising out of any claim or suit
by or on behalf of a governmental authority for damages
because of testing for, monitoring, cleaning up, removing,
containing, treating, detoxifying or neutralizing, or in any
way responding to, or assessing the effects of lead.
D. PUNITIVE OR EXEMPLARY DAMAGE EXCLUSION
This policy does not apply to a claim of or indemnification for
punitive or exemplary damages.
Punitive or exemplary damages are damages in excess of
the amount needed to compensate for bodily injury or
property damage which are imposed in order to punish You
due to Your particularly wanton, willful or malicious character
in order to make an example of or to punish You. Punitive or
exemplary damages also include any damages awarded
pursuant to statute in the form of double, treble, or other
multiple damages in excess of compensatory damages.
If suit is brought against You for a claim falling within
coverage provided under the policy, seeking both
compensatory and punitive or exemplary damages, then We
will afford a defense to such action; however, We will have no
obligation to pay for any costs, interest, or damages
attributable to punitive or exemplary damages.
Page 1 of 3
E. CONTRACTORS SPECIAL CONDITIONS
You will obtain certificates of insurance from all
independent contractors providing evidence of:
A. Limits of liability equal to or greater than the limits
provided by this policy;
B. Coverage equal to or greater than the coverages
provided by this policy.
Failure to comply with this condition does not alter the
coverage provided by this policy. However, should you fail
to comply, independent contractors will be considered your
employees and a premium charge will be made
accordingly. The entire cost of all the work sublet will be
used as payroll for the work performed.
F. MEDICAL PAYMENTS EXCLUSION
Coverage C. MEDICAL PAYMENTS (Section I) does not
apply and none of the references to it in the Coverage Part
apply.
The following is added to SUPPLEMENTARY PAYMENTS
(Section I):
8. Expenses incurred by the "insured" for first aid to
others at the time of an accident for "bodily injury" to
which this insurance applies.
G. NUCLEAR ENERGY LIABILITY EXCLUSION
A. The insurance does not apply:
1. Under any Liability Coverage to "bodily injury" or
"property damage":
a. With respect to which an "insured" under the
policy is also an insured under a nuclear energy
liability policy issued by the Nuclear Energy
Liability Insurance Association, Mutual Atomic
Energy Liability Underwriters, Nuclear Insurance
Association of Canada or any of their successors,
or would be an insured under any such policy but
for its termination upon exhaustion of its limit of
liability; or
b. Resulting from the "hazardous properties" of
"nuclear material" and with respect to which:
(1) any person or organization is required to
maintain financial protection pursuant to the
Atomic Energy Act of 1954, or any law
amendatory thereof; or
UTS-182g (6-93)
Page 2 of 3
(2) the "insured" is, or had this policy not been
issued would be, entitled to indemnity from
the United States of America, or any agency
thereof, under any agreement entered into by
the United States of America, or any agency
thereof, with any person or organization.
2. Under any Medical Payments coverage, to expenses
incurred with respect to "bodily injury" resulting from
the "hazardous properties" of "nuclear material" and
arising out of the operation of a "nuclear facility" by
any person or organization.
3. Under any Liability Coverage, to "bodily injury" or
"property damage" resulting from the "hazardous
properties" of "nuclear material" if:
a. The "nuclear material":
(1) is at any "nuclear facility" owned by, or
operated by or on behalf of, an "insured"; or
(2) has been discharged or dispersed therefrom.
b. The "nuclear material" is contained in "spent fuel" or
"waste" at any time possessed, handled, used,
processed, stored, transported or disposed of by
or on behalf of an "insured"; or
c. The "bodily injury" or "property damage" arises out
of the furnishing by an "insured" of services,
materials, parts or equipment in connection with
the planning, construction, maintenence, operation
or use of any "nuclear facility," but if such facility is
located within the United States of America, its
territories or possessions or Canada, this exclusion
c. applies only to "property damage" to such
"nuclear facility" and any property thereat.
B. As used in this endorsement:
"Hazardous properties" include radioactive, toxic or
explosive properties.
"Nuclear material" means "source material," "special
nuclear material" or "by-product materiaL"
"Source material," "special nuclear material," and
"by-product material" have the meanings given them in
the Atomic Energy Act of 1954 or in any law amendatory
thereof.
"Spent fuel" means any fuel element or fuel component,
solid or liquid, which has been used or exposed to
radiation in a "nuclear reactor."
"Waste" means any waste material:
1. containing "by-product material" other than the
tailings or wastes produced by the extraction or
concentration of uranium or thorium from any ore
processed primary for its "source material"
content; and
2. resulting from the operation by any person or
organization of any "nuclear facility" included
under the first two paragraphs of the definition of
"nuclear facility."
"Nuclear facility" means:
1. Any "nuclear reactor";
2. Any equipment or device designed or used for;
a. separating the isotopes of uranium or
plutonium,
b. processing or utilizing "spent fuel," or
c. handling, processing or packaging "waste";
UTS-182g (6-93)
3. Any equipment or device used for the processing,
fabricating or alloying of "special nuclear material" if at
any time the total amount of such material in the
custody of the "insured" at the premises where such
equipment or device is located consists of or contains
more than 25 grams of plutonium or uranium 233 or
any combination thereof, or more than 250 grams of
uranium 235;
4. Any structure, basin, excavation, premises or place
used for the storage or disposal of "waste";
and includes the site on which any of the foregoing is
located, all operations conducted on such site and all
premises used for such operations.
"Nuclear reactor" means any apparatus designed or used
to sustain nuclear fission in a self-supporting chain
reaction or to contain a critical mass of fissionable
material.
"Property damage" includes all forms of radioactive
contamination or property.
/
AUTHORIZED REPRESENTATIVE
DATE
Page 3 of 3
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
AMENDMENT OF POLLUTION EXCLUSION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
The following is added to exclusion f. of COVERAGE A (Section I):
Subparagraphs (a) and (d) (i) of paragraph (1) of this exclusion do not apply to "bodily injury" or "property damage" caused by
heat, smoke or fumes from a hostile fire. As used in this exclusion, a hostile fire means one which becomes uncontrollable or
breaks out from where it was intended to be.
CG 00 41 05 86
Copyright I nsurance Services Qffice, Inc., 1986
o
CG 00 01 11 88
CL 113
(11-88)
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
Various provisions in this policy restrict coverage. Read the entire policy carefully to determine rights, duties and what
is and is not covered.
Throughout this policy the words "you" and "your" refer to the Named Insured shown in the Declarations, and any other
person or organization qualifying as a Named Insured under this policy. The words "we," "us" and "our" refer to the
Company providing this insurance.
The word "insured" means any person or organization qualifying as such under WHO IS AN INSURED (SECTION II).
Other words and phrases that appear in quotation marks have special meaning. Refer to DEFINITIONS (SECTION V).
SECTION 1- COVERAGES b. "Bodily injury" or "property damage" for which the
COVERAGE A. BODILY INJURY AND PROPERTY insured is o~ligated.to pay.damages by reason of
DAMAGE LIABILITY the assumption of liability In a contract or agree-
ment. This exclusion does not apply to liability for
1. Insuring Agreement. damages:
a. We will pay those sums that the insured becomes (1) Assumed in a contract or agreement that is
legally obligated to pay as damages because of an "insured contract," provided the "bodily
"bodily injury" or "property damage" to which this injury" or "property damage" occurs sub-
insurance applies. We will have the right and duty sequent to the execution of the contract or
to defend any "suit" seeking those damages. We agreement; or
may at our discretion investigate any "occur- (2) That the insured would have in the absence
rence" and settle any claim or "suit" that may of the contract or agreement.
result. But:
c. "Bodily injury" or "property damage" for which
(1) The amount we will pay for damages is limited any insured may be held liable by reason of:
as described in LIMITS OF INSURANCE
(SECTION III); and (1) Causing or contributing to the intoxication of
any person;
(2) Our right and duty to defend end when we
have used up the applicable limit of insurance (2) The furnishing of alcoholic beverages to a
in the payment of judgments or settlements person under the legal drinking age or under
under Coverages A or B or medical expenses the influence of alcohol; or
under Coverage C. (3) Any statute, ordinance or regulation relating
No other obligation or liability to pay sums or to the sale, gift, distribution or use of alcoholic
perform acts or services is covered unless ex- beverages.
plicitly provided for under SUPPLEMENTARY This exclusion applies only if you are in the busi-
PAYMENTS-COVERAGES A AND B. ness of manufacturing, distributing, selling, serv-
ing or furnishing alcoholic beverages.
d. Any obligation of the insured under a workers'
compensation, disability benefits or unemploy-
ment compensation law or any similar law.
e. "Bodily injury" to:
(1) An employee of the insured arising out of and
in the course of employment by the insured;
or
b. This insurance applies to "bodily injury" and
"property damage" only if:
(1) The "bodily injury" or "property damage" is
caused by an "occurrence" that takes place
in the "coverage territory"; and
(2) The "bodily injury" or "property damage" oc-
curs during the policy period.
c. Damages because of "bodily injury" include
damages claimed by any person or organization
for care, loss of services or death resulting at any
time from the "bodily injury."
2. Exclusions.
This insurance does not apply to:
a. "Bodily injury" or "property damage" expected or
intended from the standpoint of the insured. This
exclusion does not apply to "bodily injury" result-
ing from the use of reasonable force to protect
persons or property.
CL 113 (11-88)
CG00011188
(2) The spouse, child, parent, brother or sister of
that employee as a consequence of (1)
above.
This exclusion applies:
(1) Whether the insured may be liable as an
employer or in any other capacity; and
(2) To any obligation to share damages with or
repay someone else who must pay damages
because of the injury.
This exclusion does not apply to liability assumed
Copyright, Insurance Services Office, Inc., 1982, 1988
Page 1 of 9
by the insured under an "insured contract."
f. (1) "Bodily injury" or "property damage" arising
out of the actual, alleged or threatened dis-
charge, dispersal, seepage, migration,
release or escape of pollutants:
(a) At or from premises, site or location which
is or was at any time owned or occupied
by, or rented or loaned to, any insured;
(b) At or from any premises, site or location
which is or was at any time used by or for
any insured or others for the handling,
storage, disposal, processing or treat-
ment of waste;
(c) Which are or were at any time
transported, handled, stored, treated,
disposed of or processed as waste by or
for any insured or any person or or-
ganization for whom you may be legally
responsible; or
(d) At or from any premises, site or location
on which any insured or any contractors
or subcontractors working directly or in-
directly on any insured's behalf are per-
forming operations:
(i) if the pollutants are brought on or to
the premises, site or location in con-
nection with such operations by such
insured, contractor or subcontractor;
or
(ii) if the operations are to test for,
monitor, clean up, remove, contain,
treat, detoxify or neutralize, or in any
way respond to, or assess the effects
of pollutants.
Subparagraphs (a) and (d) (i) do not apply to
"bodily injury" or "property damage" arising
out of heat, smoke or fumes from a hostile fire.
