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Leadex Resume-Qualification Statement-Bid Forms-.:_.. mS5n116sR8ff5eu 'a�nGlWalm'/FMxtyxin�uoiniwniMl wow lo}_�:. x r $s Mvi pie a3unmu sd �i dsia . ROOM mx 98T££ rid IOMMMOfl asoos =IN ss 0£T �s T6zT fmiliioa?Ioo xaavari . •� .. a. r '��sHOa •.:'sl!'!:! :' ;; ' *T O Z ' T £ and = a48p QCT�B =� = gdvqo Io suolps�Ao=d eqa septta ' Aoteq pomwK .', as =arses s= ';: •4 •� .:.:. "�: E6LOT000O 96LCSOSZTI ZTOZ WOO 560�0�►Z80ZZ'I NOSS a2tit 8 fl a xxs O II Bum xoasa�C zos�xa assrc�AS �o �.ris�x�aga damOIZI 910 alvis 8 Z 9 0 0 E 9# Ob LEADCOR -02 LGLEASON ACC>RU' �,,,.,...^ DATE(MIMIN M 1212812012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Collinsworth, Alter, Lambert, LLC 23 Eganfuskee Street Suite 102 CONTACT Lori B. Gleason PHONE . 561 776 -9001 F AIC No):. (561 427 -6730 E -sIA1L . lgleason@calllc.com Jupiter, FL 33477 INSURER (S) AFFORDING COVERAGE NAIL d INSURERA:Association Insurance Co INSURED INSURER B: EACH OCCURRENCE INSURER C PREMISES Es occurrence Leadex Corporation INSURER D: X COMMERCIAL GENERAL LIABILITY 2601 SW 69 Court INSURER E : GLP013890300 Miami, FL 33155 INSURER F : CLAIMS -MADE 1XI OCCUR COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER IYI "DYIYI W MM Y LIMITS GENERAL UABIUTY EACH OCCURRENCE $ 1,000,00 PREMISES Es occurrence $ 100. A X COMMERCIAL GENERAL LIABILITY GLP013890300 1/112013 1/1/2014 CLAIMS -MADE 1XI OCCUR MED EXP {Any one person) $ 6100 PERSONAL 8 ADV INJURY S 1,000,0 X Contractual _ GENERAL AGGREGATE i 2,000,00 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG S 2,000,0 S POLICY X PRO- LOC _ AUTOMOBILE LIABILITY __ 0 B N SINGLE LIMIT Me accidant _ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per seddenl) S AUTOS AUTOS NON -OWNED PROPERTY $ HIRED AUTOS AUTOS Per a t UMBRELLA UAB OCCUR EACH OCCURRENCE E EXCESS LAS CLAIMS -MADE AGGREGATE S DED RETENTION $ S WORKERS COMPENSATION _ X WC STATU- 10TH- I ER AND EMPLOYERS' LIABILITY YIN A ANY PROPRIETORIPARTNER/EXECUTIVE Y / N CV013862900 1/1/2013 1/1/2014 EACH ACCIDENT S 1,000,000 OFFICERIMEMB> R EXCLUDED? NIA _El _ (Mandatory In NH) E.L. DISEASE - EA EMPLOYE S 11000,00 ISyes daudbe under DESCRIP ION OF OPERATIONS below E L. DISEASE •POLICY LIMIT E 1, 0,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Scteedule, If more apace Is mgWred) The Certificate Holder Is listed as an Additional Insured {including pr oductslcompleted operations coverage) in regards to General Liability when required by written contract Waiver of Subrogation applies in favor of the Certificate Holder for General Liability and Workers Compensation coverages when required by written contract Certificate holder is expanded to read : City of South Miami Beach CERTIFICATE HOLDER CANCELLATION South Miami, City of Building Department 6130 Sunset Drive, 2nd Floor South Miami, FL ACORD 25 (2010105) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 0) 1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD benefit or for the personal gain or benefit of any other person or business entity, outside of the normal gain or benefitanticipated 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_ agency of the City within the past two years other than as :follows: / /k C�., --- (if necessary use a separate sheet to supply additional information that will not fit on this line but make reference on the line above to the separate sheet; i.e., "see attached additional information' and make reference to this document and this paragraph onto the additional sheet which