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HomeMy WebLinkAbout05.K- Public Works #32 Aip jp Consent Calendar City of San Bernardino Request for Council Action 2 Date: January 9, 2017 To: Honorable Mayor and City Council Members CO From: Mark Scott, City Manager By: Christopher H. Alanis, Interim Public Works Director L Michael Grubbs, Project Manager, Public Works in Subject: 9th Street and Sierra Way Signal Upgrade M Recommendation U) Adopt the Resolution of the Mayor and City Council of the City of San Bernardino Authorizing the City Manager to Execute a Contract with DBX, Inc., for 9th Street and z Sierra Way Signal Upgrade [Highway Safety Improvement Program HSIPL-5033(050), M Advantage Project ID 0812000003, Per Plan No. 12810 (TC12-001] CO Background This project proposes to upgrade the traffic signal at the intersection of 9th Street and a Sierra Way. The work will include removal and replacement of the existing signal equipment, damaged curb, gutter and sidewalk, installation of thermoplastic traffic c striping, construction of ADA accessible curb ramps and replacement of pavement to T match the other work. The recent engineer's estimate of the total project cost is $208,420. a� The project was approved for Federal funding under the Highway Safety Improvement Program (HSIP) Cycle 4 on June 1, 2011. Under this program, project costs are eligible Y for ninety percent Federal reimbursement. The program is administered by the California Department of Transportation (Caltrans). Authorization to proceed with the n construction phase of the project was received from Caltrans on August 12, 2016. The grant request, which was made in 2011, estimated a total project cost of $171,170.00, and a federal grant award of $154,053,00, or 90%. The $154,053.00 will be reimbursed by Caltrans on a monthly basis as costs are incurred. a Discussion The project was advertised for bids on September 9, 2016. Local advertising soliciting bids included the San Bernardino County Sun Newspaper, F. W. Dodge Company (Monrovia), High Desert Plan Room, Construction Bid Board, Inc., San Diego Daily Packet Pg. 223 Transcript, Bid America Electronic, iSqFt Plan Room, Reed Construction Data, Construction Bid Source (CBSI), Bid Ocean, Inc., and San Bernardino Chamber of Commerce. The Notice Inviting Bids and electronic copies of the construction documents were also posted on the City's website. Bids were opened publically on October 18, 2016, at 2:00 p.m. The results of the bid opening are as follows: D NAME OF BIDDER CITY BID AMOUNT DBX, Inc. Temecula, CA $321,382.00 T Belco Elecnor Gro4p_ Chino, CA $359,859.00 VT Electric, Inc. Ontario, CA $418,469.00 Engineer's Estimate $208,420.00 After a complete review of the three sealed competitive bids and verification of mathematical calculations and certifications, staff has determined that DBX, Inc. is the apparent low bidder and meets the minimum requirements of the bid specifications and guidelines. Based on the above information, DBX, Inc. is the responsible bidder and staff recommends that the contract be awarded to DBX, Inc. .Z The low bid amount substantially exceeds the engineer's estimate. Staff determined that the difference was primarily due to recent significant changes in Caltrans foundation co and pole design standards, which were implemented following the estimate. The estimated project costs are as follows: 76 TOTAL COST C Bid Amount $ 321,382.00 in Contingencies (10%) $ 32,138.00 Subtotal Construction Cost $ 353,520.00 3- Construction Management & Inspection $ 35,352.00 Total Estimated Construction Cost $ 388,872.00 Fiscal Impact The Highway Safety Improvement Program (HSIP) grant will fund $154,053. The balance of the project cost will be funded by available Measure I funds in the amount of $234,819. Conclusion E Adopt the Resolution of the City Council of the City of San Bernardino Authorizing the City Manager to Execute a Contract to DBX, Inc., for 9th Street and Sierra Way Signal Upgrade [Highway Safety Improvement Program HSIPL-5033(050), Advantage Project ID 0812000003, Per Plan No. 12810 (TC12-001] Packet Pg. 224 - 5.K.a Attachments Attachment 1 — Resolution Awarding Contract for 9th St & Sierra Way Attachment 2 — Bid Opening Report & Bid Tabulation 9th St & Sierra Way Attachment 3 — Lowest Bid Form 9th St & Sierra Way— QBX, Inc. Attachment 4 — Plan 12819 9th & Sierra Way Q M L --- --- CL Ward: 1,2 D c Synopsis of Previous Council Actions: i Cn ca L L II�A v/ Y L r Z M r 00 L C. M C 2M L L co d L �F+ Cn Q� E V �V a Packet Pg. 225 IYYM 5.K.b RESOLUTION NO. 2 RESOLUTION OF THE MAYOR AND CITY COUNCIL OF THE CITY OF SAN o L BERNARDINO AUTHORIZING THE CITY MANAGER TO EXECUTE A a 3 CONTRACT WITH DBX, INC., FOR 9TH STREET AND SIERRA WAY SIGNAL 4 UPGRADE, HIGHWAY SAFETY IMPROVEMENT PROGRAM HSIPL-5033(050), ADVANTAGE PROJECT ID 0812000003,PER PLAN NO. 12810 (TC12-001). in a 5 BE IT RESOLVED BY THE MAYOR AND CITY COUNCIL OF THE CITY OF CU 6 SAN BERNARDINO AS FOLLOWS: L a� 7 SECTION 1. DBX, Inc., 42024 Avenida Alvarado, Suite A, Temecula California c w 8 92590 is the lowest responsible bidder for 9�h Street and Sierra Way Signal Upgrade, Highway Cn 9 Safety Improvement Program,per Plan No. 12810 (TC12-001). c Z to SECTION 2. The Director of Finance is hereby authorized and directed to amend the M P Go 11 � FY16/17 Adopted Budget by transferring $234,819 from unallocated Measure I (Fund 129) 12 3: monies to provide a total funding amount of$388,872.00. L J 13 Cn SECTION 3. A contract is awarded accordingly to said bidder in a total amount of 14 15 $321,382.00 with a contingency amount of$32,138.00 but such contract shall be effective only o 16 upon being fully executed by both parties. All other bids, therefore, are hereby rejected. The 0 17 City Manager is hereby authorized and directed to execute said contract on behalf of the City. c 18 A copy of the contract is on file in the office of the City Clerk and incorporated herein by 3 a 19 reference as though fully set forth at length. o w 20 SECTION 4. The Purchasing Manager is hereby authorized and directed to issue a 0 W 21 W Purchase Order to said bidder in the amount indicated in SECTION 2 above. r c 22 SECTION 5. This contract and any amendment or modifications thereto shall not take s 23 1° effect or become operative until fully signed and executed by the parties and no party shall be a 24 c obligated hereunder until the time of such full execution. No oral agreements, amendments, m E 25 Q 1 Packet Pg. 226 1 modifications or waivers are intended or authorized and shall not be implied from any act or a� 2 course of conduct of any party. a� 3 SECTION 6. The authorization to execute this contract is rescinded if the parties to the �a c 4 contract fail to execute and return said Contract within sixty (60) days of passage of this in 5 Resolution. L 6 in 7 c L 9 c 10 •z Cl) V.- A 12 !C L L 13 2D o�S 14 rn L 15 �° U t6 16 0 U 17 18 R a 19 C 20 0 U) D 21 T• .V 22 23 /// r a 24 m E 25 is r a 2 Packet Pg.227 5.K.b 1 RESOLUTION OF THE MAYOR AND CITY COUNCIL OF THE CITY OF SAN BERNARDINO AUTHORIZING THE CITY MANAGER TO EXECUTE A d 2 CONTRACT WITH DBX, INC., FOR 9TH STREET AND SIERRA WAY SIGNAL UPGRADE, HIGHWAY SAFETY IMPROVEMENT PROGRAM HSIPL-5033(050), a 3 ADVANTAGE PROJECT ID 0812000003, PER PLAN NO. 12810 (TC12-001). _ 4 I HEREBY CERTIFY that the foregoing Resolution was duly adopted by the Mayor and in a 5 City Council of the City of San Bernardino at a meeting thereof, held on the 6 `m day of , 2017,by the following vote,to wit: in 7 ° Council Members: AYES NAYS ABSTAIN ABSENT 8 � MARQUEZ 9 _ 10 BARRIOS z M r i 1 VALDIVIA v a 12 SHORETT L 13 NICKEL 14 RICHARD a) L 15 MULVIHILL o U 16 c 0 V 17 tm Georgeann Hanna, City Clerk 18 0 The foregoing resolution is hereby approved this day of 12017. 3 a 19 0 20 0 R. CAREY DAVIS, Mayor 21 City of San Bernardino Approved as to form: 22 GARY D. SAENZ, s 23 City Attorney Q 24 By: c a� E 25 U Q 3 Packet Pg. 228 o o 0 0 0 0 0 0 0 0 0 a a a 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 o OC 0 0 0 0 0 0 vi o 0 0 0 0 0 0 0 N O N O m m O r N O �! O Lo O N 6 n o o h m v, co c? v m m 0 0 z m o v W (O (O o vS (D �. N M a N N � � r U � � N O Lu O O O O O O O O u7 O O O O O O O 1A 0 0 O O O 0 0 O N O O O O O O O M J 0 0 O O O O h (� O h O O O O M w N O (QD a m (OD w rj Co (n co h to CO O R L oo N M N O O O O a O O O o O O O O O 6 O a 0 0 0 o 0 o 0 0 0 o o v o 0 0 0 OC 0 0 0 0 0 0 co, (' o o o (D (o o N o o o N m o o m (O v O. N (O m (O m O. o o 0 0 m o ri rn'. m r 0 m (o o 0 = m o r uS vi m N v d ti m N C 4' r N N N N N 00 OD (n J U O O O O o 0 0 0 0 0 0 O O o 0 w O O O O O O N h h O O o O O O Z J LO N O O Q O O O O CA d' M O N W O ? O O N (D O'.. 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(D r -* O O N M tD m ci Packet Pg. 229 Q M Zr PQ a ) rn a F H co a Oa w z z co Q 0mL V C0 z aHQ CL W 15d U' .