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RFP #PW-2015-21 - Canyon Construction Inc Tabs 5-14Performance and Payment Bonds (As a Condition Award. Not required with Submittal.) EXHIBIT 9 & 10 N/A EXHIBIT 9 FORM OF PERFORMANCE BOND Bus Shelter Fabrication & Installation RFP#PW-20IS-2I (Required as a Condition of Award and Prior to the Contractor Receiving a Notice to Proceed. Not Required with Submittal) KNOW ALL MEN BY THESE PRESENTS: That, pursuant to the requirements of Florida Statute 255.05, we, , whose business address is and whose telephone number is , as Principal (hereinafter referred to as "Contractor"), and , whose business address is and whose telephone number is , as Surety, are bound to the City of South Miami whose business address is and whose telephone number is , [[and Miami- Dade County whose business address is and whose telephone number is ]]as Obligee, (hereinafter referred to as "City") in the amount of Dollars ($ ) for the payment whereof Contractor and Surety bind themselves, their heirs, executors, administrators, successors and assigns, jointly and severally. WHEREAS, Contractor has entered into a Contract, for the Bus Shelter Fabrication & Installation Project, awarded on the day of , 20 , under Contract Number by the City for the construction of (brief description of the Work) in accordance with drawings (plans) and specifications prepared by . which Contract is hereby made a part hereof by reference, and is hereafter referred to as the "Contract"; THE CONDITION OF THIS BOND is that the Contractor: 1. Fully performs the Contract between the Contractor and the Bus Shelter Fabrication & Installation Project, within 120 calendar days after the date of Contract commencement as specified in the Notice to Proceed and in the manner prescribed in the Contract; and 2. Indemnifies and pays City all losses, damages (specifically including, but not limited to, damages for delay and other foreseeable consequential damages), expenses, costs and attorney's fees, including attorney's fees incurred in appellate proceedings, mediation and arbitration, if any, that City sustains because of default by Contractor under the Contract or caused by or arising out of any action or proceeding to enforce the Contract or this Bond; and 3. Upon notification by the City, correct any and all patently defective or faulty Work or materials that appear within one (I) year after the issuance of the Certificate of Occupancy, and correct any and all latent defects that are discovered before the expiration of the third (3rd) year following the date of the issuance of the Certificate of Occupancy; and 4. Performs the guarantee of all Work and materials furnished under the Contract for the time specified in the Contract. If all of the forgoing conditions are met, then this Bond is void, otherwise it shall remain in full force and effect. Whenever Contractor shall be, and declared by the City to be, in default for failing to perform in strict accordance with any of the terms of the Contract, the Surety shall promptly remedy the default as well as perform in the following manner: Complete the Contract in accordance with the Contract's terms and conditions provided the City makes available, as Work progresses, that portion of the Contract Price that has not already been paid to, or on behalf of, the Contractor. The City shall not be required to pay any more than the amount of the Contract Price. The surety shall not be obligated to pay more than the maximum amount for which the Surety may be liable as set forth in the first paragraph of this bond. If the Surety fails to commence the Work within thirty (30) days of receipt of the City's declaration of a default or if the Surety fails to man the job with sufficient forces, or suspends the Work, for more than thirty (30) days, either consecutive or in combination with separate occasions, the City shall have the option, in the City's sole discretion, and without waiving its right to any other remedy or damages provided for by this bond, to complete the Work with other forces and the Surety shall pay for the cost to complete the Work. The term "balance of the Contract Price" as used in this paragraph, shall mean 95 the total amount payable by City to Contractor under the Contract and any amendments thereto, less the amount properly paid by the City to the Contractor. No right of action shall accrue on this Bond to or for the use of any person or corporation other than the City named herein. The Surety hereby waives notice of and agrees that any changes in or under the Contract