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Group 3Contact Person: Type of Project: tpepeO2 -18 -13 Page 24 of 68 Address: Telephone No.: Contact Person: ' Type of Project: Name of Agency: Address: Telephone No.: Contact Person: Type of Project: Name of Agency: Address: Telephone No.: Contact Person: Type of Project: tpepeO2 -18 -13 Page 24 of 68 SUPPLEMENT TO B1© FORM: CUSTOMER REFERENCE LISTING 1. Company Name A f S geS 01 � , SE• 1tvg4 L AtoT6C Address -f&O'-rO "6- AVE. 14;494 ' "�iv4ES, 734,30 Contact Person t5-C-07--r_ �l.S �a Contract Ar3iQUnt 6 © r ~ Telephone No /Fax loo -70 179 Z WO se-4 -71r-2-2-4-9 r 2. Company Name D ® 7` Address I � 73 fJC 2,oC � f , �� � -3 J Contact Person! 13o L--rbr.J.. - - -- Contract Amount Telephone No /Fax No gojr 61y_ 3. Cori-apany Name i°��°d� �o� �� 7-- Address 4 M f.-IF zar 7TV9 . . . L9 Fz_ �Y_3 ,11719 Contact Person II Contract Amount 4 ..T-'7 2 -- T elephone No/Fax No A, Company Name a f ;4At Address Contact Person 4EXuc AZ VS Contract Amount Telephone No /Fax No S. Company Name �1-�y �� I- I- w W-0 `` � r vp- P Address -X400 c.sla ll#D ALA waap 33 a 70 Contact Person tJeeIQ- Contract Amount �g �[ �� I , Telephone NolFax No i e,6 6 L Z4 14 SUPPLEMENT TO BID FORM: CUST OMER REFERENCE LIS TING Q E t"�- rat' a Company Name Address 4�5-,t P �L Contact Person e� � ti Z— eALr Contract Amount �t9 . Telephvne� No/Fax No�� �- � �.�� 2�9 9 .3 7567-? 74 o Company Name T _ Address WO (3,L V I> Contact Persons Contract Amount C4 e Lam! OO Telephone NolFax Ne j 2,° ®. Co rnpan y Name f ! � � s ' Address���!����' Contact Person, Contract Amount f 30®, cop Telephone No /Fax No 9 -f r �. Company Name Address ,fo ®o Contact Person Contract Amount _ 4-Li o e2-5- Telephone No /Fax No 6 4® — P7 q. s � , Company Name lP A — 06-2,9- a- ref L 10- Address Al K/ �� S -3 34?i Contact Persons U 1 3 Contract Amounts L t a fTS' Telephone No /Fax No 3 OX 2A 4� r q9 22 -3 7r ?,93 ��-is NON - COLLUSION AFFID"IT STATE OF FLORIDA COUNTY OF MIAMI -DADE P—"L �� �� being first duly sworn, deposes and states that: (1) He/She[They is /are the {' ems-' 7— (Owner, Partner, Officer, Representative oor`- Agent) of ifAfL P4 V �'6 f ° �`� _ the Respondent that has submitted the attached Proposal; (2) Ue/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 other 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 advantage against (Recipient), or any person interested in the proposed Work; (5) 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 Respondent or any other of its agents, representatives, owners, employees or parties of interest, including this affiant. Signed, sealed "d�llivgged in the presence of- Witness 1 *WT_ Witness IL N By: .� ignature Print Name and Title Date V 1710 - tpepe02-18 -13 Page 25 of 68 ACKNOWLEDGEMENT M-11109191901 1D 1 COUNTY OFMIAM,I -DADE n)� ,/ On this the 1F"I �� day of��C /� 20 'E� ,before me, the undersigned Notary Public of the State of Florida, p rson Ilya eared ( Name(s) of individual(s) who appeared before notary) t/ _ and whose name(s) is /are Subscribed to the within instrument, and he/shelthey acknowledge that he/shelthey executed it. WITNESS my hand and official seal. �s�- A, 4449-o t-� Notary Public, State of FI rida NOTARY PUBLIC: SEAL OF OFFICE: (Name of 'Notary Public: Print, Stamp or type as commis . ned.) E :7-r�j ofo lo' -a 9 Y Personally known to me, or =112930 Personal identification: Type of Identification Produced Q Thomas F. Pepe, 2011 -2013. All rights reserved. 6118113 Did take an oath, or Did Not take an oath. Page 26 of 68 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 a public entity, may not submit a Bid or proposal for a Contract with a public entity for the construction of repair of a public building or public work, may not submit bids or proposals on leases or real property to a public entity, may not be awarded to perform Work as a RESPONDENT, 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 officer or employee of the 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. This sworn statement is submitted to IS r "l , ® F- SCE i, r - f—H k � I r [print Qme of the public entity] by i L Q 6 1',Q [print individual's name and title] /R ���; for [print name of entity submitting sworn tatement] whose business address is 4 d AJ W '� ?0 ' and (if applicable) its Federal Employer Identification Number (FEIN) is (If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement: .l 2. 1 understand that a "public entity crime" as defined in Paragraph 287.133 (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 public entity or with an agency or political subdivision of any other state or of the United States, including, but not limited to , any bid, proposal or contract for goods or services to be provided to any public entity or an agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. 3. 1 understand that "convicted" or "conviction" as defined in Paragraph 287.133 (1) (b), Florida Statutes, means a finding of guilt or a conviction of 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 I, 1989, as a result of a jury verdict, non -jury trial, or entry of a plea of guilty or nolo contendere. 1 understand that 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 qc Thomas F. Pepe, 20 11-2013. All rights reserved. 6118/13 Page 27 of 68 (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 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 a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. I understand that a "person" as defined in Paragraph 287.133 (1) (e), 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 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. 7 6. Base on information and belief, the statement which I have marked below is true in relation to the entity ubmitting 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, nor any 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. 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 of July I, 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 INDENTIFIED IN PARAGRAPH I (ONE) 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 THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES, FOR CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. ; :- r' Signature] Sworn to and subscribed before me this day of 20 3 Personally known v OR Produced identification (Type of identification) Form FUR 7068 (Rev,0611 1192) Notary Public -- State of F-L My commission expires L la� (Printed, typed or stamped commissioned name of notary public) �0 Thomas F. Pepe, 2011 -2013. All rights reserved. 6/18113 YEE] state of Florida Chagoyen- Page 28 of 68 ion FE112930