additional sheet must be signed under oath). (7) Neither I nor any 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 or 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: f-y^' jy:,,,,. --• (if necessary use aseparate sheet to supply additional information that will not fit on this line but make reference on the line above to the separate sheet,. i.e., "see attached additional information" and make reference to this document and this paragraph on to the additional sheet which additional sheet must be: signed under oath). [while the ethics code still applies, if the person executing this form is doing so on behalf of a firm whose stock is publicly traded, the statement in this section (7) shall be based solely on the signatory's personal knowledge and he /she is not required to make an independent investigation as to the relationship by blood or marriage of employees; officers, or directors of the Firm, or of any of their immediate family to any appointed or elected officials of the City; or to their immediate family members]. (8) 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, brothers 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 S% inthe Firm, .or any member of those persons' immediatefamily {i.e. spouse, parents,. children, brothers and sisters} have also responded, other than the fallowing; (if :necessary use a separate sheet to supply additional information that will not fit on this line but make reference on the line above to the separate sheet; i.e., "see attached additional information " and make reference to this document and this paragraph on to the additional sheet which additional sheet must be signed under oath), [while the ethics code still applies, if the person executing this form is doing so on behalf of affirm whose stack is publicly traded, the statement in this section (8) shall be based solely on the signatory's personal knowledge and he /she is not required to make an independent investigation into the Other Firm, or the Firm he/she represents; as to their officers, directors or anyone having a$nancial interest in those Firms or any of their any member of those persons' immediate family.) (9) 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 changeouranswers to this document: Specifically after the opening of any responses to a solicitation, 1 and the Firm havean obligation to supplement this Verification Form with the name of Fall. Related Parties who have also responded totiie samesolicitationand to disclose therelationship of those -parties to me and the Firm. (10) A violation of the City's Ethics Code, the giving of anyfalse information or the failure to supplement this "Verification Form, may subject me or the Firm to immediatetermination of anyagreementwith theCity, and the - imposition of the maximum fine and /or any penalties allowed by law. Additionally, violations may be considered by and subjecttoaction by the Miami -Dade County Commission on Etfiics. Under penaltyof perjury, I declare that I have made a diligenteffort to investigate thematters towhich I am attesting hereinabove and that thestatements madehereinabove are t ue" nd correct to thebest of my knowledge,information and belief. Print Name &Titefj` / �J"�C>r /d�J��, `��- IYS�CC7 �" i ✓?C'S a"CJ'�'` Page 35 of 72 icy Thomas f. Pepe, 5071.2013. All righCS reserved. 