Documents and compliance or noncompliance with any formalities connected with the Contract shall not affect the Surety's obligation under this Bond. IN WITNESS WHEREOF, the above bonded parties have executed this instrument under their several seals on this day of , 20 , the name and the corporate seal of each corporate party being hereto affixed and these presents being duly signed by its undersigned representative. IN PRESENCE OF: (Individual, President, Managing Member or General Partner, etc.) (Business Address) (City/Scate/Zip) (Business Telephone) (Corporate Name) (President) (Business Address) (City/State/Zip) (Business Telephone) INSURANCE COMPANY: OR ATTEST: Secretary IN THE PRESENCE OF: BY: and Attorney-in-fact Signature) _(SEAL) (Agent (Business Address) (City/State/Zip (Business Telephone) STATE OF FLORIDA COUNTY OF MIAMI-DADE On this, the day of , 20 , before me, the undersigned notary public of the State of Florida, the foregoing performance bond was acknowledged by (Title), of (Corporate Officer), (Name of Corporation), a (State of Incorporation) corporation, on behalf of the corporation. WITNESS my hand and official seal. NOTARY PUBLIC: SEAL OF OFFICE: Notary Public, State of Florida (Name of Notary Public: Print, Stamp or Type as commissioned.) Personally known to me, or Personal identification: Type of Identification Produced Did take an oath, or Did Not take an oath. 96 EXHIBIT 10 FORM OF PAYMENT BOND Bus Shelter Fabrication & Installation RFP#PW-20I5-2I \ (Required as a Condition of Award and Prior to the Contractor Receiving a Notice to Proceed. Not Required with Submittal) KNOW ALL MEN BY THESE PRESENTS: That, pursuant to the requirements of Florida Statute 255.01, et seq., Florida Statutes, we, , whose business address is and whose telephone number is ,as Principal, (hereinafter referred to as "Contractor"), and , whose business address is and whose telephone number is , as Surety, are bound to the City of South Miami, whose business address is and whose telephone number is , [[and Miami-Dade County whose business address is and whose telephone number is ]]as Obligee, (hereinafter referred to as "City") in the amount of Dollars ($ ) for the payment whereof Contractor and Surety bind themselves, their heirs, executors, administrators, successors and assigns, jointly and severally. WHEREAS, Contractor has, by written agreement, entered into a Contract for the Bus Shelter Fabrication & Installation Project awarded on the day of , 20 , under Contract Number for the construction of (brief description of the Work) by the City in accordance with drawings (plans) and specifications, if any, prepared by which Contract is hereby made a part hereof by reference and is hereafter referred to as the "Contract"; THE CONDITION OF THIS BOND is that if the Contractor: I. Promptly performs the construction work in the time and manner prescribed in the Contract; and 2. Promptly makes payments to all claimants, as defined in Section 255.05, Florida Statutes, supplying Contractor with labor, materials, or supplies, used directly or indirectly by Contractor in the prosecution of the work provided for in the Contract; and 3. Pays City all losses, damages, expenses, costs, and attorney's fees, including those incurred in any appellate, mediation or arbitration proceedings, if any, that Owner sustains because of a default by Contractor under the Contract; and 4. Performs the guarantee of all work and materials furnished under the contract for the time specified in the contract, then this obligation shall be void; otherwise, it shall remain in full force and effect. Any action instituted by a claimant under this bond for payment must be in accordance with the notice and time limitation provisions in Section 255.05(2), Florida Statutes. The Surety hereby waives notice of and agrees that any changes in or under the Contract Documents and compliance or noncompliance with any formalities connected with the Contract shall not affect the Surety's obligation under this Bond. IN WITNESS WHEREOF, the above bonded parties have executed this instrument under their several seals on this day of , 20 , the name and the corporate seal of each corporate party being hereto affixed and these presents being duly signed by its undersigned representative. IN PRESENCE OF: (Individual, President, Managing Member or General Partner, etc.) (Business Address) (City/State/Zip) (Business Telephone) 97 (Corporate Name) (President) (Business Address) (City/State/Zip) (Business Telephone) INSURANCE COMPANY: BY: (SEAL) (Agent and Attorney-in-fact Signature) (Business