LAUREL ROAD
Community Development District

June 8, 2022 BOARD OF SUPERVISORS
Regular Meeting Agenda

Laurel Road Community Development District
OFFICE OF THE DISTRICT MANAGER
2300 Glades Road, Suite 410W●Boca Raton, Florida 33431
Phone: (561) 571-0010●Toll-free: (877) 276-0889●Fax: (561) 571-0013

ATTENDEES:
Please identify yourself each time you speak to facilitate accurate transcription of meeting minutes.

June 1, 2022

Board of Supervisors
Laurel Road Community Development District

Dear Board Members:
The Board of Supervisors of the Laurel Road Community Development District will hold a Regular Meeting on June 8, 2022, at 12:00 P.M., at 5800 Lakewood Ranch Blvd, Sarasota, FL 34240. The agenda is as follows:

Call to Order/Roll Call

Public Comments: Agenda Items (limited to 3 minutes per individual)

Ratification of Resolution 2022-10, Appointing and Removing Officers of the District and Providing for an Effective Date

Ratification of Resolution 2022-11, Directing the District Manager to Appoint Signors on the Local Bank Account; and Providing an Effective Date

Consideration of Resolution 2022-12, Redesignating the Primary Administrative Office and Principal Headquarters of the District and Providing an Effective Date

Consideration of Resolution 2022-13, Authorizing and Approving Change of Registered Agent and Registered Office of the District, and Providing for an Effective Date

Consideration of Responses to Supply and Install Landscaping/Hardscaping RFQ
Impact Landscaping & Irrigation, LLC
Mike Armstrong Landscaping, Inc.

Consideration of Stormwater Needs Analysis Report

Approval of May 11, 2022 Regular Meeting Minutes

Staff Reports
District Counsel: Vogler Ashton, PLLC
District Engineer: AM Engineering, LLC

Board of Supervisors
Laurel Road Community Development District June 8, 2022, Regular Meeting Agenda
Page 2

District Manager: Wrathell, Hunt and Associates, LLC
NEXT MEETING DATE: July 13, 2022 at 12:00 P.M.
QUORUM CHECK

Dale Weidemiller	In Person	Phone			No	
Pete Williams	In Person	Phone			No	
John Blakley	In Person	Phone			No	
Janice Snow	In Person	Phone			No	
John Leinaweaver	In Person	Phone	No	
Board Members’ Comments/Requests

Public Comments: Non-Agenda Items (limited to 3 minutes per individual)

Adjournment

If you should have any questions or concerns, please do not hesitate to contact me directly at
(239) 464-7114.

FOR BOARD MEMBERS AND STAFF TO ATTEND BY TELEPHONE
CALL-IN NUMBER: 1-888-354-0094
PARTICIPANT PASSCODE: 229 774 8903

Sincerely,

Chesley (Chuck) E. Adams, Jr. District Manager

LAUREL ROAD
COMMUNITY DEVELOPMENT DISTRICT

3

RESOLUTION 2022-10

A RESOLUTION OF THE BOARD OF SUPERVISORS OF THE LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT APPOINTING AND REMOVING OFFICERS OF THE DISTRICT AND PROVIDING FOR AN EFFECTIVE DATE.

WHEREAS, the Laurel Road Community Development District (the “District”) is a local unit of special-purpose government created and existing pursuant to Chapter 190, Florida Statutes, and situated entirely within the City of Venice, Florida; and

WHEREAS, the District’s Board of Supervisors desires to appoint and remove Officers of the District.

NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF SUPERVISORS OF THE LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT THAT:

Section 1.	The following are appointed as Officers of the District effective June 1,
2022:

Chesley E Adams	is appointed Secretary;

Craig Wrathell	is appointed Assistant Secretary; Craig Wrathell	is appointed as Treasurer;
 Jeff Pinder	 is appointed as Assistant Treasurer;

Section 2.	The following Officers shall be removed as Officers as of 11:59 p.m. on May 31, 2022.

Vivian Carvalho	Secretary;

Venessa Ripoli	Assistant Secretary; Jennifer Glasgow	is appointed as Treasurer;
 Amanda Lane	 is appointed as Assistant Treasurer;

Section 3.	This Resolution supersedes any prior appointments made by the Board for Secretaries, Treasurer, Assistant Secretaries, and Assistant Treasurers.

Section 4.	This Resolution shall take effect upon its passage and shall remain in effect unless rescinded or repealed.

Page 1 of 2

PASSED AND ADOPTED THIS 24TH DAY OF MAY, 2022.

ATTEST:	LAUREL ROAD COMMUNITY
DEVELOPMENT DISTRICT

Secretary/Assistant Secretary	Chair  upervisors

4889-3772-2372.2

Page 2 of 2

LAUREL ROAD
COMMUNITY DEVELOPMENT DISTRICT

4

RESOLUTION 2022-11

A RESOLUTION OF THE BOARD OF SUPERVISORS OF THE LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT DIRECTING THE DISTRICT MANAGER TO APPOINT SIGNORS ON THE LOCAL BANK ACCOUNT; AND PROVIDING AN EFFECTIVE DATE

WHEREAS, the Laurel Road Community Development District 2 ("District") is a local unit of special-purpose government created and existing pursuant to Chapter 190, Florida Statutes; and

WHEREAS, the District's Board of Supervisors desires to appoint District Chair, Treasurer and Assistant Treasurer as signors on the account.

NOW THEREFORE BE IT RESOLVED BY THE BOARD OF SUPERVISORS OF THE LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT THAT:

DESIGNATING AUTHORIZED SIGNATORIES.	The District Chair, Treasurer and Assistant Treasurer shall be appointed as signors on the local bank account.

EFFECTIVE DATE. This Resolution shall take effect upon its passage and shall remain in effect unless rescinded or repealed.

PASSED AND ADOPTED this 24th day of May, 2022.
ATTEST:	LAUREL ROAD COMMUNITY
DEVELOPMENT DISTRICT

Secretary/Assistant Secretary	Chair/Vice Chair, Board of Supervisors

LAUREL ROAD
COMMUNITY DEVELOPMENT DISTRICT

5

RESOLUTION 2022-12

A RESOLUTION BY THE BOARD OF SUPERVISORS OF THE LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT REDESIGNATING THE PRIMARY ADMINISTRATIVE OFFICE AND PRINCIPAL HEADQUARTERS OF THE DISTRICT AND PROVIDING AN EFFECTIVE DATE

WHEREAS, the Laurel Road Community Development District (“District”) is a local unit of
special-purpose government created and existing pursuant to Chapter 190, Florida Statutes; and

WHEREAS, the District desires to designate its primary administrative office as the location where the District’s public records are routinely created, sent, received, maintained, and requested, for the purposes of prominently posting the contact information of the District’s Record’s Custodian in order to provide citizens with the ability to access the District’s records and ensure that the public is informed of the activities of the District in accordance with Chapter 119, Florida Statutes; and

WHEREAS, the District additionally desires to specify the location of the District’s principal headquarters for the purpose of establishing proper venue under the common law home venue privilege applicable to the District.

NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF SUPERVISORS OF THE LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT:

PRIMARY ADMINISTRATIVE OFFICE. The District’s primary administrative office for purposes of Chapter 119, Florida Statutes, shall be located at 2300 Glades Road, Suite 410W, Boca Raton, Florida 33431.

PRINCIPAL HEADQUARTERS. The District’s principal headquarters for purposes of establishing proper venue shall be located at the offices of 5800 Lakewood Ranch Blvd., Sarasota, Florida 34240, and within Sarasota County, Florida.

EFFECTIVE DATE. This Resolution shall take effect immediately upon adoption.

PASSED AND ADOPTED this 8th day of June, 2022.

ATTEST:	LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT

Secretary/Assistant Secretary	Chair/Vice Chair, Board of Supervisors

LAUREL ROAD
COMMUNITY DEVELOPMENT DISTRICT

6

RESOLUTION 2022-13

A RESOLUTION OF THE BOARD OF SUPERVISORS OF LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT AUTHORIZING AND APPROVING CHANGE OF REGISTERED AGENT AND REGISTERED OFFICE OF THE DISTRICT, AND PROVIDING FOR AN EFFECTIVE DATE.

WHEREAS, Laurel Road Community Development District (“District”) is a local unit of special- purpose government created and existing pursuant to Chapter 190, Florida Statutes; and

WHEREAS, the District is statutorily required to designate a registered agent and a registered office location for the purposes of accepting any process, notice, or demand required or permitting by law to be served upon the District in accordance with Section 189.014(1), Florida Statutes; and

WHEREAS, the District previously designated a registered agent and a registered office location;
and

WHEREAS, at this time, the District desires to designate a new registered agent and registered office for the purposes of accepting any process, notice, or demand required or permitting by law to be served upon the District in accordance with Section 189.014(1), Florida Statutes.

NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF SUPERVISORS OF LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT:

DESIGNATION OF REGISTERED AGENT. Craig Wrathell is hereby designated as Registered Agent for the District.

REGISTERED OFFICE. The District's Registered Office shall be located at 2300 Glades Road, Suite 410W, Boca Raton, Florida 33431.

FILING. In accordance with Section 189.014, Florida Statutes, the District’s Secretary is hereby directed to file certified copies of this resolution with the County and the Florida Department of Economic Opportunity.

EFFECTIVE DATE. This Resolution shall become effective immediately upon adoption.

PASSED AND ADOPTED this 8th day of June, 2022

ATTEST:	LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT

Secretary/Assistant Secretary	Chair/Vice Chair, Board of Supervisors

LAUREL ROAD
COMMUNITY DEVELOPMENT DISTRICT

7A

LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT

CONTRACTOR'S PREQUALIFICATION STATEMENT (LANDSCAPE/HARDSCAPE)

Impact Landscaping & Irrigation, LLC

Contractor

TABLE OF CONTENTS

NOTICE TO PROSPECTIVE BIDDER APPLICATION FOR CONTRACTOR PREQUALIFICA TION
CORPORA TE OFFICERS CORPORATE STOCKHOLDERS SUPERVISORY PERSONNEL
COMPANY OWNED MAJOR EQUIPMENT STATUS OF CONTRACTS ON HAND
ALL PROJECTS APPLICANT COMPANY COMPLETED IN THE LAST TWO YEARS AFFIDAVIT FOR INDIVIDUAL
AFFIDAVIT FOR PARTNERSHIP

AFFIDAVIT FOR CORPORATION

SWORN STATEMENT UNDER SECTION 287.133(3)(A), FLORIDA STATUTES. ON PUBLIC ENTITY CRIMES

CONTRACTOR CLASSIFICATION LISTING DETERMINATION OF QUALIFIED PROSPECTIVE BIDDER

REQUEST FOR QUALIFICATIONS

SUPPLY AND INSTALL LANDSCAPING/HARDSCAPING

LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT SARASOTA COUNTY, FLORIDA

LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT (DISTRICT) requests Qualifications Submittals from firms interested in providing and installing landscaping/hardscaping seNices. Upcoming projects are in Sarasota County, Florida.

To be eligible to submit qualifications, firms must hold all required applicable state licenses in good standing, hold all required applicable federal licenses in good standing, and be authorized to do business in the State of Florida.

Applicants may request a Qualifications Submittal Package via email from AM Engineering, LLC (District Engineer). (Email echilders@amengfl.com for package) Applicants must submit one ( 1) set of the Qualifications Submittal Package by 1:00 PM on Monday April 25, 2022. Handwritten submissions will not be accepted. Submissions should be emailed to echilderssamengfl.com.

Qualified firms will be selected based on experience, qualifications of personnel, and ability to perform required services. Packages will be reviewed and rated by a qualifications committee. At that time, all qualified firms will be assigned a project and aggregate dollar limit for potential work under contract. All applicants will be promptly notified after the firms are selected. The pre-qualification decisions of the Board of Supervisors shall be valid for a period of three (3) years, after which the Board of Supervisors may either extend the prequalification period for two (2) additional one ( 1) year periods or open the prequalification process again.

Qualified firms will be eligible to bid or propose on landscape/hardscape projects subject to the firms' project and aggregate limits. Failure to pre-qualify may preclude LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT from awarding contracts to any non­ prequalified firm. All firms interested in bidding on landscape/hardscape contracts to be led by the DISTRICT are strongly encouraged to submit for pre-qualification. However, the DISTRICT is not obligated to select prequalified firms, and at its sole discretion reseNes the right to solicit bids or proposals from non-prequalified contractors for specific projects in the best interests of the DISTRICT.

Applicants may contact the District Engineer, Shawn Leins, P.E., AM Engineering, LLC. at echilders@amengfl.com until the qualification's submittal deadline for further information.

NOTICE TO PROSPECTIVE BIDDER

The information required herein is for the purposes of fairly evaluating all prospective bidders for certain LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT (District) contracts.

APPLICANTS FOR PREQUALIFICA TION AS BIDDERS FOR DISTRICT LANDSCAPE/HARDSCAPE CONTRACTS ARE HEREBY NOTIFIED THAT INCLUSION OF FALSE, DECEPTIVE OR FRAUDULENT STATEMENTS ON THIS APPLICATION CONSTITUTES FRAUD. FURTHERMORE, YOU ARE HEREWITH NOTIFIED THAT THE DISTRICT CONSIDERS SUCH ACTION ON THE PART OF THE APPLICANT TO CONSTITUTE GOOD CAUSE FOR DENIAL, SUSPENSION, OR REVOCATION OF THE PROSPECTIVE BIDDER'S QUALIFICATION FOR BIDDING ON ITS PROJECTS.

Please be advised that this application must be complete within itself without reference to any previous application or statement. All sections of the application shall be completed. If any of the requested information does not apply, it shall be indicated as "None" or "N.A." as applicable. Failure to make entries in every section of this application may result in a delay or disqualification to bid until such time as all information is provided to the District for evaluation and final decision as to qualification to bid.

The properly completed Contractor's Prequalification Statement shall be submitted to AM Engineering, LLC., (Engineer) Attention: Shawn Leins, PE, 8340 Consumer Ct., Sarasota, FL 34240. Any questions with regard to the requests for information contained herein shall be addressed to Shawn Leins, PE, via e-mail echilders@amengfl.com.

LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT CONTRACTOR PREQUALIFICATION STATEMENT

Application for Contractor Pregualification

DATE SUBMITTED	2022.
Applicant Impact Landscaping & Irrigation, LLC
[Company Name]

!_j A Partnership
A Corporation S-Corp
I_! A Subsidiary Corporation

Parent Company Name _n_/_a	

Parent Company Address:
Street Address 1562 Park Lane South Suite 700
P. 0. Box (if any)	

City  Jupiter
Telephone	561-575-9501

State	FL

Zip Code _3_3_4_5_8  	_
Fax No. 561-575-9503

1st Contact Name Joseph Floyd Jr
2nd Contact Name Joseph Floyd Sr

Title CFO	
Title  President	

Street Addre
'---,

/

P. 0. Box (if any)_ - ..,,,-----------,,-'--------------
,
·,"---,	/
City 	'-S --,�,,,--x::>"',.  '	Zip Code 	
Telephone 	/_.,._/_,_,,_,_ Fax No. 	_

1st Contact Name		_-_/	 Title 	_

2nd Contact Name/ /· /	 Title 	_

1st	-----------2nd Contact E-M -- ""-sc--------
List the location of the applicant's office which would handle DISTRICT work. Street Address	311 Sarasota Center Blvd

City Sarasota
Telephone	941-488-7700
1st Contract Name John DeGrasse

State  FL	Zip Code 34240
Fax No. 561-575-9503
Title Branch Manager

1st contact E-Mail	John.DeGrasse@impactlandscaping.net

Is the applicant Company incorporated in the State of Florida? yes (X) no (

If yes, provide the following:

Is the Company in good standing with the Florida Secretary of State Division of Corporations? yes (X) no ( )

If no, please explain 	

Date Incorporated 03/01/2007	Charter No. --L0-7-00-00-24-9-17---
If no, provide the following:

The State applicant company is incorporated in? 	

Is the company in good standing with the State? yes ( ) no ( )

In no, please explain 	

Date Incorporated 	 Charter No. 	

Isthe applicant company authorized to do business in the State of Florida? yes ( ) no ( )

Is the applicant company a registered or licensed contractor with the State of Florida? yes (x) no ( ) If yes, provide the following:
o	Type ofregistration (i.e. certified general contractor, certified electrical contractor, etc.) 	
 Irrigation & Pest Control - lawn & ornamental	

0	License No.  SCC131151769
0	Qualifying Individual  Joseph Floyd Jr

Expiration Date  _0_8_/_3_1_/2_0_2_2	
Title  CFO

o	List company(s) currently qualified under this license 	

Isthaepplicant Company a registered or licensed Contractor with Sarasota County? yes (x) no( )

Has the applicant Company performed work for an independent special district previously? yes (X) no ( )

Is the applicant company prequalified by the Florida Department of Transportation? yes ( ) no (X)

If yes, provide the following:

Work class ratings 	

Maximum capacity rating 	

Name of Applicant's Bonding Company	Capitol Indemnity Corporation
Address 1600 Aspen Commons, Suite 300, Middleton, WI 53562

Approved Bonding Capacities:	Aggregate Limit
Single Project Limit
Total Current Contracts Bonded

$ 1,000,000.00
$ 1,000,000.00
$  1,000,000.00

Name of Applicant's Bonding Agency	Insurance Office of America, Inc., Attn: Bond Dept.
Address 1855 W State Road 434, Longwood, FL 32750
Contact Name Brenna Page	Phone 866-379-3151

List the Applicant's total annual dollar value of work completed for each of the last five (5) years starting with the latest year and ending with the most current year	(01)_4 0 ,5 0 0 , 0 0 0 ------
(02)  35 500,000	(03)--==-'35 5=O'c--=O,.,._,O'c--=O O	_,
(04) 28,000,000	(05) 2=2=5 00 0 0 0 -------
List the classification(s) (refer to attached listing) of work the applicant is applying for prequalification based on the applicant company's ability to self-perform the work (excluding general contracting).

