2City of South Miami
PUBLIC WORKS & ENGINEERING DEPARTMENT
4795 SW 75 th Avenue
Miami, FL 33155
Tel. (305) 663-6350 Fax (305) 668-7208
TO: Steven Alexander, City Manager
FROM: Jorge L. Vera, Capital Improvement Project Manager
DATE: June 18, 2013
South Miami
,tAd
AU-America Gl ;
1111J.
2001
Resolution: A Resolution authorizing the City Manager to enter into a contract with Bejar
Construction Inc. for a contract price not to exceed $90,000 for the Dante Fascell Park
Jogging Trail, to be charged to Capital Improvement Program Fund account number
301-2000-572-6450.
Background: The City Commission wishes to upgrade the amenities that are in the Dante Fascell
Park. Part of the upgrade is to construct a pour in place jogging trail inside the park.
The trail is to allow the residents a comfortable and safe area to exercise while
enjoying the outdoors.
The City received bids from qualified for proposals to perform the side walk repair
work. The proposals received are shown below:
ABC Construction
Bejar Construction, Inc.
Cityworks Construction LLC
Maggolc, Inc
Metro Express Inc
Play Space Services,lnc
Sanchez Arango
V Engineering & Consulting Corp
$195,000.00
$ 84,450.00
$ 99,622.88
$148,000.00
$147,300.00
$125,172.90
$162,900.00
$115,300.00
After an evaluative process and reference check of the respective proposals, it was
determined that Bejar Construction Inc. was the lowest most responsive and
responsible bidder; and
Due to the nature of the work, there may be unknown factors that may arise. To
account for this a contingency over the contract amount of $5,550 is requested. The
contract amount, including contingency, shall not exceed $90,000.
Expense : Contract amount is not to exceed $84,450 with a contingency amount of $5,550 for a
total amount not to exceed $90,000.
Account: The expenditure is charged to Capital Improvement account number 301-
2000-572-6450, which has a balance of $100,000 before this request was
made.
Attachments: Proposed Resolution
Bid Opening report
Sunbiz corporation report
Bid solicitation in drop box
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RESOLUTION NO .: _____ _
A Resolution authorizing the City Manager to enter into a contract with Bejar
Construction Inc. for a contract price not to exceed $90,000 for the Dante Fascell
Park Jogging Trail, to be charged to Capital Improvement Program Fund account
number 301-2000-572-6450.
WHEREAS, the Mayor and City Commission wishes to install a poured in place jogging trail at
Dante Fascell Park; and
WHEREAS, through a competitive bidding process, the City published RFP # PR-DS2013-01;
and
WHEREAS, the City received a total of 8 bids listed below from qualified for contractors to
perform the construction of the jogging trail; and.
ABC Construction
Bejar Construction, Inc.
Cityworks Construction LLC
Maggolc, Inc
Metro Express Inc
Play Space Services,lnc
Sanchez Arango
V Engineering & Consulting Corp
$195,000.00
$ 84,450.00
$ 99 ,622.88
$148,000.00
$147,300.00
$125,172.90
$162,900.00
$115,300.00
WHEREAS, pursuant to a evaluative process, it was determined that Bejar Construction Inc.
submitted a proposal in the amount of $84,450 that was the lowest most responsive and responsible
bidder; and
WHEREAS, the City desires to provide a contingency over the proposal amount of $5,550 for
unknown factors that may arise during the work; and
WHEREAS, the Mayor and City Commission desire to authorize the City Manager to enter into a
contract with Bejar Construction Inc. for the Dante Fascell Park Jogging Trail Project for an total amount
including contingency not to exceed $90,000.
NOW, THEREFORE, BE IT RESOLVED BY THE MAYOR AND CITY COMMISSION OF THE
CITY OF SOUTH MIAMI, FLORIDA THAT:
Section 1: The City Manager is authorized to enter into a contract with Bejar Construction Inc.
for the Dante Fascell Park Jogging Trail for total amount including contingency not to exceed $90,000.
Section 2: The expenditure shall be charged to the Capital Improvement Program Fund
account number 301-2000-572-6450 which has a balance of $100,000 before this
request was made .
Section 3: If any section clause, sentence, or phrase of this resolution is for any reason held
invalid or unconstitutional by a court of competent jurisdiction, the holding shall not affect the validity of
the remaining portions of this resolution.
Section 3. This resolution shall take effect immediately upon adoption .
