17-1221_UNITED BUILDING & DEVELOPMENT SERVICES_Bid Forms00 41 43 — BID FORMS
1.1 Bid.
Bids will be received at the City of San Juan Capistrano City Clerk Office, 32400 Paseo
Adelanto, San Juan Capistrano, California, until 2 p.m. on December 21,2017.
NAME OF BIDDER:
To the Honorable City Council
of the City of San Juan Capistrano
32400 Paseo Adelanto
San Juan Capistrano, California 92675
L-*Lu--V-
Y4Ulc CPS
The undersigned hereby declare that we have carefully examined the location of the proposed
Work, and have read and examined the Contract Documents, including all plans, specifications,
and all addenda, if any for the following Project:
Trellis Roof Repair and Reconstruction at the Train Station — Verdugo Street
We hereby propose to furnish all labor, materials, equipment, tools, transportation, and services,
and to discharge all duties and obligations necessary and required to perform and complete the
Project, as described and in strict conformity with the Drawings, and these Specifications for
TOTAL BID PRICE indicated herein.
The undersigned acknowledges receipt, understanding, and full consideration of the following
addenda to the Contract Documents:
Addenda No.
1. Attached is the required Bid Guarantee in the amount of not less than 10% of the Total
Bid Price.
2. Attached is the completed Designation of Subcontractors form.
3. Attached is the fully executed Noncollusion Declaration form.
4. Attached is the completed Iran Contracting Act Certification form.
5. Attached is the completed Public Works Contractor Registration Certification form.
6. Attached is the completed Contractor's Certificate Regarding Workers' Compensation
form.
7. Attached is the completed Bidder Information and Experience form.
61147.02100\20950242.3 _16_ 00 41 43 - BID FORMS
A. BID SCHEDULE
The costs for any Work shown or required in the Contract Documents, but not specifically
identified as a line item are to be included in the related line items and no additional
compensation shall be due to Contractor for the performance of the Work.
In case of discrepancy between the Unit Price and the Item Cost set forth for a unit basis item,
the unit price shall prevail and shall be utilized as the basis for determining the lowest
responsive, responsible Bidder. However, if the amount set forth as a unit price is ambiguous,
unintelligible or uncertain for any cause, or is omitted, or is the same amount as the entry in the
"Item Cost" column, then the amount set forth in the "Item Cost" column for the item shall prevail
and shall be divided by the estimated quantity for the item and the price thus obtained shall be
the Unit Price.
For purposes of evaluating Bids, the City will correct any apparent errors in the extension of unit
prices and any apparent errors in the addition of lump sum and extended prices.
The estimated quantities for Unit Price items are for purposes of comparing Bids only and the
City makes no representation that the actual quantities of work performed will not vary from the
estimates. Final payment shall be determined by the Engineer from measured quantities of work
performed based upon the Unit Price.
61147.02100\20950242.3 _17_ 00 41 43 - BID FORMS
UNIT OF
EST.
UNIT
ITEM
NO.
ITEM DESCRIPTION
MEASURE
QTY.
PRICE
COST
1,
Project Management; General
LS
1
Conditions; General Contractor
I—I n
1 "I
Overhead & Profit / Fee
2.
Demolition of miscellaneous
LS
1
pI
i
items; Temporary FencingI
3.
Steel Decking; Metal
LS
1
Fabrications including gutters�l
) O b
and flashingv
4.
Wood Framing, Wood
LS
1
Treatment; & Finishing
5.
Joint Sealer
LS
1
a 00
cg� C)
S.
New Exterior Light Fixtures to
LS
1CJ
Q
Match Existing
7.
Metrolink Coordination/Flagman
LS
1
$10,000
$10,000
Cost.
g,
Permit Fees
LS
1
$1,000
$1,000
The costs for any Work shown or required in the Contract Documents, but not specifically
identified as a line item are to be included in the related line items and no additional
compensation shall be due to Contractor for the performance of the Work.
