HomeMy WebLinkAboutCompleted Bid DocsCERTIFICATION OF NON-DISCRIMINATION AND AFFIRMATIVE ACTION
As suppliers of goods or services to the City of Diamond Bar, the firm
listed below certifies that it does not discriminate in its employment
with regards to race, religion, sex, or
compliance with all federal, state, and
orders regarding non-discrimination in
pursue an affirmative course of action
action guidelines.
We agree specifically:
national origin; that it is in
local directives and executive
employment; and that it will
as required by the affirmative
1. To establish or observe employment policies which affirmatively
promote opportunities for minority persons at all job levels.
2. To communicate this policy to all persons concerned including all
company employees, outside recruiting services, especially those
serving minority communities, and to the minority communities at
large.
3. To take affirmative steps to hire minority employees within the
company.
FIRM �y L V2�
TITLE OF OFFICER SIGNING
SIGNATURE DATE
Please include any additional information available regarding equal
opportunity employment programs now in effect within your company:
0
1293492A
r
CERTIFICATION WITH REGARD TO THE PERFORMANCE OF
PREVIOUS CONTRACTS OR SUBCONTRACTS SUBJECT TO THE
EQUAL OPPORTUNITY CLAUSE AND THE FILING OF REQUIRED REPORTS
The bidder , proposed subcontractor , hereby certifies that
he has , has not .1 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 has , 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.
DATE: S- 1 7 -,-A U-2 3
(COMPANY)
BY:
k3 , � � �)� e ,". � v4ka
(TITLE)
2 0-�)-3
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 of such other
period specified by the Federal Highway Administration or by the
Director, Office of Federal Contract Compliance, U.S. Department of
Labor.
1293492. l
NON -COLLUSION DECLARATION
(TO BE EXECUTED BY BIDDER AND SUBMITTED WITH
BID) PROJECT NAME: INSTALLATION OF THREE (3),
TWO POST GABLE SHELTERS ON THE CANYON LOOP
The undersigned declares:
I am the"Q • �_t
foregoing bid.
TRAIL
of 05 the party making the
The bid is not made in the interest of, or on behalf of, any undisclosed
person, partnership, company, association, organization, or
corporation. The bid is genuine and not collusive or sham. The bidder
has not directly or indirectly induced or solicited any other bidder
to put in a false or sham bid. The bidder has not directly or indirectly
colluded, conspired, connived., or agreed with any bidder or anyone
else to put in a sham bid, or to refrain from bidding. 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.
All statements contained in the bid are true. 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, to any corporation, partnership, company,
association, organization, bid depository, or to any member or agent
thereof, to effectuate a collusive or sham bid, and has not paid, and
will not pay, any person or entity for such purpose. Any person
executing this declaration on behalf of a bidder that is a corporation,
partnership, joint venture, limited liability company, limited
liability partnership, or any other entity, hereby represents that he
or she has full power to execute, and does execute, this declaration
on behalf of the bidder.
T declare under penalty of perjury under the laws of the State of
California that the foregoing is true and correct and that this
declaration is executed on 0 a oa [date] , at
�Tc1(3 [City] , [state] .
CL'Z"n•O.V,y"
Business Name
Signature of Bidder (must be notarized)
2
1293492.1
Business Address
Attach Notary Acknowledgement Form to this form when submitting.
ATrA�HFD
3
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
validitv of that document.
State of California
County of San Bernardino
On �r. before me, Marissa Rodriguez, Notary Public
(insert name and title of the officer}
personally appeared
PP �—
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 hefshelthey executed the same in
his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
persons), 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 corr . lr
WITNESS my hynfiyind official seal.
