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Revised Per Addendum No. 1 - 6/12/2018
The PROPOSAL FORM
FOR
IMPROVEMENTS TO THE WATERLOO REGIONAL AIRPORT
CONSISTING OF
REHABILITATE WEST TERMINAL APRON
AT THE
WATERLOO REGIONAL AIRPORT
WATERLOO, IOWA
FAA AIP PROJECT NO. 349-0094-046
Waterloo Regional Airport
2790 Livingston Lane
Waterloo, IA 50703
Gentlemen:
1 . The undersigned hereby certifies that he has examined the Form of Contract, Plans, and Specifications for the
Construction of Improvements to the Waterloo Regional Airportto Rehabilitate West Terminal Apron, atthe
Waterloo Regional Airport, Waterloo, Iowa, FAA AIP Project No. 349-0094-046, and has examined the site of
the work and is familiar with local conditions pertaining to the work.
2. The extent of the work involved is to Rehabilitate West Terminal Apron, including the removal and
replacement of West Terminal Apron with a 12-inch Portland Cement Concrete Pavement section with a Hot Mix
Asphalt stabilized subbase, removal and replacement of subbase materials, removal and replacement of storm
sewer structures, adjustment of an existing storm sewer structure, installation of aircraft tie down anchors,
pavement marking in the areas shown on the plans, saw and replacement of joint sealant on the East Terminal
Apron, and all other incidental work associated with this project. This work and all other incidentals shall be
performed as shown on the Drawings and described in the Specifications.
3 . The undersigned, in compliance with your Invitation for Bids dated hereby proposes to do
the work called for in said Contract and Specifications and shown on said Plans and Addendum Nos.
and to famish all materials, tools, labor and all appliances and appurtenances necessary
for the said work at the following rates and prices:
ITEMIZED PROPOSAL
WATERLOO REGIONAL AIRPORT
WATERLOO, IOWA
PROJECT: REHABILITATE WEST TERMINAL APRON
FAA AIP PROJECT NO. 3-19-0094-046
ITEM SPEC. ESTIMATED UNIT BID TOTAL BID
NO. NO. DESCRIPTION UNIT QUANTITY PRICE PRICE
1 GP 105 MOBILIZATION AND LS1 $ QO $
DEMOBILIZATION JAG /w L2V d
2 GP 105 TRAFFIC CONTROL LS 1 $ - 000 ' $ 000
3 GP 50.06 CONSTRUCTION SURVEY LS. 1 $ Z000 � $ 7"000
4 P401 PAVEMENT REMOVAL SY 31400 $ — $ o2]c2gO —
5 PLANS REMOVAL OF STRUCTURE EA 1 $ a .5-pp $ a .S 00
6 P-152 UNCLASSIFIED EXCAVATION CY 1,700 $ .�" $
7 P-154 SUBBASE COURSE CY 690 $ 96 $ 6l0 02 O
8 P-208 AGGREGATE BASE COURSE - 6INCH SY 31400
FAAAIP #3.19.0094-046 P-I Waterloo Regional Airport
AECOM Project # 60562796 Rehabilitate West Terminal Apron
Revised Per Addendum No. I - 6/12/2018
ITEM SPEC. ESTIMATED UNIT BID TOTAL BID
NO. NO, DESCRIPTION UNIT QUANTITY PRICE PRICE
9 P403 HMA BASE COURSE TON 710 $ 3-0 $ /06 SOO -
10 P-501 104INCH PORTLAND CEMENT SY 960 $ $ '
CONCRETE PAVEMENT �y � Of/O
wl
11 P-501 12-INCH PORTLAND CEMENT SY 29440 $ 7y $ X80 S6O
CONCRETE PAVEMENT
12 P-620 RUNWAY AND TAXIWAY MARKING SF 39675 $ $ / &' -5--.3q7
] 3 P-620 REFLECTIVE'MEDIA (TYPE I, LB 260 $ a, $
GRADATIONA)
14 PLANS AIRCRAFT TIEDOWN ANCHORS IN EA 20 $ 35 $ 7 p(} u
NEW PAVEMENT
IS PLANS AIRCRAFT TIEDOWN ANCHORS IN EA 10 $ O $ p6 C
EXISTING PAVEMENT
44NCH PERFORATED SUBDRAIN
16 D-705 (SDR 35) COMPLETE, INCLUDING LF 270 $ / — $
POROUS BACKFILL AND FILTER
FABRIC
17 D-705 44NCHNON-PERFORATED SUBDRAIN LF 165 $ 7 ' $ �G.S
(SDR 35) _
18 D-705 SUBDRAIN CLEANOUT EA 3 4 9 _ ^ $
19 D-751 ADJUST EXISTING CATCH BASIN EA 2 $
20 D-751 CATCH BASIN EA 2 $$ (� O $ 9 O _
TOTAL (BASE BID) $ 6 99, 767 �-
Add Alternate Bid No. I - Saw and Seal Joints
1 P-101 SAW AND SEAL JOIN"IS LF 4,950 $ 4 f $ ,3 9 605 '_
2 CP405 Traffic Control LS 1 1 $ 6 000 $ 6 000
TOTAL INCLUDING ADD ALTERNATE $ 7 52 boo
4. It is the Airport's intention to evaluate bids reviewing both the Base Bid and Add Alternate Bid, The Airport
has limited funds available and will award only what funding allows. The Airport reserves the right to award
the contract based on the Base Bid only or the Base Bid plus Add Alternate Bid Option.
5. The undersigned understands that the above quantities of work to be done are approximate only and are
intended principally to serve as a guide in evaluating the bids. All quantities are subject to increase or decrease
and are to be performed at the unit prices stipulated herein.
6. It is understood that the schedule ofminimumwage rates, as established by the Secretary ofLabor and included
in the Specifications, are to govern on this project, and the undersigned certifies that he has examined this
schedule of wage rates and that the prices bid are based on such established wage rates.
