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Proposal for Contract SECTION C PROPOSAL Contract BID TO: Monroe County Board of Commissioners c/o Purchasing Department Public Service Building, Room 002 5100 College Road, Stock Island KEY WEST, FLORIDA 33040 BID FROM: COM~41INITY A~P~AI T r.ORP. 14005 N.W. 186 STREET HIALEAH, FL 33018 Submitted (Date): frJfJy /q6 I f The undersigned, as Bidder, hereby declares that he has examined the site of the work and informed himself fully in regard to all conditions pertaining to the place where the work is to be done; that he has examined the plans and specifications for the work and contractual documents relative thereto, and has read all bid documents, Contract Documents, General Provisions, Special Provisions and Specifications furnished; and that he has satisfied himself relative to the work to be performed. The Bidder proposes and agrees, if this proposal is accepted, to contract with the Monroe County Board of Commissioners, in the form of contract specified, to furnish all necessary materials, equipment, machinery, tools, apparatus, means of transportation and labor necessary' to and to complete the construction of: Resurfacing Taxiways and Hangar Access Marathon Airport Monroe County, Florida in full and complete accordance with the shown, noted, described and reasonably intended requiremE~nts of the plans, specifications and contract documents to the full and entire satisfaction of the Monroe County Board of Commissioners, with a definite understanding that no money will be allowed for extra work except as set forth in the attached Contract Documents for the unit prices listed opposite each item. I ~ 'i ( 1,-, It is agreed that the description under each item, being briefly stated, implies, although it does not mention, all incidentals and that the prices stated are intended to cover all such work, materials and incidentals as constitute Bidder's obligations as described in the specifications and any details not specifically mentioned, but evidently included in the contract shall be compensated for in the item which most logically includes it. The quantities for bid items listed on the attached Schedule of Bid Item sheets are estimated quantities only for the purpose of comparing bids. Any difference between these estimated quantities and actual quantities required for construction will not be allowed as a basis for claims by the Contractor for extra compensation. Compensation will be based on the unit prices and actual construction quantities and may be modified as stipulated by Sections 20-05 and 90-03 of the General Provisions. The bidder further proposes and agrees hereby to commence the work with an adequate force, plant and equipment at the time stated in the notice to the Contractor from the Owner to proceed and fully complete performance within the time period stated in the Instructions to Bidders from and after the date stated in the Notice-to-Proceed. The undersigned further agrees that in case of failure on his part to execute the said contract and the bond within ten (10) consecutive calendar days after written notice being given of the award of the contract, the check or bid bond in the amount as specified herein accompanying this bid and the monies payable thereon, shall be paid into the funds of the Monroe County Board of Commissioners as liquidated damages for such failure; otherwise, the check or bid bond accompanying this proposal shall be returned to the undersigned. Attached hereto is a certified check on the Bank of of 5 L!r~ {0} & d) ( f J?l 6L{L11+ dollars ($ made payable to the Monroe County Board of Commissioners. I acknowledge receipt of Addenda No.