155 - P-25044 ESH L4 BOOSTER.pdf

Date:

To:

Re: NU Project Name:

NU Project Number:

Request for Proposal Number:

Trade/Category:

Recommendation of Award

Your Unit Price quotation for the above-described work is hereby accepted, pending final execution of the Addendum. Please find enclosed the Recommendation of Award packet, which includes the following documents:

▪ Unit Price Addendum

▪ University of Nebraska Owner’s Protective Bond with Instructions

▪ Contractor Contact Information Sheet

Follow the steps below for timely processing of the addendum.

▪ Complete the packet as directed and information as required, provide signatures in required formats.

▪ Return the completed packet within ten (10) days.

▪ Mail the original, wet signature bond to the University department contracting the work.

The Owner requires the following information for project files. If possible, forward these items with the signed contract.

▪ Construction Schedule - preliminary, if not final

▪ Submittal Schedule

▪ Initial Schedule of Values

Note:

▪ No staging or construction may start and no contract for this work exists until contract documents are complete and Notice to Proceed has been issued.

▪ Employee labor hour records for each worker will be required with invoice : include the date of the work, trade, name of worker, and billing rate.

The Owner is exempt from payment of sales or use tax. Forms appointing your firm as a Purchasing Agent and an Exempt Sales Certificate will be distributed with the Notice to Proceed for use when purchasing tangible, personal property for this project.

Sincerely, Attachments

CC: Facilities, Procurement, Project File, Project Manager:

UNMC Facilities Management & Planning

Mark Hansen Fluid Mechanical, LLC 9991 J Street Omaha, NE 68127

ESH L4 Booster Pump Replacement P-25044

3900-24-7200 Plumbing

Jennifer Bartholomew Assistant Vice Chancellor Facilities Management & Planning

Mark Bollig

42nd and Emile, Omaha, NE 68198

Docusign Envelope ID: EA096720-709D-4B16-94E9-F663D2006374

PROJECT ADDENDUM TO AGREEMENT FOR UNIT PRICE CONSTRUCTION

Project Name:

Project Number:

Location:

Scope of Work:

Name of Contact:

Company Name:

Company Address:

Company City State Zip:

PROJECT ADDENDUM # TO AGREEMENT FOR UNIT PRICE CONSTRUCTION SERVICES FOR THE UNIT PRICE

CONTRACTORS SELECTED FROM JANUARY 1, 2024, THROUGH DECEMBER 31, 2025, FOR

TYPE PROJECTS, INVITATION NUMBER: 3900-24-7200

This Project Addendum # made and entered into , between the undersigned Contractor and Owner.

Whereas, the parties hereto have entered in the Agreement identified above (hereinafter referred to as the "Agreement"); and

Whereas, the general purpose of the Agreement was to provide for contractual terms applicable to construction services provided to the Owner by the Contractor identified above (hereinafter referred to as the "Contractor"), over the course of a two year period with specific terms necessary for any particular project to be provided for by a Project Addendum to the Agreement; and

Whereas, the Owner and the Contractor have agreed to enter into this Project Addendum # in order to obtain services and provide services respectively for the project identified above.

Now therefore, in accordance with those provisions of the Agreement providing for and permitting addenda for particular projects and Section 2.4 of the Agreement, providing for amendment by written instrument, the parties hereto, for good and valuable consideration, the sufficiency and receipt of which is hereby acknowledged, enter into this Addendum as follows:

The Project to which this Addendum shall apply is as described above and on the attached Unit Price Quotation.

For purposes of the Project described above, the Sections of the Agreement designated below shall provide as follows:

3.1 The Owner shall pay to the Contractor in warrants of the State of Nebraska for performance of the Work required by the Contract Documents, subject to additions and/or deductions by Modification as provided by the Contract Documents, for the Cost of the Work a “not to exceed” sum for direct labor costs, equipment, materials, subcontracts, quantity costs, and bond the total of which may not exceed:

___________________________________________________________ Dollars (U.S.) (_________________)

This Price is for performance of the Work in accordance with the Contract Documents listed and attached to this Amendment and marked Exhibit A through _____, as follows:

Exhibit A Unit Price Quote dated: _______________ Exhibit B Owner’s Protective Bond (Contracts exceeding $15K) Exhibit C Drawings and specifications

Dated: _______________ Addenda Numbers Issued on Construction Documents.: _______________

