HG CONSTRUCTION DEVELOPMENT & INVESTMENT, INC.Proposal Submittal Checklist Form
Bus Shelter Fabrication & Installation
RFP #-PW-2015-21
by the deadline set for within the solicitation. Fulfillment of all solicitation requirements listed is mandatory for
ideration of response to the sor itatiom Additi nal documents may be required and if so, they will be
consi I Ic 0
identified in an addendum to this Solicitation. The response shall include the following items.
Submit this checklist along with your proposal indicating the completion and submission of each required forms
and/or documents,
END OF SECTION
x
Indemnification and Insurance Documents EXHIBIT 2
J
x
Bid Form EXHIBIT 4
x
Respondents Cost and Technical Proposal, EXHBIT 5
V/
x
Signed Contract Documents (All — including General Conditions
and Supplementary Conditions if attached) EXHIBIT 6, 7 & 8
Performance and Payment Bonds (As a Condition Award. Not
required with SubmittaL) EXHIBIT 9 & 10
x
Respondents Qualification Statement
x
List of Proposed Subcontractors and Principal Suppliers
x
Non-Collusion Affidavit
X
Public Entity Crimes and Conflicts of Interest
x
Drug Free Workplace
X
Acknowledgement of Conformance with OSHA Standards
x
Affidavit Concerning Federal & Vendor
State Listings
x
Related Party Transaction Verification Form
x
Presentation Team Der laration/Affidavit of Representation
V/
Submit this checklist along with your proposal indicating the completion and submission of each required forms
and/or documents,
END OF SECTION
1 �02 Firm's Insurance Generally. -The FIRM shall provide and maintain -
i I in force and effect until all the Work to
specified hereinafter), the insurance cover3kO written on Florida approved forms and' as set forth below.,
1 03 Workers' Compensation Insurance at the statutory amount as to all employees in c6mplianoo with the
"Workers' Compensation Law" • the State • Florida including Chapter 440, Florida Statutes, as presently written
or hereafter arn�dedl and all applicable federal laws. In addition, the policy (ies) must include: Employers' Liability
at the statutory coverage amount. The FIRM shall further insure that all of its Subcontractors maintain appropriate
levels
• Worker's Compensation Insurance.
W
#rsement� as well as
verability of interest witil
#00,000 per claim and
ON
0 VA-111 US I 112 11
HUE
mi
m
t- The t6ntirkt-, has the duty to provide a defense with an Attorney or law firm approved by the City
of South Miami� which approval will not be unreasonably withheld.
F. However, as to design professional contracts; and pursuant to Section 725.08 (1), Florida Statutes,
none of the provisions set forth herein above that are in conflict with this subparagraph shall apply and this subparagraph shall set forth the sole responsibility of the design professional concerning indemnification, Thus�
"' design Z • • obligations to the City • its agencies, as well as to its �officers and ern�L
taelfradm hojZ-Mem 6TFTM4§sJr-O-M--lIabTMt—ies, damages, lossesi and costs, Including, but not limited to,
reasonable attorneys' to the extent caused by the negligence� recklesshess� or intentionally wrongful
conduct of the design professional and other persons employed or utilized by the design professional in the
performance of •
Bonita Springs FL 34135
I
I IN SD I WV D POLICY NUMBER
INSURERS) AFFORDING COVERAGE
NAIC #
INSURERA: KINSALE INSURANCE COMPANY
38920
INSURED
INSURER 6 :
Wesco Insurance - Company
25011
FIG Construction, Development and Investment. Inc.
INSURER C:
EVANSTON INSIJRANCE COMPANY
35378
7570 SW 77th Avenue
INSURER D:
F 0 B I & Funds
INSURER E:
FEDERAL INSURANCE COMPANY
20281
Miami FL 33143
INSURER F:
MED FXP (Any one peson)
COVERAGES CERTIFICATE NUMBER:
5,000
REVISION NUMBER:
1 0100023378-0
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 CLAWS.