In case of discrepancy between the Unit Price and the Item Cost set forth for a unit basis item,
the unit price shall prevail and shall be utilized as the basis for determining the lowest
responsive, responsible Bidder. However, if the amount set forth as a unit price is ambiguous,
unintelligible or uncertain for any cause, or is omitted, or is the same amount as the entry in the
"Item Cost" column, then the amount set forth in the "Item Cost" column for the item shall prevail
and shall be divided by the estimated quantity for the item and the price thus obtained shall be
the Unit Price.
For purposes of evaluating Bids, the City will correct any apparent errors in the extension of unit
prices and any apparent errors in the addition of lump sum and extended prices.
The estimated quantities for Unit Price items are for purposes of comparing Bids only and the
City makes no representation that the actual quantities of work performed will not vary from the
estimates. Final payment shall be determined by the Engineer from measured quantities of work
performed based upon the Unit Price.
61147.02100\20950242.3 _17_ 00 41 43 - BID FORMS
B. TOTAL BID PRICE:
TOTAL BID PRICE BASED ON BID SCHEDULE TOTAL OF UNIT PRICES
FOR Trellis Roof Repair and Reconstruction at the Train Station
1 1 011 .� L -i o0
Total Bid Price in Numbers
s QA kkm&u d Aty�- thfai amd 2 Lu Lza Liv -
Total Bid Price in Written Form &1 --,—
In
�,� , y^
In case of discrepancy between the written price and the numerical price, the written price
shall prevail.
The undersigned agrees that this Bid Form constitutes a firm offer to the City which cannot be
withdrawn for the number of calendar days indicated in the Notice Inviting Bids from and after
the Bid opening, or until a Contract for the Work is fully executed by the City and a third party,
whichever is earlier.
The successful bidder hereby agrees to sign the contract and furnish the necessary bonds and
certificates of insurance within ten (10) working days after the City provides the successful
bidder with the Notice of Award.
Upon receipt of the signed contract and other required documents, the contract will be executed
by the City, after which the City will prepare a letter giving Contractor Notice to Proceed. The
official starting date shall be the date of the Notice to Proceed, unless otherwise specified. The
undersigned agrees to begin the Work within ten (10) working days of the date of the Notice to
Proceed, unless otherwise specified.
The undersigned has examined the location of the proposed work and is familiar with the
Drawings and Specifications and the local conditions at the place where work is to be done.
If awarded the contract, the undersigned agrees that there shall be paid by the undersigned and
by all subcontractors to all laborers, workers and mechanics employed in the execution of such
contract no less than the prevailing wage rate within Orange County for each craft,
classification, or type of worker needed to complete the Work contemplated by this contract as
established by the Director of the Department of Industrial Relations. A copy of the prevailing
rate of per diem wages are on file at the City's Administration Office and shall be made available
to interested parties upon request. �V 3 y 0 9 (Osl
Enclosed find cash, bidder's bond, or cashier's or certified check No. from the
We-s+M SUX , Bank in the amount of 1 0()(), Coo , which is not
less than ten pe cent (10%) of this bid, payable'to C f San Juan Capistrano as bid security
and which is given as a guarantee that the undersigned will enter into a contract and provide the
necessary bonds and certificates of insurance if awarded the Work.
61147.02100\20950242.3 -18- 00 41 43 - BID FORMS
The bidder furthermore agrees that in case of bidder's default in executing said contract and
furnishing required bonds and certificates of insurance, the cash, bidder's bond, or cashier's or
certified check accompanying this proposal and the money payable thereon shall become and
shall remain the property of the City of San Juan Capistrano.
Bidder is an individual , or corporation X, or partnership , organized under
the laws of the State of r, Ci l 1 -VV) �, n I Ck—
Bidder confirms license(s) required by California State Contractor's License Law for the
performance of the subject project are in full effect and proper order. The following are the
Bidder's applicable license number(s), with their expiration date(s) and class of license(s):
If the Bidder is a joint venture, each member of the joint venture must include the required
licensing information.
