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HARTZELL CONSTRUCTION, INC.Proposal Submittal Checklist Form This checklist indicates the forms and documents required to be submitted for this solicitation and to be presented by the deadline set for within the solicitation. Fulfillment of all solicitation requirements listed is mandatory for consideration of response to the solicitation. Additional documents may be required and, if so, they will be identified in an addendum to this RFP. The response shall include the following items: Submit this checklist along with your proposal indicating the completion and submission of each required forms and/or documents. Mr Z tpepe02-18-13 Page 10 of 69 Bid Form II X Proposal Bond 14 X Performance Bond ---------- 16 X Respondents Qualification Statement ---------- 20 X Non-Collusion Affidavit 23 X Public Entity Crime, and Conflicts of Interest 25 X Drug Free Workplace --------- 27 X-------- Acknowledgement of Conformance with OSHA Standards M__� 28 X List of Proposed Subcontractors and Principal Suppliers 29 X Related Party Transaction Verification Form 30 X Indemnification and Insurance Documents 68 Submit this checklist along with your proposal indicating the completion and submission of each required forms and/or documents. Mr Z tpepe02-18-13 Page 10 of 69 BID FORM THIS PROPOSAL IS SUBMITTED TO: Steven Alexander City Manager City of South Miami 6130 Sunset Drive South Miami, FL 33143 RFP Bus Shelters Phase 2 . If this Proposal is accepted, the undersigned Respondent agrees to enter into a Contract with the City of South Miami in the form included in this RFP Package, and to perform and furnish all work as specified or indicated in this RFP for the Proposed Price, within the Contract Time and in accordance with the other terms and conditions of the RFP Package. 2. Respondent accepts all of the terms and conditions of the Advertisement, RFP, Invitation for Proposals and Instructions to Respondents, including without limitation those dealing with the disposition of Proposal Bond /Security. This Proposal will remain subject to acceptance for 90 calendar days after the day of the Proposal Opening. Respondent agrees to sign and submit the Contract, the Bonds, Insurance Policy with appropriate endorsements, Insurance Certificate, and other documents required by the RFP, within ten (10) calendar days after the date of the City's Notice of Award. 3. In submitting this Proposal, Respondent represents that: a. Respondent has examined copies of all the RFP Documents and of the following Addenda, if any (receipt of all which is hereby acknowledged.) Addendum No. Dated: ll V/ 7j Addendum No. :;tf Dated: % 7 ,-2013 Addendum No. Dated: Addendum No. Dated: Addendum No. Dated: Addendum No. Dated: b. Respondent has familiarized himself with the nature and extent of the Contract Documents, the proposed work, site, locality, and all local conditions and laws and regulations that in any manner may affect cost, progress, performance or furnishing of the Work. c. Subsurface conditions: If applicable to this RFP, the Respondent represents that: i. Respondent has studied carefully all reports and drawings, if applicable, of subsurface conditions and drawings of physical conditions. ii. Respondent has obtained and carefully studied (or assumes responsibility for obtaining and carefully studying) all such examinations, investigations, explorations, tests and studies in addition to or to supplement those referred to in (c) above which pertain to the subsurface or physical conditions at the site or otherwise may affect the cost, progress, performance, or the furnishing of the Work at the Contract Price, within the Contract Time and in accordance with the other terms and conditions of the Contract Documents. The Respondent hereby acknowledges that no additional examinations, investigations, explorations, tests, reports or similar information or data are, or will, be required by Respondent for any reason in connection with the Proposal. iii. Respondent has correlated the results of all such observations, examinations, investigations, explorations, tests, reports and studies with the terms and conditions of the Contract Documents. tpepe02 -18 -13 Page I I of 69 iv. Respondent has reviewed and checked all information and data shown or indicated in the RFP Package or in the Contract Documents with respect to existing Underground Facilities at or contiguous to the site and assumes responsibility for the accurate location of all Underground Facilities. No additional examinations, investigations, explorations, tests, reports or similar information or data in respect to any Underground Facilities are, or will be, required by Respondent in order to perform and furnish the Work at the Contract Price, within the Contract Time and in accordance with the other terms and conditions of the Contract Documents. d. Respondent has given the City written notice of all conflicts, errors or discrepancies that it has discovered in the Contract Documents and, if any conflicts, errors or discrepancies have been found and notice given, the Respondent represents, by submitting its proposal to the City, that the Respondent has received sufficient notice of the resolution thereof from the City, that such resolution is acceptable to Respondent and that the Respondent waives any claim regarding the conflicts, errors or discrepancies. e. This Proposal is genuine and not made in the interest of or on behalf of any undisclosed person, firm or corporation and is