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
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4te>t*>- 2eo-ssio *\\%3\0<°°
Z.OO r4l**V-U dALOUUA AOfbuSO
#3o5-3lS- 31/1 \
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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
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g
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)
r
Pr
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t C
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• E
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• S
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• C
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• P
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g
• P
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-
Q
u
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I
Canyon Construction, Inc. President/PM Rosa LaRue
Co
n
s
t
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t
i
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n Administration
• P
r
o
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c
t Managers
• S
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e
n
d
e
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/
F
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• S
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-
C
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t
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t
o
r
s
• S
u
p
p
l
i
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r
s
• F
i
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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
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t
(A
r
c
h
i
t
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c
t
s &
E
n
g
i
n
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s
)
President/PM Rosa LaRue
F
•
'r
o
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c
t C
o
n
t
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l
Ro
s
a L
a
R
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i
1
Co
n
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t
r
u
c
t
i
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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