Landscape

-Irr�igation-------------

FuII Service Landscape & Irrigation Main-=te=n=a=n.,_,,c=e	_

General Liability	$2,000,000	
Automobile Liability	$1,000,000
$1,000,000	
Expiration Date	10/13/2022	

What are the applicant company's current insurance limits? (provide a copy of applicant's certificate of insurance)

Workers Compensation

Has the applicant company been cited by OSHA for any job site or company office/shop safety violations in the past two years? yes ( ) no ()()

If yes, please describe each violation, fine, and resolution 	

What is the applicant's current worker compensation rating?   ._9_5	

(number)

Has the applicant company experienced any worker injuries resulting in a worker losing more than ten ( l 0) working days as a result of the injury in the past two years? yes ()() no ( )
If yes, please describe each incident See attached lose runs for the last two years

Please state whether or not your company or any of its affiliates are presently baned or suspended from
bidding or contracting on any state or federal-aid contracts in any state(s)? Yes	No _X	 If so,
state the name(s) of the company(ies) 	

thsetate(s) where barred or suspended 		 and the period(s) of debarment or suspension 	

What is the landscape/hardscape experience of the principal supervisory landscape/hardscape personnel of your organization? (Attach resumes here.)

INDIVIDUAL'S NAME	PRESENT POSITION OR OFFICE	MAGNITUDE AND TYPE OF WORK*	YEARS OF LANDSCAPE/HA RDSCAPE
EXPERIENCE	YEARS WITH FIRM	IN WHAT CAPACITY?	
Joseph Floyd Sr	President	Overseeing all operations	40 years	15 years	President	
Joseph Floyd Jr	CFO	Estimating &
Project Manageme	nt	9 years	9 years	CFO	

Karl Zainitzer	
GM	IJverseeing and managi1 projects and operations	g 30 years	6 years	GM	
John DeGrasse	Branch Manager	Overseeing and managi g	35 years projects and operations or
IWod f"n •• ,fondnn	1 year	Branch Manager	

Dwayne Sapp	Irrigation Manager 8
Designer	Design & estimate lrrig	rtion
35 years	
15 years	Irrigation Manager	

						

						

						

*Give in sufficient detail for the District to evaluate your experience in the classifications of work for which you are requesting prequalification.

Have you ever failed to complete any work awarded to you? Yes If so, where and why?

Nox

Has any officer or partner of your organization ever been an officer, partner, or owner of some other

organization that has failed to complete a landscape/hardscape contract? Yes  

No_x 

Ifso,

state name of individual, other organization and reason therefor. 	

List any and all litigation to which your organization has been a party in the last five (5) years. 		_

Has your organization or any of its affiliates ever been either disqualified or denied prequalification status by a governmental entity? no	If so, discuss the circumstances surrounding such denial or disqualification as well as the date thereof. 	

Within the past five (5) years, has your organization failed to complete a project within the scheduled contract time?	no	If so, discuss the circumstances surrounding such failure to complete a project on time as well as the date thereof. 	

STATE OF FLORIDA

COUNTY OF 	

The undersigned hereby authorize(s) and request(s) any person, firm or corporation to furnish any pertinent information requested by the LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT, or their authorized agents, deemed necessary to verify the statements made in this application or attachments hereto, or necessary to determine whether the LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT should prequalify applicant for bidding on its landscape/hardscape projects, including such matters as the applicant's ability, standing, integrity, quality of performance, efficiency and general reputation

T <""- <&.cT	 o	 SU"\-J'CM:;; ·t	i.By:---= =::=::=:=·=--==·-=-·-·	.-,,1._-..,	_
Name of Applicant Company

[Type Name and Title of Person Signing]

  , 2022.

(Corporate Seal)

Sworn to before me this L 2'4-:ay of H-+-p_r_j_/_ , 2022.
z:;l il_	 fZiv,_
Notary Public/Expiration Date
(Seal)

Kim Marie Ryter NOTARY PUBLIC STATE OF FLORIDA Comm# 00947574
Expires 1/15/2024

CORPORATE OFFICERS

Company Name	Impact Landscaping & Irrigation, LLC	Date 	

Prov",de the fio11owmg.

mfiormat10n £or Offi1cers of the aoo.rICant company and parent company, 1 any.

NAME FOR APPLICANT COMPANY	
POSITION OR TITLE	
CORPORATE RESPONSIBILITIES	
INDIVIDUAL'S RESIDENCE CITY, STATE	

Joseph Floyd Sr	President	Overseeing all operations of business	984 Patrick Dr, WPB FL 33406	

Joseph Floyd Jr	
CFO	Assist in overseeing operations and reviewing all financials of the business	3281 SW Coquina Cove APT 204
Palm City FL 34990	

				

				

FOR PARENT COMPANY (if applicable)		

				

Company Name  Impact Landscaping & Irrigation, LLC

CORPORATE STOCKHOLDERS

Provide the following information for all persons, partnerships, unincorporated companies, corporations, or any other entities owning 10% or more of the applicant comoanv stock.

NAME	

PERCENT OWNED	
BUSINESS RELATIONSHIP TO APPLICANT COMPANY	
INDIVIDUAL'S RESIDENCE CITY, STATE	
Joseph Floyd Sr	70%	President	984 Patrick Dr, WPS FL 33406	
Joseph Floyd Jr	30%	CFO	3281 SW Coquina Cove APT 204Palm City FL 34990	

				

				

				

				

Company Name

SUPERVISORY PERSONNEL
_l'-m_,_p_a_c_tL_a_n_d_s_ca-'p.	i_ng"'--------------------------------- Date  '--\l·:z.£-:: l:20?-1

What is the experience of the key management and supervisory personnel of the applicant company for both administration as well as operations? (Attach resumes of key
)ersonnel here)	

INDIVIDUAL'S NAME	

PRESENT TITLE	
DESCRIPTION OF DIRECT JOB
RESPONSIBILITIES	YEARS OF EXPERIENCE IN
PRESENT POSITION	TOTAL YEARS OF RELATED
EXPERIENCE	
Karl Zaintizer	
GM	
Oversee all operations of company	6 years	30 years	
John DeGrasse	Branch Manager	
Oversee all operations of Branch	1 year	
35 years	
Dwayne Sapp	Irrigation Designer	
Design and Estimate Irrigation Systems	
15 years	
35 years	

Ruben Torres	Maintenance Ops Manager	
Oversee all maintenance operations	
1 year	18 years	
Brett DeGrasse	Landscape Manager	
Oversee landscape install on projects	
1 year	5 years	
Jason Banks	Irrigation Manager	
Oversee irrigation install & maintenance on project	
1 year	15 years	

					

					

					

Company Name 	

COMPANY OWNED MAJOR EQUIPMENT
(Attach additional sheets if necessary)

lm_p_a_c_tL_a_n_d_sc_a_p_in_g	Date   Y_!_--z_f, 7_z _L		_

QUANTITY	

DESCRIPTION	

CAPACITY	NO. LOCATED IN	
			
FLORIDA	
OTHER	
	
(jJJ	.f'17.l,A1fc._.	..S.ht,';v				

					

					

					

					

STATUS OF CONTRACTS ON HAND
(Attach additional sheets if necessary)

Company Name

	lm_p_a_c_tL_a_n_ds_ca_pi_ng	

Date 	4_1_25_1_20_2_2	

Furnish requested information about all of applicant's active contracts, whether as prime or subcontracts; whether in progress or awarded but not yet started; and regardless of with whom contracted. All amounts to be shown to nearest $1,000. Contractor may consolidate and list as a single item all contracts which individually do not exceed 3% of total active contracts and in total do not exceed 20% of the active total contracts.
	
Applicant's Uncompleted Amount as of this Date	

Completion Date	

Owner, Location and Description of Project	Current Contract Amount as Prime	Current Contract Amount as
Subcontractor	
Current
Amount Sublet to Others	

As Prime Contractor	

As Subcontractor	
Original Contract Date	
Approved Revised Date	
Current
Estimate Date	
On separate sheet all as subcontractor	
$	
$	
$	
$	
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Subtotal Uncompleted Work	
$	
$		
	
Total Uncompleted Work on Hand	
1$	I				

Company Name

PROJECTS APPLICANT COMPANY COMPLETED IN THE LAST TWO YEARS
im_p_a_ct_L_a_nd_s_ca_p_in_g	 Date	4_12_s_12_0_22	

List all projects completed in the last two years for which the contract value individually exceeded 3% of the applicant's annual total work completed for the year the project was started. IncIud.e m the r1st .pro1ects that were started earr1er than two years but were comp1Ieted .with'mt he 1ast two years.

Project Name/Location	
Final Contract Amount	

Prime or Sub1	
Classification of Work Performed	Year Started/
Completed	

Owner Name/Location2	Name & Phone Number of Owner's Representative on
this Proiect3	
On separate sheet all as subcontractor							

							

							

							

PROJECTS APPLICANT COMPANY COMPLETED IN URBANIZED AREAS
Company Name	Impact Landscaping & Irrigation, LLC

Date

4/25/2022	_

Project Name/Location	
Final Contract Amount	

Prime or Sub4	
Classification
of Work Performed	Year Started/
Completed	

Owner Name/Location5	Name & Phone Number of Owner's Representative on this Proiect6	

On separate sheet all as subcontractor							

							

							

AFFIDAVIT FOR INDIVIDUAL

STATE OF FLORIDA
coUNTY  oF	 \ m  beach.

SS:

 s		E ,0--1.\')	 f-.	.being duly sworn, deposes and says that the financial statements contained herein are a true and accurate statement of his/her financial position as of this date, and
that the statements and answers to the questions concerning experience contained herein are correct and true as of this date; and that he/she understands that intentional inclusion of false, deceptive or fraudulent statements on this application constitutes fraud; and, that the District considers such action on the part of the applicant to constitute good cause for denial, suspension or revocation of a certificate of qualification for bidding on LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT projects,
(Applicant must also sign here)

lj/_tm[r (h

Sworn to before me this _d_K;ay of	tlpr/ / , 2022, NotaryPublic/Expirahn Date:
KimMarie  Rytef

(SEAL)

NOTARY PUBLIC STATE OF FLORIDA Convn# 00947574

.

Expires 1/15/2024

AFFIDAVIT FOR PARTNERSHIP

STATE OF FLORIDA
couNTYoFVa,,\ m °'--cJ1

SS:

  f:f)-i	S'-CH10 J"L;- isa member of the firm of	 -v?.(\Cl	LJ...,}Jc:i,0:i'\ ,I' 1=->\..::i	i..:it.Zl,/l
being duly sworn, deposes and says that the foregoing financial statements are a true and accurate statement of the financial position of said firm as of this date, and that the statements and answers to the questions of the foregoing experience questionnaire are correct and true as of the date of this affidavit; and, that he/she understands that intentional inclusion of false, deceptive or fraudulent statements on this application constitutes fraud; and, that the District considers such action on the part of the applicant to constitute good cause for denial, suspension or revocation of a certificate of qualification for bidding on LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT projects.

(Signature of a General Partner is Required)

(SEAL)

Kim Marie Ryter NOTARY PUBLIC STATE OF FLORIDA Comm# 00947574

Expires 1/15/2024

AFFIDAVIT FOR CORPORATION

STATE OF FLORIDA
couNTY oF Po) on:Beocr\     SS:

(title) 	,_'-'---""""----------  ------------------
of the    ·d<:Y\QAc :s::	\...ANoSt.r,,,.P.:.....,J'--==-   -\  "j  ,z"'-.,:.&--..TLO''-'  \...,\..,1.  
(a corporation described herein) being duly sworn, deposes and says that he/she is familiar with the books of the said corporation showing its financial position; that the foregoing financial statements are a true and accurate statement of the financial position of said corporation as of this date; and, that the statements and answers to the questions in the foregoing concerning experience are correct and true as of the date of this affidavit; and, that he/she understands that intentional inclusion of false, deceptive or fraudulent statements in this application constitutes fraud; and, that the District considers such action on the part of the applicant to constitute good cause for denial, suspension or revocation of a certificate of qualification for bidding on LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT projects.

(Officer must also sign here)

CORPORATE SEAL

Sworn to before me this cl<2+ ay of	Hpri I

, 2022.

No	xpk	

Kim Marie Ryter

(SEAL)

NOTARY PUBLIC STATE OF FLORIDA Comm# 00947574
Expires 1/15/2024

SWORN STATEMENT UNDER SECTION 287.l33(3)(a), FLORIDA STATUTES. ON PUBLIC ENTITY CRIMES

THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS.

This sworn statement is submitted to LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT for Prequalification of Landscape/Hardscape Contractors.
This sworn statement is submitted by '"If""'fb.u-	\..ANo.rc_1.\Po.:,Q : , <or-,.<t.l:f.J1	LLL
[Print Name of Entity Submitting Sworn Statement]
whose business address is  \':l..ol-	\?A.v,\ 	0'-,->vf-\...	::x.':1,-((\c\	S\.,Q..\ti,	:]ao	;J'-',l'UFL  k	:5,;.)'o
and (if applicable) its Federal Employer Identification Number (FEIN) is --· z_o_,_·~_'iS'_S_c,_-,_·(_'-\._3,_'-\_·_
(If the entity has no FEIN, include the Social Security Number of the individual signing this

sworn statement: 	.)

My name is	00 '\>4

\-u;)'::l:'.J

and my relationship to the

entity named above is 	C_·_r-:_::o_-_·	

I understand that a "public entity crime" as defined in Paragraph 287.133(l)(g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any bid or contract for goods or services to be provided to any public entity or an agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.

I understand that "convicted" or "conviction" as defined in Paragraph 287.133(l)(b), Florida Statutes, means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court ofrecord relating to charges brought by indictment or information after July 1, 1989, as a result of jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.

I understand that an "affiliate" as defined in Paragraph 287.l33(l)(a), Florida Statutes, means:

A predecessor or successor of a person convicted of a public entity crime; or,

An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term "affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted ofa public entity crime in Florida during the preceding 36 months shall be considered an affiliate.

I understand that a "person" as defined in Paragraph 287.133(l)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of an entity.

Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement. (Please indicate which statement applies.)

Neither the entity submitting this sworn statement, nor any officers, directors, executives, patiners, shareholders, employees, members, or agents who are active in management of the entity, nor any affiliate of the entity, have been charged with and convicted of a public entity crime subsequent to July l, 1989.

The entity submitting this sworn statement, or one or more of the officers, directors, executives, patiners, shareholders, employees, members or agents who are active in management of the entity or an affiliate of the entity, has been charged with and convicted of a public entity crime subsequent to July I, 1989, AND (please indicate which additional statement applies):

There has been a proceeding concerning the conviction before an Administrative Law Judge of the State of Florida, Division of Administrative Hearings. The final order entered by the Administrative Law Judge did not place the person or affiliate on the convicted vendor list. (Please attach a copy of the final order.)

The person or affiliate was placed on the convicted vendor list. There has been a subsequent proceeding before an Administrative Law Judge of the State of Florida, Division of Administrative Hearings. The final order entered by the Administrative Law Judge determined that it was in the public interest to remove the person or affiliate from the convicted vendor list. (Please attach a copy of the final order.)

The person or affiliate has not been placed on the convicted vendor list. (Please describe any action

c=

takeo by o, peod;og wHh tho flodda Dopartmeot of Mru,a	j

sTATEOF   \or-,dQ...,
couNTY oF 'Pet\ m	h
PERSONALY APPEARED BEFORE ME, the undersigned authority. =s;c_. El  o  d  3r.

g-y

		 who, after first being sworn by me, affixed his/her signature in the space (name of individual signing)

Yirm	(!tµ

provided above on this	Z 	h	day of Apr1 )	2022.
VJ?a;ue
NOTARY PUBLIC

My commission expires:		Kim Marie Ryter NOTARY PUBLIC
STATE OF FLORIDA
.,	Comm# GG947574
Expires 1/1512024

LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT CONTRACTOR CLASSIFICATION LISTING

Landscape

Hardscape

DETERMINATION OF QUALIFIED PROSPECTIVE BIDDER

The LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT ("District") is authorized to maintain a list of qualified contractors ("Prospective Bidders") to submit bids for the procurement of District landscape/hardscape projects. Any Prospective Bidder desiring to submit a bid to provide work for the District must submit a properly completed Contractor's Prequalification Statement to the District Engineer for review and evaluation. Submittal of the Contractor's Prequalification Statement shall occur prior to the bidding process.

The District shall evaluate the Prospective Bidder's Prequalification Statement and based on the District's judgment of the information provided, shall issue in writing to the Prospective Bidder, the District's rating as to the classification(s) of the Work and the maximum Bid dollar amount for which the Prospective Bidder can submit a Bid to the District.