7. The bidder shall make good faith efforts, as defined in Appendix A of 49 CFR Part 26, Regulations of the
Office of the Secretary of Transportation, to subcontract seven and one-third (7.33%) percent ofthe dollar value
of the prime contract to small business concerns owned and controlled by socially and economically
disadvantaged individuals (DBE). Individuals who are rebuttably presumed to be socially and economically
disadvantaged include women, Blacks, Hispanics, Native Americans, Asian-Pacific Americans, and Asian-
Indian Americans. The apparent successful competitor will be required to submit information concerning the
DBE's that will participate in the contract. The information will include the name and address of each DBE, a
description ofthe work to be performed by each named firm, and the dollar value ofthe contract. If the bidder
fails to achieve the contract goal stated herein, it will be required to provide documentation demonstrating that it
made good faith efforts in attempting to do so. In the event that the apparent successful competitor for this
FAAAIP #3.19-0094-046 P-2 Waterloo Regional Airport
AECOM Project # 60562796 Rehabilitate West Terminal Apron
Revised Per Addendum No. 1 - 6/12/2018
solicitation qualified as a DBE, the contract goal shall be deemed to have been met. A bid that fails to meet
these requirements will be considered nonresponsive.
8. The undersigned 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. The undersigned certifies further that he will not
maintain or provide for his employees any segregated facilities atany 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 undersigned 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, timeclocks, 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, color, religion, or national origin, because of habit, local custom, or any other reason. The
undersigned agrees that (except where he has obtained identical certifications fromproposed 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 ofthe equal opportunity clause, and
that he will retain such certifications in his files.
9. The undersigned agrees, upon written notice of the acceptance of this bid, within ninety (90) days after the
opening ofthe bids, that he will execute the Contract in accordance with the bid as accepted and give Contract
(Performance and Payment) bond on attached forms within fifteen (15) days after the prescribed forms are
presented for signature.
10. The undersigned understands, award ofcontract is contingent upon receipt ofproject funding from the Federal
Aviation Administration. If funding is not received, bid bonds will be returned to all bidders and the project
will be postponed.
11 . The undersigned further agrees that if awarded the Contract, he will commence the work within ten (10)
calendar days after the receipt of a "Notice to Proceed" and that he will substantially complete all work
according to the terms ofthe entire contract within sixty-five (65) calendar days from the date established in the
Notice to Proceed. An extension of time may be allowed when extra or additional work is ordered by the
Engineer.
12. The undersigned agrees that within 30 days after award ofthis contract, the Contractor/Subcontractor shall file a
compliance report (Standard Form 100) if s/he has not submitted a complete compliance report within 12
months proceeding the date of award. This report is required ifthe Contractor/Subcontractor meets all ofthe
following conditions:
a. Contractors/Subcontractors are not exempt based on 41 CFR 60-1,5.
b. Has 50 or more employees.
c. Is a prime contractor or first tier subcontractor.
d. There is a contract, subcontract, or purchase order amounting to $50,000 or more.
13. To satisfy Clear Air and Water Pollution Control Requirements on all Construction Contracts and Subcontracts
exceeding $100,000.00 Contractors and Subcontractors agree:
a. That any facility to be used in the performance of the Contract or to benefit from the Contract is not listed
on the Environmental Protection Agency (EPA) List of Violating Facilities.
b. To comply with all the requirements of Section 306 of the Clean Air Act (42 USC 1857(h)), and Section
508 of the Clean Water Act (33 USC 1368), Executive Order 11738, and Environmental Protection
Regulations (40 CFR Part (15)).
FAA AIP #349-0094-046 P-3 Waterloo Regional Airport
AECOM Project # 60562796 Rehabilitate West Temtinal Apron
Revised Per Addendum No. 1 - 6/12/2018
c. That as a condition for award of a Contract he shall notify the awarding official of the receipt of any
communication from EPA indicating that a facility to be utilized for performance of or benefit from the
Contract is under consideration to be listed on the EPA List of Violating Facilities.
d. To include or cause to be included in any Contract or Subcontract which exceeds $ 100,000.00 the
aforementioned criteria and requirements.
14. The contractor, by submission of this offer and/or execution of a contract, certifies that it:
a, is not owned or controlled by one or more citizens or nationals of a foreign country included in the list of
countries that discriminate against U.S. firms published by the Office of the United States trade
Representative (USTR);
b. has not knowingly entered into any contract or subcontract for this project with a contractor that is a citizen
or national of a foreign country on said list, or is owned or controlled directly or indirectly by one or more
citizens or nationals of a foreign country on said list;
c. has not procured any product nor subcontracted for the supply of any product for use on the project that is
produced in a foreign country on said list.
Unless the restrictions ofthis clause are waived by the Secretary of Transportation in accordance with 49 CFR
30. 17, no contract shall be awarded to a contractor or subcontractor who is unable to certify to the above. Ifthe
contractor knowingly procures or subcontracts for the supply of any product or service of a foreign country on
the said list for use on the project, the Federal Aviation Administration may direct, through the sponsor,
cancellation of the contract at no cost to the Government.
Further, the contractor agrees that, if awarded a contract resulting from this solicitation, it will incorporate this
provision for certification without modification in each contract and in all lower tier subcontracts. The
contractor may rely upon the certification of a prospective subcontractor unless it has knowledge that the
certification is erroneous.
The contractor shall provide immediate written notice to the sponsor ifthe contractor learns that its certification
or that of a subcontractor was erroneous when submitted or has become erroneous by reason of changed
circumstances. The subcontractor agrees to provide immediate written notice to the contractor, if at any time it
learns that its certification was erroneous by reason of changed circumstances.
This certification is a material representation offact upon which reliance was placed when making the award. If
it is later determined that the contractor or subcontractor knowingly rendered an erroneous certification, the
Federal Aviation Administration may direct, through the sponsor, cancellation of the contract or subcontract for
default at no cost to the Government.
Nothing contained in the foregoing shall be construed to require establishment of a system ofrecords in order to
render, in good faith, the certification required by this provision. The knowledge and information of a
contractor is not required to exceed that which is normally possessed by a prudent person in the ordinary course
of business dealings.
This certification concerns a matter within the jurisdiction of an agency of the United States ofAmerica and the
making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under Title
18, United States Code, Section 1001 .
15. The bidder/offeror certifies, by submission ofthis proposal or acceptance ofthis contract, that neither it nor its
principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from participation in this transaction by any Federal department or agency. It further agrees by
submitting this proposal that it will include this clause without modification in all lower tier transactions,
solicitations, proposals, contracts, and subcontracts. Where the bidder/offer/contractor or any lower tier
participant is unable to certify this statement, it shall attach an explanation to this solicitation/proposal.
