Kalban, Inc.BIDDER: Ci
CONTRACT BID FORMS
TABLE OF CONTENTS
SECTION 1 BID SCHEDULE ....................................................................................................1
SECTION 2 BID DATA FORMS
2.A BID BOND
2.13 LIST OF PROPOSED SUBCONTRACTORS
SECTION 3 NON-COLLUSION AFFIDAVIT........ F
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BIDDER: ~AA I4C -
SECTION 1 - BID SCHEDULE
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BIDDER: T A C
BID SCHEDULE
SCHEDULE OF PRICES FOR
ANNUAL 2008-2009 CURB RAMPS CONSTRUCTION PROJECT
CDBG PROJECT No. P46402
BASE BID SCHEDULE
UNIT OF
EST.
ITEM
NO.
ITEM DESCRIPTION
MEASURE
QTY.
PRICE
COST
1
Clearing & Grubbing per plans and
L
specifications. See technical
provisions.
LS
2
Disposal of Waste Materials
LS
1
-700q-
3
Construct PCC Curb Ramps per
APWA Std. Plan 111-3 including
truncated domes ARMORCAST
replaceable yellow cast in place or
approved equal. See Curb Ramp
Tabulation on Appendix A and TP-
?
2~J~oa
!
z . fQ.
7 per details and locations.
Ea
70
4
Furnish and install ONLY
Truncated Domes Detectable
Warning Surfaces - ARMORCAST
retrofit or approved equal. See
OD
M
appendix A and TP-7 per details.
Ea
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TOTAL BASE BID PRICE (SCHEDULE BID PRICE):$ /Z7, dp 0
Dollar amount in written form
ALTERNATE BID ITEM 1 .
NO.
ITEM DESCRIPTION
UNIT OF
MEASURE
EST.
CITY.
UNIT
PRICE
ITEM ,
COST
5
Construct 4-inch PCC Sidewalk
0
OO
cD~.
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per APWA Std Plan 113-1.
SF
45
6
Construct PCC Cross and
Longitudinal Gutters per APWA
/
Std. Plan 122-1. Intersection of
SF
300
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I BIDDER: -:71 C
' TOTAL ALTERNATE BID PRICE (SCHEDULE BID PRICE): $ E::2 Sy. 00
' Dollar amount in written form
TOTAL BASE BID PRICE (SCHEDULE BID PRICE):$ ~J 3~ 3 ~Q-
'
' Dollar amount in written form
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' cannot be withdrawn for the number of Working Days indicated in the Notice Inviting Bids from and
after the bid opening date, or until a Contract for the 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.
Attach h eto is a certified check, a cashier's check or a bid bond in the amount of
' 9 ollars ) said amount being not less than ten percent (10%) of the Total
Bid rice. 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
t 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
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.
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' BIDDER: ~/<6Lf~~ ~/(~C
' 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.
I Addenda Nos. d
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
I contract
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By:
Signature
~JE ~L`lo'L~
Type or Print Name
'
iJlcE GPES~ .l-f-
Title
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BIDDER: -7, C -
`/D7s GtEA-114*1(s 8(-LfD .
business Street Address
14f, e~*
City, State and Zip Code
<51 -K Sam/ /o6s
Telephone Number
Bidder's/Contractor's State of Incorporation:
Partners or Venturers:
Bidder's License Number(s): -7 5- S -6k
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
I3) If Bidder is a partnership or joint venture, give full names of all partners or joint
venturers.
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As further discussed in the Instructions to Bidders, Bidder will be require
to provide evidence that the person signing on behalf of the corporation,
_partnership or joint venture has the authority to do so.
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MINUTES OF THE BOARD OF DIRECTOR'S MEETING OP KALBAN, INC.
The Board of Directors of Kalban, Inc. held it's annual maeting on Janaary 33L 2001,
at 10950 Tuxford Street 416, Sun Valley, California 91352.
The following Directors were present:
Miron Kalebjian
Judy Kalebjian
The following RcS011_16011S were adopted:
Resolved herewith that the Officers of the Corporation are as follows:
President - Miron Kalebjian
Treasurer - Judy Kalebjian
Vice President - David L. Poole
Vice President - Michael G. Lifsey
Secretary - Bonnic Lane
Resolved herewith that all of the above named oflicers are hereby authorized to
execute documents on behalf of Kalban, file., relative to bid proposals and contracts in the
daily operations of the business.
No further husiness was discus
Mceting closed.
Miron I~fllebjian, President
i' I
Bonnie Lane, Secretary
I hereby acknowledge that the foregoing is a true and correct copy of the Resolution of
the Board of Directors of Kalban,Inc.
KALBAN, INC.
Bonnie Lane, Secretary
GAUrvFSrvlA
State of California
ss.
County of Los Angeles
On a::9&f before me, Michael Edward Lifsey, Notary Public
personally appeared
Dave Poole
hOClii£! EDyilv'ZGl l!'r5R'
Commlsslon 0 1696756
Notory PubW - Ca^fomla
trn Angol.'*3 County
twy Comm. Wires May 5, 201
who proved to me on the basis of satisfactory evidence to
be the person whose name is subscribed to the within
instrument and acknowledged to me that he executed the
same in his authorized capacity, and that by his signiture
on the instrument the person, or the entitiy upon behalf of
which the person acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of
the State of California that the foregoing paragraph is true
and correct.
WITNESS my hand and official seal
Signiture or
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document and could
prevent fradulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document:
Document Date: Signer Other Than Named Above:
Capacity Claimed by Signer
Signer's Name: I/c JOOZ
Individual ~T
Corporate Officer - Title: r~a(~-S r c7~w i
Partner
❑
Attorney - in - tact
Fj
Trustee
Guardian
Other:
Signer is Representing: &
Number of Pages:
C
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BIDDER: X& 1~C
SECTION 2
BID DATA FORMS
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BIDDER! Kalban, 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 Bidders name and page number.
