ACE CD Inc.CITY OF ROSEMEAD
HELLMAN /SAN GABRIEL INTERSECTION
IMPROVEMENTS PROJECT
CONTRACT BID FORMS
BIDDER: &-(j� C) thc—
BID SCHEDULE
SCHEDULE OF PRICES FOR
HELLMAN /SAN GABRIEL INTERSECTION IMPROVEMENTS PROJECT
ESPL 5358 (012)
BASE BID SCHEDULE
CBF -1
UNIT OF
EST.
UNIT
ITEM
NO,
ITEM DESCRIPTION
MEASURE
QTY.
PRICE
COST
Clearing & Grubbing per plans
1
and specifications. See
technical provisions TP 2, TP
/
3 & TP 4.
LS
1
s?q/ 70
2
Disposal of Waste Materials
LS
1
i
6i t�C7
Remove Existing and
3
Construct 9- Inches Thick PCC
Pavement (High Early
Strength) 520 -A -5000.
SF
22,320
�qpp1'
16,
5 qqq"
Construct 6- Inches Thick
4
Crushed Miscellaneous Base
95% Compaction over 90%
Compacted Soil.
TONS
850
��"�5
2 v
l m50
5
Cold Mill 2- Inches Existing
Pavement.
SF
5,000
(� 3°I S
6, X75° °
6
Construct 2- Inches AC
Pavement (C2- PG 64 -10).
TONS
70
\ 5 ct'
1 l7 - vo
Construct 4 -inch thick PCC
7
sidewalk per SPPWC Std Plan
113
-2.
SF
230
8
Construct PCC Curb Ramps
per SPPWC Std Plan 111 -4.
EA
2
.2,035
1-t-,o7o'
Remove Existing and
g
Construct 6- Inches Thick PCC
Driveway Approach per
SPPWC Std Plan 110
-2.
SF
900
10
Install Landscape and
Irrigation per Plans and
/
Specifications Complete.
LS
1
Install Traffic Striping, Traffic
11
Signal Loops and Pavement
Markers
LS
71 (5 D
7k 1
1
CBF -1
BIDDER:
TOTAL BASE BID PRICE (SCHEDULE BID PRICE):$ 5n 59 � ` 675
r1VN �Uvl�rvG1y11t �}y NI 'It^61 1 �U�IwiV"
Dollar amount in written form aid 5 Sevri, Cf •,,r
The undersigned agrees that these Contract Bid Forms constitute a firm offer to the Owner which
cannot be withdrawn for the number of Working Days indicated in the Notice Inviting Bids from and
afterthe bid opening date, or until a Contract forthe Work is fully executed by the Owner and a third
party, whichever is earlier. The undersigned also agrees that if there is a discrepancy between the
written amount of the Bid Price and the numerical amount of the Bid Price, the written amount shall
govern.
If the Bid Documents specify alternate bid items, the following Alternate Bid amounts shall
be added to or deducted from the Total Bid Price entered above. The owner can choose to
include one or more of the alternates in the Total Bid Price of the Project. If any of the
Alternate Bids are utilized by the Owner, the resulting amount shall be considered the Total
Bid Price for the Project
Attached hereto is a certified check, a cashier's check or a A id bo in the amount of
Dollars ($ said amount being not less than ten percent (10 %) of the Total
Bid Price. The undersigned agrees that said amount shall be retained by the Owner if, upon award,
we fail or refuse to execute the Contract and furnish the required bonds, certificates and
endorsements of insurance and other certifications within the time provided.
If awarded a Contract, the undersigned agrees to execute the formal Contract, which will be
prepared by the Owner for execution, within five (5) Calendar Days following the Letter of Award for
CBF -2
UNIT OF
EST.
UNIT
ITEM
NO.
ITEM DESCRIPTION
MEASURE
QTY.
PRICE
COST
Construct Traffic Signal
12
Improvements per Plans and
Specifications Complete.
1
LS
5 500
V
Remove, Dispose and Construct
Colored PCC Cross Walk
(Chromix) with Lithochrome
13
Colorhardener on top per Plans
and Specifications Complete per
LM Scofield Company or
Approved Equal. Contact person
5
36 �r,�6.
25
Bruce Umeck 818- 324 -3534.
SF
3,050
j 3'
Adjust Sewer Manhole to
14
Grade per SPPWC Std Plan
/
205 -2.
