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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withdrawn, the undersigned agrees to execute and deliver an agreement in the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 S �'
Dollars ($ ) in the form of D tzh Ror/d
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 Bidder Status Form.
7. The bidder is prepared to submit a financial and experience statement upon
request.
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
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:
FORM OF BID CONTRACT NO. 958 Page 2 of 3
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.
4AIP4 Cmcv je, Iv.L. 10—+F Ig
(Name of Bidder) (Date)
BY: Title U W N R
Official Address: (Including Zip Code):
X18 5 CA'WA+UVVA R -k .
I.R.S. No,
FORM OF BID CONTRACT NO, 968 Page 3 of 3
ji NON -COLLUSION AFFIDAVIT OF PRIME BIDDER
State of I VV A' )
)ss
County of 1 to 9V & 1 tAl }
R"C,k.,VA 0 0 CA1 -. > , being first duly sworn, deposes and says that: p I
1. He is u (Owner, Partner Officer Representative. or Agent) , of M i Ci W 2 A CO w t >VV
, 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)
Owner
`Title
Subscribed and sworn to before me this + Vt day of
�'u�rr � , 201,.
WtAA-"�
Title
My commission expires
�. AMANDA M. WESSEL3
i Notarial Seel s State of Iowa
" COmmisaion Nu r 712724 '
pow MY CpnraeipiEtea. -zii�
Bidder Status Form
To be completed by all bidders Part A
Please answer "Yes" or "No" for each of the following:
�] Yes ❑ No 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).
Yes ❑ No My company has an office to transact business in Iowa.
Yes ❑ No My company's office in Iowa is suitable for more than receiving mail, telephone calls, and e-mail.
Yes ❑ No My company has been conducting business in Iowa for at least 3 years prior to the first request for
bids on this project.
Yes ❑ No 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:
(,j
Dates: / l y l 1� to MVIA:� l Address: 1'J p t / A, -i h A vVA R�
City, State, Zip: Peo,s6 i A, r) -o °2'
Dates: q/�_ _/ i�7 to Address: � uquq }Nyo\Vlnrre- C{
City, State, Zip: RoSri 1 A -'Z-0 \,f, Fs
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:
2. Does your company's home state or foreign country offer preferences to resident bidders, resident labor ❑ Yes ❑ No
force preferences or any other type of preference to bidders or laborers?
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: NijvA14 4"tVe1 - 1yit:�
Signature:, t�ez Date:
You must submit the completed form to the governmental body requesting bids per 875 Iowa Administrative Code
Chapter 156, This form has been approved by the Iowa Labor Commissioner.
309£001 (09-15)
Worksheet: Authorization to Transact Business
This workshdet maybe used to help complete PartA of the Resident Bidder Status form. If at least one of the following
describes your business, you are authorized to transact business in Iowa.
KI Yes ❑ No My business is currently registered as a contractor with the Iowa Division of Labor.
M Yes ❑ No My business is a sole proprietorship and I am an Iowa resident for Iowa income tax purposes.
�]- Yes ❑ 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.
Yes ❑ 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.
❑ Yes F�9 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.
❑ Yes] 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.
❑ Yes No
My business is a limited liability partnership which has filed a statement of qualification in a
state other than Iowa, has fled a statement of foreign qualification in Iowa and a statement of
cancellation has not been filed.
❑ Yes 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.
❑ Yes ® No
My business is a limited partnership or a limited liability limited partnership whose certificate of
f
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.
❑ YesNo
My business is a limited liability company whose certificate of organization is filed in Iowa and has
not filed a statement of termination.
❑ Yes 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.
309-6001 (09-15)
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7507594800
TRANSACTION REPORT
I:e*: E0M, *Fk
P.01/01
OCT/03/2018/WED 12:04 PM
DATE START T. RECEIVER COM.TIME PAGE TYPE/NOTE FILE
OCT/03 11:57AM
13193520400
0:00:23
1
*MEMORY OR
SG3
1359001
11:58AM
15635685052 -CiA (cX
0:02:00
*MEMORY FAIL00(OOOO)
1359002
12:OOPM
15639332094
0:00:30
1
*MEMORY OR
G3
1359003
12:01PM
15152824620
0:00:48
1
*MEMORY OE
G3.
1359004
TOTAL
0:03:41
3
TRANSMISSION ERROR OCCURRED AT SOME RECEIVERS.
PLEASE GIVE THIS TRANSACTION REPORT TO SENDER.
11"RETE INC.
9835 Cottingham Rd. Peosta, IA 52068 Ph: (563) 845-0947 Fax: (563) 583-1007 Email: office@midwest<oncrete.net
10-3-18
Attn: Project Estimators
Will you be quoting: FY 2019 Sidewalk Repair Assessment Program —Zone 8
Contract No. 958
City of Waterloo, IA
YES NO
Please Circle one and fax back to 563-583-1007
Thank you,
Midwest Concrete Inc.