FAA Alp #3-19-0094-046 P-4 Waterloo Regional Airport
AECOM Project 9 60562796 Rehabilitate West Terminal Apron
Revised Per Addendum No. 1 - 6/12/2018
16. As an evidence of good faith in submitting this Proposal, the undersigned encloses bid security in the amount of
five (5) percent ofthe bid which, in case he refuses or fails to accept an award and to enter into a Contract and
file the required bonds within the prescribed time, shall be forfeited to the Waterloo Regional Airport as
liquidated damages.
17. By entering into this contract, the contractor certifies that neither it (nor he or she) nor any person or firm who
has an interest in the contractor's firm is a person or firm ineligible to be awarded Government contracts by
virtue of section 3(a) of the Davis-Bacon Act or 29 CFR 5.12(a)(1).
18. No part of this contract shall be subcontracted to any person or firm ineligible for award of a Government
contract by virtue of section 3(a) of the Davis-Bacon Act or 29 CFR 5. 12(a)(1).
19. The undersigned hereby declares that the only parties interested in this Proposal are named herein, that this
Proposal is made without collusion with any other person, firm or corporation, that no member ofthe Council,
Waterloo Regional Airport or agent ofthe City of Waterloo, Iowa, is directly or indirectly financially interested
in this bid.
20. In submitting this bid, it is understood that the right to reject any and all bids has been reserved and that this bid
may not be withdrawn for a period of ninety (90) days from the opening thereof.
21 . Contractor certifies that all employees employed by Contractor or any subcontractor working on behalf of the
Contractor are in compliance with the Immigration Reform Control Act of 1986 (IRCA) and indemnifies the
Owner and holds harmless Owner for any violations of IRCA as a result of the Contractor's employees or his
subcontractor's employees working on behalf of the Contractor on the Owner's project.
22. The undersigned certifies, to the best of his or her knowledge and belief, that:
a. No Federal appropriated funds shall be paid, by or on behalf of the Contractor, to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a member of Congress in Congress in connection with
the making of any Federal grant and the amendment or modification of any Federal grant.
b. If any funds other than Federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a member of Congress, an
officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal
grant, the Contractor shall complete and submit Standard Form-LLL, "Disclosure of Lobby Activities", in
accordance with its instructions.
c. The Undersigned shall require that the language of this certification be included in the award documents for
all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and
cooperative agreements) and that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction was
made or entered into. Submission of this certification is a prerequisite for making or entering into this
transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required
certification shall be subject to a civil penalty of not less than $ 10,000 and not more than $200,000 for each
such failure.
23. BUY AMERICAN CERTIFICATE (Title 49 U.S.C. Chapter 501)
As a condition of bid responsiveness, the bidder must how it intend to comply with the Buy American
preferences established under Title 49 U.S.C. Section 50101 . Bidder must complete the attached Buy American
certification. If the bidder requests a permissible waiver to the Buy America requirements, the Bidder identified
as with the successful bid must submit a formal waiver request and component cost calculation within the
prescribed time identified on the Buy America certification.
FAA AN #3-19-0094-046 P-5 Waterloo Regional Airport
AECOM Project # 60562796 Rehabilitate West Terminal Apron
Revised Per Addendum No. 1 - 6/12/2018
24, Drug Free Work Place, Act of 1988.
a. By submission of this offer, the offeror, if other than an individual, who is making an offer that equals or
exceeds $25,000, certifies and agrees that with respect to all employees ofthe offeror to be employed under
a contract resulting from this solicitation, it will--no later than 30 calendar days after contract award (unless
a longer period is agreed to in writing, for contracts of 30 calendar days or more performance duration;) or
as soon as possible for contracts of less than 30 calendar days performance duration, but in any case, by a
date prior to when performance is expected to be completed--
(1) Publish a statement notifying such employees thatthe unlawful manufacturer, distribution, dispensing,
possession or use of a controlled substance is prohibited in the Contractor's workplace and specifying
the actions that will be taken against employees for violations of such prohibition;
(2) Establish an on going drug-free awareness program to inform such employees about--
(a) The dangers of drug abuse in the workplace;
(b) The Contractor's policy of maintaining a drug-free workplace;
(c) Any available drug counseling, rehabilitation, and employee assistance programs; and
(d) The penalties that may be imposed upon employees for drug abuse violations occurring in the
workplace;
(3) Provide all employees engaged in performance of the contract with a copy of the statement required
by subparagraph a.(1) of this provision;
(4) Notify such employees in writing in the statement required by subparagraph a.( 1) of this provision
that, as a condition of continued employment on the contract resulting from this solicitation, the
employee will•-
(a) Abide by the terms of the statement; and
(b) Notify the employer in writing ofthe employee's conviction under a criminal drug statute for a
violation occurring in the workplace no later than 5 calendar days after such conviction;
(5) Notify the Contracting Officer in writing within 10 calendar days after receiving notice under
subdivision a.(4) (b) of this provision, from an employee or otherwise receiving actual notice ofsuch
conviction. The notice shall include the position title of the employee; and
(6) Within 30 calendar days after receiving notice under subdivision a.(4)(b) of this provision of a
conviction, take one of the following actions with respect to any employee who is convicted of a drug
abuse violation occurring in the workplace;
(a) Take appropriate personnel action against such employee, up to and including termination; or
(b) Require such employee to satisfactorily participate in a drug abuse assistance or rehabilitation
program approved for such purposes by a Federal, State, or local health, law enforcement, or
other appropriate agency.
