Kormix Inc.BIDDER: !Jr l~n 1C 1 j~
BID SCHEDULE
SCHEDULE OF PRICES FOR
ANNUAL 2008-2009 CURB RAMPS CONSTRUCTION PROJECT
CDBG PROJECT No. P46402
BASE BID SCHEDULE
UNIT OF
EST.
UNIT
ITEM
NO.
ITEM DESCRIPTION
MEASURE
QTY.
PRICE
COST
1
Clearing & Grubbing per plans and
s
kill-
ifications. See technical
spec
LS
1
provisions.
2
Disposal of Waste Materials
LS
1
boc>6
6P&
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-
E
70
,
7 per details and locations.
a
4
Furnish and install ONLY
Truncated Domes Detectable
Warning Surfaces - ARMORCAST
.p
retrofit or approved equal. See
t
il
d
Ea
12
L
~
D
a
s.
e
appendix A and TP-7 per
r
~ ~
TOTAL BASE BID PRICE (SCHEDULE BID PRICE):$ 1 A, L l lc)
amount in written form
ALTERNATE BID ITEM 1
;4S== I nCA-J ti vvr
NO.
ITEM DESCRIPTION
UNIT OF
MEASURE
EST.
QTY.
UNIT
PRICE
ITEM
COST
5
Construct 4-inch PCC Sidewalk
t.~
per APWA Std Plan 113-1.
SF
450
6
Construct PCC Cross and
Longitudinal Gutters per APWA
SF
300
L~U
Std. Plan 122-1. Intersection of
CBF-1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
BIDDER: n ~n
-),v
TOTAL BASE BID PRICE (SCHEDULE BID PRICE):$_+;i
N
Dollar amount in written fofm ~r J a~ a-0 r s A h c~L
0 Or)
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cannot be withdrawn for the number of Working Days indicated in the Notice Inviting Bids from and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 a bid bond in the amount of
Z ai rw Dollars ) said amount being not less than ten percent (10%) of the Total
Bid Price. The undersigned agrees that said amount shall be retained by the Owner if, upon award,
we fail or refuse to execute the Contract and furnish the required bonds, certificates and
endorsements of insurance and other certifications within the time provided.
If awarded a Contract, the undersigned agrees to execute the formal Contract, which will be
prepared by the Owner for execution, within five (5) Calendar Days following the Letter of Award for
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.
CBF-2
TOTAL ALTERNATE BID PRICE (SCHEDULE BID PRICE): $
BIDDER: 1 Tl G
Bidder understands and agrees that liquidated damages shall apply to this Contract in the amounts
and subject to the terms and conditions described in the Contract Form and the Contract
Documents.
Bidder acknowledges that data submitted with its Contract Bid Forms which it requires to be
' incorporated into a Contract arising out of this Submittal has been so identified by Bidder. Bidder
further acknowledges that the Owner may, at its discretion, incorporate any of the remaining data
submitted herewith into a contract arising out of this Bid.
' The undersigned acknowledges receipt, understanding and full consideration of the following
addenda to the Contract Documents.
' Addenda Nos. V
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.
1
1 CBF-3
1 BIDDER:
1 By:
*10 c14- aeLsc, L
ture Business Street Address
Type or Print Name City, State and Zip Code
Title Telephone Number
Bidder's/Contractor's State of Incorporation:
1 Partners or Joint Venturers:
1
1 Bidder's License Number(s): 111 10
1 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.
1 2) If Bidder is a corporation, enter State of Incorporation in addition to Business Address
1 3) If Bidder is a partnership or joint venture, give full names of all partners or joint
venturers.
1
As further discussed in the Instructions to Bidders, Bidder will be required
to provide evidence that the person signing on behalf of the corporation,
1 _ _ -partnership or joint venture has the authority to do so.
1 CBF-4
Bond #1000814566-015
Kormx Tnr
Bidder shall submit its Bid data in accordance with the ia-na src-w-, on each of the following Bid
Data Forms. Bidders shall prepare and use as manv si-.e5ts as are necessary to adequately
provide the information required. Bidder shall ensure thai eu---y page of its Bid Data Forms are
properly identified with the Bidder's name and page nurnbe--.
