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HomeMy WebLinkAboutNACHAND FIELDHOUSE WALKER MECHANICAL CONTRACTORS Letter of 1400 W.JEFFERSON STREET LOUISVILLE,KY 40203 Transmittal Phone:(502)636-0002 Fax: (502)636-0004 TO: CITY OF JEFFERSONVILLE Date: May 3,2019 ATTN: LES MERKLEY WMC Job: 1920 500 QUARTERMASTER CT. 3RD FLOOR MAYOR SUITE Project: NACHAND FIELDHOUSE JEFFERSONVILLE,IN 47130 RE: CONTRACT,BONDS, INSURANCE We are sending you the following: Z Attached ❑ Under Separate Cover Via: ❑ 1St Class Mail ❑Overnight ❑ Facsimile ❑ Email ® Pick-Up/Hand Deliver The following items: ❑ Submittals ❑ As Builts ❑ Insurance Certificate ® See Below ❑ Change Orders ❑ Fully Executed Contract ❑ Subcontractor Agreement Item \o. Cubic, Ihnc l)c.cription 1 3 05/03/19 AIA DOCUMENT A101-2007 CONTRACT—NACHAND FIELDHOUSE 2 1 04/25/19 PERFORMANCE&PAYMENT BOND 3 1 04/30/19 CERTIFICATE OF INSURANCE These are transmitted as indicated below: 0 For your use ❑ Approval as noted ❑ For Approval El As requested ❑ Approved for Construction ❑ For review and comment ❑ Returned for corrections ❑ For payment ❑ Return ❑ Corrected Prints ❑ For bids due: Remarks: Please find attached the Contract documents for your review and signature. Upon your review,please sign and return 2 copies. Once received,we will forward to you the fully executed copy for your records. Received By: Date: Signed: Tom Schadt Title: PROJECT MANAGER 914, s�- Document A1017M — 2007 Standard Form of Agreement Between Owner and Contractor where the basis of payment is a Stipulated Sum AGREEMENT made as of the day of in the year (In words, indicate day,month and year) ADDITIONS AND DELETIONS: May 3,2019 The author of this document has BETWEEN the Owner: added information needed for its (Nome,legal status,address and other it formation) completion,The author may also SAVE THE FIELDHOUSE COMMITTEE have revised the text of the original CITY OF JEFFERSONVILLE INDIANA AIA standard form.An Additions and Deletions Report that notes added 601 EAST COURT AVE. information as well as revisions to the • JEFFERSONVILLE,IN 47130 standard form text is available from the author and should be reviewed.A and the Contractor: vertical line in the left margin of this (Name,legal status, address and other information) document indicates where the author has added necessary information WALKER MECHANICAL CONTRACTORS,INC. and where the author has added to or 1400 W.JEFFERSON STREET deleted from the original AIA text. LOUISVILLE,KY 40203 This document has important legal consequences.Consultation with an attorney is encouraged with respect for the following Project: to its completion or modification_ (Name,location and detailed description) AIA Document A201 TM 2007, XXXXXXX NACHAND FIELDHOUSE General Conditions of the Contract 601 COURT AVE. for Construction,is adopted in this JEFFERSONVILLE,IN 47130 document by reference.Do not use MECHANICAL&ELECTRICAL RENOVATION with other general conditions unless this document is modified. The Architect; (Name,legal status, address and other information) CMTA 10411 MEETING STREET PROSPECT,KY 40059 The Owner and Contractor agree as follows. Per Plans and Specifications/Addendum#1 Issued by CMTA,Inc. Consulting Engineers. hilt AliaDocument A101",—2007.Copyright©1915.1918,1925,1937.1951,1958,1961,1963,1967,1974,1977,1987.1991,1997 and 2007 by The American Institute of Architects.MI rights reserved.WARNING:This Ale Document is protected by U.S.Copyright Law and International Treaties.Unauthorized j reproduction Or distribution of this AlA"Document,or any portion of it,may result In severe civil and criminal penalties,and Wilt be prosecuted to the maximum extent possible under the taw.This document was produced by AIA software at 14:14:43 on 11/18/2014 under Order No.7956674000 1 Which expires on 10/31/2015,and is not for resale, user Notes: {2052679279i TABLE OF ARTICLES 1 THE CONTRACT DOCUMENTS 2 THE WORK OF THIS CONTRACT 3 DATE OF COMMENCEMENT AND SUBSTANTIAL COMPLETION 4 CONTRACT SUM 5 PAYMENTS 6 DISPUTE RESOLUTION 1 TERMINATION OR SUSPENSION 8 MISCELLANEOUS PROVISIONS 9 ENUMERATION OF CONTRACT