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HomeMy WebLinkAboutItem # 6 CDBG SB821 - Exhibit B ProposalCITY OF LAKE ELSINORE CIP Project No. Z10010 & Z10041 BIDDER'S PROPOSAL CDBG & SB821 SIDEWALK IMPROVEMENTS NIB NO. (CIP PROJECT NO. Z10010 & Z10041) Company: ]) 9�� � C cv/-'os I Honorable Mayor, Members of the Council: In accordance with the Notice Inviting Bids pertaining to the receiving of sealed proposals by the City Clerk of the City of Lake Elsinore for the above titled improvement, the undersigned hereby proposes to furnish all Work to be performed in accordance with the Specifications, Standard Drawings, and the Contract Documents, for the unit price or lump sum set forth in the following schedule: Time of Completion: Twenty-five (25) Working Days from Issuance of Notice to Proceed (NTP) by City to Contractor. BID SCHEDULE ITEM NO. DESCRIPTION OF ITEMS UNIT ESTIMATED QUANTITY UNIT PRICE AMOUNT 1 Mobilization LS 1 Or �G � o0 2 Temporary Traffic Control LS 1 3 Storm Water and Non -Storm Water Pollution Control LS 1 -3000 4 I Temporary Project Identification Sign EA 4 -)000 5 Sawcut Exist. AC Pavement LF 2626 35- 61-7/1 6 Grinding AC in Place SF 5252 Ayj �i 7 Remove AC Pavement SF 7552 1 "S 3 8 Remove Curb & Gutter LF 333 �p -19131 9 Remove AC Dike LF 1241 3 f1/ J a 10 Relocate Mailbox EA 4 100 r/ 0 11 Construct 4" Asphalt Concrete TN 175 12 Construct 6" Class 11 Aggregate Base CY 135 13 Asphalt Concrete Overlay (.10') TN 38 tri VVO 14 Construct Curb & Gutter (Type 6) LF 2286 L 3 15 Construct Curb & Gutter (Type 8) LF 17 / , �,5 32.3 16 Construct Curb (Type 6A) LF 192 ( It.. C0 �� 7 -E� 17 Remove PCC Spandrel sF 476 L( 00 if 5,0 Y C-1 CITY OF LAKE ELSINORE CIP Project No. Z10010 & Z10041 18 Construct PCC Spandrel SF 476 8 e 00 (� 19 Construct PCC Sidewalk SF 10327 20 Construct PCC Drive Approach SF 2818 , a5- 17, (6 / 21 Construct ADA Curb Ramp EA 6 V 0 dV, f oo 22 ADA Ramp Truncated Dome Unit EA 2 L(-5'0 q. 00 23 Relocate Wood Fence LF 40 30 1, Z ©o 24 Relocation Roadside Sign EA 9 25 Adjust Water Valve to Grade EA 10 _75- 26 26 Adjust M.H. to Grade EA 1 0 27 Remove Concrete SF 3318 Z ?_ ` 28 Remove Tree/Large Shrub EA 7 - 'T15- 51 0 a� 29 Construct Masonry Garden Wall (2' High) SF 22 j U (� {'r p 30 Remove Masonry Garden Wall (2' High) SF 26 31 Sawcut Exis. Concrete Pavement (4 Thick) LF 392 32 Construct Concrete Step LS 1 k, 'yo .5-0 33 Minor Grading/Excavation LS 1 �-(c�t.00,7 K•f1s�f� 34 Construct AC Berm Transition LF 5 70 35 Construct Private PCC Driveway SF 407 �(, (� '77b7 36 Construct Private AC Driveway (4" Thick, 84 TN 2 "Z Z L`'<_0 37 Remove PCC Curb LF 118 Total Bid Price (Based on estimated quantities of Items 1 through 37) ,. C Note: Estimated quantities are for the purpose of Bid comparison only-, payments will be made on the basis of actual measurement of Work completed, except for lump sum (LS) and final pay (F) quantities. (S) denotes a specialty item. The Bid Price shall include, but not be limited to, sales tax and all other applicable taxes and fees. Total Bid: 3'11y -7 Total Bid: e (Figures*) 'BID MAY BE REJECTED IF TOTAL IS NOT SHOWN FOR BOTH FIGUIRES AND WORDS. C-2 CITY OF LAKE ELSINORE CIP Project No. Z10010 & Z10041 The undersigned agrees to enter into and execute a contract, with necessary bonds, at the unit prices set forth herein and in case of default in executing such contract, with necessary bonds, the check or bond accompanying this bid and the money payable thereon shall be forfeited thereby to and remain the property of the City of Lake Elsinore. The above unit prices include all work appurtenant to the various items as outlined in the Specifications and all work or expense required for the satisfactory completion of said items. In case of discrepancies between unit prices and totals, the unit prices shall govern. The undersigned declares that it has carefully examined the Plans, Specifications, and Contract Documents, and has investigated the site of the work and is familiar with the conditions thereon. Date: 1 I- VC -\(.o Contractor's State License No.: Q g116119 Class: IN 4 `$ LM C 6y-v�T _ Contractor Department of Industrial Relations Registration No. t 00000. e�', ) Registration Date: b- t3 Zo, Expiration Date: 6-� 3-o 2•:, u Address: _q5i Ste, 4- C Phone: -I I�,--t- `2(",L1- (S \- \ FAX: SGG . 38 3 . C-3 CITY OF LAKE ELSINORE CI Project No. Z10010 & Z10041 ACKNOWLEDGMENT OF ADDENDA RECEIVED CDBG & SB821 SIDEWALK IMPROVEMENTS NIB NO. - (CIP PROJECT NO. Z10010 & Z10041) The Bidder shall acknowledge the receipt of addenda by placing an "X" by each addendum received. Addendum No. 1 Addendum No. 2 Addendum No. 3 Addendum No. 4 If an addendum or addenda have been issued by the City and not noted above as being received by the Bidder, the Bid Proposal may be rejected. Bidder's 9 natl� v=:► 1 Print Name M lt`Ic��l Date Title CITY OF LAKE ELSINORE CIP Project No. Z10010 & Z10041 NON -COLLUSIpj�.AFFIDAVIT CDBG & SB821 SIDEWALK IMPROVEMENTS NIB NO. (CIP PROJECT NO. 210010 & Z10041) STATE OF CALIFORNIA ) SS COUNTY OF !