Mark Hansen Fluid Mechanical, LLC

9991 J Street Omaha, NE 68127

Plumbing

1 June 19, 2025

Eighty-Three Thousand Six Hundred Twenty-Four & 50/100 $ 83,624.50

B ✔ May 15, 2025

ESH L4 Booster Pump Replacement P-25044

4220 Dewey Court, Omaha, NE 68198

Replace the existing Domestic Water Booster Pump on the 4 Floor

Mark Hansen

9991 J Street Omaha, NE 68127

6.1

7.1

The Contractor shall commence the Work required by the Contract Documents within (10) consecutive calendar days after the date of issuance of written Notice to Proceed from the Owner directing the Contractor to proceed with the Work. The Contractor shall fully complete all work required by the Contract Documents on or before

Photographs and facsimiles of this construction project, or components of the project, must not be used without the written consent of the University and an opportunity to review the photograph or facsimile and must not be used in a manner which would, in the opinion of the University, suggest the University endorses the product or service depicted in the photograph or facsimile.

Except as specifically amended or more particularly described in this Project Addendum, all terms, provisions and conditions set forth in this Agreement are applicable to the Project described herein, and said terms, provisions and conditions of the Agreement are incorporated into this Addendum by this reference.

IN Witness Whereof, the parties to this Project Addendum have hereunto attached their signatures, with their seals attached, as of the date and year for this Project Addendum written above.

IN WITNESS WHEREOF the parties hereto have executed this Agreement the day and year first above written.

BOARD OF REGENTS OF THE

UNIVERSITY OF NEBRASKA

Sign Sign

Print Print

Title Title

FLUID MECHANICAL, LLC

October 21, 2025.

Jennifer Bartholomew

Assistant Vice Chancellor Facilities Management & Planning

Docusign Envelope ID: EA096720-709D-4B16-94E9-F663D2006374

Project Manager

Mark Hansen

NU Project Name:

NU Project No:

Campus:

Trade Category:

Region:

Contractor:

Description of Work:

6/6/2025

Anticipated Completion Date:

ESH L4 Booster Pump Replacement 5/15/2025

P-25044

UNMC ✔

Plumbing

Southeast

Fluid Mechanical

Replace the existing Domestic Water Booster Pump on the 4 Floor

Plumber RegularPlumber Regular $100.00 104.00 $10,400.00 Plumber PremiumPlumber Premium $150.00 24.00 $3,600.00

$0.00 $0.00 $0.00 $0.00 $0.00

$14,000.00

$50,924.00 10.00% $56,016.40 $3,500.00 10.00% $3,850.00

$59,866.40

Elite Insulation $2,750.00 Hiller Electric $5,575.00 Owners Contingency $446.10

$8,771.10 0.00% $8,771.10

$82,637.50

$987.00

$83,624.50

10/21/25

7/21/2025 90.0

MARK HANSEN 5/15/2025

6/19/2025

University of Nebraska - Contract Documents Unit Price Master Agreement Revised 11/2021

University of Nebraska 00 52 43 Unit Price Agreement Form November 2021 2024-2025 Unit Price Page 6 of 13

CERTIFIED COPY OF RESOLUTION

BE IT RESOLVED, that the following named individuals, and each of them, are hereby authorized as employees of

______________________________________________________________________ to execute in its behalf all contracts, agreements and releases which they, in their discretion, approve, each such employee being separately and independently authorized to so act without the concurrence or joinder in such action by and of the other named employees :

BE IT FURTHER RESOLVED, that any such contract, agreement or release executed by any of the above-name employees in the name of _____________________________________________________ should be considered a contract, agreement, or release of _____________________________________________ and shall be binding upon it.

BE IT FURTHER RESOLVED, that any similar authority heretofore granted by the Members/Manager of the Company to employees other than those named above be and hereby is terminated as of this date, and the authority granted above shall commence this date and shall continue until revoked by resolution of the Members/Managers.

I hereby certify that I am Secretary of _____________________________________________, that as such I have access to the books and records of the Company; that the foregoing is an excerpt from the minutes of the

Members/Managers� Meeting of ______________________________________a ___________________(State) Limited

Liability Company, held on the ___________ day of ________________________ , 20_____, a quorum being present;

and that no action has been taken by the Members/Managers of said Company since said date that would have effect of changing or altering the authority granted therein.