The Prospective Bidder acknowledges the right of the District to determine the Prospective Bidder to be not qualified to submit a Bid in response to the District's Advertisement for Bids at the sole determination of the District for, but not necessarily limited to, any of the following specific reasons:
Failure to submit a properly completed Prospective Bidder's Prequalification Statement in accordance with the above requirements;
Failure of the Prospective Bidder's rating by the District as to classification of the Work and the maximum Bid dollar amount to meet the requirements of the Bid;
Reason to believe that collusion exists among Bidders;
Determination of lack of competency as may be revealed by qualification statements, financial statements, experience records, or other sources;
The Prospective Bidder's uncompleted work load which, in the judgment of the District Engineer, may cause detrimental impact on timely completion of the project being bid;
The Prospective Bidder's Surety is unacceptable to District.

A qualified Prospective Bidder shall mean a Prospective Bidder which in the sole judgment of the District has the capability, in all respects, to perform fully the contract requirements, and the business integrity and reliability which will assure good faith performance. In determining the Prospective Bidder's qualifications, the following criteria will be considered:
The ability, capacity, and skill of the Prospective Bidder to perfonn the contract or provide the work required;
Whether the Prospective Bidder can perfonn the contract or provide the work promptly, or within the time specified, without delay or interference;
The character, integrity, reputation,judgment, experience, and efficiency of the Prospective Bidder;
The quality of perfo1mance of previous contract or work.  For example, the following information will be considered:
The cost overrun incurred by owners on previous contracts with Prospective Bidder;
The Prospective Bidder's compliance record with contract general conditions on other projects;
The Prospective Bidder's record for completion of the work within the Contract Time or within Contract Milestones and Bidder's compliance with scheduling and coordination requirements on other projects;
The quality, availability, and adaptability of the goods or work to the particular use required;
The Prospective Bidder's demonstrated cooperation with owners, architects, engineers, and others on previous contracts; and,
Whether the work performed and materials furnished on other contracts were in accordance with the Contract Documents.
Whether Contractor has performed previous work for an independent special district.
The previous and existing compliance by the Prospective Bidder with laws and ordinances relating to contracts or work;
The sufficiency of the financial resources and ability of the Prospective Bidder to perform the contract or provide the work;
The ability of the Prospective Bidder to fulfill its guarantee and warranty period;
Such other information as may be secured by the District Engineer having a bearing on the decision to award a contract to include, but not be limited to:
The ability, experience, and commitment of the Prospective Bidder to properly and reasonably plan, schedule, coordinate, and execute the work; and,
Whether the Prospective Bidder has ever been debarred from bidding or found ineligible for bidding on any other projects.
The District will make such inquiries and investigations as deemed necessary to verify and evaluate the applicant's statements regarding:
The necessary organization and management including landscape/hardscape experience possessed by the applicant's employees;
Adequate equipment, as shown on the equipment list, to perform normal landscape/hardscape operations for each class of work in the industry such as that called for in the Contract Documents in force at the time of application.

Open land ContrKts

O.lsin•IC°"trvt		CurrffllC°"lrKI  Renwlnl"'8.t.,,.cep.r ContrKI Date	Chance0nle,1		Vlllu.	kh dldeo/V.!.,.,
4/1$/).011

Pe..:cntro:malnc
tocompkta  t.,.., bllh,•h1•

5Star w,lpc,n:UC{due-hyiJ'.l,o(month)

JWOtntham{h<U,01ound1l ,, ltvoughendof1h,,mooth) CR AlA Oi I" Hwy R.,,.,,t,mng - #210021

KCPre,tlceHomes

4/15/2021	156,529.19

2,565.90

159,095.09

4/snon

EloMl.'tteHuntOub

KHUokew=dRanr;hUC{kolUr)		4B3,214'tS		483,214.95			12/3/201JJ	
LWRPh3-M<1inline	1/13/2022	2S4,96S.OO		2!!4,965.00	U.7,093,90		2/24/2022	
LWR PhD- fntryLlndsc.wing - bi! ng th,ough WtttCoa t	1/13(2022	B3,46SAS	4,97250	SS,440.95	lS,.7741◊		.3/3/WU	
LWRPh4-Mainlin<' LWRPh4-Llnd!.(-'f><'	3/J/ion 3/2/1.022	453,372.50
68S,7989S		453,372.SO
685,7911,95	4S.i,J7iW
1;16$,79&,IIS			
Kolb,rHomtt-{due ',, olmon!hfor pnor month)								
Allor, - Parcel D• l5 & IR Ulmmon{PO 985)	lhl/2021	l,049,&1050		1,019,64o50	lff,.l,JI		3/3non	
Altoo•Parrn!O-Littorali(P0982J	1/21/2021	41,48850		41,48850	•,l.Mre!ainageorly		12/3/;'021	
Alton - Pa1ul E. hri&,1tion Common	11/U20lB	419,447.12		479,447.12	-.,u,.		4/2/2021	
Altoo - P.ircel E- Un du ape Common & Preu,rve (PO 425)	2/1/2019	666,910.10		666,91010	ll'i-tttAO		3/3/1022	
AltonP.:,1c<'lFl (P0412)	2/1/2019	835,60240		835,602AO	N,42'.a IR 8,Hed ""I	11.3,.	1/5/2022	
AltonParcelF2(P0383}
Altot1-PartelG-A111,tryl.!lt()f.:,!s	2/1/2019
8/2]/2018	l&0,20300
338,527.65		100.203.oo l•,527.U	il1Alf,.
11,'10,A,,.	7n6.o1¼,	4/2/2021
l/5/2022	

Alton - Pmel G -AnhtryGl-B& G2·A IR& L5 (P0615)
Alton• Parrel G-An,nryGl-B- Ph.;ne 11{PO 564) QOSEO	2/1/1019
10/25/2019	992,34476
865,833AS	
(123,3S2,S0)	;: :::;:..........r.-.1.nc• .-.llon••	15.2¾	8/31/,021
4/15/1022	
Altro- Pa,cel G-ArtimyGl·B- Ph.tie tl • Babnct r,f 564	3/15/2021	123,35250		12J,3Si.50	il.1,1,U.	4/1S/iou	
Alton - Pmel G - Ph,ue 5C GJ (PO 1270)	11/12/2021	733,806.65		731,806.65	1JMO,u,		
Allon & Arli<try - Grm> Poln!e Drive and Pattel F Open lterm		96,051A0		96,0SlAO	IICl,,Ul.'1	9/ll/201fJ	
Creuwind Verano - Mlidinehrceh, Bl82 83(PO lOSO)	4/lf,/2021	108,681.SO		10:!,68.2.SO	JQ,.l.,lilmainageot'ly	6/23/2011	
Creuwind @ We,dali.e - Ph I (PD 520)	11/H/2019	1,741.55960		t.741,559.60	2JU«),7tJ.	B/5/2010	
Cteu,,,.nd @WHlllike. Ph 2 l11igat,on - Dttoder, (1253) (r<'mov.-d from PO	8.8S 11/.3/l02\	53)0000		53,100.00	A$,"11-0:I	12/3/2021	
C,euwind@ W Ualce - Ph 2 lmgacion (PO 885)	l0/2"2/2020	342,037.50	42,641.50	384,679.00	J..Q.',.lJ	1:13/2021	
Ct uv.ind@W Uai,;e - Ph21.ffldit.tpe (PO 899)	10/27/XJ20	1,002,81300	(43,ii70.00I	959,143.00	UJ,tl!J't	3/2/l0li	
Cte wind@ WrUlake -Amenity (PO 1266)	11/10/2021	484.945.70	8,2:M65	493,17().35	U7,)0S.«).	4/4/2022	
C,euwind@ WHUHe -Amentty I.Jghting (PO1204)	9/17/2021	19,900.00		19,90000	U,IQlctl		
Qeuv.ind@WeHl3kr- Ph 3 l5-{PHO)Open5pace, 8lB (1372)	i/9/lOU	4l,H16.ll		41,U16.u	•1.,ta,1.1		
C,eu,..nd@WeiUiike-PH3(PhOJ!k1m,£ntry,BuffetlS	Z/"J/1022	338,757.60		BS,757.&0	,lf'-i-'1;1;J'.,l:J.	3/2/2022	
Ctem,.fod@ We'!tlake - PH 3 {Ph 0) Berm, Entry, P.irk lR (1345)
Cte.wMnd@W"1tlake-Ph31rrigalion(l366)	2/3/201<
2/7/J.022	184,97000
313,630.00		1114,970.00
313,630.00	11 '1,.J•
l(.,.,a.1'	"3/2/2022
.3/2/1.022	
Ctr:mM:nd @Weul3k.. - Ph 3 Vafws & Ol'Coderi - IR (1346)	in/ion	76,00000		76,00000	1._:(0		
Cton!Dwn Common! - PH 2 M.:iinline fot Units	4/21/2020	54,WOOO	43,050.00	97,65000	t,7■ retasnag,,My	J/2S/20i!	
c,omownG:>mmon\-PH 3 Matnlll>efotUnits	1/11/2021	53,74000		53,740.00		12/3/2021	
Crontown Commom - PH 4 M..1nline COD	6/JS/2021	23,HO.OO		23,330.00	2,"l.QQ,etaanac,,cnlv	3/2/Z022	
Ctontown Commons - Pll 4 Units MllnHne	7/8/2021	66,180.00		66,18000	6,fill,!.(U re!;on c,,crly	3/2/2022	
Venno • Amenity Rlnil'i\ hpamton {PO 1201)	9/ll/20it	188,43.'l.20	9,707.00	197,145.10	l!J.,114,Sl ret..ina orly	3/3/ion	
Ver,ano • Ph 3E, Pl.rt 22 MlintiM (PO 1182)	8/25/2021	87,62500		87,625.00	U,?S0-61	10/29/2021	
Venno- Ph 7A,Pod03 Miinltn<'(PO 1206}	9/24/2021	105,900.00		105,990.00		3/3/1.022	
							
Vl'rmo - Ph 13, Pod 02 Mainline (PO 1224)
V..rano - Ph 4A PodA7 Mainline (PO 1207)	B/30/2021
8/30/1021	257,6SOOO
18,36500		257,65000
lB,365.00	"""""	12/3/2021	
Verano - Ph 6 P<>d E2 Mtinhne (PO 1202:)	9/11/2021	329,91000		329,970.00	l)' Utii'I	t0/27/2021	

,·

l00.1 tiQ:
tU SJ)Q

Ofidgew,ater - LS & IR.<iouth 11<-:rm, Entrance	9/10/2021	B4,7B7.90	5<1,183.S5	655,971.45	io,11:.ss:n	3.1%	2/23/2022	
OelWebb@Tradnlai-Ph3&,4	ll/11/;>019	1,714,53100	224,628.Xl	1,939,165.20	. 4-2$	20.6<.'	ll/J/2021	
Del Webb@ Tr3d1tion Opeovi""" Rd Oe1Webb@Trad!llon-Ph5A-LS& tR	2/8/lOlll
3/16/Um	S18,838.70
&19,00(;.25		SIS,83870
649,006.25	lU79,QQ lllon!vleft•r,ma,n"'ll""4w•llm1bet»l d
f0, 2:>	2,7¼	2/l /2010	
field.atGulhtre,1mPod8/PoloRd	4/28/2017	l,262,&17AS	209,68557	1,472,333.02	l,:t$4$9	0.2%	3/12/l0ll	
Fi<'ldsGtGulfure,imPodD	2/12/2019	l,02ll,1059S		1,028,105,95	-4:ZMt	4.1¼	9/10/2021	
fief1h Pod D 511eet1npe	1/20/2020	179,90i.2ll		179,902.211	1-4t40	27.t¼	9/10/2021	
Ht'fmPrl'iervePh l	3/l/20a	1,431,S0l.25	94,B70.0S	1,527,37130	$$,4U.SO	2.4%	B/24/l.021	
Hrur, P1Herve PH 2A	12/20/Xl21	375,10675	121,750.00	07,856,75	W.,91400	8.0%	4/12/2022	
l.lli:HatWateiw;av	10/ll/Xll5	2,330,314.00		i,330,314.00	11,1$$,92:		11/12/2018	
t..kes 31 W3leiway · POD R	3/20/2017	599,545.76		599,545.76	l!;l.,1BB.lt.,.n<:ei,,;t1eeltrees	3.4%	7/25/2010	
l,akei at Waterw,ay • POD U LJmtuaping	5/17/2019	176,S0060		176,806.&0	1',47 B.a! ncei1Wttttret->	7.6%	12/23/2021	
Lak.. , at W.ite -POOS MNOP	6/4(.!0ta	1,sOl,62790		l,&14,627.90	,U, &lan<ri,,1r et1tee1		12/23/WH	
Pfei.erveatW,aterway-PodV-lrr,gatfoo	U23/2Dll	405,69000		405,690.00	44,1$0.00	11.("'	4/8/1.022	
Prc,;er-ve al Wa1erw•v- Pod V- Undr.ca,pe	11/19/2020	56),49095	70,73166	6J.1,2U.61	41,58<i.8l	75%	2/3/2012	
RanchctteTownHome,;	12/N/2021	364,nuo		364,916.80	US.41	76.6%	4/11/2022	
.'ionom ,ues
Sonom.1 lile1 • rn.,w con IIact wnh h.i!.lncc, from old and punch fi!;t	3/1S/Wl6
7/H/2021	3,841,SOSOO
63,204.47		3,1!41,505.00
63,204A7	
l$,96f.	'·""	9/25/1020,
B/6/}.021	
Verand,1G.udc,n1foH	5/11/lOW	U0,591.S0	tB0,957.10	311,548.60	lOQ,S!il,9:,$5 31Ritem,wllnotbeb,lled	31	901/2021	

Mlnto-{due  of month) Puk.. -Southf1orlda

Shawe- ,

8/S/1021	87,310.10

24,601.25	lll,911.35

25.3%

'""

4/1U2022

,,,,,,", 

FilMchPodDO,J,hou,e

b',forMonfsonolfl -due by!',', ,oftlwmonlh	6/14/1021	167,75000	167,750.00	
Verano Mainline Pha,e Gl, Pod l P01tl712DI(0.7	9/30/2021		16'.l,O;i250	t:U,4lUl		4/15/20i2	
Vc,nnd.15L Lw:le Lind Holclin1s. UC							
VerandJhtatfiPhlMainhne	2/23/2022	336,025.00	336,02$00	.S¾-Q2-$00	1000%		
v..randa Oak1 Mainlin"'	U23/10ll	410,21000	.;10,no.oo	4t0,l1(l00	1000%		
Vennd;iPri!!iNvePh]8e1m	2/23/1022	86,004.55	86,06.4.SS	S:4064,SS	1000"		
v..r.in,fal'li!!il'lvrPh3Miinhne	2123120n	;oa.sssoo	:!Oll,SSS.00	197µ7,70	Sl.5¼	4/8/20ll	
Verdell Construction, UC -due by2, ,, olthe ffl<)nth-p,oJ,ocb!d to end of month							
		
H,4.l!S,200.94	
34,877,747.37				

WC Itemized Statement of Loss
IMPACT LANDSCAPING & IRRIGATION, LLC - Loss Run Detail

Valuation Date: 04/18/2022	Run Date: 04/18/2022

Claim Number Location Cause	Claimant Name		Loss Date Status	Carrier Report Date Jurisdiction State	Incurred Indemnity Paid Indemnity Indemnity 0/R	Incurred Medical Paid Medical MedicalO/R	Incurred Expense Paid Expense Expense 0/R	Total Incurred Total Paid Outstanding Reserve Applied Recovery	
Date of Hire	Date Reopened	Accident State	Lost Time Days	Litigation Status	Part of Body				
Nature of Injury			Catalyst		Date Closed				
Accident Description						
Report Totals	Claim Count : 28	$25,297.00	$37,438.75	$16,517.26	$79,253.01	
		$11,312.60	$25,173.30	$7,076.84	$43,562.74	
		$13,984.40	$12,265.45	$9,440.42	$35,690.27	
					$-3,500.00	

Valuation Date: 04/18/2022

WC Itemized Statement of Loss
IMPACT LANDSCAPING & IRRIGATION, LLC - Loss Run Detail

Lihertx

\pl

Mutual
INSURANCE

Run Date: 04/18/2022

Claim Number Location Cause	Claimant Name		Loss Date Status	Carrier Report Date Jurisdiction State	Incurred Indemnity Paid Indemnity Indemnity O/R	Incurred Medical Paid Medical Medical O/R	Incurred Expense Paid Expense Expense O/R	Total Incurred Total Paid Outstanding Reserve Applied Recovery	
Date of Hire	Date Reopened	Accident State	Lost Time Days	Litigation Status	Part of Body				
Nature of Injury			Catalyst		Date Closed				
Accident Description									
WC550C44573	PEREZ.ROBER		05/03/2021	05/03/2021	$0.00	$2,369.38	$118.49	$2,487.87	
-UNKNOV\N					$0.00	$2,369.38	$118.49	$2,487.87	
OYA- MISCELLANEOUS-NOC	Closed	$0.00	$0.00	$0.00	$0.00	
					$0.00	

7/24/13	
FL	
0	
0000 - UNDEFINED		
000 - UNDEFINED		0000 - UNDEFINED		5/24/21	
HEART IS RACING & CHEST PAINS					
WC550C46497	RAMIREZ JIMENE,CATARINA	08/31/2021	09/02/2021		$0.00	$148.00	$20.60	$168.60	
-UNKNOV\N				$0.00	$148.00	$20.60	$168.60	
OLA - MATERIAL HANDLING - MECHANICAL	Closed			$0.00	$0.00	$0.00	$0.00	
							$0.00	
11/11/19	FL	0		0000 - UNDEFINED					
000 - UNDEFINED	0000 - UNDEFINED							
CUT LEFT KNEE WITH HEDGE TRIMMER								
WC550C47293	ROMERO SALES,RONY	10/08/2021	10/11/2021	$0.00	$1,358.04	$140.31	$1,498.35	
-UNKNOV\N				$0.00	$1,358.04	$140.31	$1,498.35	
ORA- STRUCK BY/AGAINST OBJECTS OR OTHER PERSONS	Closed	$0.00	$0.00	$0.00	$0.00	
					$0.00	