2.A BID BOND
KNOW ALL MEN BY THESE PRESENTS:
THAT Kormx Inc. , as
Principal, and U. S. Specialty Insurance
, as Surety, are held firmly bound unto the
CITY OF ROSEMEAD (hereinafter called the OWNER) in the sum of
not to exrppd twenty thqu~and and no/100s
20, 000.00 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 Annual 2008-2009 Curb Ramps Construction Project as set forth in
the Notice Inviting Bids and accompanying Bid Documents, dated
2/25/09
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 23rd day of February 2009
r~- G- (SEAL) (SEAL)
Principal Surety Q
By: By:
nature Signature Ted. R. Shaw
Attonney-in-fact
CBF - 6
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
State of
County
personally appeared
me,
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.
C ttESIE B BERIRAIM
Commission # 1756!19
Notary Public - California
Los Anpillifts County
Cotnrr►, ~
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 correct.
WITNESS my hand and official eal.
Signature
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 Date:
Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name:
❑ Individual
❑ Corporate Officer - Title(s): _
❑ Partner - C Limited L General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
Signer's Nat
❑ Individual
Number of Pages:
❑ Corporate Officer - Title(s): _
❑ Partner - Limited General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
02007 National Notary Association - 9350 De Soto Ave.. P.O. Box 2402 -Chatsworth, CA 91313-2402 - www.NotionalNotary.org Item #5907 Reorder. Call Toll-Free 1-BOD-876-6x27
POWER OF ATTORNEY
AMERICAN CONTRACTORS INDEMNITY COMPANY UNITED STATES SURETY COMPANY U.S. SPECIALTY INSURANCE COMPANY
KNOW ALL MEN BY THESE PRESENTS: That American Contractors Indemnity Company, a California corporation, United States
Surety Company, a Maryland corporation and U.S. Specialty Insurance Company, a Texas corporation (collectively, the
"Companies"), do by these presents make, constitute and appoint:
Ted Shaw or Christine Forward of Pasadena, California
its true and lawful Attorney(s)-in-fact, each in their separate capacity if more than one is named above, with full power and authority
hereby conferred in its name, place and stead, to execute, acknowledge and deliver any and all bonds, recognizances, undertakings
or other instruments or contracts of suretyship to include riders, amendments, and consents of surety, providing the bond
penalty does not exceed *****One Million***** Dollars **1,000,000.00**
This Power of Attorney shall expire without further action on March 18, 2011. This Power of Attorney is granted tinder and by
authority of the following resolutions adopted by the Boards of Directors of the Companies:
Be it Resolved, that the President, any Vice-President, any Assistant Vice-President, any Secretary or any Assistant Secretary shall be and is hereby vested with full
power and authority to appoint any one or more suitable persons as Attomey(s)-in-Fact to represent and act for and on behalf of the Company subject to the following
provisions:
Attorney-in-Fact may be given full power and authority for and in the name of and on behalf of the Company, to execute, acknowledge and deliver, any and all bonds,
recognizances, contracts, agreements or indemnity and other conditional or obligatory undertakings and any and all notices and documents canceling or terminating the
Company's liability thereunder, and any such instruments so executed by any such Attomey-in-Fact shall be binding upon the Company as if signed by the President
and scaled and effceted by the Corporate Secretary.
Be it Resolved. that the signature of any authorized officer and seal of the Company heretofore or hereafter affixed to any power of attorney or any certificate relating
thereto by facsimile, and any power of attorney or certificate bearing facsimile signature or facsimile seal shall be valid and binding upon the Company with respect to
any bond or undertaking to which it is attached.
IN WITNESS WHEREOF, The Companies have caused this instrument to be signed and their corporate seals to be hereto affixed, this
15ei day of July, 2008.
AMERICAN CONTRACTORS INDEMNITY COMPANY UNITED STATES SURETY COMPANY U.S. SPECIALTY INSURANCE COMPANY
Corporate Seals Tots c,4
sEn 2L to a SEAL co By:
+ Daniel P. Aguilar, Vice President
State of California
County of Los Angeles SS:
On this 15'h day of July, 2008, before me, Deborah Reese, a notary public, personally appeared Daniel P. Aguilar, Vice President of
American Contractors Indemnity Company, United States Surety Company and U.S. Specialty Insurance Company 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 signature on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
trE
-WORM
Commlatlon 1726211
Signature h4e2 .X(Seal Kotory Public - w I
) lot N,p ~IM county Cw. *Y
11
I, Jeannie J. Kim. Assistant Secretary of American Contractors Indemnity Company, United States Surety Company and U.S.
