CONTRACT SUMMARY SHEET TO: THE OFFICE OF THE CITY CLERK, COUNCIL/PUBLIC SERVICES DIVISION ROOM 395, CITY HALL DATE: AUGUST 30,2011 FROM (DEPARTMENT): BOARD OF PUBLIC WORKS CONTACT PERSON: MARY CARTER PHONE: 213-978-0262 CONTRACT NO.: C-119370 COUNCIL FILE NO.: _ [Z] NEW CONTRACT ADOPTED BY COUNCIL: D AMENDMENT NO. DATE D ADDENDUM NO. - APPROVED BY BPW: AUGUST 26, 2011 D SUPPLEMENTAL NO. DATE D CHANGE ORDER NO. _ CONTRACTOR NAME: PALP INC., DBA: EXCEL PAVING COMPANY TERM OF CONTRACT: 70 WORKING DAYS THROUGH: DECEMBER 13, 2011 TOTAL AMOUNT: $208,350.00 ------------------------ PURPOSE OF CONTRACT: FOR THE ARRA (AMERICAN RECOVERY AND REINVESTMENT ACT OF 2009) LOS ANGELES UNIFIED SCHOOL DISTRICT VALLEY REGION HIGH SCHOOL NO.4 PEDESTRIAN IMPROVEMENTS NOTE: CONTRACTS ARE PUBLIC RECORDS - SCANNED AND UPLOADED TO THE INTERNET
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CONTRACT SUMMARY SHEET
TO: THE OFFICE OF THE CITY CLERK,COUNCIL/PUBLIC SERVICES DIVISIONROOM 395, CITY HALL
DATE: AUGUST 30,2011
FROM (DEPARTMENT): BOARD OF PUBLIC WORKS
CONTACT PERSON: MARY CARTER PHONE: 213-978-0262
CONTRACT NO.: C-119370 COUNCIL FILE NO.: _
[Z] NEW CONTRACTADOPTED BY COUNCIL: DAMENDMENT NO.
DATE D ADDENDUM NO. -APPROVED BY BPW: AUGUST 26, 2011 D SUPPLEMENTAL NO.
DATE DCHANGE ORDER NO. _
CONTRACTOR NAME: PALP INC., DBA: EXCEL PAVING COMPANY
TERM OF CONTRACT: 70 WORKING DAYS THROUGH: DECEMBER 13, 2011
TOTAL AMOUNT: $208,350.00------------------------PURPOSE OF CONTRACT:
FOR THE ARRA (AMERICAN RECOVERY AND REINVESTMENT ACT OF 2009) LOSANGELES UNIFIED SCHOOL DISTRICT VALLEY REGION HIGH SCHOOL NO.4PEDESTRIAN IMPROVEMENTS
NOTE: CONTRACTS ARE PUBLIC RECORDS - SCANNED AND UPLOADED TO THE INTERNET
AP~~!:If.f~~tican Recovery and Reinvestment Act of 2009) -Los Angeles Unified School District Valley Region High School #4
Pedestrian Improvementsw.o. M0014067
Approved Federal Project No. ESPL-5006(574)?., ,20$- FTIP ID No. LAESlILAES075
C-A--R!;fv1!J!E9""TmR:FiUT~A~Nii71 Si:i., City Attorney
BY_.~~=---
In and for the
City of Los AngelesCalifornia
TYPE OF CONTRACT ~C~A~S~H~ ___
PROPOSAL ATTACHMENTS Plan Drawings Index No. 0-34043 (4 sheets)." .......-SPECIFICATIONS Standard Specifications for Public Works Construction (Greenbook) 2009
edition as amended by the January 6, 2011 edition of the City's BrownBook.
PROJECT LOCATION 2001 Thomas Guide page no. 501-C3
COMPLETION TIME
LIQUIDATED DAMAGES
70 working days
$1,000 per calendar day
BID DATE Bids must be received no later than 10:00 a,m. on April 20, 2011 at Los Angeles City Hall;200 North Spring Street, Room 355; Los Angeles, California 90012.
8 Remove 3-foot diameter Tree Stump EA 2 300.00 lot5D·00
9 Remove 24~inch diameter Tree EA 2 'iW·0" JOLfO· ,,"10 Remove 1-inch diameter Tree EA 10 '6.;0 ss. 00
11 Perform Root Pruning and Tree Trimming EA 13 ~.<p 4940- ""12 Remove Shrubs LS 1tXJi).1!O13 Remove 12" high Concrete Curb LF 210 q.5'O lo,QS. ¢
14 Install 3" thick Concrete SF 13,000 3.0<> MODO· c<>
15 Place 4" Crushed Miscellaneous Base (CMB) SF 4,500 I. fio {p750.. ISO
16 Reconstruct 4" thick Concrete at 19 Driveways SF 3,600 4. au 1>0NtJoO·17 Construct Access Ramps EA 9 I(POD :'. I~qo» fP
18 Install Truncated Domes for Access Ramps EA 7 I.{(pO. 32-20.- "'"19 Construct Type "A" Concrete Curb LF 300 ;po (1U (p(p(jD- at>
30' <P X56'l.J. tP20 Construct Type "C" Concrete Curb and Gutter LF 100
F-2a
·SCHEDULE OF WORK AND PRICESCity of Los Angeles· Department of Public Works· Bureau of Street Services
ARRA (American Recovery and Reinvestment Act of 2009) -Los Angeles Unified School District Valley Region High School #4Pedestrian Improvements
Work Order No. M0014067
Federal Project No. ESPL-5006(574)
FTlP 10 No. LAES1/LAES075
3/15/2011
21
Adjust Sprinkler Heads and Relocate InterferingIrri ation Lines
Plant 24-inch Box Street Tree in Parkway
LS22
Total Bid Amount:
Unit abbreviations: lS = lump sum, CY = cubic yard, EA = each, LF = linear foot, and SF = square foot
NOTES
B. Access Ramps: For Bid Item No, 17, the contractor shall construct the access ramp shown on the plans and eight additional similar accessramps at locations near the project area, The City shall provide the location of these 8 access ramps to the contractor within one month after theIssuance of the Notice to Proceed (NTP).
A. Fixed Cost Item: Bid Item NO.3 is considered as Fixed Cost Item at the time of bid. The pre-printed dollar amount listed in the "Schedule ofWork and Prices" shall not be changed or deleted.
C. Specialty Items: Bid Item Nos. 2, 21, and 22 are deSignated as "Specialty Items".
qA.tii.nitial:$uljmtS$lQI!I·QN}~.l!'IptGitElq·~ue~Uannaire,o An UPQii!t$ of-!! pnof Qt.I~s~onnlllt~~ateq I .f ,E(NQc:;tiat19~~1¢:9.rtrfy,llt1Q~tp~nl;jltyQrpEiFJtji'y, unQetth9II1WSQHh~.$~teIlfeillifoitiili that th(lr& hll$bEi9l1 no
chlln.~~tq;anyofthe.respon$$ssinC$t~la$(Responsl~llity ~uestion~aire dat$Q a. I~ 10·W<lf;lsu~l1Jlttec;lbythe.fitro. Attach a coPYof that Ql,lestionnalreant;!$IgobelQw.
c..' ~. ~.f)O.Wit p'I'lEBmE~t /'.), t _./LI'/lrwvv- m 2 0 Z011
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TOTAL NUMBER OF PAGES SUElMlmO, INCl.liOING ALL AlrAdHMENT$: _ResponiijbftiiY QiJ"S1lonriaire; (Rei" 0110,10$) f;"~a
!f Y~,,~1t;i!"/~~m~l!t~!!'I~ff,lI~!.lQn!ililiH~~1WjitefrY~f·flfri}~/lI$:tt!~~tmt flfflf$l. Irl¢!i.lq~rnrgm\l\(IQ!i'.,~b!:!l.It!iln_W4ii\:I'iH~,"!1If·Q!I.e,;iirm.QVnI~ $jl~ (l\' mQf!'!'of 8,not~tiitm, or if an ,QWni!ti.~«~(jfYbll~'fftmt\biifS;.,Sln1I(~p6SltIl'lrflh'i!li.f9Ih'~ilffl:l.
YR.H..\!L eMR~h.JS£ YFt2;~ ~R-~:~ YR•.a:,~eMR·3:Jkl11, 1NlIIilIrit\le·p~tfl'il(f. yeart;; has YQur.flfl11 ever had empllll¥liEi$<.but \Nas Without WQ~Kel'tl'e<Rl!PI!n$atiQ!i
~s:::ce%.aPPi'6\1ed'S"lf.jn~tiralieEj?
IfYes. explain on Attachmel1tit each instliineEj,If No,.attach a statemeht frl;lmyour Workers' competlSa!tbriihsurlince ptQviijerthat you havaMehcorilinuo\lSly insUfEic!lfor the past fiveyaa·rs.
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vco. M0014067Federal Project No, Ef\PL-5006(574)FTIP 10 No, LAES11lAES075D Pi P$FOJUW4Q{!HI$TORY
.'(IiI¥~~rni!!!1t,:,~ubaQn!ra~()r~~CJYe" UN!)(.Q'.',W<;IlkPa.i'flo.rl'tlan~ on a contract?ClV~ IllNb(c.) E..m..PIOym.Efat-related litigation broughtpy an employee?DYes GNo
F-3e
W.O. M0014067Federal Project No. ESPL-5006(574)FTIP 10 No .• LAES1ILAES075
Under LO$Angel(js MUriiGii>slCode ~ 48;Ofl/Hj, thisrorm must he SJ!bmiltedt<>th""watding;eu#honty witHyour b(d"or propa,$'8./-on thi; oontra.ct rio.tedEibOv~;,
'At!
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A.···2, _/
w.o. M0014067 Federal Project No. ESPL-5006(574) FTIP ID No. LAES1lLAES075
o Los Angeles .Administrative Code §1U(U(h)
(h) "CItY FfI'l~aI ASsfstance~t4!nt·!I1eaJ1$ any person ~.iecelves fl'l1m,~ CitydiSd'ete finailCial assfstance In the ainQuntofOne HuridrtldThousand Dollars ($100.000.00)or-more for ~O!I1lc d~Qpment~ loll gro,wth !1XPr¢;t artiC\lta~ am!lcientjfitld bythe City. as contras.ted wtth generaliz\ldfinanclalllSSlstance such as through t~ legislation.
ClitEigOlili$of sud) assistl!oc(l.shl!ll Indude, bot are nOt limited ~I);bond fInanCIng, planning~$~ce, tax Inct:E!!1Ientnnl1ndhg:~xdtjSiv~yby'the <;Ity,lind taJlcrtldlts. and.s~U notInclude. assistance provided QY tfje. Coin!'ri~nlty DeyetOp!1lelltBahk.Citystaff assistanceshall not be regarded as financial assistance for p.urposes of th,,·. artICle. A 1000nsnall not beregardedi\S finimclal assl$tilllCe •. The torgivenes$ofa l~ shl!ll be regardlld as flnandalassistance. A l(lanshall be regarded 'asflnanCialassistancetCI thee~ent of any differentialbetween the amount of the lOim and the present·value of the payments thereunder.diStountedilVet the life pf thelCian bY the applicable fedet;>l rate as,used!n 26 U.S.C.sectipns1274(d), 78i'2(f). A reCipient shilll not be deemed' to Include lessees ands~blmees.
Los Angeles Administrative Code §10.37.1(1)
(I) "Public lease or IIclinse" •(a) Except as provided In (I)(b) •.·Publlc lease or license" means a leaSe Or license of CIty
property on which services are rendered by emplOYeli$of thl! public lessee or licenseeor sublessee or sublIcensee. or of a contractor or subcontractor. b~t only where any ofthe followtngappUeS:(1) The services are rendered on premises at least a portion of whiCh Is VIsited by
m Any Clf the SE!rvI¢escouldfeasiblybe performed byCity employees Ifth".awardlhgauthority had the l'\!qulSite finaqdal and stafffngi'<i$04rces; Or
(3) the DM has d~rmiited'ih writing tliiit coverage would further the PrQprietaryInterests of the City. . .
(b) A publiC;lessee or t1censeewtll be exempt from the r\!tlulrements of t\lisartlcte subject;to the folIQWingl1mltca!;lQ/ls: .(I) The lessee or U¢ensee.f\as annual gross revenues of 1m. than the annual grosS
revenue threshold. three hundred fifty thousand do\lal'$ ($35Q,OOOl. from businessconducted on CltyprQparty;
(2) The tessee or ilcen~emPIOYSno more than seven (.7) people total In thecompany on and. off City properw; .
(3.) To qUalIfYfot tlllsexemptii111, the l~ee or ljcensee rntjSt provide proof of Itsgross revenueS and rumber of pe<l* it empla~ In the c.amp.ny·s entireworkforce to the, awarding authority as required by regulation;
(4) Whether annual gross revenues are tess than three hurWedflfty thousand dollars($350.QO(l) shall b.e deterrnlned based on the gross revenues for th.e last tax yearprior to application or such' other period a$ may be li$ta!>Ushed by regul~tlon;
(5) The annual gross revenue threshOld shall be adjusted annually at the same rateand atthe same time as the .living W<igeISi\dJusted under ll<ictlqn 1().~7.Z(a);
(6) A lesseeor lIcen$E!,$Shall be· deemed to employ. no mere than seven (7) people Iftl1ecompany'sentih~wC!!'I\forceworked an aVerage of no more than one thousandtwo-hundred fourteen (1,~14)haurs per month for at least three-fourths (3/4) ofthe time period th~tthe reVt1nue lImltatton is measured;
(7) Public leases and licenses shall be deemed to include public subleases aridsublicenses;
(8) If a pubttclease or license has a-term-of more than two (2) years. theexempttengrantedpursuant, to thisll<iction shall expire after two (2) years but shall berenewable In two"yeatincrements upon meeting tile requirements therefor at thetime of the renewal application or such' period established by regulation,
W.O. MOOl4067Federal Project No. ESPL-5006(574)
!'TIP ID No. LAESI/LAES075SIGNATURE SHEET AND AFFIDAVIT o
(1) That I/We have read this proposal and have abided by and agree to the conditions herein and have carefully examined the projectplans and read the specifications and I/We hereby propose to furnish all materials and do all the work required to complete thework in accordance with the plans and specifications, for the unit prices or lump sums named in the Schedule of Work and Prices.Furthermore. IIWE have read and understand Ordinance No. 173677 of the "Determination of Contractor Responsibility Policy" ofthe City of Los Angeles and IIWE understand my/our obligations under this policy as a bidder and as a contractor should thiscontract be awarded to my/our finn.
