HomeMy WebLinkAboutComplete Bid PackageCIIY OT
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DEPARTMENT OF PUBTIC WORKS
OFFICIAL NOTICE
Requesl for Bids
AREA 5 RESIDENTIAT NEIGHBORHOOD ADA CURB RAMPS
IMPROVEMENT PROJECT
CDBG PROJECT NO. 602671-24
crP PROJECT NO. St254
ADDENDUM NO. 1
The following chonges to the Request for Bids (RFB) for the obove project sholl be
incorporoted into the RFB.
The Controctor sholl sign this poge os ocknowledgement of receipt of Addendum No. I
ond ottoch it io the bid.
2t25t2025
Dovid G. Liu, P.E.
Director of Publc Works/City Engineer
Dote
EXPERIENCE STATEMENT
To be responsive, the bidcter must list below a minimum of three publieagencies for which bidder has performed similar work wit.hin the past t.hreeyears. Only projects in excess of $250,000 each qualify as simil-ar forthis project.
1.Project
Contract
Type of
C11ent
Pro ject
Contract
Type of
Client
P ro j ect.
Contract
Type of
CIlent
Amount
Work
Title
Tit Ie
TiIIE SEE ATTACHED COMPLETED PROJECT REFERENCES
Amount
Work
Agency Project Manager
Dat,e Completed % Subcor-rtracl-ed
Phone
Phone
Phone
2
Agency Project Manager
Date Completed % Subcontracted
?
Amount
Work
Agency Project Manager
NOTE: I f reguest.ed by t.he City,financial sLatement. references/
comprehensive to permit an appraisal
Bidder's Signature
Date Compfeted % Subcontracted
a certified
sufficient 1y
condition.
the
and
bidder shalI furnishr
other informat.ion
hib current financial
10
VIDO SAMARZICH, INC.
General Engineering Contractor No.4332ro A
6829 BILLINGS PLACE, RANCHO CUCAMONGA, CALIFORNIA 9I7OI TELEPHONE 909-987-6377
FAX 909-987-B9BB
COMPLETED CONSTRUCTION
PROJECT REFERENCES
1. Project Name: Glenwood Place Water Main Improvements
Owner: City of Santa Ana
Phone Number: (714) 647-5629
Engineer/Contact: Mr. Alexander Olmos
Contract Amount: $ 1,400,000.00
Date of Completiont 2024
2. Project Name: South Brea Water and Sewer Improvements
Owner: City of Brea
Phone Number: (949) 285 -5 529
Engineer/Contact: Mr. Tyrone Chesanek
Contract Amount: $5,900,000.00
Date of Completion: 2024
3. Project Name: Santa Ana Blvd and 5th St Protected Bike Lane
Owner: City of Santa Ana
Phone Number: (714) 647-5655
Engineer/Contact: Mr. Sean Thomas
Contract Amount: $6, I 00,000.00
, Date of Completionz 2023
4. Project Name: Ocean Blvd Sidewalk Improvements
Owner: City of Newport Beach
Phone Number: (714) 552-5336
Engineer/Contact: Mr. Michael Sinacori
Contract Amount: $5 14,000.00
Date of Completionz 2022
5. Project Name: Annual Sidewalk Improvement Project
Owner: City of Pico Rivera
Phone Number: (562) 801-4221
Engineer/Contact: Ms. Nadia Carrasco
Contract Amount: $375,000.00
Date of Completiow 2022
Page 1 of8
VIDO SAMARZICH, INC.
General Engineering Contractor uo.4332i0 A
5829 BILLINGS PLACE, RANCHO CUCAMONGA, CALIFORNIA 9I70I TELEPHO NE 909 -9 87 -6377
FAX 909-987-89BB
6.
7.
8.
9.
Project Name: Safe Routes to School project
Owner: City of Monrovia
Phone Number: (760) 220-0722
Engineer/Contact: Mr. James Merrell
Contract Amount: $3 56,000.00
Date of Completionz 2022
Project Name: Local Street Curb Ramp Improvements phase II
Owner: City of Santa Ana
Phone Number: (714) 552-5336
Engineer/Contact: Mr. Gerardo Lechuga
Contract Amount: $399,000.00
Date of Completionz 2020
Project Name: Etiwanda Corridor Improvements project
Owner: City of Rialto
Phone Number: (714) 381-2410
Engineer/Contact: Mr. Fred Alipanah
Contract Amount: $1,098,000.00
Date of Completionz 2020
Project Name: Residential street Improvements Bishop st and Raitt st
Owner: City of Santa Ana
Phone Number: (714) 615-0892
Engineer/Contact: Mr. Michael Ortiz
Contract Amount: $ 1,279,000.00
Date of Completionz 2020
10. Project Name: Residential Street Repair Program FytS/19
Owner: City of Santa Ana
Phone Number: (714) 615-0892
Engineer/Contact: Mr. Michael Ortiz
Contract Amount: $876,000.00
Date of Completionz 2020
11. Project Name: Sidewalk Gap Closure Project
Owner: City of Palm Springs
Phone Number: (760) 323-8253 x8744
Engineer/Contact: Mr. Donn Uyeno
Contract Amount: $1,267,000.00
Date of Completionz 2020
Page 2 of8
VIDO SAMARZICH, INC.