Specialty Insurance Company, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney,
executed by said Companies, which is still in full force and effect; furthermore, the resolutions of the Boards of Directors, set out in
the Power of Attorney are in full force and effect.
In Witness Whereof, 1 have hereunto set my hand and affixed the seals of said Companies at Los Angeles, California this day
of ,
Corporate Seals
Bond No.
Agency No. ? I 0
~~ttrT ;a mot 2k to s (:))0, 1, +
46.-,L 4 0---,
Jeannie J. Kim, Assistant Secretary
1 2.6
LIST OF PROPOSED SUBCONTRACTORS
BIDDER: 1'1 a1r 1 N C~
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.
1 CBF-7
BIDDER:
f1! r'
2.6 LIST OF PROPOSED SUBCONTRACTORS (continued)
("Duplicate Next 2 Pages if needed for listing additional subcontractors.")
Name and Location Description of Work
of Subcontractor to be Subcontracted
Name: hJ
Address:
Name and Location
of Subcontractor
Name:
Address:
Name and Location
of Subcontractor
Name:
Address
Description of Work
to be Subcontracted
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
CBF-8
BIDDER: T!'1I`h 1 "-i G
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 ears:
'AIC'+.
and
Name and telephone number of person familiar with project
Contract amount Type of Work Date Completed
2.
Name and Address of
Name and telephone number of person familiar with project
Contract amount Type of Work Date Completed
3.
Name and Address of Owner
Name and telephone number of person familiar with project
Contract amount Type of Work Date Completed
4.
Name and Address of Owner
Name and telephone number of person familiar with project
Contract amount Type of Work Date Completed
CBF-9
References
Name & Title
Sean Crumby
Director of Public Works/City Engineer
City of Stanton
Stanton Public Works
Job Description:
ADA Ramps $88,000
Completion Date: 2/11/08
Telephone number
(714) 379-9222 Ext. 204
Arjan Idnani
Senior Engineer
City of La Puente (626) 780-8154
Job Description:
Construct ADA Ramps and Driveway/Sidewalks $171,898.25
Completion Date: 7/1/08
Arjan Idnani
Senior Engineer
City of La Puente Job #2 (626) 780-8154
Job Description:
Construct ADA Ramps and Driveway/Sidewalks $340,000.00
Completion Date: 9/1/08
Vennie Bermudez
Civil Engineer
City of Monterey Park (626) 307-1325
Job Description.
Construct Sidewalk in Park Area, Remove and Replace Concrete Sidewalks $78,103.51
Completion Date: 6/2/08
Omar Leyva
Project Manager
County of Orange (714) 834-4523
Transportation Department
Proiect Description:
Remove and Construct New Concrete Slab $46,177
Completion Date: 6/2/08
Omid Emam
Job Inspector
County of Los Angeles (626)607-7444
Project Description:
San Gabriel River Tunnel Realignment $222,304.75
Completion Date: 11/21/08
BIDDER:
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.
IH
Bidder
Subscribed and sworn before me
This ~ day of 200
1
1
Notary Public in and Tor
the State of California
L lN~a ~QSE L~sf2i~tJcc~
My Commission Expires: * D1D
(Seal)
LINDA ROSE E N U
a COMM. $1696449 z
Notary Public • California
2 ~C
San Bernardino County
r r, m Expires Sep. 28,2010?
CBF - 11
AA e-
Tit e
' "NONCOLLUSION AFFIDAVIT TO BE EXECUTED BY BIDDER AND SUBMITTED WITH BID"
§7106. Any public works contract of a public entity shall include an affidavit, in the following form:
i
State of California )
' County of ) ss.