� ) (NAME) affiant being first duly sworn, deposes and says: That he OF Sh is ' ~+ CQL Y -,r\ 4-,-\ (\. r'1 of (sole owner, partner rh other proper title) RiLtk Cot\,,,--\. , _ the party making the foregoing Bid, that the Bid is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation; that the Bid is genuine and not collusive or sham; that the Bidder has not directly or indirectly induced or solicited any other Bidder to put in a false or sham Bid, and has not directly or indirectly colluded, conspired, connived, or agreed with any Bidder or anyone else to put in a sham Bid, or that anyone shall refrain from bidding; that the Bidder has not in any manner, directly or indirectly sought by agreement, communication, or conference with anyone to fix the bid price of the Bidder or any other Bidder, or to fix any overhead, profit, or cost element of the bid price, or of that of any other Bidder, or to secure any advantage against the public body awarding the Contract of anyone interested in the proposed Contract; that all statements contained in the Bid are true; and, further; that the Bidder has not, directly or indirectly, submitted his or her bid price or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, or paid, and will not pay, any fee to any corporation, partnership, company associations, organization, bid depository, or to any member or agent thereof to effectuate a collusive or sham Bid. (Public Contract Code Section 7106) Address: I,. t S N' sT '�-C e, ,, d�, q 22LI Telephone No : —1 L4 ' �4 , G'S_ Print Nani-a 1 ci_t'A Q7t E -L) r� Signature: Title:�► Uv �1 Y� .} Date: SIGNING INSTRUCTIONS TO THE CONTRACTOR Non -Collusion Affidavit must be accompanied by notary certificates for signature. Note the description of the document on the notary certificate. Attach natary certificate immediately following this a e. If the Bidder fails to properly sign or omits the required signature, the bid will be considered non-responsive and will be rejected. C-5 SQ L. ctNax t -"A C a1. �� . A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of Otter t - Subscribed and sworn to (or firmed) before me on this day of 20 6. , by Ayll- 13 ce vt,.) I proved to me on the basis of satisfactory evidence to be the person(sl who appeared before me. ARA C.'OGLE + conTisol n • 2116955 4WNY Public - CIM611116 Comn1. £ Iles Ju126 19 (Seal} Signature CITY OF LAKE ELSINORE CIP Project No. Z10010 & Z10041 BOND NO. N/A BIDDER'S BOND CDBG & SB821 SIDEWALK IMPROVEMENTS NIB NO. (CIP PROJECT NO. Z10010 & Z10041) KNOW ALL MEN OR WOMEN BY THESE PRESENTS: That we Black Rock Construction Company . as PRINCIPAL, hereinafter referred to as "Contractor", and Philadelphia Indemnity Insurance Company a duly authorized corporate as "Surety," are held and firmly bound unto the City of Lake Elsinore in the penal sum of TEN PERCENT (10%) OF THE TOTAL AMOUNT OF THE BID of the Contractor above named, submitted by said Contractor to the City of Lake Elsinore for the work for said project entitled above, for the payment of which sum in lawful money of the United States, well and truly to be made, to the City of Lake Elsinore to which said bid was submitted, we bind ourselves, our heirs, executors, administrators and successors, jointly and severally, firmly by these presents. In no case shall the liability of the surety hereunder exceed the amount of 10% of the Bid Amount THE CONDITION OF THIS OBLIGATION IS SUCH That whereas the Contractor has submitted the above-mentioned Bid to the City of Lake Elsinore as aforesaid for the work for said project entitled above. NOW, THEREFORE, if the aforesaid Contractor is awarded the Contract and, within the time and manner required under the Contract documents, after the prescribed forms are presented to him or her for signature, enters into a written Agreement in the prescribed form and in accordance with the Contract documents, and files two bonds with the City of Lake Elsinore, one to guarantee faithful performance and the other to guarantee payment for labor and materials, in accordance with said Contract documents, and as required by law, and files the required insurance certificate(s) in accordance with said Contract documents, then this obligation shall be null and void; otherwise, it shall be and remain in full force and effect until execution of the Agreement or forfeiture pursuant to the Provisions of Sections 20172 and 20174 of the Public Contract Code. In the event suit is brought upon this bond by the City and judgment is recovered, the Surety shall pay all costs incurred by the City in such suit, including a reasonable attorney fee to be fixed by the court. (SIGNATURE PAGE FOLLOWS) ME CITY OF LAKE ELSINORE CIP Project No. Z10010 & Z10041 BIDDER'S BOND SIGNATURE PAGE CDBG & SB821 SIDEWALK IMPROVEMENTS NIB NO. (CIP PROJECT NO. Z10010 & Z10041) IN WITNESS WHEREOF, we have hereunto set our hands and seals on this 9th day of November 2016 F-SUNTRY: CORPORATE SURETY: Contractor Name: Black Rock Construction Company Company Name: Philadelphia Indemnity Insurance Company Address: 