not submitted pursuant to any agreement or rules of any group, association, organization, or corporation; Respondent has not directly or indirectly induced or solicited any other Respondent to submit a false or sham Proposal; Respondent has not solicited or induced any person, firm or corporation to refrain from responding; and Respondent has not sought by collusion or otherwise to obtain for itself any advantage over any other Respondent or over the CITY. Respondent understands and agrees that the Contract Price is the amount that it needs to furnish and install all of the Work complete and in place. The Schedule of Values, if required, is provided for the purpose of Proposal Evaluation and when initiated by the CITY, it shall form the basis for calculating the pricing of change orders. The Contract Price shall not be adjusted in any way so as to result in a deviation from the Schedule of Values, except to the extent that the CITY changes the scope of the Work after the Contract Date. As such, the Respondent shall furnish all labor, materials, equipment, tools, superintendence and services necessary to provide a complete, in place, Project for the Proposal Price of: LUMP SUM BASE PRICE: dollars and Alternates: #1 #2 #3 #4 Y '- 6) cents #5 #6 #7 #8 C/ f.�cF �/ o V5 A fee breakdown, if applicable, for each task must be completed in the table shown above. Failure to complete this information shall render the proposal non - responsive. 5. The ENTIRE WORK shall be completed, in full, within 120 days from the date stipulated in the NOTICE TO PROCEED. Failure to complete the entire work during the described time period shall result in the assessment of liquidated damages as set forth in the Contract. 6. Communications concerning this Proposal shall be addressed to: tpepe02 -18 -13 Page 12 of 69 RESPONDENT: A16, Goc�w,, SUBMITTED THIS At.-, DAY OF 20� fa. 4AV42 e I I Company Title Telephone Number Email -Address tpepe02-18-13 Page 1 3 of 69 RESPONDENT QUALIFICATION STATEMENT RFP Bus Shelters Phase 2 The response to this questionnaire shall be utilized as part of the CITY'S overall Proposal Evaluation and RESPONDENT selection. I . Number of similar construction 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/ On Schedule 2. List the last three (3) completed similar projects. a) Project Name: TLX5 CCA V11 t7G1 ' 4� [oC..4f Owner Name: uc�Gc,�i�lO� Owner Address: 4W 60. lat Owner Telephone: Original Contract Completion Time (Days): 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 c) Project Name: Owner Name: Owner Address: Owner Telephone: Original Contract (Days): tpepe02 -18 -13 P1 1,013 �r SG )' :27, S(o7' 7 ��, c� �� C��C Ia.- �� � �. ✓ C l✓ l Completion Time Page 20 of 69 000) vc" v &941 /�;Cl c c7 fZia n� e4 - A,517 P1 1,013 �r SG )' :27, S(o7' 7 ��, c� �� C��C Ia.- �� � �. ✓ C l✓ l Completion Time Page 20 of 69 Original Contract Completion Date: Actual Final Contract Completion Date: Original Contract Price: Actual Final Contract Price: 3. Current workload COO Project Owner Contract lo I), 'd i (' 37-3- 7F -) 4. The following information shall be attached to the proposal. a) RESPONDENT'S home office organization chart. b) RESPONDENT's proposed project organizational chart. c) Resumes of proposed key project personnel, including on -site Superintendent. 5. List and describe any: 00 a) Bankruptcy petitions filed by or against the Respondent or any predecessor organizations, b) Any arbitration or civil or criminal proceedings, or Suspension of contracts or debarring from Bidding or Responding by any public agency brought c) against the Respondent in the last five (5) years I. Government References: tpepe02 -18 -13 Page 21 of 69 List other Government Agencies or Quasi - government Agencies for which you have done business within the past five (5) years. Name of Agency: Address: Telephone No.: Contact Person: Type of Project: Name of Agency: Address: Telephone No.: Contact Person: Type of Project: Name of Agency: Address: Telephone No.: Contact Person: Type of Project: tpepe02 -18 -13 t, ai &)(a :7Z ✓a 10 °.t ✓dra /G Gl J 3�3- '�5'y!a <� "911 oo, S /G,� /oc ✓y �2" % < -_ , ✓, 3 3 y3 � Page 22 of 69 0FP8us Shelters Phase 2 being first duly sworn, deposes and states that: ()) He/She/They is/are the (Owner, Partner, Officer, Representative or attached Proposal; -- the Respondent that has submitted the (2) He/She/They is/are fully informed concerning the preparation n and nd contents of the attached Proposal —n_-._.' c .^..=.t".uunvonrexconccrn/ngsurhPropoxo|; (3) Such Proposal is genuine and ix not u collusive mr sham Proposal; (4) Neither the said Respondent nor any of its officers, partners, owners, agents, representatives, employees or. parties in interest` including this affiont, have /» any way colluded, conspired, connived oragreed. dir= cdyor indirectly, with anyother Respondent, firm, or person to submit o collusive o' uhum Proposal in connection with the Work for which the attached Proposal has been submitted; or to refrain from Bidding or proposing )n connection with such Work; orhave / » any manner, directly nr indirectly, sought by agreement or collusion, or communicati*n, or conference with ooy Respondent, 0rm, or person to fix any overhead, profit, or cost elements of the Proposal or of any Raspondenc, or to 8x any nvc,6eod ' profit, or cost elements of the Proposal Price or the proPps»|Price of any other Respondent, orto secure through any collusion, conspiracy, connivance, or unlawful agreement any advantage against (Recipient), or any person interested in the proposed Work/ (S) The price or prices quoted in the attached Proposal are fair and proper and are not tainted by any collusion, . `mmp/mcx connivance, pr unlawful agreement mn the part pf the Res 6 c*im agents, represenmt/ves.owners, employees urpa/�ieoofinteresti |d� p»»ento/ any other . ncu n�thisaffiont. Signed, sealed and delivered in the presence of. tress Witness tpcpeoz /mu WMERM UMMOMWTV IMMUMEN" D Thomas F. Pepe, 2011-2013. All rights reserved. 