Managing Member

Date

LLC / Partnership

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:

CONTACT

(A/C, No):

FAX

E-MAIL

ADDRESS:

PRODUCER

(A/C, No, Ext):

PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

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).

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.

OTHER:

(Per accident)

(Ea accident)

N / A

SUBR

WVD

ADDL

INSD

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.

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLY

NON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

DESCRIPTION OF OPERATIONS below If yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

ER

OTH-

STATUTE

PER

LIMITS(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTR

INSR

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCE

DAMAGE TO RENTED

$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY

PRO-

JECT LOC

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

© 1988-2015 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

182157.201 7/17/20257/17/2024 X

N

B 1,000,000

1,000,000 1,000,000

EPP0584696 7/17/20257/17/2024XX

A

5,000,000 5,000,000

1128 Lincoln Mall, Suite 200

(402) 434-7200UNICO Group Katie Lane klane@unicogroup.com

Lincoln, NE, 68508

EPP0584696 7/17/20257/17/2024

Deductible Any One Loss

1,000 3,000,000A Installation Floater

X

7/29/2024

Fluid Mechanical LLC 5946 County Rd P25 Kennard, NE, 68034

The Board of Regents of the University of Nebraska 1901 Y Street Lincoln, NE, 68503-2446

Y

Y

Y

2,000,000

EPP0584696 7/17/20257/17/2024

1,000,000 10,000

A 2,000,000

1,000,000 100,000

X

Re: RFP #3900-24-7200, 2024-2025 Unit Price Contracts Program, Request for Proposal Southeast-Plumbing, and Southeast-HVAC. The General Liability and Business Auto Liability policies includes a blanket automatic additional insured endorsement that provides additional insured status only when there is a written contract between the named insured and the certificate holder/entity(ies) that requires such status prior to a loss. The Umbrella policy is following form.

X

1722277992393

SFM Mutual Insurance Company 11347

EPP0584696 7/17/20257/17/2024

A

1,000,000 X

Cincinnati Insurance Company 10677

I further certify that we are engaged in business as a: Wholesaler Retailer Manufacturer Lessor Description of Product Sold, Leased, or Rented of _____________________________________________________________________________________________________________________ My Nebraska Sales Tax ID Number is 01-_________________________________.

If none, state the reason _____________________________________________________________________________________________________, or Foreign State Sales Tax Number__________________________________________ State __________________________________________.

for Sales Tax Exemption 13 Nebraska Resale or Exempt Sale Certificate FORM

Name and Mailing Address of Seller

Name

Street or Other Mailing Address

City State Zip Code

Name and Mailing Address of Purchaser

Name

Legal Name

Street or Other Mailing Address

City State Zip Code

Check Type of Certificate

Single Purchase If single purchase is checked, enter the related invoice or purchase order number ______________________________________.

Section B — Nebraska Exempt Sale Certificate

Section A — Nebraska Resale Certificate

Any purchaser, agent, or other person who completes this certificate for any purchase which is not for resale, lease, or rental in the regular course of the purchaser’s business, or is not otherwise exempted from sales and use taxes is subject to a penalty of $100 or ten times the tax, whichever amount is larger, for each instance of presentation and misuse. With regard to a blanket certificate, this penalty applies to each purchase made during the period the blanket certificate is in effect. Under penalties of law, I declare that I am authorized to sign this certificate, and to the best of my knowledge and belief, it is correct and complete.

sign here Authorized Signature Title Date

Section C — For Contractors Only from Nebraska sales tax. My Nebraska Sales or Use Tax ID Number is: _____________________________________________________.

Yes No

Do not send this certificate to the Nebraska Department of Revenue. Keep it as part of your records.

Sellers cannot accept incomplete certificates.

The Department is committed to the fair administration of the Nebraska tax laws. It is unlawful to claim an exemption for purchases of property or services that are subject to tax. Sellers are encouraged to notify the Department of any unlawful use of this form.

revenue.nebraska.gov, 800-742-7474 (NE and IA), 402-471-5729

Description of Items Sold

6-134-1970 Rev. 3-2018 Supersedes 6-134-1970 Rev. 10-2014

I hereby certify that the purchase, lease, or rental of ___________________________________________________________from the seller listed above is exempt from the Nebraska sales tax as a purchase for resale, rental, or lease in the normal course of our business. The property or service will be resold either in the form or condition in which it was purchased, or as an ingredient or component part of other property or service to be resold.