EA
6
P°a
15
Adjust to Grade Water and
Gas valves
Ea
10
5
/
/fi 75 "
W7"
TOTAL BASE BID PRICE (SCHEDULE BID PRICE):$ 5n 59 � ` 675
r1VN �Uvl�rvG1y11t �}y NI 'It^61 1 �U�IwiV"
Dollar amount in written form aid 5 Sevri, Cf •,,r
The undersigned agrees that these Contract Bid Forms constitute a firm offer to the Owner which
cannot be withdrawn for the number of Working Days indicated in the Notice Inviting Bids from and
afterthe bid opening date, or until a Contract forthe Work is fully executed by the Owner and a third
party, whichever is earlier. The undersigned also agrees that if there is a discrepancy between the
written amount of the Bid Price and the numerical amount of the Bid Price, the written amount shall
govern.
If the Bid Documents specify alternate bid items, the following Alternate Bid amounts shall
be added to or deducted from the Total Bid Price entered above. The owner can choose to
include one or more of the alternates in the Total Bid Price of the Project. If any of the
Alternate Bids are utilized by the Owner, the resulting amount shall be considered the Total
Bid Price for the Project
Attached hereto is a certified check, a cashier's check or a A id bo in the amount of
Dollars ($ said amount being not less than ten percent (10 %) of the Total
Bid Price. The undersigned agrees that said amount shall be retained by the Owner if, upon award,
we fail or refuse to execute the Contract and furnish the required bonds, certificates and
endorsements of insurance and other certifications within the time provided.
If awarded a Contract, the undersigned agrees to execute the formal Contract, which will be
prepared by the Owner for execution, within five (5) Calendar Days following the Letter of Award for
CBF -2
BIDDER: km Gb (ti1,C
the Contract, and will deliver to the Owner within that same period the necessary original Certificates
of Insurance, Endorsements of Insurance, Performance Bond, Payment Bond and all other
documentation and certification required by the Contract.
The undersigned offers and agrees that if this bid is accepted, it will assign to the purchasing body
all rights, title, and interest in and to all causes of action it may have under Section 4 of the Clayton
Act (15 U.S.C. Section 15) or under the Cartwright Act (Chapter 2 of Part 2 of Division 7 of the
Business and Professional Code), arising from purchases of goods, materials or services by the
Bidder for sale to the purchasing body pursuant to the bid. Such assignment shall be made and
become effective at the time the purchasing body tenders final payment to he Contractor.
Bidder understands and agrees that, when requested by Owner, he shall provide: (1) evidence
satisfactory to the Owner of Bidder's California contractor's license(s) in good standing; (2) evidence
that the person signing this Bid is authorized to bind Bidder to this Bid and to a contract resulting
therefrom; and (3) any other information and documentation, financial or otherwise, needed by
Owner to award a Contract to the lowest responsible and responsive bidder.
Bidder acknowledges that data submitted with its Contract Bid Forms which it requires to be
incorporated into a Contract arising out of this Submittal has been so identified by Bidder. Bidder
further acknowledges that the Owner may, at its discretion, incorporate any of the remaining data
submitted herewith into a contract arising out of this Bid.
The undersigned acknowledges receipt, understanding and full consideration of the following
addenda to the Contract Documents.
Addenda Nos.
The Bidder understands and agrees that the Total Bid Price is inclusive of all labor, materials, and
equipment or supplies necessary to complete the Work as described in the Bid Documents. If this
bid is accepted, the undersigned Bidder agrees to enter into and execute the Contract with the
necessary bonds and accept the Total Bid Price as compensation in full for all Work under the
contract.
CBF - 3
Bidder understands and agrees that liquidated damages shall apply to this Contract in the amounts
and subject to the terms and conditions described in the Contract Form and the Contract
Documents.
BIDDER: hCrc -- C I) (
0
Signature
Da>1n�( Dct ��er
Type or Prinf Na // me
PM T
T itle
fly Ct 15 Wl!fd b -,
Business Elfreet Address
GPh,e&ra, « `7 - /
City, State and Zip Code
G )-d f52 Pz 57
Telephone Number
Bidder's /Contractor's State of Incorporation: VC, A q
Partners or Joint Venturers:
Bidder's License Number(s): 94 11 0 1
NOTES:
1)
2)
3)
By its signature on this Bid, the Bidder certifies under penalty of perjury the accuracy of the
representations made on the Contract Bid Forms.
If Bidder is a corporation, enter State of Incorporation in addition to Business Address
If Bidder is a partnership or joint venture, give full names of all partners or joint
venturers.