6/18/13 I PUBLIC ENTITY CRIMES AND CONFLICTS OF INTEREST RFP Bus Shelters Phase 2 Pursuant toth mv�� f ep provisions opnragraphCU(a)ufSpction287|33.RoridaStateSmtutes—'\4peoonoraffi|iate who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit a Proposal or 6i6 on u Contract to provide any goods or services to a public entity, may not submit o Bid or proposal for a Contract with a public entity for the construction of repair of a public building or public work, moy notaubmit6ida or proposals on imumes or real property to apuNic entity, may not be awarded to perform Work as n RESPONDENT, Sub-contractor, supplier, Sub-consultant, or Consultant under o Contract with any r--|ic entity, and may not transact business with any public entity in excess of the threshold amount Category Two of 287.017, Florida Statutes, for thirty six (36) months from the date of being placed on the convicted vendor The award of any contract hereunder is subject to the provisions of Chapter |Ll Florida State Statuteu Respondents most disclose with their Proposals, the name of any officer, director, partner, associate or agent is also an officer or employee of the City of South Miami or its agencies, This sworn statement is submitted to \ [> \ by � { ~ ` � ^ »vrw�I Lprmt individual's n me and title] fo [print name of entity submitting sworn statement] l | understand that a "public entity crime" as defined in - �287|33 (1)(g), meuns a violation of any state or federal law by a person with respect Florida Statutes to and directly related to the transaction of business with any public entity or with an agency orpolitical subdivision cf 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, co||uminn, racketeering, conspiracy, or material misrepresentation. ]. | understand that "convicted" or "conviction" as defined in Paragraph 207133 (|) (b). Florida Statutes, means z finding of guilt ora conviction cfu public entity crime, with or without mnadjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, non-jury trial, or entry of a plea of guilty or no|pcontendpre. 4. { understand that an`\aff7|kate'au defined in Paragraph 287|33(|)(a). means: hd Apredeceoor or successor ofoperson convicted ofapublic 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 public entity crime. The term "affiliate" includes those oNcem, directors, exemdvea, pnoneo, shoreho|ders, emp|oyees, mem6ers, and agents who are active in (c) Thomas e. Pepe, zu|/-2o|s. All rights reserved. the management ofanaffikuue. The ownership by one person of shares constituting ocontrolling interest in any person, oropooling of equipment orincome among persons when not for fair market mJuc under an arm's length agreement, nk6| be a prima tode case that one person controls another person. Apmnon who knowingly enters into a joint venture with a person who has been convicted of public entity crime in Florida during the preceding 36 months shall bc considered anaffi|iate. S. | understand that o^peoon^ as defined in Paragraph 287133 (1) (e), Florida Statutes, means any natural person pr entity organized under the laws of any state nrnf the United States with the legal power to enter into o binding contract and which bids or proposal or applies to bid or proposal on contracts for the provision of goods or services /et by a public encity, or which otherwise transacts or applies to transact business with apu6|ic entity. The term "person" includes those officeo, directoo, executives, pn/tners, nkorcho|deo, emp|oyeco, members, and agents who are active in management of an entity. 6 Based on information and belief, the statement which | have marked below ix true in relation to the entity submitting this sworn statement. [indicate which statement nppUesj Neither the entity submitting this sworn statement, nor any ofits m0cao, directors, executives, partners, shareholders, empkoyeeu, mem6era, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. ___The entity submitting this sworn statement, or one nr more of its officers, directors, execudves, partners, shareholders, employees, members, oragents who are active in the management of the entity, oranaffi|iatecf the entity has been charged with and convicted ofa public entity crime subsequent ooJuly __.The entity submitting this sworn statement, or one ormore of its officers, directors, execudves, partners, shareholders, employees, members, or agents who are active in the management of the endty, orundfiUmrof the entity has been charged with and convicted ofa public entity crime subsequent ofJuly |. 