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PASSED AND ADOPTED this ___ day of ______ , 2013.
ATTEST: APPROVED:
CITY CLERK MAYOR
READ AND APPROVED AS TO FORM COMMISSION VOTE:
LANGUAGE, LEGALITY AND EXECUTION
Mayor Stoddard
THEREOF Vice Mayor Liebman
Commissioner Newman
Commissioner Harris
CITY ATTORNEY Commissioner Welsh
• • • • •
BID OPENING REPORT
Bid ~Iftcl': 1 0:00am
F or: 1
COMPANIES THAT SUBMITTED PROPOSALS: AMOUNT:
l. ABC CONSTRUCTION I 0;5 ,()jJ. (jJ
2. BEJAR CONSTRUCTION INC. J:b 1j<"I, t:tSO. OD
3. CITYWORKS CONSTRUCTION LLC -tb ~ I (g.;p.~~_
4. MAGGOLC, INC . ~ 1 L/y /000.00
5. METRO EXPRESS INC. Ji j L{-] ~OO. DO
6. PLAY SPACE SERVICES , INC. .4l ~ I l~ .CjO
7. SANCHEZ ARANGO Ji fLo :) .:i.ij). tJJ
8. V ENGINEERING & CONSULTING CORP. $L/ ~ I 22fYJ. 00
TH.E ABOVE BIDS HAVE NOT BEEN CHECKED.
c::::::~ :I&~~:T ;,:;E:ION AFfER THE BIDS HA4.V~E , :OMPLETELY REVIEWED,
Witness: e i--L -e ....... f~
Print Name I ) f --, 'j g~-
Witness: -:Ja/;1711)~.b?r;t(/ . ~ ___ _
llrint Nume /sigJ1lItIJTe -
lJetail by Entlty Name .. Page 1 or j
FLORIDA DEPARTMENT OF S1'A1']~ ~ -->~\ ,. .... ~~~ ~::~r~. ~ j
~.. " ~. -i ,-/. .. E!I ~ .... \.:, \!~.;, .: . ·7 .. ··~~··
DIVISION OF CORPORATIO~S :funb!$. ..:. r. "iJ·; ~""';' ·:·£,i;i~· " J .. . '. . ,., . ,
~ \: ',~:'; " '., '.\.... .'J ~2!--~: .. [.' J •
.-;.;:'~:<' . ,'. . .
Detail by Entity Name
Florida Profit Corporation
BEJAR CONSTRUCTION, INC.
Filing Information
Document Number P98000066671
FEI/EIN Number 650860667
Date Filed 07/27/1998
State or Country FL
Status ACTIVE
Last Event CANCEL ADM DISS/REV
Event Date Filed 01/24/2005
Event Effective Date NONE
Princioal Address
~326 S.W. 191 AVENUE
PEMBROKE PINES, FL 33332
Changed: 01/24/2005
MailinQ Address
~326 S.W. 191 AVENUE
PEMBROKE PINES, FL 33332
Changed: 01/24/2005
Registered Agent Name & Address
BEJAR, BENNY B
~326 SW 191 AVE
PEMBROKE PINES, FL 33332
Address Changed: 01/08/2007
Officer/Director Detail
Name & Address
Title 0
BEJAR, BENNY B
6326 SW 191 AVE
PEMBROKE PINES, FL 33332
Annual Reoorts
http://search.sunbiz.org/lnquiry /CorporationSearch/SearchResultDetaillEntity N ame/domp-p... 6/7/2013
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SECTION 4
BIDDER'S REPRESENTATION
Proposal of J3!.5J!H< CD !"-I..rrn vCr/oJ Z~c..
(Name)
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632.1::. .s;. W/ ICf I A..JE I f>E.fY1rSl"tt.YlL.£ pn·.Jf;S Fl-o ru~ A S3 :nC
(Address)
to furnish all materials, equipment, and labor and to perform all work in accordance with the Contract
Documents for:
"DANTE FASCEll PARK (PIP) JOGGING TRAil PROJECT"
(''THE PROJECT")
TO: CITY OF SOUTH MIAMI
Attn: City Clerk
6139 Sunset Drive
South Miami, Florida 33143
The undersigned, as Bidder, hereby declares that the only person or persons interested in the Bid, as
principal or principals, is or are named herein and that no other person than herein mentioned has any
interests in the Bid of the Agreement to which the Work pertains; that this Bid is made without connection
or arrangement with any other person, company, or parties making Bids or Proposals and that the Bid is In
all respects fair and made in good faith without collusion or fraud.