7!11!13/13 CUE I/I UL 'pamasas mgZll IIW £lOZ-t IOZ `�dDd'A stwogl, 0 ZL jo qg 96ed uo uid leuosiad ino joj'a!ignd Itiaua8 aga jo siagwaw oa algelltnt aou'uoptwaojul asn ao asopslp aou AM am aegi aa.ih OM 'Siagao JO'SOAlosino uoj uoladwaxa uo'ayauaq'a8apnljd punds t ainaas oi'Aalo aga ga!Maataiuoa aqa jo swiai aqi aapun salinp :ino jo aouew.lopad ino q?nougi uo '3snii jo uolalsod ino 45nou4a sn ox awoa ,few golgMaoanosai io Aauadoid'a2palmouxl Aut asn of adwa= jo asn oa aou aaaSE jagaanj wall aga put l (5) [•aaAoldwa a0 Itloyjo paaulodde jo /pue paaoala jo sjagwaw AI!wtj aatlpawwl agi ao slunWo paaulodde 'saaAoldwa Aalo jo walj aqa ul asajaiui IMMug aga 01 Se uopuSiasanul auapuadapul ue a lew oa pajlnbaj iou sl ags /aq put a3palMowl leuosiad s,,(aoatu8ls aqi uo Alabs paseq aq IIEgs (y) uolnas s!gi ul auawaimsaga 'papr is Ala!Ignd sl loots asogM way E jo jlegaq uo os Sulop sl ivaoj sign Suunaaxa uosiad aqi jl'saliddu Iles apoa sxgaa aqa alight] -(gito aapun pau8ls aq asnw aaags leuairppe galgMaaags ituopippe aqa oa uo gdw2ujed sigi put ivawnoop slg5 of aouajajaj aalEw put ;,uolatwaojul leuon!ppu pagvnit aas„ "a-i 'aaags aiEaedas aqa of anoqu aup aqa uo aouaiajai ajuw anq auy slga uo ay aou plM itga uolatwicqui (uuola!pPt Alddns oa aaags aataedas E asn Anssaaau jl) Ae< "� Pi.i"" •sMolloj sua.iE will aqa ui jl oas lui!duo jo siasn Itioa agajo ajow jo ( %S) auaojad any }o isaaaiul ut'Alaoaalpul do Apoaalp 'uMo oqM 'sjagwaw pjuoq jo sltnglo Aao paauloddE .7o /pwE paaoala Ile. jo itgi put saaAoldwa A3I] lit jo saweu agl'(qato. aapun pau8ls aq asnw aaags IEuoliippE goigMaaags Ituolpippt aga of uo gdej8ejed slgi pue ivawnoop s!qa 03 aauajajaj wltw put ,Uol2Ewjoju1 Ituoplppu pagataae aas „'•a7'aaags aataedas aqa of anogt till aqa uo aauaaajai ajew anq aup slga uo ig aou llw: aEga UORMiOjul ltuoplppt Alddns Oa aaags aatitdas t asn Anssaoau jl) :sawtu aawudas uasn alagiBuJmOpoj 4 31 01 aas sl asaiaaul asogM slenp!Mlpul "SuIMOIIOjaga uega jagao AID aqa put wa!j ano;( ao /puu noA uaaMaaq injiuoo aqa "ul ',flaaaalpul uo ApDa.ilp °asaoaaul lEloueug E seq (siaisls put saagio jq'uaapllgo'swaitd'asnods'•a•i) saagwaw Allwuj aae!Pawwl a!aga jo tut .ao 'twetW gano5 jo AID aqa jo aatoldwa do IEpwo paaulodde uo /pue paaaala ou (j') pules Twa!j aqa U1 isaaaaul Itiautuy t anEq oqM asoga jo digsuopulai aqa oa SE uopESpsanul auapuadapul uu altw oa pajinbaa aou 51 aqs /ag put aSpalMowl leuosiad s,AjoatuSls aqa uo Alalos pastq aq Iltgs "(E) uolaaas slga ul auawalms aga 'paptaa Alo!Ignd si ilooas asogM way E }o jltgaq uo as Map sr waoj slgi Eunnoaxa uosiad aga 11 'saildde pps apoosalgia aqa allgM] •(gato .aapun pau8ls aq asnw aaags (eu0ulppE 914m aaags luuolalppE aqi of uo gdui2i3nd slga put auawnaop slga oa aauaaajaa a)ltw put ,,Uo'Uwjcgw (euopippu paq=v aas,; °a'l aaags aiutdas aga 03 anogE cull aqi uo aauaiajai aytw anq awl s!ga uo ay aou 111m 31!41 uoptwjojui Ituoplppe Alddns 0a aaags aatatdas t asn Aatssaoau jl)— � :SMOIIOj St utgi jaga0 'Ailaagi jo) 2upu Aaua2e jo uosiad AUE giiM Jo 'Alp aga gaits pavtsueai Sulaq ssaulsnq tue ul'aoajlpul 30IDOa!p'isaaaiul IE}ouuug e seq Jo:A31D aga ga!M {s)ioEaauOO AuE oaut paiaiva ao paaoesue.Ii seq (sjoisisput sjagiojq "uaapllgo "sauajed'asnods -a-t) ApwEj aaElpawwl suosiad asoga jo aagwaw tuu aou 'wjiA aqa ul %s utga :iaata.i8 asaiaaul IelauEug e seg ogM auOAut .aou 'wa!j aqa aou I aagirau (E) put :[�wji j aqa ui isajaaul lelautuy EaMEq oqM asoga jo saatoldwa jo digsuopula.i aqa :oa su uoiaESnsaMwl auapuadapul ut altui oa paalnba.a aou stags /ag put aFpal,voual ltuos.iad s,boatu8ls aga uo Halos pastq aq litgs (Z) uopaas slgi ul wawaatas aga 'papEai. Aiollgnd sl jDois asogM wig t jo jltgaq to os Sulop st waoj sign 2w3noaxa uosiad aqa jl 'sallddE lilts apoo solgaa aqa allgM] '/a!:) aga jo aaaalwwoD io pjeoq t "a? 