(s) f . I have included Pages 1-13 through 1-38 of the Bid Proposal which entails the Proposal Form./ , Schedule of Bid Items :./ , Prime Contractor's Qualifications ,/ 1 the Lobbying and Conflict of Interest Clause v , the Drug-Free Workplace Form ../' , the Bid Bond J , Acknowledgment of Addenda / , Bidder's Affidavit of Compliance with FlojcJa Trench Safety ActJ , Sworn Statement Under Ordinance NO.1 0-1990 . Also include a copy of valid Contractor's licenses v or a bi~nd for the sum ~o ) ./ r) (Checkmark items above as a reminder that they are included.) ! i.-i Mailing Address: Phone Number: Date: c,!;l,(qe, ( - r.ClMMIINITY ASPHALT CORP. 14005 N.W. 186 STREET' HiAlEAH, FL 33018 / ... ..., (305) e29-0700 Signed: Witness: ~NutZ (Name) PRESIDENT (Title) li1?--' (Seal) i -1 S SCHEDULE OF BID ITEMS BIDDER.: ~OMMUNITY ASPHALT CORP. AIRPORT NAME: Marathon Airport PFC APP. NO. ~ A.I.P. NO. 312004413 WPI PROJECT NOS. 6826792 & 6826793 PROJECT DESCRIPTION: Resurfacing Taxiways and Hangar Access - Marathon Airport DATE v>(> /'1 '!J Item & Unit Spec. Item Description & Unit Estimate Price in Extended No. Price Bid in Words Unit d Numbers Total Quantity 1 MObiliZ~ ~gv 'tAJJ) L.S. 1 ft1ooo~ P-101-2.1 Dollars W {XX)'!! at ~J and Cents 2 Asohalt Pavement Millina (0" to 2") S.Y. 17,000 If.Z 4~o~ P -1 50-4. 1 at -tw () . Dollars and (' /I """-Jt^1 .J..-\ "e.. Cents I 3 Removal of EXistin~pavement S.Y. 36,500 ()/~ /;!rho tJ. P-151-4.1 at ~ Dollars and ~~ Cents I 4 Clearinq and Grubbing L.S. 1 P-150.4.2 ~ ,"vlb ttiN~,..a tJt\ Dollars t1.fXX)re '1. rm o!? \ and Cents 5 Unclassified Excavation C.Y. 13,500 P-152-4.'1 fJO!!- 0 . lllblOOO. - at e.\~~\ Dollars and D Cents 6 6" Limerock Base Course C.Y. 2,000 P-211-5.'1 ~ 00 I (J),ood ~ at ~No Dollars 0- and Cents 7 Bituminous Concrete Surface Course TON 5,400 P-401-8.1 ( 1/2" Maximum Aqqreqate) 01~ tJfoOt at ~\ -\-+1 ~~~ Dollars / and Cents 8 Bituminous Prime Coat GAL. 2,500 0 P-602-5.1 'Z 0_ t3C())~ J ~~~~j-_______j}~~===-==~_==- D~~~~~ , I oS 1-"1 G Item & Unit Spec. Item Description & Unit Estimate Price in Extended No. Price Bid in Words Unit d Numbers Total Quantity 9 Bituminous Tack Coat GAL. 3,500 2~ :fpod~ P-603-5.1 1-VJ 0 at Dollars and \:>0 Cents 10 Temporary initial markinq (yellow or white) S.F. 4,800 D~ P-620-5.1 without reflectivp media at 50% application rate at Dollars and Cents 11 Final Marking (Waterborne) SF 7,800 [tf P-620-5.:~ at Dollars and \vf!., Cents 12 Trench Drains L.F. 50 0-750-7:1 at CM~ ~ s..j ~t'1-- Dollars lboDg. and NQ Cents 13 New 1/C NO.8 Liqht Cable L-824, 5KV L.F. 350 L-108-5.1 at Dollars and Cents 14 L.F. 315 L-108-5.2 t7~ (eR Dollars Cents 15 New concrete encased 2W4 duct. PVC L.F. 55 ~lZ o~ L-110-5.1 :~:e~~'(W-rWD Dollars Cents 16 EA. 3 Of; ~O L-125-5.1 00 Dollars ~ 70" [)--- Cents 17 Taxiway stake mounted edge liqhts removal EA. 2 L-125-5.2 and reinstallation of existing taxiway stake 4'oD~ mOUn~dqe I~sd 4 Dollars at ."..\1 ~ and N Cents 18 Taxi Retroreflective Siqns EA. 2 L-125-13.1 ~,o ~Oll~ ~ J 2uJOoQ ~CWo Dollars and Cents , . t...fJ ~--~ "1 ! Item & Unit Spec. Item Description & Unit Estimate Price in Extended No. Price Bid in Words Unit d Numbers Total Quantity 19 Type I Semi-flush Marker (Style II) EA. 62 b OJ!. 111 L-853-6.1 . at ~~~ Dollars and Cents 20 Tree Relocation EA. 17 ?ro~ 0 S-580-13.1 at=fh~ ~ot1veJ '7 (DO Dollars and Cents TOTAL BID ITEMS 1 THROUGH 20: q.? W ~\k:. ~VtJ VeJ ~QAlt1 ~vuz, ~O\I~N ytv~ kv~~J t~l1tl two Jt>(ta.Y~ C(~ 00 ~N13 I -" - I (:, SECTION D BID BOND Contract KNOW ALL MEN BY THESE PRESENTS, that we Community Asphalt Corp. as Principal, hereinafter called the Principal, and Reliance Insurance Campa a corporation duly organized under the laws of the State of Florida, as Surety, hereinafter called the Surety, are held and firmly bound unto the Monroe County Board of Commissioners as Obligee, hereinafter called the Obligee, in the sum of Five Percent of Amount Bid dollars ($ 5% ) for the payment of which sum well and truly to be made, the said Principal and the said Surety bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents. WHEREAS, the Principal has submitted a bid tor: Resurfacing Taxiways and Hangar Access Marathon Airport Monroe County, Florida NOW, THEREFORE, if the Obligee shall accept the bid of the Principal shall enter into a contract with the Obligee in accordance with the terms of such bid and give such bond or bonds as may be specified in the bidding or Contract Documents with good and sufficient surety for the faithful performance of such contract and for the prompt payment of labor and material furnished in the prosecution thereof, or in the event of the failure of the Principal to enter such contract and give such bond or bonds, if the Principal shall pay to the Obligee the difference not to exceed the penalty hereof between the amount specified in said bid and such laf!~er amount for which the Obligee may in good faith contract with another party to perform 1the work covered by said bid, then this obligation shall be null and void, otherwise to remain in full force and effect. PROVIDED further, that if the Principal shall submit the apparent lowest bid acceptable to the Obligee but shall fail to meet DBE goals as set forth in the bid specifications, then Principal shall, upon request of the Obligee, submit to Obligee such additional evidence of Principal's good fai1h efforts to meet such goals in the manner and within the time required in such specifications. Failure to supply such information as required shall result in a forfeiture of this bid bond in the same manner and to the same degree as though Obligee had accepted Principal's bid and Principal had thereafter failed or refused to enter into the contract with Obligee as set forth in the immediately preceding paragraph. I - I 'C' Signed and sealed this 28th - \ Ct~n~d by: ~j(L7 W Charles J. Nielson day of MAy . 199& 1998. Community Asphalt Corp. (Principal) (Seal) J Reliance Insurance Company (Surety) (Seal) By: -Jt..w;CUca<L<J (Title) Mary C. Aceves, Attorney-in-Fact All bonds must be signed by a Florida resident agent with a legal street address; Post Office boxes Glre not acceptable. Bid will not be considered unless the bid bond is signed by both Principal and Surety. 1-20 I I "I I I I: I =I ;f~t3 =lll;ll.: I f-'1'rlr03.I],'.I:m': U...'f'.t03.lllI:ll ;l::j II :ntl;<<'l;{lllj~III'] ~ l'.'j: III =I ;1.';J ::j; RELlAl'CE SlTRETY COMPANY UNITED PACIFIC INSURANCE COMPANY I flik~ RELIANCE INSURANCE COMPANY RELIANCE NATIONAL INDEMNITY COJ\.lPANY ADMINISTRA TIVE OFFICE. PHILADELPHIA. PENNSYLVANIA POWER OF A TIORNEY KNOW ALL MEN BY THESE PRESENTS. that RELIANCE SURETY COMPANY is a corporation duly organized under the laws of the State of Del- aware. and that RELIANCE INSURANCE COMPANY and UNITED PACIFIC INSURANCE COMPANY. are corporations duly organized under the laws of the Commonwealth of Pennsylvania and that RELIANCE NA TIONAl INDEMNITY COMPANY is a corporation duly organized under the laws of the State of WisconSin Iherein collectively called "the Companies"' and that the Companies by virtue of signature and seals do hereby make. constitute and appoint Chari.. J. Nielson, Charles D. Nielson. Mary C. Aceves, Warren M. Alter. laura l.e ligon., of Mlamllak... Florid. their true and lawful Attorney(sl-in-Fact. to make. execute. seal and deliver for and on their behalf. and as their act and deed any and all bonds and undertakings of suretyship and to bind the Companies thereby as fully and to the same extent as If such bonds and undertakings and other writings obligatory In the nature thereof were signed by an Executive Officer of the Companies and sealed and attested by one other of such officers. and hereby ratifies and confirms all that their said Attorney(s).in-Fact may do in pursuance hereof. This Power of Attorney is granted under and by the authority of Article VII of the By-laws of RELIANCE SURETY COMPANY RELIANCE INSURANCE COMPANY. UNITED