General Engineering Contractor No.433210 A
6829 BILLINGS PLACE, RANCHO CUCAMONGA, CALIFORNIA 9IlOI
12. Project Name: Misc Storm Drain Improvements - 335 S. Hale Ave
Owner: City of Fullerton
Phone Number: (714) 735-6853
Engineer/Contact: Mr. David Grantham
Contract Amount: $200,000.00
Date of Completion: 2020
13. Project Name: Misc Storm Drain Improvements - Knepp Ave
Owner: City of Fullerton
Phone Number: (714) 738-6853
Engineer/Contact: Mr. David Grantham
Contract Amount: $304,000.00
Date of Completion: 2019
14. Project Name: Local Street Curb Ramp Improvements
Owner: City of Santa Ana
Phone Number: (714) 552-5336
Engineer/Contact: Mr. Gerardo Lechuga
Contract Amount: $577,000.00
Date of Completion: 2079
15. Project Name: 3'd Ave Pavement Rehabilitation and Water Improvements
Owner: City of Upland
Phone Number: (909) 291-2946
Engineer/Contact: Mr. Bob Critchfield
Contract Amount: $2,800,000.00
Date of Completion:. 2019
16. Project Name: 9th Street Pavement Rehabilitation and Water Improvements
Owner: City of Upland
Phone Number: (909) 291-2946
Engineer/Contact: Mr. Bob Critchfield
Contract Amount: $2,600,000.00
Date of Completionz 2019
17. Project Name: La Palma Ave Sidewalk Improvements
0wner: City of Anaheim
Phone Number: (714) 765-5052
Engineer/Contact: Mr. Joel Jordan
Contract Amount: $479,000.00
Date of Completionz 2019
TELEPHO NE 909 -987 - 6377
FAX 909-987_B9BB
Page 3 of8
VIDO SAMARZICH, INC.
General Engineering Contractor No.4332ro A
6829 BILLINGS PLACE, RANCHO CUCAMONGA, CALIFORNIA 9I70]TELEPHO NE 909 -987 -6377
FAX 909-987-B9BB
18. Project Name: Wilshire Avenue Bicycle Blvd hnprovements
Owner: City of Fullerton
Phone Number: (7 14) 735-6853
Engineer/Contact: Mr. David Grantham
Contract Amount: $2, 1 00,000.00
Date of Completion: 2019
19. Project Name: FY l7-18 ADA Access Ramp Improvements at Various Locations
Owner: City of Rancho Cucamonga
Phone Number: (909) 77 4-4070
Engineer/Contact: Mr. Romeo David
Contract Amount: $975,000.00
Date of Completion: 2018
20. Project Name: wilshire Avenue water and Sewer Improvement project
Owner: City of Fullerton
Phone Number: (714) 738-6895
Engineer/Contact: Mr. Gar Huang
Contract Amount: $550,000.00
Date of Completion: 2018
21. Project Name: Elm/Malden Area Street, Sewer and water Improvements
Owner: City of Fullerton
Phone Number: (714) 773-0049
Engineer/Contact: Mr. Joseph Hernandez
Contract Amount: $2,200,000.00
Date of Completion: 2018
22.Project Name: Anaheim Hills Road Water Main Replacement
Owner: City of Anaheim
Phone Number: (714) 863-8020
Engineer/Contact: Mr. Luis Tapia
Contract Amount: $600,000.00
Date of Completion: 2018
23. Project Name: CDBG ADA Wheelchair Access Rarnp Replacement at Various Locations
Owner: City of Orange
Phone Number: (714) 744-5566
Engineer/Contact: Mr. Matthew Lorenzen
Contract Amount: $204,300.00
Date of Completion: 201 8
Page 4 of8
VIDO SAMARZICH, INC.
General Engineering Contractor No.433210 A
6829 BILLINGS PLACE, RANCHO CUCAMONGA, CALIFORNIA 9I70I
24. Project Name: 2017 Citywide Curb Ramp Improvements
Owner: City of Laguna Beach
Phone Number: (818) 402-0225
Engineer/Contact: Mr. Tri Nguyen
Contract Amount: $285,000.00
Date of Completionz 2017
25. Project Name: Safe Routes to School Improvements, phase 3
Owner: City of Glendale
Phone Number: (818) 402-0225
Engineer/Contact: Mr. Gary Edsall
Contract Amount: $908,000.00
Date of Completionz 2077
26. Project Name: Heim Ave at canal St Storm Drain Improvements
Owner: City of Orange
Phone Number: (714) 744-5566
Engineer/Contact: Mr. Matthew Lorenzen
Contract Amount: $99,000.00
Date of Completionz 2017
2T.Project Name: Citywide Sidewalk Repair Project Fy l5-16
Owner: City of Santa Monica
Phone Number: (951) 522-4505
Engineer/Contact: Mr. Craig Wheeler
Contract Amount: $878,000.00
Date of Completion: 2017
28. Project Name: FY 16/17 curb Access Ramp Installation projeot
Owner: City of Huntington Beach
Phone Number: (714) 536-5259
Engineer/Contact: Mr. Joe Fuentes
Contract Amount: $679,000.00
Date of Completionz 2077
29. Project Name: Comstock Avenue Water Main Improvements
Owner: City of Whittier
Phone Number: (562) 567-9302
Engineer/Contact: Mr. Carl Hassel
Contract Amount: $578,000.00
Date of Completionz 2017
TELEPHO NE 909 -987 -6377
FAX 909-987-B9BB
Page 5 of8
VIDO SAMARZICH, INC.
General Engineering Contractor No.4332ro A
6829 BILLINGS PLACE, RANCHO CUCAMONGA, CALIFORNIA 9I70I
30. Project Name: Monterey Road Steet Improvements
Owner: City of South Pasadena
Phone Number: (626) 590-0570
Engineer/Contact: Mr. Alex Chou
Contract Amount: $1,550,000.00
Date of Completiou 2017
31. Project Name: Fletcher Avenue Reconstruction
Owner: City of South Pasadena
Phone Number: (7 02) 204-4025
Engineer/Contact: Mr. Mark Peterson
Contract Amount: $878,000.00
Date of Completionz 2016
32. Project Name: Patterson Street Reconstruction
Owner: City of Fullerton
Phone Number: (714) 732-9060
Engineer/Contact: Mr. Pete Acosta
Contract Amount: $675,000.00
Date of Completionz 2016
33. Project Name: Magnolia/Bolsa Intersection Widening
Owner: City of Westminster
Phone Number: (714) 548-3464
Engineer/Contact: Ms. Theresa Tran
Contract Amount: $978,000.00
Date of Completionz 2016
34. Project Name: 2015 Water Main Improvements
Owner: City of Westminster
Phone Number: (714) 548-3456
Engineer/Contact: Mr. Tuan Pham
Contract Amount: $1,1 00,000.00
Date of Completion: 2016
35. Project Name: Red Hill Lake Modemization
Owner: City of Rancho Cucamonga
Phone Number: (909) 477-2740
Engineer/Contact: Mr. Romeo David
Contract Amount: $300,000.00
Date of Completionz 2016
TELEPHO NE 909 -9 87 -637 7
FAX 909-987-B9BB
Page 6 of8
VIDO SAMARZICH, INC.
