HomeMy WebLinkAbout2007 02 12 Consent 402 Florida Housing Finance Corporation Disaster Relief Home Assistance Program
COMMISSION AGENDA
ITEM 402
Consent
February 12, 2007
Meeting
Mgr. Dept.
REQUEST: The Community Development Department requests that the Commission review
and approve the application of the three (3) contractors to perform the home refurbishing work
associated with the Home Again - Florida Housing Finance Corporation Disaster Relief Home
Assistance Program.
PURPOSE:
The purpose of this agenda item is to request approval of Florida Homes, Inc., TRBC, Inc., and
Platter Construction, Inc. as the contractors authorized to perform refurbishment work on
residential homes in the City of Winter Springs as part of the Home Again - Florida Housing
Finance Corporation Disaster Relief Home Assistance Program.
CONSIDERATIONS:
The City of Winter Springs, in early 2005, was awarded $300,000 in HOME Again funds by the
Florida Housing Finance Corporation to assist a limited number low-income homeowners
impacted by the hurricanes of2004.
The City of Winter Springs sought applicants to participate in the Home Again Program through
the Florida Housing Finance Corporation (FHFC) to assist homeowners with repairs necessitated
due to the hurricanes of 2004. This program is designed to perform general code-related repairs
and improvements or replacement of housing, if necessary, for low and low to moderate income
homeowners. These items can include roofs, heating systems, plumbing, electrical and other
code related housing systems. Reimbursements for repairs already completed are not eligible for
assistance. Any assistance for real property damage received from homeowner's insurance or
FEMA must be applied to the repairs or replacement of the home before any grant funds can be
applied. All applicants must be residents of Winter Springs and must meet certain established
eligibility requirements in order to participate in the Home Again Program.
The three contractors whose applications are part of this agenda item have been pre-approved for
participation in the Home Again Program by Meridian Services, the City's consultant for this
program.
February 12, 2007
Consent Agenda Item 402
Page 2
RECOMMENDATION:
It is staff s recommendation that the Commission approve the three contractors whose
application information is attached to this agenda item, to perform refurbishment work in the
City of Winter Springs associated with the Home Again Program.
ATTACHMENTS:
A. Contractor Applications
COMMISSION ACTION:
2
FROM :.MERIDiAN
FAX NO. :3523818270
Dec. 21 2006 09:46AM P2
HOUSING REHABILITATION PROGRAM
APPLICATION FOR CONTRACTOR CERTlFlCATION
A. Name Bill Herring
Company Name: Fla homes Inc R/C
Business Address: 13919 NW 145th Ave Alachua, FL 32615I ,
Mailing Address: (if different) Same
Primary Nurnber(s): 386-418-4663 (please advise what # is office home etc)
Altemate Number: 352-262-7718 cell Fax Number: 386-462-7718
E-MailAddress: flahomes@bellsouth.net
Website address: N A
Residence Address:
License Number(s):
Social Security or
Federal 1.0. Number:
B. Business is a:
~ Corporation in the Slate of Delaware
Owner(s) and address (es):
2.
Officers (name and title) and addresses:
1.
2.
Page 1 of 5
CD
FROM :.MERIDIAN
FAX NO. :3523818270
Dec. 21 2006 09:47AM P3
Page Two
C. Nameof Liability InsuringCompany:
Address;
Policy 'Number:
Comprehensive Public Liability Coverage:
Property damage Coverage: $
Workmen's Compensation Covelllge: (copy of notice if exempt)
COMMERCIAL GENERAL LIABILITY
Coverage must be afforded under a per occurrence form policy for limits not less than $1,000,000
General Aggregate, $1.000,0000 Products I Completed Operations Aggregate, $1,000,000 Personal and
Advertising Injury Liability, $1,000,000 each Occurrence, $50,000 Fire Damage Liability and $5,000
Medical Expense.
D. Name of Auto Insurance Company:
Address
Policy Number: Phone Number:
AUTOMOBILE LIABILITY
Coverage must be afforded including coverage for all Owned vehicles, Hired, and Non-Owned vehicles
for Bodily Injury and Property Damage of not less than $1,000,000 combined single limit each accident.
E.
Number of years In business under present name:
Previous business yes no
Name:
From 19 to 19
Where:
2. Name:
From 19 to 19
Where:
Page 2 of 5
FROM MER ID J AN
FAX NO. :3523818270
Scarborough Company Insurance
3811 NW 41st 5treet
P, O. Box 147050
Gainesville, FL 32614-7050
Fla Homes Inc A Delaware Corp
3131 NW 11th Street Suite 52
Gainesville, FL 32609
ACORD CERTIFICATE OF LIABILITY INSURANCE 10/10/2006
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATtON
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
INSURERA: Owners Insurance Company
INSURERB: Auto Owners Insurance Co
NAIC
THE POUClES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING
ANY REQUlREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TEMM OR CONDITIOIIi 01' fJHY CONTAACT OR cm& DOCOMENT 1IIR"noI RE9PE!CT TO WHICH lHlS CERllFICATE MAY 8E ISSUED OR
Page'1bree
F. Local creditors (banks, savings, & loans, other):
Name CAPITAL CITY BANK
Address
1.