2.A BID BOND
KNOW ALL MEN BY THESE PRESENTS:
THAT Kalban, Inc. as
Principal, and The Guarantee Company of North America USA
, as Surety, are held firmly bound unto the
CITY OF ROSEMEAD (hereinafter called the OWNER) in the sum of
Ten percent of amount bid
($10% being not less than ten percent (10%) of the Total
Bid Price; for the payment of which sum will and truly to be made, we bind
ourselves, our heirs, executors, administrators, successors, and assigns, jointly and
severally, firmly by these presents.
WHEREAS, said Principal has submitted a bid to the OWNER to perform all Work
_ required forthe Annual 200$-2009 Curb Ramps Construction Project as seiforth In
the Notice Inviting Bids and accompanying Bid Documents, dated
February 25, 2009
- 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 24th day of February , 2009 .
Kalban, Inc. (SEAL) 'rneGuarantee Company of NoMAmencaUSA (SjEAL)
Principal ~ Surety
By:.' v By.
Signat si lure
aD\'e'J 1C_e- °Stckdk Willi in, Attorney-in-Fact
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THE GUARANTEE COMPANY OF NORTH AMERICA USA
Southfield, Michigan
POWER OF ATTORNEY
KNOW ALL BY THESE PRESENTS: That THE GUARANTEE COMPANY OF NORTH AMERICA USA, a corporation organized and exisfing under the
laws of the State of Michigan, having its principal office in Southfield, Michigan, does hereby constitute and appoint
William Syrkin, Matthew C. Welty
Millennium Corporate Solutions, Inc.
its true and lawful attomey(s)-in-fact to execute, seal and deliver for and on its behalf as surety, any and all bonds and undertakings, contracts of
indemnity and other writings obligatory in the nature thereof, which are or may be allowed, required or permitted by law, statute, rule, regulation, contract
or otherwise.
The execution of such instrument(s) in pursuance of these presents, shall be as binding upon THE GUARANTEE COMPANY OF NORTH AMERICA
USA as fully and amply, to all intents and purposes, as if the same had been duly executed and acknowledged by its regularly elected officers at the
principal office.
The Power of Attorney is executed and may be certified so, and may be revoked, pursuant to and by authority of Article IX, Section 9.03 of the By-Laws
adopted by the Board of Directors of THE GUARANTEE COMPANY OF NORTH AMERICA USA at a meeting held on the 31° day of December, 2003.
The President, or any Vice President, acting with any Secretary or Assistant Secretary, shall have power and authority:
1. To appoint Attorney(s)-in-fact, and to authorize them to execute on behalf of the Company, and attach the Seal of the Company thereto, bonds
and undertakings, contracts of indemnity and other writings obligatory in the nature thereof; and
2. To revoke, at any time, any such Attomey-in-fact and revoke the authority given, except as provided below
3. In connection with obligations in favor of the Kentucky Department of Highways only, it is agreed that the power and authority hereby given to
the Attomey-in-Fact cannot be modified or revoked unless prior written personal notice of such intent has been given to the Commissioner -
Department of Highways of the Commonwealth of Kentucky at least thirty (30) days prior to the modificallon or revocation.
Further, this Power of Attorney is signed and sealed by facsimile pursuant to resolution of the Board of Directors of the Company adopted at a meeting
duly called and held on the 31" day of December 2003, of which the following is a true excerpt:
RESOLVED that the signature of any authorized officer and the seal of the Company may be affixed by facsimile to any Power of Attorney or certification
thereof authorizing the execution and delivery of any bond, undertaking, contracts of indemnity and other writings obligatory in the nature thereof, and
such signature and seal when so used shall have the same force and effect as though manually affixed.
IN WITNESS WHEREOF, THE GUARANTEE COMPANY OF NORTH AMERICA USA has caused
~w"'EEC
o
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this instrument to be signed and its corporate seal to be affixed by its authorized officer, this 13th day
of November. 2007.
THE GUARANTEE COMPANY OF NORTH AMERICA USA
'Ma~rta`c
_
STATE OF MICHIGAN
Stephen Dullard, Vice President Randall Musselman, Secretary
County of Oakland
On this 13th day of November, 2007 before me came the individuals who executed the preceding instrument, to me personally known, and being by me
duly swum, said that each is the herein described and authorized officer of The Guarantee Company of North America USA; that the seal affixed to said
instrument is the Corporate Seal of said Company; that the Corporate Seal and each signature were duly affixed by order of the Board of Directors of
said Company.
Y Cynthia A. Takai IN WITNESS WHEREOF, I have hereunto set my hand at The Guarantee
Notary Public, State of Michigan Company of North America USA offices the day and year above written.
` County of Oakland
My Commission Expires February 27, 2012
+Acting in Oakland County
/""/y' [•f.-//afG!-c,,/
I, Randall Musselman, Secretary of THE GUARANTEE COMPANY OF NORTH AMERICA USA, do hereby certify that the above and foregoing is a true
and correct copy of a Power of Attorney executed by THE GUARANTEE COMPANY OF NORTH AMERICA USA, which is still in full force and effect.
