California Professional Engineering Inc.GARVEY AVENUE
HIGHWAY SAFETY IMPROVEMENT PROJECT
HSIPL. 5358 {014)
California Professional Engineering, Inc.
BIDDER:
BID SCHEDULE
SCHEDULE OF PRICES FOR
GARVEY AVENUE -- HIGHWAY SAFETY IMPROVEMENT PROJECT
HSIPL 5358 (094)
BASE BID SCH EDULE
TOTAL BASE BID PRICE (SCHEDULE BID PRICE):$ 5, > Q — I C �
°t��ic r`C�rED tr�ri
Dollar amount in written
The undersigned agrees that these Contract Bid Forms constitute a firm offer to the Owner which
cannot be withdrawn forthe number of Working Days indicated in the Notice Inviting Bids from and
after the 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.
CBF -1
UNIT OF
EST.
UNIT
ITEM
NO.
ITEM DESCRIPTION
MEASURE
QTY.
PRICE
COST
1
Clearing & Grubbing per plans
and specifications.
LS
1
( ' 0
(1
2
Disposal of Waste Materials.
LS
1
Traffic Signal Upgrade at
Garvey Avenue and Delta
3
Avenue per Plans and
Specifications Complete.
LS
1
_
Traffic Signal Upgrade at
Garvey Avenue and
4
Rosemead Place /River
Avenue per Plans and
a
Specifications Complete.
LS
1
Traffic Signal Upgrade at
1 4 1 r
'
5
Garvey Avenue and Muscatel
Avenue per Plans and
Specifications Complete.
LS
1
TOTAL BASE BID PRICE (SCHEDULE BID PRICE):$ 5, > Q — I C �
°t��ic r`C�rED tr�ri
Dollar amount in written
The undersigned agrees that these Contract Bid Forms constitute a firm offer to the Owner which
cannot be withdrawn forthe number of Working Days indicated in the Notice Inviting Bids from and
after the 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.
CBF -1
California Professional Engineering,
At�ached her to is a certified check, a cashier's check or a bid bond in the amount of
@b 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 bythe Owner for execution, within five (5) Calendar Days following the Letter of Award for
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 understands and agrees that liquidated damages shall apply to this Contract in the amounts
of five hundred dollars ($500.00) if protect is not completed in forty -five (45) working days. The
Contract Time will begin to run ten (10) Working Days from the date of the Notice of Proceed and
subject to the terms and conditions described in the Contract Form and the Contract Documents
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 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 -2
California Professional Engineering, Inc,
BIDDER:
By; t j P t j u�i(
Sigma ' A Business Street Address
Van MTt Tien
Type or Print Name k City, State and Zip Code
President
Title Telephone Number
Bidder's /Contractor's State of Incorporation: fi p CL tt
Partners or Joint Venturers:
Bidder's License Number(s): _ ¢ c l l�q cl
Department of Industrial Relations tz�
Registered No. t�
NOTES:
1) By its signature on this Bid, the Bidder certifies under penalty of perjury the accuracy of the
representations made on the Contract Bid Forms,
2) If Bidder is a corporation, enter State of Incorporation in addition to Business Address
3) 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,
partnership mr joint venture has the authority to do so.
CBF -3
MEETING OF BOARD OF DIRECTORS
OF '
CALIFORNIA PROFESSIONAL ENGINEERING, INC.
A meeting of the Board of Directors of California Professional Engineering, Inc. was
held on July 17, 2015 whereby a resolution was passed authorizing
Van Nguyen to sign on behalf of the Corporation, by his signature, to enter into any and
all contractual obligations on behalf of this corporation.
PresAnt
f
t
See attached jurat.
9316 Mabel Avenue South El Monte, CA 91733 0 Ph: (626) 452 -8658 0 Fax: (626) 448 -0470 0 Email: van@epengineeringine.com
JURT
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 e S
Subscribed and sworn to (or affirmed)
before me on this 1'4 - hday of -
20 by V ` : `� o
U u) 0t1 ,
proved to me on the basis of satisfactory evidence to be the person(s) who appeared
before me.
Y. ,•a`°� =.. JENNIFER ORRALA
3 COMM. 2114244
j o A
a
N F Q NOTARY PUBLIC - CALIFORNIA N
M
LW ANOiLEb COUNTY
MY COMM, EIP. JUNE B, 2011
Sig ature
(Seal)
OPTIONAL INFORMATION
INSTRUCTIONS
The wording of all Jurats completed in California after January 1, 2015 must be in the form
as set forth . within this Jurat. There are no exceptions. If a Jurat to be completed does not
follow this form, the notary must correct the verbiage by using a jurat stamp containing the
correct wording or attaching a separate jurat form such as this one with does contain the
proper wording. In addition, the notary must require an oath or affirmation from the
DESCRIPTION OF THE ATTACHED DOCUMENT
document signer regarding the truthfulness of the contents of the document. The
document must be signed AFTER the oath or affirmation. If the document was previously
signed, it must be re- signed in front of the notary public during thejurat process.