O Make a good faith effort to maintain a drug-free workplace through implementation of subparagraphs
a.( 1) through a.(6) of this provision.
b. By submission of its offer, the offeror, if an individual who is making an offer of any dollar value, certifies
and agrees that other offeror will not engage in the unlawful manufacture, distribution, dispensing,
possession, or use of a controlled substance in the performance of the contract resulting from this
solicitation.
c. Failure ofthe offeror to provide the certification required by paragraphs a. or b. of this provision, renders
the offeror unqualified and ineligible for award. [See FAR 9.104-1(g) and 19.602-la.(2)(a)] .
d. In addition to other remedies available to the Government, the certification in paragraphs a. orb. of this
provision concerns a matter within the jurisdiction of an agency of the United States and the making of a
FAA AIP #3-19.0094.046 P-6 Waterloo Regional Airport
AECOM Project 4 60562796 Rehabilitate West Terminal Apron
Revised Per Addendum No. 1 - 6/12/2018
false, fictitious, or fraudulent certification may render the maker subject to prosecution under title 18,
United States Code, Section 1001 .
25. Attachment to This Bid. The following documents are attached to and made a part of this Bid:
a. Bid Guaranty in the form of ,UO k A
b. Non-Collusion Affidavit of Prime Bidder.
c. Statement of Intent — Non-Discrimination and Equal Opportunity Statement.
d. Buy American Certification Statement.
e. Bidder's Information Sheet.
f. Synopsis of Experience Record. (IDOT Certification may be substituted.)
g. Completed DBE forms "Utilization Statement" and "Letter of Intent."
26, The Bidder shall indicate whether the bid is submitted by a/an:
❑ Individual, Sole Proprietorship
❑ Partnership
.L yCorporation
❑ Joint-venture: all parties must join-in and execute all documents
❑ Other
Respectfully submitted,
Bidder
By
Signature
�7 Title
T . y 13OX Vs!J
Address
C / C ( k6U41C
(Include Z' Code)
31g - �90 - -s7 � 7
Telephone No.
FAA AIP #3- 19-0094.046 P-7 Waterloo Regional Airport
AECOM Project # 60562796 Rehabilitate West Terminal Apron
NON-COLLUSION AFFIDAVIT OF PRIME BIDDER
State of � 1
1 ' )ss
County ofc11c.
being first duly sworn, deposes and says that:
(1) He is Owner Partner Offi e resentative A ent of
Z� 41SP� 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 in interest, including this affiant.
(Signed)
Tie 4i S7` r
Subscribed and sworn to before me/
this I dayof .1UQQ. 2018•
tl -F+ ice Madaes �
Title
My Commission Expires .3 '"' 16 • 2IIyS.
eIA4 LINDA KSENN
ti COMMISSION NO. 803307
y 'n MY COMMISSION EXPIRES
*• awa* 3 — � s - ao
FAA AIP #3-19-0094-046 P-9 Waterloo Regional Airport
AECOM Project #60562796 Rehabilitate West Terminal Apron
i
NON-COLLUSION AFFIDAVIT OF SUBCONTRACTOR
(To Be Submitted After Bid But Prior to Award)
State of IOWA )
)ss
Countyof BLACK HAWK )
MILT DAKOVICH being first duly sworn, deposes and says that:
(1 ) He is 4GYeter ^_- -_ Officer-Remles € -arA rtl of
ASPRO , INC . , the Bidder thathas submitted the attached Bid:
(2) He is filly 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 hi 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 orcotmnunication 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 uNawful agreement on the part of the Bidder or any of its agents, representatives, owners, employees, or
parties in interest, including this affiant.
(Signed)
Title PR IDENT
Subscribed and sworn to before me
this 14 day of JUNE 2018.
\ "oh. &� racirj OOP, �-
Title
My Commission Expires , " � ' 1 � � •
A
0D
1
FAA AIP43- 19-0094.046 P-10 Waterloo Regional Airport
AECOM Project #60562796 Rehabilitate West Terminal Apron
STATEMENT OF INTENT
NONDISCRIMINATION
AND
EQUAL OPPORTUNITY STATEMENT
The Contractor does hereby certify to the Waterloo Regional Airport, that no person shall, in any way, be favored or
discriminated against because of his race, political or religious opinions and affiliations, national origins, sex, age, sexual
orientation, gender identity, disability, color, creed, marital status, employee union or association membership or office
herein.
If selected as the successful bidder, this contractor hereby agrees to file either a nondiscrimination and equal opportunity
statement and/or an Affirmative Action Program.
Improvements to the Waterloo Regional Airport consisting of
Reconstruct Taxiway C - North of Runway 12/30
Reconstruct Taxiway C - South of Runway 12/30
Bid Package # 1
L da��� CGI t5� QIJG t � GIti l
// COMPANY
EXECUTIVE OFFICER
54eNJ (f, /'04 E'
AFFIRMATIVE ACTION OFFICER
ADDRESS OF THE AFFIRMATIVE ACTION OFFICER
clot ks � l '(l P 1 �.� 64 -s-o� �y
PHONE NUMBER
FAA AIP #349-0094-046 P-11 Waterloo Regional Airport
AECOM Project #60562796 Rehabilitate West Terminal Apron
BIDDER'S INFORMATION SHEET
A. BIDDER'S CAPACITY: (Check One)
I . Individual ❑
2. Co-Partnership ❑
3. Corporation
Be (IF ITEM 2 I CHECKED, COMPLETE THE FOLLOWING)
State of J
Names and Addresses of Partners
1 .
2.
3 ,
4.
5 .
C. (IF ITEM 3 IS CHECKED, COMPLETE THE FOLLOWING)
State of Incorporation 7
/44
Names and Addresses of Officers:
President -� 4eL c�
Secretary e54e // G 6
Treasurer UL L a GCC
FAA AIP #3-19.0094-046 P- 12 Waterloo Regional Airport
AECOM Project #60562796 Rehabilitate West Terminal Apron
SYNOPSIS OF EXPERIENCE RECORD
� L (This synopsis must accompany Proposal Form.)
Name of Bidder � � ` - � (' cc V"C-j LA I `'
Business Address Pwo , 30X
Individual ( ) Partnership O Corporation O (Check One.)
Construction successfully completed within past five years similar in size, scope, and difficulty ofconstruction to the work
bid upon.