1989. However, there has been u 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 or6er] Sworn to and subscribed before me this day Personally known �~ OR Produced identification (Type of identification) Form PUR7068(Rev.0K||/92) m Thomas s Pepe, zuu-2mo. All rights reserved. onmo WIN 9 My commission expires (Printedtypedorstampedcommissioned name of notary public) Notary Public $tate of Florida, E,I)400?000, Carly Bittlingmeyer = ff My Commission EE 187219 My ro -; oF V�� s05/ 01 Expires 05/28/2016 RFP Bus Shelters Phase Whenever two or more Bids or Proposals which are equal with respect on price, quality and service are received by the State nrby any political subdivisions for the procurement of commodities or contractual services, u Bid or Proposal received from a business that certifies that it has implemented u 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. |n order to have m drug-free workplace program, a business shall: |) Publish n 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 progoms, 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 cf the statement specified in Subsection ({). 4) |n the statement specified inSubsection (|). notify the employees, that, usu condition ofworking of the commodities or contractual services that are under BiU, 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 nr any state, for ovim|atimn occurring in the workplace no later than five (S) 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. Aa the person authorized to sign the statement, | certify that this firm complies fully with the above requirements. (0 Thomas s Pepe, mu-2ns All rights reserved. mxus RFP Bus Shelters Phase 2 We, (Name of hereby acknowledge and agree that as CONTRACTORs for the Bus Shelters Phase 2 project os specified have the sole responsibility for compliance with all the requirements cf the Federal Occupational Safety and Health Act of|97U and all State G. Batista & Associates and local safety and health regulations, and agree to indemnify and hold harmless the City of South Miami and against any and all |iu6i|i9` claims, damages, losses and expenses they may incur due uz the failure of (Su6- contractor's nomes): 0 Thomas F. Pepe, m//-2mo. All rights reserved. m/nm/ LIST OF PROPOSED SUBCONTRACTORS AND PRINCIPAL SUPPLIERS Bus Shelters Phase 2 BIDDER shall list all Proposed Subcontractors to be used on this project if they are awarded the Contract Classification of Work Landscape Subcontractor v Address Email Sodding and Turf Work Electrical Irrigation Paving Park Amenities Graphics Utilities Excavation Building Structures Plumbing Painting Testing Laboratory Soil Fumigator Signs 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. O Thomas F. Pepe, 2011 -2013. All rights reserved. 6/18/13 Page 29 of 69 RELATED PARTY TRANSACTION VERIFICATION FORM RFP Bus Shelters Phase 2 | individually and on behalf qf ("Firm")have Name of Representative CompanylVendorlEntity read the City of South Miami ("City")'s Code of Ethics, SectiunBA- | of the City's Code of Ordinances and I hereby certify, under penalty of perjury that to the best of my knmw/eJ8e, information and belief.- ([) neither I nor the Firm have any conflict of interest (as defined in section 8A- 1) with regard to the contract or business that |, and/or the Firm, am(on) about to perform for, prto 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- 1, 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, �e..a board ur 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, spuuse, psrents, chi|dnan, brothers and sisters) has transacted or entered into any contract(s) with the City or has a financial interest, direct or indirect, in any business being transacted with the city, or with any person or agency acting for the city, other than as follows: _(use (if necessary, use a separate sheet to supply additional information that will not fit on this line; however, you must make reference, on the above line, to the additional sheet and the additional sheet must 6e signed under oath). [while the ethics code still applies, if the person executing this form is doing so on behalf ufafirm 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 m financial interest in the Rrm.];and pAno elected and/or appointed official pr employee of the City ofSouth Miami, or any of their immediate family members (i.e., mpousa, poren,s, chi|drcn, brothers and sisters) has afinancial 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 u separate names: (if necessary, use a separate sheet to supply additional information that will not fit on this line; however, you must make refercncn, on the above line, tothe additional sheet and the additional sheet must bosigned 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 osfollows: (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) 1 and the Firm further agree not to use or attempt to use any knowledge, property or resource which may come uzu, through our position cf trust, or through our performance pf our duties under the terms o/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. (0 Thomas r Pepe, zn/1-2uo, All rights reserved. (6)| and the Firm hereby acknowledge that we have not contracted or transacted any business with the City or any person or agency acting for the City, and that we have not appeared in representation of any third party before any board, commission or agency of the City within the past two years other than as necessary, use a separate sheet to supply additional information that will not fit on this line; however, you must (if make reference, on the above line, to the additional sheet and the additional sheet must be signed under oath). X:\Purchasing\Vendor Registration\ 12.28.12 RELATED PARTY TRANSACTION VERIFICATION FORM [3].docx (7) Neither / nor any employees, officers, or directors cf the Firm, nor any of their —immediate family (i.e., as u spnuse` ~n, daughter, parent, brother orsister) is related by blood ur marriage to: (A any member of the City Commission; (ii) any city employee; or (iii) any