n S 4f +~jJ4-7 being first duly sworn, deposes and says that, he or she is
Z' the party making the foregoing
bid, that the bid is not made in the interest of, or on behalf of, any undisclosed person, partnership, company,
association, organization, or corporation; that the bid is genuine and not collusive or sham; that the bidder has not
' directly or indirectly induced or solicited any other bidder to put in a false or sham bid, and has not directly or
indirectly colluded, conspired, connived, or agreed with any bidder or anyone else to put in a sham bid, or that
anyone shall refrain from bidding; that the bidder has not in any manner, directly or indirectly, sought by agreement,
' communication, or conference with anyone to fix the bid price of the bidder or any other bidder, or to fix any
overhead, profit, or cost element of the bid price, or of that of any other bidder, or to secure any advantage against
' the public body awarding the contract of anyone interested in the proposed contract; that all statements contained
in the bid are true; and, further, that the bidder has not, directly or indirectly, submitted his or her bid price or any
breakdown thereof, or the contents thereof, or divulged information or data relative thereto, or paid, and will not
' pay, any fee to any corporation, partnership, company association, organization, bid depository, or to any member
or agent thereof to effectuate a collusive or sham bid."
Pro1ect Name cio,$t, Project Number:0 is1(oyls)1
1
Company: Y 1
Date:
LINDA ROSE EST IM U
COMM. #1696449 z
O Notary Public - California o
2 • San R#-nardino County My c R, 2010
SWORN TO AND SUBSCRIBED TO BEFORE ME
This day of 1~1 20Q
/s/ Notary Public*
Rose 5><Q~Na
My Commission Expires:
) 0
1
ACKNOWLEDGMENT
State of Cali~rnia
County of
On before me,li1/f~'~ C S+~~~,~D~W y lc1cD~C
(insert name and title of the officer)
^J L~
personally appeared Lt"'~e v
who proved to me on the basis of satisfactory evidence to be the personks'J whose nameW, is e
subscribed to the within instrument and acknowledged to me that he/$te/th6y executed the same in
his/Wr/tp( it authorized capacity(iet), and that by his/t)r/th6ir signature(s) on the instrument the
person, or the entity upon behalf of which the personY 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.
LINDA ROSE ESTEINOU
WITNESS my hand and official seal. o COMM. 01696449 Z
y a Notary Public • California z
Z San Bernardino County
~j Comm. Ex ires q&n
2fl, 2010
Signatu,* } (Seal)
1
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.
1 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
entertainment areas, transportation, and housing facilities provided for employees which are segregated
by explicit directive or are in fact segregated on the basis of race, 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.
NOTE: The penalty for making false statements in offers is prescribed in 18 U.S.C. 1001.
Date:'- -IL4 _ d
Project Number: 0086 rL- l Lio Z
Company: X i r'~ C-
i
I
CERTIFICATION
WITH REGARD TO THE PERFORMANCE OF PREVIOUS CONTRACTS OR
SUBCONTRACTS SUBJECT TO THE EQUAL OPPORTUNITY CLAUSE AND
THE FILING OF REQUIRED REPORTS
The Widder, ❑proposed sub-contractor, hereby certifies that he/shel5-has, ❑has not, participated
in a previous contract or subcontract subject to the Equal Opportunity Clause, as required by
Executive Orders 10925, 11114, or 11246, and that he/shefflhas, ❑has not, filed with the Joint
Reporting Committee, the Director of the Office of Federal Contract Compliance, a Federal
Government contracting or administering agency, or the former President's Committee on Equal
Employment Opportunity, all reports due under the applicable filing requirements. 1
Date: - tAn 5 Project Number: L ContractAward: _
Awarding Agency: C71 :~j e-3
Contractor Name: r 1~X i ZN1 el- Total Number of Employees
Affiliate Company:
1 By:-.In o A
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 exemptfrom
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).
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 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.