Name of Location of Amount of
Name of Owner Project Project Contract
l �Dd r TOD 380 in4eccl�� �olt_ Ks� �� T 7oO�000
2 Dfr ;K� ,, QL46&& 107 ' pT l3 Ae�AedG•.. i / S O/ Ooo
3 'S'crS e wrl \N �}e ( 1uo
� /�UG i 000
4 �� J30X GVIc ) ` NeU(41 C�V�y / �di00�
5 Ci r(L �1W�ed VV4 4u e��;� `^Vct
Number of Contract Days Actual Number of Days to
Allowed for Above Projects Complete above Project
I A)w / ao
2 90 �v
3
4 W�? 0 X20
5
(Signed) Lod3a How 4u4ic� I ✓L c
Name of Company
(By) ] 4
(TITLE)
Date ?i//i
/ Z /V
FAA AIP #3-19-0094-046 P43 Waterloo Regional Airport
AECOM Project #60562796 Rehabilitate West Terminal Apron
UTILIZATION STATEMENT
Disadvantage Business Enterprise
The undersigned bidder/offeror has satisfied the requirements of the bid specification in the following manner.
(Please mark the appropriate box)
❑ The bidder/offeror is committed to a minimum of % DBE utilization on this
contract.
❑ The bidder/offeror, while unable to meet the DBE goal of %, hereby commits to
a minimum of % DBE utilization on this contract and also submits
documentation, as an attachment demonstrating good faith efforts (GFE).
The undersigned hereby further assures that the information included herein is true and correct, and that the DBE firm(s) listed herein have agreed to
perform a commercially useful function in the work items noted for each firm. The undersigned further understands that no changes to this statementmay
be made without prior approval from the Civil Right Staff of the Federal Aviation Administration.
_ GodesLl
Bidders/Offero Firm Name
ue Date
DBE UTILIZATION SUMMARY
Contract Amount DBE Amount Contract
Percentage
DBE Prime Contractor $ x 1 .00 = $ �0
DBE Subcontractor $ x 1 .00 =
DBE Supplier $ B— x 0.60 = $ °
DBE Manufacturer $ x 1 .00 = $
Total Amount DBE $ 3 %
DBE Goal $ �0
Note: If the total proposed DBE participation is less than the established DBE goal, Bidder must provide written documentation of the good
faith efforts as required by 49 CFR Part 26.
FAA AIP #3-19-0094-046 P-14 Waterloo Regional Airport
AECOM Project 460562796 Rehabilitate West Terminal Apron
PROPOSAL ATTACHMENT: PART F — ADDITIONAL REQUIREMENTS
ITEM 3 — DBE FORMS
LETTER OF INTENT
Disadvantage Business Enterprise
(This page shall be submitted for each DBE firm)
Bidder/Offer Name: Lc' , 5C; Arw—A'Lu� y v C "
Address: / P6� j3U� yS ?
City: r' l" L15 V le State: zip: 'd5F /
DBE Firm: DBE Firm: Advanced Traffic Control , Inc.
Address: PO Box 8958
city: Cedar Rapids State: Iowa zip: 52408
DBE Contact Person: Name: Vatign Miller Phone: rt19) 396-5+269
DBE Certifying Agency: Iowa Department of Transportation Expiration Date: 12/31 /18 renewal)
Each DBE Firm shall submit evidence (such as a photocopy) of their certification status.
Classification: []Prime Contractor El Subcontractor ❑ Joint Venture
❑Manufacturer ❑ Supplier
Work item(s)
to be performed by Description of Work Item Quantity Total
DBE
1 Mobilization LS $5,000.00
2 Traffic Control LS $85000.00
1243 Pavement Markings 33675 SF $ 155878.75
Alt 1 - Item 2ra tc ontro LS $5,000.00
The bidder/offeror is committed to utilizing the above-named DBE firm for the work described above. The estimated
participation is as follows:
DBE contract amount:$ 3 3/ 0179 Percent of total contract: %
AFFIRMATION:
The above-named DBE firm affirms that it will perform the portion of the contract for the estimated dollar value as stated above.
By: —LtfPresident
(Signature) (Title)
Note: In the event the bidder/offeror does not receive award of the prime contract, any and all representations in this
Letter of Intent and Affirmation shall be null and void.
DBE
06 / 14 / 2018 07 : 57 3193520400 TIEDT NURSERY PAGE 03/ 03
LETTER OF INTENT
Disadvantage Business .Enterprise
(This page shall he submitted for each DBE f rmJ
Ridder/Offer Name:
Address; i� C'
City,_.._.� a1. r i ' .....�_ State
DHE Firm : DBE FirI d42( - U—�e
-
C}ty; _ StacI � Zip j
DBE Contact Person: Name:. Phonc: f3tf351 0"Y
DHE Certifying Agency :
b� Expiration Dats:�5/ IQ
Each V BF Firrn shall s„bOdt ioeiI ce Auch nc n phOti"'I' f of he" cert fcation
$tntus.
Classification : ❑ Prime Contractor 12�6ubcontractor ❑ 1ollaVenture
❑ Manufacturer [] Supplier
Work item(s)
to be performed by Description DF Work Item Quantity Total
DBE eGDt �m✓/G� p ,jGCG$� 17.50 ,no
77
The bidder/offeror is committed to utilizing the above-named DBE firtm for the work described above. The
estimated participation is &5 follows:
pBb contract amount: 8 17S0@co I.Percent of total contract: i00, p
AFFIRMATION:
The above-named DfIE firmatTrms that it will perform the portion of the contract for the estimated dollar value as stated
abovt:. /
By: . r�.._. .__ (fur)
rsgman,.e)
Note: In the event the bidder/offeror does not receive award of the prime contract, any and all representations in this
Letter of }.Ment and Affirmation shall be null and void,
FAA AIP 03 - 19.0094.046 .� P- lS Watcdnn Res.ianni Airport
ALC_OM Project 460562796 Rchabilimte Wc% 'fcrmianl Apron
06/ 14 / 2018 07 : 57 3193520400 TIEDT NURSERY PAGE 02/ 03
C 41NOWADOT mmawadbit,, &
SMARTER I SIMPLER I CUSTOMER pRIVI:N""
Employee Services/civil Rights Team
800 Lincoln Way, Ames, IA 50010
Phone:
15ft239� 11422/Fax: 515=811-6502
RECEIVED : danny .wagener@owadotus
January 25 , 2018 JAN 2 9 2018
Vallarie Holm
Tiedt Nursery , Ltd .