'uolssiwwo: /qD aqi tq panaao Apoq o!Ignd tut jo jagwaw E (aiu)sl oqM jo 'Alto aqa jo lElalgo paaoala j0 paaulodde ut (aat)sl 04M JO /a!D aga )o aaAOldwa ut sl oqM° I -yg uolzoas ul paugap su'(s)aAilula.i Aut seq'wulj aqa w 75 uegi aaaEaj2l isaiaaul lEloutuy E SEq ogM auotuE aou'wal j aqa jo SAOaoailp 'siaoyjo `saatoldwa Auu aou 1,iaga!au (t,) (j put 'Alto 'a~t�� w 1/ "' 0'57 �.1. agi'galM aoesuE:li oa ao'joj wjopad of anoge (ate)wE 'wjl j aqi a0 /put'I itgi ssaulsnq e jo aaEjauOO aqi oa pie8ai gilM (I-v8 uopoas ul paugap sr,) isaaaiul)a aa!yuoa Auu aneq war j aga aou I aaga!au (1) .japaq put uolatw.wjul'a$palmou l Aw )o isaq aqa of aega Aanliad jo Ailtuad aapun 'Ajpaao Agaaag I Put saautu!pap JO apoo s,tal'J aqa jo I -VS u01aoa5 'soig33 jo apo' s,(ti!7;,} !wv'W 43no5 jo /,i!:) aga pta:l AiPu3 1aOpuan1AuodwO�) ango7u9saadaa jO OWDN aneq( „ujl j,,) Zf •' Z✓ ? `7s jo )IEgaq'uo put AptnplMlpul' aJ <.; Ri 2r Y % Ir°L7V 1 ZL }o Zg 96ed £VEIII UL pantasa� stg9u fIV "E IOZ-I IOZ `adod'd stutotl.t. o Je aliil 7 awEN r ssaua!M T �, aalDvalNOD �/On n3aa ao aat vans ga!m Xidwoa oa :(sawtu s,joaDv iuo0 -qnS) }o aanlit}aga oa anp anaui Am Xaga sasuadxa put sassol'sahwep'swiEp lhillgtll pe put Aut asuit?u put iweiW 44noS jo A3l0 oqa ssaiwjeq ploq pue lgiuwaptu oa aaa8t put'suolatlnSaa galtaq put /aa;ts juDol put aataS pe put '0L61 }o aay galtaH put XINBS leuolatd=o (taapa j aga }o swawaalnbaa aga lit gal% aaumldwoa aoj Xilllglsuodsaa alos aga aneq paylaads se iDatoad aqa ao} saolJHalNa7 se atga aaa8e put a8palnnou>lat Xgaaatl &OiD"INOD Jo aweNM! -- 7✓ t � r j {� aM IWHIW Hinos 3a J,1103H101 SOHV(7N'V.LS VHSO HIIM3:)NVWUOd O:) :1O IN3W3O®3IMON)IDV Whenever two or more Bids or Proposals which are equal with respect to price, quality and service are received by the State or by any political subdivisions for the procurement of commodities or contractual services, a Bid or proposal received from a business that certifies that it has implemented a drug-free workplace program shall be .given preference in the award process. Established procedures for processing tie Bids or proposals shall be followed if none of the tied vendors have a drug -free workplace program. In order to have a drug -free workplace .program, a business shall I} Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that shall be taken against employees for violations of such prohibition. 2) Inform employees about the dangers of drug abuse in the workplace, the business' policy of maintaining a drug -free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations. 3) Give each employee engaged in providing the commodities or contractual services that are under Bid acopy of the statement specifiedin Subsection (1). 4) In the statement specified inSubsectian {1), notify the employees,xhat, as a condition ofworking of the commodities or "contractual services that are under Bid, he employeeshall abide by the terms of the statement and shall notify the empioyee of any conviction of, or plea of guiky or nola contenders to, any violation o #Chapter 693 or of any controlled substance law of the United. "States or anystate,'for a violation occurring inthe workplace no later than five (5) business days after such conviction. -5) Impose a sanction on, or requirethe satisfactory participation in a drug abuseassistance or rehabilitation program, if such is available in the employee'scommunity, by any employee who is -so convicted. $) Make a good faith effort to cantinueta maintain adrug -free workplace through implementation a #this section: Asthepersonauthorizedtosign# hestatement, ltertifythatthisfirmcomplies #ullywiththeaboverequirements. RESPON DENT's'Signaturei , Print Name:. i"r- !