HomeMy WebLinkAboutM-Z Construction, Inc.CONSTRUCTION, INC.
P.O. Box 530
Linden, WI 53553
P: 608.341.0578
F: 888.729.2308
To: Clerk Clerk
City of Waterloo
715 Mulberry Street
Waterloo, Iowa 50703
SEALED BID & security
Project Name: Flow Equalization Facility
Overflow Connection to Satellite WPCF
Location: City of Waterloo, Iowa
Bid Category: Prime
Bid Date: @ 1:00 AM
I-.)tc)-T27
P.O. Box 530
{IIIc. Linden WI 53553
�`��� H P: 608.341.0578
CONSTRUCTION, INC. F. 888.729.2308
To: City Clerk
City of Waterloo
715 Mulberry Street
Waterloo, Iowa 50703
SEALED BID
Project Name: Flow Equalization Facility
Overflow Connection to Satellite WPCF
Location: City of Waterloo, Iowa
Bid Category: Prime
Bid Date: 1 It/17 @ 1:00 AM
CONSTRUCTION,, INC.
P.O. Box 530
Linden, WI 53553
P: 608.341.0578
F: 888.720.2308
✓J %
Revised Per Addendum No. 2 - 11/1/2017
FORM OF BID OR PROPOSAL
FLOW EQUALIZATION FACILITY OVERFLOW CONNECTION TO SATELLITE WPCF
CONTRACT NO. 880
CITY OF WATERLOO, IOWA
Honorable Mayor and City Council
Waterloo, Iowa
Gentlemen:
1. The undersigned, being a Corporation existing under the laws of the State ofl!J%1<'.��✓.) /✓'� , a
Partnership consisting of the following partners:
having familiarized (himself) (themselves) (itself) with the existing conditions on the project area
affecting the cost of the work, and with all the contract documents listed in the Table of Contents and
Addenda (if any), as prepared by the City Engineer of the City of Waterloo riow on file in the office of
the City Clerk, City Hall, Waterloo, Iowa, hereby proposes to furnish all supervision, technical
personnel, labor, materials, machinery, tools, appurtenances, equipment, and services, including
utility and transportation services required to construct and complete this FLOW EQUALIZATION
FACILITY OVERFLOW CONNECTION TO SATELLITE WPCF, City Contract No. 880„ all in
accordance with the above -listed documents and for the unit prices for work in place for the following
items and quantities:
FLOW EQUALIZATION FACILITY OVERFLOW CONNECTION TO SATELLITE WPCF
CONTRACT NO. 880
Item
No.Description
Unit
Estimated
Quantity
Unit Bid
Price
Total Bid
Priect
1
Flow Equalization Facility Overflow
Connection to Satellite WPCF
LS
1.0 $
(p
00
$// C' cti�
l� (5/at)
TOTAL BID$
--
(Y) 1 �®
2. It is understood that the quantities set forth are approximate only and subject to variation and that the
unit bid price for the work done shall govern in the actual payment to Contractor.
3. In submitting this bid, the bidder understands that the right is reserved by the City of Waterloo, Iowa,
to reject any or all bids. If written notice of the acceptance of this bid is mailed, telegraphed, or
delivered to the undersigned within thirty (30) days after the opening thereof, or at any time thereafter
before this bid is withdrawn, the undersigned agrees to execute and deliver an agreement in the
prescribed form and furnish the required bond and certificate of the insurance within ten (10) days
after the agreement is presented to him for signature, and start work within ten (10) days after
"Notice to Proceed" is issued.
4. Security in the sum of Dollars ($
in the form of';;-; , is submitted herewith in
accordance with the INSTRUCTIONS TO BIDDERS.
5. Attached hereto is a Non -Collusion Affidavit of Prime Contractor.
6. Attached hereto is a Resident Bidder Certification ( ), or Non -Resident Bidder Certification
(�X J. (Mark one.)
7. The bidder is prepared to submit a financial and experience statement upon request.
FORM OF BID
AECOM 60336756-2017
FB -1 to 2 Flow Equalization Facility
City Contract No. 880 Overflow Connection to Satellite WPCF
Revised Per Addendum No. 2 - 11/112017
8. The Prime Contractor and Subcontractor(s), which have performed an aggregate of $10,000.00 in
work for the City in the current calendar year, are prepared to submit an AAP or Update and an
EOC, within ten (10) days of notification that the bid submitted is lowest and acceptable.
9. The bidder has received the following Addendum or Addenda:
Addendum No. / Date _ /' ' �' / r,
/'7
10. The bidder shall list the MBE/WBE subcontractor(s), amount of subcontracts and bid items on the
City of Waterloo Minority and/or Women Business Pre-bid Contact Information Form submitted with
this Form of Bid or Proposal. The apparent low Bidder shall submit a list of all other Subcontractor(s)
to be used on this Project to the City of Waterloo by 5:00 p.m. the business day following the day
Bids on this Project are due along with the Non -Collusion Affidavits of All Subcontractor(s).