LrR I f I rc Ur MnUKANUL
I
I IN SD I WV D POLICY NUMBER
(MMIJI jMMIDDfYYYYj
LIMITS
i X COMMERCIAL GENERAL LIABILITY
OCCURRENCE
1,000,000
CLAIMS-MADE X OCCUR
-EACH
DAMAGE TO RENTED
100,000
PMEMISES.,(Ep Dccurrence)__
MED FXP (Any one peson)
5,000
A
1 0100023378-0
09123/2014 0912312015
-PERSONAL & ADV INJURY
s
1,000,000
GLN'L AGGR_=GATE ITMIT AP PLI ES PER:
GENERAL AGGREGATE
2,000,000
-
POLICY PRO-
JECT El LOC
PRODUCTS -COMPIOPAGG
$
2,000,000
OTHER
AUTOMOBILE LIABILITY
COMBINED SINGLE LIN41T
$
1,000,C00
(Ea
ANY AUTO
BODILY INJURY (Per person)
$
1,()00,()00
ALL OWNED x SCHEDULED
AUTO$ AUTOS
WPP1258303-00
04107/2015 0410712016
BODILY INJURY (Per accident), $
NON-OWNED
HIREDAUTOS AUTOS
PROPERTY DAMAGE
UMBRELLA LIAR X' OCCUR
EACH OCCURRENCE
4,000,000
C EXCESS LIAB CLAIMS-MACE
XOVA885115
01/1612015 09123/2015
AGGREGATE
— - ----------
4,000,000
DED RETENTION :$
S
!WORKERS COMPENSATION
PER OTH
AND EMPLOYERS'LIASILITY YIN
STATUTE I
_S� _FT3 ___ �
____
ANY PROPRIETORIPARTNERIFXrCUTIVE
D E
N/A
:�
EL EACH ACCIDENT
1,000,000
I
OFF CER/MrMBER EXCLUDED?
(Mandatory in NH)
10656523
0410212015 0410212016
DISEASE- 2A EMPLOYEE $
1,000,1300
If yes, describe, under
DESCRIPTION OF OPERATIONS below
E L DISEASE - POLICY LIMIT
$
1,000,000
Contractor's Equipment Floater
SChedljleq: $244,000
E
45465921
08118/2014 08118/2015
Leased: $300,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
Addendum No. Dated' I / c 4,016
• disciropancies that it hm
Lcre anci
Y*-FT'71 W"z
of any group, associatior,
�ured or solicited any oth
ted or
not sought by collusion
#ver the CrTY.
Alternates- #1— #2
A fee breakdown for each task included in the lump sum contract price, if applicable, must be provided.
Failure to provide this information shall render the proposal non-responsive.
5 The ENTIRE WORK shall be completed, in 'full, within 120 calendaLiays—frorn the commencement
date set forth in the NOTICE TO PROCEM Failure to complete the entire work during the described
time period shall result in the assessment of liquidated damages as may be set forth in the Contract.
6� Insert the following information for future communication with you concerning this Proposal:
Address: 7OC13 A� a Pro
Tele hone:
p
Facsimile., qw-
Contact Person
M
SUBMITTED THIS / DAY OF 2
' -
Title
m
EXHIBIT 5
RESPONDENTS COST & TECHNICAL PROPOSAL
Bus Shelter Fabrication & Installation
RFP -2 1 -21
AREA I
goy
a
SUBMITTED THIS F CLAY OF /1? 0 ;5r -20-/6 ;
PROPOSAL SUBMITTED BY�
HIE
p 9991
elegy hone Number
c,' d - 9P A
141,+1 ZsT .l3 �i Cr�T.11
RFP r
m
AHEREOF h
#
CONTRACTOR�
Signaturei�
Pr6t Signatorys Name�
Title of Signatory.
ff-I
J:K44
GENERAL CONDITIONS
Bus Shelter Fabrication & installation
RFP #PW-2015-21
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2. The Cl W— reservp% t-kp in.
■ Masai
low
tmands, instructions,
�ments. Written notice
member of the firm or to
�'-* 4ivuu �I`wr
rc�ss. Unless otherwise
be delivered to the City
M
Commencement cal -C-an—t-rgct Time:
2.5 The Contract Time shall commence to run on the date stated in the Notice to Proceed.
Startio&Lhe Proms
ct. -
_
2.6 CONTRACTOR shall start to perform its obligations under the Contract Documents on the date the
Contract Time commences to run. No Work shall be done at the site (as defined in Article 1), prior to
the date on which the Contract Time commences to run, except with the written consent of the CITY.
