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4.06 4.6 FINANCIAL\2022\PURCHASE—Emergency Water Repairs—Quaker Road— 1-24 RESOLUTION AUTHORIZING AND RATIFYING EMERGENCY WATER SYSTEM REPAIRS IN VICINITY OF 323 QUAKER ROAD, QUEENSBURY RESOLUTION NO.: , 2022 INTRODUCED BY: WHO MOVED ITS ADOPTION SECONDED BY: WHEREAS, the Town of Queensbury's Water Superintendent advised that as a result of a break that occurred in a Town water line located near 323 Quaker Road in the Town of Queensbury on or about December 30"', 2021,he arranged for immediate repairs due to the depth of excavation, traffic issues and uncertainty about the cause of the break on an emergency basis for public health and safety reasons as time would not allow for the receipt of bids, and WHEREAS, the Water Superintendent engaged Edward & Thomas O'Connor, Inc., for such repair work, and WHEREAS, the Town Board hereby determines that such repair services constituted an emergency procurement needed to best serve the Town's residents and such repairs needed to be completed immediately to protect public health and safety, NOW;THEREFORE,BE IT RESOLVED, due to the emergency nature of the above-described repairs, the Queensbury Town Board hereby waives its requirement under General Municipal Law §103 and the Town of Queensbury's Purchasing Policy and authorizes, confirms and ratifies the Town Water 4' Superintendent's engagement of Edward&Thomas O'Connor, Inc., for the provision of emergency water system repairs in the vicinity of 323 Quaker Road, Queensbury as delineated in the preambles of this Resolution, as such emergency repairs were needed to maintain public health and safety to best serve the Town's residents and should have been made as soon as possible, and BE IT FURTHER, RESOLVED, that the Town Board authorizes and directs that payment for such services in the total amount of $15,862.53 as delineated in Edward & Thomas O'Connor, Inc.'s 1/5/2022 Invoice shall be made from Misc. Contractual Account No.: 040-8340-4400, and BE IT FURTHER, RESOLVED, that the Town Board authorizes and directs the Town Budget Officer to amend the 2021 Town Budget to transfer $15,862.53 from Fund Balance Account No.: 040-0000- 0909 to Misc. Contractual Account No.: 040-8340-4400 and take any and all other necessary actions to effectuate payment, and BE IT FURTHER, RESOLVED, that the Town Board further authorizes the Town Supervisor, Water Superintendent and/or Budget Officer to take such other and further actions as may be necessary to effectuate the terms of this Resolution. Duly adopted this 24`h day of January, 2022,by the following vote: AYES NOES ABSENT: Edward Thono as O'Connor,Inc. Heavy construction/site Development/Asphalt Paving P.O.Box 377/147 Meadowbrook Rd,Glens Falls,NY 12801 O171ces(518)792-4090/Fax(510)792-4194/oconnorincLahotinail.com/www.etoconnor.coni PROJECT NAME:Town of Queensbury—Water Valve Replacement DATE:1/5/2022 INVOICE Town of Queensbury 742 Bay Road Queensbury,NY 12804 Attention: Chris Harrington Email:chrish lueensbuiy.net. Mr.Harrington, Thank you for allowing our company to fix your water line issue on Thursday 12.30.2021. Our company opened up a section of Quaker road,in front of Nemer Ford and replaced a valve.We backfilled the hole and restored the road and grass Swale.The road is being temporarily restored with cold patch.When the asphalt plants open in April,the cold patch will have to be replaced with HMA. Behind