The Contractor shall submit information on subcontractors on "SUBCONTRACTOR REQUEST AND
APPROVAL" Form to be provided by City prior to approval of contract.
The subcontractors listed on this proposal and/or submitted to the Contract Compliance Officer
cannot be changed except for the following reasons:
1) The City of Waterloo does not approve the subcontractors.
2) The subcontractors submit in writing that they cannot fulfill their subcontracts.
11. The bidder has filled in all blanks on this proposal. Those blanks not applicable are marked "none"
or "NA".
12. The bidder has attached all applicable forms.
13. The Owner reserves the right to select alternates, delete line items, and/or to reduce quantities prior
to the award of a contract due to budgetary limitations.
BY:
(Name of Bidder) (Date)
CAP
Official Address: (Including Zip Code):
Title /),,Jf. 5/dc5/r
/,y,6 E /1/ 2-/, 5 J65 S
I.R.S. No. i 9- /86 Y7
FORM OF BID
AECOM 60336756-2017
FB -2 to 2 Flow Equalization Facility
City Contract No. 880 Overflow Connection to Satellite WPCF
NON -COLLUSION AFFIDAVIT OF PRIME BIDDER
State of 2»/JdoN5/4
County of i Lt /9 )§
i'
4 A' 77 2)19'2 /21 'R/1?9/11, being first duly sworn, deposes and says that:
1. He is (Owner, Rattner, OffFC r, Rearesentative-or Aqe it) of
41 7 C'z4i.S / Y2e'& 7/7 fide. the Bidder that has submitted the attached Bid;
2. He is fully informed respecting the preparation and contents of the attached Bid and of all
pertinent circumstances respecting such Bid;
3. Such Bid is genuine and is not a collusive or sham Bid;
4. Neither the said Bidder nor any of its officers, partners, owners, agents, representatives,
employees, or parties in interest, including this affiant, has in any way colluded, conspired,
connived or agreed, directly or indirectly, with any other Bidder, firm or person to submit a
collusive or sham Bid in connection with the Contract for which the attached Bid has been
submitted or to refrain from bidding in connection with such Contract, or has in any manner,
directly or indirectly, sought by agreement or collusion or communication or conference with any
other Bidder, firm or person to fix the price or prices in the attached Bid or of any other Bidder, or,
to fix any overhead, profit or cost element of the bid price or the bid price of any other Bidder, or to
secure through any collusion, conspiracy, connivance, or unlawful agreement any advantage
against the City of Waterloo, Iowa, or any person interested in the Proposed Contract; and
5. The price or prices quoted in the attached Bid are fair and proper and are not tainted by any
collusion, conspiracy, connivance or unlawful agreement on the part of the Bidder or any of its
agents, representatives, owners, employees, or parties irt'tterest, including this affiant.
(Signed)
Title
Subscribed and sworn to before me this day of (\`�P VU bf" 20/J17
I ((fti 177 J LtC & (bV
Title
My commission expires PI
�/ - �7
NON -COLLUSION AFFIDAVITS-
AECOM 60336756-2017
NCA -1 of 2 flow Equalization Facility
City Contract No. 880 Overflow Connection to Satellite WPCF
CONTRACT NO:
PROJECT NAME:
DATE OF LETTING:
RESIDENT BIDDER CERTIFICATION
6.3
/lr% FieizJL/,92;COPif /.2U447!O,,z)
//-16 -/7
To be a qualified resident bidder, the bidder shall be a person or entity authorized to
transact business in this state and having a business for at least three years prior to the
date of the first advertisement for the public improvement. If another state or foreign
country has a more stringent definition of a resident bidder, the more stringent definition is
applicable as to bidders from that state or foreign country.
This qualification as resident bidder shall be maintained by the contractor and his subcontractors at the
work site until this project is completed.
I hereby certify that I am a resident bidder as defined above.
COMPANY NAME int Oo JT/17k 7i ,& ,//✓L
CORPORATE OFFICER (.1eatt'Tiy //Y2/97 b-1t7/7761/V
TITLE F/%,T) l/ Ai/—
DATE
i/DATE //
RESIDENT BIDDER RB -1 of 3 Flow Equalization Facility
AECOM 60336756-2017 City Contract No. 880 Overflow Connectiont of Satellite WPCF
NON-RESIDENT BIDDER CERTIFICATION
CONTRACT NO.:�
PROJECT NAME: F14v1J ....2/G 7;170/✓ (Ju/%4?.%7'rc.r'/'7' )C2)
DATE OF LETTING: //-/! -/7
7
I hereby certify that 1 am an Iowa non-resident bidder.