`2, Date: t� 1'homati P. Pepe, 2071 -2613. All nghisreservtd. 3(14/I3113 Page 31 of 72 interest in any 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 controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of apublic entity crime in Florida during the preceding 36 months shall be considered an affiliate. S. I understand that a "person" as defined in Paragraph 267:133 (1) {e), "Florida Statutes, means am, .natural person or entity organized under the laws of any state or of the United States with the legal :power to enter into binding contract and which bids or proposal or applies to bid or proposal 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 management of an entity: 6. Based on information and belief, the statement which I have marked "below is true in relation to the entity sub fitting this sworn statement. [Indicate which statement applies.] Neither the entity submitting this sworn statement, nor any of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, - - norany affiliate of the entity has been charged with and convicted of public entity crime subsequent to July I, 1969. 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 I; 1989. The entity submitting this sworn statement, or one or morea# its officers, directors, executives, partners, shareholders employees, members, or agents who areactivein themanagementoftheentiey, or an affiliate of the entiryhas been charged with and convicted ofa public entity crime subsequent of]uly I, 1969. However, there hasbeena subsequent proceedingbefare a Hearing Officer of the State of Florida, Division ro# 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 Iist:[attach a tapyof the final order.] I UNDERSTAND THAT THE SUBM155ION OFTHIS FORM TOTHE CONTRACTING OFFICER FOR THE PUBLICENTITY INDENTIFIEDiN PARAGRAPH I (ONE) ABOVE IS FORTHAT PUBLIC ENTITY ONLY;ANDTHAT THI &FORM IS VALID THROUGH DECEMBER 31 OF THECALENDARYEAR IN "WHICH IT I5 FILED. I A150 UNDERSTAND THATI AM REQUIRED TO INFORMTHePUBLIC ..ENTITY PRIORTOENTERING INTOACONTRACT IN EXCESS OF THE THRESHOLD AMOUNT;PROYIDED W SECTION 267.017,- FLORIDASTATUTES, :FOR CATEGORY TWO OF ANY :CHANGE IN THE INFORMATION CONTAINEDIN THI5FORM. f :Sworn to and subscrihed before me this t�i' O i day of .Personally known _ OR Produced identification "'�"" t�lotaryPublic�Stateof t �=P`GJP2i?��3 My commission expires �( ",! �C� (Printed, typed or stamped commissioned name o #notary public) rr .(Type of identification) "Form PUR 7066 {Rev.06 /1 1/92) PUBLIC ENTITY CRIMES AND CONFLICTS OF INTEREST Pursuant to the provisions of Paragraph (2) (a) of Section 287.133, Florida State Statutes — "A person or affiliate who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit a 'Proposal or bid on a Contract to provide any goods or services to public entity; may not submit a Bid or proposal for a Contracewith a publidentity for the construction of repair of apublic buildingor public work, may not submit bids or proposals on leases or real property toapublic entity, may not be awarded to .perform Work as a CONTRACTOR, Sub - Contractor; supplier, Sub-consultant, or Consultant under a Contract with any public entity, and may not transact business with any public entity in excess of the threshold amount Category Two of Section 287,017, Florida Statutes, for thirty six (36) months from the date of being