� o U iJ N W o ua w a U U ti z N ri d vi O [ 00 0+ W u Packet Pg. 230 Y PX BID FORM TO THE MAYOR AND COMMON COUNCIL OF THE CITY OF SAN BERNARDINO CL The undersigned declares that he has carefully examined the location of the proposed work, that he has examined the Plan and read the accompanying instructions to bidders and hereby proposes to furnish any and all required labor,materials, transportation and service for the ;, TRAFFIC SIGNAL UPGRADE AT 9T" STREET AND SIERRA WAY (TC 12 - 001) HIGHWAY SAFETY IMPROVEMENT PROGRAM HSIPL-5033(050) Cn in strict conformity with Plans and Special Provisions No. 12810, of the Public Works Division, z Department of Development Services for the City of San Bernardino and also in accordance with Standard Specifications for Public Works Construction, latest edition in effect on the first day of the advertised "Notice Inviting Sealed Bids". The undersigned proposes and agrees if this bid is co accepted, that the undersigned will contract with the City of San Bernardino, in the form of the copy 2 of the contract annexed hereto,to provide all necessary machinery, tools, apparatus and other means 06 co of maintenance, and to do all the work and furnish all the materials specified in the contract, in the manner and time therein prescribed, and that he will take in full payment therefor the following unit prices or lump sum prices,to-wit: o 'm T 3 0 J M r N _ E v Y f d _ a E B-1 a Packet Pg. 231 -- BID SCHEDULE PLAN NO. 12810 TRAFFIC SIGNAL UPGRADE AT 9TH STREET AND SIERRA WAY (TC 12-001) HIGHWAY SAFETY IMPROVEMENT PROGRAM-HSIPL-5033(050) a m L rz Item Description Unit Quantity Unit Price($) Item Total($ I MOBILIZATION LS 1 ;� 0 . T N a 2 TRAFFIC CONTROL LS I 2 50(),00 2 5©a.ob 3: CLEARING,GRUBBING,MISCELLANEOUS 1° 3 REMOVALS,UNCLASSIFIED EXCAVATION,AND LS 1 m UNCLASSIFIED FILL 2 {2 rn _ .a c 4 REMOVE ROADSIDE SIGN AND SINGLE POST EA d REMOVE EXISTING TRAFFIC SIGNAL POLES& 5 SIGNAL EQUIPMENT INCLUDING FOUNDATIONS LS I t PERPLAN �v ��( iJ' oc) L Soo 00 r TRAFFIC SIGNAL SYSTEM COMPLETE,IN-PLACE Z PER PLAN INCLUDING EMERGENCY VEHICLE 6 DETECTION SYSTEM,BATTERY BACKUP SYSTEM, LS 1 c`') PEDESTRIAN PUSH BUTTON SYSTEM AND 0o REFLECTORIZED STREET NAME SIGNS INSTALL 8"CONCRETE CURB AND GUTTER PER 7 CITY STD NO 200 TYPE W EA 115 a`) 06 8 PCC SIDEWALK PER CITY STD.NO,202 SF 110 3 cn am 9 INSTALL A.C.PAVEMENT CLASS PG 64-10 SF 2,200 i t1q m _i 10 INSTALL CLASS II AGGREGATE BASE SF 2,200 m SAWCUT AND RECONSTRUCT SECTION OF LOCAL N 11 SF 40 DEPRESSION � 2, # � �� o INSTALL ADA RAMP WITH DETECTABLE WARNING 12 SURFACE PER SPPWC PLAN 111-5,INCLUDING EA 4 _ c" RETAINING CURB - 13 ADJUST UTILITY COVERS TO FINAL GRADE EA 4 pI "I 916 . OD 14 SURVEYING PER THE SPECIAL PROVISIONS LS 1 Q THERMOPLASTIC TRAFFIC STRIPES,PAVEMENT E 15 MARKINGS&RAISED PAVEMENT MARKERS LS 1 E (INCLUDING REMOVAL OF CONFLICTING STRIPING + .., Y &MARKINGS) ILI ,�1 H Q 16 PAINT RED CURB LF 40 f O o 1 _1 TOTAL BID B-2 Packet Pg. 232 ' BID NOTES: Bids shall be submitted on the bid forms provided in the Bid and Contract Documents package. All bid forms shall be completed, signed, and sealed in accordance with these instructions and the instructions included with the individual bid forms. A bid that fails to include all bid forms, will be considered nonresponsive. CITY reserves the right to award a Contract to the lowest responsible bidder for the GRAND TOTAL 1° BID. The Bid Schedule shall be typed or clearly completed in ink. All spaces for unit prices, item CL totals, and total bid shall be completed, in figures. All prices shall be in United States Dollars. For a Lump Sum item, the unit price shall match the item total price. If a Bid Schedule is found to contain minor errors or illegible entries, the bidder agrees that the CITY may, if deemed in the public interest, in cure the error or entry,using one of the following methods: Method A. -If the sum of the item totals does not equal the total bid,but all items totals correctly indicate the products of the unit price and quantity, the CITY will consider the corrected sum of the item totals to be the Bidder's total bid. co Method B. -If the sum of the item totals equals the total bid,but the product of a unit price and a c quantity does not equal the stated item total, the CITY will determine a correct unit price by dividing the item total by the item quantity. Total bid price for the entire contract work shall include the cost of labor, materials, equipment parts, co implements, taxes and supplies necessary to complete the project, as based on the City Engineer's estimate of quantities of work. z The total price must be extended for each item of work and the total of all items inserted in the space provided. Bidders shall complete and submit entire BID DOCUMENT section as their bid to the City. Failure to do so will result in bid being non-responsive. ;a L Any situation not specifically provided for will be determined in the discretion of the City of San Cl) Bernardino (CITY), and that discretion will be exercised in the manner deemed by the CITY to best Cn protect the public interest in the prompt and economical completion of the work.. The decision of the Y CITY respecting the amount of a bid, or the existence or treatment of an irregularity in a bid, shall be final. m 0 a BIDDER declares that this BID is based upon careful examination of the work site and the Bid and m Contract Documents. 3 0 J M d C E s ca w Q w c m E U B-3 Q rr►� Packet Pg.233 BIDDER'S INFORMATION AND SIGNATURE: It is the understanding of the undersigned that the work hereinabove described shall be commenced within 10 working days from the date of the"Notice to Proceed", and shall be completed within 160 working days from the date of said notice, as directed in SECTION 4 of these Special Provisions. The undersigned further agrees that in case of default in executing the contract, or furnishing necessary bonds, all within the specified time,the proceeds of the Bidder's Guaranty accompanying this bid shall be paid to the 2 City of San Bernardino as liquidated damages. Q Licensed in accordance with an act providing for the registration of Contractor, LICENSE EXPIRATION FEDERAL TAX ID a NO..2-YQW1 CLASSIFICATION(S): 4-+010 DATE: -11-6 i 11 # q5-Z'►58 7a'i FIRM NAME: C0 BUSINESS ADDRESS: H"Z AV-Cr))-&0, 01 Vet r ao 0 _ M co L BUSINESS PHONE:qSI 2°lto "qq N FAX: CELL- R V)--72.1-L4CaF If an individual, so state. If a firm or co-partnership, give the names of all individuals, co-partners •z composing the firm. If a corporation,give the names of the president,secretary,treasurer and manager thereof: oo years Is Bidder currently a certified DBE? Yes ❑ No &" Legal Status of firm Age of firm d Annual Gross Receipts: <$1,000,000 ❑ <$5,000,000 gkl-<$10,000,000 ❑ <$15,000,000 ❑ >$15,000,000 ❑ co 06 NAME(S) ADDRESS(ES) C0 s Jl1 t'Y7t'' ` r x 2.tF}V ' l �} V oX0 a N m 3 /} 0 SIGNATURE OF BIDDER: ` 1'i` -n �'-_ .fit i` Dated: - ,20 L M .r m E BIDDER'S INITIALED ACKNOWLEDGEMENT OF ADDENDUMS: a ADDENDUM NO. 1 =f DATE: )J1. E ADDENDUM NO. 2 DATE: b 1 L M ADDENDUM NO. 3 DATE: `t ADDENDUM NO. 4 DATE: C-1 Packet Pg. 234 SPECIAL NOTICE Q The bidder's attention is directed to the sub-section entitled, "Required Listing of Proposed Subcontractors", in Section 2 of these Special Provisions regarding the requirement that proposed Fn subcontractors be listed in the bidder's bid documents. Instead of listing only subcontractors for signal and lighting work as in the past, all subcontractors are now to be listed in the bid for items of L work or portions thereof to be subcontracted in excess of one-half of one percent of the total bid or d in $10,000.00,whichever is greater. In the case where a bidder claims an inadvertent clerical error in listing subcontractors, a L notice of the claim must be submitted to the Office of the City Engineer in writing within 2 working C days after the time of the bid opening and send copies of the notice to the subcontractors involved. 'z The subcontractor listing requirement referred to above is in addition to the DBE subcontractor listing on the LOCAL AGENCY BIDDER DBE COMMITMENT (Construction Contracts) form, Exhibit 15-G and the total DBE subcontractors on the LOCAL AGENCY BIDDER DBE INFORMATION (Construction Contracts) form, Exhibit 15-G, samples of which are included Cn at the end of these BID DOCUMENTS. w The responsive low-bidder, along with the second and third low-bidders will be required to submit the LOCAL AGENCY BIDDER DBE COMMITMENT (Construction Contracts) form, m Exhibit 15-G, to the City Engineer no later than 4:00 p.m. on the fourth day, not including Fridays, ° Saturdays, Sundays and legal holidays, following the date of the bid opening. m a The responsive low-bidder awarded the contract by the Mayor and Common Council at their J regular meeting will be required to submit the LOCAL AGENCY BIDDER DBE INFORMATION M (Construction Contracts) form, Exhibit I5-G, to the City Engineer along with the executed contracts and contract bonds. w The three listings must be consistent when the subcontracting amount meets the appropriate Q dollar amount thresholds. E U CC a� w Q C-2 Packet Pg. 235 5.K.d pa `O N C i > o ',✓ r��i rte. a� CL 8 ru s°. a u 75 � tq b G o o d ^ sa v, C 1 `4 y O O d •t v a Cz a) O C C W r .2 .2 r. O O ra otn n' E E = vn � E o �n n X rn rs � C v3 Z,4 Gq (A 45,9 s; 09 C/) V) aq, ca Qq �A m a' d V V V V n. V V V V A V V V V n V V V V n � o w^ ❑ QQF ❑© ❑'Q❑ Cl MDM- m ❑_ mo b — Cn m CO m C w .G U tVC T a E! N O ? V C rc taw zu 1, a W F• `° `"VI v a m w v Packet Pg. 236 AF A WORKERS' COMPENSATION INSURANCE CERTIFICATION The Contractor shall execute the following form as required by the California Labor Code, Section 1860 and 1861: Q I am aware of the provisions of Section 3700 of the Labor Code which require every 2 employer to be insured against liability for workers' compensation or to undertake self- v, insurance in accordance with provisions of that code, and I will comply with such provisions before commencing the performance of the work of this contract. L F+ Date: i�l 1. SJY�7� � L ( Contractor) By: C'.... z M eT+-) See- trer,S, 00 (Trtle ) � Attest: 06 . By: Z5 n z � X Sll m (Title) r 3 Ul d 3 o J M E Ar U Q C d L U R Q C-5 Packet Pg. 237 w CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189 _ t6 L A notary public or other officer completing this certificate verifies only the identity of the individual who signed the a document to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document. rn State of Califomia } in County of Riverside ) On t before me, Phyllissa Martz, Notary Public Date Here Insert Name and Title of the Officer personally appeared James C. Perry Name(s)of Signer(s) R r o L who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in w his/her/their authorized capacity(ies),and that by his/her/their signature(s)on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. Z I certify under PENALTY OF PERJURY under the laws T of the State of California that the foregoing paragraph co v is true and correct. PNY`t'1'8 AATZ WITNESS my hand and official seal. Notary Public-California Cl) Riwnia Caumy 06 Commission 0 215044 Signature .! '"�M Comm.Ex t A 11.2028 06 Sgnature of Notary Pub#c s Y X m O m Place Notary Sea/Above w OPTIONAL ayi Though this section is optional, completing this information can deter alteration of the document or o fraudulent reattachment of this form to an unintended document. Description of Attached Document M Title or Type of Document: Document Date: c Number of Pages: Signer(s) Other Than Named Above: _ U Capacity(ies) Claimed by Signer(s) Signer's Name:j3naga C Perry Signer's Name: Q ®Corporate Officer — Title(s):President/Secretary/Treas. ❑Corporate Officer — Title(s): C Partner — ❑ Limited ❑General ❑ Partner — []Limited ❑General E Individual ❑Attorney in Fact i�Individual ❑Attorney irrFact E ❑Trustee ❑Guardian or Conservator ❑Trustee Guardian.or Conservator Other: El Other: a Signer Is Representing: Signer Is Representing: 02014 National Notary Association•www.NationalNotary.org •1-800-US NOTARY(1-800-876-6827) Item#5907 Packet Pg.238 (THE BIDDER'S EXECUTION ON THE SIGNATURE PORTION OF THIS PROPOSAL SHALL ALSO CONSTITUTE AN ENDORSEMENT AND EXECUTION OF THOSE CERTIFICATIONS WHICH ARE A PART OF THIS PROPOSAL) EQUAL EMPLOYMENT OPPORTUNITY CERTIFICATION The bidder QL5 't- tG , proposed D subcontractor , hereby certifies that 6 Cn he has has not participated in a previous contract or subcontract subject to the equal opportunity clause, as required by Executive Orders 10925, 11114, or 11246 L d in and that, where required, he has filed with the Joint Reporting Committee, the Director c d of the Office of Federal Contract Compliance, a Federal Government contracting or N administering agency, or the former President's Committee on Equal Employment Z M Opportunity, all reports due under the applicable filing requirements. 00 L 2 Cn 1 NOTE: The above certification is required by the Equal Employment Opportunity Regulations X of the Secretary of Labor ( 41 CFR 60-1.7 (b) (1)), and must be submitted by bidders m ii and proposed subcontractors only in connection with contracts and subcontracts which -a l are subject to the equal opportunity clause. Contracts and subcontracts which are m exempt from the equal opportunity clause are set forth in 41 CFR 60-1.5(Generally only 3 contracts or subcontracts of$10,000.00,or under,are exempt). o J Currently, Standard Form 100 (EE-1) is the only report required by the Executive M Orders or their implementing regulations. c E Proposed prime contractors and subcontractors who have participated in a previous contract or subcontract subject to the Executive Orders and have not filled the required b reports should note that 41 CFR 60-1.7 prevents the award of contracts and a p ( )(1) P subcontracts unless such contractor submits a report covering the delinquent period or such other period specified by the Federal Highway Administration or by the Director, E Office of Federal Contract Compliance,U.S.Department of Labor. Ar r a C-6 Packet Pg.239 (THE BIDDER'S EXECUTION ON THE SIGNATURE PORTION OF THIS PROPOSAL kw SHALL ALSO CONSTITUTE AN ENDORSEMENT AND EXECUTION OF THOSE CERTIFICATIONS WHICH ARE A PART OF THIS PROPOSAL) EQUAL EMPLOYMENT OPPORTUNITY CERTIFICATION d The bidder n r , proposed a subcontractor .9Mw W son E P-CAr i r, :7Ly)C , hereby certifies that 2M in he has \/ , has not participated in a previous contract or subcontract subject to the equal opportunity clause, as required by Executive Orders 10925, 11114, or 11246 co and that, where required, he has filed with the Joint Reporting Committee, the Director r of the Office of Federal Contract Compliance, a Federal Government contracting or n administering agency, or the former President's Committee on Equal Employment z M r Opportunity, all reports due under the applicable filing requirements. in 06 NOTE: The above certification is required by the Equal Employment Opportunity Regulations m of the Secretary of Labor ( 41 CFR 60-1.7 (b) (1) ), and must be submitted by bidders o and proposed subcontractors only in connection with contracts and subcontracts which m are subject to the equal opportunity clause. Contracts and subcontracts which are y exempt from the equal opportunity clause are set forth in 41 CFR 60-1.5(Generally only °' 3 Contracts or subcontracts of$10,000.00,or under,are exempt). 0 Currently, Standard Form 100 (EE-1) is the only report required by the Executive Orders or their implementing regulations. Proposed prime contractors and subcontractors who have participated in a previous 0 contract or subcontract subject to the Executive Orders and have not filled the required Q reports should note that 41 CFR 60-1.7(b)(1) prevents the award of contracts and subcontracts unless such contractor submits a report covering the delinquent period or such other period specified by the Federal Highway Administration or by the Director, Office of Federal Contract Compliance,U.S.Department of Labor. w Q C-6 Packet Pg. 240 a I (THE BIDDER'S EXECUTION ON THE SIGNATURE PORTION OF THIS PROPOSAL SHALL ALSO CONSTITUTE AN ENDORSEMENT AND EXECUTION OF THOSE CERTIFICATIONS WHICH ARE A PART OF THIS PROPOSAL) EQUAL EMPLOYMENT OPPORTUNITY CERTIFICATION The bidder DR,5,5 1 nr , proposed CL D subcontractor A(�: n S ( Vt ) (1/ hereby certifies that "7z P he has V , has not participated in a previous contract or subcontract subject to the equal opportunity clause, as required by Executive Orders 10925, 11114, or 11246 �, �n and that, where required, he has filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance, a Federal Government contracting or administering agency, or the former President's Committee on Equal Employment 'z M r Opportunity, all reports due under the applicable filing requirements. in 06 NOTE: The above certification is required by the Equal Employment Opportunity Regulations m " of the Secretary of Labor (41 CFR 60-1.7 (b) (1) ), and must be submitted by bidders o and proposed subcontractors only in connection with contracts and subcontracts which m are subject to the equal opportunity clause. Contracts and subcontracts which are N exempt from the equal opportunity clause are set forth in 41 CFR 60-1.5(GeneralIy only 3 contracts or subcontracts of$10,000.00,or under,are exempt). 0 Currently, Standard Form 100 (EE-1) is the only report required by the Executive Orders or their implementing regulations. t � Proposed prime contractors and subcontractors who have participated in a previous contract or subcontract subject to the Executive Orders and have not filled the required Q reports should note that 41 CFR 60-1.7(b)(1) prevents the award of contracts and subcontracts unless such contractor submits a report covering the delinquent period or such other period specified by the Federal Highway Administration or by the Director, Office of Federal Contract Compliance,U.S.Department of Labor. ;a r Q C-6 Packet Pg. 241 (THE BIDDER'S EXECUTION ON THE SIGNATURE PORTION OF THIS PROPOSAL - SHALL ALSO CONSTITUTE AN ENDORSEMENT AND EXECUTION OF THOSE CERTIFICATIONS WHICH ARE A PART OF THIS PROPOSAL) EQUAL EMPLOYMENT OPPORTUNITY CERTIFICATION The bidder DU . Y3C , proposed Q subcontractor i t u K V 2 V 1 ., hereby certifies that he has ,/ , has not participated in a previous contract or subcontract subject to the equal opportunity clause, as required by Executive Orders 10925, 11114, or 11246 A, in and that, where required, he has filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance, a Federal Government contracting or n administering agency, or the former President's Committee on Equal Employment z M r Opportunity, all reports due under the applicable filing requirements. L L U) 06 NOTE: The above certification is required by the Equal Employment Opportunity Regulations X m of the Secretary of Labor ( 41 CFR 60-1.7 (b) (1) ), and must be submitted by bidders o and proposed subcontractors only in connection with contracts and subcontracts which m are subject to the equal opportunity clause. Contracts and subcontracts which are N exempt from the equal opportunity clause are set forth in 41 CFR 60-1.5(Generally only 3 contracts or subcontracts of$10,000.00,or under,are exempt). 