2.
3.
G. Suppliers used frequently and currenll:y:
Name
Address
PAGE FOUR
RECENT CUSTOMERS:
NAME ADDRESS TELEPHONE
PAGE 4 OF 5
Page 5
The undersigned Contractor certifies that all information given herein is correct and further agrees:
1. That his contractor license(s) is (are) current, and that be will maintain in a current status all
license(s) as required by the County and Stale.
2. That insurance and workmen's compensation will be maintained as required by the Housmg
Rehabilitation Program.
3. To allow the Housing Rehabillnuion Program to I,:heck any n:terence named herein or elsewhere in
determining his competence and integrity as a contractor.
4. That thc work will be performed in accordance with all code standards, :toning regulations and
specifications, subject to a clear final inspection by the Housing Rehabilitation Program, Building
Inspection Department. and Properly Owner.
5. ThaI if the work. is found to be unsatisfactory by the Housing Rehabilitation Program, Of the
Building Inspector, or if contract relations between the Contractor and the Homeowner or other
parties are found to be unsatisfactory, the Contractor's name may be removed from the approved
list, with such accompanying publicity as deemed necesllary.
6. That he will abide by regulations pertaining to Equal Employment Opponunity.
7. That he has a satisfactory record regarding complaints tiled against the contractor at the state,
federal or local level and is not on any list or deban'ed contractor. issued by the Federal or State
DOL. I-IUD or DCA.
Date: _.LP .- 3 J
, 2006
J .. I!-
Signed: LV JA,. . ~~ ..1,..( ~....
Contractor I
Prillt: B t II Jt.~n~
'~~~i ~ RI L~
Page 5 of 5
CITY OF WINTER SPRINGS
HOUSING REHABILATION PROGRAM
CONFLICT OF INTEREST STATEMENT
CHECK THE FOLLOWING THAT APPLY:
I hereby certify that I am not related to any of the current City of Winter Springs
Commission members as identified below.
Mayor John F. Bush
Commissioner Michael S. ,Blake
Commissioner Donald A. Gilmore
Commissioner Joanne M. Krebs
Commissioner Sally McGinnis
Commissioner Robert S. Miller
I am related to Commission member
I hereby certifY that I am NOT a City of Winter Springs employee Nor am I related to
any City of Winter Springs employee.
I am a City of Winter Springs employee or I am related to the following City of Winter
Springs employee or employees:
Name
Department
Name
. Department
The city of Winter Springs does not currently have a CA TF (Citizen's Advisory Task Force)
committee.
Bill Herring
ApplIcant Signature
Licensing Portal - License Details
License Details
Name:
Main Address:
County:
License Mailing:
County:
LicenseLocation:
County:
licenselnfonnaUon
license Type:
Rank:
license Number:
Status:
Licensure Date:
Expires:
Special Qualifications
Bldg Code Core Course
Credit
Qualified Business Llcen..
Required
HERRING, WILLIAM CARL
FLA HOMES THe REAL TV CONSTRUCTION (DBA
13919 NW 145TH AVENUE
ALACHUA Florida 32615
ALACHUA
13919 NW :l.45TH AVENUE
ALACHUA FL
ALACHUA
3131 NW 13TH STREET
ST. .52
GAINESVILLE FL 32609
ALACHUA
Certified General COntractor
Cert General
CGC052062
Current,Actlve
1:1./28/1990
08/31/2008
Qualification Effective
03/08/2005
View. Related License Information
View. License Complaint
https:llwww.myfloridaJicense.comILicenseDetail.asp?SJD=o:&id=73 723 7
https:/Iwww.myfloridaJicense.comlviewcomplaint.asp1SlD=&licjd=737237
SWORN STATEMENT UNDER
SECTION 287.133(3)(8). Florida Statutes
ON PUBLIC ENTITY CRIMES
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR
OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
1. ThIS sworn statement is submitted to Winter Springs by Wm. Carl Herring III
for Fla. Homes Inc, whose business address is
13919 NW 145th Avenue, Alachua FL 32615
and Its Federal Emptoyer identification No. (FEIN) is
2. I understand that a .pubtlc entity crime" as defined In Paragraph 287.133(1)(0), Florida statutes,
means a violation of any state or federal law by a person with respect to and directly related to
the transaction of business with any publio entity or with an agency or pollUcal subdivision of any
other state or of the United states, Including, but not limited to, any bid or oontr8ct for goods or
services to be provided to any pubJ;c entity Of an agency or political subdivision of any other state
or of the United states and Involving antitrust, fraud, theft. bribery, collusion, racketeering,
conspiracy, or material misrepresentaUon.