7/12/21	
FL	
0	
0000 - UNDEFINED	
000 - UNDEFINED		0000 - UNDEFINED		
IW CLEANING TRUCK OUT AND MOVING THINGS, HE STEPPED ON WOOD THAT HAD A NAIL WITH HIS RIGHT FOOT, PUNCTURING FOOT

Valuation Date: 04/18/2022

WC Itemized Statement of Loss
IMPACT LANDSCAPING & IRRIGATION, LLC -Loss RunDetail

Libert):
Mutual.
INSURANCE

Run Date: 04/18/2022

Claim Number Location Cause	Claimant Name		Loss Date Status	Carrier Report Date Jurisdiction State	Incurred Indemnity Paid Indemnity Indemnity O/R	Incurred Medical Paid Medical Medical O/R	Incurred Expense Paid Expense Expense O/R	Total Incurred Total Paid Outstanding Reserve Applied Recovery	
Date of Hire	Date Reopened	Accident State	Lost Time Days	Litigation Status	Part of Body				
Nature of Injury			Catalyst		Date Closed				
Accident Description									
WC550C40942	STAGE.TAREN		10/29/2020	10/29/2020	$0.00	$5,048.11	$689.89	$5,738.00	
-UNKNOWN					$0.00	$5,048.11	$689.89	$5,738.00	
ORA - STRUCK BY/AGAINST OBJECTS OR OTHER PERSONS	Closed	$0.00	$0.00	$0.00	$0.00	
					$0.00	

6/1/20	
917/21	
FL	
0	
0330-HAND		
175 - PUNCTURE			4700-TREES		9/8/21	
IW STATES HE WAS TRIMMING AND A PALM PRAWN PUNCTURED HIM IN HIS R HAND

Total for Contract Number: WCCZ9147233202 - Impact Landscaping & Irrigation, LLC
Claim Count : 28	$25,297.00	$37,438.75	$16,517.26	$79,253.01	
	$11,312.60	$25,173.30	$7,076.84	$43,562.74	
	$13,984.40	$12,265.45	$9,440.42	$35,690.27	
				$-3,500.00	
Total for Contract Effective Date: 10/13/20
Claim Count : 28	$25,297.00	$37,438.75	$16,517.26	$79,253.01	
	$11,312.60	$25,173.30	$7,076.84	$43,562.74	
	$13,984.40	$12,265.45	$9,440.42	$35,690.27	
				$-3,500.00	

Valuation Date: 04/18/2022

WC Itemized Statement of Loss
IMPACT LANDSCAPING & IRRIGATION, LLC - Loss Run Detail

Lihertx

\P

Mutual.
INSURANCE

Run Date: 04/18/2022

Claim Number Location Cause	Claimant Name		Loss Date Status	Carrier Report Date Jurisdiction State	Incurred Indemnity Paid Indemnity Indemnity O/R	Incurred Medical Paid Medical MedicalO/R	Incurred Expense Paid Expense Expense O/R	Total Incurred Total Paid Outstanding Reserve Applied Recovery	
Date of Hire	Date Reopened	Accident State	Lost Time Days	Litigation Status	Part of Body				
Nature of Injury			Catalyst		Date Closed				
Accident Description									
WC550C46502	MOSER.JEFFREY		08/26/2021	09/02/2021	$0.00	$0.00	$0.00	$0.00	
-UNKNOWN					$0.00	$0.00	$0.00	$0.00	
0HA- MATERIAL HANDLING - MANUAL	Closed	$0.00	$0.00	$0.00	$0.00	
					$0.00	

7/16/07	FL
000 - UNDEFINED
THROWING SOD DOWN AND HURT IS ARM

0	0000 - UNDEFINED
0000 - UNDEFINED

WC550C45752	NICOLAS.DAVID	07/01/2021	07/01/2021	$0.00	$291.71	$69.30	$361.01	
-UNKNOWN				$0.00	$291.71	$69.30	$361.01	
ORA - STRUCK BY/AGAINST OBJECTS OR OTHER PERSONS	Closed	$0.00	$0.00	$0.00	$0.00	
					$0.00	

8/24/20
000 - UNDEFINED	
FL	
0
0000 - UNDEFINED	
0000 - UNDEFINED	
CUT NAIL ON LEFT THUMB WITH PIPE CUTTER

WC550C42183
-UNKNOWN

NOLASCO MATEO.DIEGO

01/25/2021	01/25/2021

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

OLA - MATERIAL HANDLING - MECHANICAL

10/5/20	FL
000 - UNDEFINED

Closed

0
0000 - UNDEFINED

0000 - UNDEFINED

$0.00

$0.00

$0.00

$0.00
$0.00

CUT HIS RIGHT KNEE WITH HEDGETRIMMER

Valuation Date: 04/18/2022

WC Itemized Statement of Loss
IMPACT LANDSCAPING & IRRIGATION, LLC - Loss Run Detail

Libert):

\p1f

Mutual
INSURANCE

Run Date: 04/18/2022

Claim Number Location Cause	Claimant Name		Loss Date Status	Carrier Report Date Jurisdiction State	Incurred Indemnity Paid Indemnity Indemnity O/R	Incurred Medical Paid Medical Medical O/R	Incurred Expense Paid Expense Expense O/R	Total Incurred Total Paid Outstanding Reserve Applied Recovery	
Date of Hire	Date Reopened	Accident State	Lost Time Days	Litigation Status	Part of Body				
Nature of Injury		Catalyst			Date Closed				
Accident Description									
WC550C43184	PENA.JULIAN		03/18/2021	03/18/2021		$0.00	$0.00	$0.00	$0.00	
-UNKNOWN					$0.00	$0.00	$0.00	$0.00	
0QV - BODILY REACTION		Closed			$0.00	$0.00	$0.00	$0.00	
								$0.00	
4/27/20	FL	0		0000 - UNDEFINED					
000 - UNDEFINED		0000 - UNDEFINED							
IW WAS COMING OFF OF A LADDER. STEPPED OFF TOO HARD AND HURT HIS KNEE STEPPING OFF

WC550C42669	PEREZ ROBLERO,WlLMAR	02/22/2021	02/22/2021	$0.00	$319.75	$53.35	$373.10	
-UNKNOWN				$0.00	$319.75	$53.35	$373.10	
ORA - STRUCK BY/AGAINST OBJECTS OR OTHER PERSONS	Closed	$0.00	$0.00	$0.00	$0.00	
					$0.00	

1/11/21	FL	0
000 - UNDEFINED	0000 - UNDEFINED
THORN IN RIGHT THIGH

0000 - UNDEFINED

WC550C46976	PEREZ.MARICELA		09/27/2021	09/27/2021		$0.00	$399.52	$44.26	$443.78	
- UNKNOWN						$0.00	$399.52	$44.26	$443.78	
0WW- INJURED BY	ANIMAL OR INSECT		Closed			$0.00	$0.00	$0.00	$0.00	
									$0.00	
7/26/21
000 - UNDEFINED		FL	0
0000 - UNDEFINED		0000 - UNDEFINED					
STUNG BY A WASP	IN THE FACE									

WC Itemized Statement of Loss
IMPACT LANDSCAPING & IRRIGATION, LLC - Loss Run Detail

Valuation Date: 04/18/2022	Run Date: 04/18/2022

Claim Number Location Cause	Claimant Name		Loss Date Status	Carrier Report Date Jurisdiction State	Incurred Indemnity Paid Indemnity Indemnity O/R	Incurred Medical Paid Medical MedicalO/R	Incurred Expense Paid Expense Expense O/R	Total Incurred Total Paid Outstanding Reserve Applied Recovery	
Date of Hire	Date Reopened	Accident State	Lost Time Days	Lttigation Status	Part of Body				
Nature of Injury	Catalyst			Date Closed				
Accident Description								
WC550C41903	HERNANDEZ ALVA.RAUL	01/06/2021	01/06/2021		$0.00	$249.68	$256.28	$505.96	
-UNKNO'M'l				$0.00	$249.68	$256.28	$505.96	
OLA - MATERIAL HANDLING - MECHANICAL	Closed			$0.00	$0.00	$0.00	$0.00	
							$0.00	
8/12/19	FL	0		0000 - UNDEFINED					
000 - UNDEFINED	0000 - UNDEFINED							
CUT HIS LEFT THIGH WITH A HEDGE TRIMMER	
WC550C43747	JOSE JIMENEZ.ANTONIO	07/22/2021	07/28/2021		$0.00	$0.00	$0.00	$0.00	
- UNKNO'M'l				$0.00	$0.00	$0.00	$0.00	
0HA - MATERIAL HANDLING - MANUAL	Closed			$0.00	$0.00	$0.00	$0.00	
							$0.00	
6/7/21	FL	0		0000 - UNDEFINED					
000 - UNDEFINED	0000 - UNDEFINED							
WAS INSTALLING A TREE AND NOW HIS BACK HURTS	
WC550C45455	LUNDEEN.PATRICK	06/14/2021	06/15/2021	$0.00	$336.47	$20.31	$356.78	
-UNKNOW-J				$0.00	$336.47	$20.31	$356.78	
0HA - MATERIAL HANDLING - MANUAL		Closed		$0.00	$0.00	$0.00	$0.00	
							$0.00	
1/18/21	FL	0	0000 - UNDEFINED					
000 - UNDEFINED		0000 - UNDEFINED		8/4/21				
IW SPRAYING ROUND UP AND PULLING WEEDS AND GOT BIT BY SNAKE IN LEFT FOREARM

Valuation Date: 04/18/2022

WC Itemized Statement of Loss
IMPACT LANDSCAPING & IRRIGATION, LLC - Loss Run Detail

Libertx
Mutual.
INSURANCE

Run Date: 04/18/2022

Claim Number Location Cause	Claimant Name		Loss Date Status	Carrier Report Date Jurisdiction State	Incurred Indemnity Paid Indemnity Indemnity O/R	Incurred Medical Paid Medical MedicalO/R	Incurred Expense Paid Expense Expense O/R	Total Incurred Total Paid Outstanding Reserve Applied Recovery	
Date of Hire	Date Reopened	Accident State	Lost Time Days	Lttigation Status	Part of Body				
Nature of Injury		Catalyst		Date Closed				
Accident Description								
WC550C42251	MARTINEZ AMBRO,YESENIA	01/27/2021	01/27/2021	$0.00	$220.00	$59.40	$279.40	
-UNKNOIIIIN				$0.00	$220.00	$59.40	$279.40	
ORA - STRUCK BY/AGAINST OBJECTS OR OTHER PERSONS	Closed	$0.00	$0.00	$0.00	$0.00	
					$0.00	

8/17/20	
FL	
0	
0000 - UNDEFINED	
000 - UNDEFINED		0000 - UNDEFINED		
POKED IN THE RIGHT EYE4 BY SOMETHING

WC550C43149	MARTINEZ PANTO,YUSIMI	03/15/2021	03/17/2021	$0.00	$137.00	$36.01	$173.01	
- UNKNOIIIIN				$0.00	$137.00	$36.01	$173.01	
ORA- STRUCK BY/AGAINST OBJECTS OR OTHER PERSONS	Closed	$0.00	$0.00	$0.00	$0.00	
					$0.00	

12/21/20	
FL	
0	
0000 - UNDEFINED		
000 - UNDEFINED		0000 - UNDEFINED		7/2/21	
UNLOADING MULCH AND BAGS FELL ON HER	
WC550C41718	MARTINEZ.JUAN	12/17/2020	12/17/2020	$0.00	$423.98	$56.06	$480.04	
- UNKNOIIIIN				$0.00	$423.98	$56.06	$480.04	
ORA - STRUCK BY/AGAINST OBJECTS OR OTHER PERSONS	Closed	$0.00	$0.00	$0.00	$0.00	
					$0.00	

12/16/19	
FL	
0	
0000 - UNDEFINED	
000 - UNDEFINED		0000 - UNDEFINED		
JUMPED OUT OF A LOADER AND HIT HIS HEAD

Valuation Date: 04/18/2022

WC Itemized Statement of Loss
IMPACT LANDSCAPING & IRRIGATION, LLC - Loss Run Detail

Libert):

\P'

Mutual.
INSURANCE

Run Date: 04/18/2022

Client: Impact Landscaping & Irrigation, LLC Line of Business: Workers Compensation Report Type: Itemized Statement of Loss Valuation Date: 04/18/2022
Run Date: 04/18/2022
Report Name: IMPACT LANDSCAPING & IRRIGATION, LLC - Loss Run Detail User Name: Josephine Foster

FREQUENCY:
Run Now CRITERIA:
Account - Include:
IMPACT LANDSCAPING & IRRIGATION, LLC 9-472332
Date Contract Effective:
01/01/2020 Through Greatest Value
Display SSN/SIN: No
Financials And Or: AND
Logo:
Liberty Mutual Insurance
Use Current Codes: Yes
FIELDS:
Date of Hire Date Reopened Accident State
Paid Lost Time Days Litigation Status Part of Body
Nature of Injury

Catalyst
Date Claim Closed Accident Description
SORT:
Date Contract Effective - Ascending Contract Number - Ascending
SUBTOTAL:
Date Contract Effective Contract Number
RECIPIENTS:
Josephine Foster - RISKTRAC - ALL

The information contained in this document is confidential and proprietary. It is for the exclusive use of liberty Mutual and its Policyholder. Do not distribute beyond these groups. This report was produced using RISKTRAC ®

Valuation Date: 04/18/2022

WC Itemized Statement of Loss
IMPACT LANDSCAPING & IRRIGATION, LLC - Loss Run Detail

Libert):

\P

Mutual
INSURANCE

Run Date: 04/18/2022

Claim Number Location Cause	Claimant Name		Loss Date Status	Carrier Report Date Jurisdiction State	Incurred Indemnity Paid Indemnity Indemnity O/R	Incurred Medical Paid Medical MedicalO/R	Incurred Expense Paid Expense Expense O/R	Total Incurred Total Paid Outstanding Reserve Applied Recovery	
Date of Hire	Date Reopened	Accident State	Lost Time Days	Litigation Status	Part of Body				
Nature of Injury			Catalyst		Date Closed				
Accident Description									
Contract Effective Date: 10/13/20
Contract Number: WCCZ9147233202 - Impact Landscaping & Irrigation, LLC	
WC550C43489	AJPACAJA TOHOM,HILDA	07/16/2021	07/16/2021		$0.00	$2,952.24	$91.94	$3,044.18	
-UNKNOWN				$0.00	$2,952.24	$91.94	$3,044.18	
OLA - MATERIAL HANDLING - MECHANICAL	Closed			$0.00	$0.00	$0.00	$0.00	
							$0.00	
11/23/20	FL	0		0000 - UNDEFINED					
000 - UNDEFINED	0000 - UNDEFINED							
CUT LEFT KNEE WHILE USING HEDGETRIMMERS								
WC550C41043	ANDRES,PETRONA	11/05/2020	11/05/2020		$0.00	$141.72	$34.65	$176.37	
-UNKNOWN				$0.00	$141.72	$34.65	$176.37	
OLA - MATERIAL HANDLING - MECHANICAL	Closed			$0.00	$0,00	$0.00	$0,00	
							$0.00	

8/17/20	
FL	
0	
0000 - UNDEFINED		
000 - UNDEFINED		0000 - UNDEFINED		11/18/20	
CUT HER RIGHT INDEX FINGER WITH HEDGE TRIMMER	

WC550C45755
-UNKNOWN

AVILA.MARIA	07/01/2021	07/01/2021

$0.00
$0.00

$107.10
$107.10

$15.00
$15.00

$122.10
$122.10

0WW- INJURED BY ANIMAL OR INSECT

Closed

$0.00

$0.00

$0.00

$0.00
$0.00

12/14/20
000 - UNDEFINED

FL	0
0000 - UNDEFINED

0000 - UNDEFINED

STUNG BY WASPS WHILE CUTTING SOME SUCKERS FROM TREES

Valuation Date: 04/18/2022

WC Itemized Statement of Loss
IMPACT LANDSCAPING & IRRIGATION, LLC - Loss Run Detail

Libert):
Mutual.
INSURANCE

Run Date: 04/18/2022

Claim Number Location Cause	Claimant Name		Loss Date Status	Carrier Report Date Jurisdiction State	Incurred Indemnity Paid Indemnity Indemnity O/R	Incurred Medical Paid Medical Medical OIR	Incurred Expense Paid Expense Expense O/R	Total Incurred Total Paid Ou1standing Reserve Applied Recovery	
Date of Hire	Date Reopened	Accident State	Lost Time Days	Litigation Status	Part of Body				
Nature of Injury			Catalyst		Date Closed				
Accident Description									
WC550C47269	CHAPMAN.GARY		10/08/2021	10108/2021	$0.00	$126.00	$15.00	$141.00	
-UNKNOWN					$0.00	$126.00	$15.00	$141.00	
0HA- MATERIAL HANDLING - MANUAL	Closed	$0.00	$0.00	$0.00	$0.00	
					$0.00	