IN WITNESS WHEREOF, I have thereunto set my hand and attached the seal of said Company this 24th day of February 2009
vJppe.xtee c~~
9. Randall Musselman, Secretary
~nIAMER r'P
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
C'C.M.~`G^~'.c`C.C?'~ .C>C- {:f.C',C-~fLYr.L~''C.C~C4<`~'~C~.tN~^(.!~.L'r'<'!'.c:OTC.'C.CY~t~''e'r•Gr.C~F>C.C`C.EF.I-C.Cr'iC`~~.GY~.tKY'~c~"'C`M~: ~`C.M.[w{
State of California
County of Orange
On 02/24/09 before me, R. Haas-Bates, Notary Public
Date Here Insert Name and Tile of the Officer
personally appeared William Syrkin
Namots) of Sgnegsl
S-BATS
[Q=NOTAR" 1J9616g
LIC CpUFORNIA
S APRIL 2T 012
who proved to me on the basis of satisfactory evidence to
be the person(a) whose name(s) is/aFe subscribed to the
within instrument and acknowledged to me that
he/she" executed the same in his/hecAgeic authorized
capacity(ies), and that by his/HeFAIR86F signature(4 on the
instrument the person(*, or the entity upon behalf of
which the person*acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph is
true and correct.
Place Notary Seal Above
WITNESS my hand and official seal.
Signature
QAZ~o s OQ ~-t - o
Signature of Notary Public
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:
Document Dale:
Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name: William
❑ Individual
Corporate Officer-Title(s): _
❑ Partner - ❑ Limited ❑ General
Attorney in Fact
Trustee
Guardian or Conservator
Other:
Signer Is Representing:
Top cf thumb here
Signer's Nar
❑ Individual
Number of Pages:
❑ Corporate Officer-Title(s): _
r Partner - ❑ Limited ❑ General
Attorney in Fact
G Trustee
Guardian or Conservator
O Other:
Signer Is Representing:
Top of Thumb here
I
02007 NOtwnal Notary Acc.oecr-9350 Do SOB AV.-POB.2402•ChetawvM. CA 91313.2402•w.vw.N.le,rarMl.,o,g Item 45907 Heorder Call Toil Free tP rji 6827
NIA ALL-FLIKFUJt
State of California
ss.
County of Los Angeles
Ong before me, Michael Edward Lifsey, Notary Public
personally appeared
Dave Poole
who proved to me on the basis of satisfactory evidence to
be the person whose name is subscribed to the within
instrument and acknowledged to me that he executed the
same in his authorized capacity, and that by his signiture
on the instrument the person, or the entitiy upon behalf of
which the person acted, executed the instrument.
Comte # 1686755
Notary Koft - Cu."fomla
Los An901011 vCAX*nn
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
Signiture
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document and could
prevent fradulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document:
Document Date: Number of Pages:
Signer Other Than Named Above: R//G,-
Capacity Claimed by Signer
Signer's Name: QQ~ZC
❑ Individual
pl corporate Officer - Title: I
❑ Partner
Attorney - in - tact
Trustee
rl
Guardian
❑
Other:
Signer is Representing:
I BIDDER: F& ~ =(V C
I 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 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.
Pursuantto Public Contract Code Section 4104, the Owner has determined that itwill allow
Bidders twenty-four (24) additional hours afterthe 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.
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BIDDER: T C
2.6 LIST OF PROPOSED SUBCONTRACTORS (continued)
["Duplicate Next 2 Pages if needed for listing additional subcontractors.-I
Name and.Location Description of Work
of Subcontractor to be Subcontracted
Name: Ax/Address:
Name and Location
of Subcontractor
Name:
Address
Description of Work
to be Subcontracted
Name and Location
Description of Work
of Subcontractor
to be Subcontracted
Name:
Address:
Name and Location
Description of Work
of Subcontractor
to be Subcontracted
Name:
Address:
Name and Location
Description of Work
of Subcontractor
to be Subcontracted
Name:
Address
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BIDDER: 1<1AL M ~ :wc
2.C 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:
f. ~c n r iryzflC-
Name and Address of Owner
Name and telephone number
Contract amount
2.
Name and Address of Owner
of person familiar with project
of Work
Date Completed
Name and telephone number of person familiar with project
Contract amount Type of Work Date Completed
3.
me and Address of Owner
Name and telephone number of person familiar with project
Contract amount Type of Work Date Completed
4.
and Address of Owner
Name and telephone number of person familiar with project
Contract amount
Type of Work
CBF-9
Date
KALBAN, INC.
GENERAL ENGINEERING CONSTRUCTION
818-504-1065 Fax:818-504-1067
Recently Completed Projects and Reference List
City of Burbank - Contact: Adam Salehi - 81 8-238-3946
2008 Sidewalk Repair Program
Removal and Replacement of Damaged PCC Various Locations
$1,100,000.00
2007 CDBG Street Project
Removal and Replacement of Damaged PCC Various Locations
$120,000.00
2006 Sidewalk Repair Project
Removal and Replacement of Damaged PCC Various Locations
$535,230.00
2005 Oak St. & Bel Air Dr. Improvements
Street Reconstruction Asphalt Resurfacing, PCC Replacment
$720,000.00
2004 CDBG Street, Alley & Sidewalk
Replacement of Asphalt Street with Portland Cement Concrete
S 598,010.00
2002-2003 CDBG Street Project
Street Reconstruction Asphalt Resurfacing, PCC Replacment
$389,1597
2001 Alley Reconstruction Project
Replacement of Asphalt Alleys with Portland Cement Concrete
5305,000.00
2000 Citywide Alley Reconstruction
Replacement of Asphalt Alleys with Portland Cement Concrete
5510,025.00
City of Anaheim - Contact: Dave Hernandez - 714-936-4795
2007-2008 Resort Maintenance
Removal and Replacement of Damaged PCC Various Locations
5260,000.00
2005-2006 Resort Maintenance
Removal and Replacement of Damaged PCC Various Locations
$120,000.00
2002 Sidewalk Replacement Annual Contract
Removal and Replacement of Damaged PCC Various Locations
$333,000.00
2001 Sidewalk Replacement Annual Contract
Removal and Replacement of Damaged PCC Various Locations
$1,600,000.00
City of Orange - Contact: Alan Throng - 714-744-5544 -
2007 Annual Concrete Replacement
Removal and Replacement of Damaged PCC Various Locations
5500,000.00
2006 ADA Access Ramps
Construct Wheelchair Access Ramps, Various Locations -
$132,276.00
2005 Annual Concrete Replacement
- Removal and Replacement of Damaged PCC Various Locations
$400,000.00
2004 Annual Concrete Replacement
Removal and Replacement of Damaged PCC Various Locations
$204,000.00
City of Norwalk - Contact: Randy Hillman - 562-929-5719
2007 Local Street Project Street Reconstruction Asphalt Resurfacing, PCC Replacment $1,640,000.00
City of LaCanada Flintridge - Contact: Ying Kwan - 81 8-790-8882
2006 School Loading Bay Improvements
Parkway Re-Construction at Loading Zone
$131,978.00
Vista Del Valle/Haskell Intersection Recon.