member of any board or agency of the City other follows: necessary, use a separate sheet to supply additional ke reference, on the above line, to the additional ile the ethics code still applies, if the person is publicly traded, the statement in this section (7) he/she is not required to make an independent loyees, 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 financial than 5m/n that O�erGrm'nor any member of those pe�pns'immed�te6amik'Ae opuus�parents, �re»�e' brothers and o(u=rs)nor any ofmyimmcdbte�mi�membem(hereinu�erre� (i.e., cm|Uren' responded toump|idtntimm6y the Otyin which )ur the Firm chm| represent o"/�oc»ah h�ueg'ar�iea^)6os mterest greater than S%in the Hnn.or any member cf those pemmn '� Ji ' ^"ypnc«v � ax»»noocia1 chi/drc»' 6r«tkcmand sisteo) huveu|sn nasponded o*hert6an thews|o»me ��efami|Y(ie� sppuue. parents, necessary, use a separate sheet to supply additional information that will not fit on this line; however, y (if make reference, on the above line, to the additional sheet and the additional sheet must be signed und ou must er 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)/ and the Firm agree that *e are obligated oo supplement this Verification Form and inform the City cf any change h/ circumstances that would change our answers urthis document. �c�ly,after the opening cf any responses tnn solicitation, / and the Firm have no obligation «/ supplement this Verification Form with the name of »UKe|atedpardesv6mhavca/onresppndedtmt6esam eap |/otat|onandtodiuc/ome the relationship of those parties toma and the Firm. (|0A violation of the City's Ethics Cod �cX���a�����m�o the «ncomsuPp/cm�n,�6�s /mPosidonofthemaximum0nemn66 cvanYa�reem�nc*i�h�he[��and�he and auWectooacdon6y the Miami-Dade ru»yPe»�|desaUowedby|nw�Add�d�»aUy'vio|n,ionsmuybecon�ideredby �uvemodeudi|iXentef�`rt investigate c�"untYCommissiono»Echic».Underpeno|tyofpe�ur�|drr|orethat| modeherein6 ��themu�ertovvhidh|ama�eobn�hereinz6ovoon6�knc,hex��c a ov 6 statements herein above myknpw/edge.infvnnctipnund6e|ie� the Signature: ~���~��2��`/ Date: X COnmmo r Pepe, zo/1-2mo, All rights reserved, u/xns Project Name: Bus Shelters Phase 2 IMM Date: July 19, 2013 Sent: Fax/E-mail/webpage This addendum submission is issued to clarify, supplement and/or modify the previously issued Request for Quacations (RFQ) Documents, and is hereby made part of the Documents. All requirements • the Documents not modified herein shall remain in full force and effect as originally set forth. It shall be the sole responsibility of the bidder to secure Addenclums that may be issued for a specific solicitation. no= As a bid bond required for this project and if s• , what is the percentage • the bid bond? No Bid Bond is required. Are there restrictions related to traffic while the shelters are under constructiong Page 1 of 2 Answer to Question #3: Yes, for the downtown location only, (SE Corner of SW 59 Place and SW 69 Street), traffic cannot be blocked during rush hours; 7:00 AM to 9:00 AM and from 4:00 PM to 6:00 PM and; traffic flow cannot be blocked for more than 4 consecutive hours. The awarded contractor must submit a M.O.T. to the City of South Miami's Public Works Department, Attention Jorge Vera, Capital Improvements Project Manager. Question #4: Is the contractor responsible to provide and install the metal City Seal affixed to the bus shelters? Question #5• No, the contractor is not responsible to provide and install the metal City Seal. The City will provide and install the seal to the completed bus shelters. Question #6: Are permit fees the responsibility of the contractor? Answer to #6: All City of South Miami permit fees will be waived. Other government entity permits, if required, are the financial responsibility of the contractor. Pre - approved City of South Miami permits have been pulled and are waiting for the awarded contractor's signature. Question #7: Does the Bus Shelter require approval from Miami -Dade County's Public Works department? Answer to Question #7: No, both Bus Shelter locations are not located on roadways maintained by Miami -Dade County. IT SHALL BE THE SOLE RESPONSIBILITY OF THE BIDDER TO SECURE ADDENDUMS THAT MAY BE ISSUED FOR A SPECIFIC SOLICITATION. Page 2 of 2 anmwfflw PROJECT DESCRIPTION FUN[? SOURCE SC3URCE FY 13 FY 14 FY IS FY 16 FY 17 T FFIC CALMING West Pinecrest Villas Traffic Calming Study and Const PTP $65,000 Pinecrest Villas Traffic Calming Phase II PTP $30,000 Bird Estates Traffic Calming Study and Construction LOGT $55000 i SW 64" Street Corridor Improvements Phase 11 CDBG $177,000 63rd Ct. Between Miller & SW 64th St. Traffic Calming P;�p:., s $40,000 Mango Terrace Traffic Calming (Construction) LOGT $24,000 60th Ave Traffic Calming PTP $50.000 _.., .� .�__��___.� .�,. .�......m.�, .�......n,... Manor Lane - Const of Traffic Calming Devices PTP $30.000 DRAINAGE IMPROVEMENTS Citywide Waterman Upgrade Project Ph I (Design) GOB _�._..,. ..._...�..�.. ��._.mM...,...__a_�.,_._ P..w.__. �.��._....._.__�..��. $80,000 aP�..�w,_.......�.�.. �,.,m�m. „ �. �4��. w..a �, .....�.......�...,..�,.._.,. Commerce Lane Road a nd Drainage Improvements S CRA $150,000 Corn Ave Road and Drainage Improvements E LOGT $30,000.. (Design and Construction) SWDTF $60,000 Citywide Stormdrain Cleanout project SWDTF $20,000 .. _. Progress Road and Drainage Improvements SMCRA mw- .e._ .�«.,.��...w.A___�..w.n.M,.., _. $180,000 ��- ��- _- ,..._.�.�....._......�� -... _.�...�_..�. ._ ._...�.