615 N. Berry St., Suite G Brea, CA 92821 Telephone No.: (909) 393-2000 Print Name: Bill Goshen, Jr. Title: Vice President Signature: X-1 z Date: November 9, 2016 Address: 251 S, Lake Ave., Suite 360 Pasadena, CA 91101 Telephone No., (626) 639-1320 Print Name: Shane Wolf Title: Attorney -in -Fact Signature: . Date: November 9, 2016 SIGNING INSTRUCTIONS TO THE CONTRACTOR Bidder's Bond must be accompanied by notary certificates for EACH signature. Note the description of the document on the notary certificate. Attach BOTH notary certificates immediately following this page. Corporate Seal may be affixed hereto. The attorney-in-fact for corporate surety must be registered, as such, in at least one county in the State of California. Attach one original Power of Attorney immediately following the notary certificates. If the Bidder fails to properly sign or omits the required signatures, the bid will be considered non-responsive and will be rejected. C-7 ALL- PURPOSE CERTIFICATE OF ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California } County of Orange } On // 4 /(o before me, Beata A. Sensi, Notary Public , ere insert name andttit e of the officer personally appeared Bill Goshen, Jr. who proved to me on the basis of satisfactory evidence to be the person(e) whose name(e) is/ate subscribed to the within instrument and acknowledged to me that he/&he4P,ey executed the same in his/he4t4& authorized capacity(a&), and that by his/hef4he signature(&) on the instrument the person(e), or the entity upon behalf of which the person(,-) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. BE.4TA A. SENSI -"' COMM.#oas12sWITNESS my hand ad official seal. - c {s7 NOTARY PUBLIC a CALWORNIA ORANGE My Comrn. Expires Dec. 14, 20170 Not ry P lic Signature (Notary Public Seal) ADDITIONAL OPTIONAL INFORMATION DESCRIPTION OF THE ATTACHED DOCUMENT 6011 CL r. lcc %eOG` (Title or description of attached document) Black Rock Construction Company (Title or description of attached document continued) Number of Pages -1 Document Date / /g 14 CAPACITY CLAIMED BY THE SIGNER ❑ Individual (s) 0 Corporate Officer Vice President (Title) ❑ Partner(s) ❑ Attorney -in -Fact C Trustee(s) ❑ Other 2015 Version %uwvv iNotaryClasses.eom 800-873-9855 INSTRUCTIONS FOR COMPLETING THIS FORM This farm complies with current California statutes regarding notary wording and, if needed, should be completed and attached to the document. Acknolwedgents from other states may be completed for documents being sent to that stale so long as the wording does not require the California notary to violate California notary law. • State and County information must be the State and County where the document signer(s) personally appeared before the notary public for acknowledgment. • Date of notarization must be the date that the signer(s) personally appeared which must also be the same date the acknowledgment is completed. • The notary public must print his or her name as it appears within his or her commission followed by a comma and then your title (notary public). • Print the name(s) of document signer(s) who personally appear at the time of notarization. • Indicate the correct singular or plural forms by crossing off incorrect forms (i,e. Ise/she/they, is /are ) or circling the correct forms. Failure to correctly indicate this information may lead to rejection of document recording. • The notary seal impression must be clear and photographically reproducible. Impression must not cover tent or lines. If seal impression smudges, re -seal if a sufficient area permits, otherwise complete a different acknowledgment form. • Signature of the notary public must match the signature on file with the office of the county clerk. Additional information is not required but could help to ensure this acknowledgment is not misused or attached to a different document, Indicate title or type of attached document, number of pages and date. Indicate the capacity claimed by the signer_ If the claimed capacity is a corporate officer, indicate the title (i.e. CEO, CFO, Secretary). • Securely attach this document to the signed document with a staple ALL- PURPOSE CERTIFICATE OF ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of Orange } On November 9, 2916 before me, Susan E. Morales, Nota!x Public ere Inser: narna and 6110 or Me anuiiQq personally appeared Shane Wolf who proved to me on the basis of satisfactory evidence to be the persons} whose name(e) is/.am subscribed to the within instrument and acknowledged to me that hem executed the same in his!her/their authorized capacity6es), and that by his/heFAhei signature(e) on the instrument the person(s), or the entity upon behalf of which the person(&) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. SUSAN E. MORALES WITNESS my hand and official seal. ; ; COMM. # 2101798 z NOTARY PUBLIC - GALIFORALIFaRNIA r Z i#r ' ORANGE COUNTY My Comm. Expires March 28,IL4 cc mor�� — Am 2019 Notary Public Signature (Notary Public Seal) ADDITIONAL OPTIONAL INFORMATION DESCRIPTION OF THE ATTACHED DOCUMENT Bid