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CONTRACT 4628 Bid CLOSED Agreement No. 4628 American Asphalt South, Inc PROPOSAL FOR THE 2013-2014 FURNISHING AND APPLICATION OF SLURRY SEAL ON VARIOUS STREETS PROJECT NO.: PW 13-15 Date �9 120 4y Company Name; "" " ✓ 11 9 1rJ� TO THE CITY OF EL SEGUNDO: In accordance with the City of El Segundo's Notice Inviting Sealed Bids, the undersigned BIDDER hereby proposes to furnish all materials, equipment, tools, labor, and incidentals required for the above stated project as set forth in the Plans, Specifications, and contract documents therefor, and to perform all work in the manner and time prescribed therein. BIDDER declares that this proposal is based upon careful examination of the work site,Plans, Specifications, Instructions to Bidders, and all other contract documents. Submittal of this bid shall be considered evidence that the BIDDER has satisfied himself regarding the contract documents,access and any other field conditions which may effect bid prices.If this proposal is accepted for award,BIDDER agrees to enter into a contract with the City of El Segundo at the unit and/or lump sum prices set forth in the following Bid Schedule.BIDDER understands that failure to enter into a contract in the manner and time prescribed will result in forfeiture to the City of El Segundo of the proposal guarantee accompanying this proposal. BIDDER understands that a bid is required for the entire work,that the estimated quantities set forth in the Bid Schedule are solely for the purpose of comparing bids, and that final compensation under the contract will be based upon the actual quantities of work satisfactorily completed.THE CITY OF EL SEGUNDO RESERVES THE RIGHT TO INCREASE OR DECREASE THE AMOUNT OF ANY QUANTITY SHOWN AND TO DELETE ANY ITEM FROM THE CONTRACT.It is agreed that the unit and/or lump sum prices bid include all apparent expenses,taxes,royalties,and fees.In the case of discrepancies in the amounts bid, unit prices shall govern over extended amounts, and words shall govern over figures. If awarded the Contract, the undersigned further agrees that in the event of the BIDDER'S default in executing the required contract and filing the necessary bonds and insurance certificates within ten working days after the date of the City of El Segundo's notice of award of contract to the BIDDER, including sending by U.S.Mail a Public Works Contract for signature by the Awardee,the proceeds of the security accompanying this bid shall become the property of the City of El Segundo and this bid and the acceptance hereof may,at the City of El Segundo's option, be considered null and void. EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE I-C-1 BIDDER certifies that in all previous contracts or subcontracts,all reports which may have been due under the requirements of any agency,State,or Federal equal employment opportunity orders have been satisfactorily filed, and that no such reports are currently outstanding. AFFIRMATIVE ACTION CERTIFICATION BIDDER certifies that affirmative action has been taken to seek out and consider minority business enterprises for those portions of the work to be subcontracted, and that such affirmative actions have been fully documented, that said documentation is open to inspection, and that said affirmative action will remain in effect for the life of any contract awarded hereunder.Furthermore, BIDDER certifies that affirmative action will be taken to meet all equal employment opportunity requirements of the contract documents. NONCOLLUSION AFFIDAVIT BIDDER declares that the only persons or parties interested in this proposal as principals are those named herein; that no officer, agent, or employee of the City of El Segundo is personally interested,directly or indirectly, in this proposal;that this proposal is made without connection to any other individual,firm,or corporation making a bid for the same work and that this proposal is in all respects fair and without collusion or fraud. I-C-2 BID SCHEDULE 2013-2014 FURNISHING AND APPLICATION OF SLURRY SEAL ON VARIOUS STREETS PROJECT NO.: PW 13-15 Company Name:. Zlwr;et?p) C.. BASE BID ITEMS �. . _ ......... Ite Estimated Unit Price Item Total m Quantities Description No. Slurry Seal Type I application 1 151,909 SY application for Mondays through /® f '1 /,7 Fridays ays ... ........ Slurry Seal Type I application 2 70,296 SY application for Saturdays and Sundays Slurry Seal Type I application for 3 23,278 SY Vista del Mar on Saturday and Sunday 4 1 LS Sandblast, restore and replace all / � ® ® street markings and striping 5 2,000 SF 2-inch deep asphalt repairs TOTAL BID: $ TOTAL BID WRITTEN IN WORDS: • e b I-C-3a ALTERNATIVE BID ITEMS (PAGE 1 OF 2) 2013-2014 FURNISHING AND APPLICATION OF SLURRY SEAL ON VARIOUS STREETS PROJECT NO.: PW 13-15 Company Name: 0 ALTERNATIVE BID ITEMS ......... .......................__-___.__ Ite Estimated Unit Price Item Total m Quantities Description (S) (S) No. Al 151,909 SY Slurry Seal Type II application for / Mondays through Fridays A2 70,296 SY Slurry Seal Type 11 application for Saturdays and Sundays Slurry Seal Type 11 application for A3 23,278 SY Vista del Mar on Saturday and Sunday A4 1 LS City Hall Parking Lot 1 Type I resurface l® Ob City Hall Parking Lot 2 Type I AS 1 LS resurface A6 1 LS Water Division Parking Lot Type I resurface A7 1 LS Maintenance Yard Parking Lot Type I resurface A8 1 LS Richmond St. City Parking Lot Type I resurface 7 .5-6,7 > ........................ Library City Parking Lot Type I _ _ A9 1 LS resurface S,Z'® �, . A10 1 LS Main St. City Parking Lot Type I resurface All 1 LS Guaymas Way City Parking Lot Type I resurface / . Al2 1 LS South Recreation and Parks City Parking Lot Type I resurface A13 1 LS Grand Ave. City Parking Lot Type I resurface c A14 1 LS Fire Station 1/Police Parking Lot Type I resurface 970 I-C-3b ALTERNATIVE BID ITEMS (PAGE 2 OF 2) 2013-2014 FURNISHING AND APPLICATION OF SLURRY SEAL ON VARIOUS STREETS PROJECT NO.: PW 13-15 Company Name; /� °�/lAI! jil- 1 "tax ALTERNATIVE BID ITEMS In Description m Estimated Unit Price Item Total No. Quantities ($) ($) ........ Construct additional parking area, apply Slurry Seal Type I, and A15 1 LS restripe to provide 9 new parking p s aces on Fire Station 1/Police � Parking Lot Rosecrans Ave. Type I resurfacing A16 23,333 SY and striping on Saturday and /® 5b Sunday I-C-3c BIDDEER'S INFORMATION Company Name: elike'ikio /1`J4off'S/4ll StJ/A/, . ill, BIDDER certifies that the following information is true and correct: Form of Legal Entity(i.e., individual, partnership, corporation, etc.) If corporation, State of Incorporation (i.e., California) �irh�4 Business im 1w oop Address _-"404#q, n/ Telephone No............rAW.1..Pl, P X �OI Facsimile No. State Contractor's License No. and ClassO 9 Original Date Issued o90s/o Expiration Date 4 The following are-the names,titles, addresses,and phone numbers of all individuals,firm members,partners,joint venturers, and/or corporate officers having principal interest in this prop 4�V/nmQa - ,046',40a/ er Nor- � The date of any voluntary or involuntary bankruptcy judgments against any principal having an interest in this proposal is as follows: xldhe All current and prior DBA's, aliases, and/or fictitious business names for any principal having an interest in this proposal are as follows: 4sore I-C-4 IN WITNESS WHEREOF,BIDDER executes and submits this proposal with the names,titles, hands, and seals of all a forenamed principals this 119 day of , 20 BIDDER Subscribed and sworn to this I day of ,20�. NOTARY PUBLIC SERI 1E GRANT „ COMM.#2031882 'z NOTARY PUBLIC-CALIFORNIA SAN BERNARDINO COUNTY My Comm.Expires June 30,201 I-C-5 PROPOSAL GUARANTEE DID BOND 2013-2014 FURNISHING AND APPLICATION OF SLURRY SEAL ON VARIOUS STREETS PROJECT NO.. PW 13-15 KNOW ALL MEN BY THESE PRESENTS that, American Asphalt South,Inc. ,as BIDDER,and The Guarantee Company of North America USA ,as SURETY,are held and firmly bound unto the City of El Segundo, in the penal sum of Ten Per erntofAmountBid DOLLARS($1J,which is ten (10%) percent of the total amount bid by BIDDER to the City of Fl Segundo for the above skated project, for the payment of which sum, 13IDDER and SURETY agree to be bound, ,jointly and severally, firmly