As used in this exclusion, a hostile fire means
one which becomes uncontrollable or breaks
out from where it was intended to be.
(2) Any loss, cost or expense arising out of any:
(a) Request, demand or order that any in-
sured or others test for, monitor, clean
up, remove, contain, treat, detoxify or
neutralize, or in any way respond to, or
assess the effects of pollutants; or
(b) Claim or suit by or on behalf of a
governmental authority for damages be-
cause of testing for, monitoring, cleaning
up, removing, containing, treating,
detoxifying or neutralizing, or in any way
responding to, or assessing the effects of
pollutants.
Pollutants means any solid, liquid, gaseous or
thermal irritant or contaminant, including smoke,
vapor, soot, fumes, acids, alkalis, chemicals and
waste. Waste includes materials to be recycled,
Page 2 of 9
reconditioned or reclaimed.
g. "Bodily injury" or "property damage" arising out
of the ownership, maintenance, use or entrust-
ment to others of any aircraft, "auto" or watercraft
owned or operated by or rented or loaned to any
insured. Use includes operation and "loading or
unloading."
This exclusion does not apply to:
(1) A watercraft while ashore on premises you
own or rent;
(2) A watercraft you do not own that is:
(a) Less than 26 feet long; and
(b) Not being used to carry persons or
property for a charge;
(3) Parking an "auto" on, or on the ways next to,
premises you own or rent, provided the
"auto" is not owned by or rented or loaned to
you or the insured;
(4) Liability assumed under any "insured con-
tract" for the ownership, maintenance or use
of aircraft or watercraft; or
(5) "Bodily injury" or "property damage" arising
out of the operation of any of the equipment
listed in paragraph 1.(2) or 1.(3) of the defini-
tion of "mobile equipment" (Section v.a.).
h. "Bodily injury" or "property damage" arising out
of:
(1) The transportation of "mobile equipment" by
an "auto" owned or operated by or rented or
loaned to any insured; or
(2) The use of "mobile equipment" in, or while in
practice or preparation for, a prearranged
racing, speed or demolition contest or in any
stunting activity.
i. "Bodily injury" or "property damage" due to war,
whether or not declared, or any act or condition
incident to war. War includes civil war, insurrec-
tion, rebellion or revolution. This exclusion ap-
plies only to liability assumed under a contract or
agreement.
j. "Property damage" to:
(1) Property you own, rent or occupy;
(2) Premises you sell, give away or abandon, if
the "property damage" arises out of any part
of those premises;
(3) Property loaned to you;
(4) Personal property in your care, custody or
control of the insured;
(5) That particular part of real property on which
you or any contractors or subcontractors
working directly or indirectly on your behalf
are performing operations, if the "property
damage" arises out of those operations; or
(6) That particular part of any property that must
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CL 113 (11-88)
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be restored, repaired or replaced because
"your work" was incorrectly performed on it.
Paragraph (2) of this exclusion does not apply if
the premises are "your work" and were never
occupied, rented or held for rental by you.
Paragraphs (3), (4), (5) and (6) of this exclusion
do not apply to liability assumed under a
sidetrack agreement.
Paragraph (6) of this exclusion does not apply to
"property damage" included in the "products-
completed operations hazard."
k. "Property damage" to "your product" arising out
of it or any part of it.
I. "Property damage" to "your work" arising out of
it or any part of it and included in the "products-
completed operations hazard."
This exclusion does not apply if the damaged
work or the work out of which the damage arises
was performed on your behalf by a subcontrac-
tor.
m. "Property damage" to "impaired property" or
property that has not been physically injured,
arising out of:
(1) A defect, deficiency, inadequacy or
dangerous condition in "your product" or
"your work"; or
(2) A delay or failure by you or anyone acting on
your behalf to perform a contract or agree-
ment in accordance with its terms.
This exclusion does not apply to the loss of use
of other property arising out of sudden and ac-
cidental physical injury to "your product" or "your
work" after it has been put to its intended use.
n. Damages claimed for any loss, cost or expense
incurred by you or others for the loss of use,
withdrawal, recall, inspection, repair, replace-
ment, adjustment, removal or disposal of:
(1) "Your product";
(2) "Your work"; or
(3) "Impaired property";
if such product, work or property is withdrawn or
recalled from the market or from use by any
person or organization because of a known or
suspected defect, deficiency, inadequacy or
dangerous condition in it.
Exclusions c. through n. do not apply to damage by
fire to premises rented to you. A separate limit of
insurance applies to this coverage as described in
LIMITS OF INSURANCE (SECTION III).
COVERAGE B. PERSONAL AND ADVERTISING IN-
JURY LIABILITY
1. Insuring Agreement.
a. We will pay those sums that the insured becomes
legally obligated to pay as damages because of
"personal injury" or "advertising injury" to which
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this coverage part applies. We will have the right
and duty to defend any "suit" seeking those
damages. We may at our discretion investigate
any "occurrence" or offense and settle any claim
or "suit" that may result. But:
(1) The amount we will pay for damages is limited
as described in LIMITS OF INSURANCE
(SECTION III); and
(2) Our right and duty to defend end when we
have used up the applicable limit of insurance
in the payment of judgments or settlements
under Coverages A or B or medical expenses
under Coverage C.
No other obligation or liability to pay sums or
perform acts or services is covered unless ex-
plicitly provided for under SUPPLEMENTARY
PAYMENTS-COVERAGES A AND B.
b. This insurance applies to:
(1) "Personal injury" caused by an offense aris-
ing out of your business, excluding advertis-
ing, publishing, broadcasting or telecasting
done by or for you;
(2) "Advertising injury" caused by an offense
committed in the course of advertising your
goods, products or services;
but only if the offense was committed in the
"coverage territory" during the policy period.
2. Exclusions.
This insurance does not apply to:
a. "Personal injury" or "advertising injury":
(1) Arising out of oral or written publication of
material, if done by or at the direction of the
insured with knowledge of its falsity;
(2) Arising out of oral or written publication of
material whose first publication took place
before the beginning of the policy period;
(3) Arising out of the willful violation of a penal
statute or ordinance committed by or with the
consent of the insured; or
(4) For which the insured has assumed liability in
a contract or agreement. This exclusion does
not apply to liability for damages that the
insured would have in the absence of the
contract or agreement.
b. "Advertising injury" arising out of:
(1) Breach of contract, other than misappropria-
tion of advertising ideas under an implied
contract;
(2) The failure of goods, products or services to
conform with advertised quality or perfor-
mance;
(3) The wrong description of the price of goods,
products or services; or
(4) An offense committed by an insured whose
business is advertising, broadcasting,
Copyright, Insurance Services Office, Inc., 1982, 1988
Page 3 of 9
publishing or telecasting.
COVERAGE C. MEDICAL PAYMENTS
1. Insuring Agreement.
a. We will pay medical expenses as described
below for "bodily injury" caused by an accident:
(1) On premises you own or rent;
(2) On ways next to premises you own or rent; or
(3) Because of your operations;
provided that:
(1) The accident takes place in the "coverage
territory" and during the policy period;
(2) The expenses are incurred and reported to
us within one year of the date of the accident;
and
(3) The injured person submits to examination,
at our expense, by physicians of our choice
as often as we reasonably require.
b. We will make these payments regardless of fault.
These payments will not exceed the applicable
limit of insurance. We will pay reasonable expen-
ses for:
(1) First aid at the time of an accident;
(2) Necessary medical, surgical, x-ray and dental
services, including prosthetic devices; and
(3) Necessary ambulance, hospital, professional
nursing and funeral services.
2. Exclusions.
We will not pay expenses for "bodily injury":
a. To any insured.
b. To a person hired to do work for or on behalf of
any insured or a tenant of any insured.
c. To a person injured on that part of premises you
own or rent that the person normally occupies.
d. To a person, whether or not an employee of any
insured, if benefits for the "bodily injury" are pay-
able or must be provided under a workers' com-
pensation or disability benefits law or a similar
law.
e. To a person injured while taking part in athletics.
1. Included within the "products-completed opera-
tions hazard."
g. Excluded under Coverage A.
h. Due to war, whether or not declared, or any act or
condition incident to war. War includes civil war,
insurrection, rebellion or revolution.
SUPPLEMENTARY PAYMENTS-COVERAGES A AND
B
We will pay, with respect to any claim or "suit" we defend:
1. All expenses we incur.
2. Up to $250 for cost of bail bonds required because of
accidents or traffic law violations arising out of the use
of any vehicle to which the Bodily Injury Liability
Page 4 of 9
Coverage applies. We do not have to furnish these
bonds.
3. The cost of bonds to release attachments, but only for
bond amounts within the applicable limit of insurance.
We do not have to furnish these bonds.
4. All reasonable expenses incurred by the insured at
our request to assist us in the investigation or defense
of the claim or "suit," including actual loss of earnings
up to $100 a day because of time off from work.
5. All costs taxed against the insured in the "suit."
6. Prejudgment interest awarded against the insured on
that part of the judgment we pay. If we make an offer
to pay the applicable limit of insurance, we will not pay
any prejudgment interest based on that period of time
after the offer.
7. All interest on the full amount of any judgment that
accrues after entry of the judgment and before we
have paid, offered to payor deposited in court the part
of the judgment that is within the applicable limit of
insurance.
These payments will not reduce the limits of insurance.
SECTION 11- WHO IS AN INSURED
1. If you are designated in the Declarations as:
a. An individual, you and your spouse are insureds,
but only with respect to the conduct of a business
of which you are the sole owner.
b. A partnership or joint venture, you are an insured.
Your members, your partners and their spouses
are also insureds, but only with respect to the
conduct of your business.
c. An organization other than a partnership or joint
venture, you are an insured. Your executive of-
ficers and directors are insureds, but only with
respect to their duties as your officers or directors.
Your stockholders are also insureds, but only with
respect to their liability as stockholders.
2. Each of the following is also an insured:
a. Your employees, other than your executive of-
ficers, but only for acts within the scope of their
employment by you. However, no employee is an
insured for:
(1) "Bodily injury" or "personal injury" to you or
to a co-employee while in the course of his or
her employment, or the spouse, child, parent,
brother or sister of that co-employee as a
consequence of such "bodily injury" or "per-
sonal injury," or for any obligation to share
damages with or repay someone else who
must pay damages because of the injury; or
(2) "Bodily injury" or "personal injury" arising out
of his or her providing or failing to provide
professional health care services; or
(3) "Property damage" to property owned or oc-
cupied by or rented or loaned to that
employee, any of your other employees, or
any of your partners or members (if you are a
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partnership or joint venture).
b. Any person (other than your employee), or any
organization while acting as your real estate
manager.
c. Any person or organization having proper tem-
porary custody of your property if you die, but
only:
(1) With respect to liability arising out of the main-
tenance or use of that property; and
(2) Until your legal representative has been ap-
pointed.
d. Your legal representative if you die, but only with
respect to duties as such. That representative will
have all your rights and duties under this
Coverage Part.