Bond, Black Rock, Lake Elsinore (Titre or description of attached document) Philadelphia Indemnity Insurance Co (Title or description of attached document continued) Number of Pages 2 Document Date 11/9/16 CAPACITY CLAIMED BY THE SIGNER ❑ Individual (s) ❑ Corporate Officer (Title) ❑ Partner(s) 71 Attorney -in -Fact ❑ Trustee(s) ❑ Other 2015 Version www.NotaryClasses.com 600-873-9865 INSTRUCTIONS FOR COMPLETING THIS FORM This form complies with current California statutes regarding notary wording and, if needed, should be completed and attached to the document. Acknohvedgents from other states may be completed for documents being sent to that state so long as the wording does not require the California notary to violate California notary law. • State and County information must be the State and County where the document signer(s) personally appeared before the notary public for acknowledgment, • Date of notarization must be the date that the signer(s) personally appeared which must also be the same date the acknowledgment is completed. • The notary public must print his or her name as it appears within his or her commission followed by a comma and then your title (notary public). • Print the name(s) of document signer(s) who personally appear at the time of notarization. • Indicate the correct singular or plural forms by crossing off incorrect forms (i.e. he/she/they is /are ) or circling the correct forms. Failure to correctly indicate this information may lead to rejection of document recording. • The notary seal impression must be clear and photographically reproducible. Impression must not cover text or lines. If seal impression smudges, re -seal if a sufficient area permits, otherwise complete a different acknowledgment form. • Signature of the notary public must match the signature on file with the office of the county clerk Additional information is not required but could help to ensure this acknowledgment is not misused or attached to a different document. Indicate title or type of attached document, number of pages and date. Indicate the capacity claimed by the signer. If the claimed capacity is a corporate officer, indicate the title (i.e. CEO, CFO, Secretary). • Securely attach this document to the signed document with a staple. IMeI:9 : PHILADELPHIA INDEMNITY INSURANCE COMPANY 231 St, Asaph's Rd., Suite 100 Bala Cynwyd, PA 19004-0950 Power of Attorney KNOW ALL PERSONS BY THESE PRESENTS. That PHILADELPHIA INDEMNITY INSURANCE COMPANY (the Company), a corporation organized and existing under the laws of the Commonwealth of Pennsylvania, does hereby constitute and appoint Todd M. Rohm, Shane Wolf, Cheryl L. Thomas and Beata A. Sensi of Rohm Insurance Agency, its true and lawful Attorney -in -Fact with full authority to execute on its behalf bonds, undertakings, reeognizancros and other contracts of indemnity and writings obligatory in the nature thereof, issued in the course of its business and to bind the Company thereby, in an amount not to exceed S25,000,000.0n. This Power of Attorney is granted and is signed and sealed by facsimile under and by the authority of the following Resolution adopted by the Board of Directors of PHILADELPHIA INDEMNIIY INSURANCE. COMPANY at a meeting duly called the I' day ofJuly, 2011 RESOLVED: That the Board oFDirectors hereby authorizes the President or any Vice President of the Company to: (t) Appoint Attorney(s) in Fact and authorize the Attorneys) in Fact to execute on behalf of the Company bonds and undertakings, contracts of indemnity and other writings obligatory in the nature thereof and to attach the seal of the Company thereto; and (2) to remove, at any time, any such Attorney -in -Fact and revoke the authority given, And, be it FURTHER RESOLVED: That the signatures of such officers and the seal of the Company may be affixed to any such Power of Attorney or certificate relating thereto by facsimile, and any such Power of Attorney so executed and certi0ed by facsimile signatures and facsimile seal shall be valid and biding upon the Company in the future with the respect to any bond or undertaking to which it is attached. IN TESTIMONY WHEREOF, PHILADELPHIA INDEMNITY INSURANCE COMPANY IIAS CAUSE{D'11RS INSTRUMENTTO BE SIGNED AND ITS CORPORATE SEA.um BE AFFIXED BY ITS AUTHORIZEI) OFFICE THIS 10"' DAY OF JUNK 2013. N 1927 96ry%=A (Seal) ""••�..,,a`•'� Robert I). O'Leary Jr., President & CEO Philadelphia Indemnity Insurance Company On this 10°i day of Junc 2013, before me came the individual who executed the preceding instrument, to me personally known, and being by me duly sworn said that he is the therein described and authorized officer of the PHILADELPHIA INDEMNITY INSURANCE COMPANY, that the seat affixed to said instrument is the Corporate seal of said Company; that the said Corporate Seat and his signature were duly affixed. rr►rr4vu+�+�_ fl�rrr sak Kr*" A IrAfteW, "mLay Rif f Ar[• li M16 1 IbrlYlr (Notary Seal) Notary Public: residing at: My commission expires: M I 'F Rata Cynwyd. PA, December 18 2016 t, Edward Sayago, Corporate