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2017-09-26 - AGENDA REPORTS - BRIDGE PREVENTATIVE MAINTENANCE PROGRAM, PROJECT M (2)
0 Agenda Item: 6 CITY OF SANTA CLARITA Q:° AGENDA REPORT CONSENT CALENDAR 7, CITY MANAGER APPROVAL: 1 j4 _ " DATE: September 26, 2017 SUBJECT: BRIDGE PREVENTATIVE MAINTENANCE PROGRAM, PROJECT M0101 - AWARD CONSTRUCTION CONTRACT DEPARTMENT: Public Works PRESENTER: Damon Letz RECOMMENDED ACTION City Council: 1. Approve the plans and specifications for the Bridge Preventative Maintenance Program, Project M0101. 2. Award the construction contract to Peterson -Chase General Engineering Construction, Inc., in the amount of $246,517 and authorize a contingency in the amount of $24,652 for a total contract amount not to exceed $271,169. 3. Increase Miscellaneous Federal Grants (Highway Bridge Program) revenue account 229- 4424.009 by $24,965 and appropriate to expenditure account M0101229-5161.001. 4. Authorize the City Manager or designee to execute all documents, subject to City Attorney approval. BACKGROUND This project will provide preventative maintenance and repairs, including sealing the bridge decks, patch spalling, and replacing expansion joints and sealants on the following City of Santa Clarita (City) bridges: Valencia Boulevard south over South Fork Santa Clara River, Bouquet Canyon Road over Santa Clara River, Centurion Way over Bouquet Canyon Channel, Urbandale Avenue over Bouquet Canyon Channel, and Sierra Highway over Solamint railroad tracks. This project supports the Sustaining Public Infrastructure theme of the City's five-year strategic plan, Santa Clarita 2020. An invitation to bid was prepared and published two times, July 6 and July 12, 2017, and was Page 1 PacketPg. 31 0 posted on the City's website. Four bids were submitted to the City and opened on August 8, 2017. The results of the bid are shown below: Company Location Bid Amount Peterson -Chase General Engineering Construction, Inc. Irvine, CA $246,517 Beador Construction Company, Inc. Corona, CA $252,300 Truesdell Corporation of California, Inc. Tempe, AZ $321,321 CPO Enterprises Inc. Covina, CA $330,211 Staff recommends the project be awarded to Peterson -Chase General Engineering Construction, Inc., the lowest responsive bidder. This contractor possesses the required state contractor's license and is in good standing with the Contractors State License Board. The contractor's bid has been reviewed for accuracy and conformance to the contract documents and was found to be complete. This project is substantially funded with Caltrans Federal Highway Bridge Program (HBP) grant funds. In June 2017, the City received Authorization to Proceed with Construction from Caltrans securing $247,837 of HBP funds. After the bids were opened, the City requested an additional $24,965 of HBP funds from Caltrans and received a commitment to increase the total HBP construction grant funds to $272,802. The project budget of $308,147 is identified for construction -related costs, including the construction contract of $271,169, inclusive of contingency, plus an additional $36,978 for related construction support costs, including labor compliance services, staff oversight, construction engineering, inspection, and project management. The requested construction contingency will cover the cost of unforeseen site conditions, potential utility conflicts not shown in record drawings, and change order requests made by the contractor. ALTERNATIVE ACTION Other action as determined by the City Council. FISCAL IMPACT Upon approval of the recommended action, adequate funds will be available to support the construction contract. ATTACHMENTS Location Map Bid Proposal for Peterson -Chase General Engineering Construction, Inc. (available in the City Clerk's Reading File) Page 2 Packet Pg. 32 I. Q\PROJECTS\PW170880e1\anal\M0101 it 6.a a , ''"' .... °'S�IycC[,A[tl't'n Exhibit Map Annual Bridge Preventive Maintenance Program --- Legend Project No. MO1O1 l - J City Boundary i r e� Bridge Saudipb i ra E gI A l March 201 6 "Itte g#�rn Cay rs n1 Clams a t ant racy at a noounntl a#_594 lrban dal aAeov erBou uetCyonCha 0.5 025 0 es atiy ra ions y�lBs Map prepared by:Cty of8 taClarih-GIB r� Packe[ Pg. 33 Z. SECTION C: PROPOSAL ,1 i Robert G. Newman, Director of Public Works City of Santa Clarita BIDDER'S CERTIFICATE I acknowledge receipt of this Addendum 1 and accept the aforementioned. .2017 r� J Date :Bgidderl'gnature THIS DOCUMENT TO BE SUBMITTED WITH BID Page 2of2 Answer #4: The MR of the joint seal on Bridge #1929 — Sierra Hwy South should be 1 '/Z" per the detail and bid quantity shown on the plans. ATTACHEMENTS L Revised Bid Schedule with revisions shown in RED 2. Concrete Repair Detail &9q W dor JeEi1�( Robert G. Newman, Director of Public Works City of Santa Clarita BIDDER'S CERTIFICATE I acknowledge receipt of this Addendum 1 and accep`-- ,2017 Date !