HomeMy WebLinkAbout6, Other Docs.pdfDECLARATION OF ELIGIBILITY TO CONTRACT
[Labor Code Section 1777.1; Public Contract Code Section 6109]
The undersigned, a duly authorized representative of the contractor,
certifies and declares that:
1. The contractor is aware of Sections 1777.1 and 1777.7 of the
California Labor Code, which prohibit a contractor or
subcontractor who has been found by the Labor Commissioner or the
Director of Industrial Relations to be in violation of certain
provisions of the Labor Code, from bidding on, being awarded, or
performing work as a subcontractor on a public works project for
specified periods of time.
2. The contractor is not ineligible to bid on, be awarded or perform
work as a subcontractor on a public works project by virtue of the
foregoing provisions of Sections 1777.1 or 1777.7 of the California
Labor Code or another provision of law.
3. The contractor is aware of California Public Contract Code Section
6109, which states:
(a) A public entity, as defined in Section 1100 [of the
Public Contract Code], may not permit a contractor or
subcontractor who is ineligible to bid or work on, or be
awarded, a public works project pursuant to Section 1777.1 or
1777.7 of the Labor Code to bid on, be awarded, or perform
work as a subcontractor on, a public works project. Every
public works project shall contain a provision prohibiting a
contractor from performing work on a public works project
with a subcontractor who is ineligible to perform work on the
public works project pursuant to Section 1777.1 or 1777.7 of
the Labor Code.
(b) Any contract on a public works project entered into
between a contractor and a debarred subcontractor is void as
a matter of law. A debarred subcontractor may not receive
any public money for performing work as a subcontractor on a
public works contract, and any public money that may have
been paid to a debarred subcontractor by a contractor on the
project shall be returned to the awarding body. The
contractor shall be responsible for the payment of wages to
workers of a debarred subcontractor who has been allowed to
work on the project.
4. The contractor has investigated the eligibility of each and every
subcontractor the contractor intends to use on this public works
21
1293492.1
project, and determined that none of them is ineligible to perform
work as a subcontractor on a public works project by virtue of the
foregoing provisions of the Public Contract Code Sections 1777.1
or 1777.7 of the Labor Code, or any other provision of law.
I declare under penalty of perjury
California that the foregoing is true
of 4/25/23 , 2023, at Oranc
under the laws of the State of
and correct. Executed this day
[e, CA (place of execution).
i
Signature
Name: Jay Schellin
Title: CFO
Name of Contractor:
Western A/V & Security
22
1293492.1
BIDDER'S VIOLATION OF LAW/SAFETY QUESTIONNAIRE
In accordance with Government Code Section 14310.5 and in conformance
with Public Contract Code Section 10162, the Bidder shall complete,
under penalty of perjury, the following questionnaire:
QUESTIONNAIRE
Has the Bidder, any officer, principal or employee of the Bidder who
has a proprietary interest in the business of the Bidder, ever been
disqualified, removed, or otherwise prevented from bidding on or
completing a federal, state or local government project because of
violation of law or a safety regulation?
YES
NO x
If the answer is yes, explain the circumstances in the following space:
STATEMENT
In conformance with Public Contract Code Section 10232, the Contractor,
hereby states under penalty of perjury, that no more than on final
unappealable finding of contempt of court by a federal court has been
issued against the Contractor within the immediately preceding two-year
period because of the Contractor's failure to comply with an order of
a federal court which orders the Contractor to comply with an order of
the National Labor Relations Board.
NOTE: The above Statement and Questionnaire are part of the
Proposal. Signing this Proposal on the signature portion
thereof shall also constitute signature of this Statement and
Questionnaire.
Bidders are cautioned that making a false certification may
subject the certifier to criminal prosecution.
?3
1293492.1
CONTRACTOR'S INDUSTRIAL SAFETY RECORD
Project Identification CITY PROJECT NO.FP 23504
Bid Date 4/26/2023
This information must include all construction work undertaken in the
State of California by the bidder and any partnership, joint venture or
corporation that any principal of the bidder participated in as a
principal or owner for the last five calendar years and the current
calendar year prior to the date of bid submittal. Separate information
shall be submitted for each particular partnership, joint venture,
corporation or individual bidder. The bidder may attach any additional
information or explanation of data, which he would like, taken into
consideration in evaluating the safety record. An explanation must be
attached of the circumstances surrounding anv and all fatalities.