3. I understand that .conV,icted" or "conviction" as defined In Paragraph 287.133(1) (b), Florida
Statues, means a finding of guilt or 8 conViction of a publlO entity cr1me, wtth or without an
adjudication of gum, In any feeleral or state trial court of record relating to charges brought by
indictment or information after July 1, 1989, as a result of jury verdict, nonjury trial, or entry of a
plea of guilty or nolo contendere.
4. I understand that an "affiliate" as defined In Paragraph 287.133(1) (8), f1Qrida Statues, means:
1. A predecessor or successor of a person convicted Of 8 pubfio entity crime; or
2. An entity under the control of any natural person who is active In the management of the
entity and who has been convicted of a public entity cr1me. The tenn "8ffiliate" Includes those
officers, dlrectoni, executives, partners, shareholders, employees, members, and agents Who
are active In the management of an affiliate. The ownership by one person of shares
constituting a controlling interest in another person, or a pooling of equipment or income
among persons when not for fair market value under an arm's length agreement, shall be 8
pr1ma facie C8S8 that one person (:bntrols another pel'$On. A person who knowingly enters
Into 8 joint venture with a person who has been convicted of 8 public entity crime in Florida
during the praceding 36 months shall be oonsldeted an affiliate.
5. I understand that 8 "person" as defined in Paragraph 287.133(1) (e), FIQrlda Statutes, means Bny
natural person or entity organized under the laws of any state or Of the United States with the
legal power to enter into 8 binding contract and wyhich blds or applies to bid on contraets for the
provtslon of goods or selVices let by a public entity, or which oth8lWlse transacts or applies to
transact business with a public entity. The term .person" includes those officers, directors,
executIves, partners, shareholders, employees, members. and agents who are active In
management of an entity.
commissioned name of notary PUblic)
Page 1 of 5
HOUSING REHABILITATION PROGRAM
APPLICATION FOR CONTRACTOR CERTIFICATION
Mailing Address. (if different)
Primary Number(s):
Alternate Number: Fax Number:
E-Mail Address:
Website address: .
Residenco Address:
License Number(s);
Social Security or
Federal I.D. Number:
B. Business is a: _ sole proprietorship _ partnership
~ _ Corporation in the State of Delaware
Owner(s) and address (es):
1.
2.
Page 1 of5
Page Two
Insurance requirements: $100,0001$300,000 coverage for contractor's public liability (including accidental death
and bodily injury), or $300,000 comprehonsive coverage and $100,000 coverage of property damage (in addition to
bodily,injury). with a certificate on insurance rrom the insurer guaranteeing ten (10) days notice to the Housing
Rehabilitation Program before discontinuing coverage. Workman's CompenRation., as applicable, is also required.
c.
Name of Liability Insuring Company: Nationwide
Address:
Policy Number
Comprehensive Public Liability Coverage:
Property Damage Covemge:
Workmen's Compensation Coverage:
D.
Name of Auto insurance Company
Andress
Policy Number:
E.
Number of years in business under present name:
Previous business? 1 yes / no
Page 2 of 5
Page Three
F. Local creditors (banks, savings, &, loans. other):
Name
Address
1.
2.
3.
O. Suppliers used frequently and currently: (Two required)
1.
Name
Address
2.
3.
4.
H.
Subcontractors: (Three required)
1.
Page 3 of 5
Page Four
1. Recent Customers:
Address
Telephone
l.
2.
3.
4.
J. Current Employees:
1.
2.
3.
4.
S.
6.
7.
8.
9.
10.
Name
Address
Telephone
Superintendent for jobs is usually (check one):
(name)
Employee
K. Have you (personally or under present or past hw"liness) been declared bankntpt during the past
five (5) years?
Yes / A no If yes, have debts been paid?
Page 4 of 5
Page Five
The undersigned Contractor certifies tha all information given herein is correct and further agrees:
I. That his contractor license(s) is (are) current, and that he will maintain in a current status all
license(s) as required by the County and State.
2. That insurance and workmen's compensation will he maintained as required by the Housing
Rehabilitation Program.
3. To allow the Housing Rehabilitation Program to cheek any reference named herein or elsewhere in
determining his competence and integrity as a contractor.
4. That the work will be performed in accordance with all code standards, wning regulalions and
specifications, subject to a clear final inspection by the Housing Rehabilitation Program, Building
Inspection Department, and Property Owner.