- THIS DOCUMENT TO BE SUBMITTED WITH BID Page 3 of 3 SECTION C: PROPOSAL FY 14-15 BRIDGE PREVENTIVE MAINTENANCE PROGRAM Federal -Aid Project BPMPL-5450(086) Bid No ENG-17-18-MO101 City Project M0101 City of Santa Clarita, California TO THE CITY OF SANTA CLARITA, AS AGENCY: In accordance with AGENCY's NOTICE INVITING BIDS, the undersigned BIDDER hereby proposes to furnish all materials, equipment, tools, labor, and incidentals required for the above -stated project as set forth in the plans, specifications, and contract documents therefore, and to perform all work in the manner and time prescribed therein. BIDDER declares that this proposal is based upon careful examination of the work site, plans, specifications, INSTRUCTIONS TO BIDDERS, and all other contract documents. If this proposal is accepted for award, BIDDER agrees to enter into a contract with AGENCY at the unit and/or lump sum prices set forth in the following BID SCHEDULE. BIDDER understands that failure to enter into a contract in the manner and time prescribed will result in forfeiture to AGENCY of the proposal guarantee accompanying this proposal. BIDDER understands that a bid is required for the entire work that the estimated quantities set forth in BID SCHEDULE are solely for the purpose of comparing bids, and that final compensation under the contract will be based upon the actual quantities of work satisfactorily completed. THE AGENCY RESERVES THE RIGHT TO INCREASE OR DECREASE THE AMOUNT OF ANY QUANTITY SHOWN AND TO DELETE ANY ITEM FROM THE CONTRACT. It is agreed that the unit and/or lump sum prices bid include all appurtenant expenses, taxes, royalties, and fees. In the case of discrepancies in the amounts bid, unit prices shall govern over extended amounts, and words shall govern over figures. If awarded the contract, the undersigned further agrees that in the event of the Bidder's default in executing the required contract and filing the necessary bonds and insurance certificates within ten working days after the date of the AGENCY's notice of award of contract to the BIDDER, the proceeds of the security accompanying this bid shall become the property of the AGENCY and this bid and the acceptance hereof may, at the AGENCY's option, be considered null and void. Company Name: Peterson -Chase General Engineering Construction, Inc. Company Address 16351 Construction Circle West Irvine, CA 92606 By: Dick W. Vo els Print Name Title: Vice President Signature: _ZDk�-_A2 1-,/ W Date: $I4 17 /J C-1 M0101 FY 14-15 Bridge Maintenance Program Federal Project BPMPL-5450(086) BID SCHEDULE - ADDENDUM 2 814/17 FY 14-15 BRIDGE PREVENTIVE MAINTENANCE PROGRAM Federal -Aid Project BPMPL-5450(086) Bid No ENG-17-18-MO101 City Project M0101 City of Santa Clarita, California BRIDGE 1938 - BOUQUET CYN OVER SANTA CLARA RIVER Item Description QTY Unit Unit Cost Total Cost IA Mobilization 1 LS G(J �� S171J 2A Traffic Control 1 LS 11 moo - JZ,, Yo p 3A Public Safety Plan 1 LS 21 q 46 4A Storm Water Pollution Prevention SWPP 1 LS -75-0Jrp ' 5A Prepare Concrete Bridge Deck Surface 26,340 SF 012 DJC 6A Treat Bridge Deck 26,340 SF v, It 17 / U s'3( 7A Furnish Bridge Deck Treatment Material 293 GAL Lig,- / �� 06 y 8A Remove Expansion Joint Seal 225 LF 3 N -71 `P 9A Type "A" Joint Seal (MR 1") 45 LF /I s'3 — 10A Type "B" Joint Seal (MR 2") 180 LF 76 /3 �. o 11A Repair Spalled Joints 6 SF 3p 3 -7Y0 12A Repair Spalled Surface Area 44 SF Y7 13A Remove Painted Pavement Marking 1 LS 15-6 14A Remove Painted Traffic Stripe 1 LS 2, 3so Z, aro 15A Remove Pavement markers 1 LS Z -yam Z at - 16A Replace Traffic Stripe in Kind 1 LS �� S'ub ' �� sd o 17A Replace Painted Pavement Marking in Kind 1 LS6frD (- 18A Replace Pavement Markers in Kind 1 LS 13;Z 137-- 3ZSUBTOTAL SUBTOTAL // 0, 73 "1- M0101 FY 14-15 Bridge Maintenance Program Federal Project BPMPL-5450(086) C-2 FY 14-15 BRIDGE PREVENTIVE MAINTENANCE PROGRAM - ADDENDUM 2 8/4117 Federal -Aid Project BPMPL-5450(086) Bid No ENG-17-18-MO101 City Project M0101 City of Santa Clarita, California BRIDGE 3679 - VALENCIA BLVD S OVER S FORK SANTA CLARA RIVER Item Description QTY Unit Unit Cost Total Cost 113 Mobilization 1 LS 1, Ttb - (, 9v® - 2B Traffic Control 1 LS , 2 jo ' Ir Z v O - 3B Public Safety Plan 1 LS 62-0 6 " 0- 4B Storm Water Pollution Prevention 1 LS g 7 / i 5B Prepare Concrete Bridge Deck Surface 6,650 SF 6B Treat Bridge Deck 6,650 SF 7B Furnish Bridge Deck Treatment Material 74 GAL 8B Repair Spalled Surface Area 16 SF 566- 6b -9B 9B Remove Pavement Markers 1 LS )5_0 r l SO lOB Replace Pavement Markers in Kind 1 LS )i �,4 e /" 6 -�,O SUBTOTAL -Z�i NS7. BRIDGE 1594 - URBANDALE AVE OVER BOUQUET CYN CHANNEL 1C Mobilization 1 LS J, 16 o .