ITEM
5 CALENDAR YEARS
CURRENT
PRIOR TO CURRENT YEAR
YEAR
2018
2019
2020
2021
2022
TOTA
2023
L
No. of Contracts
Zoz -
Z z-1
/ 92
7-
1103+3�
Total dollar amount of
93) 6�
l z j��� ��
/�
f� �Z g�
13 6 V� ��
r� � � ���
��
contracts in 1,000's
No. of lost workday
D
cj
a
(`�
cases
No. of lost work day
cases
involving permanent
transfer to
1
another job or-r%
termination of
employment
No. of lost workdays
*The information required for this item is the same as required for
columns 3 to 6, Code 10, Occupational Injuries, Summary - Occupational
Injuries and Illnesses, OSHA No. 102.
The above information was compiled
to me at this time and I declare
information is true and accurate
records.
Jay Schellin
Name of Bidder (Print)
1592 N Batavia St #2
Address
Orange 92867
City Zip Code
from the records that are available
under penalty of perjury that the
within the limitations of these
r 4A
Signat r
C7: 87dZ09 Exp:1/31/2024
State Contractor's Lic. No. & Class
714-637-7272
Telephone
24
1293492.1
AFFIDAVIT FOR CO -PARTNERSHIP FIRM
STATE OF CALIFORNIA )
) SS
COUNTY OF LOS ANGELES )
N/A
sworn, deposes and says:
being first duly
That he is a member of the co -partnership firm designated as
N/A
which is the party making the foregoing proposal or bid; that such bid
is genuine and not collusive or sham; that said bidder has not colluded,
conspired, connived or agreed, directly or indirectly, with any other
bidder or person to put in a sham bid or that such other person shall
refrain from bidding; and has not in any manner sought by collusion to
secure any advantage against the City of Diamond Bar or any person
interested in the proposed contract, for himself or for any other
person.
That he has been and is duly vested with authority to make and sign
instruments for the co -partnership by
N/A
who constitute the other members of the co -partnership.
N/A
Signature
Subscribed and sworn
to before me this
N/A day of N/A 20 N/A
N/A
Signature of Officer Administering Oath
(Notary Public)
25
1293492.1
AFFIDAVIT FOR CORPORATION BIDDER
STATE OF CALIFORNIA )
) SS
COUNTY OF LOS ANGELES )
Jay Schellin
duly sworn, deposes and says:
That he is CFO
of, Western A/V & Securit
, being first
a corporation which is the party making the foregoing proposal or bid;
that such bid is genuine and not collusive or sham; that said bidder
has not colluded, conspired, connived or agreed, directly or indirectly,
with any other bidder or person to put in a sham bid or that such other
person shall refrain from bidding; and has not in any manner sought by
collusion to secure any advantage against the City of Diamond Bar or
any person interested in the proposed contract, for himself or for any
other person.
Subscribed and sworn
to before me this
22nd
1293492.1
Signature
day of April , 20 23
( of)(,,
Signature of Officer Administering Oath
(Notary Public)
26
A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate
is attached, and not the truthfulness, accuracy, or
validity of that document.
State of California
County of 0V6,Y qk
Subscribed and sworn to (or affirmed) before me on this Z Z
day of t 1 , 20 73, by J G
proved to me on the basis of satisfactory evidence to be the
person(s) whoappeared before me.
SCARLETT M. ANDERSON�
COMM. #2396321
Notary Public • California
x Orange County
My Comm. Expires Mar. 9, 2026
AFFIDAVIT FOR INDIVIDUAL BIDDER
STATE OF CALIFORNIA )
)SS
COUNTY OF LOS ANGELES )
N/A
duly sworn, deposes and says:
being first
That he is the party making the foregoing proposal or bid; that
such bid is genuine and not collusive or sham; that said bidder has not
colluded, conspired, connived or agreed, directly or indirectly, with
any other bidder or person to put in a sham bid or that such other
person shall refrain from bidding; and has not in any manner sought by
collusion to secure any advantage against the City of Diamond Bar or
any person interested in the proposed contract, for himself or for any
other person.
Subscribed and sworn
to before me this
N/A
day of
N/A
Signature
N/A
20 NZ
N/A
Signature of Officer Administering Oath
(Notary Public)
27
1293492.1
AFFIDAVIT FOR JOINT VENTURE
STATE OF CALIFORNIA )
) SS
COUNTY OF LOS ANGELES )
N/A
duly sworn, deposes and says:
That he
N/A
of,
N/A
being first
one of the parties submitting the foregoing bid as a joint venture and
that he has been and is duly vested with the authority to make and sign
instruments for and on behalf of the parties making said bid who are:
N/A
that such bid is genuine and not collusive or sham; that said bidder
has not colluded, conspired, connived or agreed, directly or indirectly,
with any other bidder or person to put in a sham bid or that such other
person shall refrain from bidding; and has not in any manner sought by
collusion to secure any advantage against the City of Diamond Bar or
any person interested in the proposed contract, for himself or for any
other person.
