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HomeMy WebLinkAbout040113_ca06Department of Public Works O Consent Agenda Page 1 of 1 Jefferson County Board of Commissioners Agenda Request To: Board of Commissioners Philip Morley, County Administrator From: Frank Gifford, Public Works Director Agenda Date: April 1, 2013 ~~ Subject: Execution of Contract with Seton Construction for Alder Creek Tributary Culvert Replacement, Upper Hoh Road MP 2.15, County Project No. X01781, Federal Aid Project No. ER- 0801(025) Statement of Issue: Execution of Contract with Seton Construction of Port Townsend, Washington for the Alder Creek Tributary Culvert Replacement, County Project No. X01781. Analysis/Strategic Goals/Pro's Ft Con's: This contract is for construction of a new, 25 ft. span, Precast Reinforced Three-Sided Structure at Upper Hoh Road milepost 2.15. Fiscal Impact/Cost Benefit Analysis: The Contractor's bid amount is $498,801.60. Construction will be funded at 86.5% by the Federal Highway Administration, with the remaining 13.5% provided by the Rural Arterial Program (RAP) and the County Road Fund. Recommendation: Public Works recommends that the Board execute all three (3) originals of the Contract with Seton Construction and return two (2) originals to Public Works for further processing. Department Contact: Mark Thurston, P.E., Project Manager, 385-9160. Reviewed By: ~ / ~= 3/~ ~~ Philip Morl unty Admini or Date CONTRACT JEFFERSON COUNTY, WASHINGTON THIS AGREEMENT, made .and entered into this day of , 201 ,between the COUNTY OF JEFFERSON, acting through the Jefferson County Commissioners and the Director of Public Works under and by virtue of Title 36, RCW, as amended and Seton Construction of Port Townsend, Washin on hereinafter called the Contractor. WITNESSETH: That in consideration of the terms and conditions contained herein and attached and made a part of this agreement, the parties hereto covenant and agree as follows: 1. The Contractor agrees to furnish all labor and equipment and do certain work, to-wit: That The Contractor herein will undertake and complete the following described work: This contract provides for the improvement of Upper Hoh Road by replacing the culvert at Alder Creek Tributary, at milepost 2.15 in West Jefferson County near Forks, Washington. Work includes furnishing and installing a new 25 ft. span precast, reinforced, 3-sided, concrete box culvert with precast footings and precast wing walls, constructing and removing a temporary traffic bypass, stream restoration, repaving, guardrails, site restoration and other work for the total sum of Four hundred ninety eight thousand, eight hundred one dollars and sixty cents_ ($498,801.60) in accordance with and as described in the attached plans and specifications and the Standard Specifications of the Washington Department of Transportation which are by this reference incorporated herein and made a part hereof. The Contractor shall perform any alteration in or addition to the work provided in this contract and every part thereof. The Contractor shall complete the described work as follows: Contract time shall begin on the first working_daY following the Notice to Proceed Date. Be ig nning with the first working, day, the project shall be physically complete within 60 working days. The Contractor shall provide and bear the expense of all equipment, work and labor of any sort whatsoever that may be required for the transfer of materials and for constructing and completing the work provided for in this contract and every part thereof. 2. The County of Jefferson hereby promises and agrees with the Contractor to employ, and does employ the Contractor to furnish the goods and equipment described and to furnish the same according to the attached specifications and the terms and conditions herein contained, and hereby contracts to pay for the same according to the attached specifications and the schedule of unit or itemized prices hereto attached, at the time and in the manner and upon the condition provided for in this contract. The County further agrees to employ the Contractor to perform any alterations in or additions to the work provided for in this contract that may be ordered and to pay for the same under the terms of this contract and the attached specifications at the time and in the manner and upon the conditions provided for in this contract. 