COMPANY NAME:
,ri/2 <2U7/J'7/r7L2d7/ 4J //14:
CORPORATE OFFICER: L- 124'7- 5 `= //7 /7% <<te/7J44/2)
TITLE: / l'b3/ 71F
DATE: - /7
STATE/COUNTRY OF RESIDENCY: .&_2/10-1,2 0/45741 ,
Stated below are the preference(s) to resident bidders in the state/country of
(Preference to bidders, labor force, or other preferential treatment to bidders or laborers, etc.
RESIDENT BIDDER
AECOM 60336756-2017
RB -2 of 3 Flow Equalization Facility
City Contract No. 880 Overflow Connectiont of Satellite WPCF
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Attachment 1
SRF Required Front -End Specifications
(This form must be completed and signed by Prime Contractor and
submitted with the bid.)
U.S. Environmental Protection Agency
Certification of Non -Segregated Facilities
(Applicable to contracts, subcontracts, and agreements with applicants who are themselves
performing Federally assisted construction contracts, exceeding $10,000 which are not exempt
from the provisions of the Equal Opportunity clause.)
By the submission of this bid, the bidder, offeror, applicant, or subcontractor certifies that
he does not maintain or provide for his employees any segregated facilities at any of his
establishments, and that he does not permit his employees to perform their services at any
location, under his control, where segregated facilities are maintained. He certifies further that
he will not maintain or provide for his employees any segregated facilities at any of his
establishments, and that he will not permit his employees to perform their services at any
location, under his control, where segregated facilities are maintained. The bidder, offeror,
applicant, or subcontractor agrees that a breach 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 washrooms, restaurants and other eating
areas, time clocks, locker rooms and other storage or dressing areas, parking lots, drinking
fountains, recreation or entertainment areas, transportation, and housing facilities provided for
employees which are segregated by explicit directive or are in fact segregated on the basis of
race, creed, color, or national original, because of habit, local custom, or otherwise. He further
agrees that (except where he has obtained identical certifications from proposed subcontractors
for specific time periods) he will obtain identical certifications from proposed subcontractors prior
to the award of subcontracts exceeding $10,000 which are not exempt from the provisions of
the Equal Opportunity clause; that he will retain such certifications in his files; and that he will
forward the following notice to such proposed subcontractors (except where the proposed
subcontractors have submitted identical certifications for specific time periods):
NOTICE TO PROSPECTIVE SUBCONTRACTORS OF REQUIREMENT FOR
CERTIFICATIONS OF NON -SEGREGATED FACILITIES
A Certification of Non -segregated Facilities, as required by the May 9, 1967, order (33
F.R. 7808, May 28, 1968) on Elimination of Segregated Facilities, by the Secretary of Labor,
must be submitted prior to the award of a subcontract exceeding $10,000 which is not exempt
from the provisions of the Equal Opportunity clause. The certification may be submitted either
for each subcontractor for all subcontracts during a period (Le., quarterly, semiannually, or
annually).
(Aublc,
//•/�P-/7
Signature (/ Date
e ZcR7-1,5 ,f9e,Y O EAf)_
Name and Title of Signer (Please Type)
NOTE: The penalty for making false statements in offers is prescribed in 18 U.S.C. 1001.
EPA -7 5720-4.2
SRF -2
May 2015
Attachment 2
SRF Required Front -End Specifications
(This form must be completed and signed by the Prime Contractor and
submitted with the bid.)
Debarments and Suspensions
Any bidder or equipment supplier whose firm or affiliate is listed in on the U.S. General Services
Administration Excluded Parties List System web site at http://www.epls.gov/ will be prohibited
from the bidding process. Anyone submitting a bid who is listed on this web site will be
determined to be a non-responsive bidder in accordance with 40 CFR Part 31.
United States Environmental Protection Agency Washington, DC 20460
Certification Regarding Debarment, Suspension, and
Other Responsibility Matters
The prospective participant certifies to the best of its knowledge and belief that it and the
principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded from covered transactions by any Federal department or
agency;
(b) Have not within a three year period preceding this proposal been convicted of or had a
civil judgment rendered against them for commission o f fraud or a criminal offense in
connection with obtaining, attempting to obtain, or performing a public (Federal, State,
or local) transaction or contract under a public transaction: violation of Federal or
State antitrust statutes or commission of embezzlement, theft, forgery, bribery,
falsification or destruction of records, making false statements, or receiving stolen
property;
(c) Are not presently indicted for otherwise criminally or civilly charged by a government
entity (Federal, State, or local) with commission of any of the offenses enumerated in
paragraph (1) (b) of this certification; and
(d) Have not within a three-year period preceding this application/proposal had one or
more public transaction s (Federal, State, or local) terminated or cause or default.