0 Currently, Standard Form 100 (EE-1) is the only report required by the Executive Orders or their implementing regulations. Proposed prime contractors and subcontractors who have participated in a previous contract or subcontract subject to the Executive Orders and have not filled the required Q reports should note that 41 CFR 60-1.7(b)(1) prevents the award of contracts and subcontracts unless such contractor submits a report covering the delinquent period or E such other period specified by the Federal Highway Administration or by the Director, Office of Federal Contract Compliance,U.S.Department of Labor. w Q C-6 Packet Pg. 242 5.K.d AV A (THE BIDDER'S EXECUTION ON THE SIGNATURE PORTION OF THIS PROPOSAL SHALL ALSO CONSTITUTE AN ENDORSEMENT AND EXECUTION OF THOSE CERTIFICATIONS YYHICH ARE A PART OF THIS PROPOSAL) EQUAL EMPLOYMENT OPPORTUNITY CERTIFICATION The bidder DBE 17 , proposed CL subcontractor { t f , hereby certifies that r in he has \✓ , has not participated in a previous contract or subcontract subject L to the equal opportunity clause, as required by Executive Orders 10925, 11114, or 11246 v Cn and that, where required, he has filed with the Joint Reporting Committee, the Director L of the Office of Federal Contract Compliance, a Federal Government contracting or N administering agency, or the former President's Committee on Equal Employment z M r co Opportunity, all reports due under the applicable filing requirements. L L Q� n W Jr d-. NOTE: The above certification is required by the Equal Employment Opportunity Regulations m of the Secretary of Labor ( 41 CFR 60-1.7 (b) (1) ), and must be submitted by bidders ° and proposed subcontractors only in'connection with contracts and subcontracts which m are subject to the equal opportunity clause. Contracts and subcontracts which are CD exempt from the equal opportunity clause are set forth in 41 CFR 60-1.5(Generally only o contracts or subcontracts of$10,000.Q0,or under,are exempt). M Currently, Standard Form 100 (EE-1) is the only report required by the Executive Orders or their implementing regulations. E Proposed prime contractors and subcontractors who have participated in a previous Y contract or subcontract subject to the Executive Orders and have not filled the required Q reports should note that 41 CFR 60-1.7(b)(1) prevents the award of contracts and subcontracts unless such contractor submits a report covering the delinquent period or such other period specified by the Federal Highway Administration or by the Director, v Office of Federal Contract Compliance,U.S.Department of Labor. w Mr A Q G6 Packet Pg. 243 PUBLIC CONTRACT CODE Public Contract Code Section 10285.1 Statement In accordance with Public Contract Code Section 10285.1 ( Chapter 376, L Stats. 1985 }, the bidder hereby declares under penalty of perjury that the bidder has , has not been convicted within the preceding 3 years of in any offenses referred to in that section, including any charge of fraud, bribery, L 2 collusion, conspiracy, or any other act in violation of any state or federal antitrust law in connection with the bidding upon, award of, or performance of any Public Works contract, as defined in Public Contract Section 1101, with any public entity Z as defined in Public Contract Code Section 1100, including the Regents of the co 7z University of California or the Trustees of the California State University. The in term "bidder" is understood to include any partner, member, officer, director, 06 responsible managing officer, or responsible managing employee thereof, as o x m referred to in Section 10285.1. 'm T N d 3 0 J M N NOTE: The bidder must place a check mark after"has"or"has not" E in one of the blank spaces provided. r The above statement is part of the Bid. Signing this Bid on the signature a portion thereof shall also constitute signature of this Statement. E Bidders are cautioned that making a false certification may subject the certifier to criminal prosecution. Q C-7 Packet Pg. 244 Public Contract Code Section 10162 Questionnaire In conformance with Public Contract Code Section 10162,the Bidder shall complete,under penalty of perjury, the following questionnaire: a� Has the bidder, any officer of the Bidder,or any employee of the Bidder who has a proprietary interest a a� a in the Bidder,ever been disqualified,removed, or otherwise prevented from bidding on,or completing _ a federal,state or local government project because of a violation of law or a safety regulation? in m t � Yes No L --. L Q� CO M If the answer is yes,explain the circumstances in the following space, a w d d L r CO c Z c+� CO AF iU CO otS Public Contract Code 10232 Statement w X In conformance with Public Contract Code Section 10232,the Contractor,hereby states under penalty of perjury o that no more than one final unappealable finding of contempt of court by a federal court has been issued against 00 N d the Contractor within the immediately preceding two year period because of the Contractor's failure to comply J with an order of a federal court which orders the Contractor to comply with an order of the National Labor c E Relations Board. a Note: The above Questionnaire and Statement are a part of the Bid. Signing this Bid on the signature E portion thereof shall also constitute signature of this Questionnaire and Statement. Bidders are cautioned that making a false certification may subject the certifier a to criminal prosecution. C-8 Packet Pg. 245 Awl NON-COLLUSION AFFIDAVIT (Title 23 United States Code Section 112 and Public Contract Code Section 7106) m To the CITY OF SAN BERNARDINO,PUBLIC WORKS DEPARTMENT, a ENGINEERING DIVISION. D In conformance with Title 23 United States Code Section 112 and Public Contract Code 7106,the M bidder declares that the bid is not made in the interest of,or on behalf of,any undisclosed person, L partnership,company, association, organization, or corporation; that the bid is genuine and not collusive or sham; that the bidder has not directly or indirectly induced or solicited any other d bidder to put in a false or sham bid, and has not directly or indirectly colluded, conspired, connived, co or agreed with any bidder or anyone else to put in a sham bid, or that anyone shall refrain from Z bidding; that the bidder has not in any manner, directly or indirectly, sought by agreement, co communication, or conference with anyone to fix the bid price of the bidder or any other bidder, �a L L or to fix any overhead, profit or cost element of the bid price, or of that of any other bidder, or to secure any advantage against the public body awarding the contract of anyone interested in the in t proposed contract; that all statements contained in the bid are true; and,further,that the bidder has X m 0 not, directly or indirectly, submitted his or her bid price or any breakdown thereof, or the contents ;a m T thereof, or divulged information or date relative thereto, or paid, and will not pay any fee to any 3 0 J corporation,partnership, company association,organization,bid depository, or to any member or � w a� agent thereof to effectuate a collusive or sham bid. 0 t. a w E Note: The above Non-Collusion Affidavit is part of the Bid. Signing this Bid on the signature portion thereof shall also constitute signature Q of this Non-Collusion Affidavit. Bidders are cautioned that making a false certification may subject the certifier to criminal prosecution. C-9 Packet Pg.246 DEBARMENT AND SUSPENSION CERTIFICATION TITLE 49, CODE OF FEDERAL REGULATIONS, PART 29 13 The bidder, under penalty of perjury, certifies that, except as noted below, he/she or any person T associated therewith in the capacity of owner,partner, director, officer, manager: C Is not currently under suspension, debarment, voluntary exclusion, or determination of r2-) U) ineligibility by any federal agency; Has not been suspended, debarred, voluntarily excluded or determined ineligible by any federal agency within the past 3 years; in C CU Does not have a proposed debarment pending; and Has not been indicted, convicted, or had a civil judgment rendered against it by a court of U) competent jurisdiction in any manner involving fraud or official misconduct within the past 3 Z years. P 00 If there are any exceptions to this certification, insert the exceptions in the following space: L W r it XX W 0 Exceptions will not necessarily result in denial of award, but will be considered in m determining bidder responsibility. For any exception noted above, indicate below to whom it N