Sureties that will furnish the Faithful Performance Bond and the Labor and Material Payment
Bond, in the form specified herein, in an amount equal to one hundred percent (100%) of the
contract price within ten (10) working days from the date the City provides the successful bidder
the Notice of Award. Sureties must meet all of the State of California bonding requirements, as
defined in California Code of Civil Procedure Section 995.120 and must be authorized by the
State of California.
The insurance company or companies to provide the insurance required in the contract
documents must have a Financial Strength Rating of not less than "A-" and a Financial Size
Category of not less than "Class VII" according to the latest Best Key Rating Guide. At the sole
discretion of the City, the City may waive the Financial Strength Rating and the Financial Size
Category classifications for Workers' Compensation insurance.
(signatures continued on next page)
61147.02100\20950242.3 -19- 00 41 43 - BID FORMS
I hereby certify under penalty of perjury under the laws of the State of California that all of the
information submitted in connection with this Bid and all of the representations made herein are
true and correct.
Executed at � L �?� �f tV on this � day of a o 1.
(Corporate Seal)
(Bidders Name — Print or Type)
7, L,�U R"YLf
(Narfie,4 Title)
re)
Names of individual members of firm or names and titles of all officers of corporation and their
addresses are listed below: '
Name. Title
Complete Address C�q eo 1 �A Q 61 Ibr 5 .3 . U1 IS
Phone ( 14) 4 o i — a, -i ] b FAX
Name
Complete Address
Phone
Name
Complete Address
Phone
Complete Address
Title
Title
Title
F
Phone F
61147.02100\20950242.3 -20- 00 41 43 - BID FORMS
Bond No. 63409657
1.2 Bid Bond
[Note: Not required when other form of Bidder's Security, e.g. cash, certified check or
cashier's check, accompanies bid.]
The makers of this bond are, United Builders & Development Services LLC , as
Principal, and WESTERN SURETY COMPANY , as Surety
and are held and firmly bound unto the City of San Juan Capistrano, hereinafter called the City,
in the penal sum of TEN PERCENT (10%) OF THE TOTAL BID PRICE of the Principal
submitted to CITY for the work described below, for the payment of which sum in lawful money
of the United States, 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 whereas the Principal has submitted
the accompanying bid dated "2 20 for the Trellis Roof Reapir and
Reconstruction at the Train Station.
If the Principal does not withdraw its Bid within the time specified in the Contract Documents;
and if the Principal is awarded the Contract and provides all documents to the City as required
by the Contract Documents; then this obligation shall be null and void. Otherwise, this bond will
remain in full force and effect.
Surety, for value received, hereby stipulates and agrees that no change, extension of time,
alteration or addition to the terms of the Contract Documents shall in affect its obligation under
this bond, and Surety does hereby waive notice of any such changes.
In the event a lawsuit is brought upon this bond by the City and judgment is recovered, the
Surety shall pay all litigation expenses incurred by the City in such suit, including reasonable
attorneys' fees, court costs, expert witness fees and expenses.
IN WITNESS WHEREOF, the above -bound parties have executed this instrument under their
several seals this 21St day of December 20 17 , the name and corporate seal of
each corporation.
(Corporate Seal) UNITED BUILDERS & DEVELOPMENT SERVICES LLC
Contract 1 rincipal , f
By tG't,'K _
Title` 7 &;S 66&Qu
WESTERN SURETY COMPANY
(Corporate Seal) Surety
By
Attorney -in -Fact
(Attach Attorney -in -Fact Certificate) Title Alexander William Koutsoubas, Attorney in Fact
61147.02100120950242.3 -21- 00 41 43 - BID FORMS
Notary 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 M4i,1C
On 266*b if--- Z /5r . 20_L7 , before me, Cki'6 P^ V- Notary Public, personally
appeared R,?14e Cdl-1ti°Z 7R • , who proved to me on the basis of satisfactory
Name(s) of Signer(s)
evidence to be the persons) whose name($) is/are subscribed to the within instrument and acknowledged to
me that hem executed the same in his/fir authorized capacity(iea), and that by hist their
signature(oon 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 corre
CHRISTIAN V. MAYERS
'
COMM ... 2127466 C1 WITNESS my hand and official seal.
