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E.C ConstructionCITY OF ROSEMEAD HELLMAN /SAN GABRIEL INTERSECTION IMPROVEMENTS PROJECT BIDDER: •Lam' ann► & lj wv) BID SCHEDULE SCHEDULE OF PRICES FOR HELLMAN /SAN GABRIEL INTERSECTION IMPROVEMENTS PROJECT ESPL 5358 (012) BASE BID SCHEDULE CBF -1 UNIT OF EST. UNIT ITEM NO. ITEM DESCRIPTION MEASURE QTY. PRICE COST Clearing & Grubbing per plans 1 and specifications. See technical provisions TP 2, TP 3 &TP4. LS 1��7V 2 Disposal of Waste Materials LS 1 t oo 6 0 C1 Remove Existing and 3 Construct 9- Inches Thick PCC Pavement (High Early Strength) 520-A-5000. SF 22,320 p Construct 6- Inches Thick 4 Crushed Miscellaneous Base Compaction over 90% Co Compacted Soil. TONS 850 I•-4N 5 Cold Mill 2- Inches Existing Pavement. SF 5,000 2 13 0' OQ O `C 6 Construct 2- Inches AC Pavement (C2- PG 64 -10). TONS 70 22-1 1 Construct 4 -inch thick PCC 7 sidewalk per SPPWC Std Plan 113 -2. SF 230 g Construct PCC Curb Ramps per SPPWC Std Plan 111 -4. EA 2� rn JW Remove Existing and 9 Construct 6- Inches Thick PCC Driveway Approach per SPPWC Std Plan 110 -2. SF 900 Install Landscape and 10 Irrigation per Plans and Specifications Complete. LS 1 L� O° Zia• Install Traffic Striping, Traffic 11 Signal Loops and Pavement FL. Markers 1 CBF -1 BIDDER: e. l: -. O,Dyl J - rrLA etf o v TOTAL BASE BID PRICE (SCHEDULE BID PRICE):$ '/&/, 306 . -PLO /UV/z. HyevrJn.Gl7 S /kj'7 %G1.rtZ d/vw .we'> S'i� /Jar,tn Dollar amount in written form it �o rcvcsv ;� r� The undersigned agrees that these Contract Bid Forms constitute a firm offer to the Owner which cannot be withdrawn for the number of Working Days indicated in the Notice Inviting Bids from and after the bid opening date, or until a Contract for the Work is fully executed by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. Attached hereto is a certified check, a cashier's check or bid bo in the amount of � JJ ��O BaHars ( ) said amount being not less than n ercent (10 %) of the Total Bid Price. The undersigned agrees that said amount shall be retained by the Owner if, upon award, we fail or refuse to execute the Contract and furnish the required bonds, certificates and endorsements of insurance and other certifications within the time provided. If awarded a Contract, the undersigned agrees to execute the formal Contract, which will be prepared by the Owner for execution, within five (5) Calendar Days following the Letter of Award for CBF -2 UNIT OF EST. UNIT ITEM NO. ITEM DESCRIPTION MEASURE QTY. PRICE COST Construct Traffic Signal 12 Improvements per Plans and Specifications Complete. 1 LS Remove, Dispose and Construct Colored PCC Cross Walk (Chromix) with Lithochrome 13 Colorhardener on top per Plans and Specifications Complete per LM Scofield Company or Approved Equal. Contact person Bruce Umeck 818 - 324 -3534. SF 3,050 Z 3 pVf� Adjust Sewer Manhole to 14 Grade per SPPWC Std Plan EA 6 M00 o� r 15 Adjust to Grade Water and Gas Valves Ea 10 -70 00 -� TOTAL BASE BID PRICE (SCHEDULE BID PRICE):$ '/&/, 306 . -PLO /UV/z. HyevrJn.Gl7 S /kj'7 %G1.rtZ d/vw .we'> S'i� /Jar,tn Dollar amount in written form it �o rcvcsv ;� r� The undersigned agrees that these Contract Bid Forms constitute a firm offer to the Owner which cannot be withdrawn for the number of Working Days indicated in the Notice Inviting Bids from and 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. Attached hereto is a certified check, a cashier's check or bid bo in the amount of � JJ ��O BaHars ( ) said amount being not less than n ercent (10 %) of the Total Bid Price. The undersigned agrees that said amount shall be retained by the Owner if, upon award, we fail or refuse to execute the Contract and furnish the required bonds, certificates and endorsements of insurance and other certifications within the time provided. If awarded a Contract, the undersigned agrees to execute the formal Contract, which will be prepared by the Owner for execution, within five (5) Calendar Days following the Letter of Award for CBF -2 BIDDER: 0' uc +fl Vl the Contract, and will deliver to the Owner within that same period the necessary original Certificates of Insurance, Endorsements of Insurance, Performance Bond, Payment Bond and all other documentation and certification required by the Contract. The undersigned offers and agrees that if this bid is accepted, it will assign to the purchasing body all rights, title, and interest in and to all causes of action it may have under Section 4 of the Clayton