2419 E : Br€"riser Avenue
Waverly , IA 50677
RE: Affidavit of Continued DOE Certification Eligibility
Ms . Holm ,
This letter confirms receipt of your annual No Change Affidavit and supporting documentation .
The Iowa Department of Transportation (Iowa DOT) , in compliance with 49 Code of Federal
Regulations Part 26 (49 C . F . R . §§26 et seq .) , is pleased to inform you that your firm's
information has been reviewed and approved . Your firm's Disadvantaged Business Enterprise
(DBE) certification will remain valid for another year.
The DBE Directory, located at httos :l/secure iowadot qov/DBE/Directoar will continue to list
your contact information and will include the following NAICS codes and description of services
performed :
NAICS Code: 237990 , 238990, 561730
Work Types: Erosion Control (Seed , Sod, Mat, and Silt Fence) , Fencing, Herbicide
Appiication; Landscaping._(Trees_and Shrubs),_M. , i ,- _ and Retaining_Walls ; _._._.. ..._ ...
Supplier: Trees , Shrubs, Seed , Fertilizer, Erosion Control Products , Plastic
Tubing , and Fencing
As a DBE , you have the responsibility to comply with all aspects of 49 C. F. R. Part 26 ; maintain
an accurate mailing address and phone number with Iowa DOT and promptly return all
solicitation inquiries, if you have any questions , please contact this office .
Sincerely,
Danny Wegener
Civil Rights Compliance Officer
BUY AMERICAN CERTIFICATION FORM FOR MANUFACTURED PRODUCTS
(Non-building projects such as airfield/roadway construction, equipment acquisition, etc.)
As a matter of bid responsiveness, the Bidder or Offeror must complete, sign, date, and submit this
certification statement with their proposal. The Bidder or Offeror must indicate how they intend to
comply with 49 USC § 50101 by selecting one on the following certification statements. These
statements are mutually exclusive. Bidder must select one or the other ( not both) by inserting a
c�h{ee.ckmark ( ✓) or the letter 'W' .
Lh'The Bidder or Offeror hereby certifies that it will comply with 49 USC § 50101 by:
a) Only installing steel and manufactured products produced in the United States, or;
b) Installing manufactured products for which the FAA has issued a waiver as indicated by
inclusion on the current FAA Nationwide Buy American Waivers Issued listing, or;
c) Installing products listed as an Excepted Article, Material or Supply in Federal
Acquisition Regulation Subpart 25 . 108.
By selecting this certification statement, the Bidder or Offeror agrees :
1. To provide to the Owner evidence that documents the source and origin of the steel and
manufactured product.
2. To faithfully comply with providing US domestic product.
3 . To furnish US domestic product for any waiver request that the FAA rejects.
4. To refrain from seeking a waiver request after establishment of the contract, unless
extenuating circumstances emerge that the FAA determines justified .
❑ The Bidder or Offeror hereby certifies it cannot comply with the 100% Buy American
Preferences of 49 USC § 50101(a) but may qualify for either a Type 3 or Type 4 waiver under 49
USC § 50101(b) . By selecting this certification statement, the apparent Bidder or Offeror with
the apparent low bid agrees :
1 . To the submit to the Owner within 15 calendar days of the bid opening, a formal waiver
request and required documentation that support the type of waiver being requested.
2 . That failure to submit the required documentation within the specified timeframe is cause
for a non-responsive determination may result in rejection of the proposal .
3. To faithfully comply with providing US domestic products at or above the approved US
domestic content percentage as approved by the FAA.
4. To refrain from seeking a waiver request after establishment of the contract, unless
extenuating circumstances emerge that the FAA determines justified .
Required Documentation
Type 3 Waiver - The cost of the item components and subcomponents produced in the United
States is more that 60% of the cost of all components and subcomponents of the "item" . The
required documentation for a type 3 waiver is:
a ) Listing of all product components and subcomponents that are not comprised of 100% US
domestic content ( Excludes products listed on the FAA Nationwide Buy American Waivers
Issued listing and products excluded by Federal Acquisition Regulation Subpart 25. 108;
products of unknown origin must be considered as non-domestic products in their entirety) .
FAA AIP #3- 19-0094-046 P-16 Waterloo Regional Airport
AECOM Project #60562796 Rehabilitate West Terminal Apron
b) Cost of non-domestic components and subcomponents, excluding labor costs associated
with final assembly at place of manufacture.
c) Percentage of non-domestic component and subcomponent cost as compared to total
"item" component and subcomponent costs, excluding labor costs associated with final
assembly at place of manufacture .
Type 4 Waiver — Total cost of project using US domestic source product exceeds the total project
cost using non-domestic product by 25%. The required documentation for a type 4 of waiver is:
a) Detailed cost information for total project using US domestic product.
b) Detailed cost information for total project using non-domestic product.
False Statements: Per 49 USC § 47126, this certification concerns a matter within the jurisdiction of
the Federal Aviation Administration and the making of a false, fictitious or fraudulent certification
may render the maker subject to prosecution under Title 18, United States Code.
Date nature
Company Name Title
FAA AIP #3- 19-0094-046 P- 17 Waterloo Regional Airport
AECOM Project #60562796 Rehabilitate West Terminal Apron
Buy America Waiver Request
Title 49 U.S.0 Section 50101 (b)
For Airfield Development Projects funded under the
Airport Improvement Program
Revised 4/19/2010
Instructions for Permissible Waivers
Section 50101(b)(I) Waiver:
The bidder may not request a waiver based upon the best interests of the public. The FAA Office of Airports publishes such waivers at:
http:// vw v,faa.gov/airports/aip/proourement/fedeml_contract_provisions/media/buy_american_waiver.xls
Section 50101 (b)(2) Waiver:
The bidder may not request a waiver based upon insufficient supply of U.S. manufactured. The FAA Office of Airports publishes such
waivers at:
http://wvnv,faa.gov/airports/aip/procurement/federal_contract.provisions/media/buy_american_waiver.xis
Section 50101(b)Q) Waiver:
The bidder may request a waiver if 60% or more of the components are produced in the United States and final assembly
occurs in the U.S. Bidder is hereby advised that the Owner's approval with the bidder's waiver request is contingent upon
FAA approval.