NOTARY PUBLIC -CALIFORNIA —1
ORANGE COUNTY Ej
�- My Term Exp. Sept. 20, 2019
Signature of Notary Public
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document.
CAPACITY CLAIMED BY SIGNER DESCRIPTION OF ATTACHED DOCUMENT
individual
Corporate Officer
Title(s)
❑ Partner(s) ❑ Limited
❑ General
❑ Attorney -I n -Fact
❑ Trustee(s)
❑ Guardian/Conservator
❑ Other:
Signer is representing:
Name Of Person(s) Or Entity(ies)
fi l�Kovrdei yi/r1l�an� jry�pi/fi" S aV10� � I`��f�rc�f
Signer(s) Other Than Named Above n_
NOTE: This acknowledgment is to be completed for Contractor/Principal.
61147.02100\20950242.3 _22- 00 41 43 — BID FORMS
Notary Acknowledgment
A notary {public or other officer completing this certificate
verities only the identity of the individual who signed the
docurned to which this certificate is attached, and not the
truthfulness, accuracy, or validity of that document
STATE OF CA I FO N IA
COUNTY OF '??
On ' e,, 76Z4l 0 ( , before me, 01"4't 1 v a J� Notary Public, personally
appeared' +,�n�-+tet �I Ir 1C�td��� , 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.
CUFTOt1 M STAR
Commission N 2106169
ww Nolary Public . Calltorala
Los Angels Counly
Signature of Notary Public
VVITNE my hand and official seal,
OPTIONAL
Though the information below is not required by low, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document.
CAPACITY CLAIMED BY SIGNER DESCRIPTION OF ATTACHED DOCUMENT
J I ndividual
Corporate Officer
Title(s)
,ijPartner(s) Limited
General
ttorney-Irl-Fact
,_jTrustee(s)
Guardian/Conservator
[]Other:
Signer is representing:
Name Of Person(s) Or Entity(ies)
Title or Type of Document
PAW
Date
Then Named Above
NOTE: This acknowledgment is to be completed for the Attorney -in -Fact. The Power -of -Attorney to
local representatives of the bonding company must also be attached.
END OF BID BOND
61147,02100\20950242.3 -23- 00 41 43 —BID FOR44S
ACKNOWLEDGMENT OF SURETY
STATE OF California _ (Attorney -in -Fact) Bond No. 63409657
COUNTY OF Los Angele i 5s
On this 21st day of December 2017 , before me, a notary public in
and for said County, personally appeared Alexander William Kout o J2
to me personally known and being by me duly sworn, did say, that he/she is the Attorney -in -Fact of WESTERN SURETY
COMPANY, a corporation of Sioux Falls, South Dakota, created, organized and existing under and by virtue of the laws of the
State of South Dakota, that the said instrument was executed on behalf of the said corporation by authority of its Board of
Directors and that the said lexander William Koutsoubas
acknowledges said instrument to be the free act and deed of said corporation and that he/she has authority to sign said
instrument without affixing the corporate seal of said corporation.
IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal at
Northridge California , the day and year last above written.
My commission expires
Public
Form 106-9-2013
Western Surety Company
POWER OF ATTORNEY - CERTIFIED COPY
Bond No.