(2) That this proposal is genuine, and not sham or collusive, nor made in the interest or in behalf of any person not herein named, andthat IIWe have not directly or indirectly induced or solicited any other bidder to put in a sham bid, or any other person, finn orcorporation to refrain from bidding, and that I/We have not in any manner sought by collusion to secure for myself/ourselves anadvantage over any other bidder.
(3) This contract is expressly made for the benefit of the signatory parties only. It is not the intent of any of the signatory parties tocreate or discharge any duty, express or implied, to any party other than the signatory parties. Any benefit derived from thiscontract by a third party is unintended and incidental to the purpose for which this contract is made.
(4) That l/We as principal(s), acknowledge myself/ourselves as being bound by the accompanying Bid Bond when completed by theSurety.
(5) That I have read and understand the provisions ofthe Pollution Control- Sewage Spill Prevention and Response Requirementsand the Board of Public Work's Policy of "Zero Spill" requirements as contained in this Proposal. Ifawarded this contract, II Weagree to furnish all of the materials, supplies, tools. equipmentrlabor and other services necessary for the containment and clean upof any sewage or other pollutants spills or leaks occurring during the performance of this contract. I1WE further agree to actimmediately, without instructions from City staff, to contain and clean up any spill in any way involved with myI our activities onthis project without concern for who or what caused the spill.
ADDENDA w This proposal is submitted with respect to the changes to the contract included in Addenda numbers:
(FlU in Addenda reeelved) \ (). ;. L\
IIWe certify or declare under penalty of perjury that the foregoing is true andcorrect, and that if only one signature is provided, it is provided in accordancewith Note 8 in the General Instructions and Information for Bidders of thisproposal.
I.c.P. !lROW~ A DR 'l ()2n11PRESIOENT 1'.', (" J u
Signa'tUre Title
2. A( ~ ~,llil\ J(.1c),Date
;; 0 ?OTiTitle Date
AUG 2 6 2011 MICHELE E, DRAIWlICH, I\SST. SECRETARYNote: ALL SIGNATURES MUST BE PROPERLY COMPLETED AND WITNESSED BY A NOTARY
07/03/06F-4
CALIFORNIA ALL-PURPOSECERTIFICATE OF ACKNOWLEDGMENT
State of California
County of Los Angeles
t~pn2 0 2011On __ before me, C. Phillips. Notary publjc(Here ~ name and title oftbe officer)
personally appeared C. P. Brown, and Michele E. Drakulich
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s)lislare subscribed tothe within instrument and acknowledged to me that belshe/they executed the same inJbistlm'/their authorizedcapacity(ies), and that by:hislkBl'/their signature(s) on the instrument the person(s). or the entity upon behalf ofwhich the person(s) acted. executed the instrument.
I certify under PENAL TV OF PERJURY under the laws of the State of California that the foregoing paragraphis true and correct.
WITNESS my hand and official seal.
~OfNoWyPub\ic(NobUy Scol)
•
.~
COMM.#1809758 (")Notary PUbH(:-Galifornla ~LOSANG~t~s COUNTY II.
Jv~~~~M~Y~C~O~~~~~~~
•ADDmONAL OPTIONAL INFORMATION
INSTRUCTIONS FOR COMPLETING TIllS FORMAny acknowledgment comp/eu:d in California mllSt contain vtrbklge exactly asappear:J abovt in the notary seaion or a separate acAnowledgmtnt foem must beproperly completed and altached 10 thar do<:wuMl1l. 1M only exception is if adocvmenl is fa be recorded o1f/sitk 'a/Cali/ornia.. in .fUch instancu, Q:1I)' a1t~adnowledgmenl verbl'age as may be printed 011 .fIlCh a docwnenJ $(J long as lheverbtoge d«s not rt.quiu the notary 10 do .fomethlng thai is Illegalfor a notary InCali/omJa (i.e. ctttflYing 1M autlrorized C<plCi(Y o/,he signer). Please check.fhedocumetll canflJ"/or proper ~'Wording and allach IhUform ifrtl{Jllrtd.
DESCRlPTlON OF THE ATTACHED DOCUMENT
(Title or description ofattached document)
(Tide or descriptio. of attaehed docwnoot continued)
Number of Pages Document Date' __
(Additional information)
State and County infonnation must be the State and County where the documentsigner(s) J>Cf'OnallYappeared before the no!my public for lICb!owledgtn<tltDate of notarization must be the date that the signer(s) personally appeared whichmust also be the same date the acknowledgment is completed.
, The notary public must print his or her name as it appears within his or hercommission followed by a comma and then your title (notary public).Print the name(s) of document signer{s} who personally appear at the time ornotarization.Indicate the correct singular or plural forms by crossing ofT incorrect forms (t.e.helshel~ is fa«)} or circling the correct forms. Failure to correctly indicate thisinfonnation may lead to rejection of document recording-The notary seal impression must be clear and wotograprucally reproducible.Impression must not cover text or lines. If seal impression smudges, re-seal If 1\
sufficient area permits, otherwise complete a different acknow1edg:me:nt form.Signature of the notary public must match the signature on file with the office ofthe county clerk.
<!. Additional information is not required but could help to ensure thisacknowledgment is not misused or attached to a different document
.:. Indicate title or type of attached document, number of pages and date.0) Indicate the capacity claimed by the signer. If the claimed capacity is a
corporate officer, indicate the title (i.e. CEO, CFO, Secretary).Securely attach this document to the signed document
CAPACITY CLAIMED BY THE SIGNERo Individual (s)o CorporateOfficer
(Title)o Partner(s)o Attorney-in-Facto Trustee(s)o Other _
2008 Version CAP A v 12.10.07 800-873·9865 www.Notervctesses.corn
ARRA-(American Recovery and Reinvestment Act of 2009) -Los Angeles Unified School District Valley Region High School #4
Pedestrian Improvementsw.o. M0014067
FEl)ERAL PROJECT NO. ESPL-S006(574)FTIP ID NO. LAESl/LAES07S
BID BOND
(Not necessary when certified check or cashier's check accompanies bid)
We, the principal and undersigned Surety, acknowledge ourselves jointly and severalty bound to theDepartment of Public Works of the City of Los Angeles, for an amount not less than ten percent (10%) ofthetotal bid, to be paid to said Department if the proposal shall be accepted and the proposed contract awarded tothe principal, and the principal shall fail to execute the contract within the time specified by the generalinstructions in the proposal; and to furnish the required faithful performance and labor and material bonds,within the time specified. It is hereby agreed that bid errors shall not constitute a defense to forfeiture, exceptas provided by the State of California Public Contracting Code Sections 510 I through 5105, or as they may beamended.
WITNESS our hands this __7_th day of A-'-p_ril -', 20_1_1_.PALP Inc. elba Excel Paving Company
G.'f> _ f:~<~-ry(~:t~~.~~?H~~;H~:::'.r1r
I.
Print Name of Owner or President of Corporation/Company
C}~Federal Insurance Company
Print Surety's Name
15 Moumaln View RoadWarren, NJ 07059
Signature Mailing Address
Title
APR 20 2011Date
l1M\ (.~cJL(JJSecond Signature
MICHelI! IE.\ili\llAIIUJUCIII,"SST. SECfltfARYSecond Signature Title
Attorney in Fact2.Title
Title
APR 202011Second Signature Date Title
NOTE: SIGNATURE OF THE AUTHORIZED AGENT OF THE SURETY MUST BE WITNESSED BY A NOTARY. lfa bid bond issubmitted on a form other than this form, the bid' bond may not be acceptable. See Note 9 in the General Instruetiens andInformation for Bidders of this proposal for more information.
07/03/06F-5
ACKNOWLEDGMENT
State of CaliforniaCounty of Orange )
on~--.::O=-4:.:./.::O..:7:..:12=-O:::..:1..:1 before me, _...:D~e:::b::.r:::,a,::S:.:.w:.:a:.::n=s:::.on~,'-,:N.::o:::.:t=-a~ry~P~u:::.:b=l:.:iC~_(insert name and title of the officer)
personally appeared Timothy D. Rapp ,who proved to me on the basis of satisfactory evidence to be the perso~ whose namekS) is/~subscribed to the within instrument and acknowledged to me that he/~/M executed the same inhistpef/JMir authorized capacity~), and that by hiJlLller1>J;1effsignaturewon the instrument theperso~ or the entity upon behalf of which the personk8)' acted, executed the instrument.
I certify under PENALTY OF PERJU RY under the laws of the State of California that the foregoingparagraph is true and correct.
WITNESS my hand and official seal.
(Seal)
Federal Insurance CompanyVigilant Insurance CompanyPacific Indemnity Company
Know All by These Presents, That FEDERAL INSURANCE CO~P 'NY, .an Indiana corporation, VIGILANT INSURANCECOMPANY, a New York cgrporalion, and PACIFIC INDEMNITY COMPAN ,a Wisconsin corporation, do each hereby constitute andappointLinda D. Coats, Matthew J. Coats, Douglas A. Rapp an imothy D. Rapp of Laguna Hills, California---
each as their true and lawful Attorney-In- Fact to execute under such designation in their names and to affix their corporate seals to and deliver for and on their behalf as suretythereon or otherwise, bonds and undertakings and other writings obligatory in ine nature thereof (other than bail bonds) given or executed in· the course of business, and anyinstruments amending or altering the same, and consents to the mcdtncetcn or alteration of any instrument referred to in said bonds or obligations.
In Witness Whereof, said FEDERAllNSUAANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNIlY COMPANY have each executed and attested
On Ihis 16th day of November,2009 before me, a Nolary Public of New Jersey, personally came Kenneth C. Wendel, to meknown to be Assistant Secretary of FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIAC INDEMNITY COMPANY, the companies whichexecuted the foregoing Power of Attorney, and the said Kenneth C. Wendel, being by me duly sworn, did depose and say that he Is Assistant Secretary of FEDERALINSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY and knows the ccporeie seals thereof, that the seals affixed to theforegoing Power of Attorney are such corporate seals and were thereto affixed by authority of the By- Laws of said Companies; and that he signed said Power of Attorney asAssistant Secretary of said Companies by like authority; and that he Is acquainted With David B. Norris, Jr., and knows him 10be Vice President of said Companies; and that thesignature of David B. Norris, Jr., subscribed to said Power of Attorney is In the genuine handwriting of David B. Norris, Jr., and was thereto subscribed by authority of said By-Laws and In deponent's presence.
Notarla[ Seal KATHERINEJ. ADElMRNClfAIW PlJ9IJC OF NEW JERSEY
No 2316685Commlu.\on ExplrBii July 16, 2014
CERTIFICATION
"All powers 01attorney for and on behalt of the Company may and shan be executed in the name and on behalf of the Company, either by the Chairman or thePresIdent or a Vice President or an Assistant Vice President, Jointly wifh the secretary or an Assistant Secretary. under their respective designations. Thesignature of such otllcers may be engraved, printed or nthographed. The signature 01each of the following officers: Chairman, President, any Vice President, anyAsslstant Vice President, any Secretary, any Assistant Secretary and lhe seal of the Company may be affixed by facsimile to any power of attorney or to anycertificate refating thereto appoinl[ng As'Slstant Secretaries or Atlomeys- in- Fact for purposes only of execuling and attesting bonds and undertakings and otherwritings cbligatory In the nature thereof, and any such power of attorney or certiflcale bearing such facsimile signature or facsimile seal shall be valid and bindingupon the Company and any such power so executed and certified by such facsimile Signature and facsimile seal shall be valld and binding upon the Companywith respect to any bond or undertaking 10wnlch It is attached."
I, Kenneth C. Wendel, Assistant Secretary of FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, anc PACIFIC INDEMNITY COMPANY(the "Ocmpanles") do hereby certify that
(i) the foregoing extract of the 8y- Laws of the Companies Is true and correct,(11) !he ccmpanres are duly licensed and authorlzed to transact surety business in all 50 of the United Slates 01America and the Dtstnct of Columbia and are
authorized by the U.S. Treasury Department; further, Federal and Vigilant are licensed in Puerto Aico and the U.S. Virgin Islands, and Federal is licensed InAmerican Samoa, Guam, and each of the Provinces of Canada except Prince Edward [sland; and
(iii) the foregoing Power of Attorney le true, correct and In full force and effect.
Given under my hand and seals of said Companies at Warren, NJ this April?,2011
IN THE EVENT YOU WISH TO NOTIFY US OF A CLAIM, VERIFY THE AUTHENTICITY OF lHlS BOND OR NOTIFY US OF ANY OTHERMATTER, PLEASE CONTACT US AT ADDRESS LISTED ABOVE, OR BY Telephone (908) 903- 3493 Fax (908) 903- 3656
CALIFORNIA ALL-PURPOSECERTIFICATE OF ACKNOWLEDGMENT
State of California
County of ],os AngeJ es
On _,-,AP,-,R"-.-2_0_Z_0_11 before me, C. Phillips, Notary Public(Here insert name and tide of the officer)
personally appeared C.P. Brown. Michele E. Drakn1i ch
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s)ilil!are subscribed tothe within instrument and acknowledged to me that lf$sIre/they executed the same in>hilWilllr/theirauthorizedcapacity(ies), and that byJbisther/their signature(s) on the instrument the person(s). or the entity upon behalf ofwhich the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of Cali fomi a that the foregoing paragraphis true and correct. """"~
\I....,"..C, PHILLIPSJ?tL'~." COMM. #1809758 ~
;':' .~ Notary Public·CaHfornla [;.-~ 'l ,OS ANGELES COUNTY
I Myco;nm, Explre!lAUg. 16,2012 K,..._..~_~\~'G~J(~~~.;;._..,.-..r __
ADDmONAL OPTIONAL INFORMATIONINSTRUCfIONS FOR COMPLETING TIllS FORM
AIry acblO'Wledgment c<»npleted in California must coma;n l'erbtage exactly asoppear3 above in lhe notary semon or Q separate acknowleclgment/orm must beproperly completed and altocMd to thai ~nt. 1M only Clception is if adocwru!nt U 10 be recorded offJside o/O:!ifonu'Q. In .ruc!! tnstances, 019' allernativtacknowltdgmtnl verbiage as may be primed on 3uch Q document $0 long as thel1erblagt does nol requirt the notary to do something tltar iJ illegal for a notary InCaliforniil (i.e. CtrtifYing the arrthorized t;apaeity O/Iitt slgnn). Pleast cited .IMdocument canfolly for proper not.aritJI wording and OItach thi.r form If required.