1. Purchase of building materials or fixtures.

2. Purchases made by an Option 2 contractor under a Purchasing Agent Appointment on behalf of_________________________

The basis for this exemption is exemption category ______ (See the list of Exemption Categories and corresponding numbers on reverse side).

If exemption category 2 or 5 is claimed, enter the following information:

Description of Property or Service Purchased

Intended Use of roperty or Service Purchased

05 -______________________________

If exemption category 6 is claimed, the seller must enter the following information and sign this form below:

Date of Seller’s Original Purchase Was tax paid when purchased by seller? Was item depreciable?

I hereby certify that the purchase, lease, or rental by the above purchaser is exempt from the Nebraska sales tax for the following reason:

Check One Purchase for Resale (Complete Section A.) Exempt Purchase (Complete Section B.) Contractor (Complete Section C.)

(exempt entity)

Do not enter your Federal Employer ID Number.

Yes No

Nebraska sales tax pursuant to the attached Purchasing Agent Appointment and Delegation of Authority for Sales and Use Tax, Form 17.

Authorized Signature Name (please print)

Description of Property or Service Purchased

University of Nebraska

Board of Regents of the University of Nebraska

3835 Holdrege Street

Lincoln NE 68583

8905401

Asst VP/Chief Procurement Officer

Doug Carlson

Fluid Mechanical, LLC

9991 J Street

Omaha, NE 68127

6/19/2025 initiator:mary.mitilier@unl.edu;wfState:distributed;wfType:email;workflowId:749b95be9e86f944bd5ccbed64f10cb1

Who May Issue a Resale Certificate. Purchasers are to give the seller a properly completed Form 13, Section A, when making purchases of property or taxable services that will subsequently be resold in the purchaser’s normal course of business. The property or services must be resold in the same form or condition as when purchased, or as an ingredient or component part of other property that will be resold.

Who May Issue an Exempt Sale Certificate. Form 13, Section B, may be completed and issued by governmental units or organizations that are exempt from paying Nebraska sales and use taxes. See this list in the Nebraska Sales Tax Exemptions Chart. Most nonprofit organizations are not exempt from paying sales and use tax. Enter the appropriate number from “Exemption Categories” (listed below) that properly reflects the basis for your exemption.

For additional information about proper issuance and use of this certificate, please review Reg-1-013, Sale for Resale – Resale Certificate, and Reg-1-014, Exempt Sale Certificate.

Contractors. Contractors complete Form 13, Section C, part 1 or part 2 based on the option elected on the Contractor Registration Database.

To make tax-exempt purchases of building materials and fixtures, Option 1 or Option 3 contractors must complete Form 13, Section C, Part 1. To make tax-exempt purchases of building materials and fixtures pursuant to a construction project for an exempt governmental unit or an exempt nonprofit organization, Option 2 contractors must complete Form 13, Section C, Part 2. The contractor must also attach a copy of a properly completed Purchasing Agent Appointment and Delegation of Authority for Sales and Use Tax, Form 17, to the Form 13, and both documents must be given to the supplier when purchasing building materials. See the contractor information guides and Reg-1-017, Contractors, for additional information.

Also, see the Important Note under “Exemption Categories” number 3.

When and Where to Issue. The Form 13 must be given to the seller at the time of the purchase to document why sales tax does not apply to the purchase. The Form 13 must be kept with the seller’s records for audit purposes.

Sales Tax Number. A purchaser who is engaged in business as a wholesaler or manufacturer is not required to provide an ID number when completing Section A. Out-of-state purchasers may provide their home state sales tax number. Section B does not require a Nebraska ID number when exemption category 1, 2, or 5 is indicated.

Fully Completed Resale or Exempt Sale Certificate. A fully completed resale or exempt sale certificate is proof for the retailer that the sale was for resale or is exempt. For a resale certificate to be fully completed, it must include: (1) identification of the purchaser and seller, type of business engaged in by the purchaser; (2) sales tax permit number; (3) signature of an authorized person; and

(4) the date of issuance.

For an exempt sale certificate to be fully completed, it must include:

(1) identification of purchaser and seller; (2) a statement that the certificate is for a single purchase or is a blanket certificate covering future sales;

(3) a statement of the basis for exemption, including the type of activity engaged in by the purchaser; (4) signature of an authorized person; and

(5) the date of issuance.