- -31 q 60 -- 2C Traffic Control 1 LS 3, 7 too ci -10 D 3C Storm Water Pollution Prevention 1 LS 4C Cold Plane Asphalt Concrete Pavement 435 SY f $ 'j IJ 5C Hot Mix Asphalt (C2 -PG 70-10) 47 TON 6C Modify Bridge Railing 1 EA t 7C Remove Painted Traffic Stripe 1 LS 8C Remove Pavement Markers 1 LS 9C Replace Traffic Striping in Kind 1 LSI It p p ; Lto Z 10C Replace Pavement Markers in Kind 1 LS 3 - ,3 i% SUBTOTAL y�, 201(. Sb M0101 FY 14-15 Bridge Maintenance Program Federal Project BPMPL-5450(066) C-3 FY 14-15 BRIDGE PREVENTIVE MAINTENANCE PROGRAM - ADDENDUM 2 814117 Federal -Aid Project BPMPL-5450(086) Bid No ENG-17-18-MO101 City Project M0101 BRIDGE 2244 - CENTURION WAY OVER BOUQUET CANYON CHANNEL ID Mobilization 1 LS 2 6 v� 2 2 6 9 2D Traffic Control 1 LS Z, (, 0 3D Storm Water Pollution Prevention 1 LS Ci 4D Slurry Seal 5 TON S, b +Jb Z� �U C, 5D Replace Missing 5/8" Holts 3 EA / SUBTOTAL BRIDGE 1929 - SIERRA HIGHWAY S OVER SOLEMINT SPTCO I Mobilization 1 LS 2430 — 2 g� p 2E Traffic Control 1 LS 4 tl�, i 3 if 3E Public Safety Plan 1 LS $'2 4E Storm Water Pollution Prevention 1 LSi )11 117 5E Prepare Concrete Bridge Deck Surface 8,750 SF 0. �9,G /( 6E Treat Bridge Deck 8,750 SF D rj E 3 sb E 7E Furnish Bridge Deck Treatment Material 98 GAL ' — �,7 d +� 8E Remove Expansion Joint Seal 96 LF r Z -f z 9E Type "13" Joint Seal (MR 1-1/2") 96 LF 10E Repair Spalled Surface Area 2 SF 11E Minor Concrete (Sidewalk) 2 CY 21 S zoo 12E Replace Missing5/8" Bolt 1 EA '7rp 13E Remove Pavement Markers 1 LS Igo — /, f o -- 14E 14E Replace Pavement Markers in Kind 1 LS 2( 2 6 7,,2-60— ,,Z,6OSUBTOTAL SUBTOTAL 17'y, yv ? TOTAL BID IN FIGURES Z 11C, S"/ 7 f TOTAL BID IN WORDS: 7rwy &tIyez? Fv+z!,'Y -f)y oD five 14U06Rg4�, M0101 FY 14-15 Bridge Maintenance Program Federal Project BPMPL-5450(066) C-4 44 U E e CL a ❑ A S 4 a fJ. R ix 30� U ❑ Li ❑ ❑ a ❑ I� s. kit o � _ 3 � o � u A 0 0 0 0 0 0 0 0 0 0 0 0 V v, � Q 6A 69 O 69 V'1 69 Vl 69 69 69 O 6A Vl 64 V1 EH 69 69 V V V V A V V V V A V V dx ❑ ❑ ❑ ❑ El ❑ ❑� El El i� V U E e CL w U a c • Lei � J o a m� �m 00 � LL U q 4 wi d ❑ ❑ �. Q 0 0 o q q o 0 0 o �n to o kn h tss s9 s9 es 69 s9 V9 es 1 O N W N o ts y y w U a c • Lei � J o a m� �m 00 � LL U Ix O H ,z MV W N LL z O a z a as LL in .c W 4 ^� .7, 14 I ¢ In V2 ❑ ❑ D� U ❑ ❑�, i ❑ ❑ PO ac. a I 4:6. 0 I 3 a 'r a a 0. i. u I{I V y tnL V H 0. 69 61 V 69 V 69 V 64 V V% n 6) V 69 V 69 V 6A V 69 A 69 V 69 V 41 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ l Gt , � � x � Cd H LO U CL CL 8 U vCC m Fb a A is CD U f I I Ez,d ! ❑ ❑ ti d I n va sus res 64 est va va 69 V V AV V V V n o� g 'V .�+ 3 a N N 4 U vCC m Fb a A is CD U REFERENCES FY 14-15 BRIDGE PREVENTIVE MAINTENANCE PROGRAM Federal -Aid Project BPMPL-5450(086) Bid No ENG-17-18-MO101 City Project M0101 City of Santa Clarita, California The following are the names, addresses, and telephone numbers of three public agencies for which BIDDER has performed similar work within the past 3 years: 1. City of Santa Clarita - 23920 Valencia Blvd, Ste 120 Santa Clarita CA 91355 Name and Address of Owner I Agency Monica Heredia - 661-255-4332 Name and Telephone Number of Person Familiar with Project 1183,856.00 Bridge Maintenance 2015 Contract Amount Type of Work Date Completed 2. City of Irvine - One Civic Center Plaza Irvine CA 92606 Name and Address of Owner 1 Agency Dvina Buenavista - 949-724-6937 Name and Telephone Number of Person Familiar with Project $119,700.00 Bridge Maintenance and Repairs_ 2017 Contract Amount Type of Work Date Completed 3. Caltrans - 1120 N Street, Sacramento, CA 95814 Name and Address of Owner I Agency Ariel Mendoza - 209-942-6160 Name and Telephone Number of Person Familiar with Project $653.604.94 Bridge Deck Treatment 2017 Contract Amount Type of Work Date Completed The following are the names, addresses, and telephone numbers of all brokers and sureties from whom BIDDER intends to procure insurance bonds: Culbertson Insurance Services - 5500 E. Santa Ana Canvon Rd, Ste 200, Anaheim CA 92807 (714)921-0530 Great American Insurance Grou - 301 E. 4th St. Cincinnati, OH 45202 (513) 369-5000 C-7 M0101 FY 14-15 Bridge Maintenance Program Federal Project BPMPL-5450(066) Peterson -Chase General Engineering Construction, Inc. Contractors Name DEBARMENT AND SUSPENSION CERTIFICATION TITLE 49, CODE OF FEDERAL REGULATIONS, PART 29 FY 14-15 BRIDGE PREVENTIVE MAINTENANCE PROGRAM Federal -Aid Project BPMPL-5450(086) Bid No ENG-17-18-MO101 City Project M0101 City of Santa Clarita, California The bidder under penalty of perjury, certified that except as noted below, he/she or any person associated therewith in the capacity of owner, partner, director, office manager: is not currently under suspension, debarment, voluntary exclusion or determination of ineligibility by any federal AGENCY; has not been suspended, debarred, voluntarily excluded, or determined ineligible by any federal AGENCY within past three years; does not have a proposed debarment pending; and has not been indicted, convicted, or had a civil judgment rendered against it by a court of competent jurisdiction in any matter involving fraud or official misconduct within the past 3 years. If there are any exceptions to this certification, insert the exceptions in the following space. NONE Exceptions will not necessarily result in denial of award, but will be considered in determining bidders' responsibility. For any exception noted above, indicate below to whom it applies, initialing AGENCY, and dates of action. NONE NOTE: Providing false information may result in criminal prosecution or administrative sanctions. The above certification is part of the Proposal. Signing this Proposal on the signature portion thereof shall also constitute signature of this Certification. M0101 FY 14-15 Bridge Maintenance