by these presents. THE CONDITIONS OF THIS OBLIGATION ARE SUCH that,whereas BIDDER is about to submit a bidto the City of El Segundo for the above stated project,if said bid is rejected,or if said bid is accepted and a contract is awarded and entered into by BIDDER in the manner and time specified,then this obligation shall be null and void,otherwise it shall remain in full force and effect in favor of the City of El Segundo. IN WITNESS WHEREOF the parties hereto have set their names,titles, hands,and seals this 12th day of May BIDDEN* American Asph S loth,I B " 1443 rota.Ana Avenue Fontana, (909)427-8279 SURETY* The n, tee Company of o i merioa S EIi eth CoHodl,Ad �rney In Fact 1 Towne Square,Suite 1470 Southfield,MI 48076 1�6G' 62tYW-0607 Subscribed and sworn to this 12th day of May , 2014 NOTARY PUBLIC *Provide DIT)DERISURETY name, title, address and telephone number and the name, title, address and telephone number for authorized representative. **=10%of Amount Bid I-C-6 State of California ss. County of Oil �+, ±�`K rr C( g.,-Jane Doe,�kalln. ...............-� � Name and Tille of Officer em e.Nola Public') mm...,� ..,... _ _ � before rne„ � ey'r Gft� '1 rt;.vi� d personally appeared Name(}at Signer(e) proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/ subscribed to the within instrument and acknowledged to me that he/s+,re/tkq executed the same in his/W/tbeiy authorized capacity(ies), and that by his/fir/t signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) JERI MARIE GRANT acted, executed the instrument. COMM.#2031882 z NOTARY PUBLIC-CALIFORNIAK VVITN my hand and ffcial seal, U, V` SAN BERNARDINO COUNTY r` My Comm.Explrles June 30,2017 •° signature of Nol ary 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 Description of Attached Document Title or Type of Document: Document Date: m.. �. ...,_...... _. Number of Pages: .... ; Signers) Other Than Named Above: _ y Capacity(Ies) Claimed by Signer Signer's Name: ❑ Individual Top of Thumb here ❑ Corporate Officer—Title(s): _ ❑ Partner—❑ Limited ❑ General.- .. .... .. .. ....... ❑ Attorney-in-Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: _____ _----- Signer Is Representing--, _ _. _ mm.. ............ .... ..... _.... ®1999 Nalional Nolary A550cialion.9350 De Solo Ave,P.U.Box 2402 m Chalsworlh,CA 91313-2402°www„nalionalrrolary,org Prod,.No 5907 Reorder Call Toll-Free 1-800-676-6927 CALIFORNIA ALL-PURPOSE CERTIFICATE OF ACKNOWLEDGMENT State of California County ofµ.Butte On May 12, 2014 before me,..A. Abney, Notary Public ........� (Here insert name and title of the officer) personally appeared Elizabeth Collodi who proved to me on the basis of satisfactory evidence to be the person(e) whose name(s) is/efe subscribed to the within instrument and acknowledged to me that he/she/tom executed the same in Iris/her/ authorized capacity(ies), and that by hio/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. A�B�N.AA Commissn 16131 Pu IT S only a d and official seal. ���ButteiCountiifornla y Co1m,Wires Mar 26,2017 (Notary Seal) h4aatc ul'Notary IN c ADDITIONAL OPTIONAL INFORMATION INSTRUCTIONS FOR COMPLETING THIS FORM Any acknowledgment completed in California must contain verbiage exactly as DESCRIPTION OF THE ATTACHED DOCUMENT appears above in the notary section or a separate acknowledgment form must he properly completed and attached to that document. The only exception is if a Bid Bond document is to be recorded outside ofCalifonhia.In such instances,any alternative (Title or description of attached document) acknowledgment verbiage as may be printed on such a document so long as the verbiage does not require the notary to do something that is illegal for a notary in American Asphalt South, Inc. California(i.e.certifying the authorized capacity of the signer).Please check the document carefully for proper notarial wording and attach this form if required (Title or description of attached document continued) •State and County information must be the State and County where the document Number of Pages 1 Document Date 05/12/14 m signer(s)personally appeared before the notary public for acknowledgment, •Date