applies, initiating agency, and dates of action: o J M d C E U fC w w Q w C N E L U NOTES: Providing false information may result in criminal prosecution or administrative w sanctions. The above certification is part of the Bid. Signing this Bid on a the signature portion thereof shall also constitute signature of this Certification. C-10 Packet Pg. 247 CERTIFICATION By my signature on this bid or proposal I certify, under penalty of perjury under the laws of the State of California, that the foregoing questionnaire and statements of Public Contract Code Sections 10162, 10232 and 10285.1 are true and correct and that Q the bidder has complied with the requirements of Section 8103 of the Fair Employment and Housing Commission Regulations ( Chapter 5, Title 2 of the California Administrative Code ). By my signature on this bid or proposal I further certify, under penalty of perjury under the laws of the State of California and the United States of � America, that the Title 23 United States Code, Section 112, Non-Collusion Affidavit and the Title 49 Code of Federal Regulations, Part 29, Debarment and Suspension Certification are true and correct. w L b.. Date: i r_.,_ ,� z oo OWN M r (Name of Bidder) cLa SIGN co (Print Name of Person Sign'*) HERE (Signature of Bidder) ca m T m Business Address: t4-7—( ;;7 4 Oy Yli Vic- J Svu iA C;, r r r E-4 z. E w Address of Residence: S-2,&K 5�Q r '_'t= a L U f0 a� Q C-11 Mr A Packet Pg. 248 NON-LOBBYING CERTIFICATION FOR FEDERAL-AID CONTRACTS (For Projects with Federal funds over$100,000) v L The prospective participant certifies, by signing and submitting this bid or proposal, to the best of his or her knowledge and belief,that: (1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the R undersigned, to any person for influencing or attempting to influence an officer or 3: employee of any Federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of w any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment , or modification of any Federal contract, grant, loan, or N cooperative agreement. z (2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any Federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement,the undersigned shall complete and submit Standard Form L LL, "Disclosure of Lobbying Activities,"in accordance with its instructions. X m 0 m 3 0 NOTE: This certification is a material representation of fact upon which reliance was placed when this _J transaction was made or entered into. Submission of this certification is a prerequisite for making A or entering into this transaction imposed by Section 1352,Title 31,U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not E more than$100,000 for each such failure. a a The prospective participant also agrees by submitting his or her bid or proposal that he or she shall require that the language of this certification be included in all lower tier subcontracts,which exceed $100,000 and that all such sub-recipients shall certify and disclose accordingly. �a r Q C-12 Packet Pg.249 V` .DISCLOSURE OF LOBBYING ACTIVITIES COMPLETE THIS FORM TO DISCLOSE LOBBYING ACTIVITIES PURSUANT TO 31 U.S.C. 1352 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: Fla. contract Da bid/offertannlication Fla. initial b. grant b. initial award b. material change c. cooperative agreement c, post-award r' d. loan For Material Change Only: e. loan guarantee year_ quarter a f, loan insurance date of last repo 4. Name and Address of Reporting Entity 5. If Reporting Entity in No.4 is Su ardec, Enter Name and Address of P ' e: _ Prime Subawardee t,7 Tier if known ca Congressional District,if known Congressio District,if known m 6.. Federal Department/Agency: 7. Federa rogram Name/Description. to c R /FDA Number,if applicable 8. Federal Action Number,if known: }. Award Amount,if known: t w _c Z 10.. a. Name and Address of Lobby Entity b. Individuals Performing Services (including (If individual,last name,first name, ) address if different from No. I Oa) oo (last name,first name,MI) t, L (attach Continuation Sheet(s)if necessary) U) 06 II., Amount of Payment eck all that apply) 13.. Type of Payment(check all that apply) +- $ Actual planned a. retainer b. one-time fee 12. Foent(check all that apply): c. commission m Opin-kind; d. contingent fee specify: nature e deferred ..._....._ _.._.... m Value LJ f. other,speeify__rv___.__ __.._ 14. rief Description of Services Performed or to be performed and Date(s)of Service,including d officer(s),employee(s),or member(s)contacted,for Payment Indicated in Item 11: O J M (attach Continuation Sheet(s)if necessary) c 15. Continuation Sheet(s)attached: Yes No = W. Information requested through this form is authorized by Title Signat c: v 31 U.S.C.Section 1352. This disclosure of lobbying reliance y t a was placed by the tier above when his transaction was made or print N entered into. This disclosure is required pursuant to 31 U.S.C. +- 1352. This information will be reported to Congress , Title: _ t m semiannually and will be available for public inspection. Any E person who fails to file the required disclosure shall be subject V to a civil penalty of not less than$10,000 and not more than Telephone No.. " �!2CJ(p C aU 11 _Dater m $100,000 for each such failure, Y Q Authorized for Locai Reproduction Federal Use Only: Standard Form-LLL Standard Dorm L13,Rev,60.12M C-13 Packet Pg.250 INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of covered Federal action or a material change to previous filing pursuant to title 31 U.S.C.Section 1352. The filing of a form is required for such payment or agreement to make payment to lobbying entity for influencing or attempting to influence an officer or employee of any agency,a Member of Congress an officer or employee of Congress or an employee of a Member of Congress in connection with a covered Federal action. Attach a continuation sheet for additional information if the space on the form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. a M 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence,the 70- outcome of a covered Federal action. a� 2. Identify the status of the covered Federal action. 3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported,enter the year and quarter in which the change occurred. Enter the date of the last, previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name,address,city,State and zip code of the reporting entity. Include Congressional District if known. Check the appropriate classification of the reporting entity that designates if it is or expects to be a prime or subaward in recipient. Identify the tier of the subawardee,e.g.,the first subawardee of the prime is the first tier. Subawards V include but are not limited to subcontracts,subgrants and contract awards under grants. 5. If the organization filing the report in Item 4 checks"Subawardee"then enter the full name,address,city,State and zip code of the prime Federal recipient. Include Congressional District,if known. P 6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organization level to below agency name,if known. For example,Department of Transportation,United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action(item 1). If known,enter the full c Catalog of Federal Domestic Assistance(CFDA)number for grants,cooperative agreements,loans and loan ` commitments. `") 8. Enter the most appropriate Federal identifying number available for the Federal action identification in item 1(e.g., Request for Proposal(RFP)number,Invitation for Bid(IFB)number,grant announcement number,the contract �. grant.or loan award number,the application/proposal control number assigned by the Federal agency). Include L prefixes,e.g., "RFP-DE-90-001." 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency,enter the Federal amount of the award/loan commitments for the prime entity identified in item 4 or 5. 06 10. (a)Enter the full name, address,city,State and zip code of the lobbying entity engaged by the reporting entity CO identified in item 4 to influenced the covered Federal action. s (b)Enter the full names of the individual(s)performing services and include full address if different from 10(a). (n Enter Last Name,First Name and Middle Initial(MI). ca 11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity(item 4)to the lobbying entity(item 10). Indicate whether the payment has been made(actual)or will be made(planned). Check all v_ boxes that apply. If this is a material change report,enter the cumulative amount of payment made or planned to be m made. a) 12. Check the appropriate box(es). Check all boxes that apply. If payment is made through an in-kind contribution, c specify the nature and value of the in-kind payment. _J 13. Check the appropriate box(es). Check all boxes that apply. If other, specify nature. ri 14. Provide a specific and detailed description of the services that the lobbyist has performed or will be expected to y perform and the date(s)of any services rendered. include all preparatory and related activity not just time spent in actual contact with Federal officials. Identify the Federal officer(s)or employee(s)contacted or the officer(s) s employees)or Member(s)of Congress that were contacted. 