Program Federal Project BPMPL-5450(086) C -a EQUAL EMPLOYMENT OPPORTUNITY CERTIFICATION * * * (Must be filled out by the Bidder and ALL subcontractors over $10,000) * * * FY 14-15 BRIDGE PREVENTIVE MAINTENANCE PROGRAM Federal -Aid Project BPMPL-5450(086) Bid No ENG-17-18-MO101 City Project M0101 City of Santa Clarita, California This bidder Peterson -Chase G.E.0 Ijivproposed subcontractor , hereby certifies that he has , has not , participated in a previous contract or subcontract subject to the equal opportunity clause, as required by Executive Orders 10925.11114, or 11246, and that he has X , has not , filed with the Joint Reporting Committee, and Director of Office of Federal Contract Compliance, a Federal Government contracting or administering AGENCY, or the former President's Committee on Equal Employment Opportunity, all reports that are under the applicable filing requirements. Company: By: Title: Date: on. Inc. Note: The above certification is required by the Equal Employment Opportunity of the Secretary of Labor (41 CFR 60-1.7(b)(1)), and must be submitted by bidders and proposed subcontractors only in connection with contracts and subcontracts which are subject to the equal opportunity clause as set forth in 41 CFR 60-1.5, (Generally only contracts or subcontracts of $10,000 or under are exempt.) Currently, the Standard Form 100 (EEO -1) is the only report required by the Executive Orders or their implementing regulations. Proposed prime CONTRACTORS and subcontractors who have participated in a previous contract or subcontract subject to the Executive Orders and have not filed the required reports should note that 41 CFR 60-1.7(b)(1) prevents the award of contracts and subcontracts unless such CONTRACTOR submits a report covering the delinquent period or such other period specified by the Federal Highway Administration or by the Director, Office of Federal Contract Compliance, U.S. Department of Labor. M0101 FY 14-15 Bridge Maintenance Program Federal Project BPMPL-5450(086) C-9 BIDDER'S INFORMATION AND CERTIFICATION Bidder certifies that the representations of the bid are true and correct and made under penalty of perjury. EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE Bidder certifies that in all previous contracts or subcontracts, all reports which may have been due under the requirements of any AGENCY, State, or Federal equal employment opportunity orders have been satisfactorily filed, and that no such reports are currently outstanding. AFFIRMATIVE ACTION CERTIFICATION Bidder certifies that affirmative action has been taken to seek out and consider minority business enterprises for those portions of the work to be subcontracted, and that such affirmative actions have been fully documented, that said documentation is open to inspection, and that said affirmative action will remain in effect for the life of any contract awarded hereunder. Furthermore, Bidder certifies that affirmative action will be taken to meet all equal employment opportunity requirements of the contract documents. Bidder's Name: Peterson -Chase General Engineering Construction, Inc. Business Address: 16351 Construction Circle West, Irvine, CA 92606 Telephone No.: 949-252-0441 State CONTRACTOR's License No. & Class: 615976 Class A. C13. C32 Original Date: 3/23/1991 Expiration Date: 3/31/2019 The following are the names, titles, addresses, and phone numbers of all individuals, firm members, partners, joint venturers, and/or corporate officers having a principal interest in this proposal: Chase - President Dick W. Voizels - VP/ Sec./ Treas. The dates of any voluntary or involuntary bankruptcy judgments against any principal having an interest in this proposal, or any firm, corporation, partnership or joint venture of which any principal having an interest in this proposal was an owner, corporate officer, partner or joint venture are as follows: None M0101 FY 14-15 Bridge Maintenance Program Federal Project BPMPL-5450(086) C-10 All current and prior DBAs, alias, and/or fictitious business names for any principal having an interest in this proposal are as follows: IN WITNESS WHEREOF, BIDDER executes and submits this proposal with the names, title, hands, and seals of all aforementioned principals this 4 day of 8 20 17. BIDDER: Signature Name and Title of Signatory Peterson -Chase General Engineering Construction Inc. Legal Name of Bidder 16351 Construction Circle West, Irvine, CA 92606 Address 949-252-0441 33-0445961 Telephone Number Federal Tax I.D. No. SIGNATURES MUST BE MADE AND NOTARY ACKNOWLEDGMENTS OF EXECUTION OF BIDDER MUST BE ATTACHED Subscribed and sworn to this Notary Public day of , 20. M0101 FY 14-15 Bridge Maintenance Program Federal Project BPMPL-5450(066) C-11 (SEAL) CALIFORNIA JURAT WITH AFFIANT STATEMENT GOVERNMENT CODE § 8202 .c�,cY..c;C'�<,c;9Trc�<c�:Cc^��:��;.:�-�cc�'a�.c>r�.:-�'c�^,r��c�'��c:(;��:t',c:C'c-t,-�,-:<�:t:�.a�^C7ce'.c:r-�.Yac:��+�'.c.'i`�,:i.•:tiYc.'t, ;C'ic.