�a�. ,.,, FLEET REPLACEMENT �. PW Fleet Replace -Trash Crane, Truck, Aerial Lift CIP $287,000 RW Fleet Rc.placeo- Garbage &Trash Truck. Pick Up CIP $372,000 $372,000 Police Vehicles and Equipment CIP $161,390 $161,390 $161,390 $161,390 mm $161,390 Code Enforcement Fuel Efficient Vehicles CIP w $15,000 $15,000 $15,000 $15,000 GEM Parking Enforcement Electric Car CIP $14.500 ROAD INFRASTRUCTURE Citywide Trans Master Plan (Roadway, sidewalks, swales, PTP $100,000 $50,000 $50,000 $50,000 $50,000 neighborhood greeanwrays &bicycle plan) OF $100,000. Sunset Drive Improvements - (65 - 67) & (67 -69) PTP $220,000 SWDTF $100,000 $100,000 mmm $100,000 $100,000 Street Resurfacing Program - Phase III LC7GT $75,000 $75,000 $75,000 $75,000 $75,000 57th Avenue Median Improvement PTP $30,000 Citywide Guardrail and Misc Road mfrast Repairs ( LOGT $60,000 , CITY OF SOUTH MIAMI BUDGET FY f 2 # #<� SOURCE OF FUNDS , . — ©m . . nth Miami . , » :. . . tormwater Drain Trust Fund Development B . Grant . Unfunded a « «.4. C „ VC;, a J <, MDC General Obligation u,, a a a a . 'LLje�� De!��2R-_A,sistanc .,. $50,000 «a American Disability Forfeiture Law Enforcement e# z a a z $10,000 TOTAL BY YEAR l« Project Name: Bus Shelters Phase 2 21M, Date: July 23, 2013 Sent: Fax/E-mail/webpage This addendum submission is issued to clarify, supplement and/or modify the previously issued Request for Proposal (RFP) Documents, and is hereby made part • the Documents. All requirements of the Documents not modified herein shall remain in full force and effect as originally set forth. It shall be the sole responsibility of the bidder to secure Addenclums that may be issued for a specific solicitation. Sheet A- 10 1 for both shelters under General Conditions lists a $900 site visit allowance x 6 visits! Is this for each shelter — • you have 12 visits total = $10,800? I , , 0 MEMEMM I A A - 0 The project sign is to be purchased and installed by the City and is not the responsibility • the awarded contr?.ctor. Page] of Question #3• Just wanted to confirm that this project no longer requires a bid bond of 5% per the Addendum #1 dated July 19, 2013. Also, the Proposal Checklist indicates Performance Bond (pg 16) is required in the proposal, but the bid documents say this is only necessary if awarded contract. Please clarify. Answer to Question #3: The Performance Bond is a condition for the awarded contractor. A Performance Bond is not required with the proposal. Question #4• Can we have the specs and fastening details for the SS mesh ? Answer to Question #4: The mesh and attachment is to be stainless steel rust resistant "grid" pattern, architectural mesh with "u frame "' by Cambridge Architectural or approved equal. The mesh is to be installed as per manufactures specification. Awarded contractor to provide shop drawings signed and sealed by Florida registered Engineer Question #5: What type of paint is used on the steel? Answer to Question #5: (1) Roof & Beam finish - Painted finish with Tiger Drylock RAL color 6012 powder coat or approved equal. Awarded contractor must provide sample to the City's Project Manager for approval. (2) Roof System - To be hurricane proof galvanized corrugated metal panels and fasteners by Centria. To be install as per manufacture specifications. Awarded contractor provide shop drawings signed and sealed by Florida registered Engineer Question #6: Is the finish coat applied on the top side of the roof? Answer to Question #6: Yes, finish coat is applied on the top side of the roof. Page 2 of 3 Question #7: Are the existing benches and trash receptacles to be finished? Answer to Question #7: No, the existing benches and trash receptacles are not to be finished. Question #8: Is the slab 4 Inches or 6 inches? Answer to Question #8: The slab is 6" (inches.) Question #9: Will a roofer be involved in this project? Such as permits. Answer to Question #9: No a roofer is not required; this would be up to the contractor. Question #10: Plans call for soil treatment, is it necessary? Answer to Question #10: No, soil treatment is not required. Question #11: Will a final survey be required? Answer to Question #11: No, a final survey is not required. IT SHALL BE THE SOLE RESPONSIBILITY OF THE BIDDER TO SECURE ADDENDUMS THAT MAY BE ISSUED FOR A SPECIFIC SOLICITATION. Page 3 of 3 r t o' k .ACC R3 OP ID: CT �......- CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DorYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON 7WE CERTIFICATE HOLDER. 5 /1 THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED TE THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING ORDED BY AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policYOOS) must be endorsed. If SU6ROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the Certificate holder in lieu of such endorsements . PRODUCER —.... INNOVATIVE INSURANCE CONSULTANTS, INC, 5461 UNIVERSITY DRIVE, 4103 CORAL SPRINGS, FL 33067 THOMAS J. DEFRANCO INSURED HAkf2t"LL CONSTRUCTION, INC. 2301 NW 33RD COURT, STE 112 POMPANO BEACH, FL 33069 954- 340 -9551 �,FL ;FAX HARTZ -2 ySTOMR lq,.g__.__. IN8URERfS) AFFORDING COVERAGE NAIL a _.. INSURER A: STARR INDEMNITY & LIABILITY CO — INSURER 0; COMMERCE & INDUSTRY / CHARTIS __ _... _ _._... 19490 _INSURERC BRIDGEFIELD EMPLOYERS INS CO ............... _.... 10701_ __ INSURER D: ' -- -- "'- INSURER I INSURER F THIS IS . INS _ ANC" -IN. iNDICATFD CERTIFY aANY REVISION NUMBER: NOTIWITHSTANDING NYIRFO UIREMENTNTERM OR ONDTON O� F MAYO I D CONTRAGTOOR OTHER DOCUMENT WITHEROSPECT TOLWHICH TFOD FXGL OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT 10 ALL TONG CONDITIONS FXCLU81ON3 AND %T�NDITiONS OF SUCH POLICIES LIMITS THE SHOWN MAY HAVE BEEN RFDUCEO BY PAID CLAIMS. TERMS, _LTR__ . TYPE OF INSURANCE _... ,i _.