Penalties. Any purchaser who gives a Form 13 to a seller for any purchase which is other than for resale, lease, or rental in the normal course of the purchaser’s business, or is not otherwise exempted from sales and use tax under the Nebraska Revenue Act, is subject to a penalty of $100 or ten times the tax, whichever is greater, for each instance of presentation and misuse.

In addition, any purchaser, or their agent, who fraudulently signs a Form 13 may be found guilty of a Class IV misdemeanor.

Exemption Categories (Insert appropriate number from the list below in Section B)

1. Governmental units, identified in Reg-1-072, United States Government and Federal Corporations; and Reg-1-093, Governmental Units.

Governmental units are not assigned exemption numbers.

Instructions Sales to the U.S. government, its agencies, instrumentalities, and corporations wholly owned by the U.S. government are exempt from sales tax. However, sales to institutions chartered or created under federal authority, but which are not directly operated and controlled by the U.S. government for the benefit of the public, generally are taxable.

Purchases by governmental units that are not exempt from Nebraska sales and use taxes include, but are not limited to: governmental units of other states; sanitary and improvement districts; rural water districts;

railroad transportation safety districts; and county historical societies.

2. Purchases when the intended use renders it exempt. See Nebraska Sales Tax Exemption Chart.

3. Purchases made by organizations that have been issued a Nebraska Exempt Organization Certificate of Exemption (Certificate of Exemption).

Reg-1-090, Nonprofit Organizations; Reg-1-091, Religious Organizations; and Reg-1-092, Educational Institutions, identify these organizations. These organizations are issued a Certificate of Exemption with a state ID number which must be entered in Section B of Form 13.

Important Note: Nonprofit educational institutions must be accredited regionally or nationally and have their primary campus in Nebraska to be exempt from sales and use tax. Also nonprofit organizations providing any of the types of health care or services that qualify to be exempt must be licensed or certified by the Nebraska Department of Health and Human Services (DHHS) to be exempt from sales and use taxes. There is no sales and use tax exemption prior to these entities being accredited, licensed, or certified. They CANNOT issue either a Resale or Exempt Sale Certificate, Form 13, or a Purchasing Agent Appointment, Form 17, to any retailer or contractor relating to purchases of building materials for construction or repair projects performed prior to being accredited, licensed, or certified. After an entity becomes accredited, licensed, or certified upon completion of the construction project, it may submit a Form 4.

Nonprofit health care organizations that hold a Certificate of Exemption are exempt for purchases for use at their facility, or portion of the facility, covered by the license issued under the Nebraska Health Care Facility Licensure Act. Only specific types of health care facilities and activities are exempt. Purchases of items for use at facilities that are not covered under the license, or for any other activities that are not specifically exempt, are taxable. The exemption is not for the entire organization that offers different levels of health care or other activities, but is limited to the specific type of health care that is exempt. Purchases for non-exempt types of health care are taxable.

4. Purchases of motor vehicles, trailers, semitrailers watercraft, and aircraft used predominately as common or contract carrier vehicles; accessories that physically become part of the common or contract carrier vehicle;

and repair and replacement parts for these vehicles. The exemption ID number must be entered in Section B of the Form 13. An individual or business that has been issued a common or contract carrier certificate of exemption may only use it to purchase those items described above prior to the expiration date on the certificate. The certificate of exemption expires every 5 years. (See Nebraska Common or Contract Carrier Information Guide).

5. Purchases of manufacturing machinery and equipment made by a person engaged in the business of manufacturing, including repair and replacement parts or accessories, for use in manufacturing. (See Reg‑1‑107, Manufacturing Machinery and Equipment Exemption).

6. Occasional sales of used business or farm machinery or equipment productively used by the seller as a depreciable capital asset for more than one year in his or her business. The seller must have previously paid tax on the item being sold. The seller must complete, sign, and give the Exempt Sale Certificate to the purchaser. (See Reg-1-022, Occasional Sales). The Form 13 must be kept with the purchaser’s records for audit purposes.