63409657
Know All Men By These Presents, that WESTERN SURETY COMPANY, a corporation duly organized and existing under the laws
of the State of South Dakota, and having its principal office in Sioux Falls, South Dakota (the "Company"), does by these presents make,
constitute and appoint Ale. -,.ander William K utsoubas
its true and lawful attorney(s)-in-fact, with full power and authority hereby conferred, to execute, acknowledge and deliver for and on its
behalf as Surety, bonds for:
Principal: United Builders & Development Services LLC
Obligee: City of San Juan Capistrano
Aniount: $1,000,000.00
and to bind the Company thereby as fully and to the same extent as if such bonds were signed by the Vice President, sealed with the
corporate seal of the Company and duly attested by its Secretary, hereby ratifying and confirming all that the said attorney(s)-in-fact
may do within the above stated limitations. Said appointment is made under and by authority of the following bylaw of Western Surety
Company which remains in full force and effect.
":Section 7. All bonds, policies, undertakings, Powers. of Attorney or other obligations of the corporation shall be executed in the
corporate name of the Company by the President, Secretary, any Assistant Secretary, Treasurer, or any Vice President or by such other
officers as the Board of Directors may authorize. The President, any Vice President, Secretary, any Assistant Secretary, or the Treasurer
may appoint Attorneys in Fact or agents who shall have authority to issue bonds, policies, or undertakings in the name of the Company.
The corporate seal is not necessary for the validity of any bonds, policies, undertakings, Powers of Attorney or other obligations of the
corporation. The signature of any such officer and the corporate seal may be printed by facsimile."
If Bond No. C34 0965 is not issued on or before midnight of March 21, 2018 all
authority conferred in this Power of Attorney shall expire and terminate.
Western Surety Company has caused these presents to be signed by its Vice President, Paul T, Bruflat, and its
,this 21st day of December , 2017
WEST R *SURE—Y COMPANY
;9{1ITbI,F°A Paul T. rtrflat, Vice President
Qx
ss
On tlu5 21 St day of December , in the year 2017 , before me, a notary public, personally appeared
Paul T. Bruflat, who being to me duly sworn, acknowledged that he signed the above Power of Attorney as the aforesaid officer of
WE, SURETY COMPANY and acknowledged said instrument to be the voluntary act and deed of said corporation.
1}bybyhhkrh4bfvh4Y*r4�bh�e�ab0.y +
J. MOHR
s S LMNOTARY PUBLIC S. s
ANotary Public - South Dakota.
SOUTH DAKOTA
tayc,hyyy*r�sn4haMr�o,�v�.��hww t
My Commission Expires June 23, 2021
I the undersigned officer of Western Surety Company, a stock corporation of the State of South Dakota, do hereby certify that the
attached Power of Attorney is in full force and effect and is irrevocable, and furthermore, that Section 7 of the bylaws of the Company as
set forth in the Power of Attorney is now in force,
In testimony whereof, I have hereunto set my hand and seal of Western Surety Company this 21st day of
December 2017
WEST R S;UREJW COMPANY
7
Paul T, tuflat, Vice President
To validate bond authenticity, go to wav►v.cnasurg(y.vom > Ovvner/Obligee Services > Validate Bond Coverage.
Form F5306-10-2017
1.3 List of Subcontractors
In compliance with the Subletting and Subcontracting Fair Practices Act Chapter 4
(commencing at Section 4100), Part 1, Division 2 of the Public Contract Code of the State of
California and any amendments thereof, Bidder shall set forth below: (a) the name and the
location of the place of business, (b) the California contractor license number, (c) the DIR public
works contractor registration number, and (d) the portion of the work which will be done by each
subcontractor who will perform work or labor or render service to the Bidder in or about the
construction of the work or improvement to be performed under this Contract in an amount in
excess of one-half of one percent (0.5%) of the Bidder's Total Bid Price. Notwithstanding the
foregoing, if the work involves the construction of streets and highways, then the Bidder shall list
each subcontractor who will perform work or labor or render service to the Bidder in or about the
work in an amount in excess of one-half of one percent (0.5%) of the Bidder's Total Bid Price or
$10,000, whichever is greater. No additional time shall be granted to provide the below
requested information.