5. That if the work is found to be unsatisfactory by tho Housing Rehabilitation Program, or the
Building Inspector, or if contract reJations between the Contractor and the J{omClowner or other
parties are tound to be unsatlsfilctory, the Contractor's name may be removed from the approved
lil'lt, with such accompanying publicity as deemed ne(..'essary.
6. That he will abide by regulations pertaining to Equal Employment Opportunity.
7. That he ha.q a satisfactory record re~ding complaints filed against the contractor at the state.
fuderal or Jocallevel and is not on any tillt of debarred contractors issued by the Ped.eral or Slate
DOL. HUD or DCA.
Date:
Print:
Page 5 of 5
Tom Hutchison
1598 Stone Trail
Enterprise, FL 32725
Phone: 407-314.8099
Email:thutcb142@yahoo.com
John
Please find this short narrative a "filler" for some of the areas in the application left
blank.
1) I used to build homes full time from 1983 to 1992. Most of work is now comprised of
renovating homes, improving commercial spaces and buying,rchabbing and sclling or
keeping homes.
T don't have any creditors. .1 have an account at Cox Lumber (now known as HD Supply)
and Inland Materials, but, I don't use them often. I pay as I go. Tfyour projects avcrage
$15,000, T can support 4-6 at a time.
T do not have any employees. I have a brother that is a licensed roofing contractor and
builder, and I have another contractor friend. We trade labor as we need it. T havc access
to a few lahorer types that have general liability and wc exemption that work on an as
need ba..c;is.
I am a fifth generation builder from P A. T have been building in Florida since 1980. In
P A., you do not need u license to perform any trade work. I can ~o electrical, plumbing,
roofing, lile, cabinets, drywall etc. I do hire licensed professional~ as needed, but, 1 can
get a good idea of the scope of work and cost on the firstjobsite visit.
Please call with any questions,
Tom Hutchison
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW
CONSTRUCTION INDUSTRY EXEMPTION
TOM GAI.LAGHER
CHIEF FINANCIAL OFFICER
* *
This ,certifies that the individual listed below has olected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE:
10/18/2006
EXPIRATION DATE: 10/17/2008
PERSON: HUTCHISON
FEIN: 134242332
BUSINESS NAME AND ADDRESS:
T R B C INe
1588 STONE TRAIL
ENTERPRISE FL 32725
SCOPES OF BUSINESS OR TRADE:
CERTIFIED BUILDINQ CONTRACTOR
Licensee Information
Name:
Main Address:
License Mailing:
LicenseLocation:
License Xnformation
LIcense Type:
Rank:
License Number:
status:
licensure Date:
Expires:
Special Qualifications
Qualified Business
License Required
FAX NO. :3523818270
Dec. 21 2006 09:50AM P18
......b- .. ..... -
HUTCHISON, THOMAS SCOTT (Primary Ninne)
T R B C INC (DBA Nam.)
1598 STONE TRAIL
ENTERPRISE Florida 32725
certified 8ulldlng Contractor
Cert Building
CBC1251683
current,Actlve
03/09/2004
08/31/2008
Qualltlation Effective
03/09/2004
https:llwww.myfloridaHcense.comILicenseDetail.asp.lSlD=&id=2562269
11130/2006
Licensing Portal View Public Complaints
Complaint Details
Displayed is a listing of public complaints regarding the person or entity selected. The only
complaints that appear on this screen are public complaints against persons or entitles that
currently are licensed by the Department of Business and Professional Regulation.Such data
includes complaints for which probable cause has been determined or where the subject of the
complaint has waived hiS/her right to confidentiality. However, the department is precluded from
disclosing any complaints which are confidential pursuant to section 455.225(10), Florida
Statutes. If you would like to file 8 new complaint It can be fU.~Q her~.
Complaints filed with the Division of Florida Land Sales, Condominiums, and Mobile Homes, the
complaint forms and aU Information submitted to the Division are public records under the
provisions of Chapter 119, Florida Statutes, Florida's Public Record Law. Accordingly, any person
may inspect the case file and may obtain copies of any of the materials In the file. The Division
does not represent your private Interests. Any action taken by the Dtvislon will be on behalf of the
State of Florida.
Complaints created by or flied with the Division of Alcoholic Beverages and Tobacco become
public upon the completion of the Investigation. However, only those complaints created or filed
since August 21,2002, are avaUable through this site. To ascertain the existence of pUblic
complaints pertaining to viofatt'ons of aJcohot and tobacco Jaws prior to that date, please submit a
pObllc records request by contacting us via phone at 850.487.1395 or via mail at Department of
Business and Professional Regulation, Division of Alcoholic Beverages and Tobacco, '1940 North
Monroe Street, Tallahassee, Florida 32399-1020.