of notarization must be the date that the signer(s)personally appeared which The Guarantee Company of North America USA must also be the same date the acknowledgment is completed (Additional information) •The notary public must print his or her name as it appears within his or her commission followed by a comma and then your title(notary public). •Print the name(s)of document signer(s)who personally appear at the time of notarization. CAPACITY CLAIM ED BY THE SIGNER •Indicate the correct singular or plural forms by crossing off incorrect forms(i.e. El Individual (s) Wshe/they,is/are-)or circling the correct forms.Failure to correctly indicate this information may lead to rejection of document recording, ❑ Corporate Officer •The notary seal impression must be clear and photographically reproducible. Impression must not cover text or lines.If seal impression smudges,re-seal if a (Title) sufficient area permits,othehwise complete a different acknowledgment form, ❑ Partner(s) •Signature of the notary public must match the signature on file with the office of the county clerk. ❑■ Attorney-in-Fact * Additional information is not required but could help to ensure this ❑ Trustee(s) acknowledgment is not misused or attached to a different document. Other *, Indicate title or type of attached document,number of pages and date. El *.-Indicate the capacity claimed by the signer.If the claimed capacity is a corporate officer,indicate the title(i,e CEO,CFO,Secretary). •Securely attach this document to the signed document 2008 Version CAPA 02.10.07 800-873-9865 www.NotaryClasses.corn THE The Guarantee Company of North America USA GUARANTEE"' POWER OF ATTORNEY Southfield,Michigan KNOW ALL BY THESE PRESENTS:That THE GUARANTEE COMPANY OF NORTH AMERICA USA,a corporation organized and existing under the laws of the State of Michigan,having its principal office in Southfield,Michigan,does hereby constitute and appoint Barbara Midstokke,Renee Ramsey,Richard W.Pratt,John Hopkins,Elizabeth Collodi,Susan Lee,Barbara Beeny,Nancy Luttenbacher, Phillip O.Watkins,Keith T.Schuler, Melissa D.Diaz,Shawna Johnson,Patricia M.Simas Interwest Insurance Services,Inc. its true and lawful attorney(s)-in-fact to execute, seal and deliver for and on its behalf as surety, any and all bonds and undertakings, contracts of indemnity and other writings obligatory in the nature thereof,which are or may be allowed,required or permitted by law,statute,rule,regulation,contract or otherwise. The execution of such instrument(s) in pursuance of these presents, shall be as binding upon THE GUARANTEE COMPANY OF NORTH AMERICA USA as fully and amply,to all intents and purposes, as if the same had been duly executed and acknowledged by its regularly elected officers at the principal office. The Power of Attorney is executed and may be certified so,and may be revoked,pursuant to and by authority of Article IX,Section 9.03 of the By-Laws adopted by the Board of Directors of THE GUARANTEE COMPANY OF NORTH AMERICA USA at a meeting held on the 31"day of December,2003. The President,or any Vice President,acting with any Secretary or Assistant Secretary,shall have power and authority: 1. To appoint Attorney(s)-in-fact, and to authorize them to execute on behalf of the Company, and attach the Seal of the Company thereto, bonds and undertakings,contracts of indemnity and other writings obligatory in the nature thereof;and 2. To revoke,at any time,any such Attorney-in-fact and revoke the authority given,except as provided below 3. In connection with obligations in favor of the Florida Department of Transportation only,it is agreed that the power and authority hereby given to the Attorney-in-Fact includes any and all consents for the release of retained percentages and/or final estimates on engineering and construction contracts required by the State of Florida Department of Transportation. It is fully understood that consenting to the State of Florida Department of Transportation making payment of the final estimate to the Contractor and/or its assignee,shall not relieve this surety company of any of its obligations under its bond. 4. In