If a Bidder fails to specify a subcontractor or if a contractor specifies more than one
subcontractor for the same portion of work, then the Bidder shall be deemed to have agreed
that it is fully qualified to perform that portion of work and that it shall perform that portion itself.
Work to be
done by
Name of
Location of
CSLB
Contractor
DIR
Registration
% of
Subcontractor
Subcontractor
Business
License No.
Number
Work
ti
TNT
�
C�
�1(oil 5
��
ci
i
61147.02100\20950242.3 -24- 00 4143 - BID FORMS
Work to be
done by
Subcontractor
Name of
Subcontractor
Location of
Business
CSLB
Contractor
License No.
DIR
Registration
Number
% of
Work
(Attach additional sheets if necessary)
Name of
Signatur
Name an
3idder Id 04Y -d �Jm,us L -L-
M _
YUL
Dated � 1�aL� `),c) I c� (D 1 -1
61147.02100\20950242.3 _25_ 00 4143 - BID FORMS
1.4 Bidder Information and Experience Form
ARTICLE 1. INFORMATION ABOUT BIDDER
(Indicate not applicable ("N/A") where appropriate.)
NOTE: Where Bidder is a joint venture, pages shall be duplicated and information provided
for all parties to the joint venture.
1.0 Name of Bidder: Ul.l+'U Ukk t3 UkAW k CvM jg22GL) QfYWLA_ XU
2.0 Type, if Entity: l- ` l YM, Am fg L'l " G YID_
3.0 Bidder Address: H QVD I AC 1 1X'IA
Facsimile Number Telephone Number
r ex-)rJL3L a I wh-)
Email Address
4.0 How many years has Bidder's organization been in business as a Contractor?
LI&
5.0 How many
years has Bidder's organization been in business under its present
name?
f D_A-s
5.1
Under what other or former
names Os Bidder's organization
operated?
e
6.0 If Bidder's organization is a corporation, answer the following:
6.1
Date of Incorporation:
6.2
State of Incorporation:
6.3
President's Name:
_ lJ ri-z__
6.4
Vice -President's Name(s): �
ho n o Irl I— W r -
I J
6.5
Secretary's Name:
6.6
Treasurer's Name:
61147.021 00\20950242.3
-26-
00 4143 - BID FORMS
LI&
7.0 If an individual or a partnership, answer the following:
7.1 Date of Organization: Sk,0
7.2 Name and address of all partners (state whether general or limited
partnership):
?��,
'Zg6o I to ananch 6-r.
8.0 If other than a corporation or partnership, describe organization and name
9.0 List other states in which Bidder's organization is legally qualified to do business.
10.0 What type of work does the Bidder normally perform with its own forces?
11.0 Has Bidder ever failed to complete any work awarded to it? If so, note when,
where, and why:
12.0 Within the last five years, has any officer or partner of Bidder's organization ever
been an officer or partner of another organization when it failed to complete a
contract? If so, attach a separate sheet of explanation:
13.0 List Trade References:
ana,h L 1,u-mbP�
H i.-
s'h P i
61147.021 00\20950242.3 _27_ 00 41 43 - BID FORMS
pmt [ . 0+
14.0 List Bank References (Bank and Branch Address):
PRIWARVIA, ton
15.0 Name of Bonding Company and Name and Address of Agent:
[REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK]
61147.02100\20950242.3 _28_ 00 41 43 - BID FORMS
ARTICLE 2. LIST OF CURRENT PROJECTS (BACKLOG)
[**Duplicate Page if needed for listing additional current projects.**]
Project
Description of
Bidder's Work
,
Completion Date
Cost of Bidder's Work
rs e,
IKQ -vi.� pool I g
434 000
(i01r1 � U't �G �c�11
13 .Q c1 3 e'rq i n i+
1- �
30 000
COLLri
d a, c i
` I 01 S
3 q 0 OU
61147.02100\20950242.3 _29_ 00 41 43 - BID FORMS
ARTICLE 3. LIST OF COMPLETED PROJECTS — LAST THREE YEARS
[**Duplicate Page if needed for listing additional completed projects.**]
Please include only those projects which are similar enough to demonstrate Bidder's ability to
perform the required Work.