I understand that a false statement on this certification may be ground for rejection of this
proposal or termination of the award. In addition, under 18 U SC Sec. 10 01, a false statement
ma y result in a fine of up to $10,000 or imprisonment for up to 5 years, or both.
Typed Name & Title of Aut orized Representative
C.:(A..0 /U , ;
Signature of Authorized : presentative Date
❑ I am unable to certify to the above statements. My explanation is attached.
EPA Form 5700-49 (11-88)
SRF -3 May 2015
Attachment 3
SRF Required Front -End Specifications
(This form must be completed and signed by Prime Contractor and
submitted with the bid)
Disadvantaged Business Enterprise (DBE) Solicitation
It is EPA's policy that recipients of EPA financial assistance through the State Revolving Fund
programs award a "fair share" of subagreements to small, minority and women -owned
businesses, collectively know as Disadvantaged Business Enterprises (DBEs). Iowa's Fair
Share goals are:
Only work performed by certified DBEs can be counted toward the goals. In Iowa, DBEs must
be certified through the Iowa Department of Transportation (IDOT). Information on certification
requirements and a list of certified DBEs is on the IDOT website at
http://www.iowadot.gov/contracts/contracts eeoaa.htm.
Prime contractors' DBE requirements for SRF projects include:
• Taking affirmative steps for DBE participation
• Documenting the efforts and the proposed utilization of certified DBEs
PROJECT INFORMATION
SRF Applicant:
Minority -Owned Business
Enterprise (MBE) Goal
Women -Owned Business
Enterprise (WBE) Goal
2.2%
Construction
1.7%
Su..lies
0.6%
5.6%
Services
2.5%
11.3%
Goods/E• ui •ment
2.5%
10.4%
Avera • e
1.8%
7.4%
Only work performed by certified DBEs can be counted toward the goals. In Iowa, DBEs must
be certified through the Iowa Department of Transportation (IDOT). Information on certification
requirements and a list of certified DBEs is on the IDOT website at
http://www.iowadot.gov/contracts/contracts eeoaa.htm.
Prime contractors' DBE requirements for SRF projects include:
• Taking affirmative steps for DBE participation
• Documenting the efforts and the proposed utilization of certified DBEs
PROJECT INFORMATION
SRF Applicant:
(.1`17-- , : 'Tf_/?/,‘)
Bidder:
vW z (7`'1�l5- 7A)4 C? ,i'/n p../' //I/ ,
Address:
7 d, ,<' j',Y JAN) L /4/0 --,8, /J; .535,5-3
Contact Person:
/2 �• - G /)? /v1 c�' A' /? '/1/
4 7Signature:
Phone Number:
Z2 `j y, J y `e
E -Mail Address:
f}9? 2-b Aki--/A' ki_ d72S j 4 l) 1Y),9)/,/
. z:?e
Check if Prime Contractor is: ❑ Minority -Owned ❑ Women -Owned
SRF -4
May 2015
GOOD FAITH EFFORTS CHECKLIST
Please complete the checklist to determine if you have complied with the requirement to make
good faith efforts to ensure that certified DBEs have the opportunity to compete for
procurements funded by EPA financial assistance funds. Bidders/offerers must make good faith
efforts prior to submission of bids/proposals.
1. Did you ensure that DBEs are made aware of contracting opportune ies to the fullest extent
practicable through outreach and recruitment activities? ❑Yes ❑ No
2. Did you make information on forthcoming opportunities available to DBEs and arrange time
frames for contracts and establish delivery schedules, where the requirements permit, in a way
that encourages and facilitates participation by DBEs in the competitive process? This includes,
whenever possible, posting solicitation for bids or proposals for a minimum of 30 calendar days
before the bid or proposal closing date. jI Yes 0 No
3. Did you consider in the contracting process whether firms competing for large contracts
could subcontract with DBEs? This will include dividing total requirements, when economically
feasible, into smaller tasks or quantities to permit maximum participation by DBEs in the
competitive process. Er Yes ❑ No
4. Did you encourage contracting with a consortium of DBEs when a contract is too large for
one of these firms to handle individually? El Yes 0 No
5. Did you use the services of the Small Business Administration and the Minority Business
Development Agency of the Department of Commerce to identify pot ntial subcontractors?
[� Yes 0 No
6. List the potential DBE subcontractors that were contacted. Only list those that are certified
through the Iowa Department of Transportation.
Name
How Contacted
(e.g. letter, phone
cal e-mail)
Response (e.g. did not respond,
not interested, not competitive)
r liejla.0 i) 2 �' E")S'l L
tfax,
I og<
D filo r �c�J 2O/r%Q
46 /'r'afiG
K-9 6i d
.
tOnii)1 J]om�L ifrlR,
R �€'15 1,0d -s.
rhi 4) dE
Qp/�i OD&�,nQ�ar,�&
' .:
�FFr- ��sA•6�
C LA3 RE- IUO g Ecs-
co {D h)E
If
PROPOSED UTILIZATION OF DBE SUBCONTRACTORS
Please include Attachments 4 and 5 to document the proposed utilization of certified DBE
subcontractors.