11
Community Development Commission
County of Los Angeles
COUNTY LOBBYIST CODE CHAPTER 2.160
COUNTY ORDINANCE NO. 93-0031
CERTIFICATION
Name of Firm: n'X 7 t-t G 1
~c1~ ~W 1~JC 1 11 c~G? eL S,,f Uv14~ ht t, 7 Q
Address: J
State: Zip Code: 1. -1 f5fl Telephone Number: n g) ~a 7 l
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) 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;
2) That all persons/entities/firms acting on behalf of the above named firm have and will comply
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/Subcontractor)
(Date)
By (sip)
(Title)
1
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
HUD FORM 4230A
REPORT OF ADDITIONAL CLASSIFICATION AND RATE
OMB ApprovalNumber2501-0011
(Exp. 09130r2006)
1. FROM (name and address of requesting agency) ~x y✓~"
v`ac' x T
2. PROJECT NAME AND NUMBER D_ PJ0 U]6 LL lje 3li--L 66)
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3. LQQATION OF P ECT (City, County and State)
S Esc Cf r
4. BRIEF DESCRIPTION OF PROJECT
CHARACTER OF CONSTRUCTION
Cp"CfTI'e- CLIf-~ X] Cer► SI
Building ❑ Residential
~1-y C- R43 Nril ~i-
RL Heavy ❑ Other (specify)
❑ Highway
6. WAGE DECISION NO. (include modification number, if any)
7. WAGE DECISION EFFECTIVE DATE
❑ COPY ATTACHED
Z 6
a. WORK CLASSIFICATION(S)
HOURLY WAGE RATES
BASIC WAGE FRINGE BENEFIT(S) (if any)
-7
l~i<A l~~S r~rS
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9. PRIME CONTRACTOR (name, address)
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C
10. SUBCONTRACTOR/EMPLOYER, IF APPLICABLE (name, address)
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Kerr 1 /,t
till IN
yJAl.u01 C4 91~
Check All That Apply:j
❑ The work to be performed by the additional classification (s) is not performed by a classification in the applicable wage decision.
J~ 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 relationship to the wage rates contained in the
wage decision.
❑ The interested parties, including the employees or their authorized representatives, agree on the classification(s) and wage rate(s).
Supporting documentation attached, including applicable wage decision. _
i. Check One:
JKJ Approved, meets all criteria. DOL confirmation requested.
❑ One or more classifications fail to meet all criteria as explained in agency referral. DOL decision requested.
FOR HUD USE ONLY
LR2000:
Agency Representative Date
Log in:
(Typed name and signature)
Log out:
Phone Number
ui 1v & rrt_mi Pizpm i R GnrrlnN IS nRFnl FTE
WORKER'S COMPENSATION CERTIFICATION
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
that code, and I will comply with such provisions before commencing the performance of
the work of this contract.
Date: a) Project Number: r-0 I)L~AL-1
Project Name: Pm X) ID L Z U~ Cc~ ~~-r~7~ hL51 1~1`b~ ti
Company Name: ~'lGN-tom 1 ti L
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Address: Wk Se> L_ W19 7.4ti
Print Name: Xo t) C iv-(-) c~.a a I
Title: - R-, Jcd.
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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.)
1) r ~J L
3. Dollar Amount of Award:
1,-j-71, r.t L
Sc%L
i a ri j~L
1
4. Contact Person:
Y ~ 1ti l) r,
5. Pho : (include Arga Code)
~S
_
-1 p~C rt
1931
W 01 -IGLU 1 1 A- 191'1
6. Reporting Period:
7. Date Report Submitted
8. Program Code:
(Use a separate sheet for each Program Code)
Program Codes
1. Flexible Subsidy 2. Section 202/811 3. Publidlndian Housing Development, Operation and Modernization 4. H
6 HOME - State Administered 7. CDBG - Entitlement 8. CDBG - State Administered 9. Other CD Programs
omeless Assistance 5. HOME
10. Other Housing Programs
P.
rart I: Cm 1U IIICI fL 011N 1 ra an nra.
TOTAL
SECTION 3
% of Aggregate Hires
JOB
CLASSIFICATION
NEW HIRES
NEW HIRES
Who are Section 3 Residents
%
Professionals
%
Technicians
%
Office/Clerical
0/0 %
Trade: I -
Trade: L~c-c 1-
Trade:
Trade:
%/~o
Total:
.---J Y r:a....... 4 4- Qe,n+;^n Z RrrrcinLa¢¢PC fz.&--t-tnm Sunnliers Vendors,or Service Providers)
rant u: L,01171dct, rawaru vv,n,u4L.