3. The Contractor for himself, and for his heirs, executor, administrators, successors, and assigns, does hereby agree to the full performance of all the covenants herein contained upon the part of the Contractor. 4. Prior to commencing work, the Contractor shall obtain at its own cost and expense the following insurance from companies licensed in the State with a Best's rating of no less than A: VII. The Contractor shall provide to the County Risk Manager certificates of insurance with original endorsements affecting insurance required by this clause prior to the commencement of work to be performed. Page 1 of 7 Revised 10/30/12 ~t 1 ,I t The insurance policies required shall provide that thirty: (30) days- prior to cancellation, suspension, reduction or material change in the policy, notice of same shall be given to the County Risk Manager by registered mail, return receipt requested, for all of the following stated insurance policies. If any of the insurance requirements are not complied with at the renewal date of the insurance policy, payments to the Contractor shall be withheld until all such requirements have been met, or at the option of the County, the County .may pay the renewal premium and withhold such payments from the moneys due The Contractor. All notices shall name the Contractor and identify the agreement by contract number or some other form of identification necessary to inform the County of the particular contract affected. A. Workers Compensation and Employers Liability Insurance. The Contractor shall procure and maintain for the life of the contract, Workers Compensation Insurance, including Employers Liability Coverage, in accordance with the laws of the State of Washington. B. General Liability(1) - with a minimum. limit per occurrence of one million dollars {$.1,000,000) and an aggregate of not less -than two million dollars ($2,000,.000) for bodily injury, death and property damage unless otherwise specified in the contract specifications. This insurance .coverage shall contain no limitations on the scope of the protection provided and indicate on the certificate of insurance the following. coverage: 1. Broad Form Property Damage with no employee exclusion; 2. Personal Injury Liability, including extendedbodily injury; 3. Broad Form Contractual/Commercial Liability including completed operations {contractors only);. 4. Premises - operations Liability {M&C}; 5. Independent Contractors and Subcontractors; and 6. Blanket Contractual Liability. (1)Note: The County -shall be named as an additional insured party under this policy. C. .Automobile (2) - with a minimum limit per occurrence of $1,000,000 for bodily injury, death and property damage unless otherwise specified in the contract specifications. This insurance shall indicate on the certificate of insurance the following coverage: 1. Owned automobiles; 2. Hired automobiles; and, 3. Non-owned- automobiles. (2)-Note: The County shall be named as an additional insured party under this policy. Any deductibles or self-insured retention shall be declared to and approved by the County prior to the approval of the contract by the County. At the option of the County, the insurer shall reduce or eliminate deductibles or self-insured retention or The Contractor shall procure a bond guaranteeing payment of losses and related investigations, claim administration and defense expenses. The Contractor shall include all subcontractors as insured under its insurance policies or shall furnish separate certificates and endorsements for each subcontractor. All insurance provisions for subcontractors shall- be subject to all of the requirements stated herein. Failure of The Contractor to take out .and/or maintain any required insurance shall not relieve The Contractor from any liability under the Agreement, nor shall the insurance requirements be construed to conflict with or otherwise limit the obligations concerning indemnification. It is agreed by the parties -that insurers shall have no right of recovery or subrogation against the County (including its employees and other agents and agencies), it being the intention of the parties that the insurance