15. Check whether or not a continuation sheet(s)is attached. Q 16. The certifying official shall sign and date the form,print his/her name title and telephone number. c Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for E reviewing instruction, searching existing data sources, gathering and maintaining the data needed, and completing and U reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection M of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Q Reduction Project(0348-0046),Washington,D.C.20503. SF-LLL-Instructions Rev.06-04-90uENDIF)> G14 Packet Pg.251 BOND PREMIUM: NIL FORM OF BID BOND KNOW ALL MEN BY THESE PRESENTS, that we,the undenlgned, DBX INCORPORATED as Principal,and THE GUARANTEE COMPANY OF NORTH Art .R t A as Surety,are hereby and firmly bound unto the City of San Hemardioo , State of California, horeinafter referred to as"Obligee"in the penal sum of ten percent ( 10% ) of the total amount of the bid of the Principal submitted to the Obligeo for the work described below, for the payment of which sum we hereby jointly and severally bind ourselves, our heirs, executors, administrators, a successors and assigns. M THE CONDITION OF THIS OBLIGATION IS SUCH, THAT: WHEREAS, the Principal has submitted to Obligee,a certain Bid,attached hereto and hereby made a part hereof to enter into a contract in writing,for the. TRAFFIC SIGNAL UPGRADE AT _9TH STREET AND SIERRA WAY PROJECT NO. TC12-001 m in (Copy h* the exact title description of work Including loerdlon as it appears on the proposal) for which bids are to be opened on OCTOBER 11 , 2016 _ d (Insert dale of opening) NOW, THEREFORE, _ z a. If said Bid shell be rejected,or in the alternate, b. If said Bid shall be accepted and the Principal shall a a=W a Contract in the Form of eontraot attached hereto(properly completed in accordance 7t- with said Hid)end shall furnish a bond for his faithful performanoe of said � contract,and shall in all other respects perform the agrwrnent created by the accaptanco of said Bid, than this obligation shall be void;otherwise,the same shall remain in force and effect,;it being expressly understood and agreed °e that the liability of the Surety for any and aU claims hereunder shall, in no event',exceed the penal amount of this obligation as (nn herein stated. it The Surety, for value received,hereby stipulates and agrees that the obligations of said Surety and its bond shall be in no way m impaired or affected by any extension of the time within which the Obligee may accept such Did, and said Surety does hereby ° waive notice of any such extension. m w Signed, this 30TH dayof_ SEPTEMBER , 20 16 3 IN WITNESS WHEREOF, the Principal and the Surety have hereunto set thoir hands and seals, and Ruch of them as ere corporations have caused their coMomta seals to be hereto affixed and these presents to be signed by their proper officers,the A day and year first mentioned. E U cv a—. THE GUARANTEE COMPANY OF q DBX RPORTED ( E ) UH � I{ A USS (SM�) r_ _INCO Principal E CD f 0y' _ �r a By; f Signature Sttrturr Q C Pe(Y,-k C T SPENCER FLAKE, ATTORNEY—IN—FACT Prirrred Name I'T Printed Name and ?Ytla NOTE:Notarization of Principal curl Surety signatures and 7)owo�r of Aiboruey of the Surety shall accoupMy tide bum C45 Packet Pg. 252 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§1189 d ca a� A notary public or other officer completing this certificate verifies only the identity of the individual who signed the CL document to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document. aM State of California ) in County of Riverside ) m On ��R before me, Phyllissa Martz, Notary Public t co Date Here Insert Name and Title of the Officer m Cn personally appeared James C. Perry .a Name(s)of Signer(s) m m who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are ran subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies),and that by his/her/their signature(s)on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. z } I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph 00 t is true and correct. ' 131ti WITNESS my hand and official seal. ' PtiYI;UA CAT&Z in Newry Public-CWornic i 06 'i Rive**Couary Signature t} t.l � i 130"W488ion 1215M4 `Signature of Notary Public M Comm.Ex iras A 11,2024 0, X ,Y m f O 00 Place Notary Seal Above 0 OPTIONAL d Though this section is optional, completing this information can deter alteration of the document or o fraudulent reattachment of this form to an unintended document. J A Description of Attached Document •- Title or Type of Document: Document Date: Number of Pages: Signer(s) Other Than Named Above: U Capacity(ies) Claimed by Signer(s) w Signer's Name: James C Perry Signer's Name: Q R Corporate Officer — Title(s):President/Secretary/Treas. [I Corporate Officer — Title(s): 0 Partner — D Limited ❑General ❑Partner — D Limited ❑General ❑Individual ❑Attorney in Fact 0 Individual ❑Attorney ir- Fact 0 Trustee ❑Guardian or Conservator J Trustee 0 Guardian.or Conservator ❑Other: ❑ Other: Q Signer Is Representing: Signer Is Representing: 10 02014 National Notary Association -www,NationalNotary.org•1-800-US NOTARY(1-800-876-6827) Item#5907 Packet,Pg.253 5.K.d ' CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. STATE OF CALIFORNIA County of Orange L On 09/30/16 before me, Lexie Sherwood Notary Public, a Date Insert Name of Notary exactly as it appears on the official seal C personally appeared Spencer Flake Name(s)of 5ignerts) A m who proved to me on the basis of satisfactory evidence to L be the person(s) whose name(s) islare subscribed to the ar within instrument and acknowledged to me that he/she/they rn executed the same in his/her/their authorized capacity(ies), c LEXIE SHERWOOD and that by his/her/their signature(s) on the instrument the �a person(s), or the entity upon behalf of which the person(s) COMM.#2031782 d (D 4 NOTARY PUBLIC*CALIFORNIA ' acted, executed the instrument. ORANGE COUNTY n Comm.Exp.JULY 27,2017 a 1 certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. Z ch Witness my hand and official seal. co ^ a: Signature x Csmvz M Place Notary Seal Above Signature a ata Public texie Sherwood L d N OPTIONAL Though the information below is not required by law, it may prove valuable to persons relying on the document N and could prevent fraudulent removal and reattachment of the form to another document. s 0 X Description of Attached Document 00 0 2 Title or Type of Document: m N Document Date: Number of Pages: 0 3 0 J Signer(s) Other Than Named Above: A a� c Capacity(ies) Claimed by Signer(s) E s Signer's Name: Signer's Name: Q ❑ Individual ❑ Individual ❑ Corporate Officer—Title(s): ❑ Corporate Officer —Title(s): _ m ❑ Partner ❑Limited ❑General ❑ Partner ❑Limited❑General Ee ❑ Attorney in Fact RIGHTTHUMBPRINT ❑ Attorney in Fact RIGHT THU �I MBPRINT um ❑ Trustee OF ❑ Trustee OF Q ❑ Guardian or Conservator Top of thumb here ❑ Guardian or Conservator Top of thumb here ❑ Other: ❑ Other: Signer is Representing: Signer is Representing: 9 P Packet Pg.254 :"�,1�IMIMIY I Emu 40THE n The Guarantee Company of North America USA GUARANTEE Southfield,Michigan POWER OF ATTORNEY KNOW ALL BY THESE PRESENTS:That THE GUARANTEE COMPANY OF NORTH AMERICA USA,a corporation organized and existing under the laws of the State of Michigan,having its principal office in Southfield,Michigan,does hereby constitute and appoint David L.Culbertson,Charles L.Flake,Richard A.Coon,Spencer Flake Culbertson insurance Services,Inc. CL its true and lawful attorneys)-in-fact to execute, sea[and deliver for and on its behalf as surety, any and all bands and undertakings, contracts of indemnity and other writings obligatory in the nature thereof,which are or may be allowed,required or permitted by law,statute,rule,regulation,contract c or otherwise. N The execution of such instrument(s)in pursuance of these presents,shall be as binding upon THE GUARANTEE COMPANY OF NORTH AMERICA >, USA as fully and amply, to all Intents and purposes,as if the same had been duly executed and acknowledged by its regularly elected officers at the M principal office. L The Power of Attorney is executed and may be certified so,and may be revoked,pursuant to and by authority of Article IX,Section 9.03 of the By-Laws adopted by the Board of Directors of THE GUARANTEE COMPANY OF NORTH AMERICA USA at a meeting held on the 31"day of December,2003, The President,or any Vice President,acting with any Secretary or Assistant Secretary,shall have power and authority: -a C 1. To appoint Attorney(s)-in-fact, and to authorize them to execute on behalf of the Company, and attach the Seal of the Company thereto, to bonds and undertakings,contracts of indemnity and other writings obligatory in the nature thereof;and y 2. To revoke,at any time,any such Attomey-in-fact and revoke the authority given,except as provided below d 3. In connection with obligations in favor of the Florida Department of Transportation only,it is agreed that the power and authority hereby given to the Attomey-in-Fact includes any and all consents for the release of retained percentages and/or final estimates on engineering and construction contracts required by the State of Florida Department of Transportation. it is fully understood that consenting to the State of Florida Department of Transportation making payment of the final estimate to the Contractor and/or its assignee,shall not relieve this surety company of any of its obligations under its bond. Z A. In connection with obligations in favor of the Kentucky Department of Highways only,it is agreed that the power and authority hereby given to the Attorney-in-fact cannot be modified or revoked unless prior written personal notice of such intent has been given to the Commissioner— T Department of Highways of the Commonwealth of Kentucky at least thirty(30)days prior to the modification or revocation. 