3. With respect to "mobile equipment" registered in your
name under any motor vehicle registration law, any
person is an insured while driving such equipment
along a public highway with your permission. Any
other person or organization responsible for the con-
duct of such person is also an insured, but only with
respect to liability arising out of the operation of the
equipment, and only if no other insurance of any kind
is available to that person or organization for this
liability. However, no person or organization is an
insured with respect to:
a. "Bodily injury" to a co-employee of the person
driving the equipment; or
b. "Property damage" to property owned by, rented
to, in the charge of or occupied by you or the
employer of any person who is an insured under
this provision.
4. Any organization you newly acquire or form, other
than a partnership or joint venture, and over which
you maintain ownership or majority interest, will
qualify as a Named Insured if there is no other similar
insurance available to that organization. However:
a. Coverage under this provision is afforded only
until the 90th day after you acquire or form the
organization or, the end of the policy period,
whichever is earlier;
b. Coverage A does not apply to "bodily injury" or
"property damage" that occurred before you ac-
quired or formed the organization; and
c. Coverage B does not apply to "personal injury"
or "advertising injury" arising out of an offense
committed before you acquired or formed the
organization.
No person or organization is an insured with respect to
the conduct of any current or past partnership or joint
venture that is not shown as a Named Insured in the
Declarations.
SECTION 11I- LIMITS OF INSURANCE
1. The Limits of Insurance shown in the Declarations and
the rules below fix the most we will pay regardless of
the number of:
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a. Insureds;
b. Claims made or "suits" brought; or
c. Persons or organizations making claims or bring-
ing "suits."
2. The General Aggregate Limit is the most we will pay
for the sum of:
a. Medical expenses under Coverage C;
b. Damages under Coverage A, except damages
because of "bodily injury" or "property damage"
included in the "products-completed operations
hazard"; and
c. Damages under Coverage B.
3. The Products-Completed Operations Aggregate
Limit is the most we will pay under Coverage A for
damages because of "bodily injury" and "property
damage" included in the "products-completed
operations hazard."
4. Subject to 2. above, the Personal and Advertising
Injury Limit is the most we will pay under Coverage B
for the sum of all damages because of all "personal
injury" and all "advertising injury" sustained by any
one person or organization.
5. Subject to 2. or 3. above, whichever applies, the Each
Occurrence Limit is the most we will pay for the sum
of:
a. Damages under Coverage A; and
b. Medical expenses under Coverage C
because of all "bodily injury" and "property damage"
arising out of anyone "occurrence."
6. Subject to 5. above, the Fire Damage Limit is the most
we will pay under Coverage A for damages because
of "property damage" to premises rented to you aris-
ing out of anyone fire.
7. Subject to 5. above, the Medical Expense Limit is the
most we will pay under Coverage C for all medical
expenses because of "bodily injury" sustained by any
one person.
The limits of this Coverage Part apply separately to each
consecutive annual period and to any remaining period
of less than 12 months, starting with the beginning of the
policy period shown in the Declarations, unless the policy
period is extended after issuance for an additional period
of less than 12 months. In that case, the additional period
will be deemed part of the last preceding period for
purposes of determining the Limits of Insurance.
SECTION IV - COMMERCIAL GENERAL LIABILITY
CONDITIONS
1. Bankruptcy.
Bankruptcy or insolvency of the insured or of the
insured's estate will not relieve us of our obligations
under this Coverage Part.
2. Duties In The Event Of Occurrence, Claim Or Suit.
a. You must see to it that we are notified as soon as
practicable of an "occurrence" or an offense
Copyright, Insurance Services Office, Inc., 1982, 1988
Page 5 of 9
which may result in a claim. To the extent pos-
sible, notice should include:
(1) How, when and where the "occurrence" took
place;
(2) The names and addresses of any injured
persons and witnesses; and
(3) The nature and location of any injury or
damage arising out of the "occurrence" or
offense.
b. If a claim is made or "suit" is brought against any
insured, you must:
(1) Immediately record the specifics of the claim
or "suit" and the date received; and
(2) Notify us as soon as practicable.
You must see to it that we receive written notice
of the claim or "suit" as soon as practicable.
c. You and any other involved insured must:
(1) Immediately send us copies of any demands,
notices, summonses or legal papers received
in connection with the claim or "suit";
(2) Authorize us to obtain records and other in-
formation;
(3) Cooperate with us in the investigation, settle-
ment or defense of the claim or "suit"; and
(4) Assist us, upon our request, in the enforce-
ment of any right against any person or or-
ganization which may be liable to the insured
because of injury or damage to which this
insurance may also apply.
d. No insureds will, except at their own cost, volun-
tarily make a payment, assume any obligation or
incur any expense, other than for first aid, without
our consent.
3. Legal Action Against Us.
No person or organization has a right under this
Coverage Part:
a. To join us as a party or otherwise bring us into a
"suit" asking for damages from an insured; or
b. To sue us on this Coverage Part unless all of its
terms have been fully complied with.
A person or organization may sue us to recover on an
agreed settlement or on a final judgment against an
insured obtained after an actual trial; but we will not
be liable for damages that are not payable under the
terms of this Coverage Part or that are in excess of the
applicable limit of insurance. An agreed settlement
means a settlement and release of liability signed by
us, the insured and the claimant or the claimant's
legal representative.
4. Other Insurance.
If other valid and collectible insurance is available to
the insured for a loss we cover under Coverage A or
B of this Coverage Part, our obligations are limited as
follows:
Page 6 of 9
a. Primary Insurance
This insurance is primary except when b. below
applies. If this insurance is primary, our obliga-
tions are not affected unless any of the other
insurance is also primary. Then, we will share with
all that other insurance by the method described
in c. below.
b. Excess Insurance
This insurance is excess over any of the other
insurance, whether primary, excess, contingent
or on any other basis:
(1) That is Fire, Extended Coverage, Builder's
Risk, Installation Risk or similar coverage for
"your work";
(2) That is Fire insurance for premises rented to
you; or
(3) If the loss arises out of the maintenance or
use of aircraft, "autos" or watercraft to the
extent not subject to Exclusion g. of
Coverage A (Section I).
When this insurance is excess, we will have no
duty under Coverage A or B to defend any claim
or "suit" that any other insurer has a duty to
defend. If no other insurer defends, we will under-
take to do so, but we will be entitled to the
insured's rights against all those other insurers.
When this insurance is excess over other in-
surance, we will pay only our share of the amount
of the loss, if any, that exceeds the sum of:
(1) The total amount that all such other insurance
would pay for the loss in the absence of this
insurance; and
(2) The total of all deductible and self-insured
amounts under all that other insurance.
We will share the remaining loss, if any, with any
other insurance that is not described in this Ex-
cess Insurance provision and was not bought
specifically to apply in excess of the Limits of
Insurance shown in the Declarations of this
Coverage Part.
c. Method of Sharing
If all of the other insurance permits contribution
by equal shares, we will follow this method also.
Under this approach each insurer contributes
equal amounts until it has paid its applicable limit
of insurance or none of the loss remains,
whichever comes first.
If any of the other insurance does not permit
contribution by equal shares, we will contribute
by limits. Under this method, each insurer's share
is based on the ratio of its applicable limit of
insuranCe to the total applicable limits of in-
surance of all insurers.
5. Premium Audit.
a. We will compute all premiums for this Coverage
Part in accordance with our rules and rates.
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CL 113 (11-88)
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b. Premium shown in this Coverage Part as advance
premium is a deposit premium only. At the close
of each audit period we will compute the earned
premium for that period. Audit premiums are due
and payable on notice to the first Named Insured.
If the sum of the advance and audit premiums
paid for the policy term is greater than the earned
premium, we will return the excess to the first
Named Insured.
c. The first Named Insured must keep records of the
information we need for premium computation,
and send us copies at such times as we may
request.
6. Representations.
By accepting this policy, you agree:
a. The statements in the Declarations are accurate
and complete;
b. Those statements are based upon repre-
sentations you made to us; and
c. We have issued this policy in reliance upon your
representations.
7. Separation Of Insureds.
Except with respect to the Limits of Insurance, and
any rights or duties specifically assigned in this
Coverage Part to the first Named Insured, this in-
surance applies:
a. As if each Named Insured were the only Named
Insured; and
b. Separately to each insured against whom claim
is made or "suit" is brought.
8. Transfer Of Rights Of Recovery Against Others To
Us.
If the insured has rights to recover all or part of any
payment we have made under this Coverage Part,
those rights are transferred to us. The insured must
do nothing after loss to impair them. At our request,
the insured will bring "suit" to transfer those rights to
us and help us enforce them.
9. When We Do Not Renew.
If we decide not to renew this Coverage Part, we will
mail or deliver to the first Named Insured shown in the
Declarations written notice of the nonrenewal not less
than 30 days before the expiration date.
If notice is mailed, proof of mailing will be sufficient
proof of notice.
SECTION V - DEFINITIONS
1. "Advertising injury" means injury arising out of one or
more of the following offenses:
a. Oral or written publication of material that
slanders or libels a person or organization or
disparages a person's or organization's goods,
products or services;
b. Oral or written publication of material that violates
a person's right of privacy;
CL 113 (11-88)
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c. Misappropriation of advertising ideas or style of
doing business; or
d. Infringement of copyright, title or slogan.
2. "Auto" means a land motor vehicle, trailer or semi-
trailer designed for travel on public roads, including
any attached machinery or equipment. But "auto"
does not include "mobile equipment."
3. "Bodily injury" means bodily injury, sickness or dis-
ease sustained by a person, including death resulting
from any of these at any time.
4. "Coverage territory" means:
a. The United States of America (including its ter-
ritories and possessions), Puerto Rico and
Canada;
b. International waters or airspace, provided the in-
jury or damage does not occur in the course of
travel or transportation to or from any place not
included in a. above; or
c. All parts of the world if:
(1) The injury or damage arises out of:
(a) Goods or products made or sold by you
in the territory described in a. above; or
(b) The activities of a person whose home is
in the territory described in a. above, but
is away for a short time on your business;
and
(2) The insured's responsibility to pay damages
is determined in a "suit" on the merits, in the
territory described in a. above or in a settle-
ment we agree to.
5. "Impaired property" means tangible property, other
than "your product" or "your work," that cannot be
used or is less useful because:
a. It incorporates "your product" or "your work" that
is known or thought to be defective, deficient,
inadequate or dangerous; or
b. You have failed to fulfill the terms of a contract or
agreement;
if such property can be restored to use by:
a. The repair, replacement, adjustment or removal
of "your product" or "your work"; or
b. Your fulfilling the terms of the contract or agree-
ment.
6. "Insured contract" means:
a. A lease of premises;
b. A sidetrack agreement;
c. An easement or license agreement except in con-
nection with construction or demolition opera-
tions on or within 50 feet of a railroad;
d. An obligation, as required by ordinance, to in-
demnify a municipality, except in connection with
work for a municipality;
e. An elevator maintenance agreement;
Copyright, Insurance Services Office, Inc., 1982, 1988
Page 7 of 9
f. That part of any other contract or agreement
pertaining to your business (including an indem-
nification of a municipality in connection with work
performed for a municipality) under which you
assume the tort liability of another party to pay for
"bodily injury" or "property damage" to a third
person or organization. Tort liability means a
liability that would be imposed by law in the ab-
sence of any contract or agreement.