Secretary of PHII,A DF.I.PFIIA INDEMNITY INSURANCE COMPANY, do herby certify that the foregoing resolution of the Board of Directors and this Power of Attorney issued pursriant thereto on this 10nr day of June 2013 true and correct and are still in fWi force and e1Tec:t. 1 do further certify that Robert 17 O'Leary Jr., who executed the Power of Attorney as President, was on the date of execution of the attached Power of Attorney the duly elected President of PHILADELPHIA INDEMNITY INSURANCE COMPANY, In "restimony Whereof I have subscribed my name and affixed the facsimile seal of each Company this 9th day of November 20 16 •. •1 •.yNk.' y l '"..91T. • . .f L f � S err ,. •• " Vr I gr Edward Sayago, Corporate Secretary Nq� PHILADELPHIA INDEMNITY INSURANCE COMPANY f CITY OF LAKE ELSINORE CIP Project No. Z10010 &Z10041 LIST OF SUBCONTRACTORS CDBG & SB821 SIDEWALK IMPROVEMENTS NIB NO. (CIP PROJECT NO. Z10010 & Z10041) The bidder is required to fill in the following blanks in accordance with the provisions of the Subletting and Subcontracting Fair Practices Act (Chapter 2 of Division 5, Title 1 of the Government Code of the State of California) and should familiarize itself with Sections 2-3 of the Standard Specifications. Name Under Which Subcontractor is Licensed: -y License Number: h ,] '� k '� 0 0 Address of Office, Mill or Shop: +.s �. �� oMA, v f Q Specific Description of Sub -Contract: and Bid Items of Work: a _ Name Under Which Subcontractor is Licensed. r r'Ar - License Number: - Address of Office, Mill or Shop t �' r� ���� �_ �r0-', Specific Description of Sub -Contract: and Bid Items of Work _ ! ''��= }.� , ; Name Under Which Subcontractor is Licensed: License Number: Address of Office, Mill or Shop: Specific Description of Sub -Contract: and Bid Items of Work: Name Under Which Subcontractor is Licensed: License Number: Address of Office, Mill or Shop: Specific Description of Sub -Contract: and Bid Items of Work Subcontractors listed in accordance with the provisions of Section 2-3 must be properly licensed under the laws of the State of California for the type of work that they are to perform. Do not list alternate subcontractors for the same work. C-8 1 2 3 CITY OF LAKE ELSINORE CIP Project No. Z10010 & Z10041 REFERENCES CDBG & SB821 SIDEWALK IMPROVEMENTS NIB NO. (CIP PROJECT NO. Z10010 & Z10041) Failure to demonstrate adequate experience may result in rejection of the bid. For all public agency projects with a similar scope of work which you have worked on (or are currently working on) in the past three (3) years, provide the following required information: Name (Firm/Agency) Cos�'L' � Address ` Project Title Project Location QX7Z 1 Type of Work _2 Co�c� "-,e gJ Project Manager Contact 2,���r\ ti—Phone Dated Completed 2-D,iP Name (Firm/Agency) �- 1 Address Contract Amount 9- Doo rl\ Project Title Project Location n -C— � a 2-"i� % H _C� Type of Work Ick S7' Project Manager Contact Phone Ct`Ack-'4l - Dated Completed Z I ?c', w Contract Amount Name (Firm/Agency) C�_,: '1 c! rz>r t` S rU c_ el(\ Address Project Title t Project Location Type of Work CVq�— ProJect Manager Contact Phone 0, 1-o CLQ c L� Dated Completed '-� ('moo b Contract Amount � Ly—fl, 4q, 0- C-9 CITY OF LAKE ELSINORE CIP Project No. Z10010 & Z10041 List any other projects (private, older than three (3) years, etc.) that may represent qualifying or similar experience: 4. Name (Firm/Agency) Address Project Title —k\ �-- ��1- Q �4 Project Location C -A' k-,_) "C:< - Type aC'Type of Work Project Manager Contact UlA y-, Phone '52 -3'6 3-'I Dated Completed U Contract Amount q'39,R, 5. Name (Firm/Agency) Address Project Title Project Location Type of Work Project Manager Contact Dated Completed 6. Name (Firm/Agency) Address Project Title Project Location Type of Work Project Manager Contact Dated Completed Phone Contract Amount Phone Contract Amount C-10 CITY OF LAKE ELSINORE CIP Project No. Z10010 & Z10041 CONTRACTOR INFORMATION CDBG & SB821 SIDEWALK IMPROVEMENTS NIB NO. (CIP PROJECT NO. Z10010 & Z10041) Contractor's License No.: q -1S7,�)? Class: Z. , '2.. D ( EX �... mal$ a. Date first obtained: piration b. Has License ever been suspended or revoked? If yes, describe when and why: c. Any current claims against License or Bond? If yes, describe claims: -\ O V1\- a Principals in Company _(List all — attach additional sheets if necessary): NAME 1 TITLE V � Ste- ( Tec-, C-11 LICENSE NO. (If Applicable) CITY OF LAKE ELSINORE CIP Project No. Z10010 & Z10041 VIOLATIONS OF FEDERAL, STATE OR LOCAL LAWS CDBG & SB821 SIDEWALK IMPROVEMENTS NIB NO. (CIP PROJECT NO. Z10010 & Z10041) Has your firm or its officers been assessed any penalties by an agency for noncompliance or violations of Federal, State or Local labor laws and/or business or licensing regulations within the past five (5) years relating to your construction projects? YES / (circle one) Federal / State / Local (circle one) If "YES," identify and describe, (including agency and status): Have the penalties been paid? YES / NO (circle one) 2 Does your firm or its officers have any ongoing investigations by any public agency regarding violations of the State Labor Code, California Business and Professions Code or State Licensing Laws? YES 1 Q.