Act (15 U.S.C. Section 15) or under the Cartwright Act (Chapter 2 of Part 2 of Division 7 of the Business and Professional Code), arising from purchases of goods, materials or services by the Bidder for sale to the purchasing body pursuant to the bid. Such assignment shall be made and become effective at the time the purchasing body tenders final payment to he Contractor. Bidder understands and agrees that, when requested by Owner, he shall provide: (1) evidence satisfactory to the Owner of Bidder's California contractor's license(s) in good standing; (2) evidence that the person signing this Bid is authorized to bind Bidder to this Bid and to a contract resulting therefrom; and (3) any other information and documentation, financial or otherwise, needed by Owner to award a Contract to the lowest responsible and responsive bidder. Bidder acknowledges that data submitted with its Contract Bid Forms which it requires to be incorporated into a Contract arising out of this Submittal has been so identified by Bidder. Bidder further acknowledges that the Owner may, at its discretion, incorporate any of the remaining data submitted herewith into a contract arising out of this Bid. The undersigned acknowledges receipt, understanding and full consideration of the following addenda to the Contract Documents. Addenda Nos. The Bidder understands and agrees that the Total Bid Price is inclusive of all labor, materials, and equipment or supplies necessary to complete the Work as described in the Bid Documents. If this bid is accepted, the undersigned Bidder agrees to enter into and execute the Contract with the necessary bonds and accept the Total Bid Price as compensation in full for all Work under the contract. CBF -3 Bidder understands and agrees that liquidated damages shall apply to this Contract in the amounts and subject to the terms and conditions described in the Contract Form and the Contract Documents. BIDDER: E-C' J-) V1 �'�l111) By: RA nature l 6h> w0AT r'e, T or Pr Name 1' rz 4t Title 7 2 -I:zp QinI(�o A Business Street Address 5.a -"4b -, 0a City, State and Zip Cod CnU 444 - -as RL-� Telephone Number Bidder's /Contractor's State of Incorporation: 0 G l t Fo-r r j (" Partners or Joint Venturers: Bidder's License Number(s): 3 *9 1 tl 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 or joint venture has the authority to do so. CBF -4 CITY OF ROSEMEAD HELLMAN /SAN GABRIEL INTERSECTION IMPROVEMENTS PROJECT BIDDER: E` e 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. 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 - 6 BIDDER: �- ' \- n 2.113 LIST OF PROPOSED SUBCONTRACTORS (continued) [' Next 2 Pages if needed for listing addigonal subcontractors .'I Name and Location Description of Work of Subcontractor to be Subcontracted Name: S /ciF Gjt oscsf� ��vf2sY.ahx%� �L� rnc Address: yzo9 CK,c �r� .Co Et Name and Location of Subcontractor Description of Work to be Subcontracted Name: 'Pc I A'6 Address: Uc E. Nits sr. t f ✓S `a,./, /3e, rre"( , e4 Name and Location Description of Work of Subcontractor to be Subcontracted Name: /YIlL 6lr Cxfc Inc /. Address: 45`3b IF - 44 Pacw,a „,,C , C✓f Name and Location of Subcontractor Name: Address: Description of Work to be Subcontracted Name and Location of Subcontractor Name: Address: Description of Work to be Subcontracted CBF -7 BIDDER: 2.0 REFERENCES The following are the names, addresses and telephone numbers for three public agencies for which BIDDER has performed similar work within the past two (2) years: ,. Name ancVAddress Owner Name and telephone num r of person familiar with pro ect Con ra t amount Type of Work Date Completed 2. 'q & ' YVlar Name and'Addressof Owner ( 11 \ aY l o* Al yaraL me and telephone number of person Contract amount V, Ar�Q i caner nber of person familiar 3. \ l'VA D1' Name and Address p Y--es a r Name and telephone 3��oo Contract amount Type Date It I1,-- 4. Name and Address of Owner Name and telephone number of person familiar with project Contract amount Type of Work Date Completed with project `i�c._y Type of Work CBF -8 BIDDER: E: C - \,JOVK;�U Ct V) NON - COLLUSION AFFIDAVIT CBF -9 BIDDER: L- O- • 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; thatthe 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. 