1H
Availabil.itX of Lands:
4.1 The OWNER shafl furnish, as indicated in the Contract Documents, the lands upon which the Work is to
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ARTICLE 5- — INSULBANCE Contractor shall comply with the insurance requirements set forth in the RFP and
as set forth in the Supplementary Conditions to the Contract� if any. if both have insurance requirements and if
there is a conflict between the two, the insurance requirements in the Supplemental Conditions shall take
precedent.
111111 1 4 1111
1-14 0 MGM m_-- 819M
CONTRACTOR. The
claquate supervisioh and
.w,ervisor shall be mailed to
'th annotations�,
ngs wi
the CITY upon
w requirements of
1
rl
i ♦ 1 �
t i i
)cure the articles or
any excess co—
occasioned or incurred thereby,
C6.8 The CITY reserves the right, in the event the CONTRACTOR cannot provide an item(s) or
service(s) in a timely manner as requested, to obtain the good and/or services from rather sources
and deducting the cost from the Contract Price without violating the intent of the Contract,
Concerning 5ubconcr=s
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Clarifications i Inte !
93 The CONSULTANT reasonable
of the Contract Documents (in the form of Drawings or otherwise) as it may determine necessary, which
shall be consistent with, or reasonably inferable frOMi the OVerall intent of the Contract Documenm If
the CONTRACTOR seeks an increase in the Contract Price or extension of Contract Time based on a
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any item not specifically
:ulated in the s:ame
y one change, the net
additions and credit,
S for any Work not
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Im
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J.
.:. nucerxifies- Ma
Completion, certifies an evefit of default, or approves any action Which requires the appro
ival of the
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LIM
J and exempt from public
and (d) Meet all
c agency all public records
ZIA-)-i-LI
fuirements� All records
compatible with the
Rion shall to any extent,
• unenforceable shall
,-d to the fullest extent
rupervision by the
'sonnel policies, tax
:ng policies and other
ntract shall be those of
IN WITNESS WHEREOF, the parties hereto have executed the General C
inclusion as part of the Contract Documents on this a day of
ATTESTED.-
Signature:
Maria Menendez
City Clerk
Legality, and Execution Thereof:
ons to aCknoWFe—UgctFe`ir
2Q 15 ,
CONTRACTOR: 116 -P
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Steven Alexander
City Manager
RFP #PW-,2015-21
as tne
if none, then CITY's
CONSULTANT'sj if any,
m
CITY from terminating the
as the CONSULTANT.
a (1) sets of Contract
U&Lti,� �'* ..
take precedence.
set forth in the Contract
on in the General
m
ATTESTED:
Signature:
Maria Menendez
City Clerk
i-egality, arid Execution Thereof:
Signature.-
City Attorney
U11
2. List the last three (3) completed sirnil r P j
a rojects,
a
Original Contract Completion Time
(Days):
D -Xe Ae
M
C) Project Name:
Owner Name:
Owner Address:
Owner Telephone:
Y
Project Narne
Owner Narne
Telephone RUM ber
Contract
price
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p�� FTC. � ����
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a) Bankruptcy petitions filed by or against the Responde;
b) Any arbitration or civil or criminal proceedings, or
ME=
Address: ti0 / 0 4 -
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w
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:$m Rka m \
Jose + . r Director
Airport
Manager,
Osdel Director public
Ity Miami S
Gardens
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^\6 letter + recoi k 61¥ } »« \ \« d d d? +w « :m « »
wa «V :myl2<
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require anY �\rffi&i 2 » » : »\ », Please \■ «+ hesitate �
w,2 « » : »« con tad �
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1$«¥ \yk} ¥»d« and 186-586-6944.
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17
LIST OF PROPOSED SUBCONTRACTORS AND PRINCIPAL SUPPLIERS
Bus Shelter Fabrication o.
within five (5) business days after Bid Opening. e I
END OF SECTION
(Owner, Partner, Officer, Representative or Agent) of
<AIV,J.-JU
attached Proposal;
deposes and states that
the Respondent that has submitted t,�e
■
01 xm � =
IE
i4'r'TWr.WjJ0-z— and whose nam
within instrument, and he/she/th-y acknowledge that he/shelthey executed it
WITNESS my hand and official seal. 17
mz���
NOTARY PUBLIC: otary Public, St of Florida
SEAL OF OFFICE- 3 CL L Cao Z--,�
LGAL CPUZ Name of Notary Public: Print. Stamp or type as commissioned,)
Mi� "" j aptL Personally known to me, or
-j S-rnber 23, 2011
Puu'r jrdemrRefs
1"H.0 I rl')#"a'� PUN'r jrdemrRe'rs
�M
Type of Identification Produce(
Did take an oath, or
Did Not take an oath.