•DESCRIPTION OF THE AIT ACHED DOCUMENT
(Title or description or attached document)
(Title or description of attached document continued)
Number of Pages __ Document Date, _
(Additional information)
CAPACITY CLAIMED BY THE SIGNERo Individual (8)o Corporate Officer
(fitle)o Partner(s)o Attorney-in-Facto Trustee( s)o Other _
2008 Version CAP A vi2.IO,07 8()()'873-9865 WW'N.NotaryClasses.com
{Notary "'1)
State and County information must be the SI:atc and County where the documentsigner(s) personally appeared before the notary publicfor acknowledgmentDate of notarization must be the date that the signer(s) pmonally appeared whichmust also be the same date the acknowledgment is completed.The notary public must print his or ber name as it appears. within his or hercommission followed by 8 comma: and then your title (notary public).Print the name(s) of document signer{s) who personally appear at the time ofnotarization.Indicate the correct singular or plural forms by crossing off incorrect forms (I.e.M'sheltMy, is 16M) or circling the correct forms. FaiJure to correctly indicate thisinformation may lead to rejection of document recording-The notary seal impression must be clear and photographically reproducible,Impression must not cover text or lines. If seal impression smudges, re-seal if asufficient area permits, otherwise complete a different acknowledgment form.Signature of the notary public must match the signature on file with the office ofthe county clerk.
-:. Additional information is not required but could help to ensure thisacknowledgment is not misused or attached to a different document
.:. Indicate title or type of attached document, number of pages and date,
..:- Indicate the capacity claimed by the signer. If the cleirned capacity is acorporate officer, indicate the title (i.e. CEO, CFO, Secretary).
Securely attach this document to the signed document
•
BOND NO. 8220-66-37
THAT 'WE ..,_.,!,~~~".,_Ic~S:c:,!..;_Pl'l~::-..~~<:.E!.--~~:'!-N!_C:?~~~!!,~~,:,_.c~.::FQ::~~.~~.;:".,-......."...~,".,".,_,_- ..---,-" ..,~- ...,""_~_.,.""",,,+.",_,,_,,_,,"_~,--"_-.,_",-._,_'.". __.•_.._.. ,_.-...+.-_._. ,-~_ ..,--.----... .a.s PRiNCIPAL,and~." ..,+_,fS2'![~!J!.\~\',~~~..!;£r.m!~~--+- _~"._,.",_."_,~._"-"..~. __,.,...__..,_,._.. . .._._.._.._........, a corporation
org~d ~t the laws of th.e..stli!eof .." , !!:i~~~~.._,_...".-" .._"~,-,"'- - ..- _._ and .duly authorized to
transact business 1ll1(l~t th~ ll>Ws ~f'thl' S!;\t~of Cal\fQl1\iilj as $We>y, $:'; held and f'IDn1:r bound 'unto TH:ECITY OF WSANOllLIi:S, A :MCWICH'AL CQRPC1M1'tQN, as obligee, in tI!l' just and full sum ofTWO HUNDRED EIGHT THQUSAND THREE HUNDRED FIFTY AND 00/100 -·-· .. -· -· ..:~.;...._;..:..,........""..,.....:.·.:..;.,.;..;....,q:.,.~ ••.;;.'4·.:.,-'...:."'".-.'- ....·,...'-,.,..,;,,;•• ~",:,;,.,.""_."- ...~,.••...,.~,....~." •.";;,-,,;:,; ......~;.""'-',.,,.~ •.••":-,..,.,...-."...,:.,;,..-~~" •..,.,.:.._."".~~••.•;.:........••• __ .M" _._. __ ;-,..,_ ••• __ ~._ •• _..,.. __
_:::~~:::::::::-.::::-...::::::.:::=:::::;--..----::=.::::----:::::.::~::::==:::~.::::::::;::::::::~-.-::::,-_--.-..-+- ..~ D~H<Wi.($ -.1~~!leQ;.~.9..;_..._, .....),for the payment Whereof well and tnjly to be made ~,ai(tpti)lc1Pai8l\~ sure):y 1'liA<'1 t4«!l1S,~lyes>fuM) lieU:s,. ~¢¢ut9ts,administrators, successors, and assigns, ~oint1yand severally fimil)lbytlJ,ese presents.
1'1lECO'NDIUQN o$the ,furegbfn,g obligation is such, ib;;t whereas, the abo~ bOlll1cil'dprin<:ipai is .abo\ltt\[email protected] contract;" atta"hedhe~to, wlth.sal~cQ'Plilteeto do. and perfQrill tj1ld'ollowing,t~wit;ARRA (AMERICAN RECOVERY AND REINVESTMENT ACT OF 2009) - LOS ANGELES UNIFIED SCHOOL DISTRICT."" __ "" .. _. •• w_. __ •• M.~._.~. . .. ---.- ..-.-.~.---- ..-..-.------ ..-."...,.....,-,..,.,~.-~.,.,..~,.."..,..~,,,.,...,.".,..."-~",...~..,,~",...."'7'"•...,..-- •• .,.~ _ _ ••• ~••
VALLEY REGION HIGH SCHOOL #4 PEDESTRIAN IMPROVEMENTS - W.O. M0014067=-...,;"",~~•.;.........,.""'.•.•,....~.~.•~".~,..... ~....;"."".,.,.,.,,~.'~"""."t<"'"_r..,...~-·,,·;-'f'"ii':·;.~,·,r'-,:-·~-..·.·,~~ ....._~~"'l,..··"i'.;#~~~~i'h";.""'.:,;...;;~,~.'~"'".-......~..."•.""'"".~;,..,.",:;,.,;:":;.,.;"""~~,..~:.;'.;;.;••.;.&.~.:-....._~";;~"",.""-";+._,,...,..... __ ." ... ~_
CALIFORNIA ALL-PURPOSECERTIFICATE OF ACKNOWLEDGMENT
State of California
County of LOS ANGELES
On __ E'Q" _-_\L(",,"'L::.~l ],.\__ before me, MONA COVINGTON, NOTARY PUBLIC(Here insert name and title of the officer)
personally appeared _~C'-"c£P--,.~BR~Oe!.1WN",-- -,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/ase subscribed tothe within instrument and acknowledged to me that hehil!eM!ey executed the same in his/Wlr/th0ir authorizedcapacity(ies), and that by his~/tbeir signature(s) on the instrumentthe person(s), or the entity upon behalf ofwhich the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraphis true and correct.
ADDmONAL OPTIONAL INFORMATIONINSTRUCTIONS FOR COMPLETING THIS FORM
Any acknow/edgmenJ completed in California must contain verbiage exactly asappears above in the notary section or a separate acknowledgrruml form must beproperly completed and attached 10 that document. The only exception ts if adocument is to be recorded outside a/California. In such instances, any alternativeacknowledgment verbiage as may be printed on such a document so long as theverbiage does not require the notary to do something that is illegal for a notary inCalifornia (ce. ce11iJYing the authorized capacity of the signer). Please check thedocument carefully for proper notarial wording and attach this/onn ijrequired
•DESCRIPTION OF THE ATTACHED DOCUMENT
(Title or description of attached document)
(Title or description of attached document continued)
Number of Pages __ Document Date' _
(Additional information)
CAPACITY CLAIMED BY THE SIGNERo Individual (s)o Corporate Officer
(Title)o Partner(s)o Attorney-in-Facto Trustee(s)o Other _
2008 Version CAPA v12.10.07 800-873~9865 www.NotaryClasses.com
• State and County infonnation must be the State and County where the documentsigner(s) personally appeared before the notary public for acknowledgment
o Date of notarization must be the date that the signer(s) personally appeared whichmust also be the same date the acknowledgment is completed.The notary public must print his or her name as it appears within his or hercommission followed. by a comma and then your title (notary public) .
.. Print the name(s) of document signer(s) who personally appear at' the time ofnotarization.
• Indicate the correct singular or plum! forms by crossing off incorrect forms (i.e.Mtshel~ is /Qffj ) or circling the correct forms. Failure to correctly indicate thisinformation may lead to rejection of document recording.
• The notary seal impression must be clear and photographically reproducible.Impression must not cover text or lines. If seal impression smudges, re-seal if asufficient area permits, otherwise complete a different acknowledgment form.
• Signature of the notary public must match the signature on file with the office ofthe county clerk.
.:. Additional information is not required but could help to ensure thisacknowledgment is not misused or attached. to a different document.
.:. Indicate title or type of attached document, number of pages and date.
.:. Indicate the capacity claimed by the signer. If the claimed capacity is acorporate officer, indicate the title (i.e. CEO, CFO, Secretary).
Securely attach this document to the signed document
•
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraphis true and correct.
CALIFORNIA ALL-PURPOSECERTIFICATE OF ACKNOWLEDGMENT
State of California
County of LOS ANGELES
On _-,?L"L_.l.\ (",,,,.,..-->.-1 ....1__ before me, MONA COVINGTON, NOTARY PUBLIC(Here insert name and title of the officer)
personally appeared MICHELE E. DRAKULICH
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/aFe subscribed tothe within instrument and acknowledged to me that be/shettbe.y;executed the same in mslher/their authorizedcapacity(ies), and that by ftislher/!beir signature(s) on the instrument"the person(s), or the entity upon behalf ofwhich the person(s) acted, executed the instrument.
ADDITIONAL OPTIONAL INFORMATIONINSTRUCTIONS FOR COMPLETING THIS FORM
Any acknowledgmenr completed in California must contain verbiage exactly asappears above in the notary section or a separate acknowledgment form must beproperly completed and attached 10 thai document. The only exception ts if adocument is to be recorded oiustde a/California. In such instances. any alternativeacknowledgment verbiage as may be primed on such a document so long as theverbiage does not require the notary to do something thai is illegal for a notary inCalifornia (i.e. certifYing the authorized capacity o[ tbe sigmr). Please check thedocument carefully for proper notarial wording and attach this/ann ifrequired
BSignature of Notary Public
DESCRIPTION OF THE ATTACHED DOCUMENT
(Title or description of attached document)
(Title or description of attached document continued)
Number of Pages __ Document Date _
(Additional information)
CAPACITY CLAIMED BY THE SIGNERo Individual (s)o Corporate Officer
(Title)o Partner(s)o Attorney-in-Facto Trustee( s)o Other _
2008 Version CAPA v 12.10.07 800-g73~9g65 www.NoteryClesses.com
fj/...".M~~~5~~I~~10N~~ NOTARY PUBLIC. CALIFORNIA ~Ii .. ORANGE COUNlY -
Comm. Exp. MAY 27,2012
(Notary Seal)
State and County information must be the State and County where the documentsigner(s) personally appeared before the notary public for acknowledgmentDate of notarization must be the date that the signer(s) personalty appeared whichmust also be the same date the acknowledgment is completed.
• The notary public must print his or her name as it appears within his or hercommission followed by a comma and then your title (notary public).
• Print the name(:S) of document signer(s) who personally appear at the time ofnotarization.
• Indicate the correct singular or plural forms by crossing off incorrect forms (l.e.helshe/tite;T- is /6Ie) or circling the correct forms. Failure to correctly indicate thisinformation may lead to rejection of document recording.
• The' notary seal impression must be clear and photographically reproducible.Impression must not cover text or lines. If seal impression smudges, re-seal if asufficient area permits, otherwise complete a different acknowledgment fonn.Signature of the notary public must match the signature on file with the office ofthe county cleric
.:. Additional information is not required but could help to ensure thisacknowledgment is not misused or attached to a different document.
.:. Indicate title or type of attached document, number of pages and date.
.:. Indicate the capacity claimed by the signer. If the claimed capacity is acorporate officer, indicate the title (i.e. CEO, CPO, Secretary).
Securely attach this document to the signed document
ACKNOWLEDGMENT
State of CaliforniaCounty of Orange
On ~--->O,-,8!!./...!.1-"6,,-,/2,,,O,,-,-1-,-1 before me, _...::D::,ce:.::b:..:.ra=:-=S:..:.w:.::a::.:n-=-so=n::,:',-,:N:;.o:.:t::::,ary~Pc.;u",b;,:':..:iC,-:-_(insert name and title of the officer)
personally appeared Douglas A. Rappwho proved to me on the basis of satisfactory evidence to be the person(,.1!)whose name(:t) is!ef;e.subscribed to the within instrument and acknowledged to me that he/ellei~Rey executed the same inhis/ReF/tReir authorized capacity(1et!7, and that by hislAeFI~A8ir signature(:t) on the instrument theperson(III), or the entity upon behalf of which the person(:t) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California thatthe foregoingparagraph is true and correct.
WITNESS my hand and official seal.