this letter is ourT&M workup from that day,along with backup. Also attached is our insurance. Total due for this invoice is$15,862.53 Thank you, Pat O'Connor Jr,Vice President Edward and Thomas ®`Connor, Inc. BLACK TOP PAVING,EXCAVATION AND GRADING y DEALERS IN FILL,GRAVEL,SOIL AND STONE Meadowbrook Road AREA CODE 519 P.0.Box377 TELEPHONES: Q(_FICE 792-4090 3 Glens Falls,NY 12801 NO ANS. 793-2297 FAX: 792-4194 DAILY LABOR, EQUIPMENT &. MATERIAL VOUCHER T0: _ �}� I:aw� ..o ��e2k5��f DAY: T�.visd.a DATE: !Z"3 0-zO z f PROJECT y_wi n c aC �1� �; `.F���Z Re- � -,M. e..4 . P.O.# DESCRIPTION OF WORR> e-.p a-�- VrO.y , I C'o.;-r a t a, r. LABOR IR f l U �j oTA HOURS CLASS REG. =O/T PAYHR RATEP A_-MMOUNT HRS. EQUIP-KENT I.R<'t�TE �AifU#%r.%, _4T "All 4xei 4- 11 "? 19 4 v 35-0,00 t:,�.;: ?. : 795`, Wa�I�ifol)z,�' fez+ 75.°r t,a 13 77. 5'rmwl j IoolS (S-w�J�M�;ti` k )(i0.`°+ v •^ 1 1 L L �l V Do .1T5 J c i GG1.�° T r,,,��fG Duk t,•. I -0,110 f«<Ic(ufrl P, �wccCk`J�) ( ►: I 1 Dc Wye �r t p �Ccaswl604� ; TERIAL A-I i TY a RATE IAMODNT Lg S,ZI 'E a� �-'�2w, " t ��e T o O T o : o; d ! .CL1 SIGNATURE: 0 y P/{ s PECKH M MATERIALS CORP. 910303199 Hudson Falls Blktp. (91) PECKHAM MATERIALS CORP. 910303152 518-747-3353 3 91 cwsls Hudson Fails Quarry (31) 518-747-3353 3 31 ganab Ticket#: 910303189 pied.130'; ;2021 1:18:29PM Ticket#: 910303152 Customer: 173520 _Dac,.:30:;: "2021.. .. 7:19:06AM Edward & Thomas O'Connor Customer' _ P.O. BOX 377 Edward & Thomas O'Connor P.O. BOX 377 GLENS FALLS, NY 12801 P.O.: GLENS FALLS, NY 12801 Product: 1211 P.O.: Cold Patch/Winter Mix Product: 1312 Truck: Ob FOB #2: STONE .'3/4 Truck: Ogray FOB ;Su Tons LBS; ;Summary Tons I (summary Tons LBS LOSS Weight: 31.21 62,4201 Tare Weight: 13.95 27,900 i' ross Weight: 35.47 70,940 NTet Weight. 17R 26 34,520J are Weight: 29,540 t- —� {Net Weight: 20.7 41,4001 May cause burns and photosensitivity _ to skin. Contains asphalt cement, Avoid prolonged exposure to dust. hydrocarbons and non-metallic Wear a mask if possible.NOTICE: minerals. NOTICE: Driver certifies Customer/driver certifies that the the loaded gross vehicle weight Of loaded gross vehicle weight of this this vehicle is in compliance with vehicle is in compliance with all state and federal regulations. allstate and federal regulations. Job Queensbur. -Wate yQi" r. Job Quaker Rd Quaker Rd -^�—"— ENGLISH METRIC EN SH METRIC Load Total: 17.26 15.66 Load Total: 20.70 18.78 Daily Total: Daily Total: Job Total: . Job Total: Y-T-D Total: Y-T-D Total: 2,562•1.99 2,325.02 Lief Num: Ref Num: PO Deso: PO Desc: A Manufacturers Sofoty Data Sheet is at the A Manufacturers Safety Data Sheet is at the ou inspection. plant office for you inspection. plant office for y For a free Copy call 914-949-2000. For a free copy call 914-949-2D00. INVOICE Invoice Number: 974269 Peckham Materials Corp Invoice Dace: 1/1/2022 A subsidiary oJPeckham Indusd ics,Inc. PO Box 1055 1 Albany NY 12201.1055 0 914-949-2000 ���i T'J���T� r ��'��� � ��1 � �'�'•x�a _"�-� .,�- .'��.y�"�Vie- . Edward&Thomas O'Connor P.O.Box 377 Glens Falls,NY 12801 marikka@etoconnor.com •.�-�. ,�k.l`£�. .im j: -..� 'r3.' �P .l to .t Fi*'�'.ta`fl4�ur't'�»r "'�'i�.^.rvry� -�•�. � �'':..r & .C�'a-7 rG�l,... -,�:.s `' - __ 173520 Hudson Fails Quarry 1%10 Net 30 Days r�9t9uw=. ItCgYt r..i.3d.-i'rYa a-�--�.8�fl7�110D,.�"k1- � y,., ..+Sll�vil.TtCII1/$r fl JQ� �1t{'tia eT_��T�RIt" _-��a1!T�"/1II1++.��!. ✓:.Z'.''��..r��____—��... , ��t" •.....iv�� f...d++:v .