An "insured contract" does not include that part of any
contract or agreement:
a. That indemnifies any person or organization for
"bodily injury" or "property damage" arising out
of construction or demolition operations, within
50 feet of any railroad property and affecting any
railroad bridge or trestle, tracks, road-beds, tun-
nel, underpass or crossing;
b. That indemnifies an architect, engineer or sur-
veyor, for injury or damage arising out of:
(1) Preparing, approving or failing to prepare or
approve maps, drawings, opinions, reports,
surveys, change orders, designs or specifica-
tions; or
(2) Giving directions or instructions, or failing to
give them, if that is the primary cause of the
injury or damage;
c. Under which the insured, if an architect, engineer
or surveyor, assumes liability for an injury or
damage arising out of the insured's rendering or
failure to render professional services, including
those listed in b. above and supervisory, inspec-
tion or engineering services; or
d. That indemnifies any person or organization for
damage by fire to premises rented or loaned to
you.
7. "Loading or unloading" means the handling of
property:
a. After it is moved from the place where it is ac-
cepted for movement into or onto an aircraft,
watercraft or "auto";
b. While it is in or on an aircraft, watercraft or "auto";
or
c. While it is being moved from an aircraft, watercraft
or "auto" to the place where it is finally delivered;
but "loading or unloading" does not include the move-
ment of property by means of a mechanical device,
other than a hand truck, that is not attached to the
aircraft, watercraft or "auto."
8. "Mobile equipment" means any of the following types
of land vehicles, including any attached machinery or
equipment:
a. Bulldozers, farm machinery, forklifts and other
vehicles designed for use principally off public
roads;
b. Vehicles maintained for use solely on or next to
premises you own or rent;
Page 8 of 9
c. Vehicles that travel on crawler treads;
d. Vehicles, whether self-propelled or not, main-
tained primarily to provide mobility to permanent-
ly mounted:
(1) Power cranes, shovels, loaders, diggers or
drills; or
(2) Road construction or resurfacing equipment
such as graders, scrapers or rollers;
e. Vehicles not described in a., b., c. ord. above that
are not self-propelled and are maintained primari-
ly to provide mobility to permanently attached
equipment of the following types:
(1) Air compressors, pumps and generators, in-
cluding spraying, welding, building cleaning,
geophysical exploration, lighting and well
servicing equipment; or
(2) Cherry pickers and similar devices used to
raise or lower workers;
1. Vehicles not described in a., b., c. or d. above
maintained primarily for purposes other than the
transportation of persons or cargo.
However, self-propelled vehicles with the follow-
ing types of permanently attached equipment are
not "mobile equipment" but will be considered
"autos" :
(1) Equipment designed primarily for:
(a) Snow removal;
(b) Road maintenance, but not construction
or resurfacing;
(c) Street cleaning;
(2) Cherry pickers and similar devices mounted
on automobile or truck chassis and used to
raise or lower workers; and
(3) Air compressors, pumps and generators, in-
cluding spraying, welding, building cleaning,
geophysical exploration, lighting and well
servicing equipment.
9. "Occurrence" means an accident, including con-
tinuous or repeated exposure to substantially the
same general harmful conditions.
10. "Personal injury" means injury, other than "bodily
injury," arising out of one or more of the following
offenses:
a. False arrest, detention or imprisonment;
b. Malicious prosecution;
c. The wrongful eviction from, wrongful entry into, or
invasion of the right of private occupancy of a
room, dwelling or premises that a person oc-
cupies by or on behalf of its owner, landlord or
lessor;
d. Oral or written publication of material that
slanders or libels a person or organization or
disparages a person's or organization's goods,
products or services; or
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CL 113 (11-88)
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e. Oral or written publication of material that violates
a person's right of privacy.
11. a. "Products-completed operations hazard" in-
cludes all "bodily injury" and "property damage"
occurring away from premises you own or rent
and arising out of "your product" or "your work"
except:
(1) Products that are still in your physical posses-
sion; or
(2) Work that has not yet been completed or
abandoned.
b. "Your work" will be deemed completed at the
earliest of the following times:
(1) When all of the work called for in your contract
has been completed.
(2) When all of the work to be done at the site has
been completed if your contract calls for work
at more than one site.
(3) When that part of the work done at a job site
has been put to its intended use by any
person or organization other than another
contractor or subcontractor working on the
same project.
Work that may need service, maintenance, cor-
rection, repair or replacement, but which is other-
wise complete, will be treated as completed.
c. This hazard does not include "bodily injury" or
"property damage" arising out of:
(1) The transportation of property, unless the
injury or damage arises out of a condition in
or on a vehicle created by the "loading or
unloading" of it;
(2) The existence of tools, uninstalled equipment
or abandoned or unused materials;
(3) Products or operations for which the clas-
sification in this Coverage Part or in our
manual of rules includes products or com-
pleted operations.
12. "Property damage" means:
a. Physical injury to tangible property, including all
resulting loss of use of that property. All such loss
of use shall be deemed to occur at the time of the
physical injury that caused it; or
b. Loss of use of tangible property that is not physi-
cally injured. All such loss shall be deemed to
CL 113 (11-88)
CG 00 01 11 88
occur at the time of the "occurrence" that caused
it.
13. "Suit" means a civil proceeding in which damages
because of "bodily injury," "property damage," "per-
sonal injury" or "advertising injury" to which this in-
surance applies are alleged. "Suit" includes:
a. An arbitration proceeding in which such
damages are claimed and to which you must
submit or do submit with our consent; or
b. Any other alternative dispute resolution proceed-
ing in which such damages are claimed and to
which you submit with our consent.
14. "Your product" means:
a. Any goods or products, other than real property,
manufactured, sold, handled, distributed or dis-
posed of by:
(1) You;
(2) Others trading under your name; or
(3) A person or organization whose business or
assets you have acquired; and
b. Containers (other than vehicles), materials, parts
or equipment furnished in connection with such
goods or products.
"Your product" includes:
a. Warranties or representations made at any time
with respect to the fitness, quality, durability, per-
formance or use of "your product"; and
b. The providing of or failure to provide warnings or
instructions.
"Your product" does not include vending machines
or other property rented to or located for the use of
others but not sold.
15. "Your work" means:
a. Work or operations performed by you or on your
behalf; and
b. Materials, parts or equipment furnished in con-
nection with such work or operations.
"Your work" includes:
a. Warranties or representations made at any time
with respect to the fitness, quality, durability, per-
formance or use of "your work"; and
b. The providing of or failure to provide warnings or
instructions.
Copyright, Insurance Services Office, Inc., 1982, 1988
Page 9 of 9
CL 267
(11-85)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CG 21 04 11 85
EXCLUSION-PRODUCTS-COMPLETED OPERATIONS HAZARD
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
This insurance does not apply to "bodily injury" or "property damage" included within the "products------completed
operations hazard".
Copyright, Insurance Services Office, Inc., 1984
POLICY NUMBER: CLS178176
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
EXCLUSION -COVERAGE C- MEDICAL PAYMENTS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Description and Location of Premises or Classification:
Vacant Land
850 Northern Way, Winter Springs, FL 32708
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to
this endorsement.)
With respect to any locations or classification shown in the Schedule, coverage C. MEDICAL PAYMENTS (Section I) does not
apply and none of the references to it in the Coverage Part apply.
The following is added to SUPPLEMENTARY PAYMENTS (Section I):
8. Expenses incurred by the insured for first aid to others at the time of an accident for "bodily injury" to which this insurance
applies.
CG 21 3501 87
Copyright, Insurance Services Qffice, Inc., 1986
ORIGINAL
o
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
EXCLUSION - PERSONAL AND ADVERTISING INJURY
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
COVERAGE B (Section I) does not apply and none of the references to it in the Coverage Part apply.
CG 21 38 11 85
Copyright, Insurance ~ervices Office, Inc., 1984
o
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
EXCLUSION - FIRE DAMAGE LEGAL LIABILITY
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
1. The last paragraph of 2. EXCLUSIONS under Coverage A. (Section I) does not apply.
2. Paragraph 6. of LIMITS OF INSURANCE (Section III) does not apply.
3. Any reference in the Declarations to "Fire Damage Legal Liability" does not apply.
CG 21 45 11 85
Copyright, Insurance ~ervices Office, Inc., 1985
D
SCOTTSDALE INSURANCE COMPANY@
ENDORSEMENT
NO.
ATTACHED TO AND ENDORSEMENT EFFECTIVE
FORMING A PART OF (STANDARD TIME) INSURED AGENCY AND CODE
POLICY NUMBER MO. DAY YR. 12:01 NOON
A.M.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
SUBSIDENCE EXCLUSION
This policy does not apply to any claim of liability for Bodily Injury or Property Damage caused by, resulting
from, attributable or contributed to, or aggravated by the subsidence of land as a result of landslide, mudflow,
earth sinking or shifting, resulting from operations of the named insured or any subcontractor of the named
insured.
/
AUTHORIZED REPRESENTATIVE
DATE
GLS-83g(3-92)
CLS-J2 (11-91)
SCOTTSDALE INSURANCE COMPANY
8877 North Gainey Center Drive, Scottsdale, Arizona 85258
COMMON POLICY CONDITIONS
All Coverage parts included in this policy are subject to the following conditions.
A. CANCELLATION D. INSPECTIONS AND SURVEYS
1. The first Named Insured shown in the Declara- We have the right but are not obligated to:
tions may cancel this policy by mailing or deliver- 1. Make inspections and surveys at any time:
ing to us advance written notice of cancellation.
2. We may cancel this policy by mailing or delivering
to the first named insured written notice of can-
cellation at least:
2. Give you reports on the condition we find;
and
3. Recommend changes.
a. 10 days before the effective date of cancella-
tion if we cancel for nonpayment of premium;
or
b. 30 days before the effective date of cancella-
tion if we cancel for any other reason.
Any inspections, surveys, reports or recommenda-
tions relate only to insurability and the premiums to
be charged. We do not make safety inspections.
We do not undertake to perform the duty of any
person or organization to provide for the health
or safety of workers or the public. And we do
not warrant that conditions:
3. We will mail or deliver our notice to the first
Named Insured's last mailing address known to
us.
1. Are safe or healthful; or
4. Notice of cancellation will state the effective date
of cancellation. The policy period will end on that
date.
2. Comply with laws, regulations, codes or stan-
dards.
5. If this policy is cancelled, we will send the first
Named Insured any premium refund due. If we
cancel, the refund will be pro rata. If the first
Named Insured cancels, the refund may be less
than pro rata. The cancellation will be effective
even if we have not made or offered a refund
This condition applies not only to us, but also to
any rating, advisory, rate service or similar
organization which makes insurance inspections,
surveys, reports or recommendations.