policies so Aage 2 of 7 Revised 1 Q/30112 affected shall protect both parties and be primary coverage for any and all losses covered by the above described insurance. It is further agreed by the parties that insurance companies issuing the policy or policies shall have no recourse against the County (including its employees and other agents and agencies) for payment of any premiums or for assessments under any form of policy. It is further agreed by the parties that any and all deductibles in the above described insurance policies shall be assumed by and be at the sole risk of The Contractor. It is agreed by the parties that judgments for which the County may be liable, in excess of insured amounts provided herein, or any portion thereof, may be withheld from payment due, or to become due, to The Contractor until such time as The Contractor shall furnish additional security covering such judgment as may be determined by the County. The County reserves the right to request additional insurance on an individual basis for extra hazardous contracts and specific service agreements. 5. The Contractor shall comply with all Federal, State, and local laws and ordinances applicable to the work to be done under this Agreement. This Agreement shall be interpreted and construed in accord with the laws of the State of Washington and venue shall be in Jefferson County, WA. The Contractor shall indemnify and hold the County, and its officers, employees, and agents harmless from and shall process and defend at its own expense, including all costs, attorney fees and expenses relating thereto, all claims, demands, or suits at law or equity arising in whole or in part, directly or indirectly, from the Contractor's negligence or breach of any of its obligations under this Agreement; provided that nothing herein shall require a Contractor to indemnify the County against and hold harmless the County from claims, demands or suits based solely upon the conduct of the County, its officers, employees and agents, and; provided further that if the claims or suits are caused by or result from the concurrent negligence of: (a) the Contractor's agents or employees; and, (b) the County, its officers, employees and agents, this indemnity provision with respect to claims or suits based upon such negligence, and/or the costs to the County of defending such claims and suits, etc., shall be valid and enforceable only to the extent of the Contractor's negligence, or the negligence of the Contractor`s agents or employees. Claims against the County shall include, but not be limited to assertions that the use and transfer of any software, book, document, report, film, tape, or sound reproduction of material of any kind, delivered hereunder, constitutes an infringement of any copyright, patent, trademark, trade name, or otherwise results in an unfair trade practice or an unlawful restraint of competition. The Contractor specifically assumes potential liability for actions brought against the County by Contractor's employees, including all other persons engaged in the performance of any work or service required of the Contractor under this Agreement and, solely for the purpose of this indemnification and defense, the Contractor specifically waives any immunity under the state industrial insurance law, Title 51 R.C.W. The Contractor recognizes that this waiver was specifically entered into pursuant to provisions of R.C.W. 4.24.115 and was subject of mutual negotiation. 6. The Contractor's relation to the County shall be at-all times as an independent Contractor, and nothing herein contained shall be construed to create a relationship of employer-employee or master-servant, and any and all employees of the Contractor or other persons engaged in the performance of any work or service required ~of the Contractor under this Agreement shall be considered employees of the Contractor only and any claims that may arise on behalf of or against said employees shall be the sole obligation and responsibility of the Contractor. 7: The Contractor shall not sublet or assign any of the services covered by this contract without the express written consent of the County or its authorized representative. Assignment does not include printing or other customary reimbursable expenses that may be provided in an agreement. 