. - _
CONTRACT
NAME OF
SPECIFY
SECTION 3 BUSINESS CONCERN
CONSTRUCTION OR NONCONSTRUCTION CONTRACT
AMOUNT
-
$
'
r
U
_
u
$ a
L L S
$
TOTAL
$
Percentage of the total dollar amount to be awarded to Section 3 Business Concerns:
p,3
L
1
SECTION 3 ECONOMIC OPPORTUNITY REPORT (CONTRACTOR)
1. Recipient Name and Address
actor
Subcontractor)
i
i
t
t
b
t
C
S
2. Project Number. (con"ctmwam No.)
7
3. Dollar Amount of Contract:
1 t
J
~
,
-rec
p
en
on
r
u
,
(Recipien
,
6, D_L
C h Mr-
-
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t
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4 ntact Person:
5. Phone: (include Area Code)
131 ►~vc~..~Ao dcL
d
R
i
i
P
7
ort Submitted
D
t
Re
Sat, t~n~-MuJ C~
6.
eport
er
od:
ng
.
a
e
p
1
8. Project Number.
9. Federal EIN:
Dar} I• Fmntnvmant R Traininn Opportunities Drovlded to low-income individuals (Minimum Goal: 30% of New Hires)
TOTAL
LOW-INCOME
% of Aggregate Hires
JOB CLASSIFICATION
NEW HIRES
NEW HIRES
Who are low-income
%
Technicians
Office/Clerical
Professionals
Construction Trade:
Construction Trade:
c
TOTAL
'3
L S
D- r+ II• Q..knnnfr~r•fc A~unrriart ace i...,,n,c„K-ntmntr;nnik2Si%nfthePrimeContract Amount)
Number of Subcontracts awarded:
Number of Section 3 Businesses Receiving Contracts:
Z
Name of Qualified Business Concern
Construction or Non-construction Contract
Amount
ell
c el i
A
$ V
2AS ft, 1,14
$
Total Dollar Amount of Subcontracts awarded to Section 3 qualified Business Concerns:
$
Dollar Amount of All Subcontracts:
$
Percentage of the total dollar amount awarded to qualified Business Concerns:
U %
Part III: Summa of the efforts that were made to generate economic opportunities
Trained and/or Employed low-income individuals equal to r of the aggregate new hires. (Attach Resident
Certifications)
Awarded a Subcontract to qualified Business Concerns equal to of the contract amount. (Attach Business
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 - '6 I) N-f (Attach supporting documentation)
Z
SECTION 3 RESIDENT CERTIFICATION
(2008 Income Guidelines)
Employee's Name:
Employee's Address:3 (ate 2 _t /,~~c:
I hereby certify that I am a Section 3 resident; based on the following qualification(s):
- _ 1. 1 am a Public Housing Resident (Specify Name of the Public Housing site):
6) 1 am a low-income resident of the metropolitan area.
Select your household size and gross annual income level (from all sources):
HOUSEHOLD SIZE & INCOME LEVEL
❑
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 $43,950 or less
7 $47,000 or less
8 $50,050 or less
3. 1 am not a public housing or low-income resident of the metropolitan area.
Z_Z L4 --ol
Employee Signature Date
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: - l - U
This person's Job Classification is:
Name of Employer:
To Be Completed by Local Contracting Agency
Preference Category: ❑ Targeted Service Area ❑ Youthbuild ❑ McKinney Homeless ❑ Other Section 3
Census Tract Number:
SECTION 3 RESIDENT CERTIFICATION
(2008 Income Guidelines)
Employee's Name: DSO,,~L(~ ~1Gts
Employee's Address: ---`''~1eU11~~ ,1, _.Sal ~~[rcz~
I hereby certify that I am a Section 3 resident; based on the following qualification(s):
1. 1 am a Public Housing Resident (specify Name of the Public Housing site):
2. 1 am a low-income resident of the metropolitan area.
Select your household size and gross annual income level (from all sources):
HOUSEHOLD SIZE & INCOME LEVEL
❑
$26,550 or less
$30,300 or less
$34,100 or less
❑
4 $37,900 or less
5 $40,950 or less
1
7
- 6 $43,950 or less
ET
_ 7 $47,000 or less
8 $50,050 or less
3. VI m not a p lic housing or low-income resident of the metropolitan area.
Employee Signature Date
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:
16::: C r
This person's Job Classification is: Offi Ge, AG,,a. ne. r
Name of Employer:
To Be Completed by Local Contracting Agency
Preference Category: ❑ Targeted Service Area ❑ Youthbuild ❑ McKinney Homeless ❑ Other Section 3
Census Tract Number:
SECTION 3 RESIDENT CERTIFICATION
(2008 Income Guidelines)
Employee's Name:
Employee's Address: Z
/'/9-
I hereby certify that I am a Section 3 resident; based on the following qualification(s):
- . 1. 1 am a Public Housing Resident (specify Name of the Public Housing site):
I am a low-income resident of the metropolitan area.