KNOW ALL MEN BY THESE PRESENTS, that we, Midwest concrete Inc
as Principal, and West Bend Mutual Insurance
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% l 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 4th day of
October ,20 18 ,for FY 2019 Sidewalk Repair Assessment Program -Zone 8
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 accept
such Bid or execute such contract; and said Surety does hereby waive notice of any such extension.
IN WITNESS WHEREOF, the Principal and the Surety, have hereunto set their hands and seals, and such
of them as are corporations, have caused their corporate seals to be hereto affixed and these presents to be
signed by their proper officers this 4th day of October , A.D. 201 s
Midwest concrete Inc (Seal)
Principal
By gy'k &/:�
4 v�UWK'�- 1t4WZ (title)
West bend Mutual Insurance Company (Baal)
Witness Surety
1,� ry�,
Witness Kim Hess Attorney-in-fact
i VEST BEND
A MUTUAL INSURANCE COMPANY'
POWER OF ATTORNEY
THE SILVER LINING'r'
Bond No. 2395424
Know all men by these Presents, That West Bend Mutual Insurance Company, a corporation having its principal office in the City of West
Bend, Wisconsin does make, constitute and appoint:
KIM HESS
lawful Attorney(s)-in-fact, to make, execute, seal and deliver for and on its behalf as surety and as its act and deed any and all bonds,
undertakings and contracts of suretyship, provided that no bond or undertaking or contract of suretyship executed under this authority
shall exceed in amount the sum of: Seven Million Five Hundred Thousand Dollars ($7,500,000)
This Power of Attorney is granted and is signed and sealed by facsimile under and by the authority of the following Resolution adopted
by the Board of Directors of West Bend Mutual Insurance Company at a meeting duly called and held on the 2151 day of December,
1999.
Appointinen t ofAttorney-In -Fact. The president or any vice president, or any other officer of West Bend Mutual Insurance
Company may appoint by written certificate Attorneys -In -Fact to act on behalf of the company in the execution of and attesting of
bonds and undertakings and other written obligatory instruments of like nature. The signature of any officer authorized hereby
and the corporate seal maybe affixed byfacsimile to any such power ofattorney or to any certificate relating therefore and any
such power of attorney or certificate bearing such facsimile signatures orfacsimile seal shall be valid and binding upon the
company, and any such power so executed and certified by facsimile signatures and facsimile seal shall be valid and binding upon
the company in the future with respect to any bond or undertaking or other writing obligatory in nature to which it is attached.
Any such appointment maybe revoked, for cause, or without cause, by any said officer at any time.
In witness whereof, the West Bend Mutual Insurance Company has caused these presents to be signed by its president undersigned
and its corporate seal to be hereto duly attested by its secretary this 22nd day of Se tember, 2017.
Attest %aA1 t;qh'o h' MANIC aA ;f ; "�'oi:'IV "s�'"9ic. (a, a.
Christopher C. Zivygart -So ronPoaArF $`, Kevin A. Steiner
Secretary 1,� SEAL Chief Executive officer/ President
State of Wisconsin
County of Washington
On the 22nd day of September, 2017, before me personally came Kevin A. Steiner, to me known being by duly sworn, did depose and
say that he resides in the County of Washington, State of Wisconsin; that he is the President of West Bend Mutual Insurance Company,
the corporation described in and which executed the above instrument; that he knows the seal of the said corporation; that the seal
affixed to said instrument is such corporate seal; that is was so affixed by order of the board of directors of said corporation and that he
signed his name thereto b like order.
9 Y 'J `i. IiEPJ[:OL2'. ._lAtchun
'vu rney JuSporaAttorney
`•�rFOF iscc�'�:' Notary Public, Washington Co., WI
My Commission is Permanent
The undersigned, duly elected to the office stated below, now the incumbent in West Bend Mutual Insurance Company, a Wisconsin
corporation authorized to make this certificate, Do Hereby Certify that the foregoing attached Power of Attorney remains in full force
effect and has not been revoked and that the Resolution of the Board of Directors, set forth in the Power of Attorney is now in force.
Signed and sealed at West Bend, Wisconsin this 4th day of October 2018
� r/l
o.toRPoaArp'i
SEALF f. Heather Dunn
Vice President— Chief Financial Officer
Notice: Any questions concerning this Power of Attorney may be directed to the Bond Manager at NSI, a division of West Bend
Mutual Insurance Company.
1900 S. 1811, Ave. West liatd, W1 53095 1 ph (262) 3311-6430 1 1-800-236-5004 1 Fax (262) 338-5058 1 www.thesilvedining.com