Docusign Envelope ID: EA096720-709D-4B16-94E9-F663D2006374 https://revenue.nebraska.gov/about/information-guides/nebraska-sales-tax-exemptions https://revenue.nebraska.gov/files/doc/legal/regs/1-013.pdf https://revenue.nebraska.gov/files/doc/legal/regs/1-014.pdf https://revenue.nebraska.gov/businesses/important-information-contractors-performing-construction-services-nebraska https://revenue.nebraska.gov/files/doc/tax-forms/f_17.pdf https://revenue.nebraska.gov/files/doc/tax-forms/f_17.pdf https://revenue.nebraska.gov/about/information-guides#contract https://revenue.nebraska.gov/about/information-guides#contract https://revenue.nebraska.gov/files/doc/legal/regs/1-017.pdf https://revenue.nebraska.gov/files/doc/legal/regs/1-072.pdf https://revenue.nebraska.gov/files/doc/legal/regs/1-072.pdf https://revenue.nebraska.gov/files/doc/legal/regs/1-093.pdf https://revenue.nebraska.gov/about/information-guides/nebraska-sales-tax-exemptions https://revenue.nebraska.gov/about/information-guides/nebraska-sales-tax-exemptions https://revenue.nebraska.gov/sites/revenue.nebraska.gov/files/doc/tax-forms/sstp_exempt.pdf https://revenue.nebraska.gov/sites/revenue.nebraska.gov/files/doc/tax-forms/sstp_exempt.pdf https://revenue.nebraska.gov/files/doc/legal/regs/1-090.pdf https://revenue.nebraska.gov/files/doc/legal/regs/1-091.pdf https://revenue.nebraska.gov/files/doc/legal/regs/1-091.pdf https://revenue.nebraska.gov/files/doc/legal/regs/1-092.pdf https://revenue.nebraska.gov/files/doc/tax-forms/f_13.pdf https://revenue.nebraska.gov/files/doc/tax-forms/f_13.pdf https://revenue.nebraska.gov/files/doc/tax-forms/f_17.pdf https://revenue.nebraska.gov/files/doc/tax-forms/f_4.pdf https://revenue.nebraska.gov/files/doc/info/6-360.pdf https://revenue.nebraska.gov/files/doc/info/6-360.pdf https://revenue.nebraska.gov/files/doc/legal/regs/1-107.pdf https://revenue.nebraska.gov/files/doc/legal/regs/1-022.pdf https://revenue.nebraska.gov/files/doc/legal/regs/1-022.pdf

� Purchasing Agent Appointment FORM

Good L re. GreaL Service

DE?AATMEl'H OF REVENUE and Delegation of Authority for Sales and Use Tax

I Section A - Purchasing Agent Appointment I I Name and Address of Contractor Name and Address of Exempt Governmental Unit or Exempt Organization

I

Name Name

Board of Regents of the University of Nebraska Street or Other Mailing Address Street or Other Mailing Address

3835 Holdrege Street City State Zip Code City State Zip Code

Lincoln NE 68583 Name and Location of Project Appointment Information

Name Effective Date (See instructions)

Street Address Expiration Date

City State Zip Code Nebraska Exemption Number (Exempt Organizations Only)

05-8905401 Provide the contract name, number, and a description of the proJect.

The undersigned governmental unit or exe organization appoints the above-named contractor and the contractor's delegated subcontractors as als that will be annexed to real estate by them into the tax exempt construction project identified above.

sign \VP & Chtc-f Procurcm.::nl l)ff'ici ... ·1 here .......,��r:--r-:----.c�'-:--.r:1-----.-,,.,..,..,.,..,:t--;=���,..,...,-----

Title Date

Section B - Delegation of Contractor's Authority A contractor can delegate its authority to its subcontractor.

Name and Address of Subcontractor Delegation Information for the Project Identified in Section A Name Effective Date

Street or Other Mailing Address Expiration Date

City State Zip Code Portion of Project

The undersigned contractor hereby delegates authority to the above-named subcontractor to act as the purchasing agent of the named governmental unit or exempt nonprofit organization.

sign he re ► Signature of Contractor or Authorized Representative Title Date

Name and Address of Subcontractor Delegation Information for the Project Identified in Section A Name Effective Date

Street or Other Mailing Address Expiration Date

City State Zip Code Portion of Project

The undersigned contractor hereby delegates authority to the above-named subcontractor to act as the purchasing agent of the named governmental unit or exempt nonprofit organization.

sign here► Signature of Subcontractor or Authorized Representative Title Date

Name and Address of Subcontractor Delegation Information for the Project Identified in Section A Name Effective Date

Street or Other Mailing Address Expiration Date

City State Zip Code Portion of Project

The undersigned contractor hereby delegates authority to the above-named subcontractor to act as the purchasing agent of the named governmental unit or exempt nonprofit organization.