E. PREMIUMS
This policy contains all the agreements between you
and us concerning the insurance afforded. The first
Named Insured shown in the Declaration is autho-
rized to make changes in the terms of this policy with
our consent. This policy's terms can be amended or
waived only by endorsement issued by us and made a
part of this policy.
The first Named Insured shown in
the Declarations:
1. Is responsible for the payment of all premi-
ums; and
2. Will be the payee for any return premiums
we pay.
F. TRANSFER OF YOUR RIGHTS AND
DUTIES UNDER THIS POLICY
6. If notice is mailed, proof of mailing will be suffi-
cient proof of notice.
B. CHANGES
Your rights and duties under this policy may
not be transferred without our written consent
except in the case of death of an individual
named insured.
C. EXAMINATION OF YOUR BOOKS AND
RECORDS.
We may examine and audit your books and records as
they relate to this policy at any time during the policy
period and up to three years afterward.
If you die, your rights and duties will be trans-
ferred to your legal representative but only
while acting within the scope of duties as your
legal representative. Until your legal
representative is appointed, anyone having
proper temporary custody of your property
will have your rights and duties but only
with respect to that property.
Witness Whereof, the company has caused this policy to be executed and attested, but this policy shall not be valid
unless countersigned by a duly appointed representative of the company.
Secretary President .
Scottsdale Insurance Company co
ENDORSEMENT
NO. 02
ATTACHED TO AND ENDORSEMENT EFFECTIVE
FORMING A PART OF (STANDARD TIME)
POLICY NUMBER MO. DAY YA. 12:01 NOON INSURED AGENCY AND CODE
A.M.
CLS178176 03 17 94
City of Winter Springs
10005
GENERAL CHANGE ENDORSEMENT
PRODUCER
Florida League of Cities
P.O. Box 530065
135 E. Colonial Drive
Orlando, FL 32801
It is hereby understood and agreed that Form CG2024 is added to this policy
as per attached.
05/04/94
THOMAS KOULDSWORTH ORLANDO
DATE
CE-1 (1-91)
AUTHORIZED REPRESENTATIVE
ORIGINAL
POLICY NUMBER: CLS178176
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED- OWNERS OR OTHER INTERESTS
FROM WHOM LAND HAS BEEN LEASED
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Designation of Premises (Part Leased to You):
850 Northern Way
Winter Springs, FL
32708
Name of Person or Organization:
Southern Bell
500 N. Orange Avenue, Suite 400
Orlando, FL 32801
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to
include as an insured the person or organization
shown in the Schedule but only with respect to liability
arising out of the ownership, maintenance or use of
that part of the land leased to you and shown in the
Schedule and subject to the following additional
exclusions.
This insurance does not apply to:
1. Any "occurrence" which takes place after you cease
to lease that land;
2. Structural alterations, new construction or demolition
operations performed by or on behalf of the person or
organization shown in the Schedule.
CG 20 24 11 85
Copyright, Insurance ~ervices Office, Inc., 1984
D
.
LUMBERMEN'S OF FLORIDA
EXECUTIVE PAVILION SUITE 505
300 N.W. 82nd Avenue
Plantation, Florida 33324
305-474-7603 305-474-7605
WARNING TO OWNER: UNDER FLORIDA LAW, YOUR FAILURE TO MAKE SURE THAT WE ARE PAID MAY RESULT
IN A LIEN AGAINST YOUR PROPERTY AND YOUR PAYING TWICE.
TO AVOID A LIEN AND PAYING TWICE, YOU MUST OBTAIN A WRITTEN RELEASE FROM THE UNDERSIGNED
EVERY TIME YOU PAY YOUR CONTRACTOR. Cert: 391172 - 391173
065740-006 NOTICE TO OWNER/PRELIMINARY NOTICE 01/06/95
391172
WINTER SPRINGS, CITY OF
ATT: PURCHASING
1126 EAST STATE RD #434
WINTER SPRINGS FL 32708
Please be informed that the undersigned is furnishing, or has furnished the following described materials, labor,
and/or services: LABOR/MATLS INSTALL CHEM RESISTENT URETHANE ETC
for the improvement of real property described as:
NTO:195-65740 in SEMINOLE County, FL Recd:07/26/94
Street: 850 NORTHERN WAY, WINTER SPRINGS
WINTER SPRINGS FIRE STATION #26
under an order given by: AL BOSGRAAF & SONS
Florida law prescribes the serving of this notice and restricts your rights to make payments under your contract in accordance with Sectlon713.06 Florida Statutes,
IN THE EVENT THAT THE CONTRACT FOR IMPROVEMENTS IS BONDED, PURSUANT TO SECTION 713.23, FLORIDA STATUTES, SECTION 255.05,
FLORIDA STATUTES, TITLE 40 U.S.C. SECTION 270, OR ANY OTHER FORM OF BOND, THE UNDERSIGNED INTENDS TO LOOK TO THAT BOND FOR
PROTECTION AND PAYMENT. THE UNDERSIGNED REQUESTS A COPY OF THE PAYMENT BOND AND A COPY OF ANY DIRECT CONTRACTS PERTAINING
TO THE IMPROVEMENTS FOR THIS PROJECT AND AGREES TO PAY REASONABLE COPY COSTS FOR SUCH COPY.
THIS NOTICE IS NOT A LIEN, CLOUD NOR ENCUMBRANCE UPON TITLE TO YOUR PROPERTY. NOR IS IT A MATTER OF PUBLIC RECORD.
IMPORTANT INFORMATION FOR YOUR PROTECTION
Under Florida's laws, those who work on your property or provide materials and are not paid, have a right to enforce their claim for payment against your property. This claim
is known as a construction lien. If your contractor fails to pay subcontractors or material suppliers or neglects to make other legally required payments, the people who are
owed money may look to your property for payment, EVEN IF YOU HAVE PAID YOUR CONTRACTOR IN FULL PROTECT YOURSELF:
RECOGNIZE that this Notice to Owner may result In a lien against your property unless all those supplying a Notice to Owner have been paid.
LEARN more about the Construction Lien Law, Chapter 713, Part I, Florida Statutes, and the meaning of this notice by contacting an attorney or the Florida Department of
Professional Regulation. All demands pursuant to Chapter 713 Florida Statutes are to be directed to: J R NABORS WATERPROOFING INC
Van Saliba
Authorized Agent For:
J R NABORS WATERPROOFING INC
P O BOX 574892
ORLANDO FL 32857-4892
General Contractor:
BOSGRAAF, AL & SONS INC
441 SURREY RUN
CASSELBERRY FL 32707
SURETY :391173
GUIGNARD & CO
PO BOX 180817
CASSELBERRY FL 32718-0817
a6~740
P 328 391 172
WINTER SPRINGS, CITY OF
ATT: PURCHASING
1126 EAST STATE RD #434
WINTER SPRINGS FL 32708
WARNING TO OWNER: UNDER FLORIDA LAW, YOUR FAILURE TO
MAKE SURE THAT WE ARE PAID MAY RESULT IN A LIEN
AGAINST YOUR PROPERTY AND YOUR PAYING TWICE.
TO AVOID A LIEN AND PAYING TWICE, YOU MUST OBTAIN A
WRITTEN RELEASE FROM US EVERY TIME YOU PAY YOUR
CONTRACTOR.
NOTICE TO OWNER
P127657
(NOTICE TO CONTRACfOR) Date: Dec 29, 1994
TO: (OWNER)
City Of Winter Springs-City Hall
Purchasing
1126 East State Road 434
Winter Springs, FL 32708
P127656
rr1 f rn @ ~ ~ \Yl~".,
JAN - 4
, ,
CITY OF WINTER SPRINGS
PURCHASING .
. ct/..
OR'}- ~T7 C/dtlc'.
t~ : fJv~c.f/ .
c, nJ ;119 tf.
F;~ .
11 AlE .
TO: (GENERAL CONTRACfOR)
Bosgraaf & Sons Inc.
441-Surrey Run
Casselberry, FL 32707-3135
The undersigned hereby informs you that he has furnished, or is furnishing services or materials as follows:
QUARRY TILE & CERAMIC TILE, SUNDRY ITEMS
for the improvement of the real property identified as:
850 Northern Way
NK/A FIRE STATION NO. 26
Winter Springs, Seminole County, Florida
Bond No. 3189243
unde, '" o,dcr g;ven by~ & SONS JN0
Florida law prescribes serving of this notice and restricts your rigbtto make payments under your contract in accordance with Section 713.06, Florida Statutes.
If there is a PAYMENT BOND, then this notice will advise you that we intend to look to the applicable payment bond for payment of the foregoing items. Within (10) days
of receipt of this notice, you are required by Florida Statutes Section 71323, and 255.05 to furnish notice of the existance of such payment bond and a copy of said bond.
PLEASE N01E: TIllS IS NOT A LIEN, CLOUD, NOR ENCUMBRANCE UPON TIlLE TO YOUR PROPERTY, NOR IS IT A MATlER OF PUBUC RECORD.
This notice is a standard business procedure of the undersigned firm, and does not adversely reflect upon the credit-worthiness or other reputation of any person named herein.
IMPORTANT INFORMATION FOR YOUR PROTECTION:
Under Florida law, those who work on your property or provide materials and are not paid have a right to enforce their claim for payment against your properly. This claim is known as
a construction lien. If your contractor fails to pay subcontractors or material suppliers or neglects to make other legally required payment, the people who are owed money
may look to your property for payment EVEN IF YOU HAVE PAID YOUR CONTRACTOR IN FUlL.
PROTECT YOURSELF.
RECOGNIZE this Notice to Owner may result in a lien against your property unless all those supplying a Notice to Owner have been paid.
LEARN more about the Construction Lien Law. Chapter 713. Part 1, Florida Statutes, and the meaning of the Notice by contacting an attorney or the
Florida Department of Agriculture and Consumer Services, Division of Consumer Services.
By: MJ. Holleman Agent For:
Ceramic Tile Management
3928 Foothills Drive
Orlando, FL 32810
COPIES TO:
7658 (CIM) West American Ins. Co. C/O Guignard & Co. PO Box 180817 Casselberry, FL 32718
Prepared By: NORTH FLORIDA NOTIFIER, INC. 5705 ST. AUGUSTINE ROAD lAX., FL. 32207 (904) 737-7844
NF
5705 ST. AUGUSTINE ROAD
JACKSONVILLE. FL 32207
IF UNDEUVERABLE RETURN TO
SENDER WITHIN 5 DAYS
~~RTIFIED MAIL
Return Requested
IE.
CERTIFIED
f ~ to0'
MAIL
-;;;'. ".;','"
/11 ""
J., (",;
..,,,j
..,...".....,;...,
. .': ,......
1"III1.t.II,,,III,, .1..1.11...1
.~
LUMBERMEN'S OF FLORIDA
EXECUTIVE PAVILION SUITE 505
300 N.W. 82nd Avenue
Plantation, Florida 33324
305-474-7603 305-474-7605
WARNING TO OWNER: UNDER FLORIDA LAW, YOUR FAILURE TO MAKE SURE THAT WE ARE PAID MAY RESULT
IN A LIEN AGAINST YOUR PROPERTY AND YOUR PAYING TWICE.