�F '-iiMee Attached Document (Notary to cross out lines 1-6 below) ❑ See Statement Below (Lines 1-6 to be completed only by document signer[s], not Notary) Signature of Document Signer No. 1 Signature of Document Signer No. 2 (if any) A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of . Grange KALI GOGLAMAN Con�i�flon/2103746 Nomy Pukk - CdNmnla ow" Couft Com. Fa iCl3 MW 19 2019 Subscribed and sworn to (or affirmed) before me on this 4— day of August 20 17 by Date Month Year (1) Dick W. Vogels _ (and (2) ), Name(s) of Signer(s) proved to me on the basis lAatisfactory evidence to be the perso (s) o eared before me. Signatu �`- Signature oAvotary Public Seal Place Notary Seal Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: Number of Pages: Signer(s) Other Than Named Above: Document Date: <<-<,;<%C;<.(;'!-;<;c�c_{>u�f;c, =<; v,;z=.z�,��:<«:t�.C,ti;L,Y�{;z=<;c,Z;L.<;z;c,.t <; rnr•cv,,� .- ti. ti�,<.z_�:z„L�;�,Y: �'t��.Lz;zz.v -v '=f, �v`C `- 02014 National Notary Association - www.NationalNotary.org - 1 -800 -US NOTARY (1-800-876-6827) Item #5910 BID SECURITY FORMS FOR CHECK OR BOND TO ACCOMPANY BID NOTE: The following form shall be used in case check accompanies bid. Accompanying this Proposal is a *certified/cashier's check payable to the order of the City of Santa Clarita for: dollars (S ), this amount being not less than ten percent (10%) of the total amount of the bid. The proceeds of this check shall become the property of said AGENCY provided this Proposal shall be accepted by said AGENCY through action of its legally constituted contracting authorities, and the undersigned shall fail to execute a contract and furnish the required bonds within the stipulated time; otherwise, the check shall be returned to the undersigned. Project Name: FY 14-15 BRIDGE PREVENTIVE MAINTENANCE PROGRAM Federal -Aid Project BPMPL-5450(086) Bid No ENG-16-17-MO101 City Project M0101 Bidder's Signature CONTRACTOR Address City, State, Zip Code * Delete the inapplicable work. NOTE: If the bidder desires to use a bond instead of a check, the following form shall be executed, The sum of this bond shall be not less than ten percent (10%) of the total amount of the bid. M0101 FY 14-15 Bridge Maintenance Program Federal Project BPMPL-5450(086) C-12 BOND# 0284226 PROPOSAL GUARANTEE PREMIUM: NIL BID BOND FY 14-15 BRIDGE PREVENTIVE MAINTENANCE PROGRAM Federal -Aid Project BPMPL-5450(086) Bid No ENG-17-18-MO101 City Project M0101 City of Santa Clarita, California PETERSON -CHASE GENERAL KNOW ALL MEN BY THESE PRESENTS that ENGINEERING CONSTRUCTION, INC. , as BIDDER, and GREAT AMERICAN INSURANCE COMPANY as SURETY, are held and firmly bound unto the City of Santa Clarita, as AGENCY, in the penal sum of TEN PERCENT OF AMOUNT BID dollars ($ 10% ), which is ten percent (10%) of the total amount bid by BIDDER to AGENCY for the above -stated project, for the payment of which sum, BIDDER and SURETY agree to be bound, jointly and severally, firmly by these presents. THE CONDITIONS OF THIS OBLIGATION ARE SUCH that, whereas BIDDER is about to submit a bid to AGENCY for the above -stated project, if said bid is rejected, or if said bid is accepted and the contract is awarded and entered into by BIDDER in the manner and time specified, then this obligation shall be null and void, otherwise it shall remain in full force and effect in favor of AGENCY. IN WITNESS WHEREAS, the parties hereto have set their names, titles, hands, and seals, this BIDDER: Z I TH day of JULY ,20 17 PETERSON -CHASE GENERAL ENGIN�EFANG CONSTRUCTION, INC. �!ngnature f Y G� y G &L) I V_P N e and Title of Signatory 51 CONSTRUCTION CIRCLE WEST, IRVINE, CA 92606 PH. 949-252-0441 Address 750 THE CITY DRIVE SO., #4'170 ICAN INSURANCE_ -COMPANY ORANGE, CA 92868 PH. 714-740-2400 CHARLES L. FLAKE / ATTORNEY-IN-FACT Subscribed and sworn to this day of '20 NOTARY PUBLIC (SEAL) "Provide BIDDER and SURETY name, address, and telephone number and the name, title, address, and telephone number for authorized representative. IMPORTANT - Surety Companies executing Bonds must appear on the Treasury Department's most current list (Circular 570, as amended) and be authorized to transact business in the State wliere the project is located. AUTHORIZED REPRESENTATIVE: CULBERTSON INSURANCE SERVICES, INC. M0101 decal P 14-15 Bridge 450(0nance Program 5500 E SANTA ANA CANYON ROAD, STE. 201 Federal Project BPMPL-5450(085) ANAHEIM, CA C-13 92807 PH. 714-921-0530 JURAT FORM A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. STATE OF CALIFORNIA COUNTY OF ORANGE ) Subscribed and sworn to (or affirmed) before me on this 11TH day of JULY ,20 17 by CHARLES L. FLAKE proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me. r (NOTARY SEAL) NOTARY PLIBLIC SIGNATURE OPTIONAL INFORMATION �LEX��ILES�HERWOOD . 