00 Further,this Power of Attorney is signed and sealed by facsimile pursuant to resolution of the Board of Directors of the Company adopted at a meeting duly called and held on the Sth day of December 2011,of which the following is a true excerpt: O RESOLVED that the signature of any authorized officer and the seal of the Company may be affixed by facsimile to any Power of Attomey or certification fn thereof authorizing the execution and delivery of any bond,undertaking,contracts of indemnity and other writings obligatory in the nature thereof,and 06 such signature and seal when so used shall have the same force and effect as though manually affixed. y,vytga4 IN WITNESS WHEREOF,THE GUARANTEE COMPANY OF NORTH AMERICA USA has caused this instrument to be signed and w its corporate seal to be affixed by its authorized officer,this 23rd day of February,2012. X THE GUARANTEE COMPANY OF NORTH AMERICA USA In 4p y� �ntAy4" �� //•//'S�- I w.�wr+ J/ tit STATE OF MICHIGAN Stephen C. Ruschak,President&COO Randall Musselman,Secretary County of Oakland J On this 23rd day of February,2012 before me came the individuals who executed the preceding instrument,to me personally known,and being by we M duly sworn,said that each is the herein described and authorized officer of The Guarantee Company of North America USA;that the seal affixed to said a instrument is the Corporate Seal of said Company;that the Corporate Seal and each signature were duly affixed by order of the Board of Directors of r- Cynthia A. Takal IN WITNESS WHEREOF,I have hereunto set my hand at The Guarantee Notary Public,Stale of Michigan Company of North America USA offices the day and year above written. County of Oakland Q My Commission Expires February 27, 2018 #ti` Acting in Oakland County �G d I,Randall Musselman,Secretary of THE GUARANTEE COMPANY OF NORTH AMERICA USA,do hereby certify that the above and foregoing is a true = and correct copy of a Power of Attorney executed by THE GUARANTEE COMPANY OF NORTH AMERICA USA,which is still in full force and effect. u its +T+r� IN WITNESS WHEREOF,I have thereunto sat my hand and attached the seal of said Company this 30thday of September, 201 Q 4° r.re Randall Musselman,Secretary Packet Pg.255 —T BIDDER'S FIRM NAME REFERENCES - PLANS & SPECIAL PROVISIONS NO. 12810 TRAFFIC SIGNAL UPGRADE AT 3 97"STREET AND SIERRA WAY(TC12-001) HIGHWAY SAFETY IMPROVEMENT PROGRAM-HSIPL-5033(050) a �a c Date c�11 1-Ws °1 co The following are the names, addresses,and phone numbers for three public agencies for which BIDDER has performed similar work within the past two years: d Public Agency's Contract Name,Title Name&Address Type of Project Contract Amount Date Completed &Phone Number m m 1525 19-th sra rilttx- .._ z o rn 2. _ _� 1rti� ' 5y2S ,t _ r�z-�lixF6crr 4 _ X Ci 'O Lit ti�lrrt 11'i1 ?? "11r.�?__.�a�q`j m N N 3 0 J A a+ d C 3.3�sa t tr�xVAticy - l-ex (4 s M SIVIM5 2-C PaI ms. vi-ml 5`j cknj r a R-1 Packet Pg. 256 Fxht#.set (34, EXHIBIT 15-G CONSTRUCTION CONTRACT DBE COMMITMENT 1.Local Agency: CITY OF SAN BERNARDINO 2.Contract DBE Goal: _3% 3.Project Description: TRAFFIC SIGNAL UPGRADE AT 9TH STREET AND SIERRA WAY TC12-001 4. Project Location: 9T"STREET AND SIERRA WAY Q 5.Bidder's Name: ( j �—Xflc- 8.Prime Certified DBE ❑ 7.Bid Amount: 3 Z�' $2 •a� 8.Total Dollar Amount for ALL Subcontractors: �j 9.Total Number of g(.1.Subcontractors: N 10,Bid 12. 14.DB R Item 11.Description of Work,Service,or Materials Certification 13.DBE Contact Information Dollar Number Supplied Number (Must be certified on the date bids are opened) Amour ra L L ,1s4a1t CoriCrE}G Curb t cd;t 4c r Nor-Con*uct10►7 Suva Ce.S, rr+c- m in CC S1dtWta11S,'Tn5�41t (,G pure- 7 58S, NoIkenbeu< Ave,. CbVthu, a c n5- cJI C,1G.S5 i 1 A re aye-base C1 1-7 2.3 to-l3 99 9 GA, w w CN4 + recanstruc4 Sect-0,1 (D 0S iacc-1 C0 l0 13 Avis, rc.rnp -JI dclecl•Obic vY0.rni+v� ur;CCe lnelacl4n3 reFa,h; curb, z G AJJUSF u "i i l y GCSY�r +o f s J1�;1 M �rade . L Q1 3 (eartn ek r LA106!' la co Local Agency to Complete this Section $ X 21.Local Agency Contract Number: TC12-001 13.TOTAL CLAIMED DBE PARTICIPATION Co 22.Federal-Aid Project Number: HSIPL-5033(050) -a 23.Bid Opening Date: 27 m 24.Contract Award Date: IMPORTANT:identify all DBE firms being claimed for credit, aa) regardless of tier.Names of the First Tier DBE Subcontractors ar 3 their respective item(s)of work listed above must be consistent, 0 where applicable with the names and items of the work in the Local Agency certifies that all DBE certifications are valid and information on "Sub ontractor List"submitted with your bid,Written confirmation M this form is complete and accurate. a sited DBE Is require y J c t0J1-7)Eto E 25 Local Agency Representative's Signature 28.Date Preparers Signature 17.Date t v '�3afrlr- 'S C.Berry 0s,I-Zqb-qq cx1 w 27,Local Agency Representative's Name 28.Phone 18.Preparers Name 19,Phone Q 29,Local Agency Representative's Title 20.Preparers Title m DISTRIBUTION: 1.Original—Local Agency r 2.Copy—Caltrans District Local Assistance Engineer(DLAE).Failure to submit to DLAE within 30 days of contract Q execution may result in de-obligation of federal funds on contract.Include additional copy with award package. ADA Notice: For individuals with sensory disabilities,this document is available In aiteii8ta Formats. For information call(916)854-6410 or TOD (916)654.3860 or write Records and Forms Management,1120 N Street,MS-B9,Secmmento,CA 95814. Ia-1 5.K.d C) fifV(OH COWPUGIOn StPVUS W. N 945955 758 S. ROMEtx W.,C00,(fl 91723 Phone: (626)339-7000 Certified - DBE/MBE Contractor E-mail: hercon7774511 @aol.com Date- 9/2712016 a� CL M ATTN:Fharles Perry i T TO: DBX, Inc. fn RE: Traffic Signal Upgrade@ 9th Street and Sierra Way U) c ca a� PRICES INCLUDE ALL ITEMS AND QUANTITIES LISTED INCLUDING(EXCLUSION SHEET)ATTACHED. m 2EIL DE:SCRIFTION QUANTITY UNIT UNIT$ COST cn w 7 Install 8"concrete curb and gutter 115 If $ 134.21 $ 15,434.15 Z 8 Pcc sidewalk 110 sf $ 35.98 $ 3,957.80 9 Install ac pavement 2,200 sf $ 17.92 $ 39,416.30 10 Install class II aggregate base 2,200 sf $ 3.82 $ 8,403.70 oo 11 Sawcut and reconstruct section of local depression 40 sf $ 52.28 $ 2,091.20 12 Install ADA ramp wl detectable warning surface including retaining curb 4 ea $ 549.57 $ 2,198.28 i 13 Adjust utility cover to final grade 4 ea $ 193.55 $ 774.20 3 Clearing and grubbing 1 Is $ 12,741.12 $ 12,741.12 0 X m D m m 3 0 J M N C Please Review Notes Below Note: Price is based on 1-move see sheet 2 for add mob.Costs. We have excluded 30 BMP's,SWWP's,Footing Removals,All Overexcavating,Cut and Cap Q and Relocating of all Existing Utdities,Loggng and Pot Honig for any and all UUTities, " C All Weekend and Night work,Fees,Pennhs,Llcenses,A4 Survey and Staking.Shop Drwngs, N Badging,All signage and striping,Traf@c control plans,Engineedng,Water source and pemtit, U Message boards,sign postings,Light Source and Towers,Slteet sweeping,All Badging. w Traffic control plans-POtro7is.Was6auts. �( Grand Total $ 85,016.75 Note: /nrludcd trkls p,�opoBa,;please 6iad eMwAed akeat 2 of 2-114—eoa e'0a6&uets0,4 Serrhw, /M 9Avu irFd Exelas mm ottA ull tervw aad eondltsox& 1,f pa Aare aot jwz*ed Mede otZ Plcaee eaaAwo our-o#ee p Y2W of euap&w o2o 38B-7oo� Packet Pg. 258 Unified Certification Program Page Cw I Back To Ouery Form Search Returned 1 Records Tue Oct 18 10:32:14 PDT 2016 Query Criteria Firm/DBA Name:hercon Firm Type:DBE Firm ID 36158 Firm/DBA Name HERCON COMPANY,INC. Q' Address Line1 30211 AVENIDA DE LAS BANDERAS,STE 200 Address Line2 = City RANCHO SANTA MARGARI 0 State CA A Zip Code1 92688 Zip Code2 Mailing Address Linel L Mailing Address Line2 D Mailing City rn Mailing State Mailing Zip Codel f4 Mailing Zip Code2 Certification Type DBE N EMail ahemandez @herconcompany.com Contact Name ALBERT HERNANDEZ JR. Area Code (949) z Phone Number 766-6770 Alt Area Code ( } M Alt Phone Number w Fax Area Code (949) Fax Phone Number 216-9053 R Agency Name DEPARTMENT OF TRANSPORTATION d Counties 01); in Districts 00; 06 DBE NAICS 237110; U) ACDBE NAICS X m C1701 DEVELOP WATER SUPPLY;C1920 STRUCTURE EXCAVATION;C7160 ASBESTOS-CEMENT Work Codes SEWER PIPE;C7191 SEWER MANHOLE;C8903 ELECTRICAL; a A General Engineering Contractor,ASB Asbestos;B General Building Contractor,C10 Electrical Contractor; m Licenses C12 Earthwork and Paving Contractor;C16 Fire Protection Contractor;C36 Plumbing Contractor,C42 N Sanitation System Contractor,HAZ Hazardous Waste; 3 Trucks o Gender M -j Ethnicity HISPANIC A Finn Type DBE _ Back To Ouei y Form E Q d E C) U r6 Q Packet Pg. 259 http://www.dot.ca.gov/ucp/QuerySubmit.do Local Assistance Procedures Manual Exhibit 15-G Construction Contract DBE Commitment INSTRUCTIONS—CONSTRUCTION CONTRACT DBE COMMITMENT CONTRACTOR SECTION 1.Local Agency-Enter the name of the local or regional agency that is funding the contract. 