Address) (City/State/Zip (Business Telephone) STATE OF FLORIDA ) ) COUNTY OF MIAMI-DADE ) On this, the day of , 20 , before me appeared who is the (Title), of (Name of legal entity), a (State of Incorporation) company or partnership, on behalf of the corporation and who is personally known by me or who provided me with the following type of identification and who took an oath or affirmed that he/she is the person who signed the foregoing payment bond. WITNESS my hand and official seal. Notary Public, State of Florida NOTARY PUBLIC: SEAL (Name of Notary Public: Print, Stamp or Type as commissioned.) *Power of Attorney must be attached. END OF DOCUMENT OR ATTEST: Secretary IN THE PRESENCE OF: 98 Respondents Qualification Statement RESPONDENT QUALIFICATION STATEMENT Bus Shelter Fabrication & Installation RFP #PW-2015-21 The response to this questionnaire shall be utilized as part of the CITY'S overall Proposal Evaluation and RESPONDENT selection. I. Number of similar projects completed, a) In the past 5 years In the past 5 years On Schedule b) In the past 10 years In the past 10 years On Schedule 2. List the last three (3) completed similar projects, a) Project Name: Owner Name: Owner Address: Owner Telephone: 1 Original Contract Completion Time (Days): III Ukll6T. soflfr feio, mum V>\Z?> Original Contract Completion Date: Actual Final Contract Completion Date: Original Contract Price: Actual Final Contract Price: b) Project Name: Owner Name: Owner Address: Owner Telephone: Original Contract Completion Time (Days): Original Contract Completion Date: Actual Final Contract Completion Date: Original Contract Price: Actual Final Contract Price »<3 12 Owner Address: I ) Owner Telephone: P/A Original Contract Completion Time (Days): Original Contract Completion Date: p /a- Actual Final Contract Completion Date: ak Original Contract Price: Actual Final Contract Price: 3. Current workload Project Name Owner Name Telephone Number Contract Price Joe. HwA-fcWH-school f\)t>Ll^ SCUooU» TA^fA tK\.t^otl 4te>t*>- 2eo-ssio *\\%3\0<°° Z.OO r4l**V-U dALOUUA AOfbuSO #3o5-3lS- 31/1 \ &>buc 6CH00L6 * |£6,O0O • 4. The following information shall be attached to the proposal. a) RESPONDENT'S home office organization chart. - 6€£. A.fT*c+-M£C b) RESPONDENT'S proposed project organizational chart. - f>€5fc> &X-XiX\>&0 c) Resumes of proposed key project personnel, including on-site Superintendent. - 66^> AT|ioc*4i££} 5. List and describe any: I3 a) Bankruptcy petitions filed by or against the Respondent or any predecessor organizations, (^f-lQM&) b) Any arbitration or civil or criminal proceedings, or - \\q Suspension of contracts or debarring from Bidding or Responding by any public agency brought c) against the Respondent in the last five (5) years — lJq 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: MtAUl- kACfo CoXiX'l -tdJuUs L Affft [ 16 Address: Telephone No.: Contact Person: Type of Project: 111 l6t,6oi-re#(>iQ HtevAi tf>3»2& Name of Agency: CrCV Of ColAb &u6l£^> Address: Telephone No.: 3o^A(ffO' 5oS?> Contact Person: Type of Project: [UfcUoP \&Adl&icb & CXU hWMlttf O^f' Name of Agency: U\t*\ CflDUtl AutffTlOU AffiT Address: Telephone No.: Contact Person: Type of Project: 3o5- g7fe- c3326j 14 Organizational Ch< Cl i e n t I Co n s u l t a n t (A r c h i t e c t s & E n g i n e e r s ) r Pr o j e c t C o n t r o l • E s t i m a t i n g • S c h e d u l i n g • C o n t r a c t s • P e r m i t t i n g • P r e - Q u a l i f i c a t i o n I Canyon Construction, Inc. President/PM Rosa LaRue Co n s t r u c t i o n Administration • P r o j e c t Managers • S u p e r i n t e n d e n t s / F o r e m e n • S u b - C o n t r a c t o r s • S u p p l i e r s • F i e l d Personnel 1 Accounting Dept. • Accounts Receivable • Accounts Payable • Procurement • Payroll • MWBE Compliance Pr o j e c t Organizational Chart Co n s u l t a n t (A r c h i t e c t s & E n g i n e e r s ) President/PM Rosa LaRue F • 'r o j e c t C o n t r o l Ro s a L a R u e i 1 Co n s t r u c t i o n Administration Su p e r i n t e n d e n t s / F o r e m e n (Jose Llera) Su b - C o n t r a c t o r s ( F l e i t e s Const.) Su p p l i e r s ( J o h n A b e l l Corp/Wabash Valley/Builders Specialty) Fi e l d P e r s o n n e l ( R a f a e l Munoz/Jesus Otano) Accounting Dept. Silvia Gomez V. Pr o p o s e d Project Team Ro s a L a R u e Pr e s i d e n t / P r o j e c t M a n a g e r Ro s a L a R u e , President/Principal of Canyon Construction Inc., has over 26 ye a r s k n o w l e d g e and experience in the construction field. She graduated from Fl o r i d a I n t e r n