N/A
Signature
Subscribed and sworn
to before me this
N/A day of N/A , 20 N/A
N/A
Signature of Officer Administering Oath
(Notary Public) N /A
BOND No.
28
1293492.1
BID BOND Bond No. CSBA-23803
KNOW ALL PERSONS BY THESE PRESENTS that,
WHEREAS the City of Diamond Bar ("City"), has issued an invitation
for bids for the work described as follows:
Windmill/Willow Room Audio Visual & Production Control Room Project No. FP 23504
Systems Upgrade Project
WHEREAS
Western A/V, A Corporation, 1592 N. Batavia Street, Suite 2, Orange, CA 92867
(Name and address of Bidder)
("Principal"), desires to submit a bid to Public Agency for the work.
WHEREAS, bidders are required under the provisions of the California
Public Contract Code to furnish a form of bidder's security with their
bid.
NOW, THEREFORE, we, the undersigned Principal, and
Markel Insurance Company
3131 Camino del Rio N., Suite 1450, San Diego, CA 92108
(Name and address of Surety)
("Surety") a duly admitted surety insurer under the laws of the State
of California, as Surety, are held and firmly bound unto Public Agency
in the penal sum of Ten Percent of the Amount Bid
Dollars($10% ), being not less than ten percent (100) of the
total bid price, in lawful money of the United States of America, for
the payment of which sum well and truly to be made, we bind ourselves,
our heirs, executors, administrators, successors, and assigns, jointly
and severally, firmly by these presents.
THE CONDITION OF THIS OBLIGATION IS SUCH THAT, if the hereby bounded
Principal is awarded a contract for the work by City and within the
time and in the manner required by the bidding specifications, entered
into the written form of contract included with bidding specifications,
furnishes the required bonds, one to guarantee faithful performance and
the other to guarantee payment for labor and materials, and furnishes
the required insurance coverages, then this obligation shall become
null and void; otherwise, it shall be and remain in full force and
effect.
33
1293492.1
In case suit is brought upon this bond, Surety further agrees to pay
all court costs incurred by City in the suit and reasonable attorneys'
fees in an amount fixed by the court. Surety hereby waives the
provisions of California Civil Code § 2845.
IN WITNESS WHEREOF, each of which shall for all purposes be deemed an
original hereof, have been duly executed by Principal and Surety, on
the date set forth below, the name of each corporate party being hereto
affixed and these presents duly signed by its undersigned
representative(s) pursuant to authority of its governing body.
Dated:
"Principal" Western A/V, A Corporation" Surety"
Markel Insurance Company
1592 N. atavia Street, Suite 2 3131 Camino del Rio N., Suite 1450
Orange, CA 92867 San Diegor&A 92108
By: By:
Its Adrian Langre I s Attorney -in —Fact
By: By: "
Its
Note: -This bond must be dated, all
evidence of the authority of
fact must be attached.
(Sea1)
W..SCOARLETT IN. ANOERSONOMM. #2396321
tary Public • CalifomiaOrange County
omm. Expires Mar. 9, 2026
34
1293492.1
Its Z _ a
signatures must be notarized, and
any person signing as attorney--in-
(Seal)
ACKNOWLEDGMENT
A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or
validity of that document.
State of California
County of CA GM 61Pl )
On -r 122, ui'b before me, S CC�1Wi� d e(S q o �b� l C
(insert name and title of the offi er
personally appeared J(A\A S(,Y)t111 V)
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.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
SCARLETT M. ANDERSON
WITNESS my hand and official seal. COMM. #2396321 z
Notary Public • Califomia
Z Orange County
I !- V-- - My Comm. Ex ires Mar. 9, 2026
Signature _ (Seal)
ACKNOWLEDGMENT
A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or
validity of that document.
State of California
County of Orange
71
04/22/2023
before me, Melissa Ann Vaccaro, Notary Public
(insert name and title of the officer)
personally appeared Adrian Langrell
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.
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. MELISSAANNVACCAR0
M COMM. #fi2401942 n
Notary Public -California N
LL
ORANGE COUNTY a
My Comm. Expires May 12, 2026
Signaturepll�b_` (Seal)
Melissa Ann Vaccaro
Bond No. CSBA-23803
POA# 510023
JOINT LIMITED POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS: That SureTec Insurance Company, a Corporation duly organized and existing under the laws of the State of Texas and having its
principal office in the County of Harris, Texas and Markel Insurance Company (the "Company"), a corporation duly organized and existing under the laws of the state
of Illinois, and having its principal administrative office in Glen Allen, Virginia, does by these presents make, constitute and appoint:
Arturo Ayala, Daniel Huckabay, Dwight Reilly, Shaunna Rozelle Ostrom, Frank Morones, Michael D. Stong,
Ben Stong, R. Nappi, Benjamin Wolfe, Chelsea Liberatore, Adrian Langrell
Their true and lawful agent(s) and attorney(s)-in-fact, each in their separate capacity if more than one is named above, to make, execute, seal and deliver for and on
their own behalf, individually as a surety or jointly, as co -sureties, and as their act and deed any and all bonds and other undertaking in suretyship provided, however,
that the penal sum of any one such instrument executed hereunder shall not exceed the sum of:
Fifteen Million and 00/100 Dollars ($15,000,000.00)
This Power of Attorney is granted and is signed and sealed under and by the authority of the following Resolutions adopted by the Board of Directors of SureTec
Insurance Company and Markel Insurance Company:
"RESOLVED, Thatthe President, any Senior Vice President, Vice President, Assistant Vice President, Secretary, Assistant Secretary, Treasurer or Assistant Treasurer
and each of them hereby is authorized to execute powers of attorney, and such authority can be executed by use of facsimile signature, which may be attested or
acknowledged by any officer or attorney, of the company, qualifying the attorney or attorneys named in the given power of attorney, to execute in behalf of, and
acknowledge as the act and deed of the SureTec Insurance Company and Markel Insurance Company, as the case may be, all bond undertakings and contracts of
suretyship, and to affix the corporate seal thereto."
IN WITNESS WHEREOF, Markel Insurance Company and SureTec Insurance Company have caused their official seal to be hereunto affixed and these presents to be
signed by their duly authorized officers on the 4th day of January , 2023.
SureTec Insurance Company �ttuytrr Markel suranceC pang
SURANC �%%``uRANC �i.
opPORyx O
By; y SEAL cD= By ,
Michael C Keimig, Preside ?n�•tiTl �< '•,xts,i ndeyJen s Vicresi ge dent
State of Texas * j �4rr nPt``�`,` /
County of Harris:
On this 4th day of January , 2023 A. D., before me, a Notary Public of the State of Texas, in and for the County of Harris, duly commissioned and qualified,
came THE ABOVE OFFICERS OF THE COMPANIES, to me personally known to be the individuals and officers described in, who executed the preceding instrument, and
they acknowledged the execution of same, and being by me duly sworn, disposed and said that they are the officers of the said companies aforesaid, and that the
seals affixed to the proceeding Instrument are the Corporate Seals of said Companies, and the said Corporate Seals and their signatures as officers were duly affixed
and subscribed to the said instrument by the authority and direction of the said companies, and that Resolutions adopted by the Board of Directors of said Companies
referred to in the preceding instrument is now in force.
I N TESTIMONY WHEREOF, I have hereunto set my hand, and affixed my Official Seal at the County of Harris, the day and year first above written.
XENIA AIVAS
Notary Public State of Texas By
Commission # 129117659 x as, Not r Public
......_...E+= v
Commission Expires 9/10/24 My co mission expires 9/10/2024
We, the undersigned Officers of SureTec Insurance Company and Markel Insurance Company do herby certify that the original POWER OF ATTORNEY ofwhich the
foregoing is a full, true and correct copy is still in full force and effect and has not been revoked.
IN WITNESS WHEREOF, we have hereunto set our hands, and affixed the Seals of said Companies, on the 22nd day of April 2023
5 M. rBerTeclnsu nceComp y
ance Company
By. tBat, Assta
A drew Marquis, Assistan ecretar
Any Instrument Issued in excessof the penaltystated aboy is total;y void and witho&t anyvalidiQ- 510023
For verification of the authority of this Power you may call (213)812-0i3 6,n agy;b .,mssday-between 830 AM and 5:00 PM CST.
NON -COLLUSION AFFIDAVIT
TO: THE CITY OF DIAMOND BAR:
STATE OF CALIFORNIA )
SS
COUNTY OF Orange )
Jay Schellin , being first duly
sworn, deposes and says that he or she is CFO of
Western A/V & Security , 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 another 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 contact or 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.
Signa ur U
of Bidder
STATE OF CALIFORNIA )
) SS
COUNTY OF LOS ANGELES )
Subscribed and sworn to before me this IL day of A p YA � , 20 23
_S cafieN� ftdey'Scrn
Notary Public in and for the County of
�YQ1� State of California
0os{i 1, rpii- ottache4
37
1293492.1
ACKNOWLEDGMENT
A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or
validity of that document.
State of California
County of OWY19 )
On ky7 r } Z Z , 2W5 before me, hndevscnjm410:,
(insert name and title of the officer
personally appeared S Gk� s0ifM q
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.
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. o COMM. 023%321
i Notary Public • California
Orange County •
Comm. Expires Mar. 9, 20H
Signature .Ac� (Seal)