2031782 a •t: NOTARY PUBLIC *CALIFORNIA ORANGE COUNTY Comm. Exp. JULY 27, 2017 THIS OPTIONAL INFORMATION SECTION IS NOT REQUIRED BY LAW BUT MAY BE BENEFICIAL TO PERSONS RELYING ON THIS NOTARIZED DOCUMENT. TITLE OR TYPE OF DOCUMENT DATE OF DOCUMENT When executing a jurat, a notary shall administer an oath of affirmation to the affiant and shall determine, from satisfactory evidence, that the affiant is the person executing the document. The affiant shall sign the document in the presence of the notary. To order supplies, please contact McGlone Insurance Services, Inc. at (916) 484 0804. GREAT AMERICAN INSURANCE COMPANYO Administrative Office: 301 E 4TH STREET • CINCINNATI, OHIO 45202 • 513-369-5000 • FAX 513-723-2740 The number of persons authorized by this power of attorney is not more than FIVE POWER OF ATTORNEY No.0 14901 KNOW ALL MEN BY THESE PRESENTS: That the GREAT AMERICAN INSURANCE COMPANY, a corporation organized and existing under and by virtue of the laws of the State of Ohio, does hereby nominate, constitute and appoint the person or persons named below, each individually if more than one is named, its true and lawful attorney-in-fact, for it and in its name, place and stead to execute on behalf of the said Company, as surety, any and all bonds, undertakings and contracts of suretyship, or other written obligations in the nature thereof, provided that the liability of the said Company on any such bond, undertaking or contract of suretyship executed under this authority shall not exceed the limit stated below. Name Address Limit of Power DAVID L. CULBERTSON RICHARD A. COON ALL OF ALL CHARLES L. FLAKE LEXIE SHERWOOD ANAHEIM, $100,000,000.00 SPENCER FLAKE CALIFORNIA This Power of Attorney revokes all previous powers issued on behalf of the attomey(s)-in-fact named above. IN WITNESS WHEREOF the GREAT AMERICAN INSURANCE COMPANY has caused these presents to be signed and attested by its appropriate officers and its corporate seal hereunto affixed this 8TH day of DECEMBER 1 2015 Attest GREAT AMERICAN INSURANCE COMPANY 44.—.3m� Assistant Secretary Divisional Senior vice Presiden! STATE OF OHIO, COUNTY OF HAMILTON - ss: DAVID C. KITCHw (877-977-2405) On this 8TH day of DECEMBER 2015 , before me personally appeared DAVID C. KITCHIN, to me known, being duly sworn, deposes and says that he resides in Cincinnati, Ohio, that he is a Divisional Senior Vice President of the Bond Division of Great American Insurance Company, the Company described in and which executed the above instrument; that he knows the seal of the said Company; that the seal affixed to the said instrument is such corporate seal; that it was so affixed by authority of his office under the By -Laws of said Company, and that he signed his name thereto by like authority. 1 kv 0-%i This Power of Attorney is granted by authority of the following resolutions adopted by the Board of Directors of Great American Insurance Company by unanimous written consent dated June 9, 2008. RESOLVED: That the Divisional President, the several Divisional Senior Vice Presidents, Divisional Vice Presidents and Divisonal Assistant Vice Presidents, or any one of them, be and hereby is authorized, from time to time, to appoint one or more Attorneys -in -Fact to execute on behalf of the Company, as surety, any and all bonds, undertakings and contracts of suretyship, or other written obligations in the nature thereof' to prescribe their respective duties and the respective limits of their authority; and to revoke any such appointment at any time. RESOLVED FURTHER: That the Company seal and the signature of any of the aforesaid officers and any Secretary or Assistant Secretary of the Company may be affixed by facsimile to any power of attorney or certificate of either given for the execution of any bond, undertaking, contract of suretyship, or other written obligation in the nature thereof, such signature and seal when so used being hereby adopted by the Company as the original signature of such officer and the original seal of the Company, to be valid and binding upon the Company with the same force and effect as though manually affixed. CERTIFICATION I, STEPHEN C. BERAHA, Assistant Secretary of Great American Insurance Company, do hereby certify that the foregoing Power of Attorney and the Resolutions of the Board of Directors of June 9, 2008 have not been revoked and are now in full force and effect. Signed and sealed this 11TH S1029AF (06/15) day of JULY 2017 Assistant Secretary CALIFORNIA JURAT WITH AFFIANT STATEMENT GOVERNMENT CODE § 8202 :�'n:.(',<; '±C�'v('43.C:C�.i;F'.C:C-'�.C'E:iK',r'(7Ct,Gt'(:S-'.i`C'.7i eG:C7C:Sk:'[:�SG�n.L"f>6 • . ;S.%c �'CGEi:f�[7�d:Pi7[`SrC'Sa'4'�'C,d:Y'.GA s."1 ti,r%C;C.�:L:i VSee Attached Document (Notary to cross out lines 1-6 below) ❑ See Statement Below (Lines 1-6 to be completed only by document signer[s], not Notary) Signature of Document Signer No. 1 Signature of Document Signer No. 2 (if any) A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California Subscribed and sworn to (or affirmed) before me County of Gran, �e on this 4— day of Aug»st 20 17 by Date Month Year (1) Dick W. Voj,,k_- KALE 120WNIAN Coi w slon • 2103746 Nopry we - wifornis s 0" County My Cww. EMITU Mar 18 2019 (and (2) Name(s) of Signer(s) proved to me on the basis of satis,factory evidence to be the pers (s) wh r d before me. Signatur Signature o ary Public Seal Place Notary Seal Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: Document Date: Number of Pages: Signer(s) Other Than Named Above: 02014 National Notary Association - www.NationalNotary.org - 1 -800 -US NOTARY (1-800-876-6827) Item #5910 NON -COLLUSION AFFIDAVIT (Title 23 United States Code Section 112 and Public Contract Code Section 7106) FY 14-15 BRIDGE PREVENTIVE MAINTENANCE PROGRAM Federal -Aid Project BPMPL-5450(086) Bid No ENG-17-18-MO101 City Project M0101 City of Santa Clarita, California To the CITY OF SANTA CLARITA: In conformance with Title 23 United States Code Section 112 and Public Contract Code 7106, the Bidder declares that the bid is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation; that the bid is genuine and not collusive or sham; that the Bidder has not directly or indirectly induced or solicited any other bidder to put in a false or sham bid, and has not directly or indirectly colluded, conspired, connived, or agreed with any bidder or anyone else to put in a sham bid, or that anyone shall refrain from bidding; that the Bidder has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the bid price of the Bidder or any other bidder, or to fix any overhead, profit, or cost element of the bid price, or of that of any other bidder, or to secure any advantage against the public body awarding the contract of anyone interested in the proposed contract; that all statements contained in the bid are true; and, further, that the Bidder has not, directly or indirectly, submitted his or her bid price or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, or paid, and will not pay, any fee to any corporation, partnership, company association, organization, bid depository, or to any member or agent thereof to effectuate a collusive or sham bid. THE BIDDER'S EXECUTION ON THE SIGNATURE PORTION OF THE "BIDDER'S CERTIFICATION" SHALL ALSO CONSTITUTE AN ENDORSEMENT AND EXECUTION OF THOSE CERTIFICATIONS WHICH FORMA PART OF THE PROPOSAL. BIDDERS ARE CAUTIONED THAT MAKING A FALSE CERTIFICATION MAY SUBJECT THE CERTIFIER TO CRIMINAL PROSECUTION. M0101 FY 14-15 Bridge Maintenance Program Federal Project BPMPL-5450(086) C-14 NON -COLLUSION AFFIDAVIT FY 14-15 BRIDGE PREVENTIVE MAINTENANCE PROGRAM Federal -Aid Project BPMPL-5450(086) Bid No ENG-17-18-MO101 City Project M0101 City of Santa Clarita, California TO BE EXECUTED BY EACH BIDDER OF A PRINCIPAL CONTRACT STATE OF CALIFORNIA ) COUNTY OF LOS ANGELES )) § Dick W. Vo els being first duly sworn deposes and says that he is the Vice President (sole owner, a partner, president, etc.) of Peterson -Chase General Engineering Construction Inc. the party making the foregoing bid; that such bid is not made in the interest of or behalf of any undisclosed person, partnership, company, association, organization or corporation, that such bid is genuine and not collusive or sham, that said BIDDER has not directly or indirectly induced or solicited any other BIDDER to put in a false or sham bid, or that anyone shall refrain from bidding, that said BIDDER has not in any manner, directly or indirectly sought by agreements, communication or conference with anyone to fix the bid price of said BIDDER or of any other BIDDER, or to fix the overhead, profit, or cost element of such bid price, or of that of any other BIDDER, or to secure any advantage against the public body awarding the Contract or anyone interested in the proposed Contract; that all statements contained in such bid are true, and further, that said BIDDER has not, directly or indirectly, submitted his bid price, or any breakdown thereof, or the contents thereof, or divulged information or date relative thereto, or paid and will not pay any fee in connection, therewith to any corporation, partnership, company, association, organization, bid depository, or to any member or AGENCY thereof, or to any other individual information or date relative thereto, or paid and will not pay any fee in connection, therewith to any corporation, partnership, company association, organization, bid depository, or to any member or AGENCY thereof, or to any other individual, except to such person or persons as have a partnership or other financial interest with said BIDDER in his general business. Bidder: Title vice Subscribed and sworn to and before me this day of , 20_. Seal of Notary M0101 FY 14-15 Bridge Maintenance Program Federal Project BPMPL-5450(086) C-15 CALIFORNIA JURAT WITH AFFIANT STATEMENT GOVERNMENT CODE § 8202 6:sXA -"A "e" ".c:S`t:C`YC:t.[;ler..�Y.`.�C?r!C.cCiC.`�c>5'CSC.C`S•,rf,.a?'s1l'�3['n-�S'.G'C-:[��C-rc?G; n`xY`5 >c; �`.c; C`ic;�'F %ee Attached Document (Notary to cross out lines 1-6' below) ❑ See Statement Below (Lines 1-6 to be completed only by document signer[s], not Notary) Signature of Document Signer No. 1 Signature of Document Signer No. 2 (if any) A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of Orange KALI GOGLANIAN Conan elon * 2108746 N"y PubNC • CNNomin 100" County my Canon res mw 10 2010 Seal Place Notary Seal Above Subscribed and sworn to (or affirmed) before me on this 4 day of Aiigst , 20 17 by Date Month Year (1) Dick W. Vogels (and (2) Name(s) of Signer(s) proved to me on the basis of satisfactory evidence to be the person(s)an- Signature before me. Signat of f tary Public OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: Number of Pages: Signer(s) Other Than Named Above: Document Date: -�.