placed on the Convicted vendor .list ". The award of any contract hereunder is subject to the provisions of Chapter 112, Florida State Statutes. Respondents must disclose with their Proposals, the name of any officer, director, partner, associate or agent who is also an offiter or employee of2he City of South Miami or its agencies. SWORN STATEMENT PURSUANT TO SECTION 287.133 (3) (a), FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER "OATHS. I . This sworn statement is submitted to ' [print name by t-> °'tC(!Y %G-`<J ' i'Z�'fY.,e'r"t: y ­ /-. th'i*1� �atu'ertr! [print�/individual's name and title] for .t,.'C?C'.�'e,`4 )t2,(}I7 [print name of entity aubmitting' worn'statement] .business address is and (if applicable) its Federal Employer identification Number {FEIN} is G` S t'1/';70 q 9D (If the entity has no FEIN, include he Social Security Number of the individual signing his sworn statement: 2. 1 understand that a "public entity Crime " as defined in Paragraph 2$7.133 (1)(g), 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 pubic entity or withan agencyorpolitital subdivision of any other state or of the United States, including, but not limited to , anybid,proposalor contract for goods or services to be provided to any .public entity gran agency or political subdivision of any other state or of the United States and involvingantitrust,fraud, theft, bribery, Collusion, racketeering, conspiracy, or material .misrepresentation. 3,. I understand that "convicted" oi` " "conviction" as defined in .Paragraph 287:133 (I) (b }, Florid :Statutes, means a finding of guilt ora Conviction of a public entity crime; with or without an adjuditation of guilt, 1n any federal or state trial court of record relating to charges brought by indictment or information.:after July i, i4$9, as a result of a juryroerditt, non -jury trial, or entry of a plea of guilty or polo mntendere. 4. I understand that an " "affiliate" as:defined in Paragraph 2$7.133 {I) (a }, Florida Statutes, means: (a} A predecessor or successor of a person Convicted of a public entity crime; or (b} An entity under the control of any natural person who is active in the management of the entity and who has been convictedof a public entity crime. Theterm "affiliate" includes inose ofieers; direttars, executives, partners,sharehalders; employees, members,and agents who are activein 'tfie managementof an affiliate.- The ownershipby one person of shares tonstituting a Controlling Page 29 of 72 'f�Tfinmas F. Pepe, 20lt -2b13. Ali rights r¢serve$ 7tt 1113113 CKNOWLEDGEMENT STATE OF FLORIDA ) COUNTY OF MIAMI -DADE ) On this the 3 6 day of 0 U4 V %' )4 , 201�, before me, the undersigned Notary Public of the State of Florida,_ personally appeared (Name's) of individual(s) who appeared before . notary) Z d"lGI PY€"e tf` G1 P2t + ' CC! and whose name(s) is /are Subscribed to the within instrument, and he /she /they acknowledge that he /she /they executed it. WITNESS my hand and official seal. L No ic, StaI4 of Florida I � NOTARY PUBLIC:G?c SEAL OF OFFICE: (Name of Notary Public: Print, Stamp or type as commissioned.) s PEDROJ.GOMEZ 4. Personally (mown to Mme, or Y COMMfSSlC1N & EE W70i2 ?y, ° EXPIRES:,luiy7, 2014 Personal identification: ,,,, Branded Thnr Nohmy PUWic Undenvrite:s Type of Identification Produced Did take an oath, or Did Not take an oath. Page 28 of 72 is Thomas P. Pepe, 2011- 20t3.AI! nghts ieserued. NON-COLLUSION AFFICIAYIT STATE OF FLORIDA ) COUNTY OF MIAMI -DADE ) 111 z7 t ' being first duly sworn, deposes and