L "Equipment" in Section 50 10 1 shall mean the following:
a) Individual type "L" items (Airfield Lighting Equipment) as listed in FAA Advisory Circular 150/5345-53.
b) Individual bid items as established within FAA Advisory Circular 150/5370-10. The bid item application may not be applied for
the type "L" items listed in AC 150/5345-53.
c) A waiver request may only address one specific equipment item. Submit separate requests for each equipment item for which a
waiver.
d) Items listed under the Nationwide Waiver do not require further review. Please refer to the following webpage:
http://www.faa.gov/airports/aip/procurement/federal_contracl_provisions/media/buy_american_waiver.xls
2. The bidder must base the U.S. percentage upon the value that results from completing a component cost calculation table similar to the
attached format. Bidder shall avoid mere pro forma efforts to establish the waiver request percentage. The Bidder must submit the
component cost calculation table as an attachment to the waiver request.
3. Componeruxsubcomponents are the material and products composing the "equipment".
4. The final assembly of the AIP-funded "equipment" must be within the USA (Section 50101(b)(3)(B)). Final assembly is the
substantial transformation of the components and subcomponents into the end product.
S. All steel used in the "Equipment" must be produced in the United States.
6. The Buy American requirements apply to all tier contractors and subcontractors. All contractors/subcontractors are required to provide
appropriate documentation that indicates origin of manufacturer and percentage of domestic made product.
7. The bidder is hereby advised there is no implied or expressed guarantee that a requested waiver will be issued by the Federal Aviation
Administration (FAA). Less than 60% USA component/subcomponent proposed for this facility CANNOT be waived. Products made
with foreign steel are not eligible for a waiver.
S. North America Free Trade Act (NAFTA): Free Trade Agreements such as NAFTA do not apply to the AIP. Products and material
made in Canada or Mexico must be considered as foreign made products.
9. Preparation of a Component Cost Calculation Table is not necessary for equipment listed on the FAA national listing:
http://wvnv.faa.gov/airports/aip/procuremetit/federal_contract_provisions/media/buy_american_waiver.xls.
Bidder however shall submit a listing of any equipment it proposes to install on the project that is included on the National Buy
American conformance list.
Instructions for Section 50101 (b)(4) Waiver:
1 . The bidder may request a waiver if application of Buy America preferences results in a 25% cost increase in
the overall project. This waiver is rarely applicable. Consult the Owner before making this request.
FAA AIP #3- 19-0094-046 P- 18 Waterloo Regional Airport
AECOM Project #60562796 Rehabilitate West Terminal Apron
Buy America Waiver Request
Title 49 U.S.0 Section 50101 (b)(3)
For Airfield Development Projects funded under the
Airport Improvement Program
COMPONENT COST CALCULATION TABLE (Type 3 Waiver)
• lit two ofeoaPle/mAehu table, bidder may prepare asyreadslxelllm/addressee d+e .rame lrJ nrtatMn and mlculalim+saspresentedherein.
• Preparation of a ConiiUmunal7mlCalculation Table is+mineressaryforequantem listed on YIN FAA +mtlmndlisd+g:
bow�14va.a%tufeikral tvailract priellsionielediahry allarrawl wall er.rh.
• the mmpmrenl breakout shall be along major mmponenlr ofl/m equinnenl. Submit sepmme ealadm;m/for each different equipment types. [)a not canbhol the wMimPleill cast
ealcubstans eiidl(rent types ofeglripn+e .
• f Ai held de+elrgntnaprojecn, egnipmnd is defined as tlm "1." items (Ahfreld Lighting Bp+l as lishdnr FAAAdvisory Cavalar 150/53 /543 and the b) bd;vidral bid items as
sadiidedwithin FAA Adrismy Covithar 15015370-10. the tndividuld bid Beat methwlmay nal he pploollo the "l." IyBe hems.
• B, wahmludpersoo sinlladell wider sig+mnrre mddate that the s++hmitKdnf inahm+ is accurme And complete.
Equipment Type:
Cost or Foreign Manufactured Cost of USA MABU lerlured
Com onen"ubcom oneaa NnmeorMevuraehner country ororiftin Com onems1subcom onemts Com veats/Subcom ommft
Sam of US Manufactured Component/Subcomponent Costs:
Sum of all Equipment Components and Subcomponents:
Percentage of Equipment Components Manufactured in the United States: /OD X
Place of Final Assembly:
Certification Sivnature
Bidder hereby requests a waiver to Buy America preferences based upon Section 50101(b)(3) for the equipment identified above. The bidder certifies that /,X/ % of
the cost of components and subcomponents comprising the equipment are produced in the United Slates and that final assembly occurs within the United States.
I hereby certify the above information is accurate and complete.
Lad Sty cLvto4rAitf t 6 �rY'/�
Bidder's Film Name Date.
s;
FAA AIP 8349-0094-046 P49 Waterloo Regional Airport
AECOM Project 9 60562796 Rehabilitate West Terminal Apron
Buy America Conformance Listing
Title 49 U.S.0 Section 50101 (b)
For Airfield Development Projects funded under the
Airport Improvement Program
Preparation of a Component Cost Calculation Table is not necessaryfar equipment listed on the FAA national listing:
h /% n tv fat ¢ov/ai p is/ p/proc remenUlede al contractprovisionsbnedia/buip anierican ivaiverxis
Bidder shall submit a listing of equipment it proposes to install on the project that is included on the current National Boy
American conformance list.
Equipment T e Name of Manufacturer Product Number
/
oaltAd �
n04
Certification Signature:
Bidder hereby certifies that the above listed equipment,. which we propose for installation on the subject
project, are on the current National Buy America Conformance list as established at:
ham ://www.faa. aov/airuorts/aipprocuremenl/federal contract provisions/media/buy american waiver.xls
I hereby certify the above information is accurate and complete.. q
Bidder's Firm (Van a Date
Sime e
FAA AIP #3- 19-0094-046 P-20 Waterloo Regional Airport
AECOM Project # 60562796 Rehabilitate West Terminal Apron
BID BOND
KNOW AIS, MEN BY THESE PRESENTS, that we
Lodge Construction, Inc. asPdncip4Md
North American Specialty Insurance Company as Surety areheldand fumlybound
unto the Waterloo Regional Airport, 2790 Livingston Lane, Waterloo, Iowa, hereinafter call"Owner", in thepenal sum of
Five Percent of Amount Bid --------------------------------------------------- Dollars ($ 5
lawful money of the United States, for the payment of which sum will and truly be made, we bind ourselves, our heirs,
executors, administrators, andsuGeessorsJointly and severally, firmly by thesepresents. The condition of this obligation
is such that whereas the Principal has submitted the accompanying bid, dated June 14 ,201Q
for Rehabilitate West Terminal Apron, at the Waterloo Regional Airport, Waterloo, Iowa, FAAAIP Project No. 3-19-
0094-046.