-- 12129 SUB-TO 304.031TEM4-11/4 siockple TON 45.38 B.000 363.04 363.04 12130 STN-12 NO.1 STONE'112INCH' Stockpile 'TON 21.37 9.500 203.02 203.02 12130 STN 14 NO.1A STONE 114 INCH Stockpile TON 21.02 12.000 252.24 252.24 12130 STN34 . 2STONE'3/4 .';lluakei.Rd' EQN. 20:70 8750 :181:13 18t:13 12/30 M-34 #2STONE'314 Stockpile -TON 206.78 8.750 1,809.35 1,809.35 12130 SUB-TO 304.03 ITEM-4-1 114 Stockpile TON 67.98 8.000 543.84 543.84 33.52 3,352.62 3,352.62 Please detach and return this stub with your payment Make check payable to: Peckham Industries,Inc To receive Invoices via email please visit our web PO Box 1055 portal at: Albany,NY 12201-1055 www.peckham.comtportal or contact us at credit@peckham.com .. ...._......... ..___...._. ._ .. Invoice Number: 9742695 3,352.62 0.00 3,352.62 Customer Number: 173520 tt MD�scount ava�labte LDay�o€Inoi_ce T)afe u f �t rT` _ 33.52 Invoice Date: 1/1/2022 Plant: Hudson Falls Quarry Customer. Edward&Thomas O'Connor t: P.O.Box 377 Glens Falls,NY 12801 EI Page 1 of 1 INVOICE Invoice Number: 974270 Peckham Materials Corp Invoice Date: 1/1/2022 A subsidiary oJPeckham Industries,Inc. PO Box 1055 1 Albany NY 12201-1055'e 914-949-2 0 0 0 Edward&Thomas O'Connor P.O.Box 377 Glens Falls,NY 12801 marikka@etocannor.com C,ust j• i. c�"r+ca:?i e>•...� M1 -u f PIaOft 3 i�lrr ?a jY+p ftllltb�S., � 4..�'� P r DCSCFt�tton _ .__._. ..s......�...... . ....c,.s..F.�3:t,.e"�'...;..v 173520 Hudson Fails HMA 1 1%10 Net 30 Days 12130 1211 Cold Patchl4VinlerMix 0ueensburywate TON 17.26 78A00 1,34628 1,34628 I .,;,,,;:.>c ;Piscomiavaleg1,4{Daysr�itimR eeip2�flavois5- 2,,.�_iKjza...�et„S�db�teli.s��,:"�ta'te�i :: �rrr'^ �ry3Taxt�,�A's��i >E�i'�t Amontii-r 13.46 1,34628 1,346.28 Please detach and return this stub with your payment Make check payable to: Peckham Industries,Inc To receive invoices via email please visit our web PO Box 1055 portal at: Albany,NY 12201-1055 www.Deckham.com/6ortal or contact us at credit@peckham.com Invoice Number: 974270' 4 1,346.28 0.00 1,346.28 Customer Number: 173520 t � 4D�s o}tnt,�vailaklewt�ttnlOD'aye-0�Invotce�ate � '- �' 13.46 Tuvoice Date: 1/1/2022 Plant: Hudson Falls HMA Customer. Edward&Thomas O'Connor P.O.Box 377 i Glens Falls,NY 12801 i I Ei __....._ - Page 1 of 1 1/4122,10:44 AM etoconnor.com Mail-TRAFFIC QUOTE O'CONNOR CONSTRUCTION PATRICK O'CONNOR JR. ? I VICE PRESIDENT Office:(518) 792-4090(Ext.5) w ;V Cell: (518)742-0804 t _ Website: etoconnor.com Mason Hamilton<mason@donnellyconstruction.net> Tue,Jan 4,2022 at 10:36 AM To:Patrick O'Connor<pat@etoconnor.com> Cc: Brandon Briggs<Brandon@donnellyconstruction.net> Patrick, The crew ran over 8 hours on site so we will be billing for 1 overtime hour at$350.00 per hr. Out royal for the invoice will be$3000.00 $2,650.00 + 3350.00 $3,000 �I- � Thanks, Mason Hamilton Donnelly Construction 0-518-664-9435 F-518-664-1601 C-518-744-2130 [Quoted text hidden] *R Scan 2021-437,pdf 227K Patrick O'Connor<pat@etoconnor.com> _ T Tue,Jan 4,2022 at 10:41 AM To:Mason Hamilton<mason@donnellyconstruction.net> Cc:Brandon Briggs<brandon@donnellyconstrucdon.net> Ok thank you guys very much for the help. httpsg/mail.google.cornlmaiVu/0Pik-1 d5ob7b55a&view=pt&search=all&permthid=thread-f%3A1720415590424827323&simpl=msg-f%3A1720415590... 