states that: (1) (Ho /She/The Oare the w i�'�j'fC: %'�,�,,!Ti caner, Partner, Officer, Representative or Agent) of + v /470 7l/ 01'V the Respondent that has submitted the :attached Proposal; (2) He /She/They is /are fully informed concerning the preparation and contents of the attached Proposal and of all pertinent circumstances concerning such Proposal; (3) Such Proposal is genuine and is not a collusive or sham Proposal; (4) Neither the said Respondent 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 Respondent, 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 Bidding or proposing in connection with such Work; or have in any manner, directly or indirectly, sought by agreement or collusion, or communication, or conference with any Respondent, firm, or person to fix any overhead, profit, or cost elements of the Proposal or of any tither Respondent, or to fix any overhead, profit, or cost elements of the Proposal Price or the :.Proposal Price of any other Respondent; or to secure through any collusion, conspiracy, connivance, or unlawful agreement :any advant<�ge against(Recipient), or any person interested in the proposed Work; (5) The price or prices quoted in the attached Praposai are fair and proper and are nat tainted by any Collusion, conspiracy; connivance, or unlawful agreement on the part of the Respondent or any atfier 6f its agents, representatives, owners, employees arparties ofinterest, indudingttiis affiant. Signed, sealed and delivered in the presence of: Witness Signature. Witness Print NameaJnd Title Date 4pepe0Y -IS•I3 page "27 of 72 i. Government References: List other Government Agencies or Quasi- government Agencies for which you have done business within the past five (5) years. Name of Agency: f c Iv / Aq Address: Telephone No.: Contact Person: f -J7 rF%lfiir�' Type of Project: Name of Agency: 'Sch 0 C CL /a-0C iJi t Address: Telephone No.: Contact Person: Type of Project Name Agency: r 1 � J/ / JC Gi6)0 / 2)f )Da Im /Y of 5')IL .Address: TelephoneNo ,r� [ .Type of Project Page 26 of T2 ©Thomas F. Pepe, 2011 -2013. AI4 rights reserved.. .:7/11/13113 B.03 -9 List of Designated Staff: Frank J Fonseca, President University of Miami BSME 1964 Professional Engineer 1966 State General Contractor 1977 State Mechanical Contractor 1977 Certified Playground Safety Inspector Extensive experience in all phases of Construction and Industrial operations, including Accounting and Financial. Founded Leadex Corporation in 1990 and has successfully established this Corporation as a full service General Contracting and Mechanical Contracting firm, having presently over 30 full time employees. Leadex Corporation has been a leader in the parks and recreation construction specializing in playgrounds. e -mail: frank@leadexcorp.com Cellular Phone: 305.345.7474 Nelson D. Fonseca, P. E. Rensselaer BSCE 1997 Professional Engineer State of Florida Leadex Corporation's appointed Sr. design engineer for this contract will be Nelson D. Fonseca. Nelson has over ten years of experience in design and construction of major structures. He has designed projects from playgrounds to bridges. He is a Professional Engineer and the design professional for Leadex Corporation. Nelson has developed a close relationship with the design department at Playcraft System to ensure quality from the conceptual phase. He is very fluent in CAD and other design programs to accomplish the design in a timely fashion. His experience also includes the design and construction of buildings and 40 years Recertification