114/16	FL	0	0000 - UNDEFINED
000 - UNDEFINED	0000 - UNDEFINED
LIFTED MULCH BAGS

01/1912021	01120/2021	$0.00	$3,840.01	$93.02	$3,933.03	
		$0.00	$3,840.01	$93.02	$3,933.03	
Closed		$0.00	$0.00	$0.00	$0.00	
					$0.00	

WC550C42111	CHUN RAMIREZ.ANDRES
-UNKNOWN
0LB- MOBILE EQUIPMENT-OPERATOR OR RIDER INJURY

10114119	4112121	FL	0	0000 - UNDEFINED		
000 - UNDEFINED			0000 - UNDEFINED		4112121	
HE WAS DRIVING A 926M LOADER AND TOOK A TURN TOO FAST, LOST CONTROL OF MACHINE AND FLIPPED

WC550C44035	CONRAN.SEAN	04106/2021	04/06/2021	$0.00	$406.55	$55.60	$462.15	
-UNKNOWN				$0.00	$406.55	$55.60	$462.15	
ORA- STRUCK BY/AGAINST OBJECTS OR OTHER PERSONS	Closed	$0.00	$0.00	$0.00	$0.00	
					$0.00	

211121
000 - UNDEFINED	
FL	
0
0000 - UNDEFINED	
0000 - UNDEFINED	
SYLVESTER THORN POKED IN TE LEFT WRIST

Valuation Date: 04/18/2022

WC Itemized Statement of Loss
IMPACT LANDSCAPING & IRRIGATION, LLC - Loss Run Detail

Libert):
 Mutual
INSURANCE

Run Date: 04/18/2022

Claim Number Location Cause	Claimant Name		Loss Date Status	Carrier Report Date Jurisdiction State	Incurred Indemnity Paid Indemnity lndemntty O/R	Incurred Medical Paid Medical MedicalO/R	Incurred Expense Paid Expense Expense O/R	Total Incurred Total Paid Outstanding Reserve Applied Recovery	
Date of Hire	Date Reopened	Accident State	Lost Time Days	L igation Status	Part of Body				
Nature of Injury			Catalyst		Date Closed				
Accident Description									
WC550C44048	DESOUSA.JAMES		04/07/2021	04/07/2021	$0.00	$73.10	$15.00	$88.10	
-UNKNO\lvN					$0.00	$73.10	$15.00	$88.10	
0GA - HIGHWAY VEHICLES		Closed		$0.00	$0.00	$0.00	$0.00	
							$0.00	
7/29/13	FL	0	0000 - UNDEFINED					
000 - UNDEFINED		0000 - UNDEFINED						
HE WAS REAR ENDED BY ANOTHER VEHICLE	
WC550C41422	FLORES JR.RAFAEL	11/30/2020	11/30/2020	$0.00	$2,781.71	$98.79	$2,880.50	
-UNKNO\lvN				$0.00	$2,781.71	$98.79	$2,880.50	
OLA- MATERIAL HANDLING - MECHANICAL	Closed	$0.00	$0.00	$0.00	$0.00	
					$0.00	

6/29/20	
12/2/20	
FL	
0	
0000 - UNDEFINED		
000 - UNDEFINED			0000 - UNDEFINED		12/11/20	
IWWAS TRIMMING AND WHEN HE WENT TO WIPE SOMETHING OFF TRIMMER HE ACCIDENTALLY HIT GAS AND CUT BACK OF FINGERS ON LEFT H

WC550C42755
-UNKNO\lvN

FLOREXIL, VVILFRANCE	02/24/2021	02/25/2021

$0.00
$0.00

$5,146.00
$2,246.00

$606.00
$117.90

$5,752.00
$2,363.90

0GA- HIGHWAY VEHICLES

Open

$0.00

$2,900.00

$488.10

$3,388.10
-$3,500.00

7/3/07
000 - UNDEFINED

6/9/21	FL	0
0000 - UNDEFINED

0000 - UNDEFINED

ANOTHER DRIVER RAN A STOP SIGN AND HIT PASSENGER REAR/TIRE

Valuation Date: 04/18/2022

WC Itemized Statement of Loss
IMPACT LANDSCAPING & IRRIGATION, LLC - Loss Run Detail

Liberf):
Mutual.
INSURANCE

Run Date: 04/18/2022

Claim Number Location Cause	Claimant Name		Loss Date Status	Carrier Report Date Jurisdiction State	Incurred Indemnity Paid Indemnity Indemnity O/R	Incurred Medical Paid Medical MedicalO/R	Incurred Expense Paid Expense Expense O/R	Total Incurred Total Paid Outstanding Reserve Applied Recovery	
Date of Hire	Date Reopened	Accident State	Lost Time Days	Litigation Status	Part of Body				
Nature of Injury			Catalyst		Date Closed				
Accident Description									
WC550C46418	FOOTMAN.GEORGE		08/27/2021	08/30/2021	$0.00	$0.00	$0.00	$0.00	
-UNKNO\M'J					$0.00	$0.00	$0.00	$0.00	
OWN - INJURED BY	ANIMAL OR INSECT		Closed		$0.00	$0.00	$0.00	$0.00	
								$0.00	
8/23/21		FL	0		0000 - UNDEFINED				
000 - UNDEFINED			0000 - UNDEFINED		9/23/21				
STUNG BY A BEE & CLAIMED HE IS HIGHLY ALLERGIC	
WC550C43317	FRANCIS JR,DONALD	03/24/2021	03/25/2021	$25,297.00	$10,302.00	$13,913.00	$49,512.00	
-UNKNO\M'J				$11,312.60	$936.55	$4,960.68	$17,209.83	
0HA - MATERIAL HANDLING - MANUAL		Open	0	$13,984.40	$9,365.45	$8,952.32	$32,302.17	
							$0.00	
10/22/18	FL	364	0	0000 - UNDEFINED				
000 - UNDEFINED		0000 - UNDEFINED						
CLAIMS HE WAS CARRYING A BUCKET WITH A CO-WORKER AND THEY DROPPED THEIR SIDE WITHOUT TELLING HIM, NOW HIS BACK HURTS HE

WC550C41415
- UNKNO\M'J

GOSS.DENISE	11/23/2020	11/30/2020

$0,00
$0.00

$260.68
$260.68

$15.00
$15.00

$275.68
$275.68

OWN - INJURED BY ANIMAL OR INSECT

10/8/18
000 - UNDEFINED

Closed

FL	0
0000 - UNDEFINED

0000 - UNDEFINED

$0.00

$0.00

$0.00

$0.00
$0.00

GOT BIT BY SOMETHING ON LEFT LEG BEHIND KNEE

Impact Landscaping Irrigation

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BAFU©

PO Box 1303
1'1 0 il '\ E fl 5	C o 1 P	Tallahassee, FL 32302

(888) 871 -7474 Fax

Report as of: 04/11/2022	LOSS RUN REPORT	(888) 262 -4483
Claims as of: 04/10/2022

Current A

Status:

Current Exp. Mod:

0_95

Loss Ratio:14.46%

11861 IMPACT LANDSCAPING & IRRIGATION LLC	Earned Prem: $226,605

Policy Year: 2021	Policy Date: 10/31/2021 - 10/31/2022	Agent Name: JDA Insurance Group, LLC
Date of Ace:	Claim#	Case#	Claimant	Clas§ Code		Status	Paid	Reserves	Incurred	
11/312021	0	0	MENDOZA PAULINO	
9102-LAWN MAINTENANCE-COMMERCIAL OR DOMESTIC & DRV	COMP	Closed	7,145.41	0.00	7,145.41	
Nature of Injury: Fracture
Cause: Struck or Injured By Object Being	Injured Part: Clavicle Lifted
12/27/2021	0	0	SNYDER TIMOTHY	0042-LANDSCAPE GARDENING & DRIVERS	COMP	Open	0.00	3,000.00	3,000.00	
				Nature of Injury: Allergic Reaction						
				Cause: By Skin Diseases or Disorders	Injured Part: Multiple Body Parts				
11612022	0	0	SNYDER TIMOTHY	0042-LANDSCAPE GARDENING & DRIVERS	COMP	Open	0.00	575.00	575.00	
				Nature of Injury: Strained Body Part						
				Cause: Fall, Slip, or Trip Injury-Into Openings	Injured Part: Ankle - Right				
112412022	0	0	DEGRASSE TODD	0042-LANDSCAPE GARDENING & DRIVERS	MED	Closed	321.04	0.00	321.04	
Nature of Injury: Cut I Laceration /Puncture I Abrasion
Cause: Cut, Puncture, Scrape Injured By Hand	Injured Part: Leg, Upper Left
To

212212022	0	0	VILLALPANDO ESTEBAN	9102-LAWN MAINTENANCE-COMMERCIAL OR	MED	Open	0.00	3,300.00	3,300.00
DOMESTIC & DRV
Nature of Injury: Puncture
Cause: Cut, Puncture, Scrape Injured By	Injured Part: Thumb· Left Object

31312022	0	0	ELLERBEE KIMBERLY	9102-LAWN MAINTENANCE-COMMERCIAL OR	COMP	Open	40.21	13,484.79	13,525.00
DOMESTIC & DRV
Nature of Injury: Strained Body Part
Cause: Motor Vehicle-Collision or Sideswipe	injured Part: Arm, Lower Right w/A

31912022	0	0	TORRES ANTONIO	0867-Class Code Description not found...	COMP	Open	0.00	0.00	0.00
Nature of injury: Strained Body Part

	Cause: Fall, Slip, or Trip Injury-Different Lev	Injured Part: Knee- Right		
3/1612022	0	0	ADELSON DESROSIERS	0042-LANDSCAPE GARDENING & DRIVERS	COMP	Open	0.00	0.00	0.00	
Nature of injury: Cut I Laceration /Puncture I Abrasion	
				Cause: Fall, Slip or Trip Injury-Same Level	injured Part: Leg, Lower Right				
311912022	0	0	MENDOZA PAULINO	8810-CLERICAL OFFICE EMPLOYEES NOC.	MED	Open	0.00	1,600.00	1,600.00	
Nature of Injury: Bruise I Contusion
Cause: Struck or Injured By Object Being	Injured Part: Foot - Unspecified Side Lifted

3/2112022	0	0	JIMINEZ PEDRO M	8810-CLERICAL OFFICE EMPLOYEES NOC.	MED	Open	0.00	3,300.00	3,300.00
Nature of Injury: Nature of Injury Not Stated

Cause: Strain or Injury By Miscellaneous	Injured Part: Arm, Upper Right (excl. clavicle & scapu

Earned Premium

Paid

Reserves

Incurred

2021 Totals	10	14.46%	226,605.00

7,506.66

25,259.79	32,766.45

#Claims
Totals:	10

Loss Ratio Eamed Premium
14.46%	226,605.00

f1lll!	 Reservei	 tncyrred
7,506.66	25,259.79	32,766.45

	LUIS HERNANDEZ	STIHL	BR 600	BLOWER	557294718234	55	
	OSCAR VALDEZ	STIHL	BR 600	BLOWER	298556392	22	
	OSCAR VALDEZ	STIHL	BR 600	BLOWER	298556440	21	
	LADISLAO PELICO	STIHL	BR 600	BLOWER	298556444	20	
	NOEL OROZCO	STIHL	BR 600	BLOWER	298556421	19	
	LUIS HERNANDEZ	STIHL	BR 600	BLOWER	298556437	17	
	NOEL OROZCO	STIHL	BR 600	BLOWER	298556439	18	
JUPITER		STIHL	MS 192C	CHAINSAW	290820752	1	
OFFICE		STIHL	MS250	CHAINSAW	293203578	2	
OFFICE	ROBER PEREZ	STIHL	MS250	CHAINSAW	293198835	3	
	OFFICE	STIHL	MS 192C	CHAINSAW	297649757	4	
	OFFICE	STIHL	MS 192C	CHAINSAW	297649771	5	
	RIGO GONZALEZ	STIHL	MS 250	CHAINSAW	294741225	6	
OSCAR VALDEZ		STIHL		EDGER	290626940	0	
NOEL OROZCO	LUIS HERNANDEZ	STIHL		EDGER	291583872	5	
NOEL OROZCO		STIHL		EDGER	294440667	6	
LUIS HERNANDEZ		STIHL		EDGER	294440795	7	
OSCAR VALDEZ		STIHL	FC90	EDGER	294440794	8	
OSCAR VALDEZ		STIHL	FC 90	EDGER	295711433	9	
PEDRO ACOSTA		STIHL	FC90	EDGER	294440783	10	
NOEL OROZCO		STIHL	FC 90	EDGER	294440782	11	
LUIS HERNANDEZ	LUIS HERNANDEZ	STIHL	FC 90	EDGER	296069718	12	
	LUIS HERNANDEZ	STIHL	FC 90	EDGER	295137648	19	
	LADISLAO PELICO	STIHL	FC90	EDGER	297576785	14	
	LADISLAO PELICO	STIHL	FC 90	EDGER	297576780	15	
	OSCAR VALDEZ	STIHL	FC90	EDGER	297576792	13	
	LUIS HERNANDEZ	STIHL	FC90	EDGER	297576781	16	
	NOEL OROZCO	STIHL	FC90	EDGER	297576608	17	
	NOEL OROZCO	STIHL	FC 90	EDGER	297576777	18	
		STIHL	BG55	HAND BLOWER	296009737	1	
		STIHL	BG55	HAND BLOWER	295777473	2	
		STIHL	BG55	HAND BLOWER	296009741	3	
		STIHL	BG55	HAND BLOWER	295777461	4	
		STIHL	BG55	HAND BLOWER	296009734	5	
		STIHL	BG55	HAND BLOWER	296009735	6	
JOSE EDUARDO		STIHL		HAND BLOWER	294476569	8	
TRINIDAD JIMINEZ		STIHL		HAND BLOWER	295049255	9	

GUADALUPE REYES	GUADALUPE REYES	STIHL	BG86	HAND BLOWER	295276565	
SAMMY HERNANDEZ	JOSE PENA	STIHL	BG86	HAND BLOWER	291196027	

10
11

	STIHL	BG86	HAND BLOWER	294827593	12	
	STIHL	BG86	HAND BLOWER	294827598	13	
	STIHL	BG55	HAND BLOWER	297047631	17	
	STIHL	BG55	HAND BLOWER	297862434	18	
	STIHL		HEDGE TRIMMER		3	
	STIHL		HEDGE TRIMMER	283669614	6	
GUADALUPE REYES	STIHL	HL90	HEDGE TRIMMER	290757811	7	
	STIHL		HEDGE TRIMMER	286566980	8	
JOSE PENA	STIHL		HEDGE TRIMMER	289974784	11	
	STIHL		HEDGE TRIMMER	291212874	12	
	STIHL		HEDGE TRIMMER		13	
	STIHL	HL 100K	LONG TRIMMER	295051857	15	
	STIHL	HLl00K	LONG TRIMMER	295329088	16	
	STIHL	Hll00K	LONG TRIMMER	295329092	18	
	STIHL	HLlO0K	LONG TRIMMER	295051709	21	
	STIHL	HLlO0K	LONG TRIMMER	296483634	45	
GUADALUPE REYES	STIHL	HL l00K	LONG TRIMMER	297585107	25	
JOSE PENA	STIHL	HL 100K	LONG TRIMMER	297585117	24	
ANTHONY DELORTO	STIHL	HL 100K	LONG TRIMMER	297585119	22	
TOMAS MARTINEZ	STIHL	HL 100K	LONG TRIMMER	297585065	23	
GUADALUPE REYES	STIHL	HL90K	SHORT TRIMMER	294750841	14	
	STIHL	HL 90K	SHORT TRIMMER	287069137	17	
	STIHL	HL90K	SHORT TRIMMER	289974862	19	
	STIHL	HL90K	SHORT TRIMMER	295072490	20	
	STIHL	HL 90k	SHORT TRIMMER	296535213	44	
TOMAS MARTINEZ	STIHL	HL 90k	SHORT TRIMMER	297599297	28	
TOMAS MARTINEZ	STIHL	HL90k	SHORT TRIMMER	297599305	27	
JOSE PENA	STIHL	HL 90k	SHORT TRIMMER	297599308	29	
ANTHONY DELORTO	STIHL	HL90k	SHORT TRIMMER	297599281	26	
	STIHL		WEED EATER	286920344	4	
	STIHL		WEED EATER	289503743	8	
	STIHL		WEED EATER	287453552	12	
	STIHL	FS90R	WEED EATER	292256046	17	
	TIHL	FS90R	WEED EATER	2 2256044	18	
	STIHL	FS90R	WEED EATER	292256030	19	
	STIHL	FS90R	WEED EATER	295244900	20	
	STIHL	FS90R	WEED EATER	295248249	21	

JUPITER TRIM JUPITER TRIM THOMAS MARTINEZ THOMAS MARTINEZ GUADALUPE REYES GUADALUPE REYES GUADALUPE REYES THOMAS MARTINEZ SAMMY HERNANDEZ THOMAS MARTINEZ SAMMY HERNANDEZ GUADALUPE REYES SAMMY HERNANDEZ THOMAS MARTINEZ JUPITER TRIM
FELIPE RODRIGUEZ