Additional search mechanisms are available to ascertain the existence of aoy public records
pertaining to the unlicensed activity of the person or entity about which you are inquiring.
S~9.r,GI:\ for PU,b!!~__I3.~~rds" p..~rti!'.n.il1g .to Unli~,gJlsed Con.stnJ.q;ion coOlr~go.r: COIT)I;!Ji'.ints H~...r~
.S~arch fprJ~!,I_p..lic Records-P.~,n:alning tj:t.~.U.".9ttrer Unl,iC;11l.I"!.$.gq ,Compli)JD.t~ Here
Name:
Number Class Incident Date Status Disposition Disposition Date Discipline Discipline Date
No Complaint Information found.
https:/Iwww.myfloridalicense.comlviewcomplaint.asp?SJD=&licid-2S62269
11/30/2006
https:/ /www.myfloridalicense.comlrclationList.asp?recoTd. "cnt-l &LicId=2562269
11/3012006
Based on information and belief, the statement whiCh' have marked beloW Is true in relation to the
entily submitting this sworn statement (Please indicate which statement applies.)
Neither the entity submitting this sworn statement, nor any
officers, directors, executives, partners, shareholders, employees, members. or agents
Who are active in management of the entity, nor any affiliate of the entity has been
charged with and convicted of a public entity crime subsequent to July 1, 1989.
The entity submitting this swom statement, or one or more of its officers. directors,
executives, partners, shareholders. employees, members, or agents who are active in
management of the entity, or an affiliate of the entity has been charged with and convicted
of a public entity crime subsequent to July 1, 1989.
The entity submitting this sworn statement, or one or more of Its officers. directors,
executives, partners, shareholders, employees, members. or agents who are active In the
management of the entity, or an affiliate of the entity haEl been chargQd with and convicted
of a public entity crime subsequent to July 1, 1989. However. there has been a
subsequent proceeding before 8 Hearing Officer of the State of Florida, Division of
Administrative Hearings and the Final Order entered by the Hearing Officer determined
that it was not in the public interest to place the entity submitting this swom statement on
the convicted vendor list. (Attach copy of the final order.)
I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER .FOR
THE PUBLIC ENTITY IDENTifiED IN PARAGRAPH ONE (1) ABOVE IS FOR THAT PUBLIC ENTITY
ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN
WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY
PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED
IN SECTION 287.017 FLORIDA STATUI;S, FOR CATEGORY TWO OF ANY CHANGE IN THE
INFORMATION CONTAINED IN THIS FORM.
Signature
sworn to and subscribed before me this 5th day of December 2006.
Personally known
or reduced Identification
Notary PUblic - State of Fl
(Type of Identification)
My commission expires
FROM : MER ID I AN
. .
FAX NO. :3523818270
Dec. 21 2006 10:00AM P2
..-
'.
M ..
HOUSING REHABILITATION PROGRAM
APPLICATION FOR CONTRACTOR CERTIFICATION
A. ~Owl1er:. .. .-Rle~MIl V. PJ~('~) $e~ f<. PI~1il(' fl.p)
Company Name: ...P.J~+t-et" c.,tlstr~rJ.1on hlC. .
Busines5^ddres~: 500t ~rlAN1 ..b.~ Avt. ()rl~o 1 Ft. 3?812.
Mailing Addre~s: (it different) 5 ~~. . . .. ._-
PrimliTY Nwnber(s): '107- "It, 1.. i2$O .Stu\ (p~ease advise what # i~
Alternate Number: !f~.7~ 1{91~ 1689 t'l"le. Fax Number: '107- ~.~~.. 2 'i1tJ
E_MailAddress:_.._.St~plA.iier@~f.#al.i1IL.net
Website address: n /a..
, ,..0.-",,'. ........-..-..
Residence AddreSS: 3oS'f StA w~ ~_ .cf. APofk.~ .E~ 321 D 3
License Number(s): c.ae 12.5' 35" I
--hW 8e.6b.lt) or 51 0 tl (J I L.J a
Federal I.D. Number: . ~. .": ~.. ..3.V..Cl..LL1
B.
Busin~s is a: _ sole proprietorship
~ Corporation in the State of De l"kI~_
Owner(s) and address (es):
RiDhOrJ. V. PI~-H<<
....5Y.Q.L...~ L~ PM. O((A~~..~2:'.I.~...
Bon.rtit J. Pl~
SDOl G.fQn Loo. . Avf.. Ot4 '"'tAD Ft.. 3 ~ ~I.~
__ partnership
1.
2.