1/V / gnature - bh>I 1'—� VUa�Y� Typed or Printed Name - PflQS t k n l;' - Title C, C Mtn JAP, , ���j Bidder 5-8 -13 Subscribed and sworn before me This 6" day of MAN 4 20 13 p, to nxe ovx +-h basis o Sn1- �s 14A e }a o ary Public in and for the State of California My Commission Expires: 1 '2 -!3 - /6 iL Wa.t-Ie he (Seal)t6te. Pev�ro' Oj� r � SUSANCATONE r comm. #1988986 m y� Notery PuWI0-G6romu W ' LOS ANGELES COUNTY My Comm, Exp. DEC 13,201 CBF -10 CITY OF ROSEMEAD HELLMAN /SAN GABRIEL INTERSECTION IMPROVEMENTS PROJECT 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 v t^G COm4r chot1 CO , proposed subcontractor has , hereby certifies that he 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 Presidents 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. I � M M , / B- EEOC -1 CITY OF ROSEMEAD HELLMAN /SAN GABRIEL INTERSECTION IMPROVEMENTS PROJECT 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 CITY OF ROSEMEAD HELLMAN /SAN GABRIEL INTERSECTION IMPROVEMENTS PROJECT DEBARMENT AND SUSPENSION CERTIFICATION TITLE 49, CODE OF FEDERAL REGULATIONS, PART 29 The bidder, under penalty of perjury, certifies that, except as noted below, he /she or any other person associated therewith in the capacity of owner, partner, director, officer, manager: • is not currently under suspension, debarment, voluntary exclusion, or determination of ineligibility by any Federal agency; • has not been suspended, debarred, voluntarily excluded or determined ineligible by any Federal agency within the past 3 years; • does not have a proposed debarment pending; and • has not been indicted, convicted, or had a civil judgement rendered against it by a court of competent jurisdiction in any matter involving fraud or official misconduct within the past 3 years. If there are any exceptions to this certification, insert the exceptions in the following space. Exceptions will not necessarily result in denial of award, but will be considered in determining bidder responsibility. For any exception noted above, indicate below to whom it applies, initiating agency, and dates of action. Notes: Providing false information may result in criminal prosecution or administrative sanctions. The above certification is part of the Bid. Signing this Bid on the signature portion thereof shall also constitute signature of this Certification. DSC -1 CITY OF ROSEMEAD HELLMAN /SAN GABRIEL INTERSECTION IMPROVEMENTS PROJECT NONLOBBYING CERTIFICATION FOR FEDERAL -AID CONTRACTS The prospective participant certifies, by signing and submitting this bid or bid, to the best of his or her knowledge and belief, that: (1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any Federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any Federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form -LLL, "Disclosure of Lobbying Activities," in conformance with its instructions. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. The prospective participant also agrees by submitting his or her bid or bid that he or she shall require that the language of this certification be included in all lower tier subcontracts, which exceed $100,000 and that all such subrecipients shall certify and disclose accordingly. NLC -1 CITY OF ROSEMEAD HELLMAN /SAN GABRIEL INTERSECTION IMPROVEMENTS PROJECT N /-A DISCLOSURE OF LOBBYING ACTIVITIES i vrvir�� i L i nio ruKivi i U LnJGLUJt LUtit{YINU AC I IV[ I IES PURSUANT TO 31 U.S.C. 1352 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: ❑ ❑ a_ contract a. hid /offer/annliration a_ initial b. grant b. initial award b. material change c. cooperative agreement c. post -award d. loan For Material Change Only: e. loan guarantee year_ quarter f. loan insurance date of last report 4. Name and Address of Reporting Entity 5. If Reporting Entity in No. 4 is Subawardee, Enter Name and Address of Prime: Prime � Subawardee Tier , if known Congressional District, if known 6. Federal Department/Agency: Congressional District, if known 7. Federal Program Name /Description: 8. Federal Action Number, if known: 10. a. Name and Address of Lobby Entity (If individual, last name, first name, MI) CFDA Number, if applicable 9. Award Amount, if known: b. Individuals Performing Services (including address if different from No. 10a) (last name, first name, MI) (attach Continuation Sheet(s) if necessary) 11. Amount of Payment (check all that apply) 13. Type of Payment (check all that apply) $ ❑ actual ❑ planned a. retainer b. one -time fee 12. Form of Payment (check all that apply): c. commission B a. cash d. contingent fee b. in -kind; specify: nature a deferred value f. other, specify 14. Brief Description of Services Performed or to be performed and Date(s) of Service, including