Reconstruction of Intersections
$95,000.00
2002 - Verdugo Blvd Street Improvements
Street Improvements
$310,000.00
City of Pasadena - Contact: Reny Quijano - 626-744-4720
Street Reconstruction
Avenue 64 Street Improvements
51,900,000.00
Site Improvements at Various Parks
ADA Compliance PCC & Misc Structures
5485,000.00
City of Santa Clarita - Contact: Erven Jasamilla - 661-225-4344
2006 Intersection Modification
Street Reconstruction Asphalt Resurfacing, PCC Replacment
$394,793.00
2003-2004 Annual Concrete Rehabilitation
Removal and Replacement of Damaged PCC Various Locations
$231,600.00
2002-2003 Annual Concrete Program
Street Reconstruction Asphalt Resurfacing, PCC Replacment
$396,000.00
2001-2002 Annual Concrete Program
Removal and Replacement of Damaged PCC Various Locations
5218,900.00
1999-2001 Annual Concrete Program
Removal and Replacement of Damaged PCC Various Locations
4333,389.00
Los Angeles County Department of Public Works - Contact: Issa Adawiya - 626-458-4942
2007 RDC 0012247 South Bay Bike Trail $425,000.00
2004 Project ID No. FCC0000856
Rubio Diversion Invert repair Project
$423,200.00
2003 Project ID NO. FCC0000703
Ward Channel Invert and Connector Pipe Repair
5168,090.00
2002 Newburgh Street, ET AL
Street Reconstruction Asphalt Resurfacing, PCC Replacment
5298,000.00
2002 126th Street
Street Reconstruction Asphalt Resurfacing, PCC Replacment
5185,713.00
2000 Curb Ramps - CC 9102
Construction of Access Ramps, Various Locations Citywide
$523,582.00
1998-Cash Contract 7535
Removal and Replacement of Damaged PCC Various Locations
$149,328.00
City of Huntington Park - Contact: Pat Fu - 323-584-6253
2008 Alley Improvements
Reconstruct PCC Alleys
5356,230.00
2007 Alley Reconstruction Project
Reconstruct PCC Alleys
5308,993.20
City of Glendale - Contact: Sam Mody - 81 8-548-3945
2007/2008 ADA Curb Ramps
Removal and Replacement of Damaged PCC Various Locations
$1,038,000.00
2005/2006 ADA Curb Ramps
Removal and Replacement of Damaged PCC Various Locations
51,071,000.00
San Fernando Corridor Street Improvements
Street Reconstruction Asphalt Resurfacing, PCC Replacment
5422,000.00
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BIDDER: l~1/ SN C
SECTION 3
NON-COLLUSION AFFIDAVIT
CBF-10
BIDDER: '6c 0 C
' 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.
' Signature
' Typed or Printed Name
Title
Bidder
Subscribed and sworn b e me -
This _ day of 20
(Seal)
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Notary Public in and for
the State of California
My Commission Expires:
CBF - 11
t;ALII-UKNIA ALL-F'UHVVJC
State of California
ss.
County of Los Angeles
On 2--,2"e,41 before me, Michael Edward Lifsey, Notary Public
personally appeared Dave Poole
who proved to me on the basis of satisfactory evidence to
be the person whose name is subscribed to the within
instrument and acknowledged to me that he executed the
same in his authorized capacity, and that by his signiture
on the instrument the person, or the entitiy upon behalf of
which the person acted, executed the instrument.
µ tD1NARD v
Comms>ton O 1656756765 I certify under PENALTY OF PERJURY under the laws of
ati dory t'u t Calltorinlo the State of California that the foregoing paragraph is true
+t Los Angotas Courky
My Colfml.bpmMoy5.201 and correct.
WITNESS my hand and official seal
Signiture of Notaryublic
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document and could
prevent fradulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document: 11141 ~~~~G/~S//0O
Document Date: Number of Pages:
Signer Other Than Named Above:~~
Capacity Claimed by Signer
Signer's Name: DOZ C:-
Individual
Corporate Officer - Title:
Partner
Attorney - in - fact
Trustee
Guardian
Other:
Signer is Representing:
A
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' "NONCOLLUSION AFFIDAVIT TO BE EXECUTED BY BIDDER AND SUBMITTED WITH BID"
§7106. Any public works contract of a public entity shall include an affidavit, in the following form:
State of California )
' County of e r f ) ss.
being first duly sworn, deposes and says that, he or she is
Ice MCSr D aVr of A:::~tL e3lWl C/U C - 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"
'
Project Name: &W-679 er/, XP 100 Project Number:
I ,
' Company: /KIt z- gz~&Z
Address: CEi1~Ogi~3 cIJU ~cl~ t/~GLrfY C~ 9~35z
Signature:
' Title: (/~~~~c S/ ci(/'r
Date:
WORN TO AND SUBSCRIBED TO BEFORE ME
' This day o 20
' /s/ Notary Public:
My Commission Expires:
UALIt VKIVIA
State of California
ss.