SRF -5 May 2015
Attachment 4
SRF Required Front -End Specifications
(This form must be completed and signed by Prime and DBE Subcontractor
for each subcontract and submitted with the bid.)
OMB Control No: 2090-0030
Approved 8/13/2013
Approval Expires 8/31/2015
United States Environmental Protection Agency Disadvantaged Business Enterprise Program
DBE Subcontractor Performance Form
This form is intended to capture the DBE' subcontractor's2 description of work to be performed and the price of the work
submitted to the prime contractor. An EPA Financial Assistance Agreement recipient must require its prime contractor to
have its DBE subcontractors complete this form and include all completed forms in the prime contractor's bid or proposal
package.
Subcontractor Name
Project Name
Bid/Proposal No.
Assistance Agreement ID No.
(if known)
Point of Contact
Address
Telephone No.
Email Address
Prime Contractor Name
(ia2, (2‘)AiS7A add -„,,,i /41&,
Issuing/Funding Entity
Contract Item
Number
Description of Work Submitted
Construction, Services,
to the Prime Contractor Involving
Equipment or Supplies
Price of Work Submitted to
the Prime Contractor
DBE Certified by DOT SBA
Meets/exceeds EPA certification standards?
YES NO Unknown
_
Other:
1A DBE is a Disadvantaged, Minority, or Woman Business Enterprise that has been certified by an entity from which EPA accepts
certification as described in 40 CFR 33.204-33.205 or certified by EPA. EPA accepts certifications from entities that rneet or exceed
EPA certification standards as described in 40 CFR 33.202.
2Subcontractor is defined as a company, firm, joint venture, or individual who enters into an agreement with a contractor to provide
services pursuant to an EPA award of financial assistance.
EPA Form 6100-3 (DBE Subcontractor Performance Form) — Page 1
SRF -7 May 2015
OMB Control No: 2090-0030
Approved 8/13/2013
Approval Expires 8/31/2015
United States Environmental Protection Agency Disadvantaged Business Enterprise Program
DBE Subcontractor Performance Form
I certify under penalty of perjury that the forgoing statements are true and correct. Signing this form does not signify a
commitment to utilize the subcontractors above. I am aware of that in the event of a replacement of a subcontractor, I will
adhere to the replacement requirements set forth in 40 CFR Part 33 Section 33.302 (c).
Prime Contractor Signature
PrintName
(1/),A777-
S ,/� /Mil) il) f_ Calif/ (i%
Tit a
Date
PR 57,0f/Yr
//f-/6 - /;7
Subcontractor Signature
Print Name
itle
Date
The public reporting and recordkeeping burden for this collection of information is estimated to average three (3) hours
per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates,
and any suggested methods for minimizing respondent burden, including through the use of automated collection
techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200
Pennsylvania Ave., NW, Washington, D,C, 20460. Include the OMB control number in any correspondence. Do not send
the completed form to this address.
EPA Form 6100-3 (DBE Subcontractor Performance Form) — Page 2
SRF -8 May 2015
Attachment 5
SRF Required Front -End Specifications
(This form must be completed and signed by Prime Contractor and submitted with the bid
if utilizing DBE subcontractors.)
OMB Control No: 2090-0030
Approved 8/13/2013
Approval Expires 8/31/2015
United States Environmental Protection Agency Disadvantaged Business Enterprise Program
DBE Subcontractor Utilization Form
This form is intended to capture the prime contractor's actual and/or intended use of identified certified DBE1
subcontractors2 and the estimated dollar amount of each subcontract. An EPA Financial Assistance Agreement Recipient
must require its prime contractors to complete this form and include it in the bid or proposal package. Prime contractors
should also maintain a copy of this form on file.
Prime Contractor Name
I //t (2);KS;16�01/17%Da✓ ;l'✓?.
Project Name
ilde-d loftL, 7177 efvf LOvJ
Bid/Proposal No.
nn r��y
)
Assistance Agreement ID No.
(if known)
Point of Contact
(7 j k' %// S
Zio2/276-47 71947/
Address
o. 3o x 53d, //Nla E N� Gz// _I3'5 3
Telephone No.
‘o8-,31E(-D5%B`
Email Address
n?z (1):°145-
'G%I7%o NS eL?ty'0,5I1-.r
=vM
Issuing/Funding Entity
L'7%; y or / 79-7zW4 <° 7
I have identified potential DBE certified subcontractors
If yes, please complete the table below. If no, please explain:
YES
i/
NO
Currently DBE
Certified?