As further discussed in the Instructions to Bidders, Bidder will be required
to provide evidence that the person signing on behalf of the corporation,
or joint venture has the authority to
CBF -4
BIDDER: D D Systems Inc DBA Are CD Inc
Bidder shall submit its Bid data in accordance with the format shown on each of the following Bid
Data Forms. Bidders shall prepare and use as many sheets as are necessary to adequately provide
the information required. Bidder shall ensure that every page of its Bid Data Forms are properly
identified with the Bidder's name and page number.
2.A BID BOND
KNOW ALL MEN BY THESE PRESENTS:
THAT D D Systems Inc DBA Ace CD Inc , as
Principal, and Contractors Bonding and Insurance Company
, as Surety, are held firmly bound unto the
CITY OF ROSEMEAD (hereinafter called the OWNER) in the sum of
Ten percent of the bid amount
($ 10% of bid amount 1 , being not less than ten percent (10 %) of the Total
Bid Price; for the payment of which sum will and truly to be made, we bind ourselves,
our heirs, executors, administrators, successors, and assigns, jointly and severally,
firmly by these presents.
WHEREAS, said Principal has submitted a bid to the OWNER to perform all Work
required for the Hellman /San Gabriel Intersection Improvements Project as set
forth in the Notice Inviting Bids and accompanying Bid Documents, dated
NOW, THEREFORE, if said Principal is awarded a Contract for the Work by the
OWNER and, within the time and in the manner required by the above- referenced
Bid Documents, enters into the written form of Contract bound with said Bid
Documents, furnishes the required bonds (one to guarantee faithful performance
and the other to guarantee payment for labor and materials) furnishes the required
insurance certificates and endorsements, and furnishes any other certifications as
may be required by the Contract, then this obligation shall be null and void; otherwise
it shall remain in full force and effect. In the event suit is brought upon this bond by
the OWNER and judgment is recovered, said Surety shall pay all costs incurred by
the OWNER in such suit, including reasonable attorneys' fees to be fixed by the
court.
SIGNED AND SEALED, this 3rd day of
. D D Sys Inc DBA Ace CD Inc (SEAL)
Principal —
AA
B_.
Signature
0
2013
contractors Bonding and Insurance Company (SEAL)
Surety
Signature W am Syrkin, A rney -in -Fact
CBF -5
Know All Men by These Presents:
POWER OF ATTORNEY
Contractors Bonding and Insurance Company
That this Power of Attorney is not valid or in effect unless attached to the bond which it authorizes executed, but may be detached by the
approving officer if desired.
That Contractors Bonding and Insurance Company, a Washington corporation, does hereby make, constitute and appoint:
Willliam Sorkin, Sergio D. Bechara. Rebecca Haas -Bates Nathan Vamold jointly or severally
in the City of Irvine , State of California its true and lawful Agent and Attorney in Fact, with full
power and authority hereby conferred, to sign, execute, acknowledge and deliver for and on its behalf as Surety, the following described
bond.
Any and all bonds, undertakings, and recognizances in an amount not to exceed Ten Million and 00/100
Dollars ( 510.000.000.00 ) for any single obligation.
The acknowledgment and execution of such bond by the said Attorney in Fact shall be as binding upon this Company as if such bond had
been executed and acknowledged by the regularly elected officers of this Company.
The Contractors Bonding and Insurance Company further certifies that the following is a true and exact copy of the Resolution
adopted by the Board of Directors of Contractors Bonding and Insurance Company, and now in force to -wit:
"AB bonds, policies, undertakings, Powers of Attorney or other obligations of the Corporation shall be executed in the
corporate name of the Corporation by the President, Secretary, any Assistant Secretary, Treasurer, or any Vice President, or by
such other officers as the Board of Directors may authorize. The President, any Vice President, Secretary, any Assistant
Secretary, or the Treasurer may appoint Attorneys in Fact or Agents who shall have authority to issue bonds, policies or
undertakings in the name of the Corporation. The corporate seal is not necessary for the validity of any bonds, policies,
undertakings, Powers of Attorney or other obligations of the Corporation. The signature of any such officer and the corporate
sea] may be printed by facsimil or other electronic image."
IN WITNESS WHEREOF, the Contractors Bonding and Insurance Company has caused these presents to be executed by its Vice
President with its corporate seal affixed this 29th day of January 2013
00 „ n,,,
w
PO RHa1
ON": Contractors Bonding and Insurance Company
U G PPOR." _ a 9 �te 1e �
-G,
:
State of Washington • 1979 ,• `' • Roy C. Die Vice President
County of King } SS W4SXINGZG,,"I
CERTIFICATE
On this 29th day of January 1 2013
before me, a Notary Public, personally appeared Rom, who
being by me duly swom, acknowledged that he signed the above Power of
Attorney as the aforesaid officer of the Contractors Bonding and
Insurance Company and acknowledged said instrument to be the voluntary
act and deed of said corporation.