County of Los Angeles
On 2y- 07 before me, Michael Edward Lifsey, Notary Public
personally appeared Dave Poole
who proved to me on the basis of satisfactory evidence to
be the person whose name is subscribed to the within
instrument and acknowledged to me that he executed the
same in his authorized capacity, and that by his signiture
on the instrument the person, or the entitiy upon behalf of
which the person acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of
ECINAM LESEY the State of California that the foregoing paragraph is true
Commleston 0 1656765 and correct.
S ryptoly"r -co~totNa _
z Los AngMall C:wMJ
Wcorrim. bores mory 6. 2010 WITNESS my hand and official seal
i
Notary Public
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document and could
prevent fradulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document: 1t/D.d~G C US yd/U ~ 3~rl- 40 j
Document Date: Number of Pages:
r
Signer Other Than Named Above:
Capacity Claimed by Signer
Signer's Name: ~Ut/E p6bOL(t~
El Individual
6 Corporate Officer - Title:
Partner
Attorney - in - tact
E]
Trustee
Guardian
El
Other.
Signer is Representing: 1<~tq ( 0 0 _
LJ
I entertainment areas, transportation, and housing facilities provided for employees which are segregated
NON-SEGREGATED FACILITIES CERTIFICATION
FEDERALLY-ASSISTED CONSTRUCTION PROJECTS
The federally-assisted construction contractor certifies that he/she DOES NOT and WILL NOT:
Maintain or provide, for his/her employees, any segregated facilities at any of his/her
establishments.
2. Permit his/her employees to perform their services at any location, under his/her
control, where segregated facilities are maintained.
The federally-assisted contractor agrees that a breach of this certification is a violation of the Equal
Opportunity Clause in this contract. As used in this certification, the term segregated facilities means any
waiting room, work areas, restrooms and washrooms, restaurants and other eating areas, time clocks,
locker rooms and other storage or dressing areas, parking lots, drinking fountains, recreation or
by explicit directive or are in fact segregated on the basis of race, creed, color, or national origin, because
of habit, local custom, or otherwise.
' The federally-assisted contractor agrees that (except where he/she has obtained identical certifications
from proposed subcontractors for specific time periods) he/she will obtain identical certifications from
' proposed subcontractors prior to the award of subcontracts exceeding $10,000 which are not exempt
from the provisions of the Equal Opportunity Clause, and that he/she will retain such certifications in
his/her files. .
I NOTE: The penalty for making false statements in offers is prescribed in 18 U.S.C. 1001.
Date: g ey
Company:
Address:
Project Number: ~ W3&Z
I Title:
i I
P
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CERTIFICATION
WITH REGARD TO THE PERFORMANCE OF PREVIOUS CONTRACTS OR
SUBCONTRACTS SUBJECT TO THE EQUAL OPPORTUNITY CLAUSE AND
THE FILING OF REQUIRED REPORTS
The Idder, ❑proposed sub-contractor, hereby certifies that he/she as, ❑has not, participated
in a"previous contract or subcontract subject to the Equal ``0f~ portunlty Clause, as required by
Executive Orders 10925, 11114, or 11246, and that he/she as, ❑has not, filed with the Joint
Reporting Committee, the Director of the Office of Fedeffffal 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 filing requirements.
Date: Project Number: ContractAward: $
Awarding Agency: I%}l 67 / COCc 0452-27
Contractor Name: A4TSAN 1;1/ C - Total Number of Employees-'
Proposed prime contractors and subcontractors who have participated in a previous contractor 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 U.S. Department of the Interior or by the Director, Office of Federal Contract Compliance, U.S.
Department of Labor.
SF-100 (EEO-1) must be filed by;
(A) All private employers who are:
(1) Subject to Title VII of the Civil Rights Act of 1964 (as amended) with 100 or more employees.
(2) Subject to Title VII who has fewer than 100 employees, if the company is owned or affiliated with
another company, or there is centralized ownership, control or management so that the group legally
constitutes a single enterprise, and the entire enterprise employs a total of 100 or more employees.
(B) All federal contractors (private employers), who:
(1) Are not exempt as provided for by 41 CFR 60-1.5
(2) Have 50 or more employees, and
a. Are prime contractors or first-tier subcontractors, and have a contract, subcontract, or purchase
order amounting to $50,000 or more; or
b. Serve as a depository of Government funds in any amount, or
c. Is a financial institution, which is an issuing, and paying agent for U.S. Savings Bonds and Notes.
I
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).
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Name of Firm:
Address:
State:
Community Development Commission
County of Los Angeles
COUNTY LOBBYIST CODE CHAPTER 2.160
COUNTY ORDINANCE NO. 93-0031
CERTIFICATION
~D _,;5)?-/
Zip Code: Telephone Number. (g g)
Acting on behalf of the above named firm, as its Authorized Official, I make the following Certification to the
County of Los Angeles and the Community Development Commission, County of Los Angeles.
1)1/ It is understood that each person/entity/firm who applies for a Community Development
Commission contract, and as part of that process, shall certify that they are familiar with the
requirements of the Los Angeles County Code, Chapter 2.160 (Los Angeles County Ordinance
93-0031) and;
) v / That all persons/entities/firms acting on behalf of the above named firm have and will comply
2)v//
with the County Code, and;
3) /That any person/entity/firm who seeks a contract with the Community Development
Commission shall be disqualified therefrom and denied the contract and, shall be liable in civil
action, if any lobbyist, lobbying firm, lobbyist employer or any other person or entity acting on
behalf of the named firm fails to comply with the provisions of the County Code.