a t i o n a l University (FIU) with a Bachelor of Science degree in Co n s t r u c t i o n Management in 1987 and has a Building License and an Un d e r g r o u n d Utility License from the State of Florida. Her knowledge and ex p e r i e n c e h a s allowed Canyon to expand into multiple types of construction in d u s t r i e s i n b o t h the public and private sectors. Ro s a h a s e x t e n s i v e experience in working with Governmental Agencies such as Mi a m i - D a d e C o u n t y Public School System, Miami-Dade County Government, Mi a m i - D a d e A v i a t i o n Department and the Utility Industry. Sh e h a s b r o a d experience in construction management and fast tracking pr o j e c t s w h i l e the facilities are occupied. Ro s a h a s g r e a t knowledge in design review, estimating, value engineering, life cy c l e c o s t a n a l y s i s , scheduling, quality control, constructability cost control and pr o j e c t c l o s e - o u t . Ro s a w i l l b e t h e Principal-in-charge for all M-DCPS projects. Pr o p o s e d Project Team J. C . C a b a l l e r o Es t i m a t o r / S c h e d u l e r ft Je s u s C a r l o s ( J C ) Caballero has over 45 years experience in the construction in d u s t r y c o n s i s t i n g of project management, project superintendent, and es t i m a t i n g a n d scheduling. He graduated from Pratt Institute in 1974, received hi s B a c h e l o r o f Science degree in Construction Management in 1982 and has a Ge n e r a l C o n t r a c t o r ' s License from the State of Florida. Pr i o r t o c o m i n g on board with canyon, JC worked for Mike Gomez Construction, th e C o n s t r u c t i o n Management contractor responsible for the Miami-Dade Co u n t y M C C c o n t r a c t at Miami International Airport. He was responsible for pr e p a r i n g b i d packages, estimating, project management, execution of pr o d u c t i o n s c h e d u l e s and monitoring budget/cost progression on current co n t r a c t s . Hi s p a s t e x p e r i e n c e includes working at Vesallo Construction where he was re s p o n s i b l e f o r building educational facilities in Miami, such as the FIU School of H o s p i t a l i t y M a n a g e m e n t , as well as, multiple M-DCPS projects for Building Ad d i t i o n s , C l a s s r o o m Remodeling, HVCA and Chiller Replacements, Fire Alarm re t r o f i t s , D r a i n a g e Systems and Parking. J. C . w i l l b e r e s p o n s i b l e for project estimating, preparing bid packages, sc h e d u l i n g t o c o m p l y with project deadlines. and Jo s e " P e p e " L l e r a Su p e r i n t e n d e n t / F o r e m a n Pr o p o s e d Project Team • : • Jo s e " P e p e " L l e r a has over 25 years of experience in the construction industry. He h a s b e e n a P r o j e c t Superintendent for Canyon Construction over the past 3 ye a r s i n v a r i o u s projects. Jo s e ' s d u t i e s a n d responsibilities include but are not limited to the following it e m s ; C o o r d i n a t i o n among sub-contractors, suppliers and Owners; supervising an d d i r e c t i n g t r a d e s workers in the field; reviewing permitted plans and ap p r o v e d S h o p drawings to ensure quality workmanship; daily Safety Plan Co m m u n i c a t i o n s and holding safety meetings with sub-contractors and em p l o y e e s ; s u b m i t t i n g Daily Construction Reports; and adhering to the project sc h e d u l e t o a s s u r e all projects get completed on time. He h a s e x t e n s i v e knowledge and experience working with Miami-Dade County Pu b l i c S c h o o l s , M i a m i - D a d e College, Miami-Dade International Airport, several ot h e r a g e n c i e s a n d the private sector. Jo s e w i l l b e C a n y o n ' s Project Superintendent for M-DCPS projects. List of Proposed Subcontractors and Principal Suppliers LIST OF PROPOSED SUBCONTRACTORS AND PRINCIPAL SUPPLIERS Bus Shelter Fabrication & Installation RFP#PW-20I5-2I Respondent shall list all proposed subcontractors, if subcontractors are allowed by the terms of this Solicitation to be used on this project if they are awarded the Contract. Classification of Work Subcontractor Name Address Telephone, Fax & Email Landscape HlAMiedA^-lyPl -331AI ro5*^a^H>nconStf«eHo(n-ne r Sodding and Turf Work Electrical M/A U /A U/A Irrigation U/A U/A U/A Paving U/A KA r~>/k Park Amenities U/A U/A U/A Graphics U/A-MA M/A Utilities U/A U/A Excavation 3cS-~?