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
famishing 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 ofthis
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 accept such bid or execute such
Contract; and said Surety does hereby waive notice of any such extension.
1N WITNESS WHEREOF, the Principal and the Surety, have hereunto set their bands and seals, and such of them as are
corporations, have caused their corporate scale to be hereto affixed and these presents to be signed by their proper officers
this 30thdayof May A.D., 2018.
(Seal)
Witness
Principal Lodge Construction, Inc.
By
(Title)
(S
u can Specialty Insurance Ccmpany
ner (Attorney-In-Fact)
Attach Power-Of-Attomey
FARM #3-19-0094-046 P-8 Waterloo Regional Airport
A13COM Project #60562796 Rehabilitate West Terminal Apron
SWISS RE CORPORATE SOLUTIONS
NORTH AMERICAN SPECIALTY INSURANCE COMPANY
WASHINGTON INTERNATIONAL INSURANCE COMPANY
WESTPORT INSURANCE CORPORATION
GENERAL POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, THAT North American Specialty Insurance Company, a corporation duly organized and existing under
laws of the State of New Hampshire, and having its principal office in the City of Overland Park, Kansas and Washington International 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 Overland
Park, Kansas, and Westport Insurance Corporation, organized under the laws of the State of Missouri, and having its principal office in the City of
Overland Park, Kansas each does hereby make, constitute and appoint:
JAY D. FREIERMUTH, CRAIG.E, HANSEN, BRIAN M. DEIMERLY, SHIRLEY S . BARTENHAGEN, CINDY BENNETT, ANNE CROWNER,
TIM MCCULLOH„ STACY VENN, DIONE R. YOUNG, and WENDY ANN CASEY JOINTLY OR SEVERALLY
Its true and lawful Attorney(s)-in-Pact, to make, execute, seal and deliver, for and on its behalf and as its act and deed, bonds or other writings
obligatory in the nature of a bond on behalf of each of said Companies, as surety, on contracts of suretyship as are or may be required or permitted by
law, regulation, contract or otherwise, provided that no bond or undertaking or contract or suretyship executed under this authority shall exceed the
amount of: ONE HUNDRED TWENTY FIVE MILLION ($ 125,000,000.00) 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 North American Specialty Insurance Company and Washington International Insurance Company at meetings duly called and held
on March 24, 2000 and Westport Insurance Corporation by written consent of its Executive Committee dated July 18, 2011 .
"RESOLVED, that any two of the President, any Senior Vice President, any Vice President, any Assistant Vice President,
the Secretary or any Assistant Secretary be, and each or any of them hereby is authorized to execute a Power of Attorney qualifying the attorney named
in the given Power of Attorney to execute on behalf of the Company bonds, undertakings and all contracts of surety, and that each or any of them
hereby is authorized to attest to the execution of any such Power of Attorney and to attach therein the seal of the Company; and it is
FURTHER RESOLVED, that the signature of such officers and the seal of the Company may be affixed to any such Power of Attorney or to any
certificate relating thereto by facsimile, and any such Power of Attorney or certificate bearing such facsimile signatures or facsimile seal shall be
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."
\§'NruALITYj JJiii. �a�`° ptONgC �°tea ��r,MW
02' PPOR,j��G a. :'4 1.W
y Anderson, eosor sec resr ento es international Insurance Companya. X
2/ F •. Steven P. , ngton
y` g2c SEA a & Senior Vice President of Na h American Specialty Insurance Company E s�l it
= �+ SEAL : m =_ § �i : & senior Vice President of Westport Insurance Corporation
€ f—
cea
w:, 1973 "
auimmms�a"W Mike A. Ito,
Senior Vice President nnvaahingmn International msnran« cnmpnnr its
& Senior Vice Pmsldent of North American Specialty Insurance Company
& Senior vice President of Westport Insurance corporation
IN WITNESS WHEREOF, North American Specialty Insurance Company, Washington International Insurance Company and Westport
Insurance Corporation have caused their official seals to be hereunto affixed, and these presents to be signed by their authorized officers this
this 3rd day of November 120 17
North American Specialty Insurance Company
Washington International Insurance Company
State of Illinois Westport Insurance Corporation
County of Cook SS:
On this 3rd day of November , 20 17, before me, a Notary Public personally appeared Steven P. Anderson , Senior Vice President of
Washington International Insurance Company and Senior Vice President of North American Specialty Insurance Company and Senior Vice President of
Westport Insurance Corporation and Michael A. Ito Senior Vice President of Washington International Insurance Company and Senior Vice President
of North American Specialty Insurance Company and Senior Vice President of Westport Insurance Corporation, personally known to me, who
being by me duly sworn, acknowledged that they signed the above Power of Attorney as officers of and acknowledged said instrument to be the
voluntary act and deed of their respective companies. _
OFFfCWL SEAL \/ \
M. KENNY
Notary Public • slate of Illiladi
MrC 1v0aion port M. Kenny, Notary Pu lie i
I, Jeffrey Goldberg the duly elected Vice President and Assistant Secretary of North American Specialty Insurance Company, Washington
International Insurance Company and Westport Insurance Corporation do hereby certify that the above and foregoing is a true and correct copy of a
Power of Attorney given by said North American Specialty Insurance Company, Washington International Insurance Company and Westport Insurance
Corporation which is still in full force and effect.
IN WITNESS WHEREOF, I have set my hand and affixed the seals of the Companies this 30th day of /J May 2018 ,
Jef rey Goldberg, Vice President & Assistant secretary of washington International nsurance Company &
Nnnl, American Snecialtv lasumnce Comnanv & Vice President & Assistant Secretary of Westport Insurance Corporation