` (circle one) Code/Laws: Section/Article: If "yes," identify and describe, (including agency and status)- Signa a Date Print Name Title 'V�1 q Oc- ` 4)c-� C Contractor Name C-12 CITY OF LAKE ELSINORE CIP Project No. Z10010 & Z10041 DISQUALIFICATION OR DEBARMENT CDBG & SB821 SIDEWALK IMPROVEMENTS NIB NO. (CIP PROJECT NO. Z10010 & Z10041) Has your firm, any officer of your firm, or any employee who has a proprietary interest in your firm ever been disqualified, removed, or otherwise prevented from bidding on, performing work on, or completing a federal, state or local project because of a violation of law or a safety regulation? YES /(NO (circle one) If yes, provide the following information (if -more than once, use separate sheets): Date - Location: Reason: Entity: Provide Status and any Supplemental Statement: Has your firm been reinstated by this entity? YES / NO (circle one) Notes: Providing false information may result in criminal prosecution or administrative sanctions. The above certification is part of the Proposal. Signing this Proposal on the signature portion thereof shall also constitute signature of this Certification. V�) V\ � Print Name -160u�-c ��(c Contractor Name C-13 Date \W Title If the Bidder fails to properly sign or omits the required signature, the bid will be considered non-responsive and will be rejected. UTILITY AGREEMENT CDBG & SB821 SIDEWALK IMPROVEMENTS NIB NO. (CIP PROJECT NO. Z10010 & Z10041) HONORABLE MAYOR AND CITY COUNCIL CITY OF LAKE ELSINORE, CALIFORNIA The undersigned hereby promises and agrees that in the performance of the work specified in this contract for Project No. Z10010 & Z10041, CDBG/SB 821 Sidewalk Improvements, (1) (we) (it) will employ and utilize only qualified persons, as hereinafter defined, to work in proximity to any electrical secondary, primary or transmission facilities. The term "Qualified person" is defined in Title 8, California Administrative code, Section 2700, as follows: Qualified Person: A person who by reason of experience or instruction, is familiar with the operation to be performed and the hazards involved." The undersigned also promises and agrees that all such work shall be performed in accordance with all applicable electrical utility company's requirements, Public Utility Commission orders, and State of California Cal -OSHA requirements. The undersigned further promises and agrees that the provisions herein shall be and are binding upon any subcontractor or subcontractors that may be retained or employed by the undersigned, and that the undersigned shall take steps as are necessary to assure compliance by any said subcontractor or subcontractors with the requirements contained herein. ,:5ignatu 11 By: '� �5�1� •-1 Name V '-P Title (?J2CfC �J�c C&r\S1V_ Contractor Name C-14 PUBLIC CONTRACT CODE CDBG & SB821 SIDEWALK IMPROVEMENTS NIB NO. (CIP PROJECT NO. Z10010 & Z10041) Public Contract Code Section 10285.1 Statement In accordance with Public Contract Code Section 10285.1 (Chapter 376, State. 1985), the bidder hereby declares under penalty of perjury under the laws of the State of California that the bidder has has not been convicted within the preceding three years of any offenses referred to in that section, including any charge of fraud, bribery, collusion conspiracy, or any other act in violation of any state or Federal antitrust law in connection with the bidding upon, award of, or performance of, any public works contract, as defined in Public Contract Code Section 1101, with any public entity, as defined in Public Contract Code Section 1100, including the Regents of the University of California or the Trustees of the California State University. The term "bidder" is understood to include any partner; member, officer, director, responsible managing officer, or responsible managing employee thereof, as referred to in Section 10285.1. Note: The bidder must place a check mark after "has" or "has not" in one of the blank spaces provided. The above Statement is part of the Proposal. Signing this Proposal on the signature portion thereof shall also constitute signature of this Statement. Bidders are cautioned that making a false certification may subject the certifier to criminal prosecution. Public Contract Code Section 10162 Questionnaire In accordance with Public Contract Code Section 10162, the Bidder shall complete, under penalty of perjury, the following questionnaire: Has the bidder, any officer of the bidder, or any employee of the bidder who has a proprietary interest in the bidder, ever been disqualified, removed, or otherwise prevented from bidding on, or completing a federal, state, or local government project because of a violation of law or a safety regulation: Yes No If the answer is yes, explain the circumstances in the following space. Public Contract Code 10232 Statement In accordance with