<*3£&,Q roS4-Gc»nHart con str^cHon • Building <*S53 CbtUrl^AvJtV MiamifeoftCM/^i fl/f 44 3pS "«6»3 ' Structures fc>52>e> OotUM<p /U»6 Wi6Mlfie*uH,fl53UH Plumbing M/A u/A- Painting M/A u//v Testing Laboratory I62oM£> (44 sr. Soil Fumigator Signs U/A U/A H/A Other: This list shall be provided to the City of South Miami by the apparent lowest responsive and responsible Bidder within five (5) business days after Bid Opening. END OF SECTION 15 Non-Collusion Affidavit NON COLLUSION AFFIDAVIT STATE OF FLORIDA COUNTY OF MIAMI-DADE being first duly sworn, deposes and states that: (I) He/She/They is/are the (Owner, Partner, Officer, Representative or Agent) of attached Proposal; the Respondent that has submitted the (2) (3) (4) (5) He/She/They is/are fully informed concerning the preparation and contents of the attached Proposal and of all pertinent circumstances concerning such Proposal; Such Proposal is genuine and is not a collusive or sham Proposal; 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; 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 and delivered in the presence of: By: Witne Signature Print Name and Title e>/3/ig> Date ACKNOWLEDGEMENT STATE OF FLORIDA COUNTY OF MIAMI-DADE On this the [tj^ day of JWQiJ^tT , 20 \fi> , before me, the undersigned Notary Public of the State of Florida, personally appeared (Name(s) of individual(s) who appeared before y^m^mtmutmM^m^t^mmtmmtmmt 16 m MERCEDES SOSA Notary Public • Stat* of Florida Comm. Expires Mar 31,2018 Commission # Ff 080738 notary) Kp^yV" L/V f\)i^ aod^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. NOTARY PUBLIC: SEAL OF OFFICE: ublic, State of Florida Haft*' MERCEDES SOSA I Notary Public • State of Florida I My Comm. Expires Mar 31.2018 f Commission # FF 080738 (Name of Notary Public: Print, Stamp or type as commissioned.) Y\y known to me, or Personal identification: Type of Identification Produced X, Did take an oath, or Did Not take an oath. 17 Public Entity Crimes and Conflicts of Interest 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 I 12, 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. I. This sworn statement is submitted to Mh of 5oom HltVHi [print name of the public entity] by Pg€6tpepT iprint individual's name and title] [print name of entity submitting sworn statement] whose business address is 53 8> (UXX.IU€> Av£ # HZ- and (if applicable) its Federal Employer Identification Number (FEIN) is HO — Po]5rPJ3 ^ tne entity has no FEIN, include the Social Security Number of the individual signing this sworn statement: I understand that a "public entity crime" as defined in Paragraph 287.133 (l)(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. I understand that "convicted" or "conviction" as defined in Paragraph 287.133 (I) (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. 4. I understand that an "affiliate" as defined in Paragraph 287.133 (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 convicted of a public entity crime. The term "affiliate" includes those officers, 18 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 (I) (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. Based on information and belief, the statement which I have marked below is true in relation to the entity submitting 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 I, 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 I, 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. Sworn to and subscribed before me this Personally known _ 2l. day of OR Produced identification (Type of identification) Form PUR 7068 (Rev.06/1 1/92) otary Public - State of ^L-O £-\X?A My commission expires ~ ) t? (Printed, typed or stamped commissioned name of notary public) 9 >W> MERCEDESSOSA 2j#\y Public - State ot Florida My Comm. Expires Mar 31.2018 Commission # FF 080738 19 Drug Free Workplace DRUG FREE WORKPLACE 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: 1) 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 a copy of the statement specified in Subsection (I). 4) In the statement specified in Subsection (I), notify the employees, that, as a condition of working of the commodities or contractual services that are under Bid, he employee shall abide by the terms of the statement and shall notify the employee of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) business days after such conviction. 5) Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program, if such is available in the employee's community, by any employee who is so convicted. 6) Make a good faith effort to continue to maintain a drug-free workplace through implementation of this section. As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements. RESPONDENT'S Signature: le statement, I certify that thi: Print Name: E<9€A L-£.