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
contract with the Los Angeles County and the Community Development Commission, County of Los Angeles.
Authorized Official:
(Contractor/5u1(c0ntrnct0r)
(Date)
I
I certify, by signature below, that I am aware of the provisions of Section 3700 of the
California Labor Code which require every employer to be insured against liability for /
worker's compensation or to undertake self-insurance in accordance with the provisions of V
that code, and I will comply with such provisions before commencing the performance of
the work of this contract.
Date: -
Il
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WORKER'S COMPENSATION CERTIFICATION
Project Name: 0 U C/
//~~~~LLC!/t'J~
Company Name: /~e&(FAiV o j~ C
Address:
Project Number: ~~yOz
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' Print Name:
I
Title: Ole ,
Signature:
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U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
HUD FORM 4230A
REPORT OF ADDITIONAL CLASSIFICATION AND RATE
M o6n
oms waro~i
E
um 09/312006
(
)
(
1. FROM (name and address of requesting agency)
2. PROJECT NAME AND NUMBER
3. LOCATION OF PROJECT (City, County and State)
4. BRIEF DESCRI ION OF PROJECT
5. CHARACTER OF CONSTRUCTION
❑ Building ❑ Residential
❑ Heavy ❑ Other (specify)
❑ Highway
6. WAGE DECISION NO. (includ odification number, if any)
7. WAGE DECISION EFFECTIVE DATE
❑ COPY ATTACHED
a. WORK CLASSIFI TION(S)
HOURLY WAGE RATES
BASIC WAGE FRINGE BENEFIT(S) (if any)
9. PRIME CONTRACTOR (name, address)
10. S CONTRACTORIEMPLOYER, IF APPLICABLE (name, address)
Check All That Apply:
❑ The work to be performed by the additional classification(s) is not performed by a classi ation in the applicable wage decision.
❑ The proposed classification is utilized in the area by the construction industry.
❑ The proposed wage rate(s), including any bona fide fringe benefits, bears a reasonable relatio hip to the wage rates contained in the
wage decision.
❑ The interested parties, including the employees or their authorized representatives, agree on the c sification(s) and wage rate(s).
❑ Supporting documentation attached, including applicable wage decision.
I Check One:
❑ Approved, meets all criteria. DOL confirmation requested.
❑ One or more classifications fail to meet all criteria as explained in agency referral. DOL decisl requested.
FOR HUD USE ONL
LR2000:
Agency Representative Date
Log in:
(Typed name and signature)
Log out:
Phone Number
ui in~nNe /Gni\ voFVl(11IC FIIITIl1M IC (1R<(N FTF
I
t TO:
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EMPLOYMENT OPPORTUNITY COMMITMENT
of Labor Union, Workers Representative, etc.
Name of Business (Contractor):
Project Name:
The Undersigned currently holds a con
funds of the U. S. Government, or a su
You are advised that under the provisions of A
with Executive Order 11246, the undersigned is
or applicant for employment because of race,
not to discriminate in employment includes, bul
contract or subcontract, and in accordance
~d not to discriminate against any employee
igion, sex or national origin. This obligation
limited to the follow:
1. Hiring, placement, upgrading, trans r or demotion;
2. Recruitment, advertising or solicitatio for employment;
3. Treatment during employment;
4. Rates of pay or other forms of compensa 'on;
5. Selection for training, including apprentices ip; and
6. Layoff or termination.
This notice is furnished to you pursuant to the provisions of the abovi
Executive Order 11246. Copies of this notice will be posted by the
places available to employees or applicants for employment.
Project Number:
, involving
with a prime contractor holding such contract.
By:
or subcontract and
ed in conspicuous
! NOTICE OF SECTION 3 COMMITMENT
!
! TO:
(Name of Labor Union, Workers Representative, etc.
! (Address)
! Name of Business (c tractor):
I The Undersigned currently hold a contract with
Project Name:
Project Number:
I Regarding job referrals, request that consideration be given, to~iye greatest extent feasible, to
involving Block Grant (CDBG) fun Ns from the U. S. Department of Housing and Urban Development
or a subcontract with a prime contr for holding such contract.
You are advised that under the provisi s of the above contractor subcontract and in accordance
with Section 3 of the Housing and Urban evelopment Act of 1968, the undersigned is obligated to
the greatest extent feasible, to give oppo nities for employment and training to lower income
residence of the CDBG-assisted project are and o award contracts for work on the project to
business concerns which are located in or are nq( in substantial part by project area residence.
Regarding employment opportunities for Sect
' ttffe minimum numoer ana joo rmes are:
Minimum
Number
ob Clas ification
assignment of persons residing in the service area or neighborhood i which the project is located.
! The anticipated date the work will begin is
contact _
nud arsons Name
I
For additionNL information, you may
at
This notice is furnished to you pursuant to the provisions of the above contrac r subcontract and
Section 3 of the Housing and Urban Development Act of 1968. Copies of this no ' e will be posted
by the undersigned in conspicuous places available to employees or applicants fo employment.
By:
!
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SECTION 3 ECONOMIC OPPORTUNITY PLAN
1. Name and Address of Reporting Entity
(Recipient, Sub-recipient, Contractor, Subcontractor)
2. Federal Identification: (Contract/Award No.)
O Z_
3. Dollar Amount f Award:
I*
~AL1~ Z~IC -
4. Contact P rson:
5. Phone: (include Area Code)
rC~r
ort Submitted
Date Re
7
6,f/ 6~- 9/35
6. Reporting Period:
iF ►,~l - W-0
p
.