<.�Y.,�,c;�,c;.�.ti�.<:c•i;,�1.:-,.,uv—� .�.;c.�Y-,c:<`;�=Lz-;<,z.ti<-.C;r:�.<c�ezie=.tz,� .�;X,:�-.,,c-<�C.� „<',U'�';<,�;Gv �..::r:�.w?c;z%i;z�.r:L.�;Lc=4 y<.1:c=L'<:�a ©2014 National Notary Association • www.NationalNotary.org • 1 -800 -US NOTARY (1-800-876-6827) Item #5910 BIDDER'S QUESTIONNAIRE FY 14-15 BRIDGE PREVENTIVE MAINTENANCE PROGRAM Federal -Aid Project BPMPL-5450(086) Bid No ENG-17-18-MO101 City Project M0101 City of Santa Clarita, California If the bidder has answered the questionnaire within the past year and there are no significant changes in the information requested, then the bidder need not file a new questionnaire. If there are changes, indicate those changes. Should the space provided not be adequate, so indicate and complete information on a separate page(s) and attach hereto. 1. Submitted by: Dick W. Vogels Telephone: 949-252-0441 Principal Office Address: 16351 Construction 2 Type of Firm: Peterson -Chase General Engineering Construction Inc. Corporate: X Other: Individual: Partnership: 3a. If a corporation, answer these questions: Date of Incorporation: 1/3/1991 State of Incorporation: California President's Name: _ Greg Chase Vice -President's Name: Dick W_ Vogcls Secretary or Clerk's Name: Dick W. Vo els Treasurer's Name: Dick W. Vo els 3b. If a partnership, answer these questions: Date of organization: State Organized in: Name of all partners holding more than a 10% interest: Designate which are General or Managing Partners, 4. Name of person holding CONTRACTOR's license: Greg Chase License number: 615876 Class: A,C13,02 Expiration Date: 3/31/2019 5. CONTRACTOR's Representative: Dick W. V Title: Vice President Alternate: Kati Goglanian Title: Administrative Assistant 6. List the major construction projects your organization has in progress as of this date: Owner: (A) Caltrans (B) Caltrans Project Location: Los Angeles Los Angeles Type of Project: Replace Conc Cold Const concrete barriers and install midwest Plane and Place HMA guard rails M0101 FY 14-15 Bridge Maintenance Program Federal Project BPMPL-5450(086) C-16 CERTIFICATION OF NON -SEGREGATED FACILITIES FY 14-15 BRIDGE PREVENTIVE MAINTENANCE PROGRAM Federal -Aid Project BPMPL-5450(086) Bid No ENG-17-18-MO101 City Project M0101 City of Santa Clarita, California The 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 CONTRACTOR certifies further that he will not maintain or provide for his employees any segregated facilities at any of his establishments, and that he will not permit his employees to perform their services at any location, under his control, where segregated facilities are maintained. The 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, rest rooms, and wash rooms, restaurants and other eating areas, time clocks, locker rooms and other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, and housing facilities provided for employees which are segregated by explicit directive or are in fact segregated on the basis of race, creed, color, or national origin, because of habit, local custom, or otherwise. The 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 subcontracts 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. Peterson -Chase General Engineering Construction, Inc. CKOUNWI_T"fe 7 Required by the May 19, 1967 order on Elimination of Segregated Facilities, by the Secretary of Labor — 32 F.R. 7439, May 19, 1967 (F.R. Vol. 33, No. 33 — Friday, February 16, 1968 — p. 3065). M0101 FY 14-15 Bridge Maintenance Program Federal Project BPMPL-5450(066) C-17 NONLOBBYING CERTIFICATION FOR FEDERAL -AID CONTRACTS FY 14-15 BRIDGE PREVENTIVE MAINTENANCE PROGRAM Federal -Aid Project BPMPL-5450(086) Bid No ENG-17-18-MO101 City Project M0101 City of Santa Clarita, California The prospective participant certifies, by signing and submitting this bid or proposal, 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 Federal 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 agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (2) 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 Federal 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 Lobbying Activities," in conformance with its instructions. 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. The prospective participant also agrees by submitting his or her bid or proposal that he or she shall require that the language of this certification be included in all lower tier subcontracts, which exceed $100,000 and that all such sub -recipients shall certify and disclose accordingly. THE BIDDER'S EXECUTION ON THE SIGNATURE PORTION OF THE "BIDDER'S CERTIFICATION" SHALL ALSO CONSTITUTE AN ENDORSEMENT AND EXECUTION OF THOSE CERTIFICATIONS WHICH FORMA PART OF THE PROPOSAL. BIDDERS ARE CAUTIONED THAT MAKING A FALSE CERTIFICATION MAY SUBJECT THE CERTIFIER TO CRIMINAL PROSECUTION. M0101 FY 14-15 Bridge Maintenance Program Federal Project BPMPL-5450(086) C-18 DISCLOSURE OF LOBBYING ACTIVITIES COMPLETE THIS FORM TO DISCLOSE LOBBYING ACTIVITIES PURSUANT TO 31 U.S.C. 1352 1. Type of Federal Action 17 a. contract b. grant c. cooperative agreement d