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CW Roberts - Insurance & LicensesCERTIFICATE OF LIABILITY INSURANCE D o2/133i202200 ) THIS CERTIFICATE IS ISSUED AS A MATTER OF 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 OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER MCGRIFF, SEIBELS 8 WILLIAMS, INC. P.O. Box 10265 Birmingham, AL 35202 Haw NMT C Martha Lee Hawkins PHONE 800.47e FAX o Ext Aro No): E-MAIL ADDRESS: mhawkins o@mcgriff com INSURERS AFFORDING COVERAGE NAIC 0 55PublicSE 3Worksrd Avenue 55 SE 3rd Avenue INSURER A :Arch Insurance Company 11150 31 PKG8930304 INSURED C.W. Roberts Contracting, Inc. INSURER B : INSURER C : Post Office Box 1994 806 NW 9th Street (zip 34972) Okeechobee, FL 34973-1994 INSURER D INSURER E : INSURER F: 11VVCKA"=Q1 GCKI II-IGAlE Nl1MF3EK_0ZBGCBAV PrzymiAIU NIIIIARFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCEIN= ADDL SUBR WVD POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS A X COMMERCIAL GENERAL LIABILITY 55PublicSE 3Worksrd Avenue 55 SE 3rd Avenue 31 PKG8930304 10/01/2019 10/01/2020 EACH OCCURRENCE $ 2,000,000 PREMISES Ea occurrence $ 100,000 CLAIMS -MADE EKOCCUR MED EXP (Any one person) $ 5,D00 PERSONAL & ADV INJURY $ 2,000,000 X GEN'L AGGREGATE LIMIT APPLIES PER POLICY � JECOT- 0 LOC GENERAL AGGREGATE $ 4,000,000 PRODUCTS - COMP/OP AGG $ 4,000,000 $ OTHER I I A AUTOMOBILE LIABILITY 31PKG89303 10/01/2019 10/01/2020 COMBINED IN LF UMrf Ea acddent $ 5,000,000 X ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED ONLY AUTOS 1 XAUTOS ( BODILY INJURY Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ Per accident UMBRELLA LWBOCCUR HCLAIMS-MADE I EACH OCCURRENCE $ EXCESS LIAR AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y / N Y ANY PROPRIETOR/PARTNER/EXECUTiVE OFFICERIMEMBER EXCLUDED? ❑ NIA 1WC18930204X 10/01/2019 10/01/2020 PER OTH- TE R E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory In NH) if yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 $ $ $ is DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H mora space is required) The City of Okeechobee Is Included as an Additional Insured on a primary and non-contributory basis by the General Liability and Automobile Liability policies as required per written contract. In the event of cancellation by the insurance companies, the General Liability, Automobile Liability and Workers' Compensation policies have been endorsed to provide 30 days Notice of Cancellation (except for non-payment) to the certificate holder shown below. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Okeechobee AUTHORIZED REPRESENTATIVE 55PublicSE 3Worksrd Avenue 55 SE 3rd Avenue Okeechobee, FL 34974 Page 1 of 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD r C.W.ROBERTS CONTRACTING, CITY. OF OKEECHOBEE (863)763-7373 BUSINESS TAX RECEIPT No: 2632 55 SE 3rd Avenue, Okeechobee, FL 34974 Date: 9/16/19 October 1, 2019 - September 30, 2020 RECEIPT 78.75 Address: 806 NW 9TH STREET PENALTY OKEECHOBEE, FL 34974 OKEt APP/TRAN Activity: 201 CONTRACTOR O�. hyo BLDG INSP �. - um FIRE INSP Total Paid 78.75 Issuedto: C.W.ROBERTS CONTRACTING, INC C.W.ROBERTS CONTRACTING, INC PO BOX 1994 �CpRiap ' OKEECHOBEE, FL 34973 A New BTR's issued 711/19 - 9/30/19 are valid from issue date. BUSINESS TAX OFFICIAL' CITY OF OKEECHOBEE C.W.ROBERTS CONTRACTING, BUSINESS TAX RECEIPT No: '2632 (863)763-7373 55 SE 3rd Avenue, Okeechobee, FL 34974 pate: 9/16/19 October 1, 2019 - September 30, 2020 RECEIPT 78.75 Address: 806 NW 9TH STREET PENALTY, OKEECHOBEE, FL 34974, OKEFC` APP/TRAN Activity: 302 CEMENT BULK PLANTS O�• y BLDG INSP �., . O FIRE INSP Total Paid 78.75 .w �_ +•• Issued to: C.W.ROBERTS CONTRACTING, INC C.W.ROBERTS CONTRACTING, INC BOX 1994 'c[ Q R 1p OK OKEECHOBEE, FL 34973 A New BTR's issued 7/1/19 -9/30/19 are valid from issue date. BUSINESS TAX OFFICIAL STATE OF FLORIDA OKEECHOBEE