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15-077.01 Ibex Flooring, Inc.: CenterPlace Lounge Flooring CONTRACT AMENDMENT FOR THE AGREEMENT BETWEEN THE CITY OF SPOKANE VALLEY AND IBEX FLOORING, LLC Contract #15-077.01 For good and valuable consideration,the legal sufficiency of which is hereby acknowledged, City and the Ibex Flooring, LLC mutually agree as follows: 1. Purpose: This Amendment is for the Contract for the CenterPlace Lounge Flooring Replacement Project by and between the Parties, executed by the Parties on September 10, 2015, and which terminates on November 1, 2015. Total compensation under the Original Contract is not to exceed $16,836.54. Said contract shall be referred to as the "Original Contract" and its terms are hereby incorporated by reference. 2. Original Contract Provisions: The Parties agree to continue to abide by those terms and conditions of the Original Contract,dated September 10, 2015, and any amendments thereto, which are not specifically modified by this Amendment. 3. Amendment Provisions: This Amendment is subject to the following amended provisions, which are as follows. All such amendment provisions are hereby incorporated by reference herein and shall control over any conflicting provisions of the Original Contract, including any previous amendments thereto. Time of Performance is increased until December 31, 2015. 4. Compensation Amendment History: This is Amendment#1 of the Original Contract and the history of amendments to the Ibex Flooring, LLC compensation is as follows: Date Compensation Original Contract Amount 9/10/15 $16,836.54 Amendment#1 10/16/15 $0 Total Amended Compensation $16,836.54 1 The parties have executed this Amendment to the Original Contract this 91,St-day of October, 2015. CITY OF SPOKANE VALLEY: CONTRACTOR: ONA6 C LtA7,7 T__,__rr Mac K C4c,(kouh By: 1M14,U, 41,5 -Crty-Marrager Act-4 CMyMMa1.er Its: Owner ATTEST: APPROVED AS TO FORM: Air ( Fi hristine Bainbrid_e, Ci Cler• Office o I e CityAlit' e tY ! � Y 2 • ------771 IBEXFLO-01 ACATHEY ACORO` CERTIFICATE OF LIABILITY INSURANCE DATE(MM/oo/YYYY) L-------- 9111/2015 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 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 endors`emeh,t( r ,� ,,_ r1CCizl V CIS CONTACT Amy,Cathey PRODUCER . Hub International Northwest LLC (NC0ONr o,Ext):(509)838-6848 FAX (509)838 7024 400 S:Jefferson )1 I 01 E-MAIL am cache hubinternational.com Ste 408 � ADDRESS: y y� Spokane,WA 99204 INSURER(S)AFFORDING COVERAGE NAIC# ' !PARKS&RECREATION DEPT. INSURER A:American Fire and Casualty Company 24066 INSURED INSURER B:Ohio Casualty Insurance Company 24074 IBEX Flooring LLC INSURER C: PO Box 7538 INSURER D: Spokane,WA 99207 INSURER E: . INSURER F: COVERAGES . CERTIFICATE NUMBER: . .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. INSRLTI TYPE OF INSURANCE ADM.SUER POLICY EFF POLICY EXP INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS. A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR X X BKA56258417 08/02/2015 08/02/2016 pREM SESO(Ea occu ante) $ •1,000,000 MED EXP(Any one person) $ 15,000 - —PERSONAL 8ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X yea LOC • PRODU CTS-COMP/OPAGG $ 2,000,000 OTHER: $ IAUTOMOBILE LIABILITY • • COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) A ` X 'ANY AUTO X X BAA55159457 08/02/2015 08/02/2016 BODILY INJURY(Per person) $ ALL O+AHED SCHEDULEDBODILY INJURY(Per accident) $ AUTOS _AUTOS - X HIRED AUTOS X AUTOS PROPERTY DAMAGE $ (Per accident S • X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 B EXCESS LIAB ^CLAIMS-MADE US055159457 08/02/2015 08/02/2016 AGGREGATE $ 2,000,000 DED X RETENTIONS 1.0,000 . • . . $ - . WORKERS COMPENSATION I STATUTEH ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? . (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY OMIT $ A WA Stop Gap BKA56258417 08/02/2015 08/02/2016 $1M I$1M/$1M 1 DESCRIPTION OF OPERATIONS/LOCATIONS./VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE Project No.15-077: CenterPlace Regional Event Center Lounge Flooring Replacement Where required by written contract the City of Spokane Valley is included as additional insured(except on workers comp)on a Primary and Non-Contributory basis with Waiver of Subrogation,Per Project Aggregate Limits and Completed Operations per attached forms CG8810,CG8870,CG9044 and CA8810. • CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE of S okane Valle THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City P Y ACCORDANCE WITH THE POLICY PROVISIONS. 11707 E Sprague AVE STE 106 Spokane Valley,WA 99206 . • AUTHORIZED REPRESENTATIVE • • ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 9/1012015- IBEX FLOORING LLC r,N. 201 Home inicio en Espanol Contact Search L&I A-Z index Help My Severe L&I Safety Claims&Insurance Workplace Rights Trades&Licensing CVilashington State Department of O Labor & Industries IBEX FLOORING LLC Owner or tradesperson PO BOX 7538 SPOKANE,WA Principals 509-327-3331 • MYERS,NATHAN SPOKANE County BENJAMIN,PARTNER/MEMBER MYERS,ASHLI CATHRYN, PARTNER/MEMBER Doing business as IBEX FLOORING LLC WA UBI No. Business type 602 653 391 Limited Liability Company Governing persons ASHLI CATHRYN MYERS NATHAN BENJAMIN MYERS; License Verify the contractor's active registration/license/certification(depending on trade)and any past violations. Construction Contractor Active. Meets current requirements. License specialties GENERAL License no. IBEXFFL944Q9 Effective—expiration 12/06/2006—12/06/2016 Bond CBIC $12,000.00 Bond account no. FB4044 Received by L&I Effective date 11/19/2010 11/16/2010 Expiration date Until Canceled Bond history Insurance American Fire&Casualty Co $1,000,000.00 Policy no. BKA56258417 Received by L&I Effective date 07/20/2015 08/02/2015 Expiration date 08/02/2016 . .- — nA Anno oMAI-C.,I 1/2 9/1012015 IBEX FLOORING LLC Insurance history Savings No savings accounts during the previous 6 year period. Lawsuits i.against the bond or savings ._...._..-._...._.. No lawsuits against the bond or savings accounts during the previous 6 year period. L&I Tax debts No L&1 tax debts are recorded for this contractor license during the previous 6 year period,but some debts may be recorded by other agencies. License Violations No license violations during the previous 6 year period. Workers' comp Do you know if the business has employees?If so,verify the business is up-to-date on workers'comp premiums. L&I Account ID Account is current. 969,461-02 Doing business as IBEX FLOORING LLC Estimated workers reported Quarter 2 of Year 2015"31 to 50 Workers" L&I account representative T1/IDA HAYNES(360)902-5635-Email:HAYN235@Ini.wa.gov Workplace safety and health Check for any past safety and health violations found on Jobsites this business was responsible for. Citation issue date 02114/2013 Violations Inspection no. 316576099 Location 280 Valley Mall Parkway East Wenatchee,WA 98802 ©Washington State Dept.of Labor&Industries.Use of this site is subject to the laws of the state of Washington. • . .- -------- — . 9!9