Public Contract Code Section 10232, the Contractor, hereby states under penalty of perjury, that no more than one final unappealable finding of contempt of court by a federal court has been issued against the Contractor within the immediate preceding two-year period because of the Contractor's failure to comply with an order of federal court which orders the Contractor to comply with an order of the National Labor Relations Board. Note: The above Statement and Questionnaire are part of the Proposal. Signing this Proposal on the signature portion thereof shall also constitute signature of this Statement and Questionnaire. Bidders are cautioned that making a false certification may subject the certifier to criminal prosecution. C-15 Sig V[ - -to- ) Date Print Name r -� Title Contractor. Name C-16 EXHIBIT B-4 Required Bid Form CERTIFICATION OF BIDDER REGARDING NONSEGREGATED FACILITIES Project Name Cl 3c� j` s n8 ? y Name of Bidder:_co,,�-, The above named Bidder hereby certifies that: I do not maintain or provide for my employees any segregated facilities at any of my establishments, and that I do not permit my employees to perform their services at any location, under my control, where segregated facilities are maintained. As used in this certification, the term "segregated facilities" means any waiting rooms, work areas, rest rooms, wash rooms, restaurants and other eating areas, time clocks, locker rooms or other dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, and housing facilities provided for employees which are segregated by explicit directive or are in fact segregated on the basis of race, color, religion, national origin, or because of habits, local customs, or otherwise. I further agree to obtain identical certifications from all proposed subcontractors prior to the award of subcontracts exceeding $10,000. Signature: _ Name (Print): Title.-_ \J , e Date:- k� �D1(.4 Page 1 of 3 EXHIBIT B-6 Required Bid Form for bids $100,000 or more BIDDER CERTIFICATION FOR SECTION 3 COMPLIANCE (Housing and Community Development Act of 1968) Project Title: C-bC) [3 -S rc->eu.x%l lc—,�.,,�a e fi Amount of Bid: The undersigned hereby certifies that he/she has read and understands Riverside County's Section 3 Affirmative Action Program as well as Section 3 of the Housing and Community Development Act of 1968, and further certifies adoption of, and adherence to, said program, and certifies understanding of the following for all construction contracts over $100,000. I.EmBloyment O,pnflrtuuities I understand and agree that in the event that I am awarded this contract, and in the event that any new employment opportunities are created as a result of this CDBG- funded project, I will: a. Contact the U.S. Department of Housing and Urban Development (HUD) Section 3 website at www.hud.gov/section- to review the list of certified Section 3 persons, within Riverside County, to be considered for available employment opportunities; and lnitital Here b. Forward to the Economic Development Agency all detailed job descriptions for new employment opportunities and Section 3 reports, in a form, at a place, and at a time as directed by the Economic Development Agency. Complete your proposed workforce plan for this project below: .01 Inid, le3•e JOB CATEGORY NUMBER OF NUMBER OF NEW HIRES CURRENT NEW HIRES PROPOSED TO BE % OF NEW HIRES TO BE POSITIONS SECTION 3 IF SECTION 3 RESIDENTS AWARDED BID PROFESSIONALS TECHNICIANS OFFICE/CLERICAL CONSTRUCTION BY TRADE TRADE11 / TRADE TRADE r TRADE TRADE TRADE APPRENTICE TRAINING OTHER TOTAL Page 2 of 3 EXHIBIT B-6 Page 3 of 3 BIDDER CERTIFICATION FOR SECTION 3 COMPLIANCE II.SIIbcoiitl•actin O ortunitic a. I understand and agree that for any and all subcontracting opportunities that may result from this CDBG-funded project, I will contact the U.S. Department of Housing and Urban Development (HUD) Section 3 website at www.[Iud.gov/sectioiO to review the list of certified Section 3 Businesses, within Riverside County, to be considered for available subcontracting opportunities prior to selecting any subcontractor for my bid submittal. fniti Here b. I understand and agree that any and all sub -contracts and sub -tier agreements resulting from this CDBG-funded project are also subject to Section 3 compliance, and therefore, as the General/Prime Contractor, I am responsible to ensure compliance from all subcontractors. Initi Here Comnlete.vour Subcontracting Plan for this Droicet below: TRADE AMOUNT OF SUBCONTRACT($) IS THE SUBCONTRACTOR SECTION 3 ELIGIBLE? YES OR NO IF SUBCONTRACTOR IS SECTION 3, INDICATE ELIGIBLE STATUS. 