314 Donnelly Construction Inc. PO Box 150-155 Route 67 Mechanicville, NY 12118 ph.5IM64-9435 fax.518-654-1604 Maintenance&Protection of Traffic Detail Timesheet Date: Day: Su M T W hh�, F S DCI Jab# 1 �1- q-:� 7 Customer Cust. Po#.. -cjdn Street: CityfTown: DCI Foremen Name: J.. . rii S Hours Worked m m Nature of Work: U0. .clasu/c. on tt6mer Sigi a ure� Print .ame Company Responsible For B Company Responsible For Bill:.' d us:„1 Q►�.. rIT �' ?C•C;sNOR !'ON TRIA T ITI ON QC-UHFaE t'ONSTIF.UCTI�t� r,tW. �--+ G L� 31 f ' SPO 9L1n 37 47 to POAD j47 !�]G j{jj117f 14�+iF, ROAD i r..N t n r,r. I _ e.-C.� Et1�[.4. '►$`:` l�n[ij + ts!,�du FRLL3 }i. �L��L±1 =10 '�a--40?0 5'_ 792-409 I 112=. 5s1 Jt32;-i1_310 � ;:;:- :y� Furl-12-30 ITE 7 ,'`,40 1b 0 49140 Ib 0 2-:UOO 1b PT f 29000 1b FT 46340 ib N 19140- lb N i i Project: :, 61-- � : j,�J,g��jl,;ve ,`^ • ' Project: � �G� Signature: Signatu e: Print your Name: . Print your Name: ~~ 28481 28482 t f. Company Responsible For Bill:.Lpp�,I Qig ( 4 e�:,a�;'�i{i_r:, 4rli3'�JT�tJt•i 1�1i vl? SOX 77-7 r k 0,0.6 f Fir;,� INY 1220 i 'U;'-'2-3G L ITEM 3 ,;FAVEL i W91 L+40 lb G ' 7y 00 Ib PT '4494G lb MI Project: :Q4A-k2r IGLI LO-i 24MIC ?9Z2 ) . Signature: Print your Name: I 28479 O'Connor Sand Stone Land Pit rcoNukok- SAND&STONE. PO Box 377 Glens Falls.AY 12801 Office No. 518-792-4090 S Contractor's Price List New Prices Effective November 1,2021 Hours of operation:Monday-Friday 7:00 am-3:45 pm Saturday hours(April-October)7:15 am-11:45 am Call for Winter Hours Sand/Soil Per Ton Stone Perton Bank Run Sand $ 4.95 Pea Stone $ 23.50 Processed Sand(Granular) $ 8.50 #1 Crushed Natural Stone $ 19.00 Cow Sand(Screened) $ 9.00 #2 Crushed Natural Stone $ 14.95 Concrete Sand $ 8.50 #3 Crushed Natural Stone $ 14.95 Red Dirt(Screened) $ Rip Rap(4"-6" Natural) $ 17.50 Topsoil(Screened) 21.00 #1 Round Stone $ 20.00 Clay(Pond Fill) $ 8.50 #2 Round Stone $ 20.00 River Cobbles(3"-6") $ 17.50 Lime Stone Per Ton Cobble Rock(4"-12") $ 20.00 #1A Crushed $ 20.50 *Landscape Boulders/Wall Rock(13"&Up) $ 55.00 #1 Crushed $ 17.00 *1 ton min per sale Landscape/Wall Rock 42 Crushed $ 17.00 #3 Crushed $ 17.00 Limestone Subbase Per Ton Stone Dust $ 20.50 #1A's&Dust $ 19•00 Gravel Per Ton Shoulder Stone $ 16.00 Bank Run Gravel $ 5.95 Rubble $ 16.00 Item 4(Crushed) $ 11.00 Asphalt-Millings $ 20.00 Tailings(Finer Gravel) $ 12.00 Ice Contol Per Ton Mulch Per Cubic Yard Sand/Salt Mix $ 40.00 Brown French Roast $ 45.00 *Salt $ 125.00 Black $ 45.00 Road Sand $ 8.50 *1/2 ton min per sale for salt products All prices are FOB and you will be billed New York State Sales Tax. *Due to the unstable fuel pries our price per ton is subject to change without notice. **Minimum Load Charge of$20.00** ***Trucking available-$100.00 per hour(minimum 1 hour)*** iffuther assistance is needed-call Kevin O'Connor @ 518-361-0791 Casale Rent-All LLC - Clifton Park Status: Closed Invoice#: 238979-1 1641 Rt 9 518-383-7368 Phone Invoice Date; Thu 1213012021 CLIFTON PARK,NY 12065 518-371-5214 Fax Date Out: Wed 12/2912021 10:01AM www.caS21erentalf.com Operator: Delafrange,Kristian __JrCustomer#: 26364iJ Terms: On Account t EDWARD&THOMAS O'CONNOR CON: Phone 792-40M 147 MEADOWBROOK RD Job Descr: ? Queensbury,NY 12804 PO M.TOWN OF QUEENSBURY Ordered By:OCONNOOR, PATRICK,J,JR - 0 Picked up by: OCONNOOR, PATRICK,J,JR (53241) Salesman: Ken Klein 518-54-2-4301 ken@casalerentall.com f City1 Key !tams Part# Status� Returned Date Price L 8 1 DOTSON-1 GROUND MAT,8'X 4' RBtumed Thu 12/30/2021 2:12PM S256.56 PLEASE BE SURE TO HOSE OFF OR SWEEP OFF BEFORE RETURNING. I $40 PER MAT CLEANING FEE CHARGED,IF RETURNED W DIRTY.. . Total for Rental$256.56 f " +i ,. r �✓-=� i ZO C i � Tease pay froart this inVGI,- .T h.