8. The Contractor shall deliver to the County an executed bond as security for the faithful performance of this contract and for payment of all obligations of the Contractor. Page 3 of 7 Revised 10/3D/12 ~ f. 9. Attachments hereto, incorporated by reference: Certification Regarding Debarment, .Suspension, Ineligibility, and Voluntary Exclusion; and Contract Bond. Page 4 of 7 Revised 10/30/12 -_ ' IN WITNESS WHEREOF, the Contractor has executed this instrument on the day and year first below written, and the Board of County Commissioners has caused this instrument to be executed by and in the name. of said County of Jefferson the day and year first above written. Executed by the Contractor ,~~~ C ~/ ZO 1..~ -. Contracto~~ (Please print) /, __._-~ (Please print) (Signature) ~ State of Washington, Contractor Registration Number COUNTY OF JEFFERSON BOARD OF COMMISSIONERS John Austin, Chair Phil Johnson, Member David W. Sullivan, Member A roved as to form ly: ' X13 ~. David Alvarez Date Deputy. Prosecuting Attorney Frank Giffo Date Public Works Director Page 5 of 7 Revised 10/30/12 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY, AND VOLUNTARY EXCLUSION The Contractor certifies to the best of its knowledge and belief, that it and its principals: (1) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency; (2) Have not within a 3-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local} transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (3) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (2) of this certification; and (4) Have not within a 3-year period preceding this contract had one or more public transactions (Federal, State, or local) terminated for cause or default. Where the Contractor is unable to certify to any of the statements in this certification, such Contractor shall attach an explanation. Name of Contractor (Please print) Name and Title of Authorized Representative (Please print) Signature of Authorize Represe~dfive I am unable to certify to the above statement. An explanation is attached. Page 6 of 7 Revised 10/30/12 CUNTRACT BOND JEFFERSON COUNTY, W~4SHINGTQN Bona No. 21 s~ ~3~ KNOW ALL MEN 13Y THESE PRESENTS: That Seton Construction., Inca p f Port Townsend, WA , , as Principal, -and North American Specialty Insurance Com~anyy as Surety, are jointly and severalty held and bound untothe CQUNTY OF JEFFERSQN, the-penal sum of :Four hundred ninety ei ~t thousand, eight hundred one dollars-and-sixty cents Dollars. ($49$.8U1.bU), for the payment of which we jointly and severally bind ourselves, or heirs, executors, administrators, and assigns, and successors and- assigns, firmly by these presents. The condition ofthis bond is such that WHEREAS, on the 25th day ofFebruary,A.D., 201 3 ,-the said Seton Construction inc. ,Principal herein, executed a cerrtain contract with he County of Jefferson, by the terms, conditions and provisions of which contract the said Seton construction mc. ,Principal herewith, agrees to furnish all. materials and do certain. work,. to-wit: That the said .Principal. herein will undertake and. complete-the following described work: Alder Creek Tributary Culvert Replacement Upper Hoh Road MP-2.15 in .Iefferson County, Washington, as per maps, plans and specifications made a part of said contract, which contract as so executed, is hereunto attached, and is now referred to and. by this reference is incorporated herein -and made a park hereof as full. for- all purposes as if here set forth at length. N~iiV THEREFORE, if the Principal herein shalt faithfully and truly observe and comply with the terms, conditions and provisions of said- contract, in all respects-and shall: well and-truly and fully do and perform all matters and things by the said Principal undertaken to be performed under said contract, upon the terms proposed therein, and within .the time prescribed therein, and until the same is accepted, and shall pay ap laborers, mechanics,. subcontractors and rr~aterialmen, and all persons who shall supply such. contractor or subcontractor -with provisions and supplies for- the carrying on of such work, and shall in all respects faithfully perform said contract according to law, then this obligation to be void, otherwise