Subcontractor
Name/Company
Name
Company Address/Phone/Email
Estimated Dollar
Amount
�1 �N 7
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1A DBE is a Disadvantaged, Minority, or Woman Business Enterprise that has been certified by an entity from which EPA accepts
certification as described in 40 CFR 33.204-33.205 or certified by EPA. EPA accepts certifications from entities that meet or exceed
EPA certification standards as described in 40 CFR 33.202,
2Subcontractor is defined as a company, firm, joint venture, or individual who enters into an agreement with a contractor to provide
services pursuant to an EPA award of financial assistance.
EPA Form 6100-4 (DBE Subcontractor Utilization Form) — Page 1
SRF -9
May 2015
OMB Control No: 2090-0030
Approved 8/13/2013
Approval Expires 8/31/2015
United States Environmental Protection Agency Disadvantaged Business Enterprise Program
DBE Subcontractor Utilization Form
I certify under penalty of perjury that the forgoing statements are true and correct. Signing this form does not signify a
commitment to utilize the subcontractors above. I am aware of that in the event of a replacement of a subcontractor, I will
adhere to the replacement requirements set forth in 40 CFR Part 33 Section 33.302 (c).
Prime Contractor Signature
Print Name
l 2( PC -1,75-
.CV/ 60r27E.ii7)n /I
le
t
Date
Afro/erdr
,,'
/7
The public reporting and recordkeeping burden for this collection of information is estimated to average three (3) hours
per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates,
and any suggested methods for minimizing respondent burden, including through the use of automated collection
techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200
Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send
the completed form to this address.
EPA Form 6100-4 (DBE Subcontractor Utilization Form) — Page 2
SRF -10 May 2015
SECTION 00 4514
BIDDER STATUS FORM
To be completed by all bidders
Please answer "Yes" or "No" for each of the following:
Yes 0 No
❑ Yes ❑'No
O Yes ❑'No
❑ Yes allo
❑ Yes l No
Part A
My company is authorized to transact business in Iowa.
(To help you determine if your company is authorized, please review the worksheet on the next page).
My company has an office to transact business in Iowa.
My company's office in Iowa is suitable for more than receiving mail, telephone calls, and e-mail.
My company has been conducting business in Iowa for at least 3 years prior to the first request for
bids on this project.
My company is not a subsidiary of another business entity or my company is a subsidiary of another
business entity that would qualify as a resident bidder in Iowa.
If you answered "Yes" for each question above, your company qualifies as a resident bidder. Please
complete Parts B and D of this form.
If you answered "No" to one or more questions above, your company is a nonresident bidder. Please
complete Parts C and D of this form.
To be completed by resident bidders Part B
My company has maintained offices in Iowa during the past 3 years at the following addresses:
Dates: / / to / / Address:
City, State, Zip:
Dates: / / to / / Address:
City, State, Zip:
Dates: / / to / / Address:
You may attach additional sheet(s) if needed. City, State, Zip:
To be completed by non-resident bidders
Part C
1. Name of home state or foreign country reported to the Iowa Secretary of State:
£4-222/0 e ,7-2Y
2. Does your company's home state or foreign country offer preferences to resident bidders, resident labor �/
force preferences or any other type of preference to bidders or laborers? 0 Yes t_I No
3. If you answered "Yes" to question 2, identify each preference offered by your company's home state or foreign country
and the appropriate legal citation.
You may attach additional sheet(s) if needed.
To be completed by all bidders Part D
I certify that the statements made on this document are true and complete to the best of my knowledge and I know that my
failure to provide accurate and truthful information may be a reason to reject my bid.
Firm Name: 77Z (te)4.t ypi/.2 !lio/d /We-
Signature:
W L
Signature: C
Date:
You must submit the comp ted form to the governmental body requesting bids per 675 Iowa Administrative Code
Chapter 156. This form has been approved by the Iowa Labor Commissioner.
M?2818 PROJECTSW8.O350_Reinbeck NNJtP lmpmvemenls\Sped IDivsion 8\084514 Bltltler Slalus_Fann doc
00 45 14-1
Worksheet: Authorization to Transact Business
This worksheet may be used to help complete Part A of the Resident Bidder Status form. If at least one of the following
describes your business, you are authorized to transact business In Iowa.
(Yes Q No My business is currently registered as a contractor with the Iowa Division of Labor.
0 Yes WINo My business is a sole proprietorship and I am an Iowa resident for Iowa income tax purposes.
Q Yes E(No My business is a general partnership or joint venture. More than 50 percent of the general
partners or joint venture parties are residents of Iowa for Iowa income tax purposes.
Q Yes [Ei No My business is an active corporation with the Iowa Secretary of State and has paid all fees
required by the Secretary of State, has filed its most recent biennial report, and has not filed
articles of dissolution.