COUNTY BUSINESS LICENSE PENALTY ADDED: OCT 1st, 10%; NOV lst, 1556; DEC 1st, 20%; JAN 1St 25% THIS LICENSE IS FURNISHED IN PURSUANCE OF CHAPTER 205,FLORIDA STATUTES AND COUNTY ORDINANCE NO.79-2 C.W. ROBERT'S CONTRACTING INC ROBERT P FLOWERS 806 NW 9TH ST OKEECHOBEE FL 34972 BUSINESS # 03434 2019 2020 CONTRACTOR CERTIFIED GENERAL 85 T1110 LICENSE 10 VALID ONT Y Ir 1.1.0 OTHER LAW OR ORDINANCE IS VIOLATED. ESPECIALLY ZONING PRIOR COUNTY PENALTY AMOUNT DUE LICENSE # DATE PAID $72.00 $72.00 00366 7/19/2019 CELESTE WATFORD, TAX COLLECTOR OKEECHOBEE COUNTY 307 NW 5TH AVE STE B OKEECHOBEE, FL 34972 ORIGINAL CUSTOMER COPY as Form w_ V (Rev. October 2018) =Z1.0-11='Y epartment of the Treasury irtemai Revenue Servke 1 Name (as shown on your Request for Taxpayer Identification Number and Certification * Go to www.Irs.gov1FormW9 for Instructions and the latest information. tax return). Name Is required on line Give Form to the requester. Do not send to the IRS. 2 Business name/disregarded entity name, if different from above C4 3 Check appropriate box for federal tax classification of the person whose name Is entered on One 1. Check only one of the 4 Exemptions (codes apply only to is following seven boxes, certain entities, not individuals; see a oproprietor p ❑ S Corporation ❑ Partnership Instructions on page 3) ❑ fndividuaVsole ro etor or �✓ C Corporation p ❑ Trustlestate N stngle-member LLC 49 C Exempt payee code Of any) ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnershfp) ► `o Note; Check the appropriate box In the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting LLC if the LLC is classified as a single member LLC that Is disregarded from the owner unless the owner of the LLC iy a E another LLC that Is not disregarded from the owner for U.S: federal tax purposes. Otherwise, a single -member LLC that code f any) is disregarded from the owner should check the appropriate box for the tax classification of Its owner. m ❑ Other (sea Instructions) ► (Mpffnto .nr�hVdw1rd•maas4 CL 5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optional) 3372 Capital Circle NE e City, state, and ZIP code Tallahassee Florida 32308 7 Ust account numbers) here (optional) Taxpayer Identification Number TIN Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number backup withholding.For individuals, this is generally your social security number (SSN). However, for a resident alienien,,sole proprietor, or disregarded entity, see the instructions for Part 1, later. For other entitles, it is your employer identification number (EIN). If you do not have a number, see Now to get a TIN, later. or Note: If the account Is in more than one name, see the Instructions for line 1. Also see What Name and I Employer Identification number Number To Give the Requester for guidelines on whose number to enter. W _ ��� 5 9 1 6 8 3 9 5 1 Under penalties of perjury, I certify that: 1. The number shown on this form Is my correct taxpayer identification number (or I am waiting for a number to be Issued to me); and 2, l am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service QRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. t am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (f any) Indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above If you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. Seo the Instructions for Part 11, later. SignSignature of Here U.S. person ►�� p date ► General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest Information about developments related to Form W-9 and Its Instructions, such as legislation enacted after they were published, go to www.1rs.gov1FormW9. Purpose of Form An Individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer Identification number (riN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer Identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of