__ .- .......L�YND' POLICY NUMBER ' POLICY EFF `�ZSLI 'FXP ACfRFCA7E 07125/13 07/25/14 — _ $ 2,QQQ,QC GENERAL LIABILITY MM /DDiYYYY1 j tMMIDWYYYYI _�,.... LIMITS ............. __.. _.._.. t A X rOMMFFICIAl GENERAL LIABII MY SIPG- GL00395.01 Q7/25r13 I Q7l25114 EACH bCI,URRFNCF ,� DAMAGE-1 o RENTFIS _ 1,000,0C f(.AIhdS -M.AUE X OCCUR rR-ri (Ed_gccaner- e,_.._ 5 100,00 ' X , t3LKT ADC}L INSURED PRIMARY NON�CONT "RIBUTORY �— . .� � MED FnP (A.qy one pa sonj ? x,00 X BLKT WAIVER PERSONAL d ADV IN IURY � _ _. s 1,000,00 GLN L A(Y'RECAI L LIMIT APPI IES PER '. ._�.. GENERAL ACGRF0ATE g 2,000,00 ( PPRODUCTS POLICY : XRO- _, . JFGT LOC .� PROD _.. _COMPIOP AU S .. _ 2,000,00 AUTOMOBILE LIABILITY = 3 I ANY AUTO . ........... . COMDINGO SINGLE LIMIT t (Fa acr_tticnYt T hLL OWNED aUTU3 BODII Y INJURY (per 5 t Si: HEDULEO AU t US { ,BODILY INJURY (Y,r aGUSdenty _ 4 _..... HIRED AU rOS PROPERTY DAMAGE NON- OWNFDAUTOS (per acamjt t) Z DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Addltlaasi Ramaric; schedule, if more spree is requirod) MIAMi76 CITY OF SOUTH MIAMI 6130 SUNSET DRIVE MIAMI, FL 33062 SHOULD ANY OF THE A13OVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE: DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE O 1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 2512009/09) The ACORD name and logo are registered marks of ACORD UMBRELLA LIAR CCCUR - �._ ... EXCESS liAB —�..z t.t AIMS -MADE � LACH OCCURRENCE , —._. ._ . $ 2,00O,OC UEUUCTIBLE — BE038256061 ACfRFCA7E 07125/13 07/25/14 — _ $ 2,QQQ,QC RETENTION S E -_. ..._.__.___ _ .___.__.. ............. __.. _.._.. WORKERS COMPENSATION - .. $ AND EMPLOYERS LIABILITY Y 7 N G aYPROPRIEtOR1PARTNERr£ *, UrlvE) 0830- 38373 -E I X TORY LMMII X FR. _ _.. - ...._._.. - 33 RfMEhdRKR Ek''LUC£O� N t A I 09!13/12 08!13113 - E L EACH ACCIL?FNT 1,QdQ,QQ (Mandatary In NI 1) —' ? y ' tIL -SQhIP1I(7N OF OPERATIONS L.8'i� ( E.i_ DISEASE - EA LMPLOYEE 3 1,000,00 E I. DISEASE - POLICY LIMIT : s 1,QDfl.QO DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Addltlaasi Ramaric; schedule, if more spree is requirod) MIAMi76 CITY OF SOUTH MIAMI 6130 SUNSET DRIVE MIAMI, FL 33062 SHOULD ANY OF THE A13OVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE: DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE O 1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 2512009/09) The ACORD name and logo are registered marks of ACORD OP ID: MB '`%""" CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) CERTIFICATE MAY BE ISSUED OR MAY PERIAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO At I Q5/17/13 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement (s). PRODUCER INNOVATIVE INSURANCE 954- 340 -9551 CONTACT NAME; CONSULTANTS, INC. 954 - 340 -9456 FAX - -- PAHON o, Ext)' 5461 5461 UNIVERSITY DRIVE, #103 - E-MAIL CORAL SPRINGS, FL 33067 - ADDRESS: THOMAS J. DEFRANCO CUSTOMER ID #: HARTZ-2 INSURED HARTZELL CONSTRUCTION, INC. INSURER(5) AFFORDING COVERAGE NAIC # —_.... - PERSONAL & ADV IWORY S w suRER_A:STARR INDEMNITY LIABILITY CO 2301 NW 33RD COURT, STE 112 ,& _--- - -- POMPANO BEACH, FL 33069 INSURER B: COMMERCE & INDUSTRY / CHARTIS 19410 C:FNFRAL AGGREGATE S INSURER C : BRIDGEFIELD EMPLOYERS INS CO 10701 C1=N'1_ AGGREGATE LIMIT APPLIES PER INSURER D 2,000,00 INSURER E - - L INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 11­11.75 IS rO CERTIFY THAT THE POLICIES OF INSURANCE LISTFD BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED N o t VVIIHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERIAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO At I THE TERMS. FXCLI ISIONS AND CONDITIONS OF SUCI I POLICIES. LIMITS SHOWN MAY HAVF BEEN REDUCED BY PAID CLAIMS _.- —.... INS: ADD R— _. __ -- __.... __ _ TYPE OF INSURANCE _ POIJCY EFF POLICY EXP LTR _ INS: WVD' POLICY NUMBER , (MM /DD/YYYV�MM /DDNYYY LIMITS - GENERAL LIABILITY EACH OCCIIRRFNf,F S. 1,000,00 A X GOMMFRNAI ( }FNERAL LIABILITY X X SIPG- GL00395 -00 07/25/12 07/25/13 DAMACFTa_RENTFTS___ - - -- -- - - -- PRFMISFS jPa ncci,rrnncni 100,00 _ - CLAIMS -MADE X OCCUR IVIED EXP (Any one personi $ 5,00 X BLKT ADDI INSURED PRIMARY NON •GONTRIDUTORY PERSONAL & ADV IWORY S 1,000,00 X BLKT WAIVER C:FNFRAL AGGREGATE S 2,000,00 C1=N'1_ AGGREGATE LIMIT APPLIES PER PRODUCTS - COMPIOP AVG '$ 2,000,00 ' POLICY X PRO �.__--... - JEC I LOC - - L j AUTOMOBILE LIABILITY -. COMBINED SINGLE LIMIT $ (Ea BCCider,tl ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AU I US '. - .____.... BODILY INJURY iPer accidenii $ SCHEDUI FD AUTOS- . —_ -_. PROPERTY DAMAGE $ HIRED AI ITOS (Per arr_ioenq NON- OVVNLD AUTOS $ UMBRELLA LIAR -X OCCUR _ EACH OCCURRFNCE $ 2,000,00 X EXCESS LIAR [MAIMS -MADE B - 8E034243457 07/25112 07/25/13 A AGGREGATE $ 2,000,00 _.. DEUUC I IBLE b - RETENTION S $ WORKERS COMPENSATION AND X WC STATU OTH X FMPI OYFRS' LIABILITY YIN : TORY LIMITS FR_ -. C A!vv I+KUNH.t IUD /P,AF.TNER /EXECUTIVE 0830 -38373 09/13/12 09/13/13 F 1,000,00 OFF ICERIMEMBFRFXCI..IDFr,i N/A X I EACH ACCIDENT $ (Mandatory In NH) E L DISEASE - LA EMPLOYEE a 1,000,00 It ves Jesci��e monde, DESCRIPTION OF OPFRATIONS helnw - - - -- E L DISEASE - POLICY LIMIT S 1,000,00 DESCRIPTION OF OPERATIONS ! LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER IS ALSO KNOWN AS ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY. INSURANCE EVIDENCED BY THIS CERTIFICATE SHALL BE PRIMARY AND NON- CONTRIBUTORY TO