O Yes No
My business is a corporation whose articles of incorporation are filed In a state other than Iowa,
the corporation has received a certificate of authority from the Iowa secretary of state, has filed
its most recent biennial report with the secretary of state, and has neither received a certificate of
withdrawal from the secretary of state nor had its authority revoked.
O Yes 0/No My business is a limited liability partnership which has filed a statement of qualification in this
state and the statement has not been canceled.
Q Yes L1 No My business is a limited liability partnership which has filed a statement of qualification in a
state other than Iowa, has filed a statement of foreign qualification in lows and a statement of
cancellation has not been filed.
Q Yes Q'No My business Is a limited partnership or limited liability limited partnership which has filed a
certificate of limited partnership in this state, and has not filed a statement of termination,
Q Yes EJ No My business is a limited partnership or a limited liability limited partnership whose certificate of
limited partnership is filed in a state other than Iowa, the limited partnership or limited liability
limited partnership has received notification from the Iowa secretary of state that the application
for certificate of authority has been approved and no notice of cancellation has been filed by the
limited partnership or the limited liability limited partnership.
Q Yes (g No My business is a limited liability company Whose certifisate of organization is filed in Iowa and has
/ not filed a statement of termination.
Q Yes Lys No My business is a limited liability company whose certificate of organization is filed in a state other
than Iowa, has received a certificate of authority to transact business in Iowa and the certificate
has not been revoked or canceled.
M_12016_PROJECTS111003 Reanbeck YWyrP improw!1t»nts150ec5t00n 004614 &tljer$IgWs Fwmooc
00 45 14-2
BID BOND
KNOW ALL MEN BY THESE PRESENTS, that we, M -Z Construction, Inc.
as Principal, and North American Specialty Insurance Company
as Surety are held and firmly bound unto the CITY OF WATERLOO , Iowa, hereinafter called "OWNER."
in the penal sum Five Percent of Amount Bid
Dollars ($ 5% of Bid ) lawful money of the United States, for the payment of which sum will
and truly be made, we bind ourselves, our heirs, executors, administrators, and successors, jointly and
severally, firmly by these presents. The condition of this obligation is such that whereas the Principal has
submitted the accompanying bid dated the 2nd day of November , 2017 , for
Flow Equalization Facility - Overflow Connection to Satellite WPCF
NOW, THEREFORE,
(a) If said Bid shall be rejected, or in the alternate,
(b) If said Bid shall be accepted and the Principal shall execute and deliver a contract in the form
specified and shall furnish a bond for his faithful performance of said contract, and for the payment of all
persons performing labor or furnishing materials in connection therewith, and shall in all other respects
perform the agreement created by the acceptance of said Bid,
Then this obligation shall be void, otherwise the same shall remain in force and effect; it being expressly
understood and agreed that the liability of the Surety for any and all claims hereunder shall, in no event,
exceed the penal amount of this obligation as herein stated.
By virtue of statutory authority, the full amount of this bid bond shall be forfeited to the Owner in
liquidation of damages sustained in the event that the Principal fails to execute the contract and provide
the bond as provided in the specifications or by law.
The Surety, for value received, hereby stipulates and agrees that the obligations of said Surety and its
bond shall be in no way impaired or affected by any extension of the time within which the Owner may,00.Z llll ,,,,,,,
accept such Bid or execute such contract; and said Surety does hereby waive notice of any s M N'''%,
extension.
Co' • G
IN WITNESS WHEREOF, the Principal and the Surety, have hereunto set their hands and suis, qtidZs1 a .
such of them as are corporations, have caused their corporate seals to be hereto affixed and thege•Irs- y p
ents to be signed by their proper officers this 2nd day of November , A.D. 2017 cn . 'e
C.
X621/L&471',2_)
Wit ess
BID BOND
AECOM 60336756-2017
G.Q .J1t,eat'Y
Josie Benson
M -Z Construction, Inc.