of Structures. e -mail: Nelson _leadexcorp.com Cellular Phone: 305.301.9627 08/29/13 LEADEX CORPORATION Contracts Job Status 3 to 3, Job Type 18 to 18 Job# Job Name Contact Phone # Original Contract 213400 NORTHPORT K -8 GARY TAYLOR 213401 WEST GATE K -8 SCHOOL GARY TAYLOR 213402 WINDMILL POINT ELEMENTARY GARY TAYLOR Report 3- 1 -1 -04 SUPERVISOR Page 1 of 1 (772) 340 -7198 Total: 17,728.00 26,512.20 6,674.40 50,914.60 08/29/13 06:52 PM Contracts 08/29/13 LEADEX CORPORATION Job# Job Name Original Contract 200 MIAMI DADE COLLEGE 212201 NORTH 911 RELIC 405 SCHOOL DISTRICT PALM BEACH C 213810 NEW HORIZONS EL REPAIR 213809 PAHOKEE 418 SCHOOL DIST ST LUCIE COUNTY 213400 NORTHPORT K -8 213401 WEST GATE K-8 SCHOOL 213402 WINDMILL POINT ELEMENTARY 500 SCHOOL BO 213619 213616 213612 213614 213615 213617 213613 213618 ARD OF BROWARD COUNTY DEERFIELD BEACH EL 3-5 EVERGLADES ELEMENTARY 3-5 EVERGLADES ELEMENTARY K -2 LAKESIDE ELEMENTARY 3-5 LAKESIDE ELEMENTARY K -2 RIVERGLADES EL FITNESS 3 -5 RIVERGLADES K -2 SANDPIPER ELEMENTARY 501 SCHOOL BOARD OF MIAMI -DADE 213503 AVENTURA WATERWAYS K -8 213501 BEL -AIRE ELEMENTARY 213502 NATURAL BRIDGE EL Report Page 1 27,450.00 Client Total: 27,450.00 3,293.69 31,762.78 Client Total: 35,056.47 17,728.00 26,512.20 6,674.40 Client Total: 50,914.60 11,232.33 10,657.44 11,626.44 9,678.02 9,142.70 5,521.15 4,573.00 14,906.85 Client Total: 77,337.93 9,562.50 4,853.40 9,875.00 Actual Final Contract Completion / J Date: ..: r,/ 7 7rs t ''S Original Contract Price: � .� � G� L�l 4.. The following information shall be attached to the proposal. a) RESPONDENT's home office organization chart, cf7..a "' 1 b) RESPONDENT "s proposed project organizational chart. - /,a(0C -6 + c-r ,1 c) .Resumes of prapased I<ey project perso�inel, inclirdiiig an -site Supei-intendt4i7t: .:�. c-,� f��7 G� +i%o'.': 5 fisCand describe any; a} Bankruptcy petitioi7s filed by ar againsttfie Respondent ar any predecessor' organizations, ,�"y'`G",/"T�-� - b} Any arbitration or civil or criminal proceedings, or- y'y'��fh"c'.. Suspension of caneracts or debarringfi'om Bidding or Responding by any ptikalic agency brought c) against theRespandentinthelastfive {§)years !?`'r.'�7�, Paget§ of 72 �'l "homasr Yejic, 2fi112t)13. Alli cli i scive�t. 7!11/13/13 b) Project Name: Owner Name: .Owner Arch ess: Owner Telephoner Original :Contract Completion Time (Days): Original Contract Completion Dater Actual Final Contract Completion Dater Original Contract Price: Actual Final Contract Price Project Name: Owner Name: OwnerAOdress: (7ivnerTeiephorici Orignal Contract Coiripleuotr Tinie Original Contract Completion Date: <'Thoin� h Pepe.= e(I -'(i U. alii iltti ioser�ezi ?il t ?13x13 5/ 1711 3 5: 0 C) C> 31 Page 24 of 72 RESPONDENT QUALIFICATION STATEMENT The response to this questionnaire shall be utilized as part of the CITY'S overall Proposal Evaluation and CONTRACTOR selection. I. Number of siniilai° construction projects completed, a) In the past 5 years In the past S years On Schedule T > b) In the past I O years In the past 10 On Schedule 0c;) 1 List the last three (3) completed similar projects: a) Project Name: t I 'r t-7�g-r "Owner Name : 1. <1^ f..`�v.. . Owner Address: Owner Telephone:5. Original Contract Completion Time .A (Days): OrigirtaC Co�rtract CtiinipletionDate: -.»x i.tn✓� I`� '�' a:�j'� Actual Fiitial Contract Completion Cate: -. i.i+.aF .� ?✓:iP�j Oi igmal Contract Price:.. -^'�'j r{�CC). ActualPinalCOntractPrice :�Ti.G"�Y?.t� lYrirr sl,l'upn, 2011 1UI3: ?illca.ht4 i�4ax a -ed.