sign here ► Signature of Subcontractor or Authorized Representative Title Date revenue.nebraska.gov, 800-742-7474 (NE and IA) 402-471-5729 6-139-1970 Rev.11-2018 Supersedes 6-139-1970 Rev. 4-2009

Fluid Mechanical, LLC

9991 J Street

Omaha, NE 68127

ESH L4 Booster Pump Replacement 6/19/2025

4220 Dewey Court 10/21/2025

Omaha, NE 68198

6/19/2025

P-25044-ESH L4 Booster Pump Replacement-Replace the existing Domestic Water Booster Pump on the 4 Floor

Who Can Issue. Any governmental unit or nonprofit organization that is exempt from sales and use tax may appoint a contractor as its purchasing agent for building materials and fixtures that will be annexed to property that belongs to or will belong to the exempt governmental unit or exempt nonprofit organization pursuant to a construction contract or covered under an on-call, repair, or maintenance service agreement. Exempt governmental units and exempt nonprofit organizations are identified in Sales and Use Tax Regulations 1-072, 1-090, 1-091, 1-092, and 1-093.

Important Note: A nonprofit organization that has not received its sales and use tax Exempt Organization Certificate of Exemption, cannot issue either a Purchasing Agent Appointment and Delegation of Authority for Sales and Use Tax, Form 17, or a Nebraska Resale or Exempt Sale Certificate for Sales Tax Exemption, Form 13.

Appointment Information. To appoint a contractor as its purchasing agent, the exempt governmental unit or exempt nonprofit organization must complete Section A. The phrase “upon completion” or similar phrase is not an acceptable expiration date. If the project is not completed before the expiration date, a new purchasing agent appointment must be issued with the new effective and expiration dates. The purchasing agent authority for the contractor becomes effective on the later of the “effective date” or the signature date of the individual authorized to sign the Form 17 on behalf of the exempt governmental unit or exempt nonprofit organization.

When To Issue. The qualified exempt nonprofit organization or exempt governmental unit should issue the completed and signed Form 17 to the contractor BEFORE the contractor annexes any building materials. If the Form 17 is not timely issued, the Option 2 or Option 3 general contractor must pay the sales and use taxes on all building materials annexed to real estate before the effective date or signature date on the appointment.

Important Note: A copy of the completed Form 17 should be retained by the exempt governmental unit or exempt nonprofit organization. The original is to be retained by the contractor.

On-Call, Repair, or Maintenance Agreements. Exempt governmental units and exempt nonprofit organizations, in lieu of issuing a separate purchasing agent appointment to the same Option 2 or Option 3 contractor for each service call, may issue to the Option 2 or Option 3 contractor a written on-call, repair, or maintenance agreement and purchasing agent appointment that covers a calendar year or part of a calendar year. A new written agreement and purchasing agent appointment must be issued at least each calender year.

Section B Delegation of Contractor’s Authority. The contractor or subcontractor who has previously been delegated to be a purchasing agent for a portion of the project may delegate his or her authority as the purchasing agent to other subcontractors for all or a portion of the project. Contractors who are delegating their authority as the purchasing agent are only required to complete Section B.

Contractors and subcontractors must issue a separate Form 17 to each subcontractor to whom they are delegating their purchasing agent authority. The purchasing agent authority for the subcontractor becomes effective on the later of the “effective date” or the signature date of the contractor’s or subcontractor’s authorized individual.

If Section B is full and additional delegations are required, it is necessary for the contractor who is delegating his or her authority to complete a new Form 17, Section B and provide a copy of the Form 17 between the exempt governmental unit or exempt nonprofit organization and the contractor. Reproductions of this delegation must be provided to the contractor, who must retain a copy for his or her records, and to the governmental unit or exempt nonprofit organization.

When To Issue. The delegation must be issued to the subcontractor BEFORE the subcontractor annexes any building materials.

If the Form 17, Section B, Delegation of Contractor’s Authority is not issued, the Option 2 or Option 3 subcontractor must pay the sales and use taxes on all building materials annexed to real estate before the effective date or signature date on the appointment.

Other Contractor Information Purchasing Tax Exempt Building Materials and Fixtures. Option 1 and Option 3 contractors who perform construction work for an exempt governmental unit or exempt nonprofit organization can purchase the building materials and fixtures tax exempt by issuing a properly and fully competed Form 13, Section C, Block 1, to its suppliers. It is not necessary for the Option 1 or Option 3 subcontractor to attach a copy of the Form 17 to its Form 13.

