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HomeMy WebLinkAboutAll Other Required 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 works21 1293492.1 project, and determined that none of them is ineligible to perform work as a subcont ractor 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 Califor11j,.a of 2 '-111- under penalty of perjury under the laws of the State of that the foregoing i��rue and correct. Executed this day , 202�, at �� ?/t (place of execution). 1293492.1 �rp� Name: Michael Cavanagh Title: President Name of Contractor: Key Code Media Inc. 22 23 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 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. X CONTRACTOR'S INDUSTRIAL SAFETY RECORD Project Identification FP 23504 WJNDMILLJWILLOW ROOM AUDIO VISUAL & PRODUCTION CONTROL ROOM SYSTEMS UPGRADE PROJECT Bid Date 4/26/23 ------------------- This information must include all constru ction 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 expl anation of data, which he would like, taken into consideration in evaluating the safety record. An explanation must be attached of the circumstances surrounding any and all fatalities. ITEM 5 CALENDAR YEARS CURRENT PRIOR TO CURRENT YEAR YEAR 2018 2019 2020 2021 2022 TOTA 2023L No. of Contracts Total dollar amount of contracts (in l,000's) No. of lost workday cases No. of lost work day cases involving permanent transfer to another job or 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 from the records that are available to me at this time and I declare under penalty of perjury that the information is true and accurate within the limitations of these records. 1 l,{e.t Cok V)?et1'�.1, l.ttc_Name of Bidder (Print) 270 S Flower St Address Burbank, CA City 1293492.1 91502 Zip Code Signature 1010561 -C7 & C10 State Contractor's Lie. No. & Class 818-303-3900 Telephone 24 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03976756884485932,801 271$22,562,970 $35,421,807 $39,250,585 $45,298,663 $49,574,439 $192,108,464 $15,579,177 AFFIDAVIT FOR CORPORATION BIDDER STATE OF CALIFORNIA )SS COUNTY OF LOS ANGELES ) Michael Cavanagh duly sworn, deposes and says: That he is President being first ----------------------------------- of, Key Code Media Inc. 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 day of , 20 ----------------------- 1293492.1 ·)89 attached certlficatt., Signature of Officer Administering Oath (Notary Public) 26 CALIFORNIA JURAT WITH AFFIANT STATEMENT GOVERNMENT CODE § 8202 ��S�ffi: i · O•�Bl!l� ?4 See Attached Document (Notary to cross out lines 1-6 below) □ See Statement Below (Lines 1-6 to be completed only by document signer[s], not Notary) 2 6 _________________ _ Signature of Document Signer No. 1 Signature of Document Signer No. 2 (if any) A notary public or other officer completing this certificate verifies only the identity of the individual who signed the documentto which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California Countyof ks Tes NATHANIEL HORNE Notary Public -California Los Angeles County Commission # 2303 507 My comm. Expires Aug 30, 2023 Place Notary Seal and/or Stamp Above Subscribed and sworn to (or affirmed) before me on this tii+h day of Apr: l , 20.fl_, by Date I Month Year (1);VI_; cli Cl/1/ u. ,Ii Cl Y)/X8 b(and (2) ______________ ), NameJsj' of Signer{#"' proved to me on the basis of satisfactory evidence to be1heperso�=� Signature r /i Signature of Notary Public .----------------OPTIONAL---------------­ Completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type ofDocument: ��,61}�\ ¼.--C ,er�@.{, l')Y\ ]-, 21,Je,r Document Date: @ {,,,{ / d-L{ f cr:{2 d:J Number of Pages: _____ _ Signer(s) Other Than Named Above: _______________________ _ ©2017 National Notary Association