DOCUMENTS 10 INSURANCE AND BONDS ARTICLE I THE CONTRACT DOCUMENTS The Contract Documents consist of this Agreement.Conditions of the Contract(General.Supplementary and other Conditions),Drawings,Specifications,Addenda issued prior to execution of this Agreement,other documents listed in this Agreement and Modifications issued after execution of this Agreement,all of which form the Contract,and are as fully a part of the Contract as if attached to this Agreement or repeated herein.The Contract represents the entire and integrated agreement between the parties hereto and supersedes prior negotiations,representations or agreements, either written or oral.An enumeration of the Contract Documents,other than a Modification,appears in Article 9. ARTICLE 2 THE WORK OF THIS CONTRACT The Contractor shall fully execute the Work described in the Contract Documents,except as specifically indicated in the Contract Documents to be the responsibility of others. ARTICLE 3 DATE OF COMMENCEMENT AND SUBSTANTIAL COMPLETION § 3.1 The date of commencement of the Work shall be the date of this Agreement unless a different date is stated below or provision is made for the date to be fixed in a notice to proceed issued by the Owner. (Insert the date of commencement if it di,8er s from the date of this Agreement or,if applicable,.state that the date will be fixed in a notice to proceed) MAY 1,2019 If,prior to the commencement of the Work,the Owner requires time to file mortgages and other security interests.the Owner's time requirement shall be as follows: § 3.2 The Contract Time shall be measured from the date of commencement. § 3.3 The Contractor shall achieve Substantial Completion of the entire Work not later than (90)days from the date of commencement,or as follows: (Insert number ofcalendar days.Alternatively,a calendar date may be used when coordinated with the date of commencement If appropriate, insert requirements for earlier Substantial Completion of certain portions of the Work) JULY 31,2019 )reit. AIA Document A101 TM-2007.Copyrights 1915,1918,1925,1937,1951,1958,1961,1963,1967,1974,1977,1987.1991,1997 and 2007 by The American institute of Architects.All rights reserved.WARNING:This Ale Document is protected by U.S.Copyright Law and international Treaties.Unauthorized 2 reproduction or distribution of this AIA Document,or any portion of it,may resuit in severe shill and criminal penalties,and will be prosecuted to the maximum extent possible under the law.This document was produced by AIA software at 14.14:43 on 11/18/2014 under Order No 7956674000 1 which expires on 10/31/2015,and Is not for resale. User Notes: (2052679279) Portion of Work Substantial Completion Date subject to adjustments of this Contract Time as provided in the Contract Documents. (Insert provisions, if any,for liquidated damages relating to failure to achieve Substantial completion on time or for bonus payments for early completion of the Work.) ARTICLE 4 CONTRACT SUM $974,000.00 § 4,1 The Owner shall pay the Contractor the Contract Sum in current funds for the Contractor's performance of the Contract The Contract Sum shall be (S ),subject to additions and deductions as provided in the Contract Documents. § 4.2 The Contract Sum is based upon the following alternates,if any,which are described in the Contract Documents and are hereby accepted by the Owner: (State the numbers or other identification of accepted alternates. If the bidding or proposal documents permit the Owner to accept other alternates subsequent to the execution of this Agreement,attach a schedule of such other alternates showing the amount for each and the date when that amount expires.) ALTERNATE#4 -FOR NEW FIRE ALARM SYSTEM= $44,000.00 § 4.3 Unit prices,if any: (Ident fy and state the unit price;state quantity limitations; if any,to which the unit price will be applicable) Item NOT APPLICABLE Units and Limitations Price Per Unit($0.00) § 4.4 Allowances included in the Contract Sum,if any: (Identify allowance and stale exclusions,if any,from the allowance price.) Item NONE Price ARTICLE 5 PAYMENTS § 5.1 PROGRESS PAYMENTS § 5.1.1 Based upon Applications for Payment submitted to the Architect by the Contractor and Certificates for Payment issued by the Architect,the Owner shall make progress payments on account of the Contract Sum to the Contractor as provided below and elsewhere in the Contract Documents. § 5.1.2 The period covered by each Application for Payment shall be one calendar month ending on the last day of the month,or as follows: § 5.1.3 Provided that an Application for Payment is received by the Architect not later than the day of a month,the Owner shall make payment of the certified amount to the Contractor not later than the day of the month.if an Application for Payment is received by the Architect after the application date fixed above,payment shall be made by the Owner not later than (1s)days after the Architect receives the Application for Payment. (Federal,state or local lows may require payment within a certain period of time.) § 5.1.4 Each Application for Payment shall be based on the most recent schedule of values submitted by the Contractor in accordance with the Contract Documents.The schedule of values shall allocate the entire Contract Sum among the various portions of the Work.The schedule of values shall be prepared in such form and supported by such data to substantiate its accuracy as the Architect may require.This schedule.unless objected to by the Architect,shall be used as a basis for reviewing the Contractor's Applications for Payment. AMA Document A107T"F—2007.Copyright&i 1915,1918,1925,1937,1951,1958.1961,1963,1967,1974,1977,1987,1991,1997 and 2007 by The American 'nit, institute of Architects.AO rights reserved.WARNING:This AIA''Document is protected by U.S.Copyright Law and International Trestles.Unauthorized reproduction or distribution of this A1A`'Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law.This document was produced by may software at 14:14:43 on 11/18/2014 under Order No.7956674000_1 which expires on 10/31/2015,and is not for resale. User Notes: (2052679279) § 5.1.5 Applications for Payment shall show the percentage of completion of each portion of the Work as of the end of the period covered by the Application for Payment. § 5.1.6 Subject to other provisions of the Contract Documents,the amount of each progress payment shall be computed as follows: .1 Take that portion of the Contract Sum properly allocable to completed Work as determined by multiplying the percentage completion of each portion of the Work by the share of the Contract Sum allocated to that portion of the Work in the schedule of values, less retainage of percent(10%). Pending final determination of cost to the Owner of changes in the Work,amounts not in dispute shall be included as provided in Section 7.3.9 of ATA Document A201TM-2007,General Conditions of the Contract for Construction; .2 Add that portion of the Contract Sum properly allocable to materials and equipment delivered and suitably stored at the site for subsequent incorporation in the completed construction(or,if approved in advance by the Owner,suitably stored off the site at a location agreed upon in writing),less retainage of percent(10%); .3 Subtract the aggregate of previous payments made by the Owner;and .4 Subtract amounts,if any,for which the Architect has withheld or nullified a Certificate for Payment as provided in Section 9.5 of AlA Document A201-2007. § 5.1.7 The progress payment amount determined in accordance with Section 5.1.6 shall be further modified under the following circumstances: .1 Add,upon Substantial Completion of the Work,a sum sufficient to increase the total payments to the full amount of the Contract Sum,less such amounts as the Architect shall determine for incomplete Work,retainage applicable to such work and unsettled claims;and (Section 9.8.5 ofaL l Document A201-2007 requires release of applicable retainage upon Substantial Completion of Work with consent of surety, ifany.) .2 Add,if final completion of the Work is thereafter materially delayed through no fault of the Contractor, any additional amounts payable in accordance with Section 9.10.3 