-. ' '.._. Rental: .° _-_- $256.56 - Subtotal: toga Cnty Sales Tax-? J Total: (� Paid: ' Amount Due: $256.56 $17.961 $274.52 $0,00 f. $274.52 6 -� Damage Waiver is OPTIONALAND MAY BE DECLINED if you provide the Insurance required on the reverse side or Page 2 of this Contract IMPORTANT: If you decline the Optional Damage Waiver,or if you fail to pay the Damage Waiver Fee prior to commencement of the Term,you will be responsible for all damage to the Rented ltem(s),including the full(new) replacement value thereof. Initial Here to Decline Damage Waiver. Initials:_ BY SIGNING BELOW,YOU IRREVOCABLY AND UNCONDITIONALLY AUTHORIZE CASALE RENT-ALL,LLC,A NEW YORK LIMITED LIABILITY COMPANY('CASALE-)TO CHARGE ALL AMOUNTS DUE AND COMING DUE UNDER THIS RENTAL CONTRACT TO ANY AND ALL CREDITCARO(S)YOU PROVIDE TO CASALE. If any Rented Item(s)istare not returned to Casale on the scheduled return date(s),this Contract will be deemed extended,and shall continuously apply to your rental of such item(s),for the duration of such period(the"Extension Period!;provided however,that Casale may,at its sole option,terminate such Extension Period,and your rental,at any time. This is a legally binding Contract.Important Terms and Conditions appear on the Reverse Side or Page 2 hereof oncluding Casale's disclaimer,as well as the Customer's/Lessee's waiver, of all liability for personal injuries and property damage,and details of the Customees/Lessee's obligations),as well as any Instructions and/orAddenda included herewith. ANY DIFFERENT OR ADDITIONAL TERMS,WHETHER ORAL OR WRITTEN,ARE HEREBY OBJECTED TO,AND SHALL NOT BE ENFORCEABLE UNLESS SEPARATELY(AND SPECIFICALLY)APPROVED IN WRITING BY CASALE IMPORTANT.PLEASE READ CAREFULLY BEFORE SIGNING: You,for yourself and for the"Customer/Lessee,"acknowledge and agree that you have carefully reviewed,fully understand,and agree to all of the terms and conditions set forth on the front and reverse side(or Page 2)of this Contract,that you have received a complete and legible copy of this Contract,and that you PERSONALLY GUARANTEE the prompt payment and performance of all obligations of the Customer/Lessee to Casale arising hereunder and/or in connection herewith. Signature: OCONNOOR,PATRICK,J,JR(53241) WINTER HOURS:OPEN MON-FRI 7:30am TO 5:00pm,CLOSED SAT-SUNDAY �~Mw Modification#3 Printed On Thu 121302021 213:45PM software by Point-cf-Renial software www.polnt•or-rentat.com contrad-params.SOLrpt(1) U.S. Department of Labor PAYROLL MIN ' Wage and Hour Division (For Contractor's Optional Use;See Instructions at www.dol.govlwhd/forms/wh347!nstr.htm) U.S.WhIpmidBour Division Persons are not requ/red to respond to the collection of Intomrinf on unless it displays a currently valid OMB control number. Rev.Dec.2008 -NAME OFCONTRACTOR�' OR SUB CONTRACTOR[3 I ADDRESS P.O,Box377 i OMB No.:1235-0008 (+ Edward&Thomas O'Connor,Inc. Glens Falls NY'12801 !OJECTORCONT xp res• RACTNO PAYROLLN0, FOR WEEK ENDING +In Ica CT R L CATION PR 01l0212022 Water MBin Repair (4)DAYANODATE (5) l5i (7) az 'M Tu W .Th F Sa SU DEDUCTIONS N 90 NAME AND INDiVIDUALIDENTiFYINGNUMBFR LL= ° "" GROSS WITH- ET WAGES o 27 '28 29 30 31 1 ?.TOTAL RATE AMOUNT HOLDING TOTAL PAID (e.g..LAST FOUR DiGITS OF SOCIAL SECURITY o WORK o _.. NUMBER ORWORKER ..._ z _.