Officers (name and titlc) and addresses:
1. Ri~aro( V. P~~. ~....presi~+/cFO - .--
5l>>l GfU~ ~ ft.Jt. O,..l~J.D R... .~~gl~"
2. Sean __~...~e~~~_ - via presidenr 1.~oC? .....
30~5 S\AW"''''-~~~. cb__.hop~ F(....- 32.1"3 -
Page 1 of 5
Q)
FROM : MER ID I AN
FAX NO. :3523818270
Dec. 21 2006 10:01AM P3
Pago TWo
Insuranee reqairement!l: $100,000/$300,000 coverage for contractor's public liability (including accidental death
and bodily injury), or $300,000 comprehensive covel'al:o'e and $100,000 coverage of property damage (in addition to
bodily injury), with a certificate on insurance from the insurer guaranteeing ren (10) days notice to the Housing
Rehabilitation Program before discontinuing coverage. Workman's Compensation, a.,'1 applicable, iSlllso required.
, '
C. Name of Liability ~uring Company: Mid. Con~~~t ~u.oL~, % S+W:~""-J B.~~ \ AutJc..
Address:.JI2(' Pt\'Cl~ ~_,..:P(. ~~ ~1.ltCJ
PolicyNumbor: O~....6.L~ 000 ~2IlDttO..,
Comprehensive Public Liability Coverage: $ SOO, ~_OO
Property Damage Coverage: $ ~,.oo()
workmen's Compensation Coverclge: $ n I~...
(copy ofnoticc ifcxcmpt)
D.,
Name of Auto Insurance Company: S-hde t~.,., ~ Jlltli~ tl~110tl
J'~!..~~VtA. ~ ~..,.. ~~WCtxl,...._,. fL. _
PolicyNumber.--fq-6~Pbon.Number. ljb1-1 ~.O~ro
Address
E.
Number of years in business under present name: _..J.y-(f>.fS
Previous business? ___-- yes I ~ no
'{yes: I. Name: n / a.
,
FrO'm 19 to 19
Where:
2. Name: ",IrA
,
From 19 to 19
Where:
Page 2 of I)
~
FROM : MER ID I AN
. .
FAX NO. :3523818270
Dec. 21 2006 10:01AM P4
Page Three
F. .Lcx:al creditors (banks. savings, & loans, other):
.Name
Address
1. . _BM\L qf Amuieoe.. _ OrltWl.lo ..FL. 32~~'l
(, (}tJ 3 ~IV ~., l ~. liD "!.. P 57.-:-..? I):J. 1/ .
2. S'~~":"I/++."., h";A4trC'~!J:.L I./f)?'''' ':).'1- :; 333
/ S" I SOM'lik,."l,..L _.. LA-Nt. r'C(;N /30 t!4d1.,..,J [l 3 ~2S-1
3.
G. Suppliers used frequently and currently: (Two .required)
Name'
Address
1.
L.owls PI) 8..... S"3 IJ q~1/
/JfLI+-N'i-A J (;.4....._ 343 $'3.,- () i:JS'f .
HOM!._....~ot . e~ IJ hl)~q
[Iu. l#-es, 411 cP?O(-:: 6 O~_
nq,ptv\~.J 8U;l~,'", ~~.$ t/17 - ~.~3 - r~~~_
'1'3 c J~'tl (,J1+~1l .IJ/l ()It.liIJ~J..,,..ct.. "S?J':({)
~ Su.~ -rA OM h=,r Lu .-... ke~... Ct> "'7 ~..8:~ I~~T)
{Jb!3 q91._..._...Q~ PL ...,,~c?~a. ,,"
2.
3.
4.
H.
Subcontractors: (Three roquiroo)
EleWic: 1. A. t. ~\eeh:!~.. ~.,,_ Cevth.\ r; 'M rJ.,..,
2. .J"'tChnic.' ~.4.~'c..
1. Dr-A,Ot\ Pl",mle in, ~
2. _Ewaer"lJ. PI u WI 10; n, .....
Mechanical: 1. Al'r COt'lt.t...p.O of' teMirPJ f'~t'"'~
2. A. e. ELedv.l.~ ._~ ~~ ~Lo",~
1, Rt. . r()Of ~~.~.
2, ~m~ f4",~.....
3.
Plumbing:
Other:
Page 3 of 5
Page Four
I.
Recent Customers:
1.
Telephone
Current Employees:
Name
Address
2.
3.
4.
J.
Name
Address
Telephone
1.
2.
.3.
4.
5.
6.
7.
8.
9.
10.
" Superintendent for jobs is usually
contractor . . Employee,
K. Have you (personally or under present or past business) been declared bankrupt during the past
five (5) years? .
~ Yes/
Page 4 of 5
Page 5
TIhe undersigned Contractor certifies that all information given herein is correct and further agrees:
l. That his contractor license(s) is (are) current, and that be will maintain in a current status all
liconse(s) as required by the County and State.