The Bidder further declares that he or she has examined the geographic location and sites of the Work;
that he has made sufficient investigations to fully satisfy himself that such sites are suitable for this Work;
and he assumes full responsibility therefore; that he has examined the specifications for the Work and
from his own experience or from professional advice that the specifications are sufficient for the Work to
be done and he has examined the other Contract Documents relating thereto, including the Instructions to
Bidders, the Agreement, Bid, Detailed Scope of Work/Specifications, Qualification Statement, Public Entity
Crime Form, and Insurance requirements and he has read all addenda prior to the opening of Bids, and
that he has satisfied himself fully, relative to all matters and conditions with respect to the Work to which
this Bid pertains.
The Bidder proposes and agrees, if this Bid is accepted, to timely execute the Agreement with the City in
the form attached and to furnish all necessary materials, all equipment, all necessary machinery, tools,
apparatus, means of transportation, and labor necessary to complete the Work specified in the Bid and the
Agreement, and called for by the specifications and in the manner specified and to timely submit all
required bonds and insurance certificates.
NOTE; THIS SCHEDULE OF BID ITEMS IS MERELY ILLUSTRATIVE OF THE MINIMUM AMOUNT/QUANTITY
OF WORK TO BE PERFORMED UNDER THE CONTRACT. IN THE CASE OF ANY CONFLICT BETWEEN THIS
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SCHEDULE OF SID ITEMS AND THE DETAILED SPECIFICATIONS, THE DETAILED SPECIFICATIONS WILL
PREVAIL
The Bidder further proposes and agrees to comply in all respects with the time limits for
commencement and completion ofthe Work as stated in the Agreement.
The Bidder agrees to execute the Agreement and furnish the executed Agreement, all required
bonds, insurance certificates, and other required information to City within ten (10) ten calendar
days after written notice of the Award of contract. Failure on the part of the Bidder to timely
comply with this provision shall give City all rights and remedies set forth in the Instructions to
Bidders.
The undersigned agrees to accept as full compensation therefore the total of the lump sum
prices and extended unit prices items named in the following schedule. It is understood that the
unit prices quoted or established for a particular item are to be used for computing the amount
to be paid to the Contractor, based on the Work actually performed as determined by the
Agreement and the City. However, in utilizing the schedule, the Bidder agrees that in no event
shall compensation paid to the Bidder under the Agreement exceed the dollar amount of the
Bidder's Bid amount, as set forth in the attached Bid.
It is intended that all Work to be performed under this Bid shall commence apprOXimately thirty
(30) days after Agreement execution .
In no event shall City be obligated to pay for Work not performed or materials not furnished.
Bidder's Certificate of Competency No. (! ~.o v'9 7 J {
Bidder's Occupational license No . _____________ _
[SEAL]
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BID FORM
The following is a Lump Sum Bid Proposal is presented to the City. The Bid Amounts includes all items
described in the Bid Documents (Detailed Specifications). Upon receiving a Notice of Award contractor
shall submit a detail schedule of Values. Payment shall be made on the basis of Work actually performed
and completed.
The Base Bid Amount includes all material and labor for the construction of the project entitled "DANTE
FASCELL PARK (PIP) JOGGING TRAIL PROJECT."
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LUMP SUM BASE BID AMOUNT $. __ 8_'-h~)~W-O __ . __________ _
LUMP SUM BASE BID AMOUNT (IN WORDS) t=: I tS \-\-It-l Fo"""'" ~v .t b.,...J~
Taxpayer Identification Number:
(Printed Name and Title)
(Company Address)
(Company Phone Number)
[END OF SECTION]
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SECTION 6
SPECIFICATIONS/SCOPE OF WORK
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Contractor shall provide all labor, parts, materials, and equipment necessary for the installation of EPDM/Poured-
in-Place (PIP) playground surface/ jogging trail at the City of South Miami's Dante Fascell Park. (Refer to Exhibit
#1 "Aerial View, Dante Fascell Park." The Exhibit depicts the suggested route and placement of the jogging
trail.
1. Material and Workmanship
• Material and workmanship shall comply with the following:
• Performance requirements for impact attenuation and Head Injury Criteria as per U.S. Consumer
Product Safety Commission.
• Adjust thickness to meet varying critical fall heights within the repair areas ofthe jogging trail.
Minimum 1/2" to maximum 5/8" as per line items.