Option 2 contractors who perform construction work for an exempt governmental unit or exempt nonprofit organization can purchase the building materials and fixtures tax exempt by issuing a properly and fully completed Form 13, Section C, Block 2, and a copy of the Form 17 to its supplier. This delegation will not allow purchases of building materials and fixtures without payment of the tax by the contractor or subcontractor before the later of the effective date of the appointment or the signature date of the individual authorized to delegate them as a purchasing agent. In addition, the appointment cannot be made after the expiration date of the original appointment.

Form 13 and Form 17 must be retained with the supplier’s and contractor’s records for audit purposes. A contractor may reproduce copies of these documents which can be furnished to the suppliers for each invoice or order made by them.

Invoices from suppliers for the purchase of building materials by a contractor as purchasing agent, or an authorized subcontractor, must clearly identify that the purchase is for the specific Form 17 project.

Instructions Section A

Docusign Envelope ID: EA096720-709D-4B16-94E9-F663D2006374 http://www.revenue.nebraska.gov/legal/regs/slstaxregs.html#072 http://www.revenue.nebraska.gov/legal/regs/slstaxregs.html#072 http://www.revenue.nebraska.gov/legal/regs/slstaxregs.html#090 http://www.revenue.nebraska.gov/legal/regs/slstaxregs.html#091 http://www.revenue.nebraska.gov/legal/regs/slstaxregs.html#092 http://www.revenue.nebraska.gov/legal/regs/slstaxregs.html#093 http://www.revenue.nebraska.gov/tax/current/fill-in/f_13.pdf

Option 2 and Option 3 contractors who bill another contractor for work performed for an exempt governmental unit or exempt nonprofit organization are not required to collect sales tax on the amount charged for their contractor labor charges since their labor charges are not subject to tax. They do not need to obtain a Form 13 or Form 17 from the contractor.

Credit/Refund of Sales and Use Tax. Option 2 contractors who have been appointed as a purchasing agent before any materials are annexed, may withdraw tax-paid building materials from inventory that will be annexed to real estate or used to repair property annexed to real estate and receive a credit for the sales or use tax amount previously paid on those materials.

The Option 2 contractor or subcontractor may take a credit either against its current tax liability, or file a Claim for Overpayment of Sales and Use Tax, Form 7, and receive a refund of the sales or use tax paid on those materials.

Tools, Equipment, Supplies, and Taxable Services. The purchase, rental, or lease of tools, supplies, equipment, or taxable services (for example, scaffolding, barricades, machinery, building cleaning services etc.) by a contractor for use to complete an exempt project CANNOT be purchased tax exempt, even if the contractor has been issued a Form 17 for the project.

Penalty. Any person who signs this document with the intent to evade payment of tax is liable for the sales and use tax, interest, and penalty, and may be found guilty of a misdemeanor.

Authorized Signature. The purchasing agent appointment, Section A, must be signed by the proper government official or by an officer of the exempt nonprofit organization or another individual authorized by an attached power of attorney. The delegation of the prime or subcontractor’s authority, Section B, must be signed by an owner, partner, corporate officer, or other individual authorized to sign the Delegation of Contractor’s Authority.

Docusign Envelope ID: EA096720-709D-4B16-94E9-F663D2006374 http://www.revenue.nebraska.gov/tax/current/fill-in/f_7.pdf http://www.revenue.nebraska.gov/tax/current/fill-in/f_7.pdf

April 7, 2022

Re: Purchasing Agent Appointment Form 17

Vendors:

Please be advised that Purchasing Agent Appointment Form 17 cannot be used to purchase, rent or lease tools, supplies or equipment for any University construction project. The form instructions provided this information as stated below:

"the purchase, rental, or lease of tools, supplies, or equipment (i.e., scaffolding, barricades, machinery, etc.) by a Contractor for use in the completion of an exempt project CANNOT be purchased tax free, even if the Contractor has been issued a Form 17. These items do not become annexed to the real estate "

Use of the Purchasing Agent Appointment Form 17 is for the purpose to allow a contractor to purchase building materials and/or fixtures that will be annexed to property that belongs to or will belong to the governmental entity or exempt organization.

Sincerely, A VP & Chief Procurement Officer University of Nebraska System

Procure-to-Pay 3835 Holdrege Street Lincoln, NE 68583-0742 402-472-2126 nebraska.edu/p2p