(Seal)
ChubbSurety
POWEROF
ATTORNEY
Federal Insurance CompanyVigilant Insurance CompanyPacific Indemnity Company
CHUBBKnow. All by These Presents, That FEDERAL INSURANCE COMPANY, an Indiana corporation, VIGILANT INSURANCECOMPANY, a New York corporation, and PACIFIC INDEMNITY COMPANY, a Wisconsin corporation, do each hereby constitute andappoint Linda D, Coals, Matthew J. Coats, Douglas A. Rapp and Timothy D. Rapp of Laguna Hills, California-·····-
each <:IStheir true and lawful AttQmey- In- Fact to execute under such designation in their names and to affix their corporate seals to and deliver for and on their behalf as suretythereon or otherwise, bonds and undertakings and cmer 'NIitlngs obligatory in the nature thereof (other than bail bonds) given or executed in the course of business, and anyinstruments amending or altering the same, and consents to the mod!llcation or alteration of any instrument referred to in said bonds or obligations.
c
/4.., ~LL~Kenneth C. Wenle1:ASSf$taflt SecretarY
./
STATE OF NEW JERSEYCounty of Somerset
On this 16th day of November, 2009 before me, a Notary Public of New Jersey, personally came Kenneth C. Wendel, to meknown to be Assistant Secretary of FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIAC INDEMNITY COMPANY, the companies .....tllchexecuted the foregoing Power of Attorney, and the said Kenneth C, Wendel, being by me duly sworn, did depose and say that he Is Assistant Secretary of FEDERALINSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY and knows the corporate seals thereof, that the seals affixed to theforegOing Power of Attorney are such corporate seals and were thereto affixed: by authority 01 the By- Laws of said Companies; and that he Signed said Power of Attorney asAssistant Secretary of said Companies by like authority; and thai he Is acquainted with David B, Norris, Jr., and knows him to be Vice President of said Companies; and that thesignature of David B, Norris, Jr" subscribed to said Power of Attorney Is In the genuine hanct...vrit!ngof David B. Norris, Jr., and was thereto subscribed by authority 01said By-Laws and In deponent's presence,
SS.
Notarial Seal KATHERINEJ. ADELMRNOtARY PUBLICOF NEWJERSEY
No 2316685CaMMlu\on E)l:pmu,Jl.lly 16.2014,
CERTIFICATION
"AU powers of attorney for and on behalf of the Company may and shall be executed in the name and on behalf of the Company, either by the Chairman or thePresident or a Vice President or an Assistant Vice President, Jointly with the Secretary or an Assistant Secretary, under their respective designations, Thesignature of such officers may be engraved, printed or lithographed. The slgnature of each of the following officers: Chairman, President, any Vice President, anyAsetsraot VIce President, any Secretary. any Assistant secretary and me seal ot the company may be afflxea by recsimne to any power of anomey or 10anycenacate relating thereto appointing Assistant Secretaries or Attorneys" in" Fact for purposes only 01executing and attesting bonds and undertakings and otherwritings obligatory In the nature thereof, and any such power of attorney or certificate bearing such facsimile signature or facsimile seal shall be valid and bindingupon the Company and any such power so executed and certified by such facsimile signature and facsimile seal shall be valid and binding upon the Companywith respect to any bond or undertaking 10which It is attached."
I, Kenneth C. Wendal, Assistant Secretary of FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY(the "Companies") do hereby certify that
(i) the foregoing extract of the By~Laws of the Companies Is true and correct,{II) the compames are duly hcensed and authorized to transact surety busmese m all SO01 the United States of Amenca and the Dlstr1ctof Columbia and are
authorized by the U.S. 'treasury Department; further, Federal and Vigilant are licensed in PUer10Rico and the U.S. Virgin Islands, and Federal is licensed InAmerican Samoa, Guam, and each of the Provinces of Canada except Prince Edward Island; and
(iii) the foregoing Power of Attorney Is true, correct and in fun force and effect.
GIven under my hand and seals of said ccmpentes at Warren, NJ sus August 16,2011
IN THE EVENTYOUWISHTO NOTIFYUS OF A CLAIM,VERIFYTHEAUTHENTICITYOFTHIS BONDOR NOTIFYUSOF ANY OTHERMATTER,PLEASECONTACTUSAT ADDRESSLISTEDABOVE,OR BY Telephone(908)903·3493 Fax(908)903· 3656
assnret ¥,_"_"~,,_,_,,_,,,,,"","~,.,. are held and firmly b(l\lna unto the CITY OF LOS ANGELES, Calil'orlii'l, a municipal
corporation, ill the 81)111 of,.}~2.!;lJt~,~.~ED.~~.':!!..!~2.':!!'~.fII_o..!.'lRE.~.I:!.\:l.,,!.o.~~.o..~I':!y'.A..~!?.~~!.~.O~:::.~:::.::: •._._.•..•.. .
,.,.::;::;'::::;::;:::::;:::::::::::'::~:~:::;:'::::':.:':::::;:;:::::~=:;:::::':::".::;:::::;::;:;::;:':::;;:::'::':::;:.:::::;:::.:;;:::.:~:'::::;:"...:::;.::;:.::::::::::::-. __ •...•..- .._....._. Dollars($ ....•..,._._.2.~I!-.3.~~:.~~..._._.._) lawful money of the United States,. for Which, pa>'ttlent well and truly to be-made, we bind
ourselves, jointly end _oraUy, fimily by these pr¢$¢!l1;il.
Signed, sealed and .dated ",.- ..•..- - - -.-~.':!§.':!§Lt!!._. __._.•_.__.-- •••---".--.,·,-,,,,,,,,.-.,,, .•."~,.~,, ••,,.",,·4(},,U .•.The conditions of the ~oove,p.bligatiQn; is such Wtt, 1/il!~nt.!~sai'd principal ~s. been JiW<lfl!¢dlil\!lls a);fo.u!.tOientermlP
a written contract with the..CiIY dt'tlls ..,A.nl$i)l¢s.fQt ....-,,, •..~•..""- ••,,...,,.......,.,,,-.,...,,.".'T':. :,.+"'h;,"'.".....,..,,+.+-+""'.,~""'1".•"-.ARRA (AMERICAN RECOVERY AND REINVESTMENT ACT OF 2009) • LOS ANGELES UNIFIED SCHOOL DISTRICT
CALIFORNIA ALL-PURPOSECERTIFICATE OF ACKNOWLEDGMENT
State of California
County of LOS ANGELES
On _-",?S!.--->.\",b"-'--L\ L __ before me, MONA COVINGTON, NOTARY PUBLIC(Here insert name and title of the officer)
personally appeared _-'C'-',,,P-",-"'BR"'O"'WN""- --'
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/see subscribed tothe within instrument and acknowledged to me that hekllte.4hey executed the same in his/R<lr/th<:irauthorizedcapacity(ies), and that by his!Rer/tI!eU"signature(s) on the instrumentthe person(s), or the entity upon behalf ofwhich the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraphis true and correct.
WITNESS my hand and official seal.
BY:'~~~Signature of Notary Public
(Notary Seal)
17':" ..~N" t
•
/. .. COMM .• 1798405 Ig NOTARY PU8uc • CALlFORM'" ~:;; ORANGE COUNTY ..., Comm. Exp. MAY27, 2012
"..-
ADDmONAL OPTIONAL INFORMATIONINSTRUCTIONS FOR COMPLETING THIS FORM
Any ac1cnaw/edgmcnJ completed in California must comatn verbiage exactly asappears above in the notary section or a separate acknowledgmenl form must beproperly completed and attached 10 that documenl. The only exception is if adocument is to be recorded outside o/Cal(fornia. In such instances, any alternativeacknowledgment verbiage as may be primed on such a document so long as theverbiage does nOl require the notary to do something lhaJ is illegal for a notary inCalifornia {i:e. certifying the authorized capacity of tbe signer). Please check thedocument carefully for proper notarial wording and attach this form if required:
•DESCRIPTION OF THE AIT ACHED DOCUMENT
(Title or description of attached document)
(Title or description of attached document continued)
Number of Pages __ Document Date _
(Additional information)
CAPACITY CLAIMED BY THE SIGNERo Individual (s)o Corporate Officer
(Title)o Partner(s)o Attorney-in-Facto Trustee( s)o Other _
2008 Version CAPA v12, 10.07 800-873-9865 www.NotaryClasses.com
• State and County, infonnation must be the State and County where the documentsigner(s) personally appeared before the notary public for acknowledgment
• Date of notarization must be the date that the signer(s) personally appeared whichmust also be the same date the acknowledgment Is completed.The notary public must print his or her name as it appears within his or hercommission followed by a comma and then your title (notary public).Print the name(s) of document signer(s) who personally appear at the time' ofnotarization.
• Indicate the correct singular or plural forms by crossing off incorrect forms {i.e.fte/shelthey;- is I/.W ) or circling the correct forms. Failure to correctly indicate thisinformation may lead to rejection of document recording.
• The notary seal impression must be clear and photographically reproducible.Impression must not cover text or lines. 'If seal impression smudges, re-seal if asufficient area permits, otherwise complete a different acknowledgment form.Signature of the notary public must match the signature on file with the office ofthe county clerk.
.:. Additional information is not required but could help to ensure thisacknowledgment is not misused or attached to a different document
.:. Indicate title or type of attached document, number of pages and date.
.:. Indicate the capacity claimed by the signer. If the claimed capacity is acorporate officer, indicate the title (I.e. CEO, CFO, Secretary).
Securely attach this document to the signed document
•
(Notary Seal)
CALIFORNIA ALL-PURPOSECERTIFICATE OF ACKNOWLEDGMENT
On _-")?~.l!\b~-~\cJ\L-_before me, MONA COVINGTON, NOTARY PUBLIC(Here insert name and title of'the officer)
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed tothe within instrument and acknowledged to me that he/sheLtbe)Lexecuted the same in hiBlher/tbeir authorizedcapacity(ies), and that by ftislher/their signature(s) on the instrumentthe person( s), or the entity upon behalf ofwhich the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws ofthe State of California that the foregoing paragraphis true and correct.
ADDmONAL OPTIONAL INFORMATIONINSTRUCTIONS FOR COMPLETING TIllS FORM
Any acknowledgment completed in California must contain verbiage exactly asappears above in the notary section or a separate acknow/edgmsnt form must beproperly completed and attached 10 that document. The only exception is if adocument is to be recorded outside of California. In such instances, any alternativeack1wwledgmenJ verbiage as may be primed on such a document so long as theverbiage does not require the notary to do something !hal is illegal for a notary inCalifornia (i.e. certifying the authorized capacity of the signer). Please check thedocument carefully for proper notarial wording and attach this form if required
State of California
County of LOS ANGELES
personally appeared MICHELE E. DRAKULICH
WITNESS my hand and official seal.
~ ~\)-::-n:--I-~BSignature of Notary Public
DESCRIPTION OF THE ATTACHED DOCUMENT
{Title or description of attached document}
(Title or description of attached document continued)
Number of Pages __ Document Date, _
(Additional Information)
CAPACITY CLAIMED BY THE SIGNERo Individual (s)o Corporate Officer
(Title)o Partner(s)o Attorney-in-Facto Trustee(s)o Other _
MONA COVINGTONCOMM. #1798405 II:
NOTARY PUBLIC. CALIFORNIA ~ORANGE COUNTY -
Comrn. Exp. MAY 27, 2012
• State and County infonnation must be the State and County where the documentsigner(s) personally appeared before the notary public for acknowledgment
• Date of notarization must be the date that the signer(s) personally appeared whichmust also be the same date the acknowledgment is completed.
• The notary public must print his or her name as it appears within his or hercommission followed by a comma and then your title (notary public).
• Print the name(s) of document signer(s) who personally appear at the time ofnotarization.Indicate the correct singular Of plural forms by crossing off incorrect forms (i.e.fl&Ishe/tftey;- is /ftfft) or circling the correct forms. Failure to correctly indicate thisinformation may lead to rejection of document recording.
• The -notary seal impression must be clear and photographically reproducible.Impression must not cover text or lines. If seal impression smudges, re-seal if asufficient area permits, otherwise complete a different acknowledgment form.
• Signature of the notary public must match the signature on file with the office ofthe county clerk.
(. Additional information is not required but could help to ensure thisacknowledgment is not misused or attached to a different document.
.:. Indicate title or type of attached document, number of pages and date.
.> Indicate the capacity claimed by the signer. If the claimed capacity is acorporate officer, indicate the title (i.e. CEO, CFO, Secretary).
Securely attach this document to the signed document
2008 Version CAPA v12.IO.07 800-87}¥9865 www.NotaryCJasses.com
ACKNOWLEDGMENT
State of CaliforniaCounty of Orange )
On _--'0::.;8""...:1'-'6"-'=2-"'0--'1...,1 before me, __ D-;:-e.....b__ra-';-S.....w..:;ac:.;n.;:.so"'n"",.,:N__o:..;;t.:.:,ary:-<;-'P_u:.;;b"'l:..:iC-,-_(insert name and title of the officer)
personally appeared Douglas A. Rappwho proved to me on the basis of satisfactory evidence to be the person(.l!) whose name(l) isi6fe.subscribed to the within instrument and acknowledged to me that helei'telli'ley executed the same inhisli'leFilReir authorized capacity(~, and that by hisiRsrifRsir signature(1) on the instrument theperson(t), or the entity upon behalf of which the person(1) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoingparagraph is true and correct.
WITNESS my hand and official seal.
Signature (Seal)
ChubbSurety
POWEROF
ATTORNEY
Federal Insurance CompanyVigilant Insurance CompanyPacific Indemnity Company
CHuaaKnow All by These Presents, That FEDERAL INSURANCE COMPANY, an Indiana corporation, VIGILANT INSURANCECOMPANY, a New York corporation, and PACIFIC INDEMNITY COMPANY, a Wisconsin corporation, do each hereby constitute andappoint Linda D. Coats, Matthew J. Coats, Douglas A. Rapp and Timothy D. Rapp of Laguna Hills, California----
each as their true and lawful Attorney- In- Feet to execute under such designation in their names and to affix their corporate seats to and deliver for and on their behalf as suretythereon or otherwise, bonds and undertakings and other writings obligatory in the nature thereof (other than bail bonds) given or executed in the course of business, and anyinstruments amending or altering the same, and consents to the modification or alteration of any Instrument referred to In said bonds or obligations.
