LG_SONIC_SINGLE_SOURCE_PACKET.pdf

SINGLE SOURCE

CERTIFICATE OF CONDITIONS AND CIRCUMSTANCES

Instructions: The purpose of this form is to certify conditions and circumstances for the purchase of goods and services under the single source exception to the competitive bid process. This request is to be executed by the Department Director and submitted to the Purchasing Department for consideration and approval/disapproval.

Item or Services Required:

Name of Company considered Single Source:

Conditions and special circumstances for the Single Source. Please be specific:

Requesting Department Director’s Signature Date of Request

Requisition Number Buyer Name Purchasing Department Action:

Signature Date

Quotation/Documentation attached

Original to Purchasing

Copy to Mayor’s Office by Requesting Department https://v3.camscanner.com/user/download

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD WVD

PRODUCER CONTACT

NAME:

FAXPHONE

(A/C, No):(A/C, No, Ext):

E-MAIL

ADDRESS:

INSURER A :

INSURED INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

AUTOMOBILE LIABILITY

UMBRELLA LIAB

EXCESS LIAB

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

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

AUTHORIZED REPRESENTATIVE

EACH OCCURRENCE $

DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence)

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $

PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT

OTHER: $

COMBINED SINGLE LIMIT

$(Ea accident)

ANY AUTO BODILY INJURY (Per person) $

OWNED SCHEDULED

BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

HIRED NON-OWNED PROPERTY DAMAGE

$AUTOS ONLY AUTOS ONLY (Per accident)

OCCUR EACH OCCURRENCE

CLAIMS-MADE AGGREGATE $

DED RETENTION $

PER OTH-

STATUTE ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE $

If yes, describe under

E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below

INSURER(S) AFFORDING COVERAGE NAIC #

COMMERCIAL GENERAL LIABILITY

Y / N N / A

(Mandatory in NH)

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

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.

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED

REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.

If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

CERTIFICATE HOLDER CANCELLATION

© 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03)

CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)

The ACORD name and logo are registered marks of ACORD

12/2/2024

(888) 426-6662 (570) 265-3476

12572

LG Sonic Us, LLC & Novawa LLC 1326 New Seneca Turnpike Unit A2 Skaneateles, NY 13152

A 2,000,000

S 2562420 2/1/2024 2/1/2025 500,000 15,000

2,000,000 4,000,000 4,000,000

1,000,000A S 2562420 2/1/2024 2/1/2025

1,000,000A S 2562420 2/1/2024 2/1/2025 1,000,000

B

EIG 5624850 00 6/28/2024 6/28/2025 1,000,000

1,000,000 1,000,000

City of Tampa 7125 N 30th Street Tampa, FL 33610

LGSONIC-01 JSHRIMP

Gannon Associates 315 South Main St PO Box 226 Athens, PA 18810 certificates@gannonassociates.com

Selective Ins Co of America Employers Assurance Company

X

X X

X

X X

X X

Quote

Quote Number: 25075158 Our Reference: George Tsilimanis Quote Date: 12-09-2024 11:52

Valid Until:

Your Reference:

27-03-2025 Hillsborough river services 2025-2026 Pro/Pro

Payment Term: Term of Payment

Invoice address:

City of Tampa

PO BOX 2000

33602 Tampa

FL

United States

Delivery address:

David L Tippin Treatment Facility 7125 N 30th St 33610 Tampa

FL

United States

Product Code Product Name Qty List Price Total 10050 Interactive Algae Control

Annual project service costs for data management and treatment parameters changes

1 $ 8,280.00 $ 8,280.00

87316 Sim Card SIM Card: yearly fee per MPC-buoy

2 $ 358.80 $ 717.60

Sub Total $ 8,997.60 $ 0.00

Tax $ 0.00 Grand Total $ 8,997.60

Terms and conditions Project: City of Tampa - Hillsborough River Units: Pro-87E / Pro-88E Time period: 27/MAR/2025 till 26/MAR/2026 Only valid after the Lite is upgraded to Pro

Payment

• Credit card (VISA / MasterCard / American Express): Till 10.000 USD + 4%

Creditcard Fee

• Wire transfer

• Check payment

Please mention your quote number in your payment details.

Orders are standard being shipped with an Invoice and Packing list. If you require additional export documents please indicate this with your order.

Please transfer payment including the bank charges for successful handeling of your order.

All the units are ready to work on AC power supply. If your device will work on DC supply, please let us know so we can prepare it in advance.

Company details

201 Lackawanna Ave. Suite 222 Scranton Pennsylvania 18503

United States

Tel: +1 833 547 6642 E-mail: g.eiffert@lgsonic.com

Terms and conditions at: www.lgsonic.com/terms

12 month cost estimate ___$15K________SW