of AIA Document A201-2007. § 5.1.8 Reduction or limitation of retainage,if any,shall be as follows: (/fit is intended,prior to Substantial Completion of the entire Work,to reduce or limit the retainage resulting from the percentages inserted in Sections 5.1.6.1 and 5.1.6.2 above,and this is not explained elsewhere in the Contract Documents, insert here provisions for such reduction or limitation.) § 5.1.9 Except with tate Owner's prior approval,the Contractor shall not make advance payments to suppliers for materials or equipment which have not been delivered and stored at the site. § 5.2 FINAL PAYMENT § 5.2.1 Final payment,constituting the entire unpaid balance of the Contract Sum,shall be made by the Owner to the Contractor when .1 the Contractor has fully performed the Contract except for the Contractor's responsibility to correct Work as provided in Section I2.2.2 of ALA Document A201-2007,and to satisfy other requirements,if any,which extend beyond final payment;and .2 a final Certificate for Payment has been issued by the Architect. § 5.2.2 The Owner's final payment to the Contractor shall be made no later than 30 days after the issuance of the Architect's final Certificate for Payment,or as follows: ARTICLE 6 DISPUTE RESOLUTION § 6,1 INITIAL DECISION MAKER • The Architect will serve as Initial Decision Maker pursuant to Section 15.2 of AIA Document A201-2007.unless the parties appoint below another individual,not a party to this Agreement,to serve as initial Decision Maker. AIA Document A191"—2007.Copyright fb 1915,1918.1925,1937,1951,1958,1961,1963,1967,1974,1977,1987,1991,1997 and 2007 by The American tn� institute of Architects.All rights reserved.WARNING:This AlA4'Document is protected by U.S.Copyright Law and international Treaties_Unauthorized 4 reproduction or distribution of this AIAK Document,crony portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law,This document was produced by AlA software at 14:14:43 on 11/18/2014 under Order No.7956674000 1 which eapires on 10/3112015,and isnot for resale. User Notes: (2052679279) • (If the panics mutually agree,insert the name,address and other contact information of the Initial Decision Maker,if other than the Architect.) § 6.2 BINDING DISPUTE RESOLUTION For any Claim subject to,but not resolved by,mediation pursuant to Section 15.3 of AIA Document A201-2007,the method of binding dispute resolution shall be as follows: (Check the appropriate box,If the Owner and Contractor do not select a method of binding dispute resolution below, or do not subsequently agree in writing to a binding dispute resolution method other than litigation, Claims will be resolved by litigation in a court of competent jurisdiction) [X] Arbitration pursuant to Section 15.4 of A1A Document A20 1-2007 [ ] Litigation in a court of competent jurisdiction [ ] Other(Specify) ARTICLE 7 TERMINATION OR SUSPENSION § 7.1 The Contract may be terminated by the Owner or the Contractor as provided in Article 14 of AIA Document A201-2007, § 7.2 The Work may be suspended by the Owner as provided in Article 14 of AlA Document A201-2007. ARTICLE 8 MISCELLANEOUS PROVISIONS § 8.1 Where reference is made in this Agreement to a provision of AlA Document A201-2007 or another Contract Document,the reference refers to that provision as amended or supplemented by other provisions of the Contract Documents. § 8.2 Payments due and unpaid under the Contract shall bear interest from the date payment is due at the rate stated below,or in the absence thereof;at the legal rate prevailing from time to time at the place where the Project is located. (Insert rate of interest agreed upon,if any.) § 8.3 The Owner's representative: (Name,address and other information) — Bill Burns,Save the Fieldhouse Committee Chair Paul Northam,Director of Parks at City of Jeffersonville,Project Manager Mechanical Brian Baumgartle,CMTA Chris Kelting,CMTA § 8.4 The Contractor's representative: (Name,address and other information) Walker Mechanical Contractors,Inc. 1400 W.Jefferson St. Louisville,KY 40203 Tom Schadt(502)377-1219 Project Manager Inst AMA Document