• Surface shall consist of two layers. The base coat is recycled tire 100% wire free and a minimum of
1/2" EPDM rubber installed on compacted crusted stone, concrete or asphalt. Color mixture of
the fPDM wear cap shall be 50% Standard color/ 50% Black.
• Mix proportions by weight -
o Basemat 14% polyurethane 86% rubber.
o Top Surface 18% polyurethane, 82% rubber.
2. Dimensions of Jogging Trail
Note: Dimensions are appro)(l mat e and are provi ded for pl anning p urposes on l y and , sho uld not be
considered as a firm commitment. Contractor shall be responsible for exact measurements.
The jogging trail shall, at a minimum, consist of 2/1 thick PIP rubber material and, is approximately 1,375 ft
long and 6' wide.
Contractor shall be responsible to:
• Clear and grub area for the jogging trail.
• Grade and compact subgrade to allow for the installation of 4" of limerock.
• Install 4/J limerock base and compact as required.
• Install 2" thick rubber surface.
Upon completion of the project, a final inspection shall be made by the Contract Administrator or a City
designee.
3. COMPLIANCE WITH FEDERAL, STATE AND LOCAL LAWS AND CODES
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Contractor must strictly comply with Federal, State and local building safety codes. Must meet all State
and Federal safety regulations. Certified Test Data that's safety Surfacing meets or exceeds the following:
A. American Society for Testing and Materials (ASTM):
ASTM-F1292 Standards-Method for Testing various surfacing materials to determine their
"critical height" (the fall height below which a life threatening head injury would not be expected
to occur). Copies may be obtained from:
American Society for Testing Materials
100 Barr Harbor Drive
West Conshohocken, PA 19428
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B. Consumer Product Safety Commission (CPSe) -Printed Handbook for Public Playground Safety (Latest
edition). Copies may be obtained from:
US Consumer Product Safety Commission
4330 East West Highway
Bethesda, MD 20814
(301) 504-4973
C. National Playground Safety Institute (NPSI)-identification of 12 leading causes of injuries on
playgrounds. Copies may be obtained from:
National Recreation and Park Association
22377 Belmont Ridge Road
Ashburn, VA 20148-4150
D. Current Americans with Disabilities Act Guidelines (ADAG). Contractors certify that all products
(materials, equipment, processes, age appropriate signage, or other items supplied in response to this
bid) contained in its bid meet all Federal and State reqUirements, upon completion of installation of
playground surfacing, contractor shall furnish the City of South Miami a certificate so stating the surfacing
and its installation meet Federal and State requirements as outlined in the publications.
4. CLEAN-UP
Contractor shall:
A. Be responsible for protection of finished surfaces until completion of construction and sign off.
B. Not leave adhesive on adjacent surface or play equipment. Spills of excess adhesive shall be
promptly cleaned.
C. Properly dispose of all material and packing waste before leaving the job site.
D. Be responsible for supplying a dumpster at job site for all waste associated with installation of the
safety surface.
All removal and disposal fees are to be included as part of the rate per square foot as bid.
[END OF SECTION]
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STATE Or-FLORIDA
COUNTY OF MIAMI-DADE
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SECTION 9
ANTI-KICKBACK AFFIDAVIT
I, the undersigned, hereby duly sworn, depose and say that no portion of the s~ herein bid will be paid
to any employees of the CITY OF SOUTH MIAMI, its elected officials, and J3~n. (J:zl"I.I~..rT'O":; or
its design consultants, as a commission, kickback, reward or gift, directly or indirectly by me or any member of my
firm or by an officer of the corporation. c. -~ ~ ---1
By : co) c~~ --.I
SW;t and subscribed before this
~a vo J~7 .2013 ilJ..,--.&~
NO~ Public, State of F,'orlda C y
-!ir)r')r/Mr It:_" la~-<--,
(Printed Name)
My commission expires: ____ ~-+I_?-_·_'3:._+/--xr;---.:~'1
Title: 1?t';:..r \ ~.....t ~
-----
,~;.\::.'~~:;II' ANN MARIE E CLARICE f~~<;:''''~ Notlry Public • Slat, of Florida
~. '! .My Comm. E~I .r .. Feb ~3, 2017 t
~ W Commllslon ., EE 170470
"""w;r.\{\"-Bondfd Through National HoI~IY Ann.