TO AVOID A LIEN AND PAYING TWICE, YOU MUST OBTAIN A WRITTEN RELEASE FROM THE UNDERSIGNED
EVERY TIME YOU PAY YOUR CONTRACTOR. Cert: 385331-385333
062829-006 NOTICE TO OWNER/PRELIMINARY NOTICE 11/08/94
385331
WINTER SPRINGS, CITY OF
ATT: PURCHASING
1126 EAST STATE RD #434
WINTER SPRINGS FL 32708
Please be informed that the undersigned is furnishing, or has furnished the following described materials, labor,
and/or services: AIR DISTRIBUTION, DAMPERS AND FANS
for the improvement of real property described as:
NTO:1194-62829 in SEMINOLE County, FL Recd:07/26/94
Street: 850 NORTHERN WAY, WINTER SPRINGS
WINTER SPRINGS FIRE STATION #26
under an order given by: GENERAL AIR PROJ #1486-WL
Florida law prescribes the serving of this notice and restricts your rights to make payments under your contract in accordance with Sectlon713.06 Florida Statutes,
IN THE EVENT THAT THE CONTRACT FOR IMPROVEMENTS IS BONDED, PURSUANT TO SECTION 713.23, FLORIDA STATUTES, SECTION 255.05,
FLORIDA STATUTES, TITLE 40 U.S.C. SECTION 270, OR ANY OTHER FORM OF BOND, THE UNDERSIGNED INTENDS TO LOOK TO THAT BOND FOR
PROTECTION AND PAYMENT. THE UNDERSIGNED REQUESTS A COPY OF THE PAYMENT BOND AND A COPY OF ANY DIRECT CONTRACTS PERTAINING
TO THE IMPROVEMENTS FOR THIS PROJECT AND AGREES TO PAY REASONABLE COPY COSTS FOR SUCH COPY.
THIS NOTICE IS NOT A LIEN, CLOUD NOR ENCUMBRANCE UPON TITLE TO YOUR PROPERTY. NOR IS IT A MATTER OF PUBLIC RECORD.
IMPORTANT INFORMATION FOR YOUR PROTECTION
Under Florida's laws, those who work on your property or provide materials and are not paid, have a right to enforce their claim for payment against your property. This claim
is known as a construction lien. If your contractor fails to pay subcontractors or material suppliers or neglects to make other legally required payments, the people who are
owed money may look to your property for payment, EVEN IF YOU HAVE PAID YOUR CONTRACTOR IN FULL PROTECT YOURSELF:
RECOGNIZE that this Notice to Owner may result In a lien against your property unless all those supplying a Notice to Owner have been paid.
LEARN more about the Construction Lien Law, Chapter 713, Part I, Florida Statutes, and the meaning of this notice by contacting an attorney or the Florida Department of
Professional Regulation. All demands pursuant to Chapter 713 Florida Statutes are to be directed to: J R NABORS WATERPROOFING INC
Van Saliba
Authorized Agent For:
J R NABORS WATERPROOFING INC
P O BOX 574892
ORLANDO FL 32857-4892
General Contractor: 385332
BOSGRAAF, AL & SONS INC
441 SURREY RUN
CASSELBERRY FL 32707
SURETY :391173
GUIGNARD & CO
PO BOX 180817
CASSELBERRY FL 32718-0817
062829
P 328 385 331
WINTER SPRINGS, CITY OF
ATT: PURCHASING
1126 EAST STATE RD #434
WINTER SPRINGS FL 32708
FORWARDING & ADDRESS CORRECTION REQUESTED
NFN 5705 ST. AUGUSTINE ROAD
JACKSONVILLE, FL 32207
CITY OF WINTER SPRINGS - CITY HALL
PURCHASING
1126 EAST STATE ROAD 434
WINTER SPRINGS, FL 32708
1 Of 4
PAYMENT REQUEST NO. 07
ENGINEERS FILE NO. W435.00
CONTRACTOR'S APPLICATION FOR PAYMENT
BID NO. 94.002
FINANCE ACCOUNT NO. 3215
CONTRACTOR Al Bosgraaf & Sons, Inc
CONTRACT DATE
4-18-94
COMPLETION DATE
1-24-95
APPLICATION DATE 2-10-95
FOR PERIOD ENDING __.-2=.10=.9.5-------
STATEMENT OF WORK
Original Contract Price $ 329,000. Work to Date $ 333,875.57
Net Change Order $4,875.57 Amount Retained R 33,387.56
Current Contract Price 333,875.57 Subtotal 300,488.01
Work to be Done 0
Previous Pay- 275,670.51
ments Approved
Amount Due This
Payment
24,817.50
The undersigned Contractor hereby swears under penalty of perjury that (1) all previous progress
payments received from the Owner on account of work performed under the Contract referred to
above have been applied by the undersigned to discharge in full all obligations of the undersigned
incurred in connection with work covered by prior Application for Payment under said contract,
being Applications for Payment numbered 1 through _ inclusive; and, (2) all materials and
equipment incorporated in said Project or otherwise listed in or covered by this Application for
Payment are free and clear of all liens, claims, security interests and encumbrances.
Al Bosgraaf (Pres)
(Name & Title}
COUNTY OF
STATE OF FLORIDA
Before me on this 10 day of February, 95 personaIly appeared Al Bosgraaf,
, known to me, (or has produced as identification and who did (did not)
take an oath) who, being duly sworn did depose ar;d say that he is the of the
Contractor above-mentioned; that he executed the above Application for Payment and statement on
behalf of said Contractor; and that aII of the statements contained there in are true, correct and
complete.
SEAL
My commission expires:
Payment of the amount requested above is approved:
HANNELORE C. MILLER
MY COMMISSION # CC 233143 EXPIRES
October 5. 1996
THRU TROY FAIN INSURANCE.INC.
END OF SECTION
CONTINUATION SHEET
AlA DOCUMENT G703 (Instructions on reverse side)
PAGE 2 OF- 4 PAGES
AlA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT,
conl:lining Contractor's signed Certification, is atl:lched.
In l:Ibulations below, amounts are stated to the nearest dollar.
Use Column I on Contracts where variable rel:linage for line Items may apply.
APPLICATION NO.: 7
APPLICATION DATE: 2-10-95
PERIOD TO: 2-10-95
ARCHITECT'S PROJECT NO.: 93-115
WORK COMPLETED MATERIALS TOTAL BALANCE
PRESENTlY COMPLETED % 10 RElAINAGE
ITEM SCIIEDlJLED FROM PREVIOUS STORED AND STORED (IF VARIABLE)
DESCRtPTlON OF WORK VAI.tlE (G + C) FINISH
NO APPLICATION THIS PERIOD (NOT IN TO DATE RATE)
CONTINUATION SHEET
AlA DOCUMENT G703 (Instructions on reverse side)
PAGE 3 OF 14 PAGES
AlA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT,
con12lning Contractor's signed Certlflcatlon, Is attached.
In tabulations below, amounts are Stated to the nearest dollar.
Use Column I on Contracts where variable retalnage for line Items may apply.
APPLICATION NO.: 7
APPLICATION DATE: 2-10-95
PERIOD TO: 2-10-95
ARCHITECT'S PROJECT NO.: 93-115
WORK COMPLETED MATERIAJ.S TOTAL BALANCE
PRESENTLY COMPLETED RHAINAGE
ITEM SCHEDULED FROM PREVIOUS STORED AND STORED % TO (IF VARIABLE)
NO. DESCRIPTION OF WORK VALUE (G + C) FINISH
APPLICATION TillS PERIOD (NOT IN TO DATE RATE)
(0 + E) o OR E) (O+E+f) (e - G)
18 Glass & glazing 3,679.00 3,679.00 3,679.00 100 367.~
19 Gypsum board 13,546.00 13,546.00 13,546.00 100 1 , 354..:J.+}
20 Ceramic tile 6,327.00 6,327.00 ",327.00 100 632.70
21 Carpet 3,731.00 3,731.00 3,731.00 100 373.10
22 Water proofing 2,240.00 2,240.00 2,240.00 100 224.00
23 Painting 9,512.00 9,512.00 9,512.00 100 951~
24 Vinyl siding 3,784.00 3,784.00 3,784.00 100 378.40
25 Floor Coatings 4,456.00 4,456.00 4,456.00 100 445.60
26 Sliding pole,flag pole
Bath assec, chalk & (;;/1;5. a:::
tack boards 6,450.00 6,450.00 6,450.00 100 ~
27 lockers 3,808.00 3,808.00 3,808.00 100 380.80
28 Blinds 837.00 837.00 837.00 100 83: 7.0
29 H.V.A.C 14 , 189.00 14, 189.00 14, 189.00 100 1 , 418 . 90
30 Plumbing 13,552.00 13,000.00 552.00 13,552.00 100 1 ,355.20
31 Fire sprinklers 9.598.00 9,598.00 9,589.00 100 958.90
32 SJadtrical & Fire Alarm 33,636.00 33,636.00 33,636.00 100 3,363.60
33 Bond 6,451.00 6,451.00 6,451.00 100 645.10
-
CONTINUATION SHEET
AlA DOCUMENT G703 (Instructions on reverse side)
PAGE 4 OF 4 PAGES
AlA Document G702, APPI.ICATION AND CERTIFICATE FOR PAYMENT,
contllnlng Conlractor's signed Certification, Is attached.
In tabulations below, amounts are stated to the nearest dollar.
Use Column I on Contracts where variable relalnage for line Items may apply.
APPLICATION NO.: 7
APPLICATION DATE: 2-10-95
PERIOD TO: 2-10-95
ARCHITECT'S PROJECT NO.: 93-115
WORK COMPLETED MATERIAI.S TOTA L BALANCE
ITEM SCHEDUl.ED PRESENTlY COMPl.ETED % TO RETAINAGE
NO DESCRIPTION OF WORK VAUJE FROM PREVIOUS STORED AND STORED (G + C) FINISII (IF VARIABI.E)
APPl.ICATlON TillS PERIOD (NOT IN TO DATE RATE I
SECTION 00663
FORM OF CONTRACTOR'S PARTIAL RELEASE OF LIEN
KNOW ALL MEN BY THESE PRESENTS, that the undersigned,
Al Bosgraaf in consideration of partial payment in the sum of $24,587.69
receipt whereof is hereby acknowledged, and other valuable considerations and benefits to
the undersigned accruing, do hereby waive, release and quit claim all liens, lien rights,' claims or
demands of every kind whatsoever which the undersigned now has or may hereafter have, against
that certain real estate and the improvements thereof, situated in Seminole County, Florida, and
legally described as:
:850 Northern Way, Unit 4 PIT, BK 18, Pages 6,7 and 8. Seminole County
on account of work and labor performed, and/or materials furnished in, to, or about the construction
of any building or buildings situated thereon, or in improving said property above described, or any
part thereof.