GUADALUPE REYES THOMAS MARTINEZ JUIPTER TRIM JUPITER TRIM FELIPE RODRIGUEZ

RIGO GONZALEZ NOE FERNANDEZ

LUIS HERNANDEZ NOEL OROZCO RIGO GONZALEZ RIGO GONZALEZ NOELORO CO

PEDRO ACOSTA		STIHL	FS90R	WEED EATER	295248240	22	
PEDRO ACOSTA	NOEL OROZCO	STIHL	FS90R	WEED EATER	295248245	23	
LUIS HERNANDEZ	LUIS HERNANDEZ	STIHL	FS90R	WEED EATER	295248263	24	
	LADISLAO PELICO	STIHL	FS90R	WEED EATER	296572439	25	
	LADISLAO PELICO	STIHL	FS90R	WEED EATER	296572442	26	
	LUIS HERNANDEZ	STIHL	FS90R	WEED EATER	296572435	27	
	LUIS HERNANDEZ	STIHL	FS90R	WEED EATER	296572429	28	
	NOEL OROZCO	STIHL	FS90R	WEED EATER	296572453	29	
	NOEL OROZCO	STIHL	FS90R	WEED EATER	296572454	30	
	OSCAR VALDEZ	ST HL	FS90R	WEED EATER	296572414	31	
	OSCAR VALDEZ	STIHL	FS90R	WEED EATER	296572423	32	
LANDSCAPE		TCM	E820	LOADER	HFK4E400V00003940		
LANDSCAPE		TCM	E820	LOADER	61700857		
GUADALUPE REYES		TRAILER		GREEN TLR	16MB11422MD017364		
TERRENCE				TRACKER			

THOMAS MARTINEZ		JOHN DEERE		GATOR	W04X2SD032652	4	
GUADALUPE REYES		JOHN DEERE	4X2	GATOR	1M04X2XDADM081721	7	
JORGE MARIE		JOHN DEERE	4X2	GATOR	1M04X2XDVDM081958	8	
FRANCISCO CORILLO		JOHN DEERE	620i	GATOR	1JDUV41879M030395	9	
		JOHN DEERE		GATOR	MOHXOPA043383		
	CARLOS MENDEZ	JOHN DEERE	4X2	GATOR	1M04X2SJCEM090432	10	
NOEL OROZCO		JOHN DEERE	60"	LAWN MOWER	TCZ850A020020	1	
LUIS HERNANDEZ		JOHN DEERE	72"	LAWN MOWER	1TC970ADVBT020132	2	
*OPEN		JOHN DEERE	54"	LAWN MOWER	FH680DA30307	3	
NOEL OROZCO		JOHN DEERE	72"	LAWN MOWER	ITC950ADKBT020200	4	
NOEL OROZCO		JOHN DEERE	48"	LAWN MOWER	TC920AL010293	5	
JUPITER		JOHN DEERE	60"	LAWN MOWER	TC2860H010061	7	
JUPITER		JOHN DEERE	72"	LAWN MOWER	1TC970ADJBT020130	8	
JUPITER		JOHN DEERE	54"	LAWN MOWER	TC0737A062290	9	
*OPEN		JOHN DEERE	60"	LAWN MOWER	TC2860H010080	10	
*OPEN		JOHN DEERE	72"	LAWN MOWER	TC0777C050669	12	
*OPEN		JOHN DEERE	48"	LAWN MOWER	TC647AX040248	23	
*OPEN		JOHN DEERE	48"	LAWN MOWER	TC647AX040211	24	
*RETIRED FOR PARTS		JOHN DEERE	60"	LAWN MOWER	TC830AP010290	25	
LUIS HERNANDEZ		JOHN DEERE	60"	LAWN MOWER	1TC930MCKDT011637	26	
NOEL OROZCO		JOHN DEERE	60"	LAWNMOWER	1TC930MCPDT011636	27	
PEDRO ACOSTA		JOHN DEERE	72"	LAWN MOWER	1TC970RDPDT010461	28	
RIGO GONZALEZ		JOHN DEERE	60"	LAWNMOWER		29	
	NOEL OROZCO	JOHN DEERE	60"	LAWN MOWER	1TC930MCEDT014239	33	
	OSCAR VALDEZ	JOHN DEERE	60"	LAWN MOWER	1TC930MCCDT014363	30	
	LUIS HERNANDEZ	JOHN DEERE	60"	LAWN MOWER	1TC930MCKDT014361	31	
	LADISLAO PELICO	JOHN DEERE	60"	LAWN MOWER	1TC930MCLDT014240	34	
	LADISLAO PELICO	JOHN DEERE	36"	LAWN MOWER	1TCW36HPECT040017	32	
JIMMY DESOUSA		JOHN DEERE	85130-3	Z-SPRAY	ZJ36-2013-091	1	
FRANCOIS FLOREXIL		KUBOTA		GATOR	10472	5	
GUADALUPE REYES		KUBOTA		GATOR	17942	6	
LANDSCAPE		KUBOTA	R520S	LOADER	JKUR5203A01H20460		
ORLANDO		KUBOTA	R520S	LOADER	JKUR5203HO1H10997		
ORLANDO		KUBOTA	R520S	LOADER	JKUR5203C01H20522		
NOEL OROZCO		RSC		AIR COMPRESSOR	780084	1	
NOE FERNANDEZ		RSC		AIR COMPRESSOR	20085434	2	
RIGO GONZALEZ		STIHL		BLOWER	290221208	2	

RIGO GONZALEZ	STIHL		BLOWER	289316129	3	
RIGO GONZALEZ	STIHL		BLOWER	291652757	7	
THOMAS MARTINEZ	STIHL		BLOWER	362785524	10	
NOEL OROZCO	STIHL		BLOWER	294718233	12	
RIGO GONZALEZ	STIHL	BR 600	BLOWER	294853082	13	
PEDRO ACOSTA	STIHL	BR 600	BLOWER	294987088	14	
PEDRO ACOSTA	STIHL	BR 600	BLOWER	294987110	15	
NOEL OROZCO	STIHL	BR 600	BLOWER	295343129	16	

LANDSCAPE		CASE	321D	LOADER	933C51003502		
IRRIGATION		CAT		MINI EXCAVATOR			
JACK (WELLINGTON)		DITCH WITCH	RT40	RIDE ON TRENCHER	3Y1240		
KYLE (VERO)		DITCH WITCH	3700 SERIES	RIDE ON TRENCHER	3X0733		
MARIO (JUPITER)		DITCH WITCH	RT40	RIDE ON TRENCHER	320834		
MIKE FOSTER		DITCH WITCH	RT40	RIDE ON TRENCHER	CMWH314XE50000049		
TEXAS		DITCH WITCH		RIDE ON TRENCHER	3L1249		
NOEL HERNANDEZ		ECHO		BLOWER	PO4112009558	1	
		ECHO		BLOWER	P03012028717	8	
	NOEL OROZCO	ECHO		BLOWER	P03012056813	9	
OSCAR VALDEZ		ECHO		EDGER	S71612009472	1	
NOE FERNANDEZ		ECHO		EDGER	T42912003200	2	
NOEL OROZCO		ECHO		EDGER	S71612009462	3	
THOMAS MARTINEZ		ECHO		HAND BLOWER	P09112024675	6	
GUADALUPE REYES		ECHO		HAND BLOWER	P09112014272	7	
THOMAS MARTINEZ		ECHO		HEDGE TRIMMER	571712005356	1	
GUADALUPE REYES		ECHO		HEDGE TRIMMER	S85612004836	9	
THOMAS MARTINEZ		ECHO		HEDGE TRIMMER	S85312009612	10	
NOEL HERNANDEZ		ECHO		WEED EATER	T42512009335	1	
NOEL OROZCO		ECHO		WEED EATER	S74212033511	2	
NOE FERNANDEZ		ECHO		WEED EATER	T42512010363	7	
NOE FERNANDEZ		ECHO		WEED EATER	T42512009983	9	
NOE FERNANDEZ		ECHO		WEED EATER	S74112005850	11	
		ECHO		WEED EATER	S74212033504	13	
RIGO GONZALEZ		ECHO		WEED EATER	S79812033827	14	
NOE FERNANDEZ		ECHO		WEED EATER	S74012014128	15	
NOE FERNANDEZ		ECHO		WEED EATER	S63012010474	16	
NOEL OROZCO		EXMARK	60"	LAWN MOWER	941818	6	
LUIS HERNANDEZ		EXMARK	60"	LAWN MOWER	941815	11	
JUPITER		EXMARK	36"	LAWN MOWER	924828	14	
*OPEN		EXMARK	48"	LAWN MOWER	869388	15	
*OPEN		EXMARK	48"	LAWN MOWER	869418	17	
*OPEN		EXMARK	48"	LAWN MOWER	869748	18	
*OPEN		EXMARK	36"	LAWN MOWER	869233	19	
*OPEN		EXMARK	52"	LAWN MOWER	924953	20	
*ORLANDO		EXMARK		LAWN MOWER	883951		

0.0%	11/23/2021	

0.0%	
2/8/2021	

0.0%	
1/4/2022	
0.0%	9/3/2021	
0.0%	5/21/2021	
0.0%	11/5/2020	

0.0%	
3/26/2021	
0.0%	9/21/2021	

0.0%
0.0%

0.0%	6/25/2021	

0.0%	
12/3/2020	
0.0%	4/30/2021	
0.0%	10/12/2021	
0.0%	3/17/2021	

0.0%	
6/11/2021	

5-Star Developers LLC
Trevi Isle	6/21/2021

JW Cheatham
Callaway Armed Forces Reserve	2/4/2020

Kolter Homes
Alton - Jasmine Minima Replacements {PO 998)
Alton - Parcel D Preserve - Supplemental Planting {PO 1033) Alton & Artistry - Parcel G - Hood Road Plantings - ROW {PO 772) Alton & Artistry - Parcel G - Hood Road Medians {PO 867)

Minto
Meadows Ph 1 to complete 4600008057
Meadows Ph 2 4600007010

RDPll
Verizon Sebastian Landscape Verizon Sebastian Irrigation

Turtle Beach Construction
Smith Residence - TQ187

Veranda CDD

2/25/2021
3/25/2021
4/14/2020
6/24/2020

2/21/2021
2/7/2020

3/1/2020
3/1/2020

2/18/2021

Veranda Preserve	6/3/2020	
Veranda Preserve Ph 2	4/20/2021	
Becker -Ph 2	11/30/2020	
Solera @ City Center (19-010)	
9/1/2020	

Willoughby Constrution - due by 25th of the month
Sandore - 240 Locha Drive

11/5/2020

$	119,074.25		119,074.25	

$	78,984.10			

$	72,150.29		
72,150.29	
$	43,906.50		43,906.50	
$	211,161.55	24,270.00	235,431.55	
$	310,990.10		310,990.10	

$	31,864.75		
31,864.75	
$	238,133.95	6,090.00	244,223.95	

$	59,282.55			
$	17,005.00			

$	98,900.09	

2,457.00	

101,357.09	

$	317,140.00		
317,140.00	
$	204,522.20		204,522.20	
$	946,033.25	49,910.60	995,943.85	
$	262,425.00	14,301.51	276,726.51	

$	150,000.00	
20,144.20	
170,144.20	

$	3,161,573.58			

LAUREL ROAD
COMMUNITY DEVELOPMENT DISTRICT

7B

LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT

CONTRACTOR'S PREQUALIFICATION STATEMENT (LANDSCAPE/HARDSCAPE)

TABLE OF CONTENTS

NOTICE TO PROSPECTIVE BIDDER APPLICATION FOR CONTRACTOR PREQUALIFICATION
CORPORATE OFFICERS

CORPORATE STOCKHOLDERS SUPERVISORY PERSONNEL
COMPANY OWNED MAJOR EQUIPMENT STATVS OF CONTRACTS ON HAND
ALL PROJECTS APPLICANT COMPANY COMPLETED IN THE LAST TWO YEARS AFFIDAVIT FOR INDIVIDUAL
AFFIDAVIT FOR PARTNERSIIIP AFFIDAVlT FOR CORPORATION
SWORN STATEMENT UNDER SECTION 287.133(3)(A),
FLORIDA STATUTES. ON PUBLIC ENTITY CRIMES CONTRACTOR CLASSIFICATION LISTING DETERMINATION OF QUALIFIED PROSPECTIVE BIDDER

REQUEST FOR QUALIFICATIONS

SUPPLY AND INSTALL LANDSCAPING/HARDSCAPING

LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT SARASOTA COUNTY, FLORIDA

LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT (DISTRICT) requests Qualifications Submittals from firms interested in providing and installing landscaping/hardscaping services. Upcoming projects are in Sarasota County, Florida.

To be eligible to submit qualifications, firms must hold all required applicable state licenses in good standing, hold all required applicable federal licenses in good standing, and be authorized to do business in the State of Florida.

Applicants may request a Qualifications Submittal Package via email from AM Engineering, LLC (District Engineer). (Email echilders@amengfl.com for package) Applicants must submit one (l) set of the Qualifications Submittal Package by l :00 PM on Monday April 25, 2022. Handwritten submissions will not be accepted. Submissions should be emailed to echilders:g amenqfl corr..

Qualified firms will be selected based on experience, qualifications of personnel, and ability to perform required services. Packages will be reviewed and rated by a qualifications committee. At that time, all qualified firms will be assigned a project and aggregate dollar limit for potential work under contract. All applicants will be promptly notified after the firms are selected. The pre-qualification decisions of the Board of Supervisors shall be valid for a period of three (3) years, after which the Board of Supervisors may either extend the prequalification period for two (2) additional one (l) year periods or open the prequalification process again.

Qualified firms will be eligible to bid or propose on landscape/hardscapeprojects subject to the firms' project and aggregate limits. Failure to pre-qualify may preclude LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT from awarding contracts to any non­ prequalified firm. All firms interested in bidding on landscape/hardscape contracts to be led by the DISTRICT are strongly encouraged to submit for pre-qualification. However, the DISTRICT is not obligated to select prequalified firms, and at its sole discretion reserves the right to solicit bids or proposals from non-prequalified contractors for specific projects in the best interests of the DISTRICT.

Applicants may contact the District Engineer, Shawn Leins, P.E., AM Engineering, LLC. at echilders@amengfl.com until the qualification's submittal deadline for further information.

NOTlCE TO PROSPECTIVE BIDDER

The infonnation required herein is for the purposes of fairly evaluating all prospective bidders for certain LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT (District) contracts.

APPLICANTS FOR PREQUALIFlCATION AS BIDDERS FOR DISTRICT LANDSCAPE/HARDSCAPE CONTRACTS ARE HEREBY NOTIFJED THAT INCLUSION OF FALSE, DECEPTIVE OR FRAUDULENT STATEMENTS ON THIS APPLICATION CONSTITUTES FRAUD. FURTHERMORE, YOU ARE HEREWITH NOTIFIED THAT THE DISTRICT CONSIDERS SUCH ACTlON ON THE PART OF THE APPLICANT TO CONSTITUTE GOOD CAUSE FOR DENIAL, SUSPENSION, OR REVOCATION OF THE PROSPECTIVE BIDDER'S QUALlFICATION FOR BIDDING ON ITS PROJECTS.

Please be advised that this application must be complete within itself without reference to any previous application or statement. All sections of the application shall be completed. If any of the requested information does not apply, it shall be indicated as "None" or "N.A." as applicable. Failure to make entries in every section of this application may result in a delay or disqualification to bid until such time as all information is provided to the District for evaluation and final decision as to qualification to bid.

The properly completed Contractor's Prequalitication Statement shall be submitted to AM Engineering. LLC., (Engineer) Attention: Shawn Leins, PE, 8340 Consumer Ct., Sarasota, FL 34240. Any questions with regard to the requests for information contained herein shall be addressed to Shawn Leins. PE, via e-mail echilders@amengfl.com.

LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT CONTRACTOR PREQUALIFICATION STATEMENT

Application for Contractor Pregualiflcatton

DATE SUBMITTED f±fn. l	2.F5	. 2022.
I.	Applicant fv4"l'f.fu   A.Partnership
(Company Nam	/:!f.A Corporation
I _I A Subsidiary Corporation
2.	Parent Company Name MJXr: 'f\-yyyt.s L.clMdsca PTY§,.:D1.c •
Parent Company Address:
Street Address	 L{ 7S	tc£ifl- SheeJ	fucs f-
P. 0. Box (if any).	
City ,Pct,\ vy1,eJ-to	State	L-	Zip Code	3Lf z.2- /
Telephone ®,4Vt J Lo-I DJ Co	Fax No. &Lf:lj7]  (,p -2  705 
!st Contact Name ¼:Ve 'Av-m&-h--9X19  DY',	Title Px:es'idevit(DIA)-1\f_,V
2nd Contact Name k.t14:....		( JV	Title	,FshYVC,<._-to-/
Applicant Company Address (if different):
Street Address 	

P0.B.ox (if any)					 City 	State 		Zip Code 			 Telephone 		 Fax No. 		
1st Contact Name	Title 	

2nd Contact Name 	Title 	

1st Contact E-Mail,	2nd Contact E-Mail 	

List the location of the applicant"s office which would handle DISTRICT work. Street Address :isY J 5	(d?i 6-h-ee+- &s+-
City	\?Q\., Y'.'Y'.'f:_,,-bb	State  F::L-:	Zip Code6	
Telephone(s4-\)  77.l,rtDJ le	FaxNo. GL{:() 7]  Lt- 2-lDS
1st Contract Name vv;;;'i(.£		s(. Title	#c.&1d;S v
1st Contact E-Mail		\<cQ,v,n +...t,ng) \a. s	yot b,oo ,(OW)

Is the applicant Company incorporated in the State of Florida? yes 9'(no ( )

If yes, provide the following:

Is the Company in good standing with the Florida Secretary of State Division of Corporations? yes	no ( )

If no, please explain 	

I

Date Incorporated ,_\\.y.}....:::cAc y}'--l'--°t...:...;i><-J-+-_ Charter No. 59-L-'6 lo,lpl- '2.1-
I
If no, provide the following:

The State applicant company is incorporated in? 	