2. That insurance and workmen's compensation witl be maintained as reqUiTOO by the Housing
Rehabilitation Program.
3. To allow the Housing Rehabilitation Program to check any reference .named herein or elsewhere in
dul.ermining bis competence and int.egrity as a contractor.
4. That the work will be performed In accordance with all code standards, zoning regulations and
specifications., subject to a clear final inspection by the Housing Rehabilitation Pro!Vanl. BlIUding
Tnspection Depanment, and Property Owner.
5. 'lhat if the work is found to be unsatisfactory by the Housing Rehabilitation Program, OT the
Building Inspector. tlt if contract relations between the ContrctCt.or and the Homeowner or other
parties are f(Jund lo he unsatisfactory, the Contractor'S name may be removed from the approved
list, with such l1Ccompanylng publicity as deemed necessary.
6. That he will abide by regulations p",rtaining to Equal Employment Opportunhy.
7. That he has a satisfactory record re&8rding complainLS me<! apinlJt the contractor at the state,
federal or local level and is not on any list of debarred contractors issued by the Foderal or State
DOL, RUP or DCA.
Date:
Signed
Print:
Page 5 of 5
STATE OF FLORIDA
DIVISION OF WORKERS' COMPENSATlON
BUREAU OF COMPLIANCE
EMPLOYER EXEMPTIONS REPORT
Employer ID:
FEIN/SSN:
Name:
Street1:
Street2:
City: State: FL
Zip: 32812.
PLATTER
.
Licensing Portal License Details
STATE OF FLORIDA
DIVISION OF WORKERS' COMPENSATI9N
BUREAU OF' COMPLIANCE
EMPLOYER EXEMPTIONS REPORT
Employer ID: 0004~5~6
FEIN/
Name:
Street1:
Street2:
City:
State: FL
Zip: 32812
10/06/2004
00/00/0000
ORIGINAL
2008
EXPIRES
8/3012001
3110-0575311
530.00
TOTAL TAX
PREVIOUSLY
TOTAL DUE
$30.20
$30.0O
$0.00
Licensing Portal License Details
Licensee Details
Licensee Information
Licens Information
Special Qualifications
Qulaified Business License
Required
Licensing Portal View Public Complaints
complaint Details
Displayed is a listing of public complaints regarding the person or entity selected. The only complaints that
appear on this screen are public complaints against persons or entities that currently are licensed bV the
Department of Business and Professional Regulatlon.Such data Includes complaints for which probable
cause has been determined or where the subject of the complaint has waived his/her right to
confidentiality. However, the department Is precluded from disclOSing any complaints which are
confidential pursuant to section 455.225(10), florida Statutes. If you would like to file a new complaint it
can be filed. "tt.f;!re.
Complaints fifed w;th the Division of Florida Land Safes, Condominiums, and Mobile Homes, the complaint
forms and aU information submitted to the Division are pUblic records under the provisions of Chapter 119,
Florida Statutes, Rorida's Public Record law. Accordingly, any person may inspect the case file and may
obtain copies of any of the materials In the file. The Division does not represent your private interests. Any
action taken by the Division wilt be on behalf of the State of Florida.
Complaints created by or flied with the Division of AlcoholiC Beverages and Tobacco become public upon
the completion of the Investigation. However, only those complaints created or filed since August 21,
2002. are avaUabJe through this site. To ascertain the exIstence of publlc complaints pertaining t.o
violations af alcohol and tobacco raws prior to that date, please submit a publiC records request by
contacting us via phone at 850.487.1395 or via mail at Department of Business and Professional
Regulation, Division of Alcoholic Beverages and Tobacco, 1940 North Monroe Street, Tallahassee, Rorida
32399~1020.
Additional search mechanisms are available to ascertain the existence of any publiC records pertaining to
the unlicensed activity of the person or entity about which you are InqUiring.
.Search ,f'Q!:Rl,IlJlicR.e.Q2.td$ Perta.i,n.J.o.g .to Unlicen~~p, CO,ns~~uc;.t'9n C,OI).tr.~.~or Co.r:n.p-!.~ints Her.~
$.~.arch for, p'uQJ.ic Re~Qr.d..!?,PertalollJ.g.J(t all other. !JDJ!~ensed ~.QJJ').plalnts Jjgr~
Name:
Number C.... Inc;ident Date Status Disposition Oisposltlon Da.
No Complaint Information found.