Project
Description of
Bidder's Work
Completion Date
Cost of Bidder's Work
C kYy)L
v ��l COn�t
l0,0c)0'3Ul
h1►
a `
V-
�� �lTr �► 1G
e C
9.400.0o
NJ
�0nal,
Sq� dome,
a �0
00 , 00 0
61147.021 00\20950242.3 _30_ 00 4143 - BID FORMS
ARTICLE 4. EXPERIENCE AND TECHNICAL QUALIFICATIONS QUESTIONNAIRE
Personnel:
The Bidder shall identify the key personnel to be assigned to this project in a management,
construction supervision or engineering capacity.
1. List each person's job title, name and percent of time to be allocated to this project:
Ken!, Gz Lnim 40 r- IS n ?V
i tl� 1e t asGtr 'C.YI SLam,ryi:,sor q5 v
2. Summarize each person's specialized education:
3. List each person's years of construction experience relevant to the project:
C0 rkZ
4. Summarize such experience: N a
Bidder agrees that personnel named in this Bid will
relevant Work, unless substituted by personnel
approved in advance by the City.
Additional Bidder's Statements:
Isor
remain on this Project until completion of all
of equivalent experience and qualifications
If the Bidder feels that there is additional information which has not been included in the
questionnaire above, and which would contribute to the qualification review, it may add that
information in a statement here or on an attached sheet, appropriately marked:
61147.02100\20950242.3 -31- 00 4143 - BID FORMS
ARTICLE 5. VERIFICATION AND EXECUTION
These Bid Forms shall be executed only by a duly authorized official of the Bidder:
I declare under penalty of perjury under the laws of the State of California that the foregoing
information is true and correct:
Na
Sig
Na
me of Bidder SQ�u'( CQ S LLC,
nature A0
mecx,4r
e-,
'dL,*'A
Tine Pr'--A
Date I �1 If -� () J 11
61147.021 00\20950242.3 -32- 00 4143 - BID FORMS
1.5 Non -Collusion Declaration
The undersigned declares:
AA�� qq -ol N' V Q nl(�i° v 4 Sic Us L.C,
I am the of �, +i 1i'l �J 1J the party making the
foregoing Bid.
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.
I 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 C [date], at
S( �1,�cck-r + ► i 5 Y� r�c� [city]: U G. [state]. a�3r'L
Nam
Sign,
Nam
Title �,l�Q_ &A' _
61147.021 00\20950242.3 -33- 00 4143 - BID FORMS
1.6 Iran Contracting Act Certification.
(Public Contract Code section 2200 et seq.)
As required by California Public Contract Code Section 2204, the Contractor certifies subject to
penalty for perjury that the option checked below relating to the Contractor's status in regard to
the Iran Contracting Act of 2010 (Public Contract Code Section 2200 et seq.) is true and correct:
VIThe Contractor is not:
(1) identified on the current list of person and entities engaged in investment
activities in Iran prepared by the California Department of General Services in
accordance with subdivision (b) of Public Contract Code Section 2203; or
(2) a financial instruction that extends, for 45 days or more, credit in the amount of
$20,000,000 or more to any other person or entity identified on the current list of
persons and entities engaging in investment activities in Iran prepared by the
California Department of General Services in accordance with subdivision (b) of
Public Contract Code Section 2203, if that person or entity uses or will use the
credit to provide goods or services in the energy sector in Iran.