51%OWNER 30% EMPLOYEE ` Dri! * Add additional sheets if necessary Bidder (Company) Name: '(,� PDc_ic_ C c,,�;;� Authorized Representative (Type Name): Signature: Date: Page 1 of 2 EXHIBIT B-6 SUB Required Bid Form for bids $100,000 or more SUBCONTRACTOR CERTIFICATION FOR SECTION 3 COMPLIANCE (Housing and Community Development Act of 1968) Project Title: _ jO I G �- AIr10Unt Of SUbcontl c1Ct:- 1. -, 9 "Yo a,, -,--I -f The undersigned hereby certifies that he/she has read and understands Riverside County's Section 3 Affirmative Action Program as well as Section 3 of the Housing and Community Development Act of 1968, and further certifies adoption of, and adherence to, said program, and certifies understanding of the following for all construction contracts over $100,000: a. I understand and agree that in the event that I am awarded a subcontract, and in the event that any new employment opportunities are created as a result of this CDBG-funded project, I will contact the U.S. Department of Housing and Urban Development (HUD) Section 3 website at www.hud.gov/section3 to review the list of certified Section 3 persons, within Riverside County, to be considered for available employment opportunities; irliti• Here a I will forward to the Economic Development Agency all detailed job descriptions and Section 3 reports, in a form, at a place, and at a time as directed by the Economic Development Agency. Initial",r Page 2 of 2 Complete your proposed workforce plan for this project below: EXHIBIT B-6SUB Bidder (Company) Name: ?�,( ;��=jL- ')<ovk L Authorized Representative (Type Nam }: '.1y 71 Signature: L- Date: ��`�� NUMBER OF NEW HIRES NUMBER OF NEW HIRES JOB CATEGORY CURRENT % OF NEW HIRES TO BE IF PROPOSED TO BE POSITIONS SECTION 3 AWARDED SECTION 3 RESIDENTS BID PROFESSIONALS TECHNICIANS OFFICE/CLERICAL CONSTRUCTION BY TRADE TRADE r TRADE c� TRADE y TRADE TRADE TRADE APPRENTICE TRAINING OTHER TOTAL Bidder (Company) Name: ?�,( ;��=jL- ')<ovk L Authorized Representative (Type Nam }: '.1y 71 Signature: L- Date: ��`�� EXHIBIT B-7 Required Bid Form COUNTY OFRIVERSIDE C:'DBCT PROGE" BIDDER CERTIFICATION ON FEDERAL CONTRACT REQUIREMENTS PROJECT NAME CERTIFICATION: I hereby certify that I have. reviewed and understand the diversified Federal construction contract related requirements imposed on the Contractor(s) of HUD - funded construction projects, including but not limited to the following: 1. The subject project is being_ financed with Community Development Block Grant funds (24 CFR Part 570); 2. This project and all related construction contracts are subject to the U.S. Department of Housing and Urban Development's Federal Labor Standards Provisions (HUD 4010 — revised 06/2009); and I. This project is subject to all applicable laws and regulations as listed in the General Suminary of these Special Federal Provisions; and 2. If my bid is $100,000 or more, this project and all related contracts will subject to Section 3 requirements (12 U.S.C.1701u). CONTRACTOR'S NAME: Pl Q 0,11- CONTRACTOR'S LICENSE NO.: - OtLlrnoz ADDRESS. _ Czal lam,. C --k � � �Z 2 AUTHORIZED REPRESENTATIVE: �u�i� +p�,�,1 (Type Name) SIGNATURE: RE: DATE: EXHIBIT B-8 Required Bid Form QUESTIONNAIRE REGARDING BIDDERS Bidder has been engaged in the contracting business under the present name of _ _P,4 �- Q, cC -C �� , , since - / I ` 7 --'ah (Date). Present business address is: lct'S � ; (3 � � !sN4 G) zsa_--� C�2Z2_� Federal Tax ID: 7--l-13k-1ccic,\ Amount of Bid $_ 3 2 e(,, 7 California Contractor's License No.: C1413aV Expiration Date: �isl l(e DUNS Number: -'3'1 ^ (PS 4 - S 7-0 2 or CAGE Code: Because this project is Federally -funded, it is necessary to obtain information concerning minority and other group participation for statistical purposes. The U.S. Department of Housing and Urban Development (HUD) uses this information to determine the degree to which its programs are being utilized by minority business enterprises and targeted group contractors. A minority enterprise is defined by the Federal Government as a business that is fifty-one percent (51 %) or more "minority-owned". Please check applicable box concerning the ownership of your business: ❑ American Indian or Native Alaskan ❑ Asian or Pacific Islander/Native Hawaiian ❑ Black/African American ❑ Hispanic White ❑ Hasidic Jews ❑ Other _ A woman -owned enterprise is defined by the Federal Government as a business that is fifty - percent (50%) or more woman -owned. Please check applicable box concerning the ownership of your business: ❑ Woman/Female owned k� Male owned A Section'3 Contractor or Subcontractor is a business concern that is more than fifty-one percent (51%) owned by a low or very low-income person, or a business concern that provides economic opportunities to low and very low-income residents. Please check applicable box concerning the ownership of your business: ❑ Section 3 Business concern )X Non -Section 3 Business concern The United States Department of Housing and Urban Development (HUD) is authorized to solicit the information requested in this form by virtue of Title 12, United States Code, Section 1701 et seq., and other regulations. It will not be disclosed or released outside of HUD without your consent, except as required or permitted by law. EXHIBIT B-9 Required Bid Form LIST OF SUBCONTRACTORS SUBCONTRACTOR FED. I.D.# AMOUNT ADDRESS/PHONE NO. & SUPPLIERS NAME OF SUPPLIER ADDRESS/PHONE NO. CONTRACT AMOUNT This form is to be completed and submitted with the bid package.