Joseph B. uller Notary Public
I, the undersigned officer of Contractors Bonding and Insurance
Company, a stock corporation of the State of Washington, do hereby
certify that the attached Power of Attorney is in full force and effect
and is irrevocable; and furthermore, that the Resolution of the
Company as set forth in the Power of Attorney, is now in force. In
testimony whereof, I have hereunto set my hand and t e seal of the
Cont actors Bonding and Insurance Company this 1 5” day
of
Contractors Bonding and Insurance Company
Notary Public _
Stale of Washingon Roy C. Die Vice President
JOSEPH a. MULLER
MY COMMISSION EXPIRES
March 20, 201a _ _ � � j 04]5199032912 A0059511
Cont ractors Bonding and I Company
clbic
3101
3101 Western Ave., Ave., Suite 300
Seattle, WA 98121
ee nu r�m.+�r
Know All Men by These Presents:
POWER OF ATTORNEY
Contractors Bonding and Insurance Company
That this Power of Attorney is not valid or in effect unless attached to the bond which it authorizes executed, but may be detached by the
approving officer if desired.
That Contractors Bonding and Insurance Company, a Washington corporation, does hereby make, constitute and appoint:
Willliam Sorkin, Sergio D. Bechara. Rebecca Haas -Bates Nathan Vamold jointly or severally
in the City of Irvine , State of California its true and lawful Agent and Attorney in Fact, with full
power and authority hereby conferred, to sign, execute, acknowledge and deliver for and on its behalf as Surety, the following described
bond.
Any and all bonds, undertakings, and recognizances in an amount not to exceed Ten Million and 00/100
Dollars ( 510.000.000.00 ) for any single obligation.
The acknowledgment and execution of such bond by the said Attorney in Fact shall be as binding upon this Company as if such bond had
been executed and acknowledged by the regularly elected officers of this Company.
The Contractors Bonding and Insurance Company further certifies that the following is a true and exact copy of the Resolution
adopted by the Board of Directors of Contractors Bonding and Insurance Company, and now in force to -wit:
"AB bonds, policies, undertakings, Powers of Attorney or other obligations of the Corporation shall be executed in the
corporate name of the Corporation by the President, Secretary, any Assistant Secretary, Treasurer, or any Vice President, or by
such other officers as the Board of Directors may authorize. The President, any Vice President, Secretary, any Assistant
Secretary, or the Treasurer may appoint Attorneys in Fact or Agents who shall have authority to issue bonds, policies or
undertakings in the name of the Corporation. The corporate seal is not necessary for the validity of any bonds, policies,
undertakings, Powers of Attorney or other obligations of the Corporation. The signature of any such officer and the corporate
sea] may be printed by facsimil or other electronic image."
IN WITNESS WHEREOF, the Contractors Bonding and Insurance Company has caused these presents to be executed by its Vice
President with its corporate seal affixed this 29th day of January 2013
00 „ n,,,
w
PO RHa1
ON": Contractors Bonding and Insurance Company
U G PPOR." _ a 9 �te 1e �
-G,
:
State of Washington • 1979 ,• `' • Roy C. Die Vice President
County of King } SS W4SXINGZG,,"I
CERTIFICATE
On this 29th day of January 1 2013
before me, a Notary Public, personally appeared Rom, who
being by me duly swom, acknowledged that he signed the above Power of
Attorney as the aforesaid officer of the Contractors Bonding and
Insurance Company and acknowledged said instrument to be the voluntary
act and deed of said corporation.
Joseph B. uller Notary Public
I, the undersigned officer of Contractors Bonding and Insurance
Company, a stock corporation of the State of Washington, do hereby
certify that the attached Power of Attorney is in full force and effect
and is irrevocable; and furthermore, that the Resolution of the
Company as set forth in the Power of Attorney, is now in force. In
testimony whereof, I have hereunto set my hand and t e seal of the
Cont actors Bonding and Insurance Company this 1 5” day
of
Contractors Bonding and Insurance Company
Notary Public _
Stale of Washingon Roy C. Die Vice President
JOSEPH a. MULLER
MY COMMISSION EXPIRES
March 20, 201a _ _ � � j 04]5199032912 A0059511
State of California l
County of Orange 1
On 05/03/2013 before me, A. Wilkison, Notary Public
Dete Hem Insert Name and Till. of the Officer
personally appeared William Syrkin
Name(s) of Signegs)
A. VAIMON
Commission � 1866283
i '� Notary Public • California i
Orange county
M Comm. Ex ire's Sep 26, 2013
Place Notary Seal Above
who proved to me on the basis of satisfactory evidence to
be the person(&) whose nameW is/are subscribed to the
within instrument and acknowledged to me that
hefisgeMey executed the same in authorized
capacity(iee), and that by his /her signature(4 on the
instrument the person(*,, or the entity upon behalf of
which the persons} 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.