In Witness Whereof, said FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY have each executed and attestedIh~~enls:nd:;,~~~al=~;6thdayo!Nove~ber. :09. r::Kenneth C. tt'enfe[ASSiStal1t Secret;J,ry~
STATE OF NEW JERSEYCounty of Somerset
On this 16th day of November, 2009 before me, a Notary Public of New Jersey, personally came Kenneth C. Wendel, to meknown to be Assistant Secretary of FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIF1C INDEMNITY COMPANY,the companies whichexecuted the foregoing Power of Attorney, and the said Kenneth C, Wendel, being by me duly swom, did depose and say that he Is Assistant Secretary of FEDERALINSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY and knows the corporate seals thereof, that the seals affixed to theforegoing Power of Attorney are such corporate seals and were thereto affixed by authority of the By- Laws of said Companies; and that he Signed said Power of Attorney asAssistant Secretary of said Companies by like authority; and that he Is acquainted with David B. Norris, Jr., and knows him to be Vice President of said Companies; and that theSignature of David B, Norris, Jr., subscribed to said Power of Attorney Is in the genuine handwritlng of David B, Norris, Jr., and was thereto subscribed by authority of said By-Laws and In deponent's presence,
Notarial Seal KATHERINE J. ADELMRNotARY PUBLIC OF NEW JERSEY
No 2316685CemMlu\Otl ExpIres;.July 16~ 2014 .
CERTIFICATION
"All powers of attorney for and on behall of the Company may and shall be executed In the name and on behalf of the Company, either by the Chairman or thePresident or a Vice President or an Assistant Vice President, jointly with the Secretary or an Assistant Secretary, under their respective designaUons. ThesIgnature of such officers may be engraved, printed or lithographed, The signature of each 01the follOwing officers: Chairman, PresIdent, any Vice President, anyessietarn VIce ereeroem, any Secretary, any Assistant Secretary and me seal 011he Company may be anlxed by teceenne to any power of arrcmey or 10anycertificate relating thereto appointIng Assistant Secretaries or Attorneys- in- Fact for purposes only of executing and attesting bonds and undertakings and otherwritings obligatory in the nature thereof, and any such power of attorney or certificate bearing such facsimile Signature or facsimile seal shall be valid and bindingupon the Company and any such power so executed and certified by such facsimile signature and facsimile seal shall be valid and binding upon the Companywith respect to any bond or undertaking 10which it is attached."
I, Kenneth C. Wendel, Asaletant Secretary 01FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY(the uCompanles") do hereby certify thai
(i) the foregoing extract of the By- Laws of the Companies Is true and correct,(II) Ihe ccmpantes are duly ncensec and authorized to transact surety business In all 50 of the United States of America and the District of Columbia and are
authcnzad by the U.S. Treasury Department; further, Federal and Vigilant are licensed in Puerto Rico and the U.S. Virgin islands, and Federal is licensed InAmerican Samoa, Guam ..and each of the Provinces of Canada except Prlnce Edward Island; and
(III) the foregoing Power of Attorney Is true, correct and in full force and effect.
ejven under my hand and seals of sate Companies at Warren, NJ this August 16, 2011
INTHE EVENTYOUWISHTO NOTIFYUS OFA CLAIM,VERIFYTHEAUTHENTICITYOF THIS BONDOR NOTIFYUS OF ANY OTHERMAlTER, PLEASECONTACTUS AT ADDRESSLISTEDABOVE,OR BY Telephone(908) 903- 3493 Fax(908)903· 3656
Non-collusion Affidavit(Title 23 United States Code Section 112 and
Public Contract Code Section 7106)
W.O. MOOl4067Federal Project No. ESPL-SOO6(S74)
FfIP ID No. LAESIILAES07S oTo the CITY / COUNTY of LOS ANGELES
DEPARTMENT OF PUBLIC WORKS.
ln conformance with Title 23 United· States Code Section 112 and Public Contract Code 7106 the
bidder declares that the bid is not made in the interest of, or on behalf of, any undisclosed person, 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 bidder to put in a false or sham bid, and has
not directly or indirectly colluded, conspired, connived, or agreed with any bidder or anyone else to put in a
sham bid, or that anyone shall refrain from bidding; that the bidder has not in any manner, directly or
indirectly. sought by agreement, communication, or conference with anyone to fix the bid price of the bidder
or any other bidder, 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
proposed contract; that all statements contained in the bid are true; and, further, that the bidder has not,
directly or indirectly, submitted his or her bid price or any breakdown thereof, or the contents thereof, or
divulged information or data relative thereto, or paid, and will not pay, any fee to any corporation.
partnership, company association, organization. bid depository. or to any member or agent thereof to
effectuate a collusive or sham bid.
Note: The above Noncollusion Affidavit is part of the Proposal. Signing this Proposal on the signatureportion thereof shall also constitute signature of this Noncollusion Affidavit. Bidders are cautioned thatmaking a false certification may subject the certifier to criminal prosecution.
Rev. 07/03/06F-6
LIST OF SUBCONTRACTORSW.O. MOOl4067
Federal Project No. ESPL- 5006(574)FTIP ID No. LAESIILAES075()
In accordance with provisions pertaining to the listing of Subcontractors, the bidder shall list herein each first tierSubcontractor to whom it proposes to subcontract portions of the work in an amount in excess of Y, of 1% of theContractor's total bid or $10,000.00, whichever is greater, and the dollar value of each listed subcontract.
No DBE credit will be given unless the subcontracting amount is listed.
Name, Business Address, Telephone Subcontractor (1 )Certification Dollar Value of SubcontractNumber, and Contact Person License Number Agency and
and Exp. Date Certification #
1.'?TAlbi" 7~t:. lXPf:(.2..-r5 License Number: LA CT MTA $ /2y2C:, 'f. <sO
Bid Item #'s11Soecify Certlfvinc Acencv; LA City of Los Anaeles, Public of Public works: CT - State Department of Transoortation (Caltrans):
MTA Los Anqeles County Metro olitan Transportation Authority
Rev. 02/22/07F-7
LIST OF SUBCONTRACTORS (continued)W.O. MOOl4067
Federal Project No. ESPL- 5006(574)FTIP ID No. LAESIILAES075
VENDOR AND/OR SUPPLIER AND BROKER PARTICIPATION RECOGNITION
The bidder must list herein names of vendors and/or suppliersand brokers and the dollar amounts for whichthe bidderhas obligated itself (list manufacturers on page F-7).
Vendor/Supplier/Broker Name, Business Address, Telephone number,and Contact Person
Gen./Eth.: $Description of material/service rendered:
(1) Specify Certlfying agency: LA - City of Los Angeles, Bureau of Contract AdministrationCT - State of Califami a, Department of Transportation (Caltrans)MTA - Los Angeles County Metropolitan Transportation Authority
(2) DBE participation credit for a vendor and/or supplier is LIMITED TO 60% of the amount paid, unless thevendor/supplier manufactures or substantially alters the materials/supplies. Multiply the "Total DollarAmount of Subcontract" by 0.6 if applicable.
(3) DBE participation credit for brokers is LIMITED TO THE FEE OR COMMISSION charged forproviding the desired service. Multiply the "Total Dollar Amount of Subcontract" by the broker'scommission percentage.
fl,". rlF!OWN P!lESmE!tTTITLE TELEPHONE NO,NAME & SIGNATURE OF PERSON COMPLETING PAGES F-7
THROUGHF-8
07/03/06F-8
ot. "
W.O. MOOl4067Federal Project No. ESPL-5006(574)
FfIP ID No. LAES IILAES075
EQUAL EMPLOYMENT OPPORTUNITY OFFICER
PURSUANT TO EXECUTIVE ORDER 11246, THE BIDDER SHALL DESIGNATE ARESPONSIBLE OFFICIAL TO MONITOR ALL EMPLOYMENT RELATED ACTIVITY TOENSURE EQUAL EMPLOYMENT OPPORTUNITY IS BEING CARRIED OUT.
Please be advised that C_,_"',-;-"",~"Cfi0:7;",ijil-:-:N-:-:, Pc;'i'I""E",-S!...,O_i? __I\!_~1f _( Print Name and Title)
~~(;U~i.J.1]1ru;!]1l~\J';ljL hereby appoints
MICHELE E, [)f!I\!CUUrCH,ASST. SECI1ETAAV, as its Equal Employment Opportunity Officer.(Name of Appointee)
The Officer has been given the authority to establish, disseminate and enforce the EqualEmployment and Affirmative Action Policies of this firm. The Officer may be contactedat the location below concerning matters related to any affirmative actions taken by thisfirm to increase the utilization of minorities and women in its employment.
2230 LEMON AVENUEWork Location: LONG BEACH. GA 90806
e 1l w ~n.:l w • I0 "''" ·0 2- 00 c ;: •u"'" .~• ~ ..
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W.O. MOOl4067Federal Project No. ESPL-SOO6(S74)
FTIP ID No. LAESI/LAES07S
EQUAL EMPLOYMENT OPPORTUNITY CERTIFICATION
!iyJr,J(]~The bidder '::>'C;":" ...c)P;l!i'~"cJ!~'J,~,~~,"m proposedsubcontractor , hereby certifies that he has L,has not __ , participated in a previous contract or subcontract subject to the equal opportunity clauses, as
required by Executive Orders 10925, 11114, or 11246, 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 Opportunity, all reports due under the applicable filling requirements.
Note: The above certification is required by the Equal Employment Opportunity Regulations of theSecretary of Labor (41 CFR 60-\. 7(b) (I)), and must be submitted by bidders and proposedsubcontractors only in connection with contracts and subcontracts which are subject to the equalopportunity clause. Contracts and subcontracts which are exempt from the equal opportunity clauseare set forth in 41 CFR 60-\.5. (Generally only contracts or subcontracts of $10,000 or under areexempt.)
,\!-1
Currently, Standard Form 100 (EEO-I) is the only report required by the Executive Orders or theirimplementing regulations.
Proposed prime contractors and subcontractors who have participated in a previous contract orsubcontract subject to the Executive Orders and have not filed the required reports should note that 41CFR 60-1. 7(b) (I) prevents the award of contracts and subcontracts unless such contractor submits areport covering the delinquent period or such other period specified by the Federal HighwayAdministration or by the Director, Office of Federal Contract Compliance, U.S. Department of Labor.
Rev. 07/03/06F-lO
W.O. MOOl4067Federal Project No. ESPL·S006(574)
FTIP ID No. LAES IILAES075
oDEBARMENT AND SUSPENSION CERTIFICATION
TITLE 49, CODE OF FEDERAL REGULA nONS, PART 29
The bidder, under penalty of perjury, certifies that, except as noted below, helshe or any other personassociated therewith in the capacity of owner, partner, director, officer, manager:
is not currently under suspension, debarment, voluntary exclusion, or determination ofineligibility by any Federal agency;
has not been suspended, debarred, voluntarily excluded or determined ineligible by any Federalagency within the past 3 years;
does not have a proposed debarment pending; and
has not been indicted, convicted, or had a civil judgment rendered against it by a court ofcompetent jurisdiction in any matter involving fraud or official misconduct within the past3 years.
If there are any exceptions to this certification, insert the exceptions in the following space.
Exceptions will not necessarily result in denial of award, but will be considered in determining bidderresponsibility. For any exception noted above, indicate below to whom it applies, initiating agency, anddates of action.
Notes: Providing false information may result in criminal prosecution or administrative sanctions.The above certification is part of the Proposal. Signing this Proposal on the signature portionthereof shall also constitute signature of this Certification.
Rev. 07/03/06r-u
W.O. M0014067Federal Project No. ESPL-5006(574)
FTIP ID No. LAESI/LAES075
CERTIFICATION OF NON-SEGREGATED FACILITIES
(Applicable to federally assisted construction contracts and related subcontractsexceeding $10,000 which are not exempt from the Equal Opportunity Clause.)
The federally assisted construction contractor certifies that he does not maintainor provide for his employees any segregated facilities at any of his establishments, andthat he does not permit his employees to perform their services at any location, under hiscontrol, where segregated facilities are maintained. The federally assisted constructioncontractor certifies further that he will not maintain or provide for his employees anysegregated facilities at any of his establishments, and that he will not permit hisemployees to perform their services at any location, under his control, where segregatedfacilities are maintained. The federally assisted construction contractor agrees that abreach of this certification is a violation of the Equal Opportunity Clause in this contract.As used in this certification, the term "segregated facilities" means any waiting rooms,work areas, restrooms and wash rooms, restaurants and other eating areas, time clocks,locker rooms and other storage or dressing areas, transportation, and housing facilitiesprovided for employees which are segregated by explicit directive or are in factsegregated on the basis of race, creed, color, or national origin, because of habit, localcustom, or otherwise. The federally assisted construction contractor agrees that (exceptwhere he has obtained identical certifications from proposed subcontractors for specifiedtime period) he will obtain identical certifications from proposed subcontractors prior tothe award of subcontracts exceeding $10,000 which are not exempt form the provisionsofthe Equal Opportunity Clause, and that he will retain such certifications in his files.
The above certification is required by the Equal Employment Opportunity Regulations ofthe Secretary of Labor 41 CPR 60-1.8b, and must be submitted by the bidder andproposed subcontractors only in connection with contracts and subcontracts which aresubject to the equal opportunity clause. Contracts and subcontracts which are exemptfrom the equal opportunity clause are set forth in 41 CPR 60-1.5 (Generally onlycontracts or subcontracts of$IO,OOOor under are exempt).
Note: The above certification is part of the Proposal. Signing this Proposal on thesignature portion thereof shall also constitute signature of this Certification.Bidders are cautioned that making a false certification may subject the certifier tocriminal prosecution.