A101.1—2007.Copyright®1915,1918,1925,1937,1951.1958.1961.1963,1987,1974.1977,1987.1991,1997 and 2007 by The Amerieat institute of Architects.All rights reserved.WARNING:This AIA` Document is protected by U.S.Copyright Law and International Treaties.Unauthorized 5 reproduction or distribution of this 14Ar`Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law.This document vas produced by AlAsottware at 14:14:43 an 11/18/2014 under Order No.7956674000 1 which expires on 10/31/2015,and is not for resale. User Notes: (2052679279) § 8.5 Neither the Owner's nor the Contractor's representative shall be changed without ten days written notice to the other party. § 8.6 Other provisions: ARTICLE 9 ENUMERATION OF CONTRACT DOCUMENTS § 9.1 The Contract Documents,except for Modifications issued after execution of this Agreement,are enumerated in the sections below, § 9.1.1 The Agreement is this executed AIA Document A101-2007,Standard Form of Agreement Between Owner and Contractor. § 9.1.2 The General Conditions are AlA Document A201-2007,General Conditions of the Contract for Construction. § 9.1.3 The Supplementary and other Conditions of the Contract: Document Title Date Pages § 9.1.4 The Specifications: (Either list the Specifications here or refer to an exhibit attached to this Agreement.) Section Title Date Pages See attached Exhibit#1 § 9.1.5 The Drawings: (Either list the Drawings here or refer to an exhibit attached to this Agreement.) Number Title Date See attached Exhibit#2 § 9.1.6 The Addenda,if any: Number Date Pages #1 March 25,2019 6 Portions of Addenda relating to bidding requirements are not part ot'the Contract Documents unless the bidding requirements are also enumerated in this Article 9, § 9.1.7 Additional documents,if any, forming part of the Contract Documents: .1 AlA Document E201'rM-2007.Digital Data Protocol Exhibit,if completed by the parties,or the following: .2 Other documents,if any,listed below: 'List here any additional documents that are intended to form part of the Contract Documents.ALA Document A201-2007 provides that bidding requirements such as advertisement or invitation to bid, Instructions to Bidders,sample forms and the Contractor's bid are not part(Me Contract Documents init. AIA Oocurnent A101 TM—2007.Copyright 01915,1918,1925,1937,1951,1958,1961,1963,1967,1974,1977,1887,1981,1997 and 2007 by The American Institute of Architects.All rights reserved.WARNING:This AlA&Document is protected by U.S.Copyright Law and International Treaties,Unauthorized reproduction or distribution of this Ale Document or coy portion orb;may result in severe civil and criminal penalties,and will be prosecuted to the s t maximum extent possible under the law.This document was produced byAlA software at 14:14:43 on 11118/2014 under Order No.7956674000 1 which eAoires on 10/31/2015,and Is not for resale. User Notes: (2052679279) unless enumerated in this Agreement. They should be listed here only if intended to be part of the Contract Documents.) ARTICLE 10 INSURANCE AND BONDS The Contractor shall purchase and maintain insurance and provide bonds as set forth in Article 11 of AlA Document A201-2007. (State bonding requirements, Li am',and limits c fliiability for insurance required in Article 11 of AIA Document A201-2007.) Type of insurance or bond Limit of liability or bond amount($0.00) Document A312-2010(See Attached) This Agreement entered into as of the day and year first written above. • -NER(Si nature) CONTRACT° (Signature) Vice PResioen- of causr*urn (Printed name and title) (Printed name and title) tS XMA ov&- IrtiL AIA Document A101'.