2 ,2y
6. Program Code:
(Use a separate sheet for each Program Code)
Program Codes
Flexible Subsidy 2. Section 202/811 3. Public/Indian Housing Development, Operation and Modernization 4. H
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omeless Assistance 5. HOME
.
6. HOME-State Administered 7. CDBG - Entitlement 8.
CDBG- State Administered 9. Other CD Programs
10. Other Housing Programs
_a
rarcl: r_M IV IIIClllau limuur vv
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TOTAL
SECTION 3
% of Aggregate Hires
JO
B
CLASSIFICATION
NEW HIRES
NEW HIRES
Who are Section 3 Residents
%
Professionals
%
Technicians
Office/Clerical
-
Q
Trade: zef'~Weir
eS
Trade:
Trade:
Trade:
Total:
0. 11-d- or ROmice Prnvidersl
an u: L onuracl mwalu 1i V111111 "
NAME OF
SECTION 3 BUSINESS CONCERN
i 1 av vvvua.. _
SPECIFY
CONSTRUCTION OR NONCONSTRUCTION CONTRACT
CONTRACT
AMOUNT
O t7 C
$
$
$
$
$
$
$
TOTAL
$
Percentage of the total dollar amount to be awarded to Section 3 Business Concerns:
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SECTION 3 ECONOMIC OPPORTUNITY REPORT (CONTRACTOR)
1. Recipient Name and Address
( cipient, Sub-recipient. Contractor, Subcontractor)
2. Project Number. (c°ntmcunwam N°.)
3. Dollar Amount of Contract:
4. Contact Person:
5. Phone: (include Area Code)
.
6. Reporting Period:
7. Date Report Submitted
8. Project Number:
9. Federal EIN:
o.,.,a o......t...,...,...ab r.~:..t.... n....r,.+r~oiHna nr•n.ririuri 4n Inw_inrnmw individuals (Mini-,r;nar anv of New Hires)
TOTAL
LOW-INCOME
% of Aggregate Hires
JOB CLASSIFICA N
NEW HIRES
NEW HIRES
who are low-income
%
Technicians
Office/Clerical
%
Professionals
%
Construction Trade:
%
Construction Trade:
TOTAL
%
e _..a 11. 1.., ___a-__~_ A...,.A-A - ow_r.._e.:...,. r,......,.r e..,..~~..r~
Number of Subcontracts awarded:
Number of S ti
3 Businesses Receiving Contracts:
Name of Qualified Business Concern
Constr
o
o Non-construction Contract
Amount
$
$
Total Dollar Amount of Subcontracts awarded to Section 3 qua' ied Business Concerns:
$
Dollar Amou of All Subcontracts:
$
-Percentage of the total dollar amount awarded to qualif ed iness Concems:
%
Part III: Summary of the efforts that were made to
Trained and/or Employed _ low-income individuals equal to of the aggregate new hire \ttach Certifications)
Awarded a Subcontract to _ qualified Business Concerns equal to of the contract amoCertifications)
duals through:
Attempted to recruit low-income indivi
Advertised through local media, television, radio, newspaper (Attach copy of advertisement)
Signs prominently displayed at the project site
Contacts with community organizations
Contacted management to notify residents and posted or distributed flyers at public housing authoParticipated in a HUD program or other program which promotes the training or employment of low-incParticipated in a HUD program or other program which promotes the award of contracts to Section 3 Qualified Business
Concems
Contacted agencies administering HUD Youth-Build programs. (Attach list)
Maintained a file of eligible, qualified low-income Residents and qualified Business Concerns for future employment.
' OTHER-
(Attach supporting documentation)
SECTION 3 RESIDENT CERTIFICATION
(2008 Income Guidelines)
Employee's Na e:
Employee's Addre
hereby certify that I I
1. lama
a Section 3 resident; based on the following qualification(s):
!(bllc Housing Resident (Specify Name of the Public Housing site):
resident of the metropolitan area.
hold size and gross annual income level (from all sources):
2. 1 am a low-i
Select your
HOUSE LD SIZE & INCOME LEVEL
L
1\ $26,550 or less
2 $30,300 or less
❑
3 $34,100 or less
❑
4 $37,900 or less
❑
5 $40,950 or less
❑
6 \$0,950 or less
❑
7
,000 or less
❑
8
$N,050 or less
3. 1 am not a public housing or low-income
Employee Signature
Must Be Completed by Employer \
The above-named person is a permanent full-time employee who was hired on:
' The above-named person is a new-hire employee who was hired on:
This person's lob Classification is:
Name of Employer:
Date
' To Be Completed by Local Contracting Agency
' Preference Category: ❑ Targeted Service Area ❑ Youthbuild ❑ McKinney Homeless ❑ Other Sect, 3
Census Tract Number:
I
of the metropolitan area.
.
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A Section 3 responsive bidder who commits to hire Section 3 Residents by directing employment and training
opportunities toward low- and very low-income persons, particularly those who are recipients of government
assistance for housing, may use any combination of outreach efforts to meet the Section 3 commitment made
when a Section 3 Economic Opportunity Plan has been submitted.
' REMEMBER: All employees of a business/firm count toward meeting your Section 3 compliance goals-
Section 3 New Hires do not have to be construction workers, they just have to be a part of your permanent,
' full-time staff.
SAMPLE OUTREACH EFFORTS FOR CONTRACTORS
' SEEKING SECTION 3 RESIDENT EMPLOYEES
• Enter into "first-source" hiring agreements with organizations representing Section 3 residents,
such as Work Source or a local Workforce Investment Board. For more information, visit
http://www.calwia.orq/lwia/index.cfm
I • Sponsor a HUD-certified "Step-Up" employment and training program for Section 3 residents.
' Advertise training and employment positions by distributing flyers (Notice of Section 3
Commitment or other flyer that identifies the positions to be filled, the qualifications required, and
where to obtain additional information about the application process) to every occupied dwelling
unit in the housing development(s) adjacent to the project site.
'
Post training and employment position flyers in public housing developments, offices of the local
government, and other conspicuous places.
'
Contact State-approved apprenticeship programs to gain access to potentially low-income
residents who are actively seeking job-placement and training. For more information on local
'
apprenticeship programs, you can visit the California Department of Industrial Relations' database
of local apprenticeship programs by visiting http://www.dir.ca.govtdatabases/dastaigstart.asp
'
Contact agencies administering HUD Youthbuild programs, and requesting their assistance to
recruit current HUD Youthbuild program participants who are in need of permanent placement.
• Advertise any positions to be filled through the local media, such as community television ,
t
networks, newspapers of general circulation, or commonly-used job placementwebsites such as
www.monster.com
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Business Name:
Business Address:
SECTION 3 BUSINESS CERTIFICATION FORM
Telephone Number:
Contract/Bid Amount:
1. The above mentioned business firm is a ion 3 business concern based on the following qualifications:
❑ 51-percent owned by Section 3 R idents
(Submit Resident certifications with this buss ss certification form)
❑ At least 30-percent Permanent, full-tim 43uess yees are Section 3 Residents
Total Number of all full-time employees /f Section 3 qualified Employees
(Submit the Resident Certification form(s) with Certification form)
2. The above mentioned business firm is not a Section 3 business c cern, but commits to the Section 3 goal:
❑ Written Commitment (Section 3 Economic opportunity Plan), tline intentions to:
Hire Section 3 qualified residents at least 30-percent aggregate ew hire positions, and/or
Subcontract 25-percent or more of the contract amount to Sectio qualified business concerns.
THE UNDERSIGNED DECLARES THAT THE ABOVE INFORMATION IS COMPLENAND CORRECT
Signature of Owner/Principal
Business Name
To Be Completed by Local Contracting Agency
Preference Category: oTargeted Service Area oYouthbuild LiOther - Census Tract Number:
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S)kCTION 3 ECONOMIC OPPORTUNITY REPORT (CONTRACTOR)
1. Recipient ame and Address
(Recipient, Su ecipient, Contractor, subcontractor)
2. Project Number: (contracuA.W No.)
.
3. Dollar Amount of Contract:
4. Contact Person:
5. Phone: (include Area Code)
6. Reporting Period:
7. Date Report Submitted
-
6. Project Number:
9. Federal EIN:
_ n_.....-a....iH..~ _ .iasa fn Inw_inrnmC inrfivitil lal5 IKAWmum rover 3nL of New HirP_c\
F~j
TOTAL
LOW-INCOME
% of Aggregate Hires
JOB CLASSIFICATION
NEW HIRES
NEW HIRES
who are low-income
%
Technicians
%
Office/Clerical
%
Professionals
%
Construction Trade:
Construction Trade:
TOTAL
%
r'1_J rl. Au._-.J.al , ..r'PAOArAd Mnlmrl Gmnunn
rill ll. VVVVVrr4.----
Number of Subcontracts awarded:
'
Number of Sech 3 sinesses Receiving Contracts:
Name of Qualified Business Concern
Constructio r No -construction Contract
Amount
$
$
Total Dollar Amount of Subcontracts awarded to Section 3 qualified Bu ass Concerns:
$
Dollar Amount of All bcontracts:
$
Percentage of the total dollar amount awarded to qualified Business oncerns:
%
Part III: Summary of the efforts that were made to
Trained and/or Employed low-income individuals equal to of the aggregate new hires. (Attach esident
Certifications)
Awarded a Subcontract to _ qualified Business Concerns equal to of the contract amount. (Attach B ine:
Certifications)
Attempted to recruit low-income individuals through:
Advertised through local media, television, radio, newspaper (Attach copy of advertisement)
Signs prominently displayed at the project site
Contacts with community organizations
Contacted management to notify residents and posted or distributed flyers at public housing authority (Attach list)
Participated in a HUD program or other program which promotes the training or employment of low-income individuals
Participated in a HUD program or other program which promotes the award of contracts to Section 3 Qualified Business
Concerns
Contacted agencies administering HUD Youth-Build programs. (Attach list)
Maintained a file of eligible, qualified low-income Residents and qualified Business Concerns for future employment.
OTHER-
(Attach supporting documentation)
'
Name of Firm: _
Address:
- to
'
State: CA-
I
1
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1
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FEDERAL LOBBYIST CERTIFICATION
1A C
6
Zip Code: f J `J Telephone Number: (I I g) jOy / fJ(os
Acting on behalf of the above named firm, as its Authorized Official, I make the following Certification to the U. S.
Department of Housing and Urban Development and the Community Development Commission, County of Los
Angeles.
1) No Federal appropriated funds have been paid by or on behalf of the above named firm to any
person 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 the awarding of any Federal contract, the making of and Federal grant, loan or
cooperative agreement, and any extension, continuation, renewal, amendment, or modification
thereof, and;
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 or any 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 above named firm shall complete and
submit Standard Form-LLL, "Disclosure Form to Report Lobbying", in accordance with its
instructions, and;
3) The above name firm shall require that the language of this certification be included in the award
documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under
grants, loans, and cooperative agreement) and that all sub-recipients shall certify and disclose
accordingly.
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 the 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.
Authorized Official:
% i;~A
(Conmaor/Subcontractor)
(Date)
(Title)