General Engineering Contractor No. 4332t0
^
6829 BILLINGS PLACE, RANCHO CUCAMONGA, CALIFORNIA gIZOI
36. Project Name: 2015 Concrete Improvements
Owner: City of Inglewood
Phone Number: (714) 468-7319
Engineer/Contact: Mr. Hunter Nguyen
Contract Amount: $425,000.00
Date of Completion: 2015
37. Project Name: El Centro Avenue Rehabilitation
Owner: City of South Pasadena
Phone Number: (626) 590-0570
Engineer/Contact: Mr. Alex Chou
Contract Amount: $1, 100,000.00
Date of Completion: 2015
38. Project Name: Concrete Bus Pads
Owner: City of Rancho Cucamonga
Phone Number: (714) 545-3456
Engineer/Contact: Curt Billings
Contract Amount: $1 75,000.00
Date of Completion: 2015
39. Project Name: ADA Wheelchair Ramps
Owner: City of Orange
Phone Number: (7 14) 7 44-5566
Engineer/Contact: Mr. Matthew Lorenzen
Contract Amount: $275,000.00
Date of Completion: 2015
40. Project Name: 2}l4Water Improvement
Owner: City of Westminster
Phone Number: (714) 548-3456
Engineer/Contact: Mr. Tuan Pham
Contract Amount: $1,1 00,000.00
Date of Completion: 2015
41. Project Name: ADA Sidewalk Improvement
Owner: City of Artesia
Phone Number: (951) 314-6984
Engineer/Contact: Mr. Chuck Burkhardt
Contract Amount: $200,000.00
Date of Completionz 2014
TELEP HO NE 9 09 -9 87 - 637 7
FAX 909-987-B9BB
Page 7 of8
VIDO SAMARZICH, INC.
General Engineering Contractor uo.433210 A
5829 BILLINGS PLACE, RANCHO CUCAMONGA, CALIFORNIA 9IlOI
42. Project Name: YLHS Park Bryant Cross Feeder pipeline
Owner: Yorba Linda Water District
Phone Number: (714) 701-3104
Engineer/Contact: Mr. Joe polirnino
Contract Amount: $675,000.00
Date of Completion: 2013
43. Project Name: County Road Storm Drain
Owner: City of Pomona
Phone Number: (909) 322-7471
Engineer/Contact: Mr. Dave Barron
Contract Amount: $570,000.00
Date of Completionz 2013
44. Project Name: Adams Square park
Owner: City of Glendale
Phone Number: (818) 548-2864
Engineer/Contact: Mr. Hagop Kassabian
Contract Amount: $ l, 1 00,000.00
Date of Completion: 2010
45. Project Name: Various Public Work Purchase Orders and Contracts 2000-2013
Owner: City of Pasadena
Phone Number: (626) 484-5640
Engineer/Contact: Mr. Dale Torstenbo - dtorstenbo@cityofpasadena.net
Contract Amount: $2,500,000.00
Date of Completion: 2000-20i3
46. Project Name: Misc Park Improvements From 2000-2010
Owner: City of Glendale
Engineer/Contact: George Balteria - (951) 201-2710
Peter Vierheilig - pvierheilig@ci.glendale.ca.us
Contract Amount: $3,500,000.00
Date of Completion: 2000-2010
TELEPHO NE 909 -9 87 -637 7
FAX 909-987-B9BB
Page 8 of8
BTDDERIS PROPOSAL
CITY Or DIAIIIOND BAR
AREA 5 RESIDENEIAL NEIGIIBORHOOD
ADA CT'RB RA!{P IMPROVEMENT PRO.'ECT
CDBG PROJECT NO. 60257L-24
CIP PROiIECT NO. Sr254
Date March 4 , 2025
To the City Council of the City of Diamond Bar:
The Undersi_gned hereby declares:
(a) That the only
principals are
Vido Samazich, lnc.
persons or part.ies interested in this proposal asthe following:
Vido Samarzich - President
Vido L. Samarzich - Vice President
Monika Samarzich - Secretary
(If the bidder is a corporation, give t.he name of the corporation
and the name of its presidentr secretary, treasurer, and manager.If a co-partnership, give Lhe name, under which the co-partpersh1-p
does business, and the names and addresses of al1 co-partners. Ifan individual, state the name under which the contract is to bedrawn. )
(b) That this proposal is made without coflusion with any person/ firmor corporat.ion.
(c) That he has carefully examined the location of the proposed work
and has familiarized irimself with aII of the physical and cl-imaticconditions, 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 theCit,y of Diamond Bar to him at the ad.dress furnj-shed by him to thecity of Dlamond Bar when this proposal form was obtainerl.
(e) That he has carefully examinecl the specifications, both general
and detail, and the drawings attached hereLo, and. communicationssent to him as aforesaid, and makes this proposal in accordance
t.herewith.
15
(f)That, if this bid is accepted he will enter into a written contract
for the performance of the proposed work with Lhe cit.y of Diamoncl
Bar.
(g) That he proposes to enter int.o such Contract and to accept in fullpayment for the work actually done thereunder the prices shown inthe attached schedule. It is understood and agreed. that thequantities set forth are estimates and. that the uniL prices wiIIapply to the actual quantities whatever they may be.
Accompanying this proposal is a certified or cashier's check orbidder's bond, payable to the order of the City of Diamond Bar inthe sum of
1Oo/o of total bid amount DOLLARS ($ 10% of total bid amount ) .