—2007.Copyright C 1915,1918,1925.1937,1951,1958,1961,1963,1967,1974,1977,1987,1991,1997 and 2007 by The Atherican institute of Architects.All rights reserved.WARNING:This AIA`Document is protected by U.S.Copyright 1.aw and international Treaties.Unauthorized 7 reproduction or distribution of this AIA` Document,or any portion of it,may result in severs civil anti criminal penalties,and will be prosecuted to the ( maximum extent possible under the law.This document was produced by AIA software at 14:14:43 on 11/1812014 under Order No.7958674000_1 which expires on 10131/2015.and is not for resale. (2052679279) User Notes: EXHIBIT# 1 Nachand Fieldhouse Mechanical and Electrical Renovation VNFR18 Save the Fieldhouse Committee March 2019 City of Jeffersonville TABLE OF CONTENTS Section 000003-Specification Index Cover Section 000003 Specification Index Section 000010 Project Directory Section 000020 Invitation to Bidders Section 000100 Instructions to Bidders AIA Document A701 —Instruction to Bidders Section 000120 Supplementary Instructions to Bidders Section 000300 Proposal Form Form 96 Section 000310 Bidders Checklist Section 000410 Bid Security Form AIA Document A310—Bid Bond Section 000450 Non-Collusion Affidavit Section 000500 Agreement Form AIA Document A101 —Standard Form of Agreement between Owner and Contractor Section 000600 Contractor's Bond for Construction AIA Document A312—Performance Bond AIA Document A312—Payment Bond Section 000700 General Conditions ALA Document A201 —General Conditions of the Contract Section 000800 Supplementary Conditions Division 1 General Requirements Section 010100 Summary of Work Section 012200 Unit Prices Section 012300 Alternates Section 012600 Contract Modification Procedures Section 012900 Payment Procedures Section 013100 Project Management and Coordination Section 013200 Construction Progress Documentation Section 013300 Submittal Procedures Section 014000 Quality Requirements Section 014200 References Section 015000 Temporary Facilities and Controls Section 016000 Product Requirements Section 017300 Execution Section 017413 Cleaning Section 017423 Final Cleaning Section 017700 Closeout Procedures Section 017823 Operation and Maintenance Data Section 017839 Project Record Documents DIVISION 9 FINISHES Section 095113 Acoustical Panel Ceilings Section 099120 Painting DIVISION 20-MECHANICAL 200100-General Provisions—Mechanical 200200-Scope of the Mechanical Work 200300-Shop Drawings,Maintenance Manuals and Parts Lists 200400-Demolition 201100-Sleeving,Cutting,Patching,Firestopping&Repairing SPECIFICATION INDEX 000003 EXHIBIT# 1 Nachand Fieldhouse Mechanical and Electrical Renovation VNFR18 Save the Fieldhouse Committee March 2019 City of Jeffersonville 201300-Pipe,Pipe Fittings,&Pipe Support 202100-Valves 202200-Insulation—Mechanical 202400-Identifications,Tags,Charts,Etc. 202500-Hangers,Clamps,Attachments,Etc. 203100-Testing,Balancing, Lubrication and Adjustments DIVISION 23—HVAC 230200-HVAC Equipment 231200-Sheet Metal DIVISION 25—Building Automation System 250400-Controls—Direct Digital 250400-Controls—Direct Digital(Add Alternate#2) DIVISION 26-ELECTRICAL 260501-General Provisions-Electrical 260502-Scope of the Electrical Work 260503-Shop Drawings,Etc. 260504-Sleeving,Cutting,Patching&Repairing for Electrical Systems 260505-Excavation,Trenching,Backfilling&Grading 260506-Demolition,Restoration&Salvage 260508-Coordination Among Trades,Systems Interfacing and Connection of Equipment Furnished by Others 260510-Description of Electrical System 260519-Low-Voltage Electrical Power,Conductors,Cables, Splicing Devices and Connectors 260526-Grounding and Bonding 260529-Hangers and Supports for Electrical Systems 260533-Raceways&Fittings for Electrical Systems 260535-Cabinets,Outlet Boxes&Pull Boxes for Electrical Systems 260553-Identifications for Electrical Systems 260573-Electrical Studies 262200-Dry-Type Low-Voltage Transformers 262416-Panelboards 262726-Wiring Devices and Plates 262813-Fuses 262816-Enclosed Switches and Circuit Breakers 264313-Surge Protection for Low-Voltage Electrical Power Circuits 265113-Lighting DIVISION 28—ELECTRONIC SAFETY AND SECURITY 283100-Fire Alarm Detection System(Voice) 283111-Fire Alarm END OF INDEX SPECIFICATION INDEX 000003 EXHIBIT#2 Nachand Fieldhouse - Mechanical and Electrical Upgrades Mechanical M1.0 Mechanical Legend , General Notes , Schedules and Details M2.0 Floor Plans - Mechanical Demolition M3.0 Floor Plans - Mechanical M4.0 Roof Plans - Mechanical EXHIBIT#2 Electrical E0.1 Symbols Legend & General Notes E0.2 Light Fixture Schedule E1.1 First Floor Plan - Demolition