officer(s), employee(s), or member(s) contacted, for Payment Indicated in Item 11: (attach Continuation Sheet(s) if necessary) 15. Continuation Sheet(s) attached: Yes ❑ No 16. Information requested through this form is authorized by Title 31 U.S.C. Section 1352. This disclosure of Signature: lobbying reliance was placed by the tier above when his t transaction was made or entered into. This disclosure's Print Na 1 required pursuant to 31 U.S.C. 1352. This information Will be reported to Congress semiannually and will be available for public inspection. Any person who fails to Title: file the required disclosure shall be subject to a civil , f penalty of not less than $10,000 and not more than Telephone o.: $100,000 for each such failure. Federal Use Authorized for Local Reproduction Standard Form - LLL 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 forth 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, subgrants 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. 8. 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 (IFB) 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 awardlloan 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 all 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 all preparatory and related activity not just time spent in actual contact with Federal officials. Identify the Federal officer(s) or employee(s) contacted or the officer(s) employee(s) or Member(s) of Congress that were contacted. 15. Check whether or not a continuation sheet(s) is attached. 16. The certifying official shall sign and date the form, print his/her name title and 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 (0348 -0046), Washington, D.C. 20503. SF- LLL - Instructions Rev. 06 -04- 90eENDIF» CITY OF ROSEMEAD HELLMAN /SAN GABRIEL INTERSECTION IMPROVEMENTS PROJECT EXHIBIT 15 -G1 Local Assistance Procedures Manual Local Agency Bidder UDBE Commitment (Construction Contracts) INSTRUCTIONS - LOCAL AGENCY BIDDER UDBE COMMITMENT (CONSTRUCTION CONTRACTS) ALL BIDDERS: PLEASE NOTE: It is the bidder's responsibility to verify that the UDBE(s) falls into one of the following groups in order to count towards the UDBE contract goal: 1) African Americans; 2) Asian - Pacific Americans; 3) Native Americans; 4) Women. This information may be submitted with your bid. If it is not, and you are the apparent low bidder or the second or third low bidder, it must submitted and received as specified in the Special Provisions. Failure to submit the required UDBE commitment will be grounds for finding the bid nonresponsive A UDBE is a firm meeting the definition of a DBE as specified in 49 CFR and is one of the following groups: African Americans, Asian - Pacific Americans, Native Americans, or Women. The form requires specific information regarding the construction contract: Local Agency, Location, Project Description, Total Contract Amount, Bid Date, Bidder's Name, and Contract UDBE Goal. The form has a column for the Contract Item Number and Item of Work and Description or Services to be Subcontracted or Materials to be provided by UDBEs. Prime contractors shall indicate all work to be performed by UDBEs including, if the prime is a UDBE, work performed by its own forces, if a UDBE. The UDBE shall provide a certification number to the Contractor and expiration date. Enter the UDBE prime's and subcontractors' certification numbers.The form has a column for the Names of UDBE contractors to perform the work (who must be certified on the date bids are opened and include the UDBE address and phone number). IMPORTANT: Identify all UDBE firms participating in the project regardless of tier. Names of the First -Tier UDBE Subcontractors and their respective item(s) of work listed should be consistent, where applicable, with the names and items of work in the "List of Subcontractors" submitted with your bid. There is a column for the UDBE participation dollar amount. Enter the Total Claimed UDBE Participation dollars and percentage amount of items of work submitted with your bid pursuant to the Special Provisions. (If 100% of item is not to be performed or furnished by the UDBE, describe exact portion of time to be performed or furnished by the UDBE.) See Section "Disadvantaged Business Enterprise (DBE)," of the Special Provisions (construction contracts), to determine how to count the participation of UDBE firms. Exhibit 15 -G1 must be signed and dated by the person bidding. Also list a phone number in the space