The prospective participant certifies, by signing and submitting this bid or proposal, to the bestof his or her knowledge and belief, that:
(I) No Federal appropriated funds have been paid or will be paid, by or on behalf of theundersigned, to any person for influencing or attempting to influence an officer oremployee of any Federal agency, a Member of Congress, an officer or employee ofCongress, or an employee of a Member of Congress in connection with the awarding ofany 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 cooperativeagreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to anyperson for influencing or attempting to influence an officer or employee of any Federalagency, a Member of Congress, an officer or employee of Congress, or an employee of aMember of Congress in connection with this Federal contract, grant, .loan, or cooperativeagreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosureof Lobbying Activities," in conformance with its instructions. e
This certification is a material representation of fact upon which reliance was placed when thistransaction was made or entered into. Submission of this certification is a prerequisite formaking or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Anyperson who fails to file the required certification shall be subject to a civil penalty of not lessthan $10,000 and not more than $100,000 for each such failure.
The prospective participant also agrees by submitting his or her bid or proposal that he or sheshall 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.
Rev. 07/03/06F-13
W.O. MOOl4067Federal Project No. ESPL·5006(574)
!'TIP 10 No. LAESIILAES075
()
r!\U~!!~C2230 lEMWNGBEA
..1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type:
IAl a, contract ~ a. bid/offer/aoolication [It] a. initialb. grant b. initial award b. material changec. cooperative agreement c.· post-awardd. loan For Material Change Only:e. loan guarantee year __ quarterf. loan insurance date of last report
4. Name and Address of Reporting Entity 5. If Reporting Entity in No.4 is Subawardec,
[2(PrimeEnter Name and Address of Prime:o Subawardee
18A EXCEL PAVING COMPANYTier ___ • ifknown
i(NAVENUEH. CA 9Q!bQ§ressional District, ifknown Ceneresstonet District, ifknown
6. Federal Department/Ageney: 7. Federal Program Name/Description:
eFDA Number, if applicable
8. Federal Action Number, ifknown: 9. Award Amount. if known:
10. a. Name and Address of Lobby Entity b. Individuals Performing Services (including(If individual, last name, first name, MI) address ifdifferent from No. lOa)
(last name, first name, MI)
(attach Continuation Sheet(s) if necessary)
11. Amount of Payment (check all that apply) 13. Type of Payment (check all that apply)
$ o actual o planned~
a. retainer- b. one-time fee12. Form of Payment (check all that apply):
~c. commission~B a. cash ~ d. contingent fee
b. in-kind; specify: nature ~ e deferredvalue. f. other, specify
14. Brief Description of Services Performed or to be performed and Date(s) of Service, includingofficer(s), employee(s), or member(s) contacted, for Payment Indicated in Item 11:
(attach Continuation Sheet(s) if necessary)
15. Continuation Sbeet(s) attached: Yes 0 No 0'16. Information requested through this form is authorized by Title (2) l,. JA ~31 U.S.C. Section 1352. This disclosure of lobbying reliance Signature:
was placed by the tier above when his transaction was made orentered into. This disclosure is required pursuant to J 1 U.S.C. Print Name: C.\"', $fli)\f1!l'I PfiESiDENl1352. This information will be reported to Congresssemiannually and will be available for public inspection. Any
Title:.person who fails to file the required disclosure shall be subjectto a civil penalty of not less than $10,000 and not more than
Telephone No.: !562l5~Q·51141 APR 2 0 0$\00,000 for each such failure. Date:
Authorized for Local ReproductionFederal Use Only: Standard Form ~ LLL
DISCLOSURE OF LOBBYING ACTIVITIESCOMPLETE THIS FORM TO DISCLOSE LOBBYING ACTIVITIES PURSUANT TO 31 USC 1352
INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES aThis disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiationor receipt of covered Federal action or a material change to previous filing pursuant to title 31 U.S.c. section 1352. The filingof a form is required for such payment or agreement to make payment to lobbying entity for influencing or attempting toinfluence an officer or employee of any agency, a Member of Congress an officer or employee of Congress or an employee of aMember of Congress in connection with a covered Federal action. Attach a continuation sheet for additional information if thespace on the form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer tothe implementing guidance published by the Office of Management and Budget for additional information.
I. Identity the type of covered Federal action for which lobbying activity is and/or has been secured to influence, theoutcome of a covered Federal action.
2. Identity the status of the covered Federal action.3. Identity 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 narne, 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 subawardrecipient. Identity the tier of the subawardee, e.g., the first subawardee of the prime is the first tier. Subawardsinclude 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 zipcode of the prime Federal recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organization levelbelow agency narne, 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 fullCatalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans and loancommitments.
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 prefixes,e.g., "RFP-DE-90-00!."
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter theFederal amount of the award/loan commitments for the prime entity identified in item 4 or 5.
10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entityidentified in item 4 to influenced the covered Federal action.(b) Enter the full names of the individual(s) performing services and include full address if different from 10 (a). EnterLast Name, First Name and Middle Initial (MI).
I!. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (item 4) to thelobbying entity (item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check allboxes that apply. If this is a material change report, enter the cumulative amount of payment made or planned to bemade.
12. Check the appropriate box(es). Check all boxes that apply. [f payment is made through an in-kind contribution,specify the nature and value of the in-kind payment.
13. Check the appropriate box(es). Check all boxes that apply. If other, specify nature.14. Provide a specific and detailed description of the services that the lobbyist has performed or will be expected to
perform and the date(s) of any services rendered. Include all preparatory and related activity not just time spent inactual contact with Federal officials. Identity the Federal offieer(s) or employee(s) contacted or the officer(s)employee(s) or Member(s) of Congress that were contacted.
15. Check whether or not a continuation sheet(s) is attached.16. The certifying official shall sign and date the form, print his/her name title and telephone number.
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time forreviewing instruction, searching existing data sources, gathering and maintaining the data needed, and completing andreviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection ofinformation, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork ReductionProject (0348-0046), Washington, D.C. 20503.
F-15
oW.O. MOOl4067
Federal Project No. ESPL-5006(574)FTIP 10 No. LAESlILAES075
CERTIFICATION OF COMPLIANCE WITH CHILD SUPPORT OBLIGATIONS
The undersigned hereby agrees that _-:-:".-".- will:Name of Business
I. Fully comply with all applicable State and Federal employment reporting requirements for itsemployees.
2. Fully comply with and implement all lawfully served Wage and earnings Assignment Orders andNotices of Assignment.
3. Certify that the principal owner(s) of the business are in compliance with any Wage and EarningsAssignment Orders and Notices of Assignment applicable to them personally.
4. Certify that the business will maintain such compliance throughout the terms of the contract.
5. This certification is a material representation off act upon which reliance was placed when the partiesentered into this transaction
6. The undersigned shall require that the language ofthis Certification be included in all subcontracts andthat all subcontractors shall certify and disclose accordingly.
Upon signing below, the bidder by his/her signature affixed hereto declares under penalty of perjury thathe/she has read the Child Support Assignment Orders contained in the City's Ordinance No. 17240I andaccepts all the City's requirements contained therein throughout the duration ofthis project.
Title
C.P. BROWNPRESIDENT
Company Name
Date
07/03/06F-16
COMPLIANCECITY OF LOS ANGELES
OffIce of the City Administrative OfficerContractor Enforcement Section
200 North Main Street. Room 1240, Los Angeles, CA 90012Phone: (213) 978-7650 - Fax: (213) 978-7616
EQUAL BENEFITS ORDINANCE COMPb'ANCE FORMYour company must oe certified BS complying with Los Angeles Administrative Code Section 10,8.2.1, EqualBenefits Ordinance, prior to the execution of a City agreement. This foan must be retyrned to the CIN departmentawarding the agreement. If responding to a request for bid/proposal, submil this form with Ihe bid/proposal.
City Dept. Awarding Agreement: ' Confact/Phone: ----------SECTION 1. CONTACT INFORMATIONCompany Nama: PALP, INC. DBA EXCEL PAVING COMPANYCompany Address: 2230 LEMON AYE •• P.O. BOX 16405City: LONG BEACH Slate: CA. Zip: 90806Contact Person: Miche 1e Dr a ku 1ich Phone: 5 6"2"/';:;5;9';;'9::',5"'B"'4"1r--F-ax-: -'S"6"'2"/""S1I"9rl·-l'f14"'gres-I am a one-person contractor, and Ihave no employees. DYes D No (if you answered "Yes," go to Secllon 3)Approximate Number of Employeas In the United States: 231Are any of your employees covered by a collective bargaining agreement or union trusl fund? ~Yes DNa
SECTION 2. COMPLIANCE QUESTIONSHas your company prevlously submitted a Compliance Form and all supporting documentatlon?Jm Yes 0 NoIf Yes, AND the benefits provided to your emp/owes have not changed since that time, continue onto Section 3.
If No, OR if the benefits provided to your employees have changed since that time, complete the rest of this form.
In th.e table below, check a/l benefits that your company currently provides to employees or to which youremployees have access. Provide Infonmation for each benefits camer If your employees have access tomore than one carrier. Note: some benefits are available or apply to employees because they have a spouseor domestic partner to whom the benefll applies, such as bereavement leave that allows an employee time offbecause of the death of a spouse or domestic partner; other benefits are provided directly 10 the spouse ordomestic oartner such. as medical insurance that covers the soouss or domestic oartner as a deoendent.
Avallable/Appll.sAvallable/Applle. to Dom... tlc
to Spouse. of Paltn.,. ofEmploy.... Emnlov....
I I
BENEFIT(S) YOURCOMPANY CURRENTLY
OFFERS
This Benefit I.Not Offered
to Employee..11
This BenefitI.Available toEmploy...
I1o r.T1 I filflo Gil I roY
'add'"nnol ""rrI";;",f';-;;'h>o ment,\.;'no;;! , Ill" NAma of Carrlerl.1l
I2
Denta' r arrtar 1: rw::1f\..1.. oDe";';;1 Carrier2: oo o o
w.o. M0014067Federal Project No. ESPL·5006(574)FTIP ID No. LAESl/LAES075 COMPLIANCE
YOU MUST SUBMIT SUPPORTING DOCUMENTATION TO VERIFY EACH BENEFIT MARKED. Without properdocumentation for each carrier and each benefit marked, your company cannot be certified as complying with theESO.lf documentation for a particular benefit does not exist, attach an explanation. Refer to the "Documentation toVerify Compliance with the Equal Benefits Ordinance" fact sheet for more information on the type of documentationthat must be submitted to verify compliance with the EBO.
If in the Table in Section 2 you indicated that your company does not provide all benefits equally throughout itsentire operations to all your employees with spouses and employees with domestic partners of the same anddifferent sex, you may:
o a. Request additional time to comply with the EBO. Provisional Compliance may be granted toContractors who agree to fully comply with the EBO but need more time to incorporate the requirements ofthe EBO into their operations. Submit the Application for Provisional Compliance (OCC/EBO-3) andsupporting documentation with this Compliance Form.
o b. Request to be allowed to comply with the EBO by providing affected employees with the cashequivalent. Your company must aqree to provide employees with a cash eguivalent. In most cases, thecash equivalent is the amount of money equivalent to what your company pays for spousal benefits that areunavailable for domestic partners, or vice versa. Submit a completed Application for Reasonable MeasuresDetermination (OCC/EBO-2) and supporting documentation with this Compliance Form.
o c. Comply on a Contract-by-Contract Basis. Compliance may be granted on a contract-by-contract basisfor those Contractors who have multiple locations in the U.S. but cannot comply with the EBO throughoutthe Contractor's operations. Indicate below the compliance category you are requesting:o Contractor has multiple operations located both within and outside City limits. Contractor will comply with
the EBO only for the operation(s) located within City limits and for employee(s) located elsewhere in theUnited States who perform work relating to the City agreement. Supporting documentation for theaffected operation(s)/employees must be submitted.
D Contractor has no offices within City limits but does have (an) employee(s) working on the Cityagreement located elsewhere in the United States. Contractor will comply with the EBO only foremployee(s) located elsewhere in the United States who perform work relating to the City agreement.Supporting documentation for the affected employee(s) must be submitted.
SECTION 3. EXECUTE THE DECLARATION AND SUBMIT THE FORM TO THE AWARDING DEPARTMENTThis form must be returned to the City department awarding the agreement. If responding to a request forbid/proposal, submit this form with the bid/proposal to the awarding department. The awarding department willforward the form to the Department of Public Works, Bureau of Contract Administration, Office of ContractCompliance for review.
DECLARATION UNDER PENALTY OF PERJURYI deciare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, andthat I am authorized to bind this entity contractually.
~.PR2 0 2011 at ,,.,.,.1& "~Cti CAUfiORMAExecuted this .day of , in the year " --..;-'-:.:.::=-:0::,:_::..:.:___ .(Cily) , -(S-I'-Ie)-
2230 LEMON AVENUEL9;Mir.n~~Mte~~CASGBS6
Name of Signatory (please print) City, State, Zip Code
FED. 95-3612914Federal 10 NumberTitle
F·17b
Form OCC/EBO·1(Rev. 06106) Page 2
w.o. M0014067Federal Project No. ESPL-5006(S74)FTIP ID No. LAESllLAES075 COMPLIANCE
CITY OF LOS ANGELESDepartment of Public Works
Bureau of Contract AdministrationOffice of Contract Compliance
1149 S. Broadway, 3rd Floor, Los Angeles, CA 90015Phone: (213) 847-1922 - Fax: (213) 847-2777
DOCUMENTATION TO VERIFY COMPLIANCE WITH THE EQUAL BENEFITS ORDINANCESection 2 of the Equal Benefits Ordinance Compliance Form (Form OCC/EBO-1) requires that you submitsupporting documentation to the Office of Contract Compliance to verify that all benefits marked in your response(s)are offered in a nondiscriminatory manner. This list is intended to be used only as a guide for the type ofdocumentation needed.
Health, Dental, Vision Insurance: A statement from your insurance provider that spouses and domestic partnersreceive equal coverage in your medical plan. This may be in a letter from your insurance provider or reflected in theeligibility section of your official insurance plan document. Note that "domestic partner" includes same-sex as wellas different-sex partners so that the definition of "domestic partner" contained in the plan document must includedifferent-sex partners.
Pension/401 (k) Plans: Documentation should indicate that participating employees may designate a beneficiary toreceive the amount payable upon the death of the employee. Submit a blank beneficiary designation form.