❑ The City has exempted the Contractor from the requirements of the Iran Contracting
Act of 2010 after making a public finding that, absent the exemption, the City will be
unable to obtain the goods and/or services to be provided pursuant to the Contract.
The amount of the Contract payable to the Contractor for the Project does not
exceed $00,000.
Sig
Printed
Title: rt S L� �_i
Firm Name: Uk. -AS bLtaldkim Gi-nbwc� rmtko( DAVLU
Date: hq-cl l o , of a -
Note: In accordance with Public Contract Code Section 2205, false certification of this form shall
be reported to the California Attorney General and may result in civil penalties equal to the
greater of $250,000 or twice the Contract amount, termination of the Contract and/or ineligibility
to bid on contracts for three years.
<Month> <Year> _34_ 00 4143 — BID FORMS
Pipeline Project XXXX
61147.02100\20950242.3
1.7 Public Works Contractor Registration Certification
Pursuant to Labor Code sections 1725.5 and 1771.1, all contractors and subcontractors that
wish to bid on, be listed in a bid proposal, or enter into a contract to perform public work must be
registered with the Department of Industrial Relations. See htto://www.dir.ca.Qov/Public-
Works/PublicWorks.html for additional information.
No bid will be accepted nor any contract entered into without proof of the contractor's and
subcontractors' current registration with the Department of Industrial Relations to perform public
work.
Bidder hereby certifies that it is aware of the registration requirements set forth in Labor Code
sections 1725.5 and 1771.1 and is currently registered as a contractor with the Department of
Industrial Relations.
Name of Bidder: &.IJdLnq aTJ &MtAq0tyu�LLC
DIR Registration Number: 1 0000 3H Q s
DIR Registration Expiration: D
Bidder further acknowledges:
Name of I
Signature
1. Bidder shall maintain a current DIR registration for the duration of the project.
2. Bidder shall include the requirements of Labor Code sections 1725.5 and 1771.1
in its contract with subcontractors and ensure that all subcontractors are
registered at the time of bid opening and maintain registration status for the
duration of the project.
3. Failure to submit this form or comply with any of the above requirements may
result in a finding that the bid is non-responsive.
Name and Title 2'm W V L re ,;�,k L
su-m co s LCC
<Month> <Year> -35- 00 4143 — BID FORMS
Pipeline Project XXXX
61147.02100\20950242.3
1.8 Contractor's Certificate Regarding Workers' Compensation.
I am aware of the provisions of section 3700 of the Labor Code which require every employer to
be insured against liability for workers' compensation or to undertake self-insurance in
accordance with the provisions of that code, and I will comply with such provisions before
commencing the performance of the work of this Contract.
Name of BidderriY u, WM us L Lei
Signature Al
P
/-
NameiL
Title Pre �
Dated I ��Q 11-7
<Month> <Year> -36- 00 4143 — BID FORMS
Pipeline Project XXXX
61147.02100\20950242.3
United Building and Development Services
29801 Monarch Drive
San Juan Capistrano, CA. 92675
Lic. # B-974934
Name / Address
City of San Juan Capistrano
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
Estimate
Date
Estimate #
9/11/2017
160
Project
Description
Rate
Total
The following bid is for the project (Trellis Roof Repair) San Juan Capistrano
Train Station
Install new metal roofing and gutter system to match existing front trellis
Install new wood beams and stain to match existing front trellis
install new lighting fixtures and plugs to match existing front trellis
Prevailing wages apply to all labor
Framing and staining of wood trellis
52,333.00
52,333.00
Labor and Materials
Electrical as called out on plans to match front trellis
6,540.00
6,540.00
Fabrication and installation of metal brackets per plans
19,208.00
19,208.00
Labor and Materials
Misc: Perimeter fencing and scissors lifts
3,719.00
3,719.00
Metrolink coordination 8days
10,000.00
10,000.00
Permit fees
1,000.00
1,000.00
General contractors overhead and profit / fees
17,934.00
17,934.00
Total $110,734.00