provided and print the name of the person to contact. Local agencies should complete the Local Agency Contract Award, Federal -aid Project Number, Federal Share, Contract Award Date fields and verify that all information is complete and accurate before signing and filing. Page 15 -32 July 31, 2009 LPP 09 -02 Local Assistance Procedures Manual . EXHIBIT 15 -G1 Local Agency Bidder UDBE Commitment (Construction Contracts) EXHIBIT 15 -G1 LOCAL AGENCY BIDDER UDBE COMMITMENT (CONSTRUCTION CONTRACTS) NOTE: PLEASr /E� REFER TO INSTR CTIONS ON THE REVERSE SIDE OF THIS FORM y LOCAL AGENCY: V 1"�wv CATJON1 '^ PROJECT DESCRIP . I �,Q� r N h TOTAL CONTRACT AMOUNT: $ BID DATE: try n 1 1 � BIDDER'S N AME: _ L� y { V`� , O • 9/ L CONTRACT UDBE GOAL: C ONTRACT EM NO. ITEM OF WORK AND DESCRIPTION OR SERVICES TO BE SUBCONTRACTED OR MATERIALS O BE PROVIDED (or contracted if the b idder is a UDBE) UDBECERTNO. AND EXPIRATION DATE NAME OF EACH UDBE (Must be certified on the date bids are opened- include UDBE address and phone number) DOLLAR AMOUNT UDBE For Local Agency to Complete: Local Agency Contract Number: Federal -aid Project Number: Federal Share: Total Claimed UDBE Participation $ Contract Award Date: Local Agency certifies that all UDBE certifications have been verified and information is complete and accurate. Print Name Signature Date Local Agency Representative (Area Code) Telephone Number: atum o Br er 3 L Ul A �, Dal ea o e TeL.1Yo. �, J A VC" V V Person to Contact lease Type or Print) Local Agency Bidder UDBE Commitment (Construction Contracts) (Rev 626/09) Distribution: (1)Original —Local agency files Page 15 -31 LPP 09 -02 July 31, 2009 CITY OF ROSEMEAD HELLMAN /SAN GABRIEL INTERSECTION IMPROVEMENTS PROJECT Local Assistance Procedures Manual Exhibit 15 -H UDBE Informat - Good Faith Effort EXHIBIT 15 -H UDBE INFORMATION —GOOD FAITH EFFORTS UDBE INFORMATION - GOOD FAITH EFFORTS Federal -aid Project No. SRTSL 5218 (012)- Bid Opening Date The City of Rosemead established an Underutilized Disadvantaged Business Enterprise (UDBE) 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 document adequate good 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 UDBE firm was not certified at bid opening, or the bidder made a mathematical error. Submittal of only the "Local Agency Bidder UDBE Commitment" form 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 dates of each publication in which a request for UDBE 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 dates and methods used for following up initial solicitations to determine with certainty whether the UDBEs were interested (please attach copies of solicitations, telephone records, fax confirmations, etc.): Names of UDBEs Solicited Date of Initial Follow Up Methods and Dates Solicitation Page 15 -33 LPP 09 -02 July 31, 2009 Exhibit 15 -H UDBE Information -Good Faith Effort Local Assistance Procedures Manual C. The items of work which the bidder made 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 sufficient work to facilitate UDBE participation was made available to UDBE firms. Items of Work Bidder Normally Breakdown of Amount Percentage Performs Item Items M Of (Y/N) Contract 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: E. Efforts made to assist interested UDBEs 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: Page 15 -34 July 31, 2009 UP 09 -02 Local Assistance Procedures Manual Exhibit 15 -H UDBE 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 from 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 i.e. lists, Internet a e download, etc.): ) Name of Agency/Organization Method/Date of Contact Results H. Any additional data to support a demonstration of good faith efforts (use additional sheets if necessary): NOTE: USE ADDITIONAL SHEETS OF PAPER IF NECESSARY. Page 15-34a LPP 09 -02 July 31, 2009 CITY OF ROSEMEAD HELLMAN /SAN GABRIEL INTERSECTION IMPROVEMENTS PROJECT EXHIBIT 15 -G2 Local Assistance Procedures Manual Local Agency Bidder DBE Information (Construction Contracts) INSTRUCTIONS - 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 DBE shall provide a certification number to the Contractor and expiration date. Enter DBE prime and subcontractors certification number. The DBE contractors should notify the Contractor in writing with the date of the decertification if their status should change during the course of the contract. The form has a column for the Names 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 UDBEs listed on the UDBE Commitment form (Exhibit 15-GI), regardless of tier. Names of the First -Tier DBE subcontractors and their respective item(s) of work listed should be consistent, where applicable, with the names and items of work in the "List of Subcontractors" submitted with your bid. There is a column for the DBE 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 Enterprise (DBE)," of the Special Provisions (construction contracts ) to determine how to count the artici anon of DBE p firms. P 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 the 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 of contract execution. Failure to submit a completed and accurate form within the 15 -day time period may result in the de- obligation of funds on this project. District DBE Coordinator should verify that all informations is complete and accurate. Once th information has been verified, the District Local Assistance Engineer signs and dates the form. rage 13-OZD July 31, 2009 LPP 09 -02 Local Assistance Procedures Manual I EXHIBIT 15 -G2 Local Agency Bidder DBE Information (Construction Contracts) EXHIBIT 15 -G2 LOCAL AGENCY BIDDER DBE INFORMATION (CONSTRUCTION CONTRACTS) (Inclusive of all DBEs including the UDBEs listed at bid proposal) NOTE: PLEASE REFER TTOINnST UCTIONS ON THE REVERSE SIDE OF THIS FORM LOCAL AGENCY: `-' t� C p /� r� 1'��4w,r,.�1v'r'M LOCATION' PROJECT DESCRIP TOTAL CONTRACT AMOUNT: $ BID DATE: BIDDER'S N AME: CONTRACT UDBE GOAL: C ONTRACT ITEM NO. ITEM OF WORK AND DESCRIPTION OR SERVICES TO BE S UBCONTRACTED OR MATERIALS O BE PROVIDED (or contracted if the b idder is a DBE DBE CERT NO. AND EXPIRATION DATE NAME OF EACH DBE (Must be certified on the date bids are opened - include DBE address and phone number) DOLLARAMOLINT DBE For Local Agency to Complete: Local Agency Contract Number: Federal -aid Project Number: Federal Share: Contract Award Date: Local Agency certifies that all DBE certification have been verified and Information is complete and accurate. - Print Name Signature Date Local Agency Representative Area Code Telephone Number: Total Claimed DBE Participation $ 0 ignature of Bidder ��),{ /� 'p— �Day (Area Code) Tel. No. V n y'C_ ( A W For Caltrans Review: Print Name Signature Date Caltrans District Local Assistance Engineer Person to contact (Please Type or Print) Local Agency Bidder DBE lnforroation(Construction Contarcts) (Rev 6/26/09) Distribution: (1) Copy – Fax or scan a copy to the Caltrans District Local Assistance Engineer (DLAE) within 15 days of contract execution. Failure to send a copy to the DLAE within 15 days of contract execution may result in de- obligation of funds for this project. (2) Copy– Include in award package to Caltmns District Local Assistance (3) Original –Local agency files L Page 15 -32a PP 12 -01 January 27, 2012 BIDDER: E. C . Cm, 5 * o a. Ca , Bidder shall submit its Bid data in accordance with the format shown on each of the following Bid Data Forms. Bidders shall prepare and use as many sheets as are necessary to adequately provide the information required, Bidder shall ensure that every page of its Bid Data Forms are properly identified with the Bidder's name and page number. 2.A BID BOND KNOW ALL MEN BY THESE PRESENTS: THAT E. C. Construction Co. as Principal, and Travelers Casualty and Surety Company of America , as Surety, are held firmly bound unto the CITY OF ROSEMEAD (hereinafter called the OWNER) in the sum of Ten Percent of Bid Amount DOLLARS ($ 10% 1 , being not less than ten percent (10 %) of the. Total. Bid Price; for the payment of which sum will and truly to be made, we bind ourselves, our heirs, executors, administrators, successors, and assigns, jointly and severally, firmly by these presents. WHEREAS, said Principal has submitted a bid to the OWNER to perform all Work required for the Hellman /San Gabriel Intersection Improvements Project as set forth in the Notice Inviting Bids and accompanying Bid Documents, dated May 8, 2013 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 6th day of May 2013 Traveler E. & Surety E. C. Construction Co. (SEAL) Com an df America (SEAL) Principal Surety 0 B &,4,zx y: ti By: By: U� ignature XBRO K • WRL RS gnature ' Gary B. Merrill PP'G5 r A 6NT Attorney-In-Fact CBF -5 a CALIFORNIA ALL - PURPOSE ACKNOWLEDGMENT Cora CODE y 1189 State of California County of Los Angeles On May 6, 2013 before me, Priya Neilly, Notary Public Date Here Insert Name and Title of the Officer personally appeared Gary B. Merrill 