PACIFIC INSURANCE COMPANY, and RELIANCE NATIONAL INDEMNITY COMPANY which provisions are now in full force and effect, reading as follows: ARTICLE VII. EXECUTION OF BONOS AND UNOERT AKINGS 1 The Board 01 Directors, the Pre.Wjent. the Chairman of the Board. any St!nior Vice President. InV Vice President Of Assistant Vie. Prestdent Of other OHIC8f desu;ln.ted bv the Board of DIrectors shall have pOwer and auth()(ity to 1.1 apJ)Ofnt Anorney(sHn.Fact and to authorize them to e)(ecute on behalf of the CQ(T"lpanv. bond. and undertlkiogs. recognIzances. contracts 01 tndemnt.Cy and other wnttngs obligatory In the nature thereof, and (b) to remove .ny such Attorney(s).in-FICt It any time.nd revoke the power Ind authonty given to them. 2. Anorneylsl'fn-Fact shall have powee' and IUthority, subject to the terms and limitations of the POWef of Attorney iSSUed to them, to e)(ecut, deliver on behalf of the Company. bonds and undertakIngs. recogniZi!nces. conUects of indemntty and other writings obligatory in the nature thereot. The corporate sa.. ia not nece.uary tor the validity of any bonds and undertakings. recognizances. contracts of Indemnity and otllet' writings obligatory in the nature thereof. J Altorney(sl-I,"l.FaC1 shall have power and authority to 8)(ecute aHida....its required to be attached to bonds. recogniZIf\Ces, contracts of Indemnity or other conditional or obllgatorv undertak.lngs and th€y shall also haVE! power and authority to certify the flnanei.1 statement of the Company and to COpHlS of the By-laws of the Company ()( Iny arttcle or sectIon thereol This Power of Attorney IS sIgned and sealed by faCSimIle under and by authority of the following resolution adopted by the Executl..... and Finance Commm&es of (he Boards of Directors of RelIance Insurance Company, Unl{e<r Pacific Insurance Company .nd Reliance NatIonal Indemnity Company by Unanimous Consent dated u of February 28. 1994 and by the Execullv, and Financial Committee of the Board of Directors of Reliance Surety Company by Unanimous Consent dated as of March 31, 1994. -ReSOlved that the signatures of such director. and oHicers and the seal 01 the Company may be .HiKed to any such Power of Anorney or any certificates relatIng thereto by facsImile. and any such Power of Attorney or certificate bearing such facsimile sionatures Q( facsimile seaf sha/l be vahd Ind btnding upon the Company and any such Power so executed and cen,lfled by facsimile signatures and facsimile seal shall be .....Iid and bindino upon the Company, In the future with respect to any bond Of undertakIng to which It IS attached. ~ IN WITNESS WHEREOF. the Companies have caused these presents to be signed and their corporate seals to be hereto affixed, this February 1, 1998. RELIANCE SURETY COMPANY RELIANCE INSURANCE COMPANY UNITED PACIFIC INSURANCE COMPANY RELIANCE NATIONAL INDEMNITY COMPANY {)~J 7~ ST ATE OF Pennsylvania COUNTY OF Philadelphia Ls. On this. February 1, 1998. before me. Valencia Wortham, personally appeared David T. Akers. who acknowledged himself to be the Senior Vice President of the Reliance Surety Company, and the Vice President of Reliance Insurance Company, United Pacific Insurance Company, and Reliance National Indemnity Company and that as such. being authorized to do so. executed the foregoing instrument for the purpose therein contained by signing the name of the corporation by himself as its duly authorized officer. In witness whereof. I hereunto set my hand and official seal. ~X1UO- Yv~~ Notary Public in and for the State of Pennsylvania Residing at Philadelphia Notarial Seal Valencia Wonr.am. Notary Pc-~ffc Phtlad61phl3 Phliadelpnia Coun My CommiSSion Expues Nov. 18.2'600 I. Anita Zippert. Secr'"tary of RELIANCE SURETY COMPANY. RELIANCE INSURANCE COMPANY. UNITED PACIFIC INSURANCE COMPANY. and RELIANCE NA TIONAL INDEMNITY COMPANY do hereby certify that the above and foregoing is a true and correct copy of the Power of Attorney executed by said Companies. which is still in full force and effect. IN WITNESS WHER~E~~~'''O'O ,., m, "'od ,od ,fI,,,d m. ",', of ",d Com"o,,, '71:; of . rtt~;,l -/ Secret2ry ,\ -;; II '~~~~/ 19/Y r " ".T" SECTION E DRUG-FREE WORKPLACE FORM The unde'rsigned Contractor, in accordance with Florida Statute 287.087, hereby certifies that: COMMUNITY ASPHA.l T COAP_ (Name of Business) 1. Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. 2. Inform such employees about the dangers of drug abuse in the workplace, the business' policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation and employee assistance programs and the penalties that may be imposed upon employees for drug abuse violations. 3. Give each employee engaged in providing the commodities or contractual services that are under bid a copy of the statement specified in Sub-section (1). 4. In the statement specified in Sub-Section (1), notify the employees that as a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of or plea of guilty or nolo contendere to any violation of Chapter 893 (Florida Statutes) or of any controlled substance law of the United States or any state for a violation occurring in the workplace no later than five (5) days after such conviction. 5. Impose a sanction on or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community or any employee who is so convicted. 6. Makl3 a good faith effort to continue to maintain a drug-free workplace through implementation of this section. As a person authorized to sign the statement, I certify that this firm complies fully with the above requirements. Date: ! -~) I SECTION F PRIME BIDDER'S QUALIFICATIONS Each contractor shall furnish with his bid the following completed and signed statements on "evidencl3 of competency" and "evidence of financial responsibility", which is in accordance with General Provision 20-02. 1 . Name of Bidder: COMMUNITY ASPHALT COOP. 2. Business Address: 14005 N.W. 186th STREET, HIALEAH, FL 3301~ 3. Telephone Number: (305) 829-0700 4. When Organized: 5~tQtn1 her 2-2, ll1 f0 D 5. WhE~re Incorporated: ( I ft{ \- cQ fA- 6. How many years have you been engaged in the contracting business under the present firm name? 1,/ 7. What is the type of construction work in which you are principally engaged? G~l\aX (~-+Vll~k~ ~ ~~ ~.~ 8. On separate sheet list major contracts in past 10 years. ~ a1:t~ 9. On separate sheet list equipment and plant available for this project. ~ ~~J 11. Creelit Available for this Contract: $ 5v-.o.tfcuQ,u~ \1MI\~t;2~ ~a cJiu~ NO 10. Enclose a copy of latest Financial Statement. 12. Contracts now in hand, Gross Amount: $ 13. Have you ever refused to sign a contract at your original bid? I-;'~ 14. Have you ever been declared in default on a contract? NU 15. Remarks: (The above statements must be subscribed and sworn to before a Notary Public.) By: r(?Jlq~ COMMUNITY ASPHALT caw. JOS~~N~ PRESIDENI Date: Firm Name: Title: ~ Notary Public: "t."" '" .." ~ '''to Susana Herrera * 'l'il.iJiT * My Commission CCG1733S .... 'f~., Expires March 16. 2001 "t, I' ,\'~' 1-23 SECTION G DISCLOSURE OF LOBBY ACTIVITIES Certification of Contracts. Grants. Loans and Cooperative Agreements The undersigned certifies, to the best of his or her knowledge and belief, that: (1) No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned 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 the awarding of any Federal contract, the making of any Federal Grant, the making of any Federal loan, the entering into of any cooperative agreements and the extension, continuation, renewal, amendment or modification of any Federal contract, Grant, loan or cooperative agrE!ement. (2) If any funds other than Federal appropriate 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 contract, Grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form - LLL, "Disclosure of Lobby Activities", in accordance with its instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants and contracts under Grants, loans and cooperative agreements) and that all sub-recipients 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 $100,000 for each such failure. Signed: ;r- .., ,'"':\ - V'--''\../~''-'' Contract8r'~ ut~g~~~~~E~r s J SE L. PRESIDENT: Dated: (, (~) 0 [) ( 1-:''< SECTION H ACKNOWLEDGMENT OF RECEIPT OF ADDENDUM Acknowledgment of Addenda I Addendum No. Signature Date !!;; ~ >>; I I ::t:~ A A. a A. A. .,-r 0 '2+ IOt~ J'rJ 0 I 1-':)r SECTION I DISADVANTAGED BUSINESS ENTERPRISE PROGRAM Contract (As Required by Division III, Section 150 of the General Provisions) DBE Subcontractors Names/Addresses/identity* Subcontract Work Item ~\ tJ:~I~:k. _Uo.J,ut ~, Mette~~\~ ~~?~ ~W. ~~ t1fJl~ ~a,"Jl(. ' it.~o~ . .., (. t1Bo ~IIJ 1,0::. cll{'7 m~ ~ . l ;{;~ ~~. *4 (T. ~ ~~~Va tJ~~ Dollar Value of Subcontract Work eA, 4-t7o D1 . S:+Vf fl ~ 1 (0 t:f1t6 J,"lll ,,~~e. ~vo Total Dollar Value of Subcontract Work Total Dollar Value of Basic Bid Total DBE Percent (Round to nearest 1/10 percent) ~*~f~ % *(Black Hispanic, Asian American, American Indian, and other economically disadvantaged.) I-?(; SECTION J BIDDER'S AFFIDAVIT IN COMPLIANCE WITH FLORIDA TRENCH SAFETY ACT (SECTION 553.60-553.64, FLORIDA STATUTES) STATE OF FLORIDA ) )SS COUNTY OF MONROE ) BEFORE ME, the undersigned authority, personally appeared JOSE l. FERNANDEZ who, being duly sworn, deposes and says as follows: That he is the duly authorized representative of being its COMMUNrTY ASP~T COA? (Name of Bidder) PRESIDENT (Owner) (Partner) (President or other Corporate Officer) and as such, has full authority to execute this Bidder's Affidavit. 1. The full legal name and business address of the person or entity submitting this bid: COMMUNITY ASrllAL T conr. '. "14005 N.W. 186 STREET ;":';." ' HIAU::AH, t-L 33018 2. By submission of this bid and subsequent execution of this Contract, the undersigned bidder certifies that as successful bidder (Contractor) all trench excavation done within his control (by his own forces or by his subcontractors) shall be accomplished in strict adherence with OSHA Trench Safety Standards contained in 19 CFR, s.1926.650, Sub-part P, including all subsequent revisions or updates to these Standards as adopted by the Department of Labor and Employment Security. 3. The bidder acknowledges that included in the various items listed in the Schedule of Prices Bid and in the Total Amount Bid are costs for complying with the Florida Trench Safety Act (Sections 553.60-553.64, Florida Statutes). The bidder further identifies the costs to be summarized below: 1.~)7 Unit Unit Extended Quantit Cost Cost A 00 2.00 OD B C D TOT AL: $ 100 Signature of Authorized Representative: COMMUNITY ASP l T COftP. JOSE L FERNANDEZ PRESIDENT: Title ~ /3 )q fJ (Date STATE OF: ~(&' i'J fA t)Ctck- COUNTY OF: ~ ,ti{~ SUSANA HERRERA ,; ,\,.J.1 '11, ...'. .J'\~~ (1- Susana Herrera *l"'vJJJ! * My CommIssIon CC617338 ...... ~~ ""," Expires March 16, 2001 4/( ,,, l'.~'" (Print name of Notary Public) "', i ( \ ;') C')C') \ f'Jly Commission Expires ~ ~)J~~~ I 1/ , , i I 1-2( SECTION K SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a), FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES This form must be signed and sworn to in the presence of a Notary Public or other official authorized to administer oaths. 1. This sworn statement is submitted with Bid, Proposal or Contract No. . for -----p 04/U-",-)1C\ IO.~; L0(U\(Y c-t- 1~(L'11~((.'\ {lU..R.-6A- m{.v1{.~-., CL,.~~ 2. This sworn statement is submitted by (name of entity submitting sworn statement) _COLUAUNITY ASPH~LT ~. whose business address is 14005 N.W. 186th STREET, HIALEAH, FL 33018 and (if applicable) its Federal Employer Identification Number (FEIN) is 59-2023298 (If the entity has no FEIN, include the Social Security Number of the individual signing thlls sworn statement: .) 