Select your household size and gross annual income level (from all sources):
HOUSEHOLD SIZE & INCOME LEVEL
❑
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 $43,950 or less
❑
7 47.000 or less
8 $50,050 or less
3. 1 am not a public housing or low-income resident of the metropolitan area.
Z --Z LA
Employee Signature Date
Must Be Completed by Employer
The above-named person is a permanent full-time employee who was hired on: 1 ~j> g
The above-named person is a new-hire employee who was hired on: -
This person's Job Classification is: 1~3v
Name of Employer:
To Be Completed by Local Contracting Agency
Preference Category: ❑ Targeted Service Area ❑ Youthbuild ❑ McKinney Homeless ❑ Other Section 3
Census Tract Number:
SECTION 3 RESIDENT CERTIFICATION
(2008 Income Guidelines)
Employee's Name:
Employee's Address: PP o,6JgL~2
417
~
I hereby certify that I am a Section 3 resident; a ed on the following qualification(s):
1. I am a Public Housing Resident (specify Name of the Public Housing site):
I am a low-income resident of the metropolitan area.
Select your household size and gross annual income level (from all sources):
HOUSEHOLD SIZE & INCOME LEVEL
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 $43,950 or less
7 $47,000 or less
❑
8 $50,050 or less
3. 1 am not a public housing or low-income resident of the metropolitan area.
12LZ~10 5?
Employee Signature ate
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: Tcl}r, G or-~
This person's Job Classification is:
Name of Employer: i~L~_~ Tel L
To Be Completed by Local Contracting Agency
Preference Category: ❑ Targeted Service Area ❑ Youthbuild ❑ McKinney Homeless ❑ Other Section 3
Census Tract Number:
SECTION 3 RESIDENT CERTIFICATION
(2008 Income Guidelines)
Employee's Name: Ul Y 16n [r CJ
Employee's Address: A~E
hereby certify that I am a Section 3 re Niden `Based o the following qualification(s):
1. 1 am a Public Housing Resident (Specify Name of the Public Housing site):
2. I am a low-income resident of the metropolitan area.
Select your household size and gross annual income level (from an sources):
HOUSEHOLD SIZE & INCOME LEVEL
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 $43,950 or less
7 $47,000 or less
❑
8 $50,050 or less
3. m not a public housing or low-income resident of the metropolitan area.
Employee Signature ate
r
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: ir311--~ gltc
T
This person's Job Classification is:
Name of Employer: -1+4
To Be Completed by Local Contracting Agency
Preference Category: ❑ Targeted Service Area ❑ Youthbuild ❑ McKinney Homeless ❑ Other Section 3
Census Tract Number:
02/24/2009 13:06 9895959066 KORMX INC PACE 02/02
SECTION. 3 RESIDENT CERTIFICATION
pop income Guidelines)
employee's Name;
Employee's Address:
1 hereby certify that I am a Section 3 resident; based on the following qualification(s):
2.
I am a Public Housing Resident (Spe&y Name of the Public Housing aite):
I am a low-income resident of the metropoinan area.
Select your household size and gross annual Income level an sources):
HOUSEHOLD SIZE 9 INCOME (LEVEL
1 $26,550 or less
2 $30,300 or less
3 $34,100 or less
4 $$7,900 or less
5 $40,950 or less
6 $43,950 or less
7 $47,000 or lose
g $50,050 or less
3. 1 am not a public housing or low-income resident of the metropolitan area.