It being the understanding of the undersigned that this is a Partial Waiver and Release of Lien
which the undersigned has against the premises described herein, only to the extent of--the
.payments specified and only for materials furnished or work done up until! " ,'('::7 (but not'
. releasing or waiving charges for changes, additions, or extras), the undersigned warrants that no
assignment of said liens or claims, nor the right to perfect a lien. against said real estate, by virtue of
the accrual of said payment, has or will be made, and that the undersigned has the right to execute
this Partial Waiver and Release, and that all laborers employed by the undersigned, and all bills for
materials and supplies furnished by others to the undersigned in connection with the construction of
Improvements upon the aforesaid premises, to the extent of the payment herein referred to, have
been fully paid. it)
IN WITNESS WHEREOF, I/we have executed this instrument under seal this day of February 10, 1995.
WITNESSES: Cathy Calfee
Al Bosgraaf
END OF SECTION
00663- 1
1 Of 4
CONTRACTOR'S APPLICATION FOR PAYMENT
PAYMENT REOUEST NO. 07
ENGINEERS FILE NO. W435.00
BID NO. 94.002
FINANCE ACCOUNT NO. 3215
CONTRACTOR Al Bosgraaf & Sons,Inc
CONTRACT DATE
4-18-94
COMPLETION DATE
1-24-95
APPLICATION DATE 2-10-95
FOR PERIOD ENDING 2-10-95
STATEMENT OF WORK
Work to be Done
Previous Pay 275,670.51
ments Approved
333875, 57
Original Contract Price $ 329,000. OONork to Date $ 333,875.57
I
Net Change Order 4875.57 Amount Retained 33,387.56
Current Contract Price Subtotal 300,488.01
The undersigned Contractor hereby swears under penalty of perjury that (11 all previous progress 1;\ Il
payments received from the Owner on account of work performed under the Contract referred to
above have been applied by the undersigned to dischurge in full all obligations of the undersigned
incurred in connection with work covered by prior Application for Payment under said contract,
being Applications for Payment numbered 1 through _ inclusive; and. (21 all materials and
equipment incorporated in said Project or otherwise listed in or covered by this Application for
pa~ment a- ~,and clear of all liens, claims, security interests Adenc'brances.
Amount Due This
Payment
24,817.50
Al Bosgraaf, Pres
(Name & Title)
CITY OF WINTER SPRINGS, FLORIDA
1126 EAST STATE ROAD 434
WINTER SPRINGS. FLORIDA 32708-2799
Telephone (407) 327.1800
February 23, 1995
Attn: Gail Clapp
NationsBank Trust
One Financial Plaza, 13th Floor
Fort Lauderdale, FL 33394
RE: City of Winter Springs, Construction Fund
93 Series
Dear Gail,
Please issue checks payable against the City of Winter Springs,
1993 Series Construction Fund to the following:
Allsteel, Inc.
135 S. Lasalle, Dept 3048
Chicago, IL 60674-3048 $238.16
Ai Bosgraaf & Sons, Inc.
441 Surrey Run
Casselberry, FL 32707 $24,817.50
Conklin, Porter & Holmes
P.O. Box 2808
Sanford, Fl 32772-2808 $199.81
Please return the checks to the city for distribution.
Thank you.
Sincerely,
CITY OF WINTER SPRINGS
cc:City Clerk
Harry E. Martin
Finance Director
HEH/mj
enclosures(3)
Nations Bank of North Carolina, N.A.
Nations Bank
66-19
530
Date
8056383
03/02/95
Trust and
Investment Services
ACCOUNT NAME
WINTER SPRGS IMP REF 93 CONST
IN PAYMENTOF
PER PAYMENT REQUEST #7 DTD 021095
PAY
. ******24817. 50
To the Order of AL BOSGRAAF & SONS INC
441 SURREY RUN
CASSELBERRY FLORIDA 32707
1-3 Pages
SECTION 00680
CONTRACTOR'S APPLICATION FOR PAYMENT
PAYMENT REOUEST NO. 06
ENGINEERS FILE NO. W435.00
BID NO. 94.002
APPLICATION DATE 12-14-94
COMPLETION DATE 12-24-94
FOR PERIOD ENDING 12-14-94
CONTRACT DATE 4-18-94
STATEMENT OF WORK
The undersigned Contractor hereby swears under penalty of perjury that (1) all previous progress
payments received from the Owner on account of work performed under the Contract referred to
above have been applied by the undersigned to discharge in full all obligations of the undersigned
incurred in connection with work covered by prior Application for Payment under said contract,
being Applications for Payment numbered 1 through _ inclusive; and, (2) all materials and
equipment incorporated in said Project or otherwise listed in or covered by this Application for
Payment are free and clear of all liens, claims, security interests and encumbrances,
DATED 12-14 1994
BY
CONTRACTOR Al Bosqraaf & Sons, Inc
Al Bosgraaf, Pres
(Name & Title)
(Contractor)
00680-1
CITY OF WINTER SPRINGS, FLORIDA
1126 EAST STATE ROAD 434
WINTER SPRINGS, FLORIDA 32708-2799
Telephone (407) 327-1800
December 23, 1994
Attn: Gail Clapp
Nations Bank Trust
One Financial Plaza, 13th Floor
Fort Lauderdale, FL 33394
RE: City of Winter Springs, Construction Fund
93 Series
Dear Gail,
Please issue checks payable against the City of Winter Springs,
1993 Series Construction Fund to the following:
Al Bosgraaf & Sons, Inc.
441 Surrey Run
Casselberry, FL 32707
$92,694.39
Conklin, Porter & Holmes
P.O. Box 2808
Sanford, FL 32772-2808
$6,927.85
Home Depot
Commercial Acct.
P.O. Box 660335
Dallas, Tx 75266-0335
$731.00
Murphy Bed Center
851 E. Hwy 434
Longwood, FL 32750
$1,284.50
Please return the checks to the city for distribution.
Thank you.
Sincerely,
CITY OF WINTER SPRINGS
Harry E. Martin
Finance Director
HEM/mj
enclosures (4)
cc:City Clerk
NATIONSBANK 0001153
Account For the Account Of 63-27
Number Winter Springs 93 Const 631
Description Payment Request # 6 Date 1/4/95
Pay Amount
To the $**92,694.39
Order of AL BOSGRAAF & SONS, INC
441 SURREY RUN
CASSELBERRY, FL 32707
Page 1--3
SECTION 00680
CONTRACTOR'S APPLICATION FOR PAYMENT
PAYMENT REQUEST NO. 05
ENGINEERS FILE NO. W0435. 00
BID NO. 94.002
FINANCE ACCOUNT NO. 3215
CONTRACTOR Al Bosgraaf & Sons, Inc
CONTRACT DATE 4-18-94
COMPLETION DATE 11-24-94
APPLICATION DATE 10-?R-94
FOR PERIOD ENDING 10-27-94
STATEMENT OF WORK
Original Contract Price $ 329,000. Work to Date $ 203.306.80
Net Change Order
Amount Retained
Current Contract Price
Subtotal
Work to be Done
Previous Pay-
ments Approved
Amount Due This
Payment
57,469.32
The undersigned Contractor hereby swears under penalty of perjury that (1) all previous progress
payments received from the Owner on account of work performed under the Contract referred to
above have been applied by the undersigned to discharge in full all obligations of the undersigned
incurred in connection with work covered by prior Application for Payment under said contract,
being Applications for Payment numbered 1 through inclusive; and, (2) all materials and
equipment incorporated in said Project or otherwise lis ed in or covered by this Application for
paymen~ee and clear of all liens, claims, security interests and encumbrances.
DATE
(Contractor)
BY Al Bosgraaf, Pres
(Name & Title)
00680-1
COUNTY OF Seminole
STATE OF FLORIDA
Before me on this 27 day of 0ctober, 1994 personally appeared Albertus Bosgraaf
, known to me, (or has produced FL Dr Lic as identification and.who did (did not)
take an oath) who, being duly sworn did depose and say that he is the President of the
Contractor above-mentioned; that he executed the above Application for Payment and statement on
behalf of said Contractor; and that all of the statements contained therein are true, correct and
complete.
SEAL Jean A. Pabst
Payment of the amount requested above is aproved:
CONTINUATION SHEET
AlA DOCUMENT G 703 (Instructions on reverse side)
PAGE 2 oI3 PAGES
AlA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT,
containing Contractor's signed Certification, is attached.
In tabulations below, amounts are stated to the nearest dollar.
Use Column I on Contracts where variable retainage for line items may apply.
APPLICATION NO.: 5
APPLICATION DATE: 10-28-94
PERIOD TO:10-27-94
ARCHITECT'S PROJECT NO.: 93-115
WORK COMPLETED MATERIALS TOTAL BALANCE
PRESENTLY COMPLETED RETAINAGE
ITEM DESCRIPTION OF WORK SCHEDULED FROM PREVIOUS STORED AND STORED % TO (IF VARIABLE)
NO. VALUE APPLICATION THIS PERIOD (NOT IN TO DATE (G + C) FINISH RATE)
(D + E) D OR E) (D+E+F) (C - G)
G703-1992
CONTINUATION SHEET
AlA DOCUMENT G 703 (Instructions on reverse side)
PAGE 3 OF3 PAGES
AlA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT,
containing Contractor's signed Certification, is attached.
In tabulations below, amounts are stated to the nearest dollar.
Use Column I on Contracts where variable retainage for line items may apply.
APPLICATION NO.: 5
APPLICATION DATE: 10-28-94
PERIOD TO: 10-27-94
ARCHITECT'S PROJECT NO.: 93-115
A B C D E F G H I
WORK COMPLETED MATERIALS TOTAL BALANCE
PRESENTLY COMPLETED RETAINAGE
ITEM SCHEDULED FROM PREVIOUS STORED AND STORED % TO (IF VARIABLE)
NO. DESCRIPTION OF WORK VALUE (G + C) FINISH
APPLICATION THIS PERIOD (NOT IN TO DATE RATE)
(D + E) D OR E) (0 + E + F) (C - G)
SECTION 00663
FORM OF CONTRACTOR'S PARTIAL RELEASE OF LIEN
KNOW ALL MEN BY THESE PRESENTS, that the undersigned,
Al Bosgraaf in consideration of partial payment in the sum of $ 57,469.32
receipt whereof is hereby acknowledged, and other valuable considerations and benefits to
the undersigned accruing, do hereby waive, release and quit claim all liens, lien rights,' claims or
demands of every kind whatsoever which the undersigned now has, or may hereafter have, against
that certain real estate and the improvements thereof, situated in County, Florida, and
legally described as:
850 Northern Way, Unit 4 PIT, BK 18, Page 6,7 and 8. Seminole County
on account of work and labor performed, and/or materials furnished in, to, or about the construction
of any building or buildings situated thereon, or in improving said property above described, or any
part thereof.