ANY OTHER INSURANCE. A WAIVER OF SUBROGATION APPLIES IN FAVOR OF THE ADDIITONAL INSUREDS WITH RESPECT TO GENERAL LIABILITY AND WORKERS COMPENSATION. -� � 4ArV hrCLLH1IVIV HARTZ -1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HARTZELL CONSTRUCTION, INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2301 NW 33RD CT, SUITE 112 POMPANO BEACH, FL 33069 AUTHORIZED REPRESENTATIVE V 1953.2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD rri X R CL) rt 0 CL) (D 0 0 17) • FRA I W, • • m I mp I I all rM I "Milk 3 �v I pw tai PMMK "M* 14 omft wi I > r-j- (D "Milk 3 �v I pw tai PMMK "M* 14 omft wi I I® THIS IS NOT A BILL - DO NOT PAY 482175-8 RENEWAL BUSINESS NAME I LOCATION RECEIPT NO. 503308-9 HARTZELL CONTRUCTION INC STATE# CGC061592 DOING BUS IN DADE CO OWNER HARTZELL CONTRUCTION INC Se a of Business C, *v WORKER/S 9 GENERAL BUILDING CONTRACTOR 5 THIS IS ONLY A LOCAL BUSINESS TAX RECEIPT. It DOES NOT PERMIT THE HOLDER TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE DO NOT FORWARD COUNTY OR CITIES. NOR DOES IT EXEMPT THE HOLDER ROM ANY OTHER i PERMIT OR LICENSE FICOURED BY LAW. THIS 19 HARTZELL CONTRUCTION INC NOT A CERTIFICATION OF THE HOLDERS OUA• EDWARD HOLMAN PRES TONS. 2301 NW 33 CT 112 PAYMENT RECEIVED POMPANO BEACH FL 33069 MIAMI•DADE COUNTY TAX COLLECTOR: 08/13/2012 60060000127 000075.00 !Jim SEE OTHER SIDE Formw_9 (Rev. December 2011) 'Department of the Treasury Internal Revenue Service I cv ca cz cn a. r-L a) 0) Name (as show on your Request for Taxpayer Identification Number and Certificatill CO entity name, if dfiffolcot from above M Check appropriate box for federal tax classification: ❑ Individual/sole proprietor ❑ C Corporation ET151-c-rporation ❑ Partnership ❑ Trust/estate [J Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) o, M Other (see instructions) b- ess (number, street, and apt, or suite no.) vC4, 11 Reque! ?2� state, and ZIP code 113 ccountinumber(s) here name and address Give Form to the requester. Do not send to the IRS, Exempt payee Under penalties of perjury, I certify 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. 1 am a U,S. citizen or other U.S, person (defined below), Certification instructions. You must Lross out item 2 above if you have been notified by the IRS that you are currently Subject to backup withholding because you have failed to report al I erest and dividends on your tax return, For- real estate transactions, item 2 does not apply, For mortgage interest paid, acquisition or aband ant of secured property, cancellation of debt, contributions town individual retirement arrangement (IRA), and generally, payments other than ' .rest and divi y on are not required to sign the Certification, but YOU must provide your correct HN. See the instructions an pace 4. Signature of Here U�S. person 1� 1 C>--14— u.s . person yyy Date 7 Genera�l Instructio s Note, If a requester gives you a form other than Form W-9 to Section references are to the Internal Revenue Code unless otherwise request your TIN, You must use the requester's form if it is substantially similar noted. to this Form W-9. Purpose Form of Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: A person who is required to file an information return with the IRS must obtain your correct taxpayer identification - An individual who is a U.S. citizen or U,S. resident alien, number IN to report, for example, income paid to you, real estate transactions, mortgage interest - A partnership, corporation, company, or association created or you paid, acquisition or abandonment of secured property, cancellation organized in the United States or under the laws of the United States, of debt, or contributions you made to an IRA. - An estate (other than a foreign estate), or Use Form W-9 only if you are a U.S. person (including a resident - A domestic trust (as defined in Regulations section 301.7701 -7). alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to- Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to 1. Certify that the TIN you are giving is correct (or you are waiting for a pay a withholding tax on any foreign partners' share of income from such business. number to be issued), Further, in certain cases where a Farm W-9 has not been received, a 2. Certify that you are not subject to backup withholding, or partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if 3. Claim exemption from backup withholding if you are a U.S. exempt payee, If applicable, you are also certifying that you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, as a U.S, person, your allocable share of any partnership income from a U.S. trade or business is provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income, not subject to the withholding tax on foreign partners' share of effectively connected income, Car- No, 10231X Form W-9 (Rev. 12-2011) STATE OF FLORIDA DEPARTM99T OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD 1940 NORTH MONROE STREET (850) 487-1395 TALLAHASSEE FL 32399-0783 PINTOj ANDERSON M HARTZELL PAINTING 4120 NE 22ND AVENUE LIGHTHOUSE POINT FL 33064 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you heft For information about our services, please log onto www.myfloridalicense.com There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about the Department's initiatives, Our mission at the Department is: License Efficiently, Regulate Fairly, We constantly strive to serve you better so that you can serve your customers, Thank you for doing business in Florida, and congratulations on your new license! KNEMMMUM 27