3. My name is JOSE L. FERNANDEZ (please print name of individual signing) relationship to the entity named above is and my PRESIDENT 4. I understand that a "public entity crime", as defined in Paragraph 287.133(1 )(g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or of the United States, including, but not limited to, any bid or contract for goods or services to be provided to any public entity or an agency or political subdivision of any other state or of the United States and involving anti-trust, fraud, theft, bribery, collusion, racketeering, conspiracy or material mis-representation. 5. I understand that "convicted" or "conviction", as defined in Paragraph 287.133(1 )(6), Florida Statutes, means a finding of guilt or a conviction of a public entity crime with or without an adjudication of guilt in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, non-jury trial or entry of a plea of guilty or nolo contendere. 6. I understand that an "affiliate", as defined in Paragraph 287.133(1 )(a), Florida Statutes, means: a_ A predecessor or successor of a person convicted of a public entity crime; or 1- ~) (I b. An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term "affiliate" includes those officers, directors, executives, partners, shareholders, employees, members and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person or a pooling of equipment or income among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. 7. I understand that a "person", as defined in Paragraph 287.133(1 )(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity or which otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers, directors, executives, partners, shareholders, employees, members and agents who are active in management of an entity. 8. Based on information and belief, the statement which I have marked below is true in mlation to the entity submitting this sworn statement. (Indicate which statement applies.) -~ Neither the entity submitting this swom statement nor any of its officers, directors, executives, partners, shareholders, employees, members or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement or one or more of its officers, directors, executives, partners, shareholders, employees, members or agents who are active in the management of the entity or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989, AND (please indicate which additional statement applies) There has been a proceeding concerning the conviction before a Hearing Officer of the State of Florida, Division of Administrative Hearings. The Final Order entered by the Hearing Officer did not place the person or affiliate on the convicted vendor list. (Please attach a copy of the Final Order.) ! :. The person or affiliate was placed on the convicted vendor list. There has been a subsequent proceeding before a hearing officer of the State of Florida, Division of Administrative Hearings. The Final Order entered by the hearing officer determined that it was in the public interest to remove the person or affiliate from the convicted vendor list. (Please attach a copy of the Final Order.) The person or affiliate has not been placed on the convicted vendor list. (Please describe any action taken by or pending with the Department of General Services.) , ' Signatum of Authorized Representative: !~ COMMUNI ASPHALT . JOSE L. FERNANDEZ PRESIDENT Title (p /3 /Cf8 date I STATE OF: f(ttY; J {^'- ()i cXR /' COUNTY OF: The foreqoing instrument was acknowledged before me this 3 rcP. ~ 195fL, by E L. FERNANDEZ PRESIDENT fi: -~ (SolecQorporatiofl:9r Partnership) who i personal! known t e-.S)j who has produced as iden Ica Ion and w i ,did not take an oath. (Print name of Notary Public) , My Commission Expires .5/10 (?J;O I i I .."" 