2.Contract DBE Goal-Enter the contract DBE goal percentage as it appears on the project advertisement. 3.Project Location-Enter the project location as it appears on the project advertisement. 4.Project Description-Enter the project description as it appears on the project advertisement(Bridge Rehab,Seismic Q- Rehab,Overlay, Widening, etc). 5.Bidder's Name-Enter the contractor's firm name. rn 6.Prime Certified DBE-Check box if prime contractor is a certified DBE. 7.Bid Amount-Enter the total contract bid dollar amount for the prime contractor. S.Total Dollar Amount for ALL Subcontractors—Enter the total dollar amount for all subcontracted contractors. SUM=(DBEs+all Non-DBEs).Do not include the prime contractor information in this count. 9.Total number of ALL subcontractors—Enter the total number of all subcontracted contractors. SUM=(DBEs+all y Non-DBEs).Do not include the prime contractor information in this count. "vn 10. Bid Item Number-Enter bid item number for work,services,or materials supplied to be provided. 0 11.Description of Work,Services,or Materials Supplied-Enter description of work,services,or materials to be provided.Indicate all work to be performed by DBEs including work performed by the prime contractor's own forces,if the prime is a DBE. If 100%of the item is not to be performed or furnished by the DBE,describe the exact portion to be performed or furnished by the DBE. See LAPM Chapter 9 to determine how to count the participation of DBE firms. t 12.DBE Certification Number-Enter the DBE's Certification Identification Number.All DBEs must be certified on = the date bids are opened. z 13.DBE Contact Information-Enter the name,address,and phone number of all DBE subcontracted contractors. Cn Also,enter the prime contractor's name and phone number,if the prime is a DBE. 14.DBE Dollar Amount-Enter the subcontracted dollar amount of the work to be performed or service to be provided.Include the prime contractor if the prime is a DBE. See LAPM Chapter 9 for how to count full/partial participation. y 15.Total Claimed DBE Participation-$:Enter the total dollar amounts entered in the"DBE Dollar Amount"column. in %: Enter the total DBE participation claimed("Total Claimed DBE Participation Dollars"divided by item`Bid 06 Amount").If the total%claimed is less than item"Contract DBE Goal,"an adequately documented Good Faith Effort vn (GFE)is required(see Exhibit l5-H DBE Information-Good Faith Efforts of the LAPM). 16.Preparer's Signature-The person completing the DBE commitment form on behalf of the contractor's firm must X sign their name. 0 17.Date-Enter the date the DBE commitment form is signed by the contractor's preparer. a 18.Preparer's Name-Enter the name of the person preparing and signing the contractor's DBE commitment form. m 19.Phone-Enter the area code and phone number of the person signing the contractor's DBE commitment form. y 20.Preparer's Title-Enter the position/title of the person signing the contractor's DBE commitment form. 3 0 LOCAL AGENCY SECTION J A 21.Local Agency Contract Number-Enter the Local Agency contract number or identifier. 0 22.Federal-Aid Project Number-Enter the Federal-Aid Project Number. E 23.Bid Opening Date-Enter the date contract bids were opened. 24.Contract Award Date-Enter the date the contract was executed. 0 25.Local Agency Representative's Signature-The person completing this section of the form for the Local Agency Q must sign their name to certify that the information in this and the Contractor Section of this form is complete and accurate. 26.Date-Enter the date the DBE commitment form is signed by the Local Agency Representative. E 27.Local Agency Representative's Name-Enter the name of the Local Agency Representative certifying the contractor's DBE commitment form. Q 28.Phone-Enter the area code and phone number of the person signing the contractor's DBE commitment form. 29.Local Agency Representative Title-Enter the position/title of the Local Agency Representative certifying the contractor's DBE commitment form. Page 2 of 2 D-2 July 23,2015 Packet.Pg. 260 Air A Local Assistance Procedures Manual Exhibit 15-H DBE Information-Good Faith Effort EXHIBIT 15-H DBE INFORMATION—GOOD FAITH EFFORTS DBE INFORMATION- GOOD FAITH EFFORTS a� Federal-aid Project No. HSIPL-5033(050) Bid Opening Date 0 1i The city or San Bernardino established a Disadvantaged Business Enterprise(DBE)goal of = 0 3 %for this project.The information provided herein shows that a good faith effort was made. Cn Lowest,second lowest and third lowest bidders shall submit the following information to document adequate good faith efforts.Bidders should submit the following information even if the"Local Agency Bidder DBE M Commitment"form indicates that the bidder has met the DBE goal.This will protect the bidder's eligibility for award of the contract if the administering agency determines that the bidder failed to meet the goal for various in reasons,e.g.,a DBE firm was not certified at bid opening,or the bidder made a mathematical error. R Submittal of only the"Local Agency Bidder DBE Commitment"form may not provide sufficient documentation 0) to demonstrate that adequate good faith efforts were made. co t The following items are listed in the Section entitled"Submission of DBE Commitment"of the Special Provisions: Z c� A. The names and dates of each publication in which a request for DBE participation for this project was placed by the bidder(please attach copies of advertisements or proofs of publication): d R L Publications Dates of Advertisement d FO 06 Y co Y rn B. The names and dates of written notices sent to certified DBEs soliciting bids for this project and m the dates and methods used for following up initial solicitations to determine with certainty p whether the DBEs were interested(please attach copies of solicitations,telephone records,fax confirmations,etc.): m N d Names of DBEs Solicited Date of initial Follow Up Methods and Dates o Solicitation —' c� Y a� c E Y Y a _ E Y Y a Page 15-1 OB 12-04 D-3 June 29,2012 Packet Pg.261 Exhibit 15-H Local Assistance Procedures Manual DBE Information-Good Faith Effort C. The items of work which the bidder made available to DBE firms including,where appropriate, any breaking down of the contract work items(including those items normally performed by the bidder with its own forces) into economically feasible units to facilitate DBE participation.It is the bidder's responsibility to demonstrate that sufficient work to facilitate DBE participation was a made available to DBE firms. Items of Work Bidder Normally Breakdown of Amount Percentage C Performs Item Items M Of (Y/N) Contract inc� L d D. The names,addresses and phone numbers of rejected DBE firms,the reasons for the bidder's rejection of the DBEs,the firms selected for that work(please attach copies of quotes from the Y' firms involved), and the price difference for each DBE if the selected firm is not a DBE: N c Names,addresses and phone numbers of rejected DBEs and the reasons for the bidder's rejection 'z of the DBEs: M T CO L L 1%09* in Names,addresses and phone numbers of firms selected for the work above: in s rn X C13 CO T N E. Efforts made to assist interested DBEs in obtaining bonding, lines of credit or insurance,and any 3 technical assistance or information related to the plans,specifications and requirements for the � work which was provided to DBEs: M .r m c E z c� a E Y Q Page 15-2 June 29,2012 D-4 OB 12-04 Packet Pg.262 Local Assistance Procedures Manual Exhibit I5-H DBE Information-Good Faith Effort F cc F. Efforts made to assist interested DBEs in obtaining necessary equipment,supplies,materials or 0 CL related assistance or services,excluding supplies and equipment the DBE subcontractor purchases or leases from the prime contractor or its affiliate: c rn Fn L L W G. The names of agencies, organizations or groups contacted to provide assistance in contacting, recruiting and using DBE firms(please attach copies of requests to agencies and any responses received, i.e., lists, Internet page download, etc.): Name of Agency/Organization Method/Date of Contact Results c Z co T .. 00 H. Any additional data to support a demonstration of good faith efflorts (use additional sheets if L necessary): rn r rn NOTE: USE ADDITIONAL SHEETS OF PAPER IF NECESSARY, m 0 m T y d 3 0 M m c E t U ca a w E w a Page 15-3 OB 12-04 D-5 June 29,2012 Packet Pg. 263 �wwwr�rrr o W o6 wa u. :py�a g �Y - wgw `oH o� aF Rio =`$� w zo°k �wi�°� a� N 4 Z 2s LLoo�m tieW - o$ z�PZi as a c�imv �r5z w° a °wN �g t7 o, y V ` JwwN a m wu z c N$ a � $Q U N �o 4 «� � w wm W =° V. 95 i<g U h NZ - oZ 22 OF 2� $ f w Uo OUrc= $O ZO�r OYm nW H. 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