Discipline Discipline Date
https:/Iwww.myfloridalicensc.comlviewcomplaint.a.c;p.?SID--&licid=...3090784
12/412006
Licensee Information
Name:
Main Address;
License Mailing:
LicenseLocatlon:
License Information
Ucense Type:
Rank:
License Number:
Status:
Licensure Date:
Expires:
Certified Residential Contractor
Application In Progress
Special Qualifications
Qualification Effective
https:llwww.my.tloridalicen!re.com/LicenseDetan.a.c;p?SIlF&id=3401372
121412006
License Details
Licensee Information
Name:
MaIn Address:
ORANGE
County :
License Mailing:
LicenseLocation:
License Information
License Type:
Rank:
License Number:
Status:
Licensure Date:
Expires:
Construction Financial Officer
Fin Officer
FRO:l781
Current
08/16/2006
Special Qualifications
Qualification Effective
Vie_w..J~.~late_cLl-icens..e. Inform~..t!Qn
View .l..~!:;'tose CQJIlplaint
https:l/www.myfloridalicense.comlLicense.OetaiI.asp?S.ID=&id=3408728
12/4/2006
https://www.myfloridalicense.com/I.icenseDetail.asp.?SITF&id=2942548
12/4/2006
SWORN STATEMENT UNDER
SECTION 287.133
ON PUBLIC ENTITY C
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR
OTHER OFFICIAL AUTHORIZED TO ADMIISTER OATHS.
l. This sworn statement is submitted to Winter Springs by
whose business address is
and its Federal Employer identification No. (FEIN) in
2. I understand that a "public entity crime" deftned In Paragraph 287.133(1)(g), fJoridll SbttutM.
mean. violation of any state or federal law by person with respect to and directly related to the
transaction of business with any public entity or with an agency or political subdivision of any other
state or of the United States, including, but not limited to, any bid or contract for goods or services
to be provided to any public entity or an agency or political subdivision of any other state or of the
United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or
material misrepresentation.
3. I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1) (b) Florida
Statues means a finding of guilt or a conviction of a public entitiy crime, with or without an
adjudication of guilt, in any federal or state trial court of record relating to charges brought by
indictment or information after July 1, 1989, as a result of jury verdict, nonjury trial, or entry of a
plea of guilty or nolo contendere.
4. I understand that an "affiliate" as defined in Paragraph 287.133(1) (a) Florida Statues, means:
1. A predecessor successor of a person convicted of a public entity crime; or
1. An entity under the control of any natural person who is active in the management of the entity
and who has been convicted of a public entity crime. The term "affilate" includes those
officers, directors, executives, partners, shareholders, employees, members, and agents who
are active in the management of an affiliate. The ownership by one person of shares
constituting a controlling interest in another person, or a pooling of equipment or income
among persons when not for fair market value under an arm's length agreement, shall be a
prime facie case that one person controls another person. A person who knowingly enters
into a joint venture with a person who has been convicted of a public entity crime in Florida
during the preceding 36 months shall be considered an affiliate.
5. I understand tha a "person" as defined in Paragraph 287.133(1) (e) Florida Statues means any
natural person or entity organized under the laws of any state or of the United States with the legal
power to enter into a binding contract and which bids or applies to bid on contracts for the
provision of goods or services let by a public entity, or which otherwise transacts or applies to
transact business iwht a public entity. The term "person' includes those officers, directors,
executives, partners, shareholders, employees, members, and agents who are active in
management of an entity.
6. Based on information and belief, the statement which I have marked below is true in relation to
the entity submitting this sworn statement (Please indicate which statement applies.)
Neither the entity submitting this sworn statement, nor any
officers, directors, executives, partners, shareholders, employees, members, or agents
who are active in management of the entity, or an affilate of the entity has been charged with and convicted
of a public entity crime subsequent to July 1, 1989.
The entity submitting this sworn statement, or one of more of its officers, directors,
executives, partners, shareholders, employees, members or agents who are active in
management of the entity, or an affiliate of the entity has been charged with and convicted
of a public entity crime subsequent to July 1, 1989.
The entity submitting this sworn statement, or one or more of its officers, directors,
executives, partners, shareholders, employees, members, or agents who are active in the
management of the entity, or an affiliate of the entity has been charged with and convicted
of a public entity crime subsequent to July 1, 1989. However, there has been a
subsequent proceeding before a Hearing Officer of the State of Florida, Division of
Administrative Hearings and the Final Order entered by the Hearing Officer determined
that it was not in the public interest to place the entity submitting this sworn statement on
the convicted vendor list. (Attach copy of the final order.)
I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR
THE PUBUC ENTITY IDENTIFIED iN PARAGRAPH ONE (1) ABOVE IS FOR THAT PUBLIC EtmTV
ONLY AND. THAT THIS FORM IS VALID THROUGH OECEMBER 31 OF THE CALENDAR VEAR IN
WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBUC ENTITY
PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDEP
IN SECTION 287.017 FLORIDA STATUES, FOR CATEGORY TWO OF ANY CHANGE IN THE
INFORMATION CONTAINED IN THIS FORM.