IM
This sworn statement is submitted to
and (-if applicable) its Federal Employer Identification Number (FEIN) is (if the
entity has no FEIN, incWe the Social Security Number of the individual signing this sworn statement:
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ar
Pro. Liasal
followed given preference in the award process. Established procedures for processing tie Bic,
if none of the tied vendors have . drug-free -r.. order
program, a business shall:
J service are received
kr - fr rm be
shall or Proposals II
f 1 r
services that are under
nployee shall abide by the
r
Put
ACKNOWLEDGEMENT OF CONFORMANCE WITH OSHA STANDARDS
Bus Shelter Fabrication Installation
RFP - 15- 1
TO THE CITY OF SOUTH NTH h1IAMI
I` y s
IF
AFFIDAVIT
FEDERAL j-, r a•�
The person� or entity, who is responding to the City's solicitation, hereinafter referred to as "Respondent", must
certify that Respondent's name Does Not aDDear on the State of Al L-Eb�ti
If the Respondent's - Does appear
if Applies" next to the applicable "Listing." The "Listings" can be accessed through the following link to the Florida
Department of Managernelit Services .
er��ed discrio�inatc� com hints vendor lists
PUBLIC: p+ Noty Public, State.o = forida
�g .
Y RA �
SEAL
°.
I PF ?- aA i . CF IJ otary Public: Print,
m. t y `i; } }«Ihi 39i0N 4l or pe as commissioned.)
G XPIR .SS P1 erwL r2 3 1�
i -nded MW vnt.rt r � i Und n E.�ra
22
i -1 . . .... an in e Irm, nor any member of
those persons' immediate family (Le., 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 (if necessary, use a separate sheet to supply additional information that will nai
must make reference, on the above line i to the additicital s%ii-Ar J t .'J iumaLSL-t
3�05__ -0 - 1111010011111
91
knbW[ed
have a financial interest in the Firm.]'A and
( N
no elected and/or aAp. x 'Kf7'
members spouse, parents; children, brothers and sisters) has a financial interest, j
contract between you and/or your Firm and the City other than the following inddu
forth following their use a separate names-.
Ine', OWever, you
mu
t st be signed under
in behalf of a fh-m whose
their immediate family
tly or indirectly, in the
whose interest is set
IN
before any board, commission or agency of the City within the past two years other than as
follows:
•
spouse, parents� chllclren�
• as "Related Parties") has
ie who has a finaricial
spouse, parents,
(9) 1 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
ail Related Parties who have also responded to the same solicitation and to disclose the relationship of those
parties to me and the Firm.
Date: — 9 LA 41
M,
r
s entIII
ity in which that
participate in any way in
w
ionships with any o the
y or
matter would affect the
ould affect the Public
'the specified relationships
L&MM.W&A-11111A I?LIIIFIta
aphs (b)(1) through (6) tcM
cvflffl��- I
m
interest may be directly affected by official actions or by official actions by the city or city agency of which the
person is an official, officer or employee
END OF SECTION
!
Pursuant to '92.525(2), Florida Statutes, the undersigned, &&" f 11-11"AA)G�0— ®, makes the following
declaration under penalty of perjury:
Listed below are all 'individuals who may make a presentation on behalf of the entity that the affiant
represents Please note, No person shall appear before any tornmittee on; behalf of anyone unless he
or she has be
it
�.r i
fees.
NAME
LM
For the purpose of this Affidavit of Representation only, the listed members of the presentation team,
with the exception of any person otherwise required to register as a lobbyist, shall not be required to
pay any registration fees. The Affidavit of Representation shall be filed with the City Clerk's office at the
time the committee's proposal is submitted to the City as part of the procurement process.
Under penalties of perjury, I declare that I have read the foregoing declaration and that the facts stated
in it are true and specifically that the persons listed above are the members of the presentation team of
the entity listed below
0