-12-x, f gjcN
ployee Signatu Date
Must Be Gomplpted by Employer
The above-named person Is a permanent fun-Lime employee who was hired on_ 1
The above-named person is a new-Dire employee who was hired on: ~ ~t ~ ~
This parson's Job Clawffla icon is:
Name of Employer: Vzy-sm ~h1 t To Be Completed by Local CoawAcftc Ageucy
Freftwce Czftmy: ❑ Targeted Swvirc Area ❑ YowhbuUd ❑ DCBu=CY Ho®otess ❑ Other 5WM 3
census Tr%01-h=ba:
1e/10 3!DVd VInSNIN3d S38DISAVS LL609L96b61 BE W 600Z/VZ/Z0
Statistical Information on Contractor
INSTRUCTIONS: All contractors responding to bid solicitations must complete this form for proper
consideration of their bid. The information requested below is for statistical purposes only. On final
analysis and consideration of award, a bidder will be selected without regard to gender, race/ethnicity,
creed, color, religion, sex, national origin, age, marital status, or disability. Categories listed below are
based upon those described in 49 CFR 6.23.5.
NAME OF FIRM:_ Y1 pY-r` r- r i
BUSINESS STRUCTURE: b rn 1 I
(Corporation, Non-pi
Joint Venture, Sole Proprietorship, etc.)
TOTAL NUMBER OF EMPLOYEES IN FIRM (Including Owners):
CULTURAL/ETHNIC COMPOSITION OF FIRM - Please break down the total number of employees in
your firm into the following categories:
RACE/ETHNIC COMPOSITION
OWNERS/PARTNERS/
ASSOCIATE
PARTNERS
MANAGERS
STAFF
Male
Female
Male
Female
Male
Female
White/Non-Hispanic
Black/African American
His anic/Latin American
Asian American
American Indian/Alaskan Native
All Others
Please indicate by percentage how the ownership of the firm is distributed.
WHITE/NON-
BLACK/AFRICAN
HISPANIC/LATIN
ASIAN
AMERICAN
ALL
HISPANIC
AMERICAN
AMERICAN
AMERICAN
INDIAN/
OTHERS
ALASKAN
NATIVE
Men
%
(1 %
%
%
Women
%
f7 %
!7 %
%
J
Is your firm currently certified as a minority, women-owned, disadvantaged or disabled veteran's business
enterprise by a public agency? ❑YES ~§NO
(If yes, complete the following and attach a copy of your notice of certification.)
Agency Expiration Date
Agency Expiration Date
I declare under penalty of perjury under the laws of the state of California that the above information is
true and accurate. I understand that the City reserves the right to audit the above information at any time,
and that I will notify the City if there are any changes in this firm's ownership.
Aut orized Signature Print Authorized Name and Title Date
C:1Do=a a and SetWWVmurz¢1My Docnmena\C[P Projects\Davi.-Be \Smwucpl lnfonnehon on ContacWdoe
Annual Curb Ramp Project
Federal Requirements
Page 2
6. The primary contractor acknowledges and accepts that the "Notice to All
Employees", along with the Federal Wage Determination, must be posted for the
entire duration of the project. It must be posted in a visible location where the
employees do not feel any type of threat to look at it. It cannot be posted inside
the office. It must be out in plain view.
7. The primary contractor acknowledges and accepts that if he or his company does
not follow the Federal regulations, then the primary contractor can be placed on
the debar list and loose their license.
8. The primary contractor acknowledges that the following handouts were provided:
a. Notice To All Employees Poster
b. Federal Labor Standards Provisions (form HUD-4010)
c. A Contractor's Guide to Davis-Bacon Wage Requirements for
Federally-Assisted Construction Projects dated June 2006
d. Statistical Information on Contractor
X,2rL-,), -,c t" L
Contractor
Address
Telephone Number: 7)d")
By:
34~L ZZ Date: Z-Z...tjct
Title: ~r-z7
; c P, t
Contractor's signature must be notarized. Attach acknowledgements hereto.
ACKNOWLEDGMENT
State of Calif nia
County o
On
417t4 before me, Gti
(insert name and title of the offi r)
personally appeared _u VI. L /
who proved to me on the basis of satisfactory evidence to be the personSs' whose name islafte
subscribed to the within instrument and acknowledged to me that he/,tee/they executed the same in
his/h6r/Weir authorized capacity(ierg), and that by his/Kr/thtir signature.(.aj' on the instrument the
person(p), or the entity upon behalf of which the person(,s'f 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.
Signatur
INDA ROSE E TEINOII
cOMM, 01696449 Z
N01ary Public • California o
San Bernardino county
fd Comm. Ex Tres Sep. 28.20101
(Seal)