It being the understanding of the undersigned that this is a Partial Waiver and Release of Lien
which the undersigned has against the premises described herein, only to the extent of the
payments specified and only for materials furnished or work done up until (but not
releasing or waiving charges for changes, additions, or extras), the undersigned warrants that no
assignment of said liens or claims, nor the right to perfect a lien against said real estate, by virtue of
the accrual of said payment, has or will be made, and that the undersigned has the right to execute
this Partial Waiver and Release, and that all laborers employed by the undersigned, and all bills for
materials and supplies furnished by others to the undersigned in connection with the construction of
Improvements upon the aforesaid premises, to the extent of the payment herein referred to, have
been fully paid.
, IN WITNESS WHEREOF, I/we have executed this instrument under seal this day Oct 28 1994
Al Bosgraaf, Pres
WITNESSES: Jean A. Pabst
END OF SECTION
',' I
.j:
00663-1
NalionsBank-
63-27
631
Trust and
Investment Services
PT 8092287
NationsBank of Florida, N.A.
Account
Number
Date
11/10/94
.
Amount
******57469.32
To The
Order
Of
AL BOSGRAAF & SONS INC
441 SURREY RUN
CASSELBERRY FLORIDA 32707
WINTER SPRGS IMP REF 93 CONST
Payment In Settlement As Described Below
Amount
PAYMENT REQUEST #05 DTD 102894
$*****57469.32
0311 21 07
Keep This Portion For Your Records
CITY OF WINTER SPRINGS, FLORIDA
1126 EAST STATE ROAD 434
WINTER SPRINGS. FLORIDA 32708-2799
Telephone (407) 327-1800
November 2, 1994
Attn: Gail Clapp
NationsBank Trust
One Financial Plaza, 13th Floor
Fort Lauderdale, FL 33394
Re: 1993 Series, Project Fund
Dear Gail,
Please issue a check drawn on the City of Winter Springs
Project Fund for 1993 Series Bond for the following:
Al Bosgraaf & Sons, Inc.
441 Surrey Run
Casselberry, FL 32707
$57,469.32
Please return the check to the city for distribution.
Thank you.
Sincerely,
CITY OF WINTER SPRINGS
Harry E. Martin, Finance Director
HEM/mj
enclosure
cc: City Clerk
.
SECTION 00680
CONTRACTOR'S APPLICATION FOR PAYMENT
PAYMENT REQUEST NO. 04
ENGINEERS FILE NO. LV0435.00
BID NO. 94.002
FINANCE ACCOUNT NO. 3215
CONTRACTOR Al Bosgraaf & Sons. Inc
CONTRACT DATE 4-18-94
COMPLETION DATE 10-8-94
APPLICATION DATE FOR PERIOD ENDING 9-22-94
9-23-94
STATEMENT 'OF WORK
Original Contract Price
Net Change Order Amount Retained
Current Contract Price 329,000 Subtotal
Work to be Done
Previous Pay-
ments Approved
Amount Due This
Payment
The undersigned Contractor hereby swears under penalty of perjury that (1) all previous progress
payments received from the Owner on account of work performed under the Contract referred to
above have been applied by the undersigned to discharge in full all obligations of the undersigned
incurred in connection with work covered by prior Application for Payment under said contract,
being Applications for Payment numbered 1 through _ inclusive; and, (2) all materials and
equipment incorporated in said Project or otherwise listed in or covered by this Application for
Payment are free and clear of all liens, claims, security interests .and encumbrances.
DATED 9-23 1994
(Contractor)
BY Al Bosgraaf /President
(Name & Title)
00680-1
: I
f
!
!
i
\!,'.
J
k
-J
:J
,1;
. ,
"
'I
I
,(
~
,~,
r~
i
".
CONTINUATION SHEET
AlA DOCUMENT G 703 (Instructions on reverse side)
AlA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT,
containing Contractor's signed Certification, is attached.
In tabulations below, amounts are stated to the nearest dollar.
Use Column I on Contracts where variable retainage for line items may apply.
ITEM
NO.
DESCRIPTION OF WORK
18 Glass & glazing
19? ~Gypsum board
20 Ceramic tile
21 Carpet
22 Water proofing
23 Painting
24 Vinyl siding
25 Floor coatings
26 Sliding pole,Flag pole
Bath accessories
Chalk & tackboard
27 Lockers
28 Blinds
29 H.V.A.C
30 Plumbing
31 Fire Springlers
32 Electrical & fire alarm
33 Bond
C
SCHEDULED
VALUE
3,679.00
13,546.00
6,327.00
3,731 .00
2,240.00
9,512.00
3,784.00
4,456.00
6,450.00
3,808.00
837.00
14,189.00
13,552.00
9,598.00
33,636.00
6,451.00
329,000.00
D
E
WORK COMPLETED
FROM PREVIOUS
APPLICATION THIS PERIOD
(D + E)
2,020.00
F
MATERIALS
PRESENTLY
STORED
(NOT IN
D OR E)
3,000.00
APPLICATION NO.:
APPLICATION DATE:
PERIOD TO:
ARCHITECT'S PROJECT NO.:
TOTAL
COMPLETED
AND STORED
TO DATE
(D+E+F)
2,020.00
7,500.00
13,700.00
6,451.00
9-23-94
9-22-94
93-115
H
BALANCE
TO
FINISH
(C - G)
1,659.00
13,546.00
6,327.00
3,731.00
2,240.00
9,512.00
3,784.00
4,456.00
6,450.00
3,808.00
837.00
14,189.00
6,052.00
PAG13 OF3 PAGES
CONTINUATION SHEET
AlA DOCUMENT G703 (Instructions on reverse side)
PAGE2 OF 3 PAGES
AlA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT,
containing Contractor's signed Certification, is attached.
In tabulations below, amounts are stated to the nearest dollar.
Use Column I on Contracts where variable retainage for line items may apply.
APPLICATION No.:04
APPLICATION DATE: 9-23-94
PERIOD TO: .9-22-94
ARCHITECT'S PROJECT NO.: 93-115
WORK COMPLETED MATERIALS TOTAL BALANCE
PRESENTLY COMPLETED RETAINAGE
ITEM DESCRIPTION OF WORK SCHEDULED FROM PREVIOUS STORED AND STORED % TO (IF VARIABLE)
NO. VALUE APPLICATION THIS PERIOD (NOT IN TO DATE (G + C) FINISH RATE)
(0 + E) o ORE) (D + E + F) (C - G)
1 Mobilization 4,000.00 4,000.00 4,000.00 100 400.00
2 Site work 26,096.00 16,500.00 16,500.00 60 9,596.00 1,650.00
3 Termite control 448.00 448.00 448.00 100 44.80
4 Concrete 22, 165.00 22,165.00
5 Footings 3,625.00 3,625.00 3,625.00 100 362 50
6 Concrete slab 8,000.00 8,000.00 8,000.00 100 800.00
,
7 Masonry 15,627.00 15,627.00 15,627.00 100 1 ,562.70
8 Tie beams 4,506.00 4,000.00 506.00 4,506.00 100 450.60
9 Metal fabrications 5,013.00 1,700.00 850.00 2,550.00 50 2,463.00 255.00
10 Rough carpentry 24,829.00 24,829.00 24,829.00 100 2,482.90
11 Trusses 15,448.00 7,900.00 7,548.00 15,448.00 100 1 , 544 . HO
12 Finish carpentry 13,500.00 2,950.00 2,950.00 27 10,550.00 295.00
13 Insulation 4,990.00 4,990.00
14 Shingles 6,480.00 3,000.00 3,000.00 48 3,480.00 300.00
15 Doors & frames 10,886.00 1,000.00 1 , 000 . 00 10 9,886.00 100.00
16 Overhead doors 14,767.00 14,767.00
17 Finish hardware 12,824.0C 12,824.00
COUNTY OF Seminole
STATE OF FLORIDA
. 11vC:- A At. ~ /'
Before me on this 23rd day of September 1994 personally appeared Al Bosgraaf
, known to me. (or has produced as identification and who did (did not)
take an oath being duly sworn did depose and say that he is the President of the
Contractor above-mentioned; that he executed the above Application for Payment and statement on
behalf of said Contractor; and that all of the statements contained therein are true, correct and
complete.
SEAL
Karen L. Pendarvis
END OF SECTION
SECTION 00663
FORM OF CONTRACTOR'S PARTIAL RELEASE OF LIEN
KNOW ALL MEN BY THESE PRESENTS, that the undersigned,
Al Bosgraaf in consideration of partial payment in the sum of $ 51,185.40
receipt whereof is hereby acknowledged, and other valuable considerations and benefits to
the undersigned accruing, do hereby waive, release and quit claim all liens, lien rights, claims or
demands of every kind whatsoever which the undersigned now has, or may hereafter have, against
that certain real estate and the improvements thereof, situated in County, Florida, and
legally described as:
850 Nothern Way, Unit 4 PIT BK 18 Page 6,7 and 8. Seminole County
on account of work and labor performed, ana/or materials furnished in, to, or about the construction
of any building or buildings situated thereon, or in improving said property above described, or any
part thereof.
It being the understanding of the undersigned that this is a Partial Waiver and Release of Lien
which the undersigned has against the premises described herein, only to the extent of the
payments specified and only for materials furnished or work done uJ) until (but not
releasing or waiving charges for changes, additions, or extras), the undersigned war!ants that no
assignment of said liens or claims, nor the right to perfect a lien against said real estate, by virtue of
the accrual of said payment, has or will be made, and that the undersigned has the right to execute
this Partial Waiver and Release, and that all laborers employed by the undersigned, and all bills for
materials and supplies furnished by others to the undersigned in connection with the construction of
improvements upon the aforesaid premises, to the extent of the payment herein referred to, have
been fully paid.
IN WITNESS WHEREOF, I/we have executed this instrument under seal this day of Sept 23
1994
END OF SECTION
00663-1
Nations Bank
Trust and
Investment Services
PI 8090170
NationsBank of Florida, N.A.
Date 10/06/94
Account Number Account Name
WINTER SPRGS IMP REF 93 CONST
Payment In Settlement As Described Below
Amount $*****52650.9
PER PAYMENT REQ '04 DTD 092294
Keep This Portion For Your Records
CITY OF WINTER SPRINGS, FLORIDA
1126 EAST STATE ROAD 434
WINTER SPRINGS. FLORIDA 32708-2799
Telephone (407) 327-1800
September 29, 1994
Attn: Gail Clapp
NationsBank Trust
One Financial Plaza, 13th Floor
Fort Lauderdale, FL 33394
Re: 1993 Series Project Fund
Dear Gail,
Please issue checks drawn on the Cltv of Winter Springs
Project Fund for 1993 Series Bond for the following:
Al Bosgraaf & Sons, Inc.
441 Surrev Run.
Casselberry, FL 32707 $52.650.00
NCI Nationwlde Construction, Inc.
P.O. Box 181132
Casselberrv, FL 32707 $1,339.33
Please return the checks to the city for distribution.
Thank vou.
Sincerely,
CITY OF WINTER SPRINGS
Harry E. Martin
Finance Dlrector
HEM/mj
enclosure
co: City Clerk