'lJ, ..t..... ~.j{ '1- Sl;san~ Herrera * ?;~::jJf *- L~.,., Cry~-.n'I~,Slcn CCG173~ _",;:;;;~,/ I f/,,, , /1:;' 1-31 SECTION L SWORN STATEMENT UNDER ORDINANCE NO. 10-1990 MONROE COUNTY, FLORIDA ETHICS CLAUSE COMMUNITY ASPHALT ~. warrants that h@as not em'ployed, retained or otherwise had act on hi@behalf any former County officer or employee in violation of Section 2 of Ordinance No. 10-1990 or any County officer or employee in violation of Section 3 of Ordinance No.1 0-1990. For breach or violation of this provision the County may, in its discretion, terminate this Contract without liability and may also, in its discretion, deduct from the Contract or purchase price or otherwise recover the full amount of any fee, commission, percentage, gift or consideration paid to the former County officer or employee. z Date: (Signature)Jf o r 3 Jq 0 I ( STATE OF: rl(r(; J R [):~ cO ~ COUNTY OF: PERSONALLY APPEARED BEFORE M~e undersigned authorityJOSE L. FERNANDEZ who, after first being swom by me affi~e~her sig~re (name of individual signing) in the space provided abov ,on this .~ I day of ~vn.Q , 19~. SUSANA HERRERA (Print name of Notary Public) My Commission Expires ~ ~01 Up 1'20 0 \ '\~",. ''', ...~ .::..~j_'\. '-;., Susana Herrom *l~-!/{ * MyCommls"onCC617333 '". ~&-j ~"" f>:rwcs March 10 700' "', ..' {Cf pt. I. r::, SECTION M CERTIFICATION OF NONSEGREGATED FACILITIES Contract (As Required by Division III, Section 120 Subsection 120-02 Equal Employment Opportunity Requirements of the General Provisions) The federally assisted construction contractor 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 federally assisted construction contractor certifies that he will not maintain or provide, for his employees, 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 federally assisted construction contractor 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, timelocks, locker rooms and other storage or dressing areas, parking lots, drinking Ifountains, recreation or entertainment areas, transportation, and housing facilities provided for employees which are segregated by explicit directives 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 federally assisted construction contractor 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 subcontractors exceeding $10,000 which are not exempt from the provisions of the equal opportunity clause and that he will retain such certifications in his files. Signature of $:rl COMMUNITY ASPHAlT~. JOSE L. FERNANDEZ PRESIDENT Title ! -- ...-~; ,-] . "J, SECTION N FEDERAL WAGE DECISION Use the latest publication or the attached publication dated 02/14/1997 if that is the latest list issued for Monroe County. 1- 3.~ MEO:3 $5,000,0001$10,000,000 Agg. IF Installation Floater Max. ValuG of E.quip. Installed VLP1 Ha18rdoue $300,000 (R~uires MC5-90) VLP~~ ca~o $SOO,ooo (Requires MOS-OO) VLP~' Transporter $1,000,000 (Requires MCS-90) 8Ll BallHe Liability Max. value of property , HKL1 Hangar1<"pers' Ueblltty $300,000 HKL:2 $500,000 Ht<L3 $1,000,000 AlR1 Al/'C~ft liability $2S,OOO I 000 AJR:~ $1.000,000 AIRa $1,000,000 AEC> 1 Architects' Errors & Omicslons $2.SO,OQO/occurrencQ/S500,OOO A99. AE~2 $500 ,OOOIoccu rronocl$ 1 ,000,000 Agg. AE03 $1,OOO,OOOIocourrenccl$3,OOO,QOO Agg. llliWRANCE AG~NTS STATEMENT I have reviewed the above requirements with the bidder named below. The following deductibles apply to the corresponding policy: Workers Compensation - $250 000 d d t"bl Auto Liabilit _ ' ,e uc 1 e - y $5,000 Property ~amage Dedu ['bI General Liability _ $25 000 S If I c 1 e , ensured Retention POLICY: DEDUCTlBLES; liability policies are x Occurrence Claim4=~. ~ ' v-.12& <~- ~ Sl ature Aon Ri6k Services, Inc, Insurance Agency stDllER'S STATEMENt I understand the Insurance that will be mandatory If awarded the contract and will comply in full with all the requirements, COt~MUNnY ASPHALT CORP. Bidder i:fr.