[END OF SECTION]
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State of }
} 55:
County of }
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SECTION 10
NON-COLLUSIVE AFFIDAVIT
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__ ....IrS.", . .o!....1---"-t-L_jj_---.J1'---..:..rS.=,:t:=-· ~~_:t... _______ being first duly sworn, deposes and says that:
a) H~she is the OL0>-1 <;;. f"'-, (Owner, Partner, Officer, Representative or
Agent) ~i%ft>0 COI-U-r-r..x''T'"''U t..? ,:z:::-...... c... « the Bidder that has submitted the attached Proposal;
b) He/she is fully informed respecting the preparation and contents of the attached Proposal and of all
pertinent circumstances respecting such Proposal;
c) Such Proposal is genuine and is not collusive or a sham Proposal;
d) Neither the said Bidder nor any of its officers, partners, owners, agents, representatives, employees or
parties in interest, including this affiant, have in any way colluded, conspired, connived or agreed, directly or
indirectly, with any other Bidder, firm, or person to submit a collusive or sham Proposal in connection with the
Work for which the attached Proposal has been submitted; or to refrain from proposing in connection with
such work; or have in any manner, directly or indirectly, sought by person to fix the price or prices in the
attached Proposal or of any other Bidder, or to fix any overhead, profit, or cost elements of the Proposal price
or the Proposal price of any other Bidder, or to secure through any collusion, conspiracy, connivance, or
unlawful agreement any advantage against (Recipient), or any person interested in the proposed work;
e) The price or prices quoted in the attached Proposal are fair and proper and are not tainted by any
collUSion, conspiracy, connivance, or unlawful agreement on the part of the Bidder or any other of its agents,
representatives, owners, employees or parties in interest, including this affiant.
Signed, sealed and delivered
~~
Witness
5tateof 1l~)
IZ 1 ~:
Countyof ~
(Printed Name)
?~S'~<;;::U7 -~
(Title)
BEFORE ME, the undersigned authority, personally appeared to me
well known and known by me to be the p -on described I ein and who exec goin g Affidavit and
acknowledged to and before me that xecute said Affidavit for the purpose
therein expressed.
I'lt WITN ESS , my hand and official seal this -'J-day of _-'---l...:=':;I--" 2013.
I ~ ';)-~/?-iJ--; 7 • • « «
ANNMARIE E CLARKE
• 1;~ Notary Public, 51.Ie III FloriQa
[END OF SECTION]
{. : : • ~ MV Comm , E~plrea Feb ~3, 2Q 17
~~ ~~i Commlulon , EE 87QA70
';r"W.I.ft"" Bondtd ThrOll9h Natlon.1 Holtry Au n.
Notary Public State of Florid a at Large
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SECTION 11
SWORN STATEMENT ON PUBLIC ENTITY CRIMES
SECTION 287.133(3)(a), FLORIDA STATUTES
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL
AUTHORIZED TO ADMINISTER OATHS.
1. This sworn statement is submitted to the CITY OF SOUTH MIAMI
by ____ ~~~~~~ __ ~-I~~~I~~~~~· ~I~-"~~~~~-~~~·,-~~-,-~-----------------
[print individual's name and title)
for ______ 0(~r~_~~" ____ (2_·._D_~_J_r_~ __ J_C_'T1 __ c_0 __ -r_.~_-_.~ __ Q __________________ _
[print name of entity submitting sworn statement]
whose business address is
and (if applicable) its Federal Employer Identification Number (FEIN) is c.,V-"" -a 8 b iJ €:. ~ '1
(If the entity has no FEIN, include the Social Security Number of the individual
sign ing this sworn statement: _____________________________ _
2. I understand that a "public entity crime" as defined in Paragraph 287.133(1)9gl, Florida Statutes, means a
violation of any state or federal law by a person with respect to and directly related to the transaction of business
with any public entity or with an agency or political subdivision of any other state or the United States, including,
but not limited to, any bid or contract for goods and services to be provided to any public entity or an agency or
political subdivision of any other state or of the United States involving antitrust, fraud, theft, bribery, collusion,
racketeering, conspiracy, or material misrepresentation.
3. I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes,
means a finding of guilt or a conviction or a public entity crime, with or without an adjudication of gUilt, in any
federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as
a result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.