Bereavement Leave: Your bereavement leave or funeral leave policy indicating the benefit is offered equally. Ifyour policy allows employees time off from work because of the death of a spouse, it should also allow for time offbecause of the death of a domestic partner. If the policy allows time off for trie death of a parent in-law or otherrelative of a spouse, it must include time off for the death of a domestic partner's equivalent relative.
Family Leave: Your company's Family and Medical Leave Act policy. All companies with 50 or more employeesmust offer this benefit. Your policy should indicate that employees may take leave because of the serious medical ~,','','condition of their spouse or domestic partner. :. ,)
Parental Leave: Your company's policy indicating that employees may take leave for the birth or adoption of achild. If leave is available for step-children (the spouse's child) then leave should also be made available for thechild of a domestic partner.
Employee Assistance Program (EAP): The benefit typically refers to programs that allow employees and theirfamily members access to counselors who provide short-term counseling and referrals to assist in dealing withissues such as family problems, addiction, and financial and legal difficulties. Your company'sEAP policy mustconfirm that spouses, domestic partners and their parents and children are equally eligible (or ineligible) for suchbenefits. If provided through a third party, a statement from the third party provider regarding eligibility is required.
Relocation & Travel: Your company's policy confirming that expenses for travel or relocation will be paid on thesame basis for spouses and domestic partners of employees.
Company Discounts, Facilities & Events: Your company's policy confirming that to the extent discounts, facilities(such as a gym) and events (such as a company holiday party) are equally available to spouses and domesticpartners of employees.
Credit Union: Documentation from the credit union indicating that spouses and domestic partners have equalaccess to credit union services.
Child Care: Documentation that the children of spouses (step-children) and children of domestic partners haveequal access to child care services.
Other Benefits: Documentation of any other benefits listed to indicate that they are offered equally.
Bureau of Contract AdministrationOffice of Contract Compliance
1149 S. Broadway, 3,d Floor, Los Angeles, CA 90015Phone: (213) 847-1922 - Fax: (213) 847-2777
APPLICATION FOR PROVISIONAL COMPLIANCE WITH EQUAL BENEFITS ORDINANCECOMPLETE AND SUBMIT THIS FORM ONLY IF APPLICABLE. Contractors entering into, amending, or biddingon a City contract who agree to comply with the Equal Benefits Ordinance ("EBO") but need more time toincorporate the requirements of the EBO into their operations must submit this form, and supporting documentation,to the Department of Public Works, Bureau of Contract Administration, Office of Contract Compliance ("OCC").(This form must be submitted with the EBO Compliance Form OCC/EBO-1.) The Contractor may be grantedadditional time to incorporate the requirements of the EBO only in the circumstances indicated below. Fill out allsections that apply. Attach additional sheets if necessary.
__ A. OPEN ENROLLMENT FOR HEALTH, DENTAL ANDIOR VISION INSURANCE PLANSThe Contractor may be granted additional time to implement the requirements of the EBO if equal benefits cannotbe provided until after the first open enrollment process following the date the contract with the City is executed. Toqualify, the Contractor must submit evidence that reasonable efforts are being undertaken to implement therequirements of the EBO. Additional time granted may not exceed two years from the date the contract with the Cityis executed, and applies only to benefits for which an open enrollment period is applicable.
____ . Date domestic partner (same and different sex) coverage will become effective_
You must submit copies of correspondence between your company and your insurance provider(s)documenting your effort to obtain domestic partner coverage for same- and different-sex couples. Youshould also submit verification of the next open enrollment date or the date the benefits become available.
__ B. ADMINISTRATIVE ACTIONS AND REQUESTS FOR EXTENSIONThe Contractor may be granted additional time to implement the requirements of the EBO if the administrativeactions necessary to incorporate the EBO cannot be completed prior to the date that the contract with the City isexecuted. Additional time granted for the completion of the administrative action shall apply only to those benefitsthat require administrative actions and may not exceed three months. Upon written request by the Contractor and atthe discretion of the OCC, the Contractor may be granted additional time to complete the administrative actions.Administrative actions may include personnel policy revisions and the development and distribution of employeecommunications.
Describe below or on an attachment the administrative actions needed and the anticipated completion dates.Attach supporting documentation such as the relevant portions of your current policy and the changes youplan to make.
If you are requesting an extension beyond three months, explain why more than three months is needed and attachany supporting documentation that may be relevant.
C. COLLECTIVE BARGAINING AGREEMENTSCompliance with the EBO may be delayed until the expiration of a Contractor's current collective bargainingagreement(s) (CBA). When the CBA is renegotiated, the Contractor must propose to the union for incorporation ()into the CBA the EBO requirements so that all benefits provided to employees with spouses are also extended to " ,-employees with domestic partners. Provisional compliance status may be granted if all of the following conditionsare met.
1. The provision of some or all of the benefits offered to the Contractor's employees are governed by one or moreCBA(s) but domestic partner coverage for same- and different-sex couples is not offered under the CBA(s).
Required Information: Indicate below the name of each CBA for which Provisional Compliance is beingrequested and the time period the CBA covers.
Name of Bargaining Unit: Start date:. End date:. _Name of Bargaining Unit: Start date: End date:. _Name of Bargaining Unit: Start date: End date:. _
2. The Contractor agrees to propose to the union that the EBO requirements be incorporated into each of theCBA(s) by signing the statement below.
When the CBA is renegotiated, we will propose to the union that the EBO requirements beincorporated into the CBA so that all benefits provided to employees with spouses will be extendedto employees with same or different sex domestic partners. After the CBA expires, we will provide,upon request by the City, reports on the status of the efforts to incorporate the EBO requirementsinto the CBA.
By the end of negotiations, we agree to notify the OCC of the result by submitting a statement whichwill indicate: (1) when the issue of same and different sex domestic partners was raised duringnegotiations; and (2) whether or not the EBO requirements was incorporated into the CBA. Weunderstand that a separate statement must be submitted for each CBA for which prOVisional,'. )Compliance was requested.
Signature Title DateName of Signatory (Print)
3. For benefits not strictly governed by a CBA, the Contractor must establish policies so that those benefits areprovided in accordance with the requirements of the EBO. For example, the Contractor may be required toexpand the existing bereavement leave policy to allow an employee with a domestic partner time off in event ofthe domestic partner's death even if the CBA does not require the employer to do so.
Required documentation: A listing of benefits not strictly governed by the CBA along with the Contractor'spolicies as they relate to those benefits.
EXECUTE THE DECLARATION AND SUBMIT THE FORM TO THE AWARDING DEPARTMENT: This form, andthe Equal Benefits Ordinance Compliance Form (Form OCC/EBO-1) must be returned to the City departmentawarding the agreement. If responding to a request for bid/proposal, submit this form with the bid/proposal to theawarding department. The awarding department will forward the form to the OCC for review.
DECLARATION UNDER PENALTY OF PERJURYI declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, andthat I am authorized to bind this entity contractually.
Executed this day of " in the year " at ~~ ' __(City) (Stale)
Name of Company Name of Signatory (Print) Signature Title
Department of Public WorksBureau of Contract Administration
Office of Contract Compliance1149 S. Broadway, 3 ,d Floor, Los Angeles, CA 90015
Phone: (213) 847-1922 - Fax: (213) 847-2777
APPLICATION FOR REASONABLE MEASURES DETERMINATION - CASH EQUIVALENT COMPLIANCE
Name of Company Federal 10 Number
Street Address City, State Zip
Contact Person/Title Telephone Number Fax Number
Before the Department of Public Works, Bureau of Contract Administration. Office of Contract Compliance (OCC) will approvea contractor's application to comply with the Equal Benefits Ordinance (EBo) by paying a cash equivalent, the OCC mustdetermine that: (a) the contractor has made a reasonable yet unsuccessful effort to provide equal benefits; or (b) under thecircumstances, it would be unreasonable to require the contractor to provide benefits to domestic partners (or spouses ifapplicable). To apply, contractors must submit:
1. An explanation and documentation that demonstrates: (a) the Contractor has made a reasonable, yet unsuccessful,effort to provide equal benefits; or (b) under the olrcurnstances, it would be unreasonable to require the contractor toprovide equal benefits rather than paying the cash equivalent. See EBO Regulation #2B(1 )(a) and #2B(1 )(b).
2. This completed application. Fill in the company's information, then read and sign the acknowledgement below.3. A completed Equal Benefits Ordinance Compliance Form (Form OCC/EBO-l). Be certain that box "b" on page two of the
form is checked.4. A draft of the memorandum that will be distributed to affected employees informing them of the cash equivalent option.5. Copies of the revised policies, such as bereavement, for which the cash equivalent is not applicable.
If approved by the OCC, a contractor will be allowed to comply with the EBO by paying its employees with domestic partnersthe cash equivalent of benefits made available to the spouses of its employees. The cash equivalent is the difference betweenthe amount an employer pays to provide an employee with spousal or family coverage and the amount that an employer paysto provide an employee with employee-only coverage. For example, an employer pays $200 per month to provide benefits foran employee and his/her spouse, and $150 per month to provide benefits for an employee with employee-only coverage. Thecash equivalent that must be paid to the employee with a domestic partner is $50 per month.
For benefits for which a cash equivalent is not applicable, such as bereavement leave, the employer must amend its policies sothat domestic partners are treated in the same manner as spouses. For example, if the policy allows an employee three daysoff in the event of the death of a spouse or the spouse's parents, the policy must be amended to allow an employee three daysoff in the event of the death of a domestic partner or the domestic partner's parents.
ACKNOWLEDGEMENT REGARDING APPLICATIONI declare under penalty of perjury under the laws of the State of California that I am authorized to bind thecompany/entity listed above. Iunderstand that this Application must be approved by the OCC before compliance bypayinq the cash eqUivalent will be allowed. By signing below, Iagree on behalf of the company that if this Applicationis approved by the OCC, the company will comply with the EBO by providing employees with domestic partners thecash equivalent of the benefits that are made available to employees with spouses. For those benefits to which thecash equivalent is not applicable, such as for bereavement leave or family leave, the company agrees to amend itspolicies so that the domestic partners of employees will be treated in the same manner as the spouse of an employee.The relatives of domestic partners will be treated in the same manner as relatives of spouses. The company furtheragrees to provide a memorandum notifying our affected employees of the availability of the cash equivalent option ifthey have domestic partners for whom equal benefits cannot be provided.
Executed this __ day of _~ , in the year " at -----c=..,----------(City) , (State)
Name of Signatory (Print) Signature Title Date
F-17fForm OCC/EBO-2 (Rev. 06/06)
w.o. M0014067Federal Project No. ESPL-5006(S74)FTIP ID No. LAES1/LAES075 CITY OF LOS ANGELES
Department of Public WorksBureau of Contract Administration
Office of Contract Compliance1149 S. Broadway, 3rd Floor, Los Angeles, CA 90015
Phone: (213) 847-1922 - Fax: (213) 847-2777
INSTRUCTIONS FOR COMPLETING EQUAL BENEFITS ORDINANCE FORMS
l"\', ."J
1. Start with the Equal Benefits Ordinance (EBO) Compliance Form (Form OCC/EB0-1). Your company must bedetermined to be in compliance with the EBO before a contract with the City may be executed. In Section 2 of theform, indicate what benefits your company currently offers its employees. If a benefit is not offered, indicate thebenefit is not offered.
If your company currently does not offer equal benefits to employees with spouses and employees with same ordifferent sex domestic partners, you may, on page two of the EBO Compliance Form, request one of the followingby checking the appropriate box on the form:a. Request additional time to come into compliance with the EBO. This is available to contractors who agree
to fully comply with the EBO but need additional time to add domestic partner coverage, to change companypolicies, or to negotiate the addition of domestic partner coverage to a collective bargaining agreement.Complete the Application for Provisional Compliance (Form OCC/EBO-3) and return it with the EBOCompliance Form (Form OCC/EBO-1). You must submit supporting documentation to verify why additional timeis needed.
b. Request to be allowed to comply with the EBO by providing employees the cash equivalent. This isavailable to contractors who meet both of the following: (1) agree to provide employees with domestic partnersthe cash equivalent of the benefits offered to employees with spouses; and (2) have demonstrated that theyhave taken reasonable yet unsuccessful efforts to comply, or that it would be unreasonable under thecircumstances to require the contractor to provide equal benefits rather than pay the cash equivalent toemployees. Complete the Application for Reasonable Measures Determination (Form OCC/EBO-2) and returnit with the EBO Compliance Form (Form OCC/EBO-1). You must submit the supporting documentationreguested in the Reasonable Measures Form.
c. Request to be allowed to comply with the EBO on a contract-by-contract basis. If your company can onlycomply with the EBO for those locations or employees covered by the EBO, you may apply for compliance on acontract-by-contract basis. Contact the Department of Public Works, Office of Contract Compliance foradditional information. Check the appropriate box on the EBO Compliance Form (Form OCC/EBO-1) andsubmit supporting documentation regarding the locations and employees affected by the EBO.
2. Obtain supporting documentation. The City must verify that each benefit offered by your company is offeredequally. Refer to the EBO supporting documentation information sheet for the type of documentation that will berequired. You must submit supporting documentation for each benefit checked in Question 2 of the EBOCompliance Form (Form OCC/EBO-1).Unless otherwise specified in the RFB/RFP/RFQ, you do not need to submit supporting documentation with thebid or proposal. However, because supporting documentation will be required if you are selected for award of acontract, you must have the supporting documentation readily available for submission. A delay in the submission ofdocumentation will result in a delay in the execution of your contract. If you have already been notified that youhave been selected for the award of a contract, supporting documentation must be submitted immediatelyto avoid delays.
3. Submit the EBO Compliance Form (Form OCC/EBO-1) to the awarding department. If you are requestingadditional time to comply or to be allowed to pay employees the cash equivalent, you must also submit theappropriate forms (see #1 above) and supporting documentation with the EBO Compliance Form.