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 person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. PRIYA NEILLY Commission # 1948491 Z ,; = Notary Public - California z �";:'®}P�✓ Los Angeles County My Comm. Expires Sep 13, 2015 Place Notary Seal Above I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and-corrrect. WITNESS my h9fid agf.Kofficial seal. Signature: Though the information below is not qr ur= i d by law, it may and could prevent fraudulent removal and reattac 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: ❑ Corporate Officer — Title(s): ❑ Individual ❑ Partner — ❑ Limited ❑ General Top of thumb here Ek Attorney in Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: Signer's Name: ❑ Corporate Officer — Title(s): ❑ Individual ONINNINNO ❑ Partner — ❑ Limited ❑ General Top of thumb here ❑ Attorney in Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: valuable to 96rsons relying on the document of this torrrl,6 another document. Number of Pages: 0 2010 National Notary Association - NationalNotary.org • 1- 800 -US NOTARY (1- 600 -8]6 -682]) Item #5907 WARNING: THIS POWER OF eAP POWER OF ATTORNEY TRAVELERS Farmington Casualty Company St. Paul Mercury Insurance Company Fidelity and Guaranty Insurance Company Travelers Casualty and Surety Company Fidelity and Guaranty Insurance Underwriters, Inc. Travelers Casualty and Surety Company of America St. Paul Fire and Marine Insurance Company United States Fidelity and Guaranty Company St. Paul Guardian Insurance Company Attorney -In Fact No. 223256 Certificate No. 005339629 KNOW ALL MEN BY THESE PRESENTS: That Farmington Casualty Company, St. Paul Fire and Marine Insurance Company, St. Paul Guardian Insurance Company, St. Paul Mercury Insurance Company, Travelers Casualty and Surety Company, Travelers Casualty and Surety Company of America, and United States Fidelity and Guaranty Company are corporations duly organized under the laws of the State of Connecticut, that Fidelity and Guaranty Insurance Company is a corporation duly organized under the laws of the State of Iowa, and that Fidelity and Guaranty Insurance Underwriters, Inc., is a corporation duly organized under the laws of the State of Wisconsin (herein collectively called the "Companies "), and that the Companies do hereby make, constitute and appoint Gary B. Merrill of the City of Pasadena , State of California , their true and lawful Attomey(s) -in -Fact, each in their separate capacity if more than one is named above, to sign, execute, seal and acknowledge any and all bonds, recognizances, conditional undertakings and other writings obligatory in the nature thereof on behalf of the Companies in their business of guaranteeing the fidelity of persons, guaranteeing the performance of contracts and executing or guaranteeing bonds and undertakings required or permitted in any actions or proceedings allowed by law. I Y WITNFS WHEREOF, EREOF, the Compy have caused this instrument to be signed and their corporate seals to be hereto affixed, this 18th January U 3 of Farmington Casualty Company Fidelity and Guaranty Insurance Company Fidelity and Guaranty Insurance Underwriters, Inc. St. Paul Fire and Marine Insurance Company St. Paul Guardian Insurance Company St. Paul Mercury Insurance Company Travelers Casualty and Surety Company Travelers Casualty and Surety Company of America United States Fidelity and Guaranty Company (, I.51/., ' 6 NN I NS4 N 11NS4q� k §Pt19NOL ,yA� ®R. /�y� 4 197 8~, SE AL State of Connecticut City of Hartford ss. By: 6 — Rubcrt L. Raney, enmr Vice Pirxident On this the 18th day of January 2013 before me personally appeared Robert L. Raney, who acknowledged himself to be the Senior Vice President of Farmington Casualty Company, Fidelity and Guaranty Insurance Company, Fidelity and Guaranty Insurance Underwriters, Inc., St. Paul Fire and Marine Insurance Company, SL Paul Guardian Insurance Company, SL Paul Mercury Insurance Company, Travelers Casualty and Surety Company, Travelers Casualty and Surety Company of America, and United States Fidelity and Guaranty Company, and that he, as such, being authorized so to do, executed the foregoing instrument for the purposes therein contained by signing on behalf of the corporations by himself as a duly authorized officer. a .Ttr In Witness Whereof, I hereunto set my hand and official seal. � My Commission expires the 30th day of June, 2016. P tObBU�+ Marie C. Tetreault, Notary Public 58440 -8 -12 Printed in U.S.A.