4. I understand than an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes, means:
a. A predecessor or successor of a person convicted of a public entity crime; or
b. An entity under the control of any natural person who is active in the management of the entity
and who has been convicted of a public entity crime. The term "affiliate" includes those officers,
directors, executives, partners, shareholders, employees, members, and agents who are active in
the management of an affiliate. The ownership by one person of shares constituting a controlling
interest in another person, or a pooling of equipment or income among persons when not for fair
market value under an arm's length agreement, shall be a prima facie case that one person
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controls another person. A person who knowingly enters into a joint venture with a person who
has been convicted of a public entity crime in Florida during the preceding 36 months shall be
considered an affiliate.
5. I understand that a "person" as defined in Paragraph 287.133(1)(ej, Florida Statutes, means any natural
person or entity organized under the laws of any state or of the United States with the legal power to enter into a
binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public
entity, or which otherwise transacts or applies to transact business with a public entity. The term "person"
includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are
active in the management of an entity.
6, Based on information and belief, the statement that I have marked below is true in relation to the entity
submitting thJlsworn statement. (Indicate which statement applies.]
f
.,/ ~ Neither the entity submitting this sworn statement, nor any officers, directors, executives, partners,
shareholders, employees, members, or agents who are active in the management of the entity, not any affiliate of
the entity, has been charged with and convicted of a public entity crime subsequent to July 1, 1989.
__ This entity submitting this sworn statement, or one or more of its officers, directors, executives,
partners, shareholders, employees, members, or agents who are active in the management of the entity, or an
affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989.
__ The entity submitting this sworn statement, or one or more of its officers, directors, executives,
partners, shareholders, employees, members, or agents who are active in the management of the entity, or an
affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989.
However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of
Administrative Hearings and the Final Order entered by the Hearing Officer determined that it was not in the
public interest to place the entity submitting this sworn statement on the convicted vendor list. [attach a copy of
the final order]
I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY
IDENTIFIED IN PARAGRAPH 1 ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID
THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND HAT I AM
REQUIRED TO INFORM THE PUBLIC ENTITY PRJ~ G NTER~NG I TO A CONTRACT IN EXCESS OF THE ..-'" THRESHOLD AMOUNT PROVIDED IN SECT l eN 287 .0 1 /FLOR I DA S TUTES, FOR CATEGORY TWO OF ANY
CHANGE IN THE INFORMATION CONTAIN ED IN THIS FOR
.. -
ffl-ignature of Ent'l , s6bmlttl!1_ Swo rn Statement
Sworn to and subscribed before me this K day of ¥ 2013.
\ \
Personally known ____________________ ---,,.--__
:f!~~ OR produced identification Notary Publfc -State of
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My commission expires -=>-/J->j?--lJ1 '1'
(type of identification) J I -!knrn 4o ~ C /a..J<e--
(Printed, typed or stamped Commissioned Name Notary Public)
_"II,,, ANNMARIE E CLARKE
' .... ~~~~'., J'IJ¥,~<-Nolary PubliC ' State 01 Florida f:: ": .§ My Comm. e_plfes Feb 23. 2017
~'" '3; Commlaslon II Ee 170470
'(1 d>;>'$ AI ',:r"r..:,ti\'" Iondecf ltllough INllOnai HoI.,y ,It
[END OF SECTION]
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SECTION 16
RElATED PARTY TRANSACTION VERIFICATION FORM
~~ , individually and on behalf of
CJ J-l.frr"'1--JC'r"'O 0 ::-C:.t-.l~ ("Firm")
have read the City of South Miami ("City")'s Code of Ethics, Section 8A-l of the City's Code of Ordinances and I
hereby certify, under penalty of perjury that to the best of my knowledge, information and belief:
..
(1) neither I nor the Firm have any conflict of interest (as defined in section 8A-i) with regard to the contract or
business that I, and/or the Firm, am(are) about to perform for, or to transact with, the City, and
(2) neither I nor any employees, officers, directors of the Firm, nor anyone who has a financial interest greater
than 5% in the Finn, has any relative{s), as defined in section SA-I, who is an employee of the City or who is(are)
an appointed or elected official of the City, or who is(are) a member of any public body created by the City
Commission, i.e., a board or committee of the City, and
(3) neither I nor the Firm, nor anyone who has a financial interest greater than 5% in the Firm, nor any member of
those persons' immediate family (i.e., spouse, parents, children, brothers and sisters) has transacted or entered
into any contract(s) with the City or has a financial interest, direct or indirect, in any business being transacted
with the city, or with any person or agency acting for the city, other than as follows:
___________________ (use a separate sheet to supply additional information that will
not fit on this line but make reference to the additional sheet which must be Signed under oath).