-CLASSIFICATION .HOURS WORKED EACH DAY HOURS� OF PAY ..EARNED FICA TAX OTHER DEDUCTIONS-FOR WEEK Bruce Hutchinson•2099 HH Operator o oas 0.75 $97.Og $652.17 .- s a.00 8.00 $135.87 $334.60 $470.47 $1,213.67 g6.91 zssl 1.684.14 Richard Spencer Jr.'8019 HH Operator a F.581:84 . 0 $114.75 $208.32 5323.07 $1,129.40 S 0.00 g.00 46.91 25.62 ' $1,452.42 ... . Patrick O'Connor Sr.*1303 HH Operator o 0 $117.45 $299.12 $416.57 $1,070.80 s Sao 8.00 46.91 25.82 $1487.37 14 Lloyd McKessesy'3658 HH Labor o 8.00 27.27 27.01 $89.00 $245.66 $334.66 $828.65 $1,163.31.Louis Woodcock`3027 HH Labor c $434.56 ' $84.36 $134.86 $219.22 $883.59 s . aoa 8.00, 2z27 2zas .'$1,102.8t 0 $92.2 $230.6 $ .90 $882.77 Peter Durrin•9644 HH.Teamster a $351.9G .._. .... . ... ... 3 7 322 s 6.as G.00 .. 32.71 25.95 ..•,,$�1,205.67 ,.r_..... Kenneth Harris*3409 HH Teamster o 0 $ 8.51 $768.61 80.3 6 $168.1 5 $� 6 3.44 5.00 32.11 24.20 $1,017.12 `S While completion of Forth WH-3471s optional,It Is mandatory for covered contractors and subcontractors performing worker Fedamlly financed or assisted construction contracts to respond to the Infonnallon colloeflon containad In 29 C.F.R.§§3.3.6,6(a).The Copeland Act (40 U.S.C.§3145)contractors and subeomractom performing work on Federally financed or assisted consWetlon contracts la"furnish weekly a statement with respect to the wages paid each employee during the preceding weok'U.S.Department of Labor(OOL)regulations at 29 C.F.R.§5.6(a)(3xg)require contractors to submit weeky a copy of all payrolls to the Federal agency contracting for or financing the construction protect,accompanied by a slgnad'Statement or Compllance'Indicating thatlhe payrof s are correct and complete and that each laborer or mechanto has bean paid not less than the proper Davis-Baoon prevailing wage rate for the work performed.DOL and federal contmcrmg agencies revolving this Information rovlmv the Information to determine that emptoyeas have received legally required wages and tinge benefits. Public Burden Statamant We estimate that is will take an average of 55 minutes to complete this collection,Including time for reviewing Instructions,searching existing date sources,gathering and maintaining the data needed,and completing and reviewing the collection of Information.It you have any comments regarding these estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Division,U.S.Department of Labor,Room S3502.200 Constitution Avenue,N.W. Washtngton,D.C.7.0210 '' - (over) Date January 4,2022 (b)WHERE FRINGE BENEFITS ARE PAID IN CASH Sherry M.Gilligan Administrative Assistant ❑ — Each laborer or mechanic listed in the above referenced payroll has been paid, (Name of Signatory Party) (Title) as indicated on the payroll,an amount not less than the sum of the applicable do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed (f)That I pay or supervise the payment of the persons employed by In the contract,except as noted in section 4(c)below, Edward&Thomas O'Connor,Inc. (c)EXCEPTIONS on the (Contractor or Subcontractor) EXCEPTION(CRAFT) EXPLANATION Quaker Road Water Main Repair ;that during the payroll period commencing on the (Building or Work) - 27th day of December 2021 and ending the 2nd day of January 2022 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Edward&Thomas O'Connor, Inc. from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or Indirectly from the full wages earned by any person,other than permissible deductions as defined in Regulations,Part 3(29 C.F.R.Subtitle A),issued by the Secretary of Labor under the Copeland Act,as amended(48 Stat.948, 63 Stat.108,72 Stat.967;76 Stat.357;40 U.S.C.§3145).and described below: CDPHP Health Insurance Simple IRA Plan REMARKS: - . . - .. ..... EE's on CDPHP Health Insurance: Bruce Hutchinson,Patrick O'Connor Sr.,Richard Spencer Jr., (2)That any payrolls otherwise under this contract required to be submitted for the above period are Peter Durrin,Kenneth Harris correct and complete;that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained In any wage determination incorporated into the contract;that the classifications EE's on Simple IRA: Bruce Hutchinson,Patrick O'Connor Sr.,Richard Spencer Jr.,Kenneth Harris set forth therein for each laborer or mechanic conform with the work he performed, (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training,United States Department of Labor,or IF no such recognized agency exists in a State,are registered with the Bureau of Apprenticeship and Training,United States Department of Labor. (4)That: (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS,FUNDS,OR PROGRAMS NAME AND TITLE Stg.NATURE Sherry M.Gilligan — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in Administrative Assistant , the above referenced payroll, payments of fringe benefits as listed in the contract THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTaJAY SUB JECT THE;CCN7 't!TOR OR' have been or will be made to appropriate programs for the benefit of such employees, SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION.SEE SECTION 1001 OF TITLE 18 A .'ECTION 3720 OF except as noted in Section 4(c)below. TITLE 31 OF THE UNITED STATES CODE CERTIFICATE OF LIABILITY INSURANCE 712'12'W2D021"YY"°° "r ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDEIRL 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 CCONT CT' House NAMHughes insurance Agency,Inc, 'PHONE N E�: (518)793-3131 (Alc po: (518)793-3121 328 Bay Road ADDRESS: PO BOX 4630 ,INSURER(S)AFFORDING COVERAGE NAIC N Queensbury NY 12804 INSURERA: Michigan Millers Mutual Ins Co 1 14508 INSURED INSURER B:. Edward&Thomas O'Connor Inc INSURER c: Po BOX 377 INSURER D: INSURER E; Glens Falls NY 12801 INSURERF: COVERAGES CERTIFICATE NUMBER: 21-22 Master REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. LTR TYPE OF INSURANCE FNSD" WVD POLICYNUMBER MMIODriYYY MM1D0 LIMITS X COMMERCIALGENERALLIABILITY EACH OCCURRENCE. -. ,.Is 1.000,OOD DAMAGEr+=+'- 100,000 ' CLAIMS-MADE ©OCCUR .�. iPREMISESMeooamence GDO MED EXP(Any one person) S 5' A C0534722 11/01/2021 11/01/2022 :PERSONAL aADVINJURY ($ 1-000,000 GEN'LAGGREGATELIMITAPPIJESPER: GENERALAGGREGATE Is 2,000,000 POLICY©JECr LOC PRODUCTS-COMP/OPAGG I S 2,000.000 OTHER: I$ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1.000,000 We accidan ANYAUTO BODILY INJURY(Per personl $ A OWNED SCHEDULED :V0701245 11/01/2021 11/01/2022 BODILY INJURY(Per accident) S AUTOS ONLY 'AUTOS HIRED .NON-OWNED P TY DAMAGE $ AUTOS ONLY AUTOS ONLY Peraaldentl $ .UMBRELLALIA9 OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAR CLAIMS-MADE C0702281 11/01/2021 11/01/2022 AGGREGATE S 5,000,000 Ir DIED I X1 RETENTION$ 10,000 _ $ WORKERS COMPENSATION P I OT}I- AND EMPLOYERS'LIABILITY YIN' -ST A TUTE ER A ANY PROPRIETORIPARTNER/EXECUMVE NIA TWO118132 11/01/2021 11/01/2022 E.L.EACH ACCIDENT S. 1,OOO,DDD OFFICERIMEMBER EXCLUDFA? 1,000.00O (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ Byes,describe under 1,000-000 DESCRIPTION OF OPERATIONS below El,DISEASE-POLICYLIMIT $ Leased Rented Equipment A C0534722 11/01/2021 11/01/2022 Limit/ 750,000 Deductible/ 1,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more spare is requirod) Subject to all policy terms,limitations and conditions:Re:Water Main Repair, 323 Quaker Road,Queensbury NY 12804. Certificate Holder is Additional Insured when required by written contract,agreement or permit. CERTIFICATE HOLDER. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Queenshury ACCORDANCE WITH THE POLICY PROVISIONS. 742 Bay Road AUTHORED REPRESENTATIVE l� Queensbury NY 12804 */Vj4�(-" +l ©1988-2015ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured Edward and Thomas O'Connor Inc (518)792-4090 PO Box 377 Glens Falls,NY 12801 1c.NYS Unemployment Insurance Employer Registration Number of Insured 1 d.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically or Social Security Number limited to certain locations in New York State, i.e., a Wrap-Up 141484778 Policy) 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Michigan Millers Mutual Ins Co 3b.Policy Number of entity listed in bog"1a" Town of Queensbury W0118132 742 Bay Road Queensbury,NY 12804 3c. Policy effective period 11/1/2021 to 11/1/2022 3d. The Proprietor,Partners or Executive Officers are included. (Only check box if all partners/officers included) X all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "T' insures the business referenced above in box "la" for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"T'. The Insurance Carrier will also notify the above certificate holder with in 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment ofpremiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (T'Itese notices may be sent by regular mail.) Otherwise,this Certfeate is valid for one year after this form is approved by the insurance carrier or its licensed agen4 or until the policy expiration date listed in box"3c",whichever is earlier. Please Note:Upon the cancellation of the workers' compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Linda Abodeely (Print name of authorized representative or licensed agent of insurance carrier) Approved by: e., �+' December 27,2021 (Signature) (Date) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 518-793-3131 Please Note.Only insurance carriers and their licensed agents are authorized to issue Form C-105.2.Insurance brokers are NOT authorized to issue it. C-105.2(9-07) www.wcb.stateny.us Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1. The head of a state or municipal department,board,commission or office authorized or required by Iaw to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,and notwithstanding any general or special statute requiring or authorizing the issue of such permits,shall not issue such permit unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter.Nothing herein,however,shall be construed as creating any liability on the part of such state or municipal department,board, commission or office to pay any compensation to any such employee if so employed. 2. The head of a state or municipal department,board,commission or office authorized or required by law to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter,notwithstanding any general or special statute requiring or authorizing any such contract,shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter. C-105.2 (9-07) Reverse