Is the company in good standing with the State? yes ( ) no ( )
In no, please explain 	

Date Incorporated 	Charter No. 	

£I	W

Ts the applicant company authorized to do business in the State of Florida? yes ( ) no ( )

Is the applicant company a registered or licensed contractor with the State of Florida? yes ( ) no If yes, provide the following:
Type ofregistration (i.e. certified general contractor, certified electrical contractor, etc.) 	

License No. 	 Expiration Date 	

Qualifying Individual 	 Title 	

List company(s) currently qualified under this license 	

Is the applicant Company a registered or licensed Contractor with Sarasota County? yesyi no( )

Has the applicant Company performed work for an independent special district previously? ye	no()

Is the applicant company prequalified by the Florida Department of Transportation? yes ( ) no j!J
If yes, provide the following:

Work class ratings 	

Maximum capacity rating 	
Name of Applicant's Bonding Company -=-"'b=-..r.n...,,.....,""V),._._._._..±..e.._  ._R_f--=..  ,t-'"""".1-.-..::....:V\.Cc..==--·-----

&...1.y. ,	\ 37

Address	\4 DD l	LU.LC:\ l t?YDo \c.. bY-1\tt:,. Okla}toJYaL ', 01c.. ,(

se.e

Approved Bonding Capacities:	Aggregate Limit	$  Y10601(!)00 •OD 	.i..1- _1 _,.,../
Single Project Limit	$  4-000 ec,o, c:c>

1

Total Current Contracts Bonded	$  i;oz..( 4!?5• SD
Name of Applicant's Bonding Agency _h ,.,€Gl'l.:e»>::!.....!::C=  .J.:.::...i.-:C-==---tA.S::.i<-==LLVo...:L..&.,.nA.lJl. ill-l.l(..._'£'=-"-­ 

Address  

P_......:O •-	::;_O=---.:cX

..._S_L_---= ==-----------------

Contact Name _	_..1:tWj  Y14_, 

._..\J)c...c........,,c.=,_..L,_  s 

Phone LtOLt- 4£(1-<3 4 D

List the Applicant's total annual dollar value of work completed for each of the last five (5) years starting with the latest year and ending with the most current year	(0I) U?l Lt3  Z..,4 -Zt> 1  (::;6)	
(02) 1± \D	00 I, 6		(03) \01:ZZ D1 17 LD, 52- 
(04)]>/h, 63-Z... ''5	:	(05)	7 I  2..'-"'<:lI '5'52:., b3 
List the classification(s) (refer to attached listing) of work the applicant is applying for prequalification based on the applicant company's ability to self-perform the work (excluding general contracting).
ldVAdsCfLi?C<		

What are the applicant company's current insurance limits? (provide a copy of applicant's certificate of insurance)

General Liability Automobile Liability Workers Compensation Expiration Date

p4.

Has the applicant company been cited by OSHA for any job site or company office/shop safety violations in the past two years? yes ( ) no

Tfyes, please describe each violation, fine, and resolution 	

What is the applicant's current worker compensation rating?

April 25, 2022

Re:	Mike Armstrong Landscaping, Inc.
Surety Bonding

To Whom It May Concern:

This is to advise you that based upon our current information, we are willing to entertain bonds for Mike Armstrong Landscaping for construction contracts up to the amounts of $2,000,000 (Single Job)/ $4,000,000 (Aggregate), subject to the usual underwriting criteria. This program has been set to meet the day-to-day needs of this company. Requests for surety credit above this line of credit are welcomed and reviewed on a case-by-case basis. Mike Armstrong's bond rate is a $25/$15/$10 sliding rate.

Granite is an "A+" rated company by A.M. Best, with a financial size of XV ($2 billion or greater) and is a federally approved surety by the United States Department of the Treasury.

Please understand that any arrangements for surety credit are a matter between contractor/applicant and ourselves and we assume no liability to any third parties if for any reason we do not supply said bonds.

This letter is not an assumption of liability nor is it a bond. It is issued only as a letter of recommendation requested from us by our client. This letter expires December 31, 2022.

Sincerely, Granite Re, Inc.

Senior Underwriter

U00l Quoilbrook Drive • Oklahoma City, Oklahoma 7313-4 • -405/752-2600 • Fa• -405/7-49-6800 • 800/-4-40-5953
Website: www.gronitere.com

• • • • • •

WORKFORCE BUSINESS SERVICES

• • • • • • • • • • • • •

• • • •

YOUR HARD MARKET SOLUTION

April 25, 2022

RE: Mike Armstrong Landscaping Inc 8475 69th Street East
Palmetto, Fl 34221

To Whom It May Concern:

The above is a client of Workforce Business Services. Their EMR is as follows:

12/31/2017 to 12/31/2018 .73
12/31/2018 to 12/31/2019 .78
12/31/2019 to 12/31/2020 .88
12/31/2020 to 12/31/2021 .85
12/31/2021 to 12/31/2022 .89

If you have any questions please feel free to contact me at 800-353-5304 ext 623.

Sincerely,

Stacey L. Sweeney
Workers' Compensation Representative (866) 293-3600, Extension 623

rNDfVlDUAL 'S	PRESENT

NAME		POSITION OR OFFICE

MAGNITUDE AND TYPE OF WORK*

YEARS OF LANDSCAPE/HA RDSCAPE EXPERlE CE
l\.l.s
:2.D

YEARS WlTH FIRM

TN WHAT CAPACITY'!

:L?:>
2-\3s

'

40+
l lo lo 11
\?
\ \

Has the applicant company experienced any worker injuries resulting in a worker lo	more than ten ( I0) working days as a result of the injury in the past two years? yes ( ) no (\)""

If yes. please describe each incident 	

Please state whether or not your company or any of its affiliates are presently barred or suspended from
bidding or contracting on any state'or federal-aid contracts in any statc(s)? Yes   	No_£_  Ifso,
state the name(s) of the company(ies) 	

the state(s) where barred or suspended 		 anthde period(s) of debarment or suspension 	

What i the landscape/hardscape experience of the principal supervisory landscape/hardscape personnel of your organization? (Attach resumes here.)

*Give in sufficient detail for the District to evaluate your expenence m the classifications of work for which you arc requesting prequalification.

Have you ever failed to complete any work awarded to you?  Yes

No )G

Tf so, where and why? 	

Has any officer or partner of your organization ever been an officer, partner, or owner of sox:ther
organization that has failed to complete a landscape/hardscape contract? Yes	 No	If so,
state name of individual, other organization and reason therefor. 	

List any and all litigation to which your organization has been a party in the last five (5) years.	tv'/  A-

Has your organization or any of its affiliates ever been either disqualified or denied prequalification status by a governmental entity?  O  If so, discuss the circumstances surrounding such denial or disqualification as well as the date thereof. 	

Within the past five (5) years, has yourorganization failed to complete a project within the scheduled contract time? \JO  If so, discuss the circumstances surrounding such failure to complete a project on time as well as the date thereof. 	

STATE OF FLORIDA	\
COUNTY OF (y\_a J\CLt-c..e .
The undersigned hereby authorize(s) and request(s) any person, firm or corporation to furnish any pertinent information requested by the LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT, or their authorized agents, deemed necessary to verify the statements made in this application or attachments hereto, or necessary to determine whether the LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT should prequalify applicant for bidding on its landscape/hardscape projects, including such matters as the applicant' ability, standing, integrity, quality of performance, efficiency and general reputation	1

This 2,_csm day of bµr,\ , 2022.

(Corporate Seal)

Sworn to before me this2 S   day of f\ \ \   , 2022.

I\ \

®'-L,,J<....>.,Ooewa""-"di®..-..clx.  wc...::k---14	2.026
Notary Public/Expiration Date
(Seal)

ioilwjl	Commission II HH 221883

!	' Notary A- :t Florida

\lllff\. / My Comm. Expir!!SApr 1, 2026
Bonded throu1h National Notary Assn.

CORPORATE OFFICERS
Company Name 

NAME FOR APPLICANT COMPANY	
POSITION OR TITLE	
CORPORATE RESPONSIBILITIES	
INDMDUAL'S RESIDENCE CITY,STATE	
Ke-	1\-nvus: 'DY 5.,-,	.pv-!$ ckvd-	C)l,OY1-e-v	PC(,\r)\e:t-fo., Fl-	
..._;				

				

				

FOR PARENT COMPANY (ifaoolicable)		

				

Pro.vdt e the fioIlowm iwonnatton tior Off,icers of thc aoor,cant company and parent company, ·1rany.

Company Name

CORPORATE STOCKHOLDERS

NAME	

PERCENT OWNED	
BUSINESS RELATIONSHIP TO APPLICANT COMPANY	
INDIVIDUAL'S RESIDENCE CITY, STATE	
N/ 'A				

				

				

				

				

Provide Lhe following infonnation for all persons, partnerships. unincorporated companies, corporations. or any other entities owning I 0% or more of the applicant company stock.

SUPERVISORY PERSONNEL
CompanyName	}\,l.A"\Zt:.	 D1TDY'Ls    SCCc.fiYVJ,  ·	Date  

1-Vb_.;; --+---'2'-DZ..:._?---'=::....- 

What is the experience oflhe key management and supervisory personnel oflhe applicant company for both administration as well as operations? (Attach resumes of key

ersonnel here

INDIVIDUAL'S NAME	YEARS OF DESCRIPTION OF DIRECT JOB	EXPERIENCE IN
PRESENT TITLE	PRESENT POSITION	TOTAL YEARS OF RELATED EXPERIENCE
2.D
\7

	

		

		

		

Company Name

COMPANY OWNED MAJOR EQUIPMENT

(Attach additional sheets if necessary)

QUANTITY	

DESCRIPTION	

CAPACITY	NO. LOCATED IN	
			
FLORIDA	
OTHER	
	5e£	CGfur V\-ec)'-				

					

					

					

					

Insured Copy

Description of Property
TRACTOR 5425 T
LOADER 9048
CT332 COMPACT TRACK LOADER
279c· SKID STEER  LOADER
5lOOt  UTILITY  TRACTOR
2012 SKISTER LOADER W/HULCHER
TRACK LOADER 299
2015 JD 333E SKID STEER LOADER

CONTRACTORS EQUIPMENT SCHEDULE

Year, Make, Model and Serial Number
2005 JD IV5425Sl40103
2008 JD B4L00952
2011 JOHN DEERE T9332TK161851
2011 CATERPILLAR  HBT02263
2013  JD 1LV5100ECDY140575
1T0333DHCBD208301
2011 CAT JSP01662
SN 1T0333EHEFE288723

2012 JOHN DEERE 333D SKID 1T0333DHCBD208301
STEER LOADER

2016 JOHN DEERE SKID STEER MODEL •328 E 2017 JOHN DEERE 26G CONPACT EXCAVATOR W/ BUCKET & AUGER
2017 CATERPILLAR  299D2
2018 JOHN DEERE 333G JOHN DEERE EXCAVATOR MODEL 26G
2018 JOHN DEERE 333G COMPACT TRACK LOADER 2018 JOHN DEERE 333 G COMPACT TRACK LOADER 2017 JOHN DEERE 331G COMPACT TRACT LOADER 2017 JOHN DEERE 331G
COMPACT TRACT LOADER

1T0328EKJGE294870
1FF026GXJGK262193

FD201968 1T0333GKLJF331999
2018 1FF026GXJJK264047
S/Ns 1T0333GKKJF340856 SN: 150333GMLJF338646 SN: 1T0331GKJHF318310 SN: 1T0331GKPHF318322

2019 BRANSON 5220 TRACTOR SN: CPGF00036
BUSH & LOG LOADER

2018 JOHN DEERE 317G COMPACT TRACT LOADER 2019 JOHN DEERE 333G
COMPACT TRACK LOR BASE

SNa 1T0317GJKKJ350662
1T0333GKAKF354599

2018 BOXER 700HD COMPACT	5752
LOADER

2019 JOHN DEERE 3316 COMPACT TRACK LOADER 2020 JOHN DEERE MODEL:
3116 COMPACT TRACK LOADER
2020 BRANSON 35/SC TRACTOR WITH LOADER 2019 JOHN DEERE HODEL:
330G SKID STEER LOADER
2019 JOHN DEERE TRAC
LOADER W/BUCKET 333G

1T0331GKPKF352851
S/N: 1T0331GKPKF352851 FJ7H00001 1T0330GKVKF346225
1T0333GMKLF386823

2020 JOHN DEERE MULCHING	•1TOMH60DJL0000469
HEAD MH60D

2021 JOHN DEERE 333G COMPACT TRACK LOADER 2021 BLUE DIAMOND TREE BOOM

SN: 1T0333GMPMF405161
SN: 109771

Page 2 of 13
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
IM-F-30 (01-15)	Policy Number: 01 8848	Tl'8"88trtlc,n !!ff1:lotivo  Dato: 10-01-2021

STATUS OF CONTRACTS ON HAND
(Attach additional sheets if necessary)
CompMy No,,e	 \z-e< 	 	 SCa-f V\C·	Date	LJ:{?:.--S /-z..oz_-z_. Furnish requested information about all of applicant's active contracts, whether as prime or subcontracts: whether in progress or awarded but not yet started; and regardless of with whom contracted. All amounts to be shown to nearest $1.000. Contractor may consolidate and hst as a single ,tern all contracts which individually do not exceed 3°0 of total active contracts and

Applicant's Uncompleted Amount ns of this Date	

Comolet1on Date	

Owner, Location and Descriotion of Proiecl	Current Contract Amount as
Pnme	Current Contract Amount as
Subcontractor	
Current Amount Sublet to Others	

As Prime Contractor	

As Subcontractor	
Original Contract Date	
Approved Revised Date	
Current Estimate Date	
n -- --	.,,j f" <,
(\Cl.Cl_ 4 4BdS T -	-·1'	s \,t>u.l.115.'it	$-	s 3-1t.1'd11. tO	s'\ 1.2-	$ --	1:>/1'--¼/2..2-		/ z.:z_	
W\ e,.\-ena...	V\ \	--_-<L-
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'-	$  -		$ l .Y>\S,c		y/17?)2-\		<.t.lbC/z.:z..	
C,{_ fv\µ_">J)	s l,14CJ,945tt	---	
$	s 31eZ./¥1'1So	s	--	o/t.z-{ 15	Ct/ct}z	\	5 / 2-!/1.,,-z_	
	
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Subtotal Uncomoletcd Work	s.	('5'01rJ:\,S:	s		
				
Total Uncomoleted	
Work on Hand	Is2.,\5 1					

in total do not exceed 20% of the active total contracts

-	-	-

Company Name

PROJECTS APPLICANT COMPANY COMPLETED TN THE LAST TWO YEARS
(\½7L..e		 LG.ACLScc<.f ,L,VIC.	Date_lf/,_2-£_,_/-=20"'--=z_:'	":-z_=--	

List all projects completed in the last two years for which the contract value individually exceeded 3% of the applicant's annual total work completed for the year the project
was started. IncIudc. m the r1st p.roJects that were stancd carr1er than two years but were compIetcd w1"t1i1.11 the Iast two years.

Project Name/Location	
Final Contract Amount	

Prime or Sub1	
Class1fica11on
of Work Performed	Year Started/ Completed	

Owner	
Name/Location2	Name & Phone Number of Owner's Represmtallve on
this Project3	
6r	?	Phct	,f	1/5t,1,l1&	Pr-iYn-€...	C/,,r-.e	2-02-[	{\	vt.£,,  {
'-\'-1.l- 't!ir-\nl	
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	Pr\Y"fe.	L-a.M({<;o;_p<:	2.C>Z-D	C:..r, .,,.,._,
Y\-ea..,f M	f\.Or.1  I
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Cc,.  , C.,J\.tVL r/	--	64b1-Z:Z(.4t	pr'\	$ca,p-c	2n2-D	n	-	M•-	'Pc=t:¼:- V\"6	v		
								'tY.\- z_"iJ.!ll \ I	
&, ca..,(2.oyuJe +	IIp	U:7'5.S2.1.f,L\I	>f>n	I	rr 1,..&scc,...pe,	2.CJ lct	V	y:>CJ..:::Jt- 'y\ ,. n	V
C\L.l\-3us-u 11	
			I				

							

PROJECTS APPLICANT COMPANY COMPLETED IN URBANIZED AREAS
Company Name	P_	..-,v,F	ra	JD ,\_M_O.

Date

	2-Sw-z--z_	

Project Name/Location	
Final Contract Amount	

Prime or Sub4	
Classification
of Work Performed	Year
Staned/ Completed	

Owner Name/Locations	Name & Phone Number of Owner's Representative on
this Proiect6	
N /J/\-							
7							

							

							

'-  \	'

.._J	)

AFFIDAVIT FOR INDMD UAL

STATE OF FLORIDA

COUNTY OF 	

SS:

	,, being duly sworn, deposes and says that the financial statements contained herein are a true and accurate statement of his/her financial position as of this date, and that the statements and answers to the questions concerning experience contained herein are correct and true as of this date; and that he/she understands that intentional inclusion of false, deceptive or fraudulent statements on this application constitutes fraud; and, that the District considers such action on the part of the applicant to constitute good cause for denial, suspension or revocation of a certificate of qualification for bidding on LAUREL ROAD COMMUNITY DEVELOPMENT DISTRJCT projects.

(Applicant must also sign here)

Sworn to before me this 	dayof 	,2022.