(4) no elected and/or appointed official or employee of the City of Miami, or any of their immediate family
members (i.e., spouse, parents, children, brothers and sisters) has a financially interest, directly or indirectly, in
the contract between you and/or your Firm and the City other than the follOWing individuals whose interest is set
forth following their names: _____________________ _
___________________ (use a separate sheet to supply additional information that will
not fit on this line but make reference to the additional sheet which must be signed under oath). The names of all
City employees and that of all elected and/or appointed city officials or board members, who own, directly or
indirectly, an interest of five percent (5%) or more of the total assets of capital stock in the firm are as follows:
_____________ (use a separate sheet to supply additional information that will not fit on this
line but make reference to the additional sheet which must be signed under oath).
(5) I and the Firm further agree not to use or attempt to use any knowledge, property or resource which may
come to us through our position of trust, or through our performance of our duties under the terms of the
contract with the City, to secure a special privilege, benefit, or exemption for ourselves, or others . We agree that
we may not disclose or use information, not available to members of the general public, for our
personal gain or benefit or for the personal gain or benefit of any other person or business entity, outside of the
normal gain or benefit anticipated through the performance of the contract.
(6) I and the Firm hereby acknowledge that we have not contracted or transacted any business with the City or
any person or agency acting for the City, and that we have not appeared in representation of any third party
before any board, commission or agency of the City within the past two years other than as
foll o w s: (u se a separate sheet to supply additional information that will not fit
on this line but make reference to the additional sheet which must be signed under oath). Neither I nor any
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employees, officers, or directors of the Firm, nor any of their immediate family (Le ., as a spouse, son, daughter,
parent, brother or sister) is related by blood Of marriage to: (i) any member of the City Commission; (ii) any city
employee; or (iii) any member of any board or agency of the City other than as follows:
_____________ (use a separate sheet to supply additional information that will not fit on this
line but make reference to the additional sheet which must be signed under oath}.
(7) No Other Firm, nor any officers or directors of that Other Firm or anyone who has a financial
interest greater than 5% in that Other Firm, nor any member of those persons' immediate family (i.e., spouse,
parents, children, broth ers and sisters) nor any of my immediate family members (hereinafter referred to as
"Related Parties") has responded to a solicitation by the City in which 1 or the Firm that I represent or anyone who
has a financial interest greater than 5% in the Firm, or any member of those persons' immediate family (Le.
spouse, parents, children, brothers and sisters) have also responded, other than the following :
______________ (use a separate sheet to supply additional information that will not fit on
this line but make reference to the additional sheet which must be signed under oath).
(8) I and the Firm agree that we are obligated to supplement this Verification Form and inform the City of any
change in circumstances that would change our answers to this document. Specifically, after the opening of any
responses to a soliCitation, I and the Firm have an obligation to supplement this Verification Form with the name
of all Related Parties who have also responded to the same solicitation and to disclose the relationship of those
parties to me and the Firm.
(9) A violation of the City's Ethics Code, the giving of any false information or the failure to supplement this
Verification Form, may subject me or the Firm to immediate termination of any agreement with the City, and the
imposition ofthe maximum fine and/or any penalties allowed by law. Additionally, violations may be considered
by and subject to action by the Miami-Dade County Commission on Ethics.
Under penalty of perjury, I declare that I have made a diligent effort to investigate the matters to which I am
attestin here-In a 0 -nd th at he statements made hereinabove are true and correct to the best of my
know edge , info r 'T'iatio n and bel ~ .
Date : __ ~~ ____ =-________ __
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RELATED PARTY TRANSACTION VERIFICATION FORM
We, t:S~ (Jpf-l.t-r+-J~()') ::c: .... 7 (Name of CONTRACTOR), hereby acknowledge and agree that as
CONTRACTORs for the DANTE FASCELL PARK PIP JOGGING TRAIL project as specified have the sole responsibility
for compliance with all the requirements of the Federal Occupational Safety and Health Act of 1970, and all State
and local safety and health regulations, and agree to indemnify and hold harmless the City and Consultant against
any and all liability, claims, damages, losses and expenses they may incur due to the failure of (Sub-consultant's
names):
to comply with such act or regulation.
~ ~c~ __ -
Witness
BY: _rS:->-1 =-f"5_>_ ....... _i-J __ I_f!'_c:_"'~ __ n ___ _
Name
Title
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