(Title or description of attached document)
• State and county information must be the state and county where the
document signer(s) personally appeared before the notary public.
(Title or description of attached document continued)
• Date of notarization must be the date the signer(s) personally
appeared which must also be the same date the jurat process is
completed.
Number of Pages Document Date
• Print the names) of the document signer(s) who personally appear at
the time of notarization.
• Signature of the notary public must match the signature on file with the
Additional information
office of the county clerk.
• 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 jurat form.
Additional information Is not required but could help
to ensure this jurat is not misused or attached to a
different document.
Indicate title or type of attached document, number of
pages and date.
• Securely attach this document to the signed document with a staple.
209 Version wvYr�;lvotaryClxaascs -corn 808 -873 -98(35
California Professional Engineering, Inc.
BIDDER
2.13 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 about the 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.
Pursuant to 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, other than 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.
CBF -5
California Professional Engineering, Inc.
BIDDER;
2.B LIST OF PROPOSED SUBCONTRACTORS (continued)
( "Duplicate Next 2 Pages it needed for listing additional subcontractors . "I
N ame and Location Description of Work
of Subcontractor to be Subcontracted
License No.:
Department J
M
C�C"t(�LkE�
t SSO`E2.4S!
Name and Location
of Subcontracto
Name:
Address._
License No.:
Department
ndustrial Relation Registration
Description of Work
to be Subcon tracted
Name and Location
of Subcontra
Description of Work
to be Subcontracted
Name:
Address:
License No.:
Department of Industrial Relation Registration No.
Name and Locatio
of Subcontractor
Description of Work
to be Subcontracted
Name:
Address:
License No.:
Department of Industrial Relation Registration No.
Name and Location
of Subcontractor
Description of Work
to be Subcontra
Name:
Address:
License No.:
Department of Industrial Relation Registration No.
CBF -6
alif'ornia Professional Engineering, Inc.
BIDDER:
_ t f�
2.0 REFERENCES �yyyp�
The following are the names, addresses and telephone numbers forth ree public agencies for which BIDDER
has performed similar work within the past two (2) years:
`ylz� i' 6 ' A nah2,M , CA q'i 28c
IVame ana Haaress or
POWri" ' L0go
Name and telephone i
A
Contract amount
2. jPTL
Name
Type of Wo
I oi AOvcvb qoo s . �
I Address of Owner
I fLDfz ((0
d tele number of
p' r T� , �- - J
amount
3. t � t`SY R 1 l LE r i
Name and Address c
G'eL- 'aY1
Name and telephone
�1 - 7 6 1
Contract amount
4 ( Zt4 t ��
Name and Address of
L)d '20
Date Completed
I D2-Li 1
Name and telephone number of person familiar with project
Contract amount Type of Work Date Completed
vne�
ter of person familiar with project
ivlS`� r-�t° e�G So�1
av?d;Lz� i�- ll -o1 -
Date Completed
-me Lh' - M�2 m CA
u, Iso
familiar with project g
Type of Work Date Completed
51 - 61 @ "e, 0r U-, Tlt8t(¢o
person familiar with project
1/Ic1 tc v� BG P Wes&._
Type of Work
CBF -7
GARVEY AVENUE
HIGHWAY SAFETY IMPROVEMENT PROJECT
HSIPL 5358 (014)
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 California Professional Engineering, Inc.
proposed
subcontractor tA a 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.
l +0( *- I
CITY OF O'. U -. 1
GARVEY AVENUE
HIGHWAY SAFETY IMPROVEMENT PROJECT
HSIPL 5358 (014)
CBF -8
BiQ*(o Professional Enginee Inc.
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 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. , P
Signature
Van Nguyen
Typed or Printed Name
President
Title
California Professional Engineering, Inc.
Bidder
Subscribed and sworn before me
This _ day of
Notary Public in
the State of Cal.
My
Expires:
r
(Seal)
CBF -9
J U RAT
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 S
Subscribed and sworn to (or affirmed) before me on this day of 71e_4
20 by V 9�T tad
proved to me on the basis of satisfactory evidence to be the persons) who appeared
before me.