£o& Date: 0 /l V /\*> 20 Acknowledgement of Conformance with OSHA Standards ACKNOWLEDGEMENT OF CONFORMANCE WITH OSHA STANDARDS Bus Shelter Fabrication & Installation RFP#PW-20I5-2I TO THE CITY OF SOUTH MIAMI IPC^ • , (Name of CONTRACTOR), hereby acknowledge and agree that as CONTRACTOR for the Bus Shelter Fabrication & Installation 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 of South Miami and R.J. Behar & Company, Inc., (Consultants) against any and all liability, claims, damages, losses and expenses they may incur due to the failure of (Sub-contractor's names): to comply with such act or regulation. CONTRACTOR BY: fcoSfr lAe^CS. Name Title Witness 21 Affidavit Concerning Federal & State Vendor Listings AFFIDAVIT CONCERNING FEDERAL AND STATE VENDOR LISTINGS The person, or entity, who is responding to the City's solicitation, hereinafter referred to as "Respondent", must certify that the Respondent's name Does Not appear on the State of Florida, Department of Management Services, "CONVICTED, SUSPENDED, DISCRIMINATORY FEDERAL EXCLUDED PARTIES and COMPLAINTS VENDOR LISTINGS". If the Respondent's name Does appear on one or all the "Listings" summarized below, Respondents must "Check if Applies" next to the applicable "Listing." The "Listings" can be accessed through the following link to the Florida Department of Management Services website: http://www.dms.myflorida.com/business operations/statepurchasing/vendor information/convicted susp ended_discriminatory_complaints_vendor_lists I, ~ DECLARATION UNDER PENALTY OF PERJURY (hereinafter referred to as the "Declarant") state, under penalty of perjury, that the following statements are true and correct: (I) I represent the Respondent whose name is ~EB1P (2) have the following relationship with the Respondent (Owner (if Respondent is a sole proprietor), President (if Respondent is a corporation) Partner (if Respondent is a partnership), General Partner (if Respondent is a Limited Partnership) or Managing Member>(if Respondent is a Limited Liability Company). (3) I have reviewed the Florida Department of Management Services website at the following URL address: http://www.dms.myflorida.com/business_operations/state_purchasing/vendor_information/convicted_suspended_di scriminatory_complaints_vendor_lists (4) I have entered an "x" or a check mark beside each listing/category set forth below if the Respondent's name appears in the list found on the Florida Department of Management Services website for that category or listing. If I did not enter a mark beside a listing/category it means that I am attesting to the fact that the Respondent's name does not appear on the listing for that category in the Florida Department of Management Services website as of the date of this affidavit. Check if Applicable Convicted Vendor List Suspended Vendor List Discriminatory Vendor List Federal Excluded Parties List Vendor Complaint List FURTHER DECLARANT SAYETH NOT. f) (Signature of ACKNOWLEDGEMENT STATE OF FLORIDA ) COUNTY OF MIAMI-DADE ) On this the j _ day of appeared ILo/,* Lfi, R.Jr . 20_ following identification foregoing Affidavit as the Declarant. f S> • before me, the undersigned authority, personally _ who is personajjy^know to me or who provided the and who took an oath or affirmed that t^ijt he/she/tfiey executed the WITNESS my hand and official seal. NOTARY PUBLIC: SEAL (Name of Notary Public: Print, Stamp or type as commissioned.) " - - m 22 MERCEDES SOSA \y Public • State ot Florida k# My Comm. Expires Mar 31.2018 '"'•HfJ,^ Commission # FF 080738 m Related Party Transaction Verification Form RELATED PARTY TRANSACTION VERIFICATION FORM I _____ , individually and on behalf of (^MUfti ^*%XAV*1, ("Firm")have Name of Representative CompanylVendor/Entity read the City of South Miami ("City")'s Code of Ethics, Section 8A-1 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 Firm, has any relative(s), as defined in section 8A-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, [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 (2) 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 of employees or those who have a financial interest in the Firm.]; 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: i ___v _(use (if necessary, use a separate sheet to supply additional information that will not fit on this line; however, you must make reference, on the above line, to the additional sheet and the 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 (3) 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 of those who have a financial interest in the Firm.]; and (4) no elected and/or appointed official or employee of the City of South Miami, or any of their immediate family members (i.e., spouse, parents, children, brothers and sisters) has a financial 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 use a separate names: M- /A (if necessary, use a separate sheet to supply additional information that will not fit on this line; however, you must make reference, on the above line, to the additional sheet and the additional sheet 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: i. Mj_V (if necessary, use a separate sheet to supply additional information that will not fit on this line; however, you must make reference, on the above line, to the additional sheet and the 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 (4) shall be based solely on the signatory's personal knowledge and he/she is not required to make an independent investigation as to the financial interest in the Firm of city employees, appointed officials or the immediate family members of elected and/or appointed official or employee.] (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 23 before any board, commission or agency of the City within the past two years other than as follows: __A (if necessary, use a separate sheet to supply additional information that will not fit on this line; however, you must make reference, on the above line, to the additional sheet and the additional sheet must be signed under oath). X:\PurchasingWendor Registration 12.28.12 RELATED PARTY TRANSACTION VERIFICATION FORM [3].docx (7) Neither I nor any employees, officers, or directors of the Firm, nor any of their immediate family (i.e., 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: M l(\f necessary, use a separate sheet to supply additional information that will not fit on this line; however, you must make reference, on the above line, to the additional sheet and the 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 I 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 (i.e. spouse, parents, children, brothers and sisters) have also responded, other than the following: # . necessary, use a separate sheet to supply additional information that will not fit on this line; however, you must make reference, on the above line, to the additional sheet and the 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 (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 financial 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 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. (10) 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 of the 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 attesting hereinabove and that the statements made hereinabove are true%id correct to the best of my knowledge, information and belief. Signature: Print Name & Title: Date: 24 Presentation Team Declaration/Affidavit of Representation PRESENTATION TEAM DECLARATION/AFFIDVAIT OF REPRESENTATION This affidavit is not required for compliance with the City's Solicitation; however, it may be used to avoid the need to register members of your presentation team as lobbyists. Pursuant to City Ordinance 28-14- 2206 (c)(9), any person who appears as a representative for an individual or firm for an oral presentation before a City certification, evaluation, selection, technical review or similar committee, shall list on an affidavit provided by the City staff, all individuals who may make a presentation. The affidavit shall be filed by staff with the Clerk's office at the time the committee's proposal is submitted to the City Manager. For the purpose of this subsection 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. No person shall appear before any committee on behalf of an anyone unless he or she has been listed as part of the firm's presentation team pursuant to this paragraph or unless he or she is registered with the City Clerk's office as a lobbyist and has paid all applicable lobbyist registration fees. Pursuant to '92.525(2), Florida Statutes, the undersigned, declaration under penalty of perjury: makes the following 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 committee on behalf of anyone unless he or she has been listed as part of the firm's presentation team pursuant to this paragraph or unless he or she is registered with the Clerk's office as a lobbyist and has paid all applicable lobbyist registration fees. NAME TITLE Jose? 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 ,2015 • Print name of entity being represented Executed this davof Signature of Representative Print Name and Title 29