to remain in full force and erect. :.:WITNESS our hands. this .25th day of February.. ,.201..3 . Seton Construction, Inca North American Specialty Insurance Company PRINCIPAL. SURETY COMPANY By: s : s~ $y: Joanne Reinkensmeyer .Attorney-in-fact Address of local office and agent- of surety company: Hentschell & Associates, Ina 621 Pacific Ave._ Suite 400 Tacoma, WA 98402 Page. 7 of 7 Revised ! t)13l)/ 12 t j _ NAS SURETY GROUP ~. r-_ NORTH. AMERICAN SPECIALTY INSURANCE COMPANY - - WASHINGTON INTERNATIONAL INSURANCE COMPANY .GENERAL POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS, THAT North American Specialty Insurance Company, a corporation duly organized and existing under laws of the State of New Hampshire, and having its principal office in the City of Manchester, New Hampshire, and Washington International Insurance Company, a corporation organized and existing under-the laws of the State of New Hampshire and having. its principal office in the City of Schaumburg, Illinois, each does hereby make; constitute and. appoint: THOMAS P. HENTSCHELL, BRADLEY A. ROBERTS, JULIE A. CRAKER; KAREN A. INGRAM, KAREN J. SMITH and. JOANNE REINKENSMEYER JOINTLY OR SEVERALLY- . Its true. and lawful Attorney(s)-in-Fact, to make, execute, seal and deliver, for and on its behalf and as its act and deed, bonds or other writings obligatory in the nature of a bond on behalf of each of said Companies, as surety, on contracts of suretyship as are or may be required.or permitted by .law, regulation,. contract or otherwise, provided that no bond or undertaking or contract or suretyship executed under this authority shall exceed the amount of FIFTY MILLION ($50,000,000.00) DOLLARS This Power of Attorney is granted and is signed by facsimile under and by the authority of the following Resolutions adopted by the Boards of .Directors of both North American Specialty Insurance Company and Washington International Insurance Company at meetings duly called and held on the 9~' of May, 2012: "RESOLVED, that any two of the Presidents, any Managing Director, any Senior Vice President, any Vice President,-any Assistant Vice President; the Secretary or any Assistant Secretary be, and each or any of them hereby is authorized to execute a Power of Attorney qualifying the attorney named in the .given Power of Attorney to execute on behalf of the Company bonds, undertakings and all contracts of surety, and that each or any of them hereby is authorized to attest to the execution of any such. Power of Attorney and to .attach therein. the seal of the Company; and it is FURTHER RESOLVED, that the signature of such officers and. the seal of the Company may be affixed to any. such -Power of Attorney or to any certificate relating thereto by facsimile, and any such Power of Attorney or certificate bearing such facsimile: signatures. or facsimile seal shall be binding- upon the Company when so affixed and in the future with regard to any bond, undertaking or contract of surety to which it is attached." ~~1ltlilllil7p~~~ ti~,A~' ~,tA11TY~ ~~i~i _ O'•., S~~ ~ ~ , Steven P. Anderson, Senior Vice President of Washington International Insurance Company l ~~ By ~j SEAL~`~s' ~~ ~ 1973 ¢~ ~ ti & Senior Vice President of North American Specialty Insurance Company t S .j-~: ~ ~ ~• ? ~~~ ~, , NNIItt111~~,~ ~~.. By +~~- "~~~~ . •~ David M. Layman, Vice President of Washington International Insurance Company & Vice President of North American Specialty Insurance Company IN WITNESS WHEREOF, North American Specialty Insurance Company and Washington International Insurance Company -have caused-their official seals to be hereunto affixed; and these presents to be signed by their authorized officers this20th day of June 2012 , North American Specialty Insurance Company Washington International Insurance Company State of Illinois County of Cook ss: On this 20th day of June , 2012 ,.before me, a Notary Public personally appeared Steven P. Anderson ,Senior Vice President of Washington International Insurance Company and Senior Vice President of North American Specialty Insurance Company and David M. Layman , Vice President of Washington International Insurance Company and Vice President of North American Specialty Insurance Company, personally known to me, who being by me duly sworn, acknowledged that they signed the above Power of Attorney as officers of and acknowledged said instrument to be the voluntary act and deed of their respective companies. _.