Notary Public/Expiration Date:

(SEAL)

AFFIDAVIT FOR PARTNERSHIP

STATE OF FLORIDA

COUNTY OF 	

SS:

		, is a member of the firm of 	 being duly sworn, deposes and says that the foregoing financial statements are a true and accurate statement of the financial position of said firm as of this date, and that the statements and answers to the questions of the foregoing
experience questionnaire are correct and true as of the date of this affidavit; and, that he/she understands that
intentional inclusion of false, deceptive or fraudulent statements on this application constitutes fraud; and, that the District considers such action on the part of the applicant to constitute good cause for denial, suspension or revocation of a certificate of qualification for bidding on LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT projects.

(Signature of a General Partner is Required)

Sworn to before me this 	day of 	,2022.

Notary Public/Expiration Date:

(SEAL)

AFFIDAVIT FOR CORPORATION

+-e

STATE OF FLORIDA
COUNTY OF  YY\ Cl....V\0...... 

(titl_e) -::'--i.:: ""'-' ..::z...>.....:..,,-----.-------.-----::----==--------------
ofthe	1	1

(a corporation described herein) being uly sworn, deposes and says that he/she is familiar with the books of the said corporation showing its financial position; that the foregoing financial statements are a true and accurate statement of the financial position of said corporation as of this date; and, that the statements and answers to the questions in the foregoing concerning experience are correct and true as of the date of this affidavit; and, that he/she understands that intentional inclusion of false, deceptive or fraudulent statements in this application constitutes fraud; and, that the District considers such action on the part of the applicant to constitute good cause for denial, suspension or revocation of a certificate of qualification for bidding on LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT projects.

CORPORATE SEAL

Sworn to before me this 2S4YI day of f\Q(\ \   , 2022.

otary	Iricl2

_,0,U
Public/Expiration Date:

f. '4ii,_\ Plotary Public • State of Florida

•:.t.,ii,·•·•...

ALAPIA HEDRICK

1"•'i!, My Comm. Expires Apr 1, 2026

Commission# HH 221883

.	Bonded throogh Plattonal Notary Assn.

(SEAL)

SWORN STATEMENT UNDER SECTION 287.133(3)(a), FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES

THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS.

I.	This sworn statement is submitted to LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT

for Prequalification of Landscape/Hardscape Contractors.
This sworn statement is submitted by	{'v\.,uLe_.

UtM&	

whose business address is

<211

15

<Y'1

, [	eqEfntityr5ubmittin

CCL

Q·'PY\.."6

:t-w<plt1:;	¾34  2,(

and (if applicable) its Federal Employer Identification Number (FEIN) is	59 - 2...'4  {o z -z(_ 

(If the entity has no FEIN, mclude the Social Security Number of the indiv1dual signing this

My name is ---' '--....:::....-...:......l_ ...::...-.,_._...:...........:....:::..._....:....._.,... ---+	 anmy drelationship to the
entity named above is   0=-_..:. ------1-	;_---'---=-_._"'-"-=-----'-'---------
I understand that a "public entity crime" as defined in Paragraph 287.133( l )(g). Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with tbe United States, including, but not limited to. any bid or contract for goods or services to be provided to any public entity or an agency or political subdivision of any other state or of the United States and involving antitrust. fraud, theft, bribery. collusion, racketeering, conspiracy, or material misrepresentation.

I understand that "convicted" or "conviction" as defined m Paragraph 287.133( I)lb), Flonda Statutes, means a finding of guilt or a conviction of a public entity crune. with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or inforn,ation after July I. 1989, as a result of jury verdict, nonjury trial, or entry of a plea of guilty or nolo contcndcrc.

I understand that an "affiliate" as defined in Paragraph 287. I33( I )(a). Florida Statutes, means:

A predecessor or successor of a person convicted of a public entity crime; or,

An entity under the control of any natural person who is acll\ e in the management of the entity and who has been convicted of a public entity crime. The tenn "affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active m the management ofan affiliate. The ownership by one person of shares constituting a controlling interest in another person. or a pooling of equipment or income among persons when not for fair market value under an arm's length agreement, shall be a prima facic case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted ofa public entity crime m Florida during the preceding 36 months shall be considered an affiliate.

I understand that a "person" as defined in Paragraph 287.133( I )(e), Flonda Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or appHes to transact business with a public entity. The term "person" includes those officers, directors. executives, partners, shareholders, employees. members. and agents who are active in management of an entity.

Based on information and belief. the statement which I have marked belo\\ is 1rue m rela1ion to the entity submitting this sworn statement. (Please indicate which statement applies.)

Neither the entity submitting this sworn statement, nor any officers, directors, executives, partners, shareholders, employees, members, or agents who are active in management of the entity, nor any affiliate of the entity, have been charged with and convicted of a public entity crime subsequent to July I, 1989.

The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, members or agents who are active in management of the entity or an affiliate of the entity, has been charged with and convicted of a public entity crime subsequent to July I, 1989, AND (please indicate which additional statement applies):

There has been a proceeding concerning the conviction before an Administrative Law Judge of the State of Florida, Division of Administrative Hearings. The final order entered by the Administrative Law Judge did not place the person or affiliate on the convicted vendor list. (Please attach a copy of the final order.)

The person or affiliate was placed on the convicted vendor list. There has been a subsequent proceeding before an Administrative Law Judgeof the State of Florida, Division of Administrative Hearings. The final order entered by the Administrative Law Judge determined that it was in the public interest to remove the person or affiliate from the convicted vendor list. (Please attach a copy of the final order.)

The person or affiliate hasnot been placed on the convicted v n taken by or pending with the Florida Department of Management Se

STATEOF Pl
COUNTY OF  '{V\J	
PERSONALY APPEARED BEFORE ME, the undersigned authority, 	_
		 '"""¥. h	 ?5 who, after first being sworn by me, affixed his/her signature in the space (name of individual signing)

provided above on this _ _.].;.--=:;..5---... 

day of  f\µ(:\ \	2022.

My commission expires:	y I \ l 2...a 26

LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT CONTRACTOR CLASSIFICATION LISTING

I.	Landscape

Hardscape

DETERMl1'ATIO  OF QUALIFIED PROSPECTIVE BIDDER

The LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT ("District") is authorized to maintain a list of qualified contractors ("Prospective Bidders") to submit bids for the procurement of District landscape,bardscape projects. Any Prospective Bidder desiring to submit a bid to provide work for the District must submit a properly completed Contractor's Prequalification Statement to the District Engineer for review and evaluation. Submittal of the Contractor's Prequalification Statement shall occur prior to the bidding process.

The District shall evaluate the Prospective Bidder's Prequalilicalion Statement and based on the District's judgment of the mfonnation provided, shall issue in writing to the Prospective Bidder, the District's rating as to the classification(s) of the Work and the maximum Bid dollar amount for which the Prospective Bidder can submit a Bid to the District.

The Prospective Bidder acknowledges the right of the District to determine the Prospective Bidder to be not qualified to submit a Bid in response to the District's Advertisement for Bids at the sole determination of the District for. but not necessarily limited to, any of the following specific reasons:
Failure to submit a properly completed Prospective Bidder's Prequalificahon Statement in accordance with the above requirements;
Failure of the Prospective Bidder's rating by the District as to classification of the Work and the maximum Bid dollar amount to meet the requirements of the Bid;
Reason to believe that collusion exists among Bidders;
Determination of lack of competency as may be revealed by qualification statements. financial statements. experience records, or other sources;
The Prospective Bidder's uncompleted work load which, in the Judgment of the Distnct Engineer, may cause detrimental impact on timely completion of the project being bid;
The Prospective Bidder's Surety is unacceptable to District.

A qualified Prospective Bidder shall mean a Prospective Bidder which in the sole judgment of the District has the capability, in all respects, to perfonn fully the contract requirements. and the business integrity and reliability which
will assure good faith perfonnance. In detennining the Prospective Bidder's qualifications, the following criteria will be considered:

The ability, capacity, and skill of the Prospective Bidder to perfonn the contract or provide the work required;

Whether the Prospective Bidder can perform the contract or provide the work promptly. or within the time specified, without delay or interference;

The character, integrity, reputation, judgment, experience, and efficiency of the Prospective Bidder;

The quality of performance of previous contract or work. For example, the following mformat1on will be considered:

The cost overrun incurred by owners on previous contracts with Prospective Bidder;

The Prospective Bidder's compliance record with contract general conditions on other projects;

The Prospective Bidder's record for completion of the work within the Contract Time or within Contract Milestones and Bidder's compliance with scheduling and coordination requirements on other proJects:
The quality, availab1hty, and adaptability of the goods or work to the parncular use required;

The Prospective Bidder's demonstrated cooperatton with owners. architects, engineers. and others on previous contracts; and,
Whether the work performed and materials furnished on other contracts were m accordance with the Contract Documents.
Whether Contractor has performed previous work for an independent special district.

The previous and existing compliance by the Prospective Bidder with laws and ordinances relating to contracts or work;
The sufficiency of the financial resources and ability of the Prospective Bidder to perform the contract or provide the work:
The ability of the Prospective Bidder to fulfill its guarantee and warranty period;

Such other information as may be secured by the D1stnct Engineer havmg a bearing on the decision to award a contract to include, but not be limited to:
The ability, experience, and commitment of the Prospective Bidder to properly and reasonably plan, schedule. coordinate, and execute the work; and,
Whether the Prospective Bidder has ever been debarred from bidding or found ineligible for bidding on any other projects.
The District will make such inquiries and investigations as deemed necessary to verify and evaluate the applicant's statements regarding:
The necessary organization and management including landscape/hardscape experience possessed by the applicant's employees;
Adequate equipment, as shown on the equipment list, to perform nonnal landscape/hardscape operations for each class of work in the industry such as that called for in the Contract Documents in force at the time of application.

LAUREL ROAD
COMMUNITY DEVELOPMENT DISTRICT

9

1	MINUTES OF MEETING
2
LAUREL ROAD COMMUNITY DEVELOPMENT DISTRICT
BOARD OF SUPERVISORS MEETING
Wednesday, May 11, 2022, at 12:15 p.m.
5800 Lakewood Ranch Blvd,
Sarasota, FL 34240
8
9	Board Members present at roll call:
10
11	Pete Williams	Chairperson
12	John Leinaweaver	Vice Chairperson
13	John Blakley	Assistant Secretary
14	Janice Snow	Assistant Secretary
15
16	Also present at roll call via speakerphone or in-person:
17
18	Vivian Carvalho	District Manager-PFM Group Consulting LLC
19	Amanda Lane	Assistant Chief District Accountant-PFM Group Consulting

	LLC		
Ed Vogler	District Counsel- Vogler Ashton	(via phone)	
Shawn Leins	District Engineer- AM Engineering	(via phone)	
Bobbi Claybrooke	District Engineer- AM Engineering	(via phone)	
Tom Panaseny	Neal Communities	(via phone)	
Jim Schier	Neal Communities		
John McKay	J.H. McKay, LLC		
Pam Curran	Neal Communities		
Chuck Adams	Wrathell, Hunt and Associates, LLC		

20
21
22
23
24
25
26
27
28
29
30	FIRST ORDER OF BUSINESS	Administrative Matters
31
32	Call to Order and Roll Call
33
34	The Board of Supervisors’ Meeting for Laurel Road CDD was called to order at 1:20 p.m.
35	Ms. Carvalho proceeded with roll call and confirmed quorum to proceed with the meeting.
36	Those in attendance are outlined above either in person or via speakerphone.
37
38	Public Comment Period
39
40	There were no members of the public present.
41
42

43	SECOND ORDER OF BUSINESS	Business Matters
44
45	Consideration of the Minutes of
46	the April 13, 2022, Board of
47	Supervisors’ Meeting
48
49	The Board reviewed the Minutes from the March 9, 2022, Board of Supervisors’ Meeting.
50

ON MOTION by Mr. Williams, seconded by Mr. Leinaweaver, with all in favor, the Board approved the Minutes of the April 13th, 2022, Board of Supervisors’ Meeting.

51
52
53
54
55
56
57	Consideration of Resolution 2022-
58	08, Approving a Preliminary
59	Budget for Fiscal Year 2023 and
60	Setting a Public Hearing Date
61	[Suggested Hearing Date of
62	August 10, 2022]
63
64	Ms. Carvalho explained that there were significant changes to the proposed budget. In
65	speaking with the developer, there were various areas that were coming online.
66

ON MOTION by Mr. Williams, seconded by Ms. Snow with all in favor, the Board approved the Preliminary Budget for Fiscal Year 2023 and Setting a Public Hearing Date for August 10, 2022 at 12:00PM.

67
68
69
70
71
72
73	Consideration of Resolution 2022-
74	09, Designating Date, Time, and
75	Location for Landowners Meeting
76
77	Ms. Carvalho suggested the date to conduct the Landowners Meeting for November 8,
78	2022, at 12:00 p.m.
79

ON MOTION by Mr. Williams, seconded by Mr. Leinaweaver, with all in favor, the Board approved Designating Date, Time, and Location for Landowners Meeting for November 8, 2022 at 12:00PM at this location.

80
81
82
83
84
85
86
87	Letter from Supervisor of
88	Elections, Sarasota County
89
90	Ms. Carvalho suggested a motion to accept the Letter from Supervisor Elections.
91
92

ON MOTION by Mr. Williams, seconded by Mr. Blakley, with all in favor, the Board approved the Letter from Supervisor of Elections, Sarasota County.

93
94
95
96
97
98
99
100	Consideration of Landscape
101	Contractors RFQ
102
Ms. Claybrooke stated that they have submitted an advertisement and initially received
no responses and later submitted the advertisement again on May 9. They will come
back in June with recommendations based on the resubmittal.
106
107
108	Review and Consideration of the
109	Stormwater Needs Analysis
110	Report
111
112	Ms. Carvalho suggested a motion to approve the Analysis Report proposal.
113

ON MOTION by Mr. Williams, seconded by Ms. Snow, with all in favor, the Board approved the Stormwater Needs Analysis Report proposal.

114
115
116
117
118
119
120
121	Ratification of Funding Request
122	No. 73
123
124	Ms. Carvalho suggested a motion to approve the Funding Request No.73.
125

ON MOTION by Mr. Williams, seconded by Mr. Blakley, with all in favor, the Board approved the Funding Request No. 73.

126
127
128
129
130
131
132	Review of District Financial
133	Statements
134
135	Ms. Carvalho suggested a motion to approve the District Financial Statements through
136	March 31, 2022.
137

ON MOTION by Mr. Williams, seconded by Mr. Leinaweaver, with all in favor, the Board accepted the District Financial Statements.

138
139
140
141
142
143

144
145	THIRD ORDER OF BUSINESS	Other Business
146
147	Staff Reports
148
149	District Counsel –	No Report
150
151	District Engineer –	No Report
152
District Manager –	Ms. Carvalho stated that the tax collector agreement did not get
included on the agenda but it is a standard agreement with Sarasota County Tax Collector
to utilize the tax authority for the CDD assessments.	Ms. Carvalho suggested a motion
to approve.
157

ON MOTION by Mr. Williams, seconded by Mr. Leinaweaver, with all in favor, the Board approve the filing of the Sarasota County Tax Collector Agreement.

158
159
160
161
162
163
Ms. Carvalho stated for the record the next scheduled meeting is June 8, 2022, at 12:00
p.m. Ms. Claybrooke stated she will need the reports for Stormwater and Wastewater
Needs by or before the next scheduled meeting if they have to be approved and submitted
by June 30, 2022.
168
169	Audience Comments and
170	Supervisor Requests
171
172	There were no audience comments or supervisor requests.
173
174	FOURTH ORDER OF BUSINESS	Continuance
175
176	There were no other questions or comments.
177

ON MOTION by Mr. Williams, seconded by Mr. Blakley, with all in favor, the May 11, 2022, Board of Supervisors’ Meeting for the Laurel Road Community Development District at 1:27 p.m. was continued to May 24, 2022, at 12:00 p.m. at this location.

178
179
180
181
182
183
184
185
186
	 		 	
Secretary / Assistant Secretary	Chairperson / Vice Chairperson

LAUREL ROAD
COMMUNITY DEVELOPMENT DISTRICT

10C

Laurel Road Community Development District	
	
BOARD OF SUPERVISORS FISCAL YEAR 2021/2022 MEETING SCHEDULE	
	
LOCATION
5800 Lakewood Ranch Boulevard, Sarasota, Florida 34240	
	
DATE	POTENTIAL DISCUSSION/FOCUS	TIME	
			
October 13, 2021	Regular Meeting	12:15 PM	
			
November 10, 2021	Regular Meeting	12:15 PM	
			
November 18, 2021	Special Meeting	11:00 AM	
			
December 8, 2021	Regular Meeting	12:15 PM	
			
December 16, 2021	Continued Meeting	11:00 AM	
			
January 12, 2022	Regular Meeting	12:15 PM	
			
February 9, 2022	Regular Meeting	12:15 PM	
			
March 9, 2022	Regular Meeting	12:15 PM	
			
April 13, 2022	Regular Meeting	12:15 PM	
			
May 11, 2022	Regular Meeting	12:15 PM	
			
May 24, 2022 CANCELED	Continued Meeting	12:00 PM	
			
June 8, 2022	Regular Meeting	12:00 PM	
			
July 13, 2022	Regular Meeting	12:00 PM	
			
August 10, 2022	Regular Meeting	12:00 PM	
			
September 14, 2022	Regular Meeting	12:00 PM