4. The forms and documentation will be forwarded to the Office of Contract Compliance for review. If additionalinformation or supporting documentation is needed, the Contractor Enforcement Section will contact you to obtainthe information. Because your contract cannot be executed until you have been determined to be incompliance with the EBO, you must respond promptly to any request for additional information.
F-17g
Form OCC/EBO-10 (Rev. 06106)
CITY OF Los ANGELESBOARD OF PUBLIC WORKS
MEMBERS CALIFORNIA JOHN l. REAMER. JR.Inspector of Public works
andDirectorCYNTHIA M. RUll
PRESIDENT
JULIE B. GUTMANVICE PRESIDENT
Bureau ofCONTRACT ADMINISTRATION
1149 S.Broadway, 3'd FloorLos Angeles, CA 90015
PAULA A. DANIELSPRESIDENT PRO· TEMPORE
ANTONIO VlllARAIGOSAMAYOR (213) 847·1922
hllp:/lbca.locily.orgVALERIE LYNNE SHAW
COMMISSIONER
ANDREA A. ALARCONCOMMISSIONER
JAMES A. GIBSONEXECUTIVE OFFICER
April 22, 2010
RECEIVEDAPR 26 2010
Michele E. DrakulichPALP Inc. dba Excel Paving Co.2230 Lemon AvenueLong Beach, CA 90806
We received your EEO and Affirmative Action documents that you submitted to fulfill your contract requirement, asmandated by Los Angeles Administrative Code 10.8.4, and is approved as follows:
AFFIRMATIVE ACTION PLAN APPROVAL PLAN NO: 9731
PALP Inc. dba Excel Paving Co.2230 Lemon AvenueLong Beach, CA 90806
X Approved - Contractor completed, signed and submitted the City's Affirmative Action Plan.
___ Approved - Contractor submitted its own Affirmative Action Plan which meets the City's minimumrequirements .
• APPROVAL EXPlRATION DATE: 5/1/2011
• This Plan is valid through the date shown above. The contractor may reference this approval forother City-funded contracts within the approval period. If the approval is 30 days or less fromthe expiration, the contractor mnst submit a new Plan to the Office of Contract Compliance andthe Plan must be approved before any new contract is awarded.
If you have any questions regarding this matter, please call Rolando Tuasor at (213) 847-2642. The Bureau ofof Contract Administration, Office of Contract Compliance is located at 1149S. Broadway St., Suite 300, Los Angeles,CA 90015.
AN EQUAL OPPORTUNITY - AFFIRMA TlVE ACTION EMPLOYER
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c !EXCELPAVING COMPANYA GENERAL ENGINEERING CONTRACTOR
STATE UCENSE NO. 688659A
P.O. BOX 1640LONG BEACH, CA 908()6.S19
(562) 599-584FAX (562) 591-748
.'
C. P. Brown, President: 30+ years experience working for other general contractorswith the past 24 years being self employed in own generalengineering contracting business.
INCUMBENCY AND SIGNATURE CERTIFICATE OFPALP,INC.
Tbe undersigned, Marcia S. Miller, being the duly elected and IncumbentSecretary of Palp, Iae., dba Excel Paving Company, a California corporation (the"Corporation"), hereby certifies that the persons named below are, on and as datehereof, the duly qualified, elected and acting Officers of the Corporation holding theoffice set fortb opposite their names below, such officers being authorized to sign, Inthe name of and on behalf of tbe Corporation.
Curtis P. Brown President and Chief Executive omcer
Curtis P. Brown m Vice President and CbiefOperating Officer
Vice President and Chief Financial OfficerBruce E. Flatt
George R. McRae Vice President
Marcia S. Miller Secretary
Michele E. DrakuJich Assistant Secretary
IN WITNESS WHEREOF, the undersigned has executed this Certificate asof the date set forth below.
Date: January 27, 2010
." .'
Bonding Agent: Rapp Surety Services23461 South Pointe Drive
..Suite 345Laguna Hills CA 92653
Office: (949) 457·1060Fax: (949) 457·1070
Contact: Douglas A. Repp
Surety: Federellnsurance CompanyC/O SUrety Department801 South Figueroa SlIeet23"' FloorLos Angeles CA 90017
P.O. Box 30127Los Angeles CA 90030-0127
Insurance Carner: The Woodltoo CompanyOne Park PlazaSuite 400Irvine CA 92614
Contact: WIlliam WooditooOffice: (949) 553-9800Fax: (949) 553·0670
PREVIOUS JOB REFERENCES #2
Contractor'S Name: Palp Inc. DBA Excel Paving Co.
Project Name: Slauson Ave.lSR-90 Impvts.
Project Description: On ramp & off ramp widening on SR90, Traffic MitigationAdded left turn on Slauson Signalization & Signing &Storm Drain Impvts.
Location: Slauson Ave. @ SR90 Culver City, Los Angeles
Construction Value: $2,136,269.00
4/09Date of Completion:
General Contractor Information:Palp Inc. DBA Excel Paving Company
Contact: David Cook
Phone: 562/599-5841 Ext. 239
Fax: 562/591-7485
Owner Information: Playa Capitol Company LLC
Contact: Cliff Ritz
Phone: 310/448-4678
Fax: 310/822-5336
PREVIOUS JOB REFERENCES #4
Contractor's Name: Palp Inc. DBA Excel Paving Company
Project Name: Alameda Street
Project Description: Redesign of Arterial Streets and Storm Drain Impvts.
Location: Intersection of Alameda Street and N. Spring St., L.A.
Construction Value: $3,197,043.00
Date of Completion: 11109
General Contractor Information:Palp Inc. DBA Excel Paving Company
Contact: Bruce Flatt
Phone: 562/599-584 I
Fax: 562/591-7485
Owner Information: City of Los Angeles
Contact: Steve Chen
Phone: 2 13/485-4516
Fax: 213/485-4838
PREVIOUS JOB REFERENCES #6
Contractor's Name: PaIp Inc. DBA Excel Paving Company
Project Name: Pier E Berths E24-326
Project Description: Asphalt Utility Removals, Grade, New Asphalt Pavingand New Concrete RTG Runways, Storm DrainImpvts., Sewer and Water
Location: Pier E, Long Beach, CA
Construction Value: $5,251,800.00
Date of Completion: 1108
General Contractor Information:Palp Inc. DBA Excel Paving Co.
Contact: Bruce Flatt
Phone: 562/599-5841
Fax: 562/591-7485
Owner Information: The Port of Long Beach
Contact: Gary Card emone
Phone: 562/590-4172
Fax: 562/901-1732
PREVIOUS JOB REFERENCES #8
Contractor's Name: Palp Inc. DBA Excel Paving
Project Name: North Maclay Ave.
Project Description: Street Beautification and Improvement of North MaclayAvenue
Location: North Maclay Ave. from 1st Street to Eighth Street
Construction Value: $3,682,624.00
7/08Date of Completion:
General Contractor Information:Palp Inc. DBA Excel Paving Co.
Contact: Bruce Flatt
Phone: 562/599-5841
Fax: 562/591-7485
Owner Information: City of San Fernando
Contact: Ron Ruiz
Phone: 818/898- 123 7
Fax: 818/361-6728
WORK EXPERIENCE 11-30-10 OPEN JOBS%
.Job # Project Description PROJECT NAME EST. FINAL WORK WORKCONTRACT COMPL. BACKLOG
4042 TUDOR.fWESTWD REPL 945760.01 TUTOR SALIBA PERINI, JV 2,419,610 98.4% 38,8694093 TRANSIT HUB-SAN FERN VLYI1.A LOS ANGELES COUNTY DEPARTMENT 1,473,973 100.0%
4240 CAL TRANS LlNCOLN:07-1660U4 CALTRANS 13,385,340 99.3% 87,891
4242 CHANDLERI1.ANKERSHIM: Cl08099 CITY OF LOS ANGELES-DPW 5,421,529 100.0%
4245 LlNNIE CANAL COURT: Cl08109 LOS ANGELES COUNTY DEPARTMENT 290,422 100.0%
43~2 VERMONT AVE.- E.LA # C-l09146 LOS ANGELES COUNTY DEPARTMENT 1,392,670 100.0%
4324 USC, FIGUEROA & JEFFERSON UNIVERSITY OF SOUTHERN CALIF. 1,584,799 100.0%
4328 HIGHLAND AVE.:L.A. 109718 L.A.COUNTY DEPT. PUBLIC WORKS 3,449,309 99.8% 6,951
4329 SUNSET BLVD. Cl09716-1 L.A.COUNTY DEPT. PUBLIC WORKS 2,068,410 99.9% 1,335
4330 HARBOR GATEWAY:L.A. C-l09717 L.A. COUNTY DEPT. PUBLIC WORKS 2,743,862 100.0%
4370 ALAMEDA ST NO SPRG ST Cll0421 CITY OF LOS ANGELES 2,738,012 100.0%
4508 ALVARADO TRANSIT CORRIDOR: LA COMMUNITY REDEVELOPMENT AGY 2,203,013 91.9% 177,396
4526 LAKEWOOD BLVD PH 2:DOWNEY CITY OF DOWNEY 2,451,660 100.0%
4549 RAMIRE2 CANYON:MALlBU 06821 TORRES CONSTRUCTION 395,835 100.0%
4566 CLEVELAND HS:RESEDA LOS ANGELES UNIFIED SCHOOL 1,479,297 100.0%
4567 LANKERSHIMNARIOUS LOC:LA LA COMMUNITY REDEVELOPMENT AGY 1,228,138 84.1% 195,128
4573 ATHERTON STRM DRAIN:LB R-6732 CITY OF LONG BEACH 1,538,789 99.7% 4,594
4597 WlLSHIREIFAIRFAX:LOS ANGELES MATT CONSTRUCTION CO. 1,125,815 100.0%
4598 CHEVIOT HILLS:LA Cll3689 CITY OF LOS ANGELES-DPW 943,818 100.0%
4611 USC ST IMPROVEMENT:LOS ANGELES UNIVERSITY OF SOUTHERN CALIF. 2,350,000 92.3% 181,913
4613 STORM DRAIN POLLlDUST:POLB7328 PORT OF LONG BEACH 4,417,616 100.0%
4618 FEDEXRAMP BURBANK AIRPORT FEDERAL EXPRESS 4,012,057 100.0%
4639 4 INTERSECTIONS:LB & LKWD THE BOEING COMPANY 1,349,682 100.0%
4649 SUNNYMEAD BLVD:MORENO VALLEY C/O MORENO VALLEY 2,628,000 95.7% 113,383
4651 BALBOAIVICTORY BLVD:LOS ANGELE CITY OF LOS ANGELES 1,118,416 99.7% 2,880
4661 BIKE ROUTE:LONG BEACH R-6762 CITY OF LONG BEACH 241,798 99.9% 138
4673 EQUIP RENTAUBCH MAINT:LNG BCH CITY OF LONG BEACH 69,175 100.0%
4679 HANSCOMIPETERSON AVE.:SO. PASA CITY OF SOUTH PASADENA 1,668,667 100.0%. 4681 ARBORVITAE ST.:L.A. C-115478 CITY OF LOS ANGELES-DPW 1,895,018 87.0% 246,391
4684 08-09 OVRLAY/SEAL:SANTA CLARA CITY OF SANTA CLARITA 5,244,663 99.7% 15,736
4690 BNSF-POLA:BNSF RIR BURLINGTON NORTHERN SANTA FE 71.000 12.1% 62,410
4692 CENTINELALA TIJERAI1.A CIENEGA: PLAYA CAPITAL CO 1,242,662 0.7% 1,233,915
4695 NO STATE COLLEGE-LOT E:FULRTON BALI CONSTRUCTION 15,785 100.0%
4698 HARBOR PLAZA BLVD:LONG BEACH TUCKER ENG 243,351 100.0%
4699 KAISER-BELLFLOWER BLVD:DOWNEY KAISER FOUNDATION 137,048 100.0%
4700 IMPERIAL HWY ST IMPRV:LYNWDOD CITY OF LYNWOOD 1,303,279 100.0%
4703 AIRCARRIER RAMP:LB ARPRT R6m CITY OF LONG BEACH 5,289,943 69.5% 1,610,950
4705 WASHINGTON BLVD:CULVER CITY CITY OF CULVER CITY 523,369 100.0%
4707 GRAVES AVENUE:COUNTY OF LA LOS ANGELES COUNTY DEPARTMENT 470,592 100.0%
4709 RES ST REPAIR PH VI:SANTA ANA SANTA ANA, CITY OF 2,847,706 100.0%--4711 CONSTITUTION AVE.:LOS ANGELES TOTAL TEAM CONSTRUCTION 43,050 100.0%
4782 VARIOUS STS Z-2 :LA HABRA HGTS LA HABRA HEIGHTS 445,977 99.6% 1,972
BOB HOPE AIRPRT:BURBANK E06-53 BURBANK/GLENDALE/PASADENAVERDUGOIBARRINGTON:GLENDALE CITY OF GLENDALEMAT ARRESTING SYS:BURBANK ARPl BURBANK/GLENDALEIPASADENATAXIWAY DELTA:LONG BEACH R6757 CITY OF LONG BEACHSO REGION ELEM SCH #7:LAUSD LOS ANGELES UNIFIED SCHOOLUSC-SCH CIN ARTS:LOS ANGELES HATHAWAY DINWIDDIE CONSTRUCTICCERRITOSIEL RITa AVE.:GLENDALE CITY OF GLENDALE
41,215
134,903
16,824
8.450
Final ContractAmount
36,710
7,5978,200
1,200
9,296
3,190306,515
1,601,060
221,979
1,353,2n2,427,816
540,525
58,853
514,419
444,555
6,3533,570,9201,782,650
2,431,00313,177,103
585,4323,642,247
816,228415,720
19,1301,197,065
4499 KAISER CANTARA ST.:PANORAMA KAISER FOUNDATION HEALTH PLAN 81,999 20.1% 65,519
4502 WEST CHAPMAN SEWER:GG7805 GARDEN GROVE SANI DIST 1,967,739 100.0%