E1.2 Second Floor Plan - Demolition E2.1 First Floor Plan - Lighting E2.2 Second Floor Plan - Lighting E3.1 First Floor Plan - Power & Systems E3.2 Second Floor Plan - Power & Systems E4.0 Power Riser Diagrams E4.1 Fire Alarm Riser & Electrical Details E4.2 Electrical Panel Schedules UE1.0 Electrical Site Plan E Form ST-105 Indiana Department of Revenue State Form 49065 R4/8-05 General Sales Tax Exemption Certificate Indiana registered retail merchants and businesses located outside'ndiana may use this certificate.The claimed exemption must be allowed by Indiana code. Exemption statutes of other states are not valid for pumht.ses from Indiana vendors.This exemption certificate can not be Issued for the purchase of Utilities, Vehicles, Watercraft,or Aircraft. Purchaser must be registered with the Department of Revenue or the appropriate taxing authority of the purchaser's state of residence. Sales tax must be charged unless all Information in each section is fully completed by the purchaser.Purchasers not able to provide all required information must pay the tax and may file a claim for refund(Form GA-110L)directly with the Department of Revenue. Name of Purchaser City of Jeffersonville Business Address 500 Quartermaster Ct City Jeffersonville state IN zip 47130 ra Purchaser must provide minimum of one ID number below.'r Provide your Indiana Registered Retail Merchant's Certificate TID and LOC Number as shown on your Certificate 0031209530 .- 010 'HIM(10 digits) LOC#(3 digits) If not registered with the Indiana DOR,provide your State Tax ID Number from another State 1356001067 Indiana *See instructions on the reverse side if you do not have either number. State ID# State of Issue (4 Is this a ®blanket purchase exemption request or a 0 single purchase exemption request? (check one)' 4 Description of items to be purchased. -77 Purchaser must indicate the type of exemption being chimed for this purchase. (check one or explain) 0 Sales to a retailer,wholesaler,or manufacturer for resale only. ❑ Sale of manufacturing machinery,tools,and equipment to be used directly in direct production. CI Sales to nonprofit organizations claiming exemption pursuant to Sales lax Information Bulletin#10. (May not he used for personal hotel rooms and meals.) ❑ Sales of tangible personal property predominately used(i,reater then 50 percent)in providing public transportation-provide USDOT#. er3•: A person or corporation who is hauling under someone el.cc's motor carrier authority,or has a contract as a school bus operator,must o- provide their SS#or FID#in lieu of a State ID#in Section#1. USDOT# cy; Vi:0 Sales to persons,occupationally engaged as farmers,to be used directly in production of agricultural products for sale. Note:A farmer not possessing a State Business License#may enter a FID#or a SS#in lieu of a State ID#in Section#1. ❑ Sales to a contractor for exempt projects(such as public schools,government,or nonprofits). [I Sales to Indiana Governmental Units(agencies,cines,to.vns,municipalities,public schools,and state universities). • ❑ Sales to the United States Federal Government-show agency name. Note:A U.S.Government agency should enter its Federal Identification Number(FID#)in Section#1 in lieu of a State ID#. ❑ Other-explain. „ hereby certify under the penalties of perjury that the property purchased by the use of this exemption certificate is to be used for an exempt purpose pursuant Ell e tate Gross Retail Sales Tax Act,I inna Code 6-2.5,and the item purchased is not a utility,vehicle,watercraft,or aircraft. ;fir i I confum my understan ' g t • =• either j•.gli e t or intentional),and/or fraudulent use of this certificate may subject both me personally and/or the business entity y;; res-nt to .e r !ray f tax,interest,and civil and/or criminal penalties. /� Signature of Purchaser T 0 Date (/ r/ Printed Name 1C14.0 t '�s• t-VPR-44.04 Title 1.11J0TADi . e.tz___ The Indiana Department of Revenue may request verification of registration in another state if you are an out-of-state purchaser. Seller must keep this certificate on file to support exempt sales.