~ _ _ ~q~~- ~..~ .. _ ~ ~lJ LK?NNA D. SKLEl~iS Notary ~bliC+S~e of ptiools Donna D. Sklens, Notary Public M C~~i>~iala 101116/Z019 I, Jeffrey Goldberg__the duly elected Assistant Secretary of North American Specialty Insurance Company and Washington International Insurance Company, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney given by said North American Specialty Insurance Company and Washington International- Insurance Company, which is -still in full force and effect. IN WITNESS WHEREOF, I have set my hand and affixed the seals of the Com antes this °~~ 'day of 20 J. p ~~S~zC~wLj, .~~~` Jeffrey Goldberg, Vice. President & Assistant Secretary: of Washington International Insurance Company & North American Specialty Insurance Company '`~~'a'~~~ CERTIFICATE ~3F LIABILITY' INSURANCE DATEIMMIDDlYYYY) 1.r..-~ 2 ! 14 /2013 THIS CERTIFICATE IS ISSUED AS A MATTER DF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE t)F INSURANGE DOES NOT CQNSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERI(Sj, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies} must be endorsed. If SUBROGATION IS WAIVED, subject to the tenors and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRaoucER co+vTacT Trina Maher NA1fAE: _ __ - 4 Kuresman Insurance PHONE (360) 692-6131 FAX (360) 692-6187 A/C No 9321 Sayshore Dr . NW ADDRIESS: trlnam@kureSraan].ns . Com STE 1 I 1 _-- INSURE S AFFORDING COVERAGE NAIC # Silverdale WA 98383-8350 INSURERA:Llbert Northwest Insurance Co -INSURED INSURER B _ SE'tOn COIlSt1^L7.G'trlrJn, Inc. INSURERC: 4640 Discovery Rd INSURER D INSURER E :_ _ Port Townsend WA 98368 INSURER F COVERAGES CERTIFICATE NUMBER:LLIG>~~t3V1:3axy REV1510N NUMBER: TFIIS IS TO CERTIFY THAT THE POLICIES DF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NDTW17H5TANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY 'fHE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS, EXCLU510NS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE A DL 8R POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM1DDlYYYY LIMITS GENERAL LIABILITY EACFI OCCURRF.NCF $ ~. , O00 ~ 000 X L'OMMERCIAI GENERAL LIABILITY PREMISES La occu cncol $ 100 , 000 A CLAIMS-MADE OCCUR X O9 1b-15-D2 10/30/2012 0/3p/2p13 MEUEXP(Anyonoperson) $ 5,000 PERSONAL 8 ADV INJURY $ ~. , OOO , O O O GENERAL AGGREGATE $ 2 , 000 , OOO CLN'L AGGREGATE LIMIT APPLIES PER PRODUCTS -COMP/OP AGG $ 2 , 000 , O O 0 X F'C)l.l('Y PRO- LOC $ AUTOM061LE LIA8ILITY COMBINED SINGLE LIMIT La accident 1 , 000 , 000 A ANY AUTO BODILY INJURY (E'er person) _ $ Ati.OWNF.D X SCIIE:DULED X 09 16-16-02 0/30/2012 10/30/2013 BODILY INJURY (Per accident) $ _ AUTOS AUTOS X X NON-ONAUFD PROPERTY DAMAGE $ HIRFO AUTOS AUTOS Per ac:crdertt Undennsured motorist $ ], O00 000 X UMBRELLA LIAR OCCUR L:ACFI OCCURRENCE. $ 2 ~ 000, 000 A EXCESS UAB CLAIMS-MAt}E AGGREGATE $ Dt=1) RETENTIONS 09 16-16-02 0/30/2012 10/30/2013 $ j~ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WC STATU- X DT}i- ANY NFtUF'htrl-iOWF'ARTNERIEXNCIJIIVE Y~ N 1 A Dg 16-16-02 0/30/2012 0/30/2013 Fl FACHACCIDENi $ 1 000 000 Off ?CL•RIMEM6ER EXCLUUEU'~ {Mandatory in NH) E L DISEASE. - EA EMPLOYE $ 1 000 000 I! yus desenbe urxiHr UE:SCRIPTION OF OPERATIONS glow -,-~ E L. DISEASE -POLICY LIMIT $ 2 000 000 A LEASED/RENTED EQUIP 09 16-16-02 - 10/30/2012 0/30/2013 $300, 000 $1000 DED bESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES IAttach ACORD 101, Additional Remarks 5chedtrle, if more space is required) CERTIFICATE HOLDER IS LISTED A5 ADDITIONAL INSURED PER CG8416. RE: ALDER CREEK TRIBUTARY CULVERT REPLACEMENT COUNTY PROJECT #X03781 FEDERAI.~ AID NO ER-0801 (02.5) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE A80VE DESCRIBED POLICIES BE CANCELLED BEF©RE THE EXPIRATION DATE THEREOF, N©TICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. JEFFERSON COUNTY TREET 623 SHERIDAN S PORT TOWNSEND , WA 983 GB AUTHORIZED REPRESENTATIVE Mark Maherry/MWM ~i~`~`~'~• ~,~" ~ .~''~,~;~-' ACORD 25 {2010105} IN5026 ;:~U~rtr51 Cf1 C7 '1988-2410 ACORD CORPORATION. All rights reserved. The AGORD Warne and logo are registered marks of ACORD