WITNESS my hand and official seal.
Signature l f`1 'C o o00f3�
Signature of NotJ0fPu1uAc
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document: Bid Bond
Document Date: 05/03/2013
Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name: William Syrkin
❑ Individual
Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑ General
0 Attorney in Fact
J Trustee Top of thumb here
Guardian or Conservator
Other:
Signer Is Representing:
Contractors Bonding and Insurance Company
Signer's Nat
❑ Individual
Number of Pages: One
❑ Corporate Officer — Title(s):
❑I Partner — ❑ Limited ❑ General
Attorney in Fact
Ll Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
RIGNTTHNMBPAINT
eP SK;Nl;h3
®201ST National Wary ASeo.iatioo- fM0 De Soto Ave_ P.O. Bar 2402 -Chat rlh, CA 9131 &2402•w NatlonalNotaryorg Item n597 Reamer. Call Toll -Free 14300- 876-6829
BIDDER: AC15- (p I VqCs
2.B LIST OF PROPOSED SUBCONTRACTORS
In compliance with the "Subletting and Subcontracting Fair Practices Act," Sections 4100
through 4114 of the California Public Contract Code, and any amendments thereto, each
Bidder shall provide the information requested below for each subcontractor who will
perform work, labor or render service to Bidder in or aboutthe construction of the Work in an
amount in excess of one -half of one percent (greater than 0.5 %) of the Bidder's Total Bid
Price, or, in the case of bids or offers for the construction of streets or highways, including
bridges, in excess of one -half of 1 percent of the Contractor's total bid or ten thousand
dollars ($10,000), whichever is greater, and shall further set forth the portion of the Work
which will be done by each subcontractor. Bidder shall list only one subcontractor for any
one portion of the Work.
Pursuantto Public Contract Code Section 4104, the Owner has determined that it will allow
Bidders twenty -four (24) additional hours after the deadline for submission of bids to submit
the information requested by the Owner about each subcontractor, otherthan the name and
location of each subcontractor.
If the Bidder fails to specify a subcontractor for any portion of the Work to be performed
under the Contract, it shall be deemed to have agreed to perform such portion itself, and
shall not be permitted to subcontract that portion of the Work except under the conditions
hereinafter set forth below.
Subletting or subcontracting of any portion of the Work in excess of one half of one percent
(greater than 0.5 %) of the Total Bid Price or, in the case of bids or offers for the construction
of streets or highways, including bridges, in excess of one -half of 1 percent of the
Contractor's total bid or ten thousand dollars ($10,000), whichever is greater, for which no
subcontractor was designated in the original bid shall only be permitted in cases of public
emergency or necessity, and then only after Owner approval.
BIDDER: 1kCr Cl� tyke .
2.13 LIST OF PROPOSED SUBCONTRACTORS (continued)
I"Duplicale Next 2 Pages if needed for gsfing additmal subwntractorsl" I
Name and Location Description of Work
of Subcontractor to be Subcontracted
Name: &Ajjyk
Address tzar robe
C('r,�r.✓fTtl �r ��- �1�s►I D�.mn Rt rnt�aP �rl�wu�c
Name and Location Description of Work
of Subcontractor to be Subcontracted
Name: MCl Coil( ye.
Address q� CA I n 'Foe VC, A L
Name and Location
of Subcontractor
Name:
Address:
Description of Work
to be Subcontracted
Name and Location
of Subcontractor
Name:
Address
Description of Work
to be Subcontracted
Name and Location
of Subcontractor
Name:
Address:
Description of Work
to be Subcontracted
CBF -7
BIDDER: kY co iii
2.0 REFERENCES
The following are the names, addresses and telephone numbers for three public agencies for which BIDDER
has performed similar work within the past two (2) years:
�. LOS A PP( 0 e! A0 J LQ m EI_ '7Cy3 Ckn i LcAgae G' V1 J "I
Name and Address of Ow her 7 �
lrNKc KI"n -7 y�357�d1Se
Name and telephone number of person familiar with project
�►fi� /fl ® �tq r)c
Contract amount Type of Work Date Completed
2. 4i/d/ S'01�1 n i4nat
Namb of Owner
person
Contract amount
I t / p /p
3. ¢ 'd 4 UI Yneh/r Pt�r / sy
Name and Address of Owner f
&A A s, Hyq yyl `r
Name and telephone number of person fami!
S4-2, NIP
4. C
of
with project
a c
Type of
U
eL .
'on
1�
wrtn project
Type of Work
w
11 - VJ 19571
ber of person familiar with project
re & 1
Date Completed
AY
CBF - S
BIDDER: A - co ih C-
NON - COLLUSION AFFIDAVIT
CBF -9
BIDDER: AC15 CD I yr L
NON - COLLUSION AFFIDAVIT
In accordance with Public Contract Code Section 7106, the undersigned, being first duly
sworn, deposes and says that he or she holds the position listed below with the bidder, 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 fixthe 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 association, organization, bid depository, or to any member or agent
thereof to effectuate a collusive or sham bid.
Sig — n e
Typed or Printed
RlcSlGew�F
Title
/SCE Ci> INIt
Bidder
Subscribed and sworn before me
This, day of , 20_
(Seal)
Notary Public in and for
the State of California
My Commission Expires:
CBF -10
The Bidder shall list the name and address of each subcontractor to whom the Bidder proposes to
subcontract portions of the work, as required by the provisions in Section 2 -1.01, "General," of the special
provisions.
EQUAL EMPLOYMENT OPPORTUNITY CERTIFICATION
The bidder
subcontractor
proposed
hereby certifies that he
has _ , has not _ participated in a previous contract or subcontract subject to the equal
opportunity clauses, as required by Executive Orders 10925, 11114, or 11246, and that, where required,
he has filed with the Joint Reporting Committee, the Director of the Office of Federal Contract
Compliance, a Federal Government contracting or administering agency, or the former President's
Committee on Equal Employment Opportunity, all reports due under the applicable filling requirements.
Note: The above certification is required by the Equal Employment Opportunity Regulations of the
Secretary of Labor (41 CFR 60- 1.7(b) (1)), and must be submitted by bidders and proposed
subcontractors only in connection with contracts and subcontracts which are subject to the equal
opportunity clause_ Contracts and subcontracts which are exempt from the equal opportunity
clause are set forth in 41 CFR 60 -1.5. (Generally only contracts or subcontracts of $10,000 or
under are exempt.)
Currently, Standard Form 100 (EEO -1) is the only report required by the Executive Orders or their
implementing regulations.
Proposed prime contractors and subcontractors who have participated in a previous contract or
subcontract subject to the Executive Orders and have not filed the required reports should note
that 41 CFR 60- 1.7(b) (1) prevents the award of contracts and subcontracts unless such
contractor submits a report covering the delinquent period or such other period specified by the
Federal Highway Administration or by the Director, Office of Federal Contract Compliance, U.S.
Department of Labor.
HEOC -I
Noncollusion Affidavit
(Title 23 United States Code Section 112 and
Public Contract Code Section 7106)
To the City of Rosemead, Los Angeles County
DEPARTMENT OF PUBLIC WORKS.
In conformance with Title 23 United States Code Section 112 and Public
Contract Code 7106 the bidder declares 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 association, organization, bid
depository, or to any member or agent thereof to effectuate a collusive or sham
bid.
Note: The above Noncollusion Affidavit is part of the Bid. Signing this Bid on
the signature portion thereof shall also constitute signature of this
Noncollusion Affidavit.
Bidders are cautioned that making a false certification may subject the
certifier to criminal prosecution.
NA -1
DEBARMENT AND SUSPENSION CERTIFICATION
TITLE 49, CODE OF FEDERAL REGULATIONS, PART 29
The bidder, under penalty of perjury, certifies that, except as noted below, he /she or any
other person associated therewith in the capacity of owner, partner, director, officer,
manager:
• is not currently under suspension, debarment, voluntary exclusion, or
determination of ineligibility by any Federal agency;
• has not been suspended, debarred, voluntarily excluded or determined ineligible
by any Federal agency within the past 3 years;
• does not have a proposed debarment pending; and
• has not been indicted, convicted, or had a civil judgement rendered against it by
a court of competent jurisdiction in any matter involving fraud or official
misconduct within the past 3 years.
If there are any exceptions to this certification, insert the exceptions in the following
space.
Exceptions will not necessarily result in denial of award, but will be considered in
determining bidder responsibility. For any exception noted above, indicate below to
whom it applies, initiating agency, and dates of action.
Notes: Providing false information may result in criminal prosecution or administrative
sanctions.
The above certification is part of the Bid. Signing this Bid on the signature
portion thereof shall also constitute signature of this Certification.
DSC -1
NONLOBBYING CERTIFICATION
FOR FEDERAL -AID CONTRACTS
The prospective participant certifies, by signing and submitting this bid or bid, to the
best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of
the undersigned, to any person for influencing or attempting to influence an
officer or employee of any Federal agency, a Member of Congress, an officer or
employee of Congress, or an employee of a Member of Congress in connection
with the awarding of any Federal contract, the making of any Federal grant, the
making of any Federal loan, the entering into of any cooperative agreement, and
the extension, continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid
to any person for influencing or attempting to influence an officer or employee of
any Federal agency, a Member of Congress, an officer or employee of Congress,
or an employee of a Member of Congress in connection with this Federal
contract, grant, loan, or cooperative agreement, the undersigned shall complete
and submit Standard Form -LLL, "Disclosure of Lobbying Activities," in
conformance with its instructions.
This certification is a material representation of fact upon which reliance was placed
when this transaction was made or entered into. Submission of this certification is a
prerequisite for making or entering into this transaction imposed by Section 1352, Title
31, U.S. Code. Any person who fails to file the required certification shall be subject to
a civil penalty of not less than $10,000 and not more than $100,000 for each such
failure,
The prospective participant also agrees by submitting his or her bid or bid that he or she
shall require that the language of this certification be included in all lower tier
subcontracts, which exceed $100,000 and that all such subrecipients shall certify and
disclose accordingly.
NLC -1
DISCLOSURE OF LOBBYING ACTIVITIES
UUMrLt I t I till t-UKM I U UI5CLUbh LUt1t3YINli AG I IVI I IEb PURSUAN 1 fU 31 U.S.C. 1352
1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type:
a. nnntmct ❑ a. hid /offer /annlicAtion ❑ a. initial
b, grant b. initial award b. material change
c. cooperative agreement c. post -award
d, loan For Material Change Only:
e. loan guarantee year _ quarter
IF- loan insurance date of last report
4. Name and Address of Reporting Entity S. If Reporting Entity in No. 4 Is Subawardee,
Enter Name and Address of Prime:
Prime r - I Subawardee
Tier _ , if known
Congressional District, if known
6. Federal DepartmentlAgency:
8. Federal Action Number, if known:
Congressional District, if known
7. Federal Program Name /Description:
CFDA Number, if applicable
9. Award Amount, if known:
10. a. Name and Address of Lobby Entity
(If individual, last name, first name, MI)
b. Individuals Performing Services (including
address if different from No. 10a)
(last name, first name, MI)
(attach Continuation Sheet(s) if necessary)
11. Amount of Payment (check all that apply) 13. Type of Payment (check all that apply)
$ actual planned a. retainer
b. one -time fee
12. Form of Payment (check all that apply): C. commission
e a. cash d. contingent fee
b. in -kind; specify: nature a deferred
value f. other, specify
14. Brief Description of Services Performed or to be performed and Date(s) of Service, including
officer(s), employee(s), or member(s) contacted, for Payment Indicated in Item 11:
(attach Continuation Sheet(s) If necessary)
15. Continuation Sheet(s) attached: Yes r - 1
No n
16. information requested through this form is authorized by
Title 31 U.S.C. Section 1352. This disclosure of
Signature:
lobbying reliance was placed by the tier above when his
- - --
transaction was made or entered into. This disclosure is
print Name:
Q
required pursuant to 31 U.S.C. 1352. This information
will be reported to Congress semiannually and will be
I
available for public inspection. Any person who fails to
Title:
file the required disclosure shall be subject to a civil
/+
penalty of not less than $10,000 and not more than
Telephone No.: 0 -
$100,000 for each such failure.
Federal Use
Authorized for Local Reproduction
Standard Form - LLL
EXHIBIT 15 -G1 Local Assistance Procedures Manual
Local Agency Bidder UDBE Commitment (Construction Contracts)
INSTRUCTIONS - LOCAL AGENCY BIDDER
UDBE COMMITMENT (CONSTRUCTION CONTRACTS)
ALL BIDDERS:
PLEASE NOTE: It is the bidder's responsibility to verify that the UDBE(s) falls into one of the following
groups in order to count towards the UDBE contract goal: 1) African Americans; 2) Asian - Pacific
Americans; 3) Native Americans; 4) Women. This information may be submitted with your bid. If it is not,
and you are the apparent low bidder or the second or third low bidder, it must submitted and received as
specified in the Special Provisions. Failure to submit the required UDBE commitment will be grounds for
finding the bid nonresponsive
A UDBE is a firm meeting the definition of a DBE as specified in 49 CFR and is one of the following groups:
African Americans, Asian- Pacific Americans, Native Americans, or Women.
The form requires specific information regarding the construction contract: Local Agency, Location, Project
Description, Total Contract Amount, Bid Date, Bidder's Name, and Contract UDBE Goal.
The form has a column for the Contract Item Number and Item of Work and Description or Services to be
Subcontracted or Materials to be provided by UDBEs. Prime contractors shall indicate all work to be performed by
UDBEs including, if the prime is a UDBE, work performed by its own forces, if a UDBE. The UDBE shall
provide a certification number to the Contractor and expiration date. Enter the UDBE prime's and subcontractors'
certification numbers.The form has a column for the Names of UDBE contractors to perform the work (who must
be certified on the date bids are opened and include the UDBE address and phone number).
IMPORTANT: Identify all UDBE firms participating in the project regardless of tier. Names of the First -Tier
UDBE Subcontractors and their respective item(s) of work listed should be consistent, where applicable, with the
names and items of work in the "List of Subcontractors" submitted with your bid.
There is a column for the UDBE participation dollar amount. Enter the Total Claimed UDBE Participation dollars
and percentage amount of items of work submitted with your bid pursuant to the Special Provisions. (If 100% of
item is not to be performed or furnished by the UDBE, describe exact portion of time to be performed or
furnished by the UDBE.) See Section "Disadvantaged Business Enterprise (DBE)," of the Special Provisions
(construction contracts), to determine how to count the participation of UDBE firms.
Exhibit 15 -G1 must be signed and dated by the person bidding. Also list a phone number in the space provided
and print the name of the person to contact.
LOCAL agencies should complete the Local Agency Contract Award, Federal -aid Project Number, Federal
Share, Contract Award Date fields and verify that all information is complete and accurate before signing and
filing.
Page 15 -32
July 31, 2009 LPP 09 -02
Local Assistance Procedures Manual EXHIBIT 15 -G1
Local Agency Bidder UDBE Commitment (Construction Contracts)
EXHIBIT 15 -Gl LOCAL AGENCY BIDDER UDBE COMMITMENT (CONSTRUCTION CONTRACTS)
NOTE: PLEASE REFER TO INSTRUCTIONS ON THE REVERSE SIDE OF TH FORM
LOCAL AGENCY: C/ ` )Zme meQ cl LOCATION: �F-Y -12, aki4 �I K Gx b�g t C
PROJECT DESCRIPTION: �>14e.- rtfF( ^9h l.-W�ftar/(m N�tT'S
TOTAL CONTRACT AMOUNT:$
BID DATE: 5 l U t '{
AA
BIDDER'S NAME: ka C A 1 r L
CONTRACT UDRE GOAL: i/
NTRACT
ITEM NO.
ITEM OF WORK AND DESCRIPTION
OR SERVICES TO BE
SUBCONTRACTED OR MATERIALS
O BE PROVIDED (or contracted if the
bidder is a UDBE)
UDBECERT
AND EXPIRATION
DATE
NAME OF EACH UDBE
(Must be certified on the date bids
are opened - include UDBE
address and phone number)
DOLLAR AMOUNT
UDBE
o S
Ga A MeA er
V {Lt tl1"( V
170
For Local Agency to Complete:
Local Agency Contract Number:
Federal -aid Project Number:
Federal Share:
Contract Award Dale:
Local Agency certifies that all UDBE certifications have been verified and
information is complete and accurate.
Print Name Signature Date
Local Agency Representative
(Area Code) Telephone Number:
Total Claimed UDBE
Participation
$ 43 Grpd
— ^ --
a
Stgnatuur er
SJB� /3 �,1685,2025'l
ate Area Code) 'e , No.
tsQNNy boot✓
rerson to Contact Pease Type or F nnq
Local Agency Bidder UDBE Commitment (Construction Contracts)
(Rev 626109)
Distribution: (1) Original— Local agency files
Page 15 -31
LPP 09 -02 July 31, 2009