connection with obligations in favor of the Kentucky Department of Highways only,it is agreed that the power and authority hereby given to the Attorney-in-Fact cannot be modified or revoked unless prior written personal notice of such intent has been given to the Commissioner— Department of Highways of the Commonwealth of Kentucky at least thirty(30)days prior to the modification or revocation. Further,this Power of Attorney is signed and sealed by facsimile pursuant to resolution of the Board of Directors of the Company adopted at a meeting duly called and held on the 6th day of December 2011,of which the following is a true excerpt: RESOLVED 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,contracts of indemnity and other writings obligatory in the nature thereof, and such signature and seal when so used shall have the same force and effect as though manually affixed. . IN WITNESS WHEREOF,THE GUARANTEE COMPANY OF NORTH AMERICA USA has caused this instrument to be signed and its corporate seal to be affixed by its authorized officer,this 23rd day of February,2012. THE GUARANTEE COMPANY OF NORTH AMERICA USA STATE OF MICHIGAN Stephen C.Ruschak,Sr.Vice President,COO Randall Musselman,Secretary County of Oakland On this 23rd day of February,2012 before me came the individuals who executed the preceding instrument,to me personally known, and being by me duly sworn,said that each is the herein described and authorized officer of The Guarantee Company of North America USA;that the seal affixed to said instrument is the Corporate Seal of said Company;that the Corporate Seal and each signature were duly affixed by order of the Board of Directors of Cynthia A. Takai IN WITNESS WHEREOF,I have hereunto set my hand at The Guarantee Notary Public,State of Michigan Company of North America USA offices the day and year above written. County of Oakland My Commission Expires February 27,2018 l J TL fxa Acting in Oakland County I,Randall Musselman,Secretary of THE GUARANTEE COMPANY OF NORTH AMERICA USA,do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney executed by THE GUARANTEE COMPANY OF NORTH AMERICA USA,which is still in full force and effect. 0�,G IN WITNESS WHEREOF,I have thereunto set my hand and attached the seal of said Company this 12th day of May ,2014 Randall Musselman,Secretary CONTRACTOR'S LICENSE DECLARATION (Business and Professions Code Section 7028.15) 1. BIDDER'S Contractor's License Number is: YW9Class No.: 2. The expiration date of BIDDER'S Contractor License is: SPI#1 r ,:V m 20 /y. 3. BIDDER acknowledges that Section 7028.15(e)of the Business and Professions Code provides as follows: "A licensed contractor shall not submit a bid to a public agency unless his or her contractor's license number appears clearly on the bid,the license expiration date is stated, and the bid contains a statement that representations herein are made under penalty of perjury. Any bid not containing this information, or a bid containing information which is subsequently proven false, shall be considered non-responsive and shall be rejected by the public agency." The undersigned declares,under penalty of perjury,that the representations made by the undersigned in this bid proposal are true and correct. Executed on r�QJU f�0/K,at T (insert City and State where Declaration signed)„ ..: ........................_.............. _ w.. t,ure 416 t9l�he Typ d Name 5al*4-ryl Title Company Name I-C-7 NON-COLLUSION AFFIDAVIT TO BE EXECUTED BY BIDDER AND SUBMITTED WITH BID State of California ) ss. County of ) "le ,being first duly sworn, deposes and say that he or she is i' of l the party making the foregoing bid that the bid is not made in the interest of,or on behalf of,any undisclosed person,partnership,company,association,organization,or corporation;that the bid is genuine and not collusive or sham;that the BIDDER has not directly or indirectly induced or solicited any other BIDDER to put in a false or sham bid, and has not directly or indirectly colluded,conspired,connived,or agreed with any BIDDER or anyone else to put in a sham bid, or that anyone shall refrain from bidding;that the BIDDER has not