Sign-dture
(S
MARiSSA RODRiGUEZ
asE Notary Public California
San Bernardino County
commission # 2334707
Mv Comm, Expires Oct 23, 2024
BIDDER'S PROPOSAL
CITY OF DIAMOND BAR
INSTALLATION OF THREE (3), TWO POST GABLE SHELTERS ON THE CANYON LOOP
TRAIL
CITY PROJECT NO. FP17500
Date (YN Lq, k, , 20 Q 3
To the City Council of the City of Diamond Bar:
The Undersigned hereby declares:
(a) That the only persons or parties interested in this proposal as
principals are the following:
z\ clE V\1 e `)
(If the bidder is a corporation, give the name of the corporation
and the name of its president, secretary, treasurer, and manager.
If a co -partnership, give the name, under which the co -partnership
does business, and the names and addresses of all co-partners. If
an individual, state the name under which the contract is to be
drawn.)
(b) That this proposal is made without collusion with any person, firm
or corporation.
(c) That he has carefully examined the location of the proposed work
and has familiarized himself with all of the physical and climatic
conditions, and makes this bid solely upon his own knowledge.
(d) That by submitting this Bidder's Proposal, he acknowledges receipt
and knowledge of the contents of those communications sent by the
City of Diamond Bar to him at the address furnished by him to the
City of Diamond Bar when this proposal form was obtained.
(e) That he has carefully examined the specifications, both general
and detail, and the drawings attached hereto, and communications
sent to him as aforesaid, and makes this proposal in accordance
therewith.
14
1293492.1
(f} That, if this bid is accepted, he will enter into a written
contract for the performance of the proposed work with the City of
Diamond Bar.
(g) That he proposes to enter into such Contract and to accept in full
payment for the work actually done thereunder the prices shown in
the attached schedule. It is understood and agreed that the
quantities set forth are estimates and that the unit prices will
apply to the actual quantities whatever they may be.
Accompanying this proposal is a certified or cashier's check or
bidder's bond, payable to the order of the City of Diamond Bar in
the sum of
- DOLLARS ( $Ll � } .
Said bidder's bond has been duly executed by the undersigned bidder and
by a financially sound surety company authorized to transact business
in this state.
It is understood and agreed that should the bidder fail within ten
(10 ) days after award of contract to enter into the contract and furnish
acceptable surety bonds, then the proceeds of said check, or bidder's
bond, shall become the property of the City of Diamond Bar; but if this
Contract is entered into and said bonds are furnished, or if the bid is
not accepted then said check shall be returned to the undersigned, or
the bidder will be released from the bidder's bond.
Address
of
Bidder
��(�, �C\(-, (�I1)0
City Zip Code
15
12934911
Telephone of Bidder
Signature of Bidder
BID SCHEDULE
CITY OF DIAMOND BAR
CONTRACT DOCUMENTS AND SPECIFICATIONS
INSTALLATION OF THREE (3), TWO POST GABLE SHELTERS ON THE CANYON LOOP
TRAIL
CITY PROJECT NO. PP17500
ITEM ESTIMATED DESCRIPTION UNIT
NO. QUANTITY UNIT WRITTEN IN WORDS PRICE AMOUNT
INSTALLATION OF THREE (3),
1 1 1 TWO POST GABLE SHELTERS ON it�i
THE CANYON LOOP TRAIL '7L/, oar yr U[
MANDATORY BID SCHEDULE ITEMS:
TOTAL AMOUNT BID (IN FIGURES)
TOTAL AMOUNT BID, SCHEDULE (WRITTEN IN WORDS);
Bid Schedule Note: Bid Price indicated refers to all items illustrated
on the plans and details, and delineated within the specifications
installed and completely in place with all applicable portions of the
construction documents and include all costs connected with such items
including, but to necessarily limited to, materials, transportation,
taxes, insurance, labor, overhead, and profit, for General Contractor
and Subcontractors.
All work called for on the construction documents are to provide a
completed project with all systems operating properly and ready for
use.
Award will be based on the items of Bid Schedule. Therefore, Contractor
shall completely fill out Bid Schedule.
Accompanying this proposal is \ f� U°r A
(Insert "$ ? Ll L)0 # U -:; cash" ,
"cashier's check", "certified check", or "bidder's bond" as
the case may be) in the amount equal to at least ten percent
(10 0 ) of the total bid.
The undersigned further agrees that in case of default in
executing the required contract, with necessary bond, within
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1293492.1
ten (10) days, not including Sundays and legal holidays, after
having received notice that the Contract has been awarded and
ready for signature, the proceeds of the security
accompanying his bid shall become the property of the City of
Diamond Bar, and this proposal and the acceptance thereof may
be considered null and void.
70\, fin\ �)s �3
NAME OF BIDDER (PRINT)
ADDRESS
C) A Lk V%LJ
CITY
SIGNATURE
Z) 3 S
ZIP CODE
DATE
�e�
TELEPHONE
STATE
CONTRACTOR
LICENSE
NO. AND CLASSIFICATION
I declare under penalty of Perjury of the laws of the State of California
that the representations made herein are true and correct in accordance
with the requirements of California Business and Professional Code
Section 7028.15.
CONTRACTOR SIGNATURE OR AUTHORIZED OFFICER
17
1293492.1
LIST OF SUBCONTRACTORS *
BID OPENING DATE S ( 8 -,9Q:J 3
PROJECT INSTALLATION OF THREE (3), TWO POST GABLE SHELTERS ON THE CANYON
LOOP TRAIL PROJECT NO. FP17500
LOCATION
CLIENT
CONTRACTOR
Name Under
Which
Subcontractor
is
Licensed
License
No.
Address
of
Office, Mail,
or
Shop
Percent
of
Total
Contract
Specific
Description
of
Subcontract
* In compliance with the provisions of the Public Contract Code
Section 4104, the undersigned bidder herewith sets forth the name,
IS
1293492-1
DECLARATION 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
20
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 under
the laws of the State of
California
that
the foregoing is true and
correct. Executed this day
of
J 6
2a.A-3, at u :� �,n �,
(place of execution) ,
Signature
Name:
Title: r ' i`-,'�� f
Name of Contractor:
21
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
Pra osal. Signing this Proposal on the signature ❑rtion
thereof shall also constitute signature of this Statement and
Questionnaire.
Bidders are cautioned that making a false certification ma
subject the certifier to criminal rosecution.
22
1293492.1
CONTRACTOR'S INDUSTRIAL SAFETY RECORD
Project Identification Y VJS 1 J 13
Bid Date S - / @ ` Q 0 -) 3
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 any and all fatalities.
ITEM 5 CALENDAR YEARS CURRENT
PRIOR TO CURRENT YEAR YEAR
2018 2019 2020 2021 2022 TOTAL
No. of Contracts 1 91 10 7 113 1 i�1-3
Total dollar amount of
contracts in 1,000's 37 5 C 3 17 J 3 C7 7 1 q3�
No. of lost workday
cases C) C1) C] ;7
No. of lost work day
cases
involving permanent
transfer to
another job or d
termination of
em 1 o ment
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.
Name of Bidder (Print
Addres
City Zip Code
Signature
C I (- .-)
State Contractor's Lic. No. & Class
C9U'-11 3fU --q
Telephone
23
I293492A
AFFIDAVIT FOR CORPORATION BIDDER
STATE OF CALIFORNIA }
) SS
COUNTY OF LOS ANGELES )
u.sbeing first
duly sworn, deposes and says:
That he is
of, Ct �t3 Q4
r
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.
Signature
Subscribed and sworn
to before me this
1 1 day of ;, �� _ , 20 5
Signature of Offi
25
1293492.1
SEE
r `ItMl ikering Oath
(Notary Public)
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 San Bernardino
Cn before me,
Marissa Rodriguez, Notary Public
(insert name and title of the officer)
personally appeared T117A ju {. }�
who proved to me on the basis of satisfactory evidence to be the persons)whose names) 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
persons), or the entity upon behalf of which the person(s) acted, executed the instrument.
1 certify under PENALTY F P JURY under the laws of the State of California that the foregoing
paragraph is true andXorre
WITNESS myX�d and official seal.
Signature
(Seal)
aL QF MARISSA RODRIGLJET
Notary Public - California
'- San 6ernardino County _5
Commission n 2334707
My Comm. Expires Oct 23, 2024
BID BOND
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:
Installation of Three (3), Two Post Gable Shelters on the Canyon Loop Trail pro ' ect No. FP17500
WHEREAS Tot Lot Pros, Inc. - 14588 El Moiino St., Fontana, CA 92335
Wame 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
Old Republic Surety Company - 445 S Moorland Road Suite 200 Brookfield, WI 53005
(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 amount bid***
Dollars ($ 10% of amount bid** ) , being not less than ten percent (10 0 ) 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.
32
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: May 15, 2023
"Principal"
Tot Lot Pros, Inc.
By� -� =
Its
By:
Its
"Surety"
Old Republic Surety Company
By . _ c-'--
ts - Attorney -In -Fes :-jucnnsrnit-~
By:. -
VS
Note: This bond must be dated, all signatures must be notarized, and
evidence of the authority of any person signing as attorney--in--
fact must be attached.
(Seal)
1293492.1
SSE
ATTACHED
33
(Seal)
► CKNOWLEDGMENT
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 Fresno
On May 15, 2023 b e f o r e m e, Roberta Voss, Notary Public
(insert name and title of the officer)
personallyappeared Justin Smit
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.
Signature "'_z' (Seal)
RoeERTA Voss
NOTARY PUBLIC -CALIFORNIA
COMMISSION # 2387978
FRESNO COUN 1'Y
W Camm. Exp. January 19. 2028
* ,k
OLIO REPUBLIC SURETY COMPANY
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS: That OLD REPUBLIC SURETY COMPANY, a Wisconsin stock insurance corporation, does make. constitute and
appoint:
Roberta Voss, Justin Smit of Fresno. CA
its true and lawful Attorneys) -in -Fact, with full power and authority for and on behalf of the company as surety, to execute and
deliver and affix the seal of the company thereto (if a seal is required), bonds: undertakings, recognizances or other written obligations in the nature thereof,
(other than bail bonds, bank depository bonds, mortgage deficiency bonds, mortgage guaranty bonds, guarantees of installment paper and note
guaranty bonds, self-insurance workers compensation bonds guaranteeing payment of benefits, or black lung bonds), as follows:
ALL WRITTEN INSTRUMENTS
and to bind OLD REPUBLIC SURETY COMPANY thereby, and all of the acts of said Attorneys -in -Fact, pursuant to these presents, are ratified and confirmed.
This appointment is made under and by authority of the board of directors at a special meeting held on February 18, 1982.
This Power of Attorney is signed and sealed by facsimile under and by the authority of the following resolutions adopted by the board of directors of the OLD
REPUBLIC SURETY COMPANY on February 18,1982,
RESOLVED that, the president, any vice-president or assistant vice president, in conjunction with the secretary or any assistant secretary, may appoint
attorneys -in -fact or agents with authority as defined or limited in the instrument evidencing the appointment in each case, for and on behalf of the company to
execute and deliver and affix the seal of the company to bonds, undertakings, recognizances, and suretyship obligations of all kinds; and said officers may
remove any such attorney -in -fact or agent and revoke any Bower of Attorney previously granted to such person.
RESOLVED FURTHER, that any bond, undertaking, recognizance, or suretyship obligation shall be valid and binding upon the Company
(i) when signed by the president, any vice president or assistant vice president, and attested and sealed (if a seal be required) by any secretary or assistant
secretary; or
(ii) when signed by the president, any vice president or assistant vice president, secretary or assistant secretary; and countersigned and sealed (if a seal be
required) by a duly authorized attorney -in -fact or agent; or
(iii) when duly executed and sealed (if a seal be required) by one or more attorneys -in -fact or agents pursuant to and within the limits of the authority
evidenced by the Power of Attorney issued by the company to such person or persons -
RESOLVED FURTHER that the signature of any authorized officer and the seal of the company may be affixed by facsimile to any Power of Attorney or
certification thereof authorizing the execution and delivery of any bond, undertaking, recognizance, or other suretyship obligations of the company; and such
signature and seal when so used shall have the same force and effect as though manually affixed -
IN WITNESS WHEREOF, OLD REPUBLIC SURETY COMPANY has caused these presents to be signed by its proper officer, and its corporate seal to be
affixed this 16th day of August 2022
''l51sun"OLD REPUBLIC SURETY COMPANY
_
Assylant Secreta. N ~'%,,,,'`' ~ President
STATE OF WISCONSIN, COUNTY OF WAUKESHA - SS
On this 16th day of August 2022 , personally came before me, Alan Eayk
and Karen J Haffner , to me known to be the individuals and officers of the OLD REPUBLIC SURETY COMPANY
who executed the above instrument, and they each acknowledged the execution of the same, and being by me duly sworn, did severally depose and say: that
they are the said officers of the corporation aforesaid, and that the seal affixed to the above instrument is the seal of the corporation, and that said corporate seal
and their signatures as such officers were duly affixed and subscribed to the said instrument by the authority of the board of directors of said corporation-
2`L� ii ' A
AUBL�G Notary Public
y t,
My Commission Expires: 5eptember 28, 2026
CERTIFICATE (Expiration of notary's commission does not invalidate this instrument)
I, the undersigned, assistant secretary of the OLD REPUBLIC SURETY COMPANY, a Wisconsin corporation, CERTIFY that the foregoing and attached
Power of Attorney remains in full force and has not been revoked; and fuilhermore, ihat the Resolutions of the board of directors set forth in the Power of
Attorney. are now in force. -
ti7 r - ti
COAPOA.rr _ v - 15th May 2023
31 1047 - o ` SEAL ; = Signed and sealed at the City of Brookfield, W%' this- day of ---- __.. _------- ,
rase % Y
ti
oriSC 22262 (3-06)
❑iBudu❑ & Defendis Ins Brokers
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 _ San `Bernardino
On -. h
before me,
Marissa Rodriguez, Notary Public
(insert name and title of the officer)
personally appeared V, .S ~-�
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
persons), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PE
paragraph is true
WITNESS
Signature _
RJURY under the laws of the State of California that the foregoing
d and official sea].
S�,L ov r MARISSA RODRIGUEZ
Notary Pubkic . California z
San Bernardino County
*�, y Commission A' 2334707
r'tr-� NF My Comm. Expires Oct 23, 2024
EXPERIENCE STATEMENT
To be responsive, the bidder must list below a minimum of three public
agencies for which bidder has performed similar work within the past five
years. Only projects in excess of $50,000 each qualify as similar for this
project.
1 . Project Title
Contract Amount Ciu
Type of Work S
Client U c, w1 rr,,&,
Agency Project Manager Phoneo 1 �} �� D �] 5
Date Completed
3u i
a
Subcontracted !S 70
2. Project Title��,eYt,
Contract Amount
Type of Work o r, 1 ,
Client A`�������,
Agency Project
Manager M. t\\,,A
Phone')(-O
�i �� •- �C r)--?
Date Completed
) I - J::) ` J 0 1 4
% Subcontracted
3. Project Title ') 0.r aL4
Contract Amount 7�,)3 Qo , ,
Type of Work rik u,\ �,<<
Clients r����C U, c
Agency Project Manager C_��J• +r ',1� Phone C] 0`1
Date Completed (,� ` C) I -,au_2 u R Subcontracted Q %,
NOTE: If requested by the City, the bidder shall furnish a certified
financial statement, references, and other information sufficiently
comprehensive to permit an appraisal of his current financial condition.
Bidder's Signature
9
1293492.1