Information returns includo, but are not limited to, the following. • Form 1099 -INT (Interest earned or paid) • Form 1099 -DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan Interest), 1098-T (tultion) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S, person (including a resident alien), to provide your correct TIN. if you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form w-9 (Rev. 10-2018) ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 08/06/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF 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 OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER MCGRIFF, SEIBELS & WILLIAMS, INC. P.O. Box 10265 Birmingham, AL 35202 CONTACT TracyFarragut NAME: 9 PHOE FAX (A/C, No, Ext): 800-476-2211 (A/C, No): E-MAIL tfarra ut me riff.com ADDRESS: 9 @ 9 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A Arch Insurance Company 11150 INSURED C.W. Roberts Contracting, Inc. Post Office Box 1994 806 NW 9th Street (zip 34972) Okeechobee, FL 34973-1994 INSURER B : 31PKG8930303 INSURER C : 10/01/2019 INSURER D : $ 2,000,000 INSURER E : $ 100,000 INSURER F : COVERAGES CERTIFICATE NUMBER:WWD8FT8Q REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY 31PKG8930303 10/01/2018 10/01/2019 EACH OCCURRENCE $ 2,000,000 DAMAGE D PREM SESO(EaEoccurrrence) $ 100,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GE 'L AGGREGATE POLICY OTHER: X LIMIT APPLIES PER: PROT- ❑ LOC JEC PRODUCTS - COMP/OP AGG $ 4,000,000 $ A AUTOMOBILE X LIABILITY ANY AUTO OWNED AUTOS ONLY_ HIRED AUTOS ONLY _ SCHEDULED AUTOS NON -OWNED AUTOS ONLY 31PKG8930303 10/01/2018 10/01/2019 COMBINED SINGLE LIMIT (Ea accident) $ 2,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB _ OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A 31WCI8930203 10/01/2018 10/01/2019 X PER STATUTE OTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 $ $ $ $ $ DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CANCELLATION City of Okeechobe Public Works 55 SE 3rd Avenue Okeechobee, FL 34974 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �� f / / 474-- Arnon oc /O(14C/(14\ Page 1 of 1 © 1988-2015 ACORD CORPORATION. All rightd s reserve. rt. Arnon Arnon C.W.ROBERTS CONTRACTING, (863)763-7373 CITY OF OKEECHOBEE BUSINESS TAX RECEIPT No: 2632 Date: 5/07/19 55 SE 3rd Avenue, Okeechobee, FL 34974 OCTOBER 1, 2018 - SEPTEMBER 30, 2019 Address: 806 NW 9TH STREET OKEECHOBEE, FL 34974 Activity: 302 CEMENT BULK PLANTS Issued to: A C.W.ROBERTS CONTRACTING, INC C.W.ROBERTS CONTRACTING, INC PO BOX 1994 OKEECHOBEE, FL 34973 RECEIPT PENALTY APP/TRAN BLDG INSP FIRE INSP Total Paid 45.94 45.94 BUSINESS TAX RECEIPT OFFICIAL C.W.ROBERTS CONTRACTING, (863)763-7373 Address: 806 NW 9TH STREET OKEECHOBEE, FL 34974 Activity: 201 CONTRACTOR Issued to: A CITY OF OKEECHOBEE BUSINESS TAX RECEIPT 55 SE 3rd Avenue, Okeechobee, FL 34974 OCTOBER 1, 2018 - SEPTEMBER 30, 2019 C.W.ROBERTS CONTRACTING, INC C.W.ROBERTS CONTRACTING, INC PO BOX 1994 OKEECHOBEE, FL 34973 No: 2632 Date: 5/07/19 RECEIPT 45.94 PENALTY APP/TRAN 10.00 BLDG INSP 50.00 FIRE INSP 15.00 Total Paid 120.94 liNA-11n TV/1AM_ BUSINESS TAX RECEIPT OFFICIAL OKEECHOBEE COUNTY STATE OF FLORIDA } Business Tax Receipt IN CONSIDERATION of the TOTAL SUM OF MONEY shown hereon, the receipt of which is hereby acknowledged. Company ID #: 9605 No. 1781 018-2019 5/8/2019 Contractor (0015A) (31-40 Employees) $0.00 Manufacture (0024) (31-40 Employees $0.00 Transfer Fee $3.00 TOTAL $3.00 C.W. ROBERTS CONTRACTING, INC is hereby licensed to engage in the business, profession or occupation of Contractor (0015A) (31-40 Employees)(LIC#CGC1505785), Manufacture (0024) (31-40 Employees) at 806 NW 9TH STREET in Okeechobee, Florida, for the period beginning the 8TH day of MAY 2019 and ending on the30th day of September, 2019 Celeste Watford, C.F.0 - Tax Collector