ADDENDUM 1 TO BID DOCUMENTS FOR ... - Port Canaveral

CANAVERAL HARBOR 44 FOOT CHANNEL PROJECT – PACKAGE 1Form-4NOTICE OF WORK COMPLETIONNUMBERS REFERENCE ATTACHED INSTRUCTIONSPAGE 1 OF 2Contractor Name:Contract #:Description of Work Performed:Date Work Completed:Final Contract Value:12345PUR-ITB-13-5/CN1-8-10-12-014ACANAVERAL PORT AUTHORITYPROJECTThe following Lower-Tiered Subcontractors have completed their Work at the Project Site: (Add attachment if morespace is needed)6aLower-Tiered Subcontractor’sNamebContract NumbercDescription of WorkdDate CompletedLocation of your payroll records (Receipt of this form will initiate the payroll audit process):Address:7City, State Zip Code:Contact/Phone #:The undersigned acknowledges request for termination of coverage under the OCIP as of the date indicated above for thespecified Subcontract. Should we return to the Project Site, we will be working under our own insurance program and mustprovide Sponsor with a Certificate of Insurance showing our own coverage as detailed in our contract. Prior to execution ofthe Contract and performing any work at the Project Site.Signed by: 8TitleDateApproved by: 9Project ManagerDateMail to: OCIP Administrator Fax to: Shannon FugateInsurance Office of AmericaInsurance Office of America4020-B Plank Road Fax: (800) 568-2991Fredericksburg, VA Phone: (540) 785-7575Email: Shannon.Fugate@ioausa.comALL FORMS ARE AVAILABLEELECTRONICALLY.Please email the OCIP Administrator arequest.OAFORM 4 ED 7-1-20112012-10/436743 00 73 16.11 - 9 ADDENDUM #1