in any manner, directly or indirectly,sought by agreement,communication, or conference with anyone to fix the bid price of the BIDDER or any other BIDDER,or to fix any overhead,profit,or cost element of the bid price, or of that of any other BIDDER, or to secure any advantage against the public body awarding the contract of anyone interested in the proposed contract;that all statements contained in the bid are true;and further,that the bidder has not,directly or indirectly,submitted his or her bid price or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, or paid, and will not pay, any fee to any corporation, partnership, company association, organization, bid depository, or to any member or agent thereof to effectuate a collusive or sham bid. �f��r%�h , r�o�xt��c. SLK,iture Name of Bidder/Company Name Typed Name Date Title I-C-8 WORKER'S COMPENSATION CERTIFICATION Section 1861 OF THE LABOR CODE (Workers' Compensation) Pursuant to Section 1861 of the Labor Code,the BIDDER, in submitting his/her PROPOSAL, shall sign the following certification: "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." cs of Signature of Bidder: - _.............. Title: le M2*—----- Business Name„ Business Address: A7 ,V4 Telephone Number: 70/ 7�,��•��0 Dated this A9 day of /'� , 20 I-C-9 DESIGNATION OF SUBCONTRACTORS 2013-2014 FURNISHING AND APPLICATION SLURRY SEAL ON VARIOUS STREETS PROJECT NO.: PW 13--1155 Aerl;vo Company Name: /�.yIn�, G)A, Zhe. BIDDER will perform the majority of the work and proposes to subcontract certain portions of the work which are in excess of one-half of one percent (1/2 of 1%) of the bid and to procure materials and equipment from suppliers and vendors as follows: Description of Name of portion of Work Estimated Subcontractor Address Subcontracted $Amount X ke S (Number and Street) * r (City,Zip Code) r°k` � 1/5 tg _..................._— .—...—........................................._...............n................. _. .............. .—._......................................................._.................................................................. I—C-10 REFERENCES Company Name: �f1�°1^/lt?h /!`1/�NQ�r �CJ -Tfr The following are the names, addresses, and telephone numbers for public agencies for which BIDDER has performed similar work as the prime contractor or major subcontractor within the past five (5) years: - I„ Project Title: See 1176C� Li,3T/ Location: Name and address of owner Name and current telephone number of person familiar with project Type of Work„ Contract amount:$ ......._. ................................................... Date completed: Amount of work done by my/our firm under contract$ _ Did your firm have any financial interest in Project? 2„ Project Title: Location: Name and address of owner Name and current telephone number of person familiar with project Type of Work: Contract amount:$ Date completed: Amount of work done by my/our firm under contract$ ..._._ITITITIT_..._._......mmmmmmmmmmmmmmmmmmmmmmm Did your firm have any financial interest in Project?............ I-C-11 G !L! 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Project Title: Location: Name and address of owner Name and current telephone number of person familiar with project: Type of Work: Contract amount:$ ITmm mmmmmmmm mmmmmmmmmmmmmmmm mmmmmmIT Date completed: �mmmmmmmmmmmmm Amount of work done by my/our firm under contract$ Did your firm have any financial interest in Project?mITITITIT mmm 5. Project Title: Location: Name and address of owner I-C-12 Name and current telephone number of person familiar with project: Type of Work: Contract amount: Date completed: Amotint of"work done by rny/ottr firm under contract Did your firm have any financial interest in Bidder may altach additional rqfe)-ence Pa ges i J'Ileces.valy. 'ne following are the names,addresses,and telephone mirnbers For all brokers and sureties from wliorn BIDDER intend's to procure insurance bonds: gee Waded Zl:rl ............... ................................................. ........................................ .................................................................................. .......................................................................................... ..................................................................... I-C-13 BROKERS & SURETIES FROM WHOM THE BIDDER INTENDS TO PROCURE INSURANCE AND BONDS BONDING AGENT: INTERWEST INSURANCE SERVICES, INC. 1357 E. LASSEN AVENUE CHICO, CA 95973 (530)897-3154 SURETY COMPANY: GUARANTEE COMPANY OF NORTH AMERIC, USA ONE TIME SQUARE, SUITE 1470 SOUTHFIELD, MI 48076 (248)281-0281 INSURANCE AGENT: INTERWEST INSURANCE SERVICES, INC. 368 E.YOSEMITE AVENUE, SUITE 100 MERCED, CA 95340 (209)724-2324 BIDDER'S STATEMENT OF PAST CONTRACT DISQUALIFICATIONS 2013-2014 FURNISHING AND APPLICATION OF SLURRY SEAL ON VARIOUS STREETS PROJECT NO.: PW 13-15 Company Name: A/VrizqM ?JIagll.iyoll Please state all instances of being disqualified, removed, or otherwise prevented from bidding on, or completing, a federal, state, or local government project due to a violation of a law or safety regulation. I. Have you ever been disqualified from any government contract? Yes ❑ No X 2. If yes, explain the circumstances: AlIle y me (Please Print) I-C-14 INSURANCE REQUIREMENTS [MUST BE SUBMITTED WITH PROJECT PROPOSAL] 2013-2014 FURNISHING AND APPLICATION OF SLURRY SEAL ON VARIOUS STREETS, PROJECT NO.: PW 13-15 Company Name: To be awarded this contract, the successful bidder must procure and maintain the following types of insurance with coverage limits complying, at a minimum,with the limits set forth below: Type of Insurance Limits Commercial general liability: $2,000,000 Business automobile liability: $1,000,000 Workers compensation: Statutory requirement Commercial general liability insurance must meet or exceed the requirements of ISO-CGL Form No.CG 00 01 11 85 or 88. The amount of insurance set forth above must be a combined single limit per occurrence for bodily injury, personal injury, and property damage for the policy coverage. Liability policies must be endorsed to name the City, its officials,and employees as "additional insureds"under said insurance coverage and to state that such insurance will be deemed"primary"such that any other insurance that may be carried by the City will be excess thereto. Such endorsement must be reflected on ISO Form No. CG 20 10 1185 or 88, or equivalent. Such insurance must be on an"occurrence,"not a "claims made,"basis and will not be cancelable or subject to reduction except upon thirty(30)days prior written notice to the City. Insurer will agree in writing to waive all rights of subrogation against the City, its officers, officials, employees and volunteers for losses arising from work performed by Contractor for the City. Automobile coverage must be written on ISO Business Auto Coverage Form CA 00 01 06 92,including symbol 1 (Any Auto). The Consultant must furnish to the City duly authenticated Certificates of Insurance evidencing maintenance of the insurance required under this Agreement,endorsements as required herein,and such other evidence of insurance or copies of policies as may be reasonably required by the City from time to time. Insurance must be placed with admitted insurers with a current A.M. Best Company Rating equivalent to at least a Rating of"A:VII." Certificate(s)must reflect that the insurer will provide thirty (30)day notice of any cancellation of coverage. The Consultant will require its insurer to modify such certificates to delete any exculpatory wording stating that failure of the insurer to mail written notice of cancellation imposes no obligation, and to delete the word "endeavor" with regard to any notice provisions. The City requires California Worker's Compensation Coverage with the associated Waiver. Out-of-state coverage will not be accepted in lieu of the California coverage,because the work is being performed in the State of California. By signing this form, the bidder certifies that it has read, understands, and will comply with these insurance requirements if it is selected as the City's consultant. Failure to provide this insurance will render the bidder's proposal "nonresponsive." Date B *er/'s S1 flatyure I-C-15 END PROPOSAL SECTION I-C-16