JENNIFER ORRALA
ComIS3 2114244 ,n
NOTARY PUBLIC ' CALIFORNIA tr
LOS ANGELES' COUNTY
111 gym•+" MY Comm. EIN, JUNE
Ig ture _ _ (Seal)
OPTIONAL INFORMATION INSTRUCTIONS
The wording of all Jurafs completed in California after January 1, 2015 must be in the form
as set forth . within this Jurat. There are no exceptions. If a Jurat to be completed does not
follow this form, the notary must correct the verbiage by using ajurat stamp containing the
correct wording or attaching a separate jurat form such as this one with does contain the
proper wording. In addition, the notary must require an oath or affirmation from the
DESCRIPTION OF THE ATTACHED DOCUMENT document signer regarding . the truthfulness of the contents of the document. The
document must be signed AFTER the oath or of ini ation. If the document was previously
signed, it must be re- signed in front of the notary public during the jurat process.
(Title or description of attached document)
(Title or description of attached document continued)
Number of Pages Document Date
Additional information
• State and county information must be the state and county where the
document signer(s) personally appeared before the notary public.
• Date of notarization must be the date the signer(s) personally
appeared which must also be the same date the jurat process is
completed.
• Print the name(s) of the document signer(s) who personally appear at
the time of notarization.
• Signature of the notary public must match the signature on file with the
office of the county clerk.
• 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 jurat form.
Additional information Is not required but could help
to ensure this jurat is not misused or attached to a
different document.
Indicate title or type of attached document, number of
pages and date.
• Securely attach this document to the signed document with a staple.
2855 Ver lon ww +m.NuLrryClasses.conr 5110- 873 -9865
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 __ .
GARVEY AVENUE
HIGHWAY SAFETY IMPROVEMENT PROJECT
HSIPL 5358 (014)
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.
DSG1 -
GARVEY AVENUE
HIGHWAY SAFETY IMPROVEMENT PROJECT
HSIPL 5358 (014)
NONIIOBBYING 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
CITY !F R
GARVEY AVENUE
HIGHWAY SAFETY IMPROVEMENT PROJECT
HSIPL 5358 (014)
INSTRUCTIONS FOR COMPLETION OF SF -LLL,
DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or
receipt of covered Federal action or a material change to previous filing pursuant to title 31 U.S.C, section '1352. The filing of a
form is required for such payment or agreement to make payment to lobbying entity for influencing or attempting to influence an
officer or employee of any agency, a Member of Congress an officer or employee of Congress or an employee of a Member of
Congress in connection with a covered Federal action. Attach a continuation sheet for additional information if the space on the
form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to the implementing - - -- --
guidance published by the Office of Management and Budget for additional information.
1. Identify the type of covered Federal action for which lobbying activity is and /or has been secured to influence, the
outcome of a covered Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropriate classification of this report. If this is a follow -up report caused by a material change to the
information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last.
previously submitted report by this reporting entity for this covered Federal action.
4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District if known
Check the appropriate classification of the reporting entity that designates if it is or expects to be a prime or subaward
recipient. Identify the tier of the subawardee, e.g.. the first subawardee of the prime is the first tier. Subawards include
but are not limited to subcontracts. subgraots and contract awards under grants.
5. If the organization filing the report in Item 4 checks "Subawardee" then enter the full name, address, city, state and zip
code of the prime Federal recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organization level
below agency name, if known. For example. Department of Transportation. United States Coast Guard,
7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of
Federal Domestic Assistance (CFDA) number for grants. cooperative agreements, loans and loan commitments.
S. Enter the most appropriate Federal identifying number available for the Federal action identification in item 1 (e.g_
Request for Proposal (RFP) number, Invitation for Bid (IFS) number, grant announcement number, the contract grant. or
loan award number, the application /proposal control number assigned by the Federal agency), Include prefixes, e.g..
"RFP- DE -90- 001."
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency. enter the
Federal amount of the award /loan commitments for the prime entity identified in item 4 or 5.
10. (a) Enter the full name, address, city. state and zip code of the lobbying entity engaged by the reporting entity identified in
item 4 to influenced the covered Federal action.
(b) Enter the full names of the individual(s) performing services and include full address if different from 10 (a). Enter Last
Name, First Name and Middle Initial (MI).
11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (item 4) to the lobbying
entity (item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that
apply. If this is a material change report, enter the cumulative amount of payment made or planned to be made.
12. Check the appropriate box(es). Check ail boxes that apply. If payment is made through an in kind contribution, specify
the nature and value of the in -kind payment.
13. Check the appropriate box(es). Check all boxes that apply. If other, specify nature.
14. Provide a specific and detailed description of the services that the lobbyist has performed or will be expected to perform
and the date(s) of any services rendered. Include ail preparatory and related activity riot just time spent in actual contact
with Federal officials. Identify the Federal officers) or employee(s) contacted or the officers) employee(s) or Members)
of Congress that were contacted.
15. Check whether or not a continuation sheet(s) is attached.
16. The certifying official shall sign and dale the form. print his /her name title antl telephone number.
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for
reviewing instruction, searching existing data sources. gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information.
including suggestions for reducing this burden, to the Office of Management and Budget. Paperwork Reduction Project (0343- 0046).
Washington. U.C. 20503. SF- LLL- Instmctions Rev. 06 -04 90«ENDIF>.
DISCLOSURE OF LOBBYING ACTIVITIES
COMPLETE THIS FORM TO DISCLOSE LOBBYING ACTIVITIES PURSUANT'r0 31 U.S.C. 1;
1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type:
❑ a contract ❑ a hid /offPr /annlication ❑ a initial
b. grant b. initial award b. material change
c. cooperative agreement c. post-award
d. loan
e. loan guarantee
I. loan insurance
4. Name and Address of Reporting Entity
For Material Chan Only:
}
year_ quarter
t� date of last report
5. If Reporting Entity in N . 4 is Subawardee,
Enter Name and Add ss of Prime:
Prime Subawardee
Tier , if known
Congressional District, if known
6. Federal Department/Agency:
8. Federal Action Number, if known.
Congr sional District, if known
7. Federal Program Name /Description:
CFDA Number, if applicable
Award Amount, if known:
10. a. Name and Address of Lobby Entity j b. Individuals Performing Services (including
(If individual, last name, first name, W address if different from No. 10a)
j (last name, first name, MI)
(atta Continuation Sheet(s) if necessary)
11. Amount of Payment (check I that apply) 13. Type of Payment (check all that apply)
$ actual J planned a, retainer
b. one -time fee
12. Form of Payment (che all that apply): c. commission
e a. cash d. contingent fee
b. in -kind; sp afy: nature e deferred
value f, other, specify
14. Brief Descriptio of Services Performed or to be performed and Date(s) of Service, including
officer(s), emp yee(s), or member(s) contacted, for Payment Indicated in Item 11:
(attach Continuation Sheet(s) if necessary)j\ v
15. Contim. tion Sheets) attached: Yes El No V9
16. Informati n uested through this form is authorized by
req uested
Title 31 .S.C. Section 1352. This disclosure of Signature:. V _ _
lobbyi reliance was placed by the tier above when his
trans ction was made or entered into. This disclosure is Print Name.: Wen
Ng
wen red pursuant to 31 U.S.C. 1352. This information —
will e reported to Congress semiannually and will be President
av liable for public inspection. Any person who fails to Title:
the required disclosure shall be subject to a civil pp 2
alty of not less than $10.000 and not more than Telephone No g�?" ✓�? Date:
0,000 for each such failure.
erat Use Only_
Authorized for Local Reproduction
Standard Form - I_LL
09- 'I2 -97
GARVEY AVENUE
HIGHWAY SAFETY IMPROVEMENT PROJECT
HSIPL 5358 (014)
EXFIR #T 154 Local Assistance Procedures Manual
Local ,Agency Bidder UDBE Commitment (Construction {Contracts)
INSTRUCT'IO.NS - LOCAL, AGENCY BIDDER
UDBE COMMI'T'MENT (CONS'T'RUCTION CON'T'RACTS)
I 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 firth mceting the definition of a DBE; as specified in 49 CFR and is one or the following groups:
African Americans, Asian- Paicific Americans, Native Americans, sir 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 U0136 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 UDBB, I)rime contractors shall indicate all work to be performed by
UDBEs including, if tire prime is a UDBlS, work performed by its own forces, ifa UDBE. "fhe UDBE shall
provide a certification number to the Contractor and expiration (late. Enter the UDBI? prime's and subcontractors'
certification numbers.The form has a column for the Names of UDBE contactors to perform the work (who must
I be certified on the (late bids are opened and include the UDBE address and phone number).
IMI)OR "PANT: ldentify all UDBE: firms participating in the pr(Iject regardless of tier. Names of the First - Pier
UDBE Subcontractors and their respective item(s) of work listed sftouhl be consistent, where applicable, with the
names and items of work in the "List of SUbMltlaetol'S" 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 nr furnished by the UDBE, describe exact portion of tithe to be performed or
Furnished by the UDBE.) See Section "Disadvantaged Business L,morprise (l;)BE;)," of the Special provisions
(construction contracts), to determine how to count the participation of UDBF; firms.
Exhibit 15-GI 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 Nmnber, Federal
Share, Contract Award.Date fields and verify that all information is complete and accurate before signing and
filing.
Page I5 -32
Jute 31, 2009 LPP 09 -02
Local Assistaoce Procedut-es Mamial EXHIBIT 15-Gl
Local Agency Bidder UDBE Cotamitiocat (Construction Contracts)
EXHIRITI- LOCAL AGENCY BIDD ( U DBE COMMITM (CONSTRUCTION CONTRACTS)
NOTE: PLEASE REFER TO INSTRUCTIONS ON THE REVERSE SIDE OF I'll IS FORM
L.O('Al, AGENCY :_ — LOCI A [ON (AN.CK awamca
wa 6 1 Yo v ....... LT- rD,ecr
............. . .... . . . .......
WDDA*1*E:-0- ).0
1.3 1 DDER'S NAME: Cali omia Professional ngincering, ne.
.. .......... . .... - - ------------------------- -- — ------ --
c,wrRACTUDRECK)AW
CONTRACT MAN OP WORK AND DF-SUIP I 10\1 111EBE (�ERI NO. NIFOWEA01 WBF O
DUAR AMOLM f
"AMN IA I - - TT
OR SERVTFS TO BE YNDEXPIRATKM ust be certificdon dic (late bids UDBU
I lt;ti6ONII'R;\Cll�I)ORNIA'I'ERIAI ... S jDA'1 F arc opened - include 111)BE
VO 13F PROVIDED (or contracted if tlic tiddrem and Wmw mmko
pkida is a UDBE)
For Local Agency to Complete:
oval A CmaoictNumbcr: Fetal Claimed U08F
I
-------- ------ ---- ..... .. .. ...... . . ..... .... . Pei tic i pat ion
Federal-aid prqj"t Numbm ...... . .. --- — - -- - . ..... . ....... ... ................ ... . .. . ............
Fccleml share:
Comma A"ard Date
Local Agency ccilit - Ics t all IiDBF certrfr aUens have been verilicd laid
information is complete and amnatc,
m
W�w
Print �anYc
I mW Agency RWmmw&c
(Ami C odo I dephow Nundcr.
Van Nguyen
Biddcr UDBF Commilmew (Cvwm,mwi , omw
fW W&M
Distribution, (110liginal 1.mdltgcnc) ldc's
Page 1501
LPP0902 July 3L2H9
CITY OF ROSEMEA®
GARVEY AVENUE
HIGHWAY SAFETY IMPROVEMENT PROJECT
HSIPL 5358 (014)
Local Assistance Procedures Manual Exhibit 15 -11
UDBE Information - Good Faith Effort
EXHIBIT I5 -H UDBE INFORMATION —GOOD FAITH EFFORTS
UDBE INFORMATION - GOOD FAITH EFFORTS
Federal -aid Project No, II$I 5218 (M� )_ Laid Opening Date �
_ file Cit of Rosemea ,__,established an Underutilized Disadvantaged Bosiness Enterprise
(tJL)B goal of 6 % for this project. The information provided herein shows that a good faith effort was
made.
Lowest, second lowest and third lowest bidders shall submit the following information to t10butnent adequate
clood faith efforts. Bidders should submit the following information even if the "Local Agency Bidder UDBE
Commitment" form indicates that the bidder has met the UDBE? goal. This will protect the bidder's eligibility for
award of the contract if the administering agency determines that the bidder failed to meet the goal for various
reasons, e.g., a E1D13Ei firm was not certified at bid opening, or the bidder made a mathematical error.
Submittal of only the "Local Agency Bidder UDBE Comminnent"fonn may not provide sufficient
documentation to demonstrate that adequate good faith efforts were made.
The following items are listed in the Section entitled "Submission of UDBE. Commitment' of the Special
Provisions:
A. The names and (fates of each publication in which a request for UDBEi participation for this
project was placed by the bidder (please attach copies of advertisements or proofs of
publication):
Publications Dates of Advertisement
-- .-_._.---- ...... .... ' - - - - - -- — - --------------
..._..._._.... -- - - --
B. The names and dates of written notices sent to certified UDBEs soliciting bids for this project
and the states and methods uscd for following up .initial solicitations to determine with certainty
whether the UDI31',s were interested (please attach copies of solicitations, telephone records, fax
confirmations,, etc.):
Names of LiDBE.s Solicited Date o'f lnitial Follow Up Methods and Dates
HE
Page 15 -33
L)P 09 -02 July 31, 2009
Exhibit 1541
UDBE Information -Good Faith Effort
Local Assistance Procedures Manual
C. The items of work which the bidder trade available to UDBE firms including, where
appropriate, any breaking down of the contract work items (including those items normally
performed by the bidder with its own forces) into economically feasible units to facilitate UDBE
participation. It is the bidder's responsibility to demonstrate that sufficientwork to facilitate
UDBE participation was made available to UDBE firms-
Items or Work Bidder Normally Breakdown of Amount Percentage
Performs Item Items { 6) Of
(Y /N) Conti
D. The names. addresses and phone numbers of rejected UDBE firms, the reasons for the bidder's
rejection of the UDBEs, the firms selected for that work (please attach copies of quotes from the
firms involved), and the price difference for each UDBE if the selected firm is not a UDBE:
Names, addresses and phone numbers of rejected UDBEs and the .reasons for the bidder's
rejection of the UDBEs:
Names, addresses and phone numbers of firms selected for the work above:
- t1t___C, Z_ Qbb
E. Efforts mace to assist interested 1..'DBE,s in obtaining bonding, lines of credit or insurance, and
any technical assistance or information related to the plans, specifications and requirements for
the work which was provided to UDBEs:
Pate l; -3d
JWY 31, 2009 LIT 09 -02
Local Assistance Procedures Manual
P:ziribit 15 -H
BORE Information - Good Faith Effort
F. Efforts made to assist interested UDBEs in obtaining necessary equipment, supplies, materials or
related assistance or Services, excluding supplies and equipment the UDBE subcontractor
purchases or leases :Prom the prime contractor or its affiliate:
-- - -- -- -- - - --
G. The names of agencies, organizations or groups contacted to provide assistance in contacting,
recruiting and using UDBE Firms (please attach copies of requests to agencies and any responses
received, ix., lists. Internet page download, etc.);
Name of Agencv/Organication Method/Date of Contact Results
. ............. - -------- _......_ -- -- ._ ......
. --
14. Any additional data to support a demonstration of good faith efforts (use additional sheets if
necessary):
..__._....--_ ... __ ......... _. .....
.--'-.--------__.-----.----._._._..._—
NOTE: USE ADDITIONAL, SIJEF.TS OF PAPER IF NECESSARY.
Page 15 -34a
UP 09 -02 - Julv 31, 2009
NOR Ms r
GARVEY AVENUE
HIGHWAY SAFETY IMPROVEMENT PROJECT
HSIPL 5358 (014)
EYF11131 "F 15 -G2 Local Assistance Procedures Mannal
Local Agency Bidder Mr Information (Construction Contracts)
INSTRUC:TION'S - LOCAL AGENCY BIDDER DBE INFORMATION
(CONSTRUCTION CONTRACTS)
SUCCESSFUL BIDDER:
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 DBEs. Prime contractors shall indicate all work to be performed by
DBEs including work performed by its own forces, if a DBE- The he EIBE3 shall provide a certification number to the
Contractor and expiration date. Enter [)BF, prime and subcontractors certification number. The DBE contractors
should notify the Contractor in writing with the (late of the decertification if their stators should change during the
course of the contract. The fornr has a column for the Narnes of DBE certified contractors to perform the work
(must be certified on the date bids are opened and include DBE address and phone number_
IMPORTANT: Identify all DBE firms participating in the project -- including all LJI)BEs listed on the tIMBE
Commitment form (E?xhibit 15 -G1), regardless of tier. Names of the First -Tier DBEs subcontractors and their
respective itetn(s) ol'work listed should be consistent, where applicable, with the names and items of work in the
"List ar Subcontractors" submitted with your bid.
There is a column for the L)BF participation dollar amount. Enter the Total Claimed DBE 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 DBE;, describe exact portion of time to be performed or furnished
by the DBE.) See Section "Disadvantaged Business Eriterprise (DBE)," of tile Special Provisions (construction
contracts) to determine how to count the participation of DBE firms.
Exhibit 15 -G2 must be signed and dated by the successful bidder. Also list a phone number in the space provided
and print the name of tile person to contact.
Local agencies should complete the Local Agency Contract Number, Federal -aid Project Number
Federal Share, Contract Award Date fields and verify that all information is complete and accurate before signing
and sending a copy of the form to the District Local Assistance Engineer within 15 days ofcontract execution.
Failure to submit a completed and accurate form within the 15-clay time period may result in the de- obtigation of
finds on this project.
District DBE Coordinator should verify that all informations is complete in([ accurate. Once the
information has been verified, the .District Local Assistance Engineer signs and dates the form.
Page 15_321)
Juh 31, 2009 LPP 09 -02
Local Assistance Procedures Manual EVlV0[|5'&2
Local A Biddei 0*E,/ N i (C onstruction
Exn}8lT/ LOCAL /tGDNCY BIDDER DBE IMF0xMA7l0M (CONSTRUCTION CONTRACTS)
(Inclusive o(x|| DBEs including the UDB5o|istodo, bid proposal)
NOTE: PLEASE REFER T0 INSTRUCTIONS 0mTILE, REVERSE SIDE {}|lB|SFORM
mwEcro
*n\xscOCI
BID DATL
000ER'SxAwK
C,nvrxxCroVuC0O»L: -�o
x«c/ 1IIENI OF xOxu AND n[SCwmr1On 111 oaw0UwT
:v. rccs - to oc AND Fxmxx |K.w tile (late bill, IDBF
rxxcrcoux>xATEmxIS AT hnop,*a/oawrnat^awnss '
PD BF PROVIISD for contracted ir tile I "we, minkr)
9
1wo
For Local Agency toComplete;
Lzsa A (v''mu*vvb*c ... .... ........ ... _ ........
_____�_____
Federal-aid ,viectx`mb*,:__ ... ....... __ ... _ .......
______�_���
f0awmMV_
Contract Award Ditc:__
fillorniation
i*m^:uu/,,ninummoonxeuuiom/i,ow`����,o".~o�.x
wwmu
|mco| A
x**mow�iw
For Caltraxis Review:
-
Date����
nAWonned DBs
mxi"pmw
V Person mc"mxu
�
s �
�^^A f 'aw"m~o.cpm^*omu^*mm
C-altoln, District ['nal Assistance
Distri (/>c"»/-*^mpmo"v»'mouCa�m�u��u�xo|»n~m"�a�iom,Vou\�)vu�,/�ar�v/wnx,u�x"*�w��i"ww
,.xoo^/p*lku/'^{�oio`iou'i»�so/cwuou"uu//i"omoom,"|t/o.c-Tuigw/oeofsw&/o,mi/pv,,u
p)ro,/uuo�,.,rom�pck�r*camm,n.,r�|",umna�mu,
Page 1430
LPP{l'0| Jummrl 27.2012
California Professional Engineering, Inc. dba
BIDDER: California Profession Electrical Engineering
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 manysheets 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.
:• �
KNOW ALL MEN BY THESE PRESENTS:
THAT California Professional Engineering, Inc. dba California Professional Electrical Engine
Principal, and The Hanover Insur C ompany
as Surety, are held firmly bound unto the
CITY OF ROSE AD (hereinafter called the OWNER) in the sum of
Ten Percent of The Bid Amount
($ 10% ), 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 forthe Garvey Avenue Highway Safety Improvement Proiect setforth
in the Notice Inviting Bids and accompanying Bid Documents, dated
Augusts 2015
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
Sid 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
maybe 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.
20 5
CBF -4
SIGNED AND SEALED, this 30th day of_
CALIFORNIA 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 }
s
On I) tJ 1 before me, C7�r- t
ereinsertna n iteo t co m r r r
personally appeared V F4n
who proved to me on the basis of
>atisfactory ebMdence to be the person(s) whose
name(s) is /are subscribed to the within instrument and acknowledged to me that
he /she /they executed the same in his /her /their authorized capacity(ies), and that by
his /her /their signature(s) on the instrument the person(s), or the entity upon behalf of
which the person(s) 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 ° °w JENNIFER ORRALA
Comm.A 2114241 '
g (� ® o NOTARY PUBLIC
•CALIFOANIA N
LOS ANOELES COUNTY
°+ P- ^ MY Comm, EAP, JUNE 0, 2018'
s
Notary; blic Signa} re (Notary Public Seal)
ADDITIONAL OPTIONAL INFORMATION
DESCRIPTION OF THE ATTACHED DOCUMENT
(Title or description of attached document)
(Title or description of attached document continued)
Number of Pages Document Date
CAPACITY CLAIMED BY THE SIGNER
❑ Individual (s)
❑ Corporate Officer
(Title
❑ Partner(s)
❑ Attorney -in -Fact
❑ Trustee(s)
❑ Other
^011 Version , hitii %ry Classes.ccrrr 45;0-8?3 -98655
INSTRUCTIONS FOR COMPLETING THIS FORM
This form complies with current California statutes regarding notary wording and,
f needed, should be completed and attached to the document. Acknowledgments
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
sigreds) 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 / the);- 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.
CALIFORNIA ALL-PURPOSE 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 July 30, 2015 before me, Christine T. Hoang Notary Public,
Date Insert Name of Notary exactly as it appears on the official seal
personally appeared Yung T. Mullick
0 .�4._-MCN HRISTINEIHOANG N C OM{yi. # 2008757 � OTARY PUBLIC•CALIFORNIA ORANGE COUNTY Y COMM. EXP. PE8 26, 2017
Place Notary Seal Above
who proved to me on the basis of satisfactory evidence to
be the person(s) whose name(s) is /are subscribed to the
within instrument and acknowledged to me that he /she /they
executed the same in his /her /their authorized capacity(ies),
and that by his /her /their signature(s) on the instrument the
persori or the entity upon behalf of which the person(s)
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
Witn
Sign
OPTIO)
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 the form to another document.
Description of Attached Document
Title or Type of Document:
Document Date:
Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name:
❑ Individual
❑ Corporate Officer— Title(s):_
❑ Partner ❑ Limited ❑ General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer is Representing:
Number of Pages:
Signer's Name:
❑ Individual
❑ Corporate Officer — Title(s):
❑ Partner ❑ Limited ❑ General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer is Representing:
THE HANOVER INSURANCE COMPANY
MASSACHUSETTS BAY INSURANCE COMPANY
CITIZENS INSURANCE COMPANY OF AMERICA
POWERS OF ATTORNEY
CERTIFIED COPY
KNOW ALL MEN BY THESE PRESENTS: That THE HANOVER INSURANCE COMPANY and MASSACHUSETTS BAY INSURANCE COMPANY, both
being corporations organized and existing under the laws of the State of New Hampshire, and CITIZENS INSURANCE COMPANY OF AMERICA, a
corporation organized and existing under the laws of the State of Michigan, do hereby constitute and appoint
James W. Moilanen, Yung T. Mullick, and /or Jennifer C. Anaya
of Mission Viejo, CA and each is a true and lawful Attorney(s) -in -fact to sign, execute, seal, acknowledge and deliverfor, and on its behalf, and as its act and
deed any place within the United States, or, if the following line be filled in, only within the area therein designated any and all bonds, recognizances,
undertakings, contracts of indemnity or other writings obligatory in the nature thereof, as follows:
Any such obligations in the United States, not to exceed Ten Million and No /100 ($10,000,000) in any single instance
and said companies hereby ratify and confirm all and whatsoever said Attorney(s) -in -fact may lawfully do in the premises by virtue of these presents.
These appointments are made under and by authority of the following Resolution passed by the Board of Directors of said Companies which resolutions
are still in effect:
"RESOLVED, Traffic President or any Vice President, in conjunction with any Vice President, be and they are hereby authorized and empowered io appoint
Attorneys -in -fact ofthe Company, in its name and as its acts, to execute and acknowledge for and on its behalf as Surety any and all bonds, recognizances,
contracts of indemnity, waivers of citation and all otherwritings obligatory in the nature thereof, with powerto attach thereto the seal of the Company. Any
such writings so executed by such Attemeys-in4act shall be as binding upon the Company as if they had been duly executed and acknowledged bythe
regularly elected officers of the Company in theirown proper persons." (Adopted October 7, 1981 -The Hanover Insurance Company; Adopted April 14, 1982
- Massachusetts Bay Insurance Company; Adopted September 7, 2001 - Citizens Insurance Company of America)
IN WITNESS WHEREOF, THE HANOVER INSURANCE COMPANY, MASSACHUSETTS BAY INSURANCE COMPANY and CITIZENS INSURANCE
COMPANY OF AMERICA have caused these presents to be sealed with their respective corporate seals, duly attested by two Vice Presidents, _
this Gad day of January 2012.
THE HANOVER INSURANCE COMPANY
.� l cry MASSACHUSETTS BAY INSURANCE COMPANY
g ...� •2 CITIZENS' PSSjU�RA�NCE OMPANY OF AMERICA
Robert Vice Preslsieut
THE COMMONWEALTH OF MASSACHUSETTS
�- r - --- -- ^,.v'`
COUNTY OF WORCESTER ) ss. Sot tronstrom, to President
On this 3rd day of January 2012 before me came the above named Vice. Presidents of The Hanover Insurance Company, Massachusetts Bay Insurance
Company and Citizens Insurance Company of America, tome personally known to be the individuals and officers described herein, and acknowledged that
the seals affixed to the preceding instrument are the corporate seals of The Hanover Insurance Company, Massachusetts Bay Insurance Company and
Citizens Insurance Company of America, respectively, and that the said corporate seals and their signatures as officers were duly affixed and subscribed to
said instrument by the authority and direction of said Corporations.
°P w, BARSARAA. GARLICK
�� yin �`9�NgIRMa3lh Of AlA568G1U5Atl6 ft /���/', f X .�� {j
I,tyE �uim6xplr�s Sept 21, 2Ct9
Barbara A. Garlick, Notary Public
My Commission Expires September 21, 2018
I, the undersigned Vice President of The Hanover Insurance Company, Massachusetts Bay Insurance Company and Citizens Insurance Company of America,
hereby certify thatthe above and foregoing is a full, true and correct copy ofthe Original Power of Attorney issued by said Companies, and do hereby further
certify that the said Powers of Attorney are still in force and effect.
This Certificate may be signed by facsimile under and by authority of the following resolution of the Board of Directors of The Hanover Insurance Company,
Massachusetts Bay Insurance Company and Citizens Insurance Company of America.
of America)
That any and all Powers of
:y and Carlifietl Copies of such Powers of Attorney and certification in respect thereto, granted and executed
lion with any Vice President of the Company, shall be binding on the Company to the same extent as if all
though one or more of any such signatures thereon may be facsimile." (Adopted October 7, 1981 - The
1982- Massachusetts Bay Insurance Company; Adopted September 7, 2001- Citizens Insurance Company
GIVEN under my hand and the seals of said Companies, at Worcester, Massachusetts, this 30th day of 7 n1y 20
THE HANOVER INSURANCE COMPANY
MASSACHUSETTS BAY INSURANCE COMPANY
CIT INSURANCE COMPANY OF AMERICA
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