Said bidderrs bond has been duly executed. by the undersigned bidder andby a financially sound surety company authorized to transact businessin this state.
It is understood and agreed that shou1d the bidder fail within ten(10) days after award of contract to enter into the contract and furnishacceptable surety bonds, then the proceeds of said checkr or bidder'sbond, shall- becottte Llte properLy of t-he CiLy of D-Laniorid. Bar; buL if LhisContract is enLered 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.
515 Cabrillo Park Dr, Suite 315
Address of Bidder
Santa Ana, CA
City Zip Code
92701
(909) 987-6377
TeIep of Bidder
Siginat.u f Bidder
L6
BID SCHEDULE
CI|IY OE DIAIIIOIID BAR
CONTRACT DOCT'!4ENTS ASID SPECTE'ICATIONS
AREA 5 RESIDENTIAL IIEIGHBORITOOD
EDA CURB RA!{P IMPROVEMENT PROJECT
CDBG PROJECT NO. 60261L-24
CTP PROJECT NO. SI25II
BID SCHEDUIJE
ITEM
NO.
EST.
QUANT.UNlT
DESCRIPTION
WRITTEN IN WORDS
UN]T
PRICE AMOUNT
1 1 t,.s CONSTRUCTION STAKING ANI)
MONUMENT PRESERVAT]ON 2,L7o,u 2,Z7o.oo
2 6 EA
REMOVE EXISTING
IMPROVEMENTS AND CONSI'RUCT
CURB RA}{P PER SPPWC STD.
PLAN 111-5, TNCLUDfNG
MOB]LIZATION, TRAFFIC
CONTROL, AND PUBL]C SAFETY
ff,soo.oo 5l,ooo,oo
3 ]-19 LF
REMOVE EXISTING CURB AND
GUTTER AND CONSTRUCT CURB
AND GUTTER PER SPPWC STD.
PLAN 120-3
1o.oo l6,lto.oo
4 318
REMOVE EXIST]NG SIDEWALK
AND CONSTRUCT CONCRETE
SIDEWALK PER SPPWC STD
PLAN IL3_2
J-o. oo 6,360. oo
5 B1B >.E
REMOVE PAVEMENT SURFACE,
BASE, AND SUBGRADE, AND
]NSTALL 4_ET WIDE HMA PLUG
70, oo 2'r,5'to.oo
6 7 LS
REMOVE EXISTING
CONFL]CT]NG YELLOW
CROSSWALK PA]NT AND
RESTORE STRIPING AND RED
CURB PAINT
lSoo.oo 750o. o,
BID SCHEDUTE ITEUS:
TOrAIJ A!{Ot NE (rN FIet RES} -}l0 7 | 78o.oo
71
BID SCHEDULE TOTAL AMOUNT (WRITTEN IN WORDS):oue Hq/DRED
Bid Schedule Note: Bid Pri-ce indicated refers to al-1 items ill-ustratedon the plans and details, and delineated within the specificat.ionsinstalled and completely in place with all applicable port.ions of theconstruction documents and include aIl cosLs connected with such itemsincluding, but to necessarily Iimited Lo, materials, Lransportation,taxes, insurance, rabor, overhead, ancl profit, for Gene::a1 Cont::act.orand Subcontractors.
AIl work called for on the construction d.ocuments are to provide acompleted project with all systems operating properly and ready for
use.
Award of the project shall be determined based on the lowest responsiblebidder. Theref ore, Lhe ColtLracLor siraIl cornpleLely f iIl ouL Lire BicI
Schedule.
Accompanying this proposal is
(Insert u$^-^LttUAJlI ,ttcashier's checkt', t'certif ied check", or t'bidder,s bondtr asthe case may be) in the amount equal to at least ten percent
(10%) of the total bid.
The undersigned further agrees that in case of default in
executing the required contract, with necessary bond, within
ten (10) days, not includinq Sundays and legaI ho11days, after
having received notice that. the contract has been awarded anclready for signature, the proceeds of the security
accompanying his bid shalI become the property of the City of
Diamond Bar, and this proposal and the acceptance thereof may
be considered null and void.
bidder's bond
Vido Samazich, lnc.
NAME OF BIDDER (PRINT)
515 Cabrillo Park Dr, Suite 315
3t4t2025
ADDRESS
1B
DATE
Santa Ana, CA 92701 (909) e87-6377
CITY
433210 Class A
ZIP CODE TELEPHONE
STATE CONTRACTOR LICENSE NO. AND CLASS]FICATION
I declare under penalty of Perjury of the laws of the State of Callforniathat the representations made herein are true and correct in accordancewith the requirements of Callfornia Business and Professional CodeSection 1028.
CONTRAC OR AUTHORIZED OFFTCER
L9
LIST OE SUBCONTRACTORS *
BrD OPENTNG DATE 3t4t2025
Area 5 Residential Neighborhood ADAPROJECT Curb Ramp lmprovement Project PROJECT NO. CIP Proj. No. 51254
LOCATION Diamond Bar, CA
CLIENT City of Diamond Bar
CONTRACTOR Vido Samarzich, lnc.
Name Under
Which
Subcontractor
is
Licensed
License
No.
Address
of
Office, Mai1,
or
Shop
Percent
of
Total
Contract
Specific
Description
of
Subcontract
Superior Pavement
Markings, lnc.776306
5312 Cypress St
4%o
Striping
Cypress, CA 90630
* fn compliance with t.he provisions of the Public Contract CodeSection 4104t the undersigned bidder herewith sets forth the name,
Iocation of the place of business, and Cal-ifornia contractor
20
license of each Subcontractor - who will perform work or labor orrender service to t.he Prime cont.ractor, specialry fabricat.es anclinstalls a portion of the work or improvement necessary Lo completeconstruction contained in the plans and specifications, in anamount in excess of one-harf (L/z) of one percent (1%) of theGenerar contractor's total bid amount or, in the case of bids oroffers for the construction of streets or highways, incrudingbridges in excess of one-ha]f of 1 percent (0.5%) of the prime
contractor's total bid or ten thousand ($10r000.00), whichever isgreater, and the portion of the work which witl be done by eachSubcontractor.