By Ctt7C
-3)f)`'N 1
North American Speciate Insurance Company
By
Spy
(Seal)
Attorney -in -Fact
Todd Schaap
BB -1 of 1 Flow Equalization Facility
City Contract No. 880 Overflow Connection to Satellite VUPCF
ti
t�t:l59[4�499C��
NAS SURETY GROUP
NORTH AMERICAN SPECIALTY INSURANCE COMPANY
WASHINGTON INTERNATIONAL INSURANCE COMPANY
GENERAL POWER OF ATTORNEY
KNOW ALL lty
nce Company, a
on duly
anized and
laws of he State of New Hampshiire,, and having SENTS, its principal officeT North an n the City of Manchester, New Ha npshi e,l and Washington
International
ng under
Insurance Company, a corporation organized and existing under the laws of the State of New Hampshire and having its principal office in the City of
Schaumburg, Illinois, each does hereby make, constitute THOaMAS nd point
O. CHAMBERS, TODD SCAAAP
and KIMBERLY S. RASCH
JOINTLY OR SEVERALLY
Its true and lawful Attorney(s)-in-Fact, to make, execute, seal and deliver, for and on its behalf and as its act and deed, bonds or other writings
n contracts of suretyship as are or
lobligatory in the nature ofaw, regulation,, contract or otherwise, provided that no bond obond on behalf of each of said rrundertaking or panies, as contract or suretyship executed under this uthoy be rityrshall exceed the
by
amount of: FIFTY MILLION ($50,000,000.00) DOLLARS
This Power of Attorney is granted and is signed by facsimile under and by the authority of the following Resolutions adopted by the Boards of
Directors of both North American Specialty Insurance Company and Washington International Insurance Company at meetings duly called and held
"RESOLVED, that any two of the Presidents, any Managing Director, any Senior Vice President, any Vice President, any Assistant Vice President,
on the 9t of May, 2012:the Secretary or any Assistant
e a Pwer of
y qualifying the
torney
in the given Power of Attomey to execu eeto
onand each or any of them hereby is authorized behalf of the Company bonds, undertakings and all contracts of su etty, and that each or anytof them named
hereby is authorized to attest to the execution of any such Power of Attomey and to attach therein the seal of the Company; and it is
he seal of the
y may
r of Attorney or
certificate relating therto by RESOLVED, csimile,sandature of such officers any such Power of Attomey or certificate bearing such facs facsimile signaturessuch
o raeeimile seal hall be any
binding upon the Company when so affixed and in the future with regard to any bond, undertaking or contract of surety to which it is attached."
O\\\ALIrr/ .4 (,iI(JIgL (/"�`//_ OPvOgq Nde
�yi SEAL ,4 c By t' SEAL�F'';�i
VAS Steven P. Anderson, Senior Vice President or Washington International Insurance Company �f ms
z.ssyi' SEAL 'm= &Senior Vice President of North American Specially Insurance Company
ny \A 1973
4i oir 10
//dlllllal\\\\\\\ B mrance omPany
Michael A. Ito, error '�ce'reso ento 'm ngon nternat one n
& Senior Vice President of North American Specialty Insurance Company
IN April 20he .
official sealslto be hereuntoEaafffixedort and these presents Specito be signed by their authorized Washingtonfficerthis14thday of April
Company have caused their
North American Specialty Insurance Company
Washington International Insurance Company
State of Illinois ss:
County of Cook
On this 14th day of April , 2016 before rine, a Notary Public personalty appeared Steven P. Anderson , Senior Vice President of
erican Specialty
el
ance
SWashingtn Internaonal Insurance Company and enior Vice President of Washington International Insurrance Company and Senior r Vice President of North Vice r s President of NorthrAmer can Specialtyally apCompany and pearIto
Company,pyper on d innally strumeto me, nt to be the being aby me duly sworn, y act and deed of theired respectivethat they
signed the above Power of Attomey as officers of and
OFFICIAL SEAL
M KENNY
NOTARY PUBLIC, STATE OF IWNOIS
MY COMMISSION EXPIRES 1210412017
I, Jeffrey Goldberg , the duly elected Assistant Secretary of North American Specialty Insurance Company and Washington
International Insurance Company, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attomey given by said North
American Specialty Insurance Company and Wahiilgton International Insurance Company, which is still in full force and effect.
IN WITNESS WHEREOF, 1 have set my hand and affixed the seals of the Companies this 2nd day o//f1Nov wee , 2017
•A
Jeffrey Goldberg,Vice President& Assistant Secretary of 1
Washington International Insurance Company
& North American S it' Insurance Company
Public '1
STATE OF WISCONSIN )
COUNTY OF Racine
ON THIS 2nd day of November
2017
before me, a notary public, within and for said County and State, personally appeared
Todd Schaap to me personally known, who being duly sworn,
upon oath did say that he is the Attorney -in -Fact of and for the
North American Specialty Insurance Company , a corporation
of New Hampshire , created, organized and existing under and
by virtue of the laws of the State of New Hampshire ; that the corporate seal
affixed to the foregoing within instrument is the seal of the said Company; that the seal
was affixed and the said instrument was executed by authority of its Board of Directors;
and the said Todd Schaap did acknowledge that he/she
executed the said instrument as the free act and deed of said Company.
uJU- JitAtictim
Jac ie Sheldon
Notary Public, Racine County, Wisconsin
My Commissiox'4/13/2019
apSP�AY p�tON
i9ari
Jq c�C/ s
SPA
SHOREVEST.
Surety Services, Inc.
t7� W��.Sif•�.P'"' �� 4
•
e, WI 53126
2626 262 8Drive35.9576 orII800.264.1634
PNONE:
FAX: 262.835.9649