2t
2.
3.
DECI.ARJATION OF ELIGIBILITY TO CONTRACT
ILabor code section 1,1'71 .1,; pubric contract code sectlon 6109]
The undersigined, a duly auLhorized representative of t.he contractor,certif ies and dec]ares that:
The contractor is aware of sections Liil.1 and liii.T of thecalifornia Labor code, whi-ch prohibit a contractor orsubcontractor who has been found by the Labor Commissioner or theDirector of Industrial Relations to be in violatlon of certainprovisions of the Labor code, from bidding orrr being awarded, orperforming work as a subcontractor on a public works project forspecified periods of time.
The contractor is not ineligible to bid on, be awarded or perform
work as a subcontractor on a public works project by virtue of theforegoing provisions of Sections 1177.1 or 7'l17.1 of the CaliforniaLabor Code or another provision of law.
The contractor i-s aware of California Public Contract Code Section6109, which states:
(a) A public entj-ty, as defined in Section 1100 [of thePubIic Contract, Codel, may not permit a contractor orsubcontractor who is ineligible to bid or work orrr or be
awarded, a pubric works pro ject pursuant to section 17'l"t .l or!777.7 of the Labor Code to bid on, be awarded, or perforn
work as a subcontractor orr a public works project. Everypublic works projecL shall contain a provision prohibiting acontractor from performing work on a public works project
with a subcontractor who is ineligibre to perform work on thepublic works project pursuant to Section 71-17.1 or tl7i.1 ofthe Labor Code,
(b) Any contract on a public works project. entered into
between a contractor and a debarred subcontractor is void asa matter of law. A debarred subcontractor may noL receive
any public money for performing work as a subconLractor on apublic works contract, and any public money that may have
been paid to a debarred subcontractor by a contractor on theproject sha}l be returned to the awarding body.The
contractor sha1l be responsible for the payment_ of wages t-o
workers of a debarred subcontractor who has been allowed to
work on the project.
The contractor has investigated the eligibilit.y of each and every
subcontractor the contractor intends to use on this public works
4.
22
1.
project., and determined that none of them is ineligj-bre to perform
work as a subcontractor on a public works project by virLue of theforegoing provisions of the Public Contract Code Sections tl'7j.1or L1"l'l .7 of the Labor code/ or any other provision of raw.
f declare under
California t.hat
of March 4
penalty of perjury under the laws of the State ofthe foregoing is true and correct. Executed this day
2025, at Santa Ana, CA (pIace of execution)
Name: Vido L. Samarzich
Titf e: Vice president
Name of Contractor:
Vido Samarzich, lnc.
23
BTDDERI S VIOI.ATTON OF LAW/SAFETY QUESTIONNAIRE
In accordance with Government Code Section 14310.5 and in conformancewith Publ-ic Contract Code Sect.ion 70162, the Bidder shall complete,under penarty of perjury, tLre forlowing questionnaire;
QT'ESEIONNAIRE
Has the Bidderr anY officer, principal- or employee of the Bidder whohas a proprietary interest in the business of the Bidder, ever beendisqualified, removed, or otherwi-se prevented from bidding on orcompleti-ng a f ederal-, state or Iocal- giovernment pro ject because ofviolation of law or a safety regulation?
YES
If the answer is yes, explain the circumstances in the following space:
STATEMENT
fn conformance with Public Contract Code Section 70232, the Contractor,hereby states under penalty of perjury, that. no more than on finafunappealable finding of contempt of court by a federal court has beenissued against the Contractor within the immediately preceding two-yearperiod because of the Contractor's fail-ure to comply wit.h an order ofa federal court which orders the Contractor to comply with an order ofthe National Labor Relations Board.
NOTE:The above statement and Questionnaire are part of theProposal. signing this proposar on the signature portion
thereof shalr arso constitute signature of this statement and
QueEtionnaire.
Bidders are cautioned that making a false certification maysubiect the certifier to criminal prosecution.
NO t/
24
CONTRACTORIS INDUSERIAL SAFETY RECORD
Area 5 Residentiat Neighborhood ADAPro ject f dentif ication Curb Ramp lmprovement Project gid Date 3t412025
This information must include alI construct.ion work undertaken in theState of California by the bidder and. any partnership, joint venture orcorporation that any principal of the bidder participated in as aprincipal or owner for the fast three calendar years and the currentcalendar year prior to t.he date of bid submit.tal. Separate informationshaIl be submitted for each particular partnership, joint venture,corporation or individual bidder. The bidder may attach any additionafinformation or explanati-on of data, whj-ch he would like, taken int.oconsideration in evaluating the safety record. An explanation must beat.tached of the ci-rcumstances surroundi and a1I fataliti
*The information required for this item is the same as required forcolumns 3 to 6, Code 10, Occupat-ional lr-rjuries, Surrurary - OccupatiopalInjuries and Illnesses, OSHA No. lO2.
The above information was compiled
to me at thls time and f declare
information is true and accuraLe
records.
Vido Samazich, lnc.
from the records that. are
under penalty of perjury
avai Iable
that the
of these
Name of Bidder
515 Cabrillo Park Dr
(P ri nt.
Suite 315
S ignatu
State Contractor's Lic. No. & Class
(eoe) e87-6377
Telephone
25
Address
Santa Ana, CA 92701
UII I}an ata
ITEM 3 CALENDAR YEARS
PRIOR TO CURRENT YEAR
CURRENT
YEAR
2022 2023 2024 TOTAL 2025
No. of Contracts 5 4 7 16 2
Total dollar amount of
contracts (in 1.000's)4800 8700 13500 27000 20000
No. of lost workday
cases 0 0 0 0 0
No. of lost work day
cases
involving permanent
transfer to
anotherjob or
tenrrination of
employment
0 0
No. of lost workdays 0 0 0 0 0
433210 Class A
City Zip Code
0
STATE OF CAL]FORNTA
COUNTY OF LOS ANGELES
ATFIDAVIT FOR CORPORATION BIDDER
)
)SS
)
Vido L. Samarzich , being' firstduly sworn,
That he is
deposes and says:
Vice President
of , Vido Samarzich, lnc.
a corporation which is the parl-y making the foregoi-ng pr:oposaJ or bid;that such bid is genuine and noL collusive or sham; that said bidderhas not col1uded, conspired, connived or agreed, directly or indirectly,with any other bidder or person to put in a sham bid or that such otherperson shall refrain from biddlng; and has not in any manner: sogght bycollusion to secure any advantage aqainst the City of Diamond Bar orany person interested in the proposed cont.ract, for himself or for anyother person.
Signature
Subscribed and sworn
to before me this
day of ,20
Si gnat-rrre of fjf f i cer Admi ni st-eri ng Oath
(Notary PubIic)
2'7
notary public or other officer completing this
cate verifies only the identity of the individual
signed the document to which this certificate
attached, and not the truthfulness, accuracy, or
rlidity of that document.
State of California
County s1 Orange
Subscribed and sworn to (or affirmgQ).bqfop me on 16;s 4th
day of March 2025 , by Vido L. Samarzich
proved to-me on the basis of satisfactory evidence io Oe tfre
person(g/who appeared before me.
(Seal)
COMM. #2369579 z
Notary Public . California ?
niveisioe cilrir""- 9
Bond No.:VIDSA-2264
BID BOND
KNOW ALL PERSONS BY THESE PRESENTS that,
WHEREAS the city of Diamond Bar ("city"), has j-ssued an invitation
for bids for the work described as fol_Iows:
AREA 5 RES]DENTIAL NEIGHBORHOOD
ADA CURB RAMP IMPROVEMENT PROJECT
CDBG PROJECT NO. 60267I_24
CIP PROJECT NO. SI254
WHEREAS Vido Samarzich, lnc. , 515 Cabrillo Park Dr, Suite 315, Santa Ana, CA 92701
(Name and address of(rrPrincipal"), desires to submit a bid to
WHEREAS, bidders are required under the
Publ-ic Contract Code to furnish a form of
bid.
Biddei)
Publ-ic Agency for
provisions of the
bidder's security
the work.
Cal-if ornia
with their
NOW, THEREEORE, w€r the undersigned Principal, and
O|1l Republic Surety Company,6 Jenner, Suite 230, lrvine, CA 92618
(Name and address of Surety)("Suretyrr) a duly admitt.ed surety j-nsurer under the laws of the State
of California, as Surety, are hel-d and firmly bound unto Public Agency
in the penal sum of Ten PercentOf TheTotalAmount Bid
DoIIars 19 10% Of Bid l, being not less than ten percent (l-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
Pri-ncipal is awarded a contract for t.he work by City and within t.he
time and i.n 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 material-s, and furnishes
the required insurance coverages, then this obligation shal-l- become
null- and void; otherwise, it. shall- be and remain in fulI force and
effect.
an
In case suit is brought upon this bond, Surety further agrees to payalI court costs incurred by City in the suit and reasonable attorneys'fees in an amount fixed by the court. Surety hereby waives theprovisions of California CiviI Code S 2845.
IN WITNESS WHEREOF, each of which shaLl for all- purposes be deemed anoriginar hereof, have been duty executed by principal- and surety, onthe date set forth below, the name of each corporate party being heretoaffixed and these presents dury signed by its undersignedrepresentative (s) pursuant to authority of its qoverning body.
Dated: February 27th,2025
frPrincipal "
Vido Samarzich, lnc.
tt Suretyrt
Old Republic Surety Company
This bond must be dated, all
evidence of the authority of
fact must be attached.
signatures
any person
must be
signing
(SeaJ-)(Seal-)
35
By:
Its >..r-r-':-,'- tz^\.
** ****i OLD REPUBLIC SURETY COMPANY****
POWER OF ATTORNEY
KNOWALL MEN BY THESE PRESENTS: That OLD REPUBLIC SURETY COMPANY, a Wisconsin stock insurance corporaiion, does make, constitute and
appoint:
Randy Spohn, Matthew R. Dobyns, Hamilton Kenney, Ashley M. Spohn of Santa Ana, CA
its true and lawful Attorney(s)-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 hail bonds, bank depository honds, moftgage deficiency bonds, mortgage guaranty bonds, guaranfees of installment paper and noteguaranty 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 wilh authority as defined or limited in the inslrument 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 Power ofAttorney 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 assrstant 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 altorney-in-fact or agent; or
(iii) when duly executed and sealed (if a seal be required) by one or more atlorneys-in-fact or agents pursuant to and within the limits of the authority
evidenced by the Power ofAttorney 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
certiflcation 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,
affixed this 11th
OLD REPUBLIC SURETY COMPANY has caused these presents to be signed by its proper officer, and its corporate seal to be
day of
STATE OF WISCONSIN, COUNTY OF WAUKESHA - SS
On this I 1th dav of August 2022 , personally came before me,Alan Pavlic
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 inslrument is the seal of the corporation, and thal said corporale seal
and their signatures as such offlcers were duly affixed and subscribed to the said instrument by the authority of the board of directors of said corporation.
OLD REPUBLIC SURETY COMPANY
President
Auqust _, 2022
.,nillrrrllirir/,,,...{ic suPc;|',,
="-'g ;itt;:
Z-'o-t ,r"' , '-T
i.
,,,,,,,,,1, ,,*N.-'
CERTIFICATE
My Commission Expires: September 29, 2026
(Expirotion of nolory's commission does nol involidote this instrument)
l, the undersigned, assistant secretary of the OLD REPUBLIC SURETY COMPANY, a Wisconsin corporation, CER'fiF'/ that the foregoing and attached
Power of Attorney renrains in full force and has not been revoked; and furthermore, that the Resolutions of lhr: board of directors set forth in the Power of
Attorney, are now in force.
n'::i"t?:.,.
S?'coneoarrr "b'' 27th Fel-rluarv 2o2s
74 7OgZ ; It Sfef" . i i Signed and sealed at the City of Brookfield, Wl this - "" . oay ot
--
"1L-
"-..rrr-"., Z':;,--"tS fuA'4k@
R.S. Bonding & lns Agency lnc
CALIFORNIA ALL.PURPOSE ACKNOWLEDGM ENT
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
On February 27th, 2025 before me, ERIKA G. MORGAN, NOTARy pUBLIC,
personally appeared MATTHEW R. DOBYNS ,
X 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 heThh{+hey executed the same in hiq/he#their
authorized capacity (ies), and that by his/het/tfuir signature(s) on the
instrument the person$), or the entity upon behalf of which the person(s)
acted, executed the instrument.
I ceftify under PENALTY OF PERJURY under the laws of the State of
California that the foregoing paragraph is true and correct.ERIKA G.
coMM. #2354018
NCTARY PUBLIC o CATIFORNIA
OMNGE COUNry
Comm.
Though the data below is not required by law, it may prove valuable to persons relying on the document and
could prevent fraudulent reattachment of this form.
CAPACITY CLAIMED BY SIGNER
E INDIvIDUAL
E conpomTE oFFIcER
E mnrrurnls; n uurreoX nrronNEY-rN-FAcr
E rnusrrelsyE cuanorAN/coNsERvAToRE ornrnr _
SIGNER IS REPRESENTING:
NAME OF PERSON(S) OR ENTTTY(rES)
DESCRIPTION OF ATTACHED DOCUMENT
WITNESS mU hand and official seal.
OPTIONAL
ACKNOWLEDGMENT
A notary public or other officer compteiing tfris
certificate verifies only the identity of the individual
attached, and not the truthfulness, accuracy, or
validity of that document.
who signed the document to which this certificate is
State of California ^
County of orange
)
on March 4,2025 before r", Desmond G. Warren, Notary public
(insert name and title of the officer)
personally appeared Vido L' Samarzich
who proved io me on '
subscribed to the within instrument and acknowledged to me thathelgh€tlie! executed [he sime inhisll2zllfi authorized capacitylyttf, and that byhistfittfir signatfre[efon the instrument the
personlrT, or the entity upon behalf of which the persorypfacted, executed the instrument.
I certifo 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 (Seal)
CERTIEICATION OF NON-DISCRIMINATION A}TD AFFIRMATI\IE ACTION
As suppliers of goods or services to the City of Diamond Bar, the firmIisted below certifies that it does not discriminate in its employmentwith regards to race, rerigion, sex/ or nationar origin; that it is incompliance with alI federal, state, and l-ocaI directives ancl executiveorders regarding non-discrimination in employment; and that rt willpursue an affirmative course of action as required by tl-re affirmativeaction guidelines.
We agree specifically:
1. To establish or observe employment policies which affirmativelypromote opportunities for minority persons at all job levers.
2- To communicate this policy to all persons concerned including allcompany employees, outside recruiting services, especj-a11y thoseserving minority communities, and to the minoriLy communiLies atIarge.
3. To take affirmative steps to hire minority employees within the
company.
FIRM Vido Samazich, lnc.
TITLE OF
S]GNATURE
Please incl-ude any additional-
opportunity employment programs
DATE 3t412025
information available regarding equal
now in effect within your company:
We are an equal opportunity employer.
36
CERTIFICATION WITH REGARD TO THE PERFORI,TA}IEE OF
PREVIOUS CONTRACTS OR SUBCONTRACTS ST'B.]ECT TO THE
EQUAI, OPPORTT,NITY CIJAUSE A}ID TIIE EIIJING OT REQUIRED REPORTS
The- biddar, y' , proposed subcontractor
-t
hereby certif ies thathe has v , has not _, participated in a previous contract orsubcontract subject to tfre Equal Opportunity Clause, as required bvExecutive orders 10925, LLLLA, or 1-L246, and that he has t/ I nr" rol, filed with the Joint Reporting Committee, the Director of tir" officeof Federal Contract Compliance, a Federal Government contracting oradministering agency, or t.he former president's committ.ee on EquaIEmployment Opportunit.y, al-L reports due under the applicable fiiinqrequirements.
Vido Samarzich, lnc.
Vice President
DATE:March 4
(TITLE)
, 2025
NOTE: The above certification is required by the Equal Employmentopportunity Regulations of the secretary of Labor (4L cFR G0*1.7 (b)(1), and must be submitted by bidders and proposed subcontractors onlyin connection with contracts and subcontracts whi-ch are sub;ect to theEqual opportunity Clause. Contracts and subcontracts which are exemptfrorn the Equar opportunity clause are set forth in 4l cER 60-1.5.(Generally only contracts or subcontracts of $10r 000 or under areexempt).
Currently, Standard Form 100 (EEO-1) is the only report required by theExecutive Orders or their implementing regulations.
Proposed prime contractors and subcontractors who have participated ina previous contract or subcontract sub]ect to the Executive Orders andhave not filed the required reports should note that 47 CFR 60-1.7 (b)(1) prevents the award of contracts and subcontracts unless suchcontractor submits a report covering the delinquent period of such otherperiod specified by the Federal Highway Administration or by theDirector, Office of Federal Contract Compliance, U.S. Department ofLabor.
(COMPANY)
31
NON.COLLUSION
(ro BE EXECUTED BY BTDDER
DECI,ARMION
AIiID ST,BMITTED WITH BID)
The undersigned declares :
I am the Vice President of Vido Samarzich lnc., the party makingthe foregoing bid.
The bid is not made in the interest of, or on behalf of, any undisclosedperson, partnershi-p, company, association, organl_zation r orcorporation. The bid is genuine and. not collusive or sham. The bidderhas not directly or indirectly induced or solicited any other bidder toput in a false or sham bid. The bidder has not directly or indirectlycolIuded, conspired, connived., or agreed with any bidder or anyone elseto put in a sham bid, or to refrain from bidding. The bidder has not inany manner, direct.ly or indirectly, sought by agreement/ communicat.ion,or conference with anyone to fix the k,id price of the bidder ot: anyother bidder, or to fix any overhead, profitr or cost element of thebid price, or of that of any ot.her bidder.
A11 statements contained in the bid are true. The bidder has not,directly or indirectly, submitted his or her bid price or any breakdownthereof, or the contents thereof, or divulged information or datarel-ative thereto, to any corporation, partnership, company,association, organization, bid depository, or to any member or agentthereof, to effectuate a collusive or sham bicl, and has not paicl, andwill not pay, any person or entity for such purpose. Any personexecuting this declaratj-on on behalf of a bidder that 1s a corporat.ion,partnership, joint vent.ure, limited riabirity company, limitedIiability partnership, or any other entity, hereby represents Lhat heor she has full power to execute, and does execute, this declaration onbehalf of the bidder.
f declare under penalty of perSury
Cal-ifornia that the foregoing isdeclaration is executed on
Santa Ana Icity], CA Istate]
Vido Samazich, lnc.
Business Name Signatu of
515 Cabrillo Park Dr, Suite 315, Santa Ana, CA 92701
Business Address
Attach Notary Ac,knowledgement Form to
under the laws of the State oftrue and correct and that thi-s
March 4 2025 [date], at
(must be notarized)
3B
thie form when submitting
ACKNOWLEDGMENT
A notary public or other officer cornpleting tnis
certificate verifies only the identity of the individual
who signed the document to which this certificate is
aftached, and not the truthfulness, accuracy, or
validity of that document.
State of California ^County of Urange )
On March 4,2025 before r", Desmond G. Warren, Notary public
(insert name and title of the officer)
personally appeared Vido L' Samarzich
who proved to me on '
subscribed to the within instrument and acknowledged to me that'helghdtli;1(,! executed ihe sa-me inhislfi€rtlbcfauthorized capacityfie(f,and that by hislfil!frft signatuieito; tne instrument thepersonffior the entity upon behalf of which the personJf,acted-, execuied the instrument.
I certifo under PENALry OF PERJURY under the laws of the State of California that the foregoingparagraph is true and correct.
WITNESS my hand and officiatseal.
Signature
,o,, lllf'9
(Rev. October 201 8)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
ldentification Number and Certification
for instructions and the latest information.
not leave this line
Requester's name
Give Form to the
requester, Do not
send to the lRS.
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting
code (if any)
(Appli* toeccounts majntaihed outside be U.S)
(optional)
)Goto
on your
lnc.
is required on
<'i
oE"(!
o_co.oocooaE
ClEzfr
fo
'6
g
U,oo
@
EnteryourTlNintheappropriatebox.TheTlNprovided,ust,atc@
backup withholding. For individuals, this is generally your social security numbjr (SSN). However, for aresident alien, sole proprietor, or disregarded entity, iee the instruction; for part l, latei. For other
gJitip9, it is your employer identification number (ElN). lf you do not have a number, see How to get aIIN, later.
1 The number shown on this form is my correct taxpayer identification number (or I am waiting {or a number to be issued to me); and2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the lnternal RevenueService (lRS) that I am subject.to backup withholding as a resuit of a failure to report all inieresi or dividends, or (c) the IRS has notified me that I amno longer subject to backup withholding; and
3, I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions' You must cross out item 2 above if you have been notified by the IRS that you are currenily subject to backup withholding because
f:,Hiff1} j:!:111]1y?:l alg gividelds on your tax return. For real estate transactions, itern2 does not appry. ror mortsase interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an indlvidual retirement arrangement (RA),;nd generally, paymentsother than lnterest and dlvldends, to sign the certlficatlon, but you must provide your correct TlN. See the instrucilons for part ll, later,
Here Date> 31412025
General lnstructions r Form -1099-DlV (dividends, including those from stocks or mutual
funds)
. Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
. Form 1 009-8 (stock or mutual fund sales and cedain other
transactions by brokers)
o Form 1 099-5 (proceecls from real estate transactions)
. Form 1099-K (merchant card and third party network transactions)
o Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
. Form '1099-C (canceled debt)
o Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TlN.
lf you do not retum Form W-9 to the requester with a TlN, you might
be subject to backup withholding. See What is backup withholding,
latar.
Section references are to the lnternal Revenue Code unless otheMise
noted.
Fufure developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published , go to www.irs.govlFormWg.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
lg1lingalion number [lN) which may be your social security number
(SSN), individual taxpayer identification number (lTtN), adopiion
taxpayer identlfication number (ATIN), or employer identification number
(ElN), to repod on an information return the amount paid to you, or other
amount reportable on an information return. Examples of inlormation
returns include, but are not limited to, the following.
o Form 1099-lNT (interest earned or paid)
3 Check appropriate box for federal tax classilication of the person whose name is entered on line 1 . Check only one of thefollowing seven boxes,
! lnoividua/sole proprietor or E C Corporauon n S Corporation E partnership f] TrusVestate
single-member LLC
n UmiteO liability company. Enter the tax classification (C=C corporation, S=S corporation, p=parlnership) >
No!e: Check the appropriate box in the line above for the tax classirication of the single-member owner. Do not checkLLC if the LLC is classified as a single-member LLC that is disregarded from the own-ei unless the owner of the LLC isanoiher LLC that is not disregarded from the owner for U.S. fediral tax purposes. OtheMise, a singte-member LLC
is disregarded from the owner should check the appropriate box for the tax classification of iis owner.
Other (see instructions) >
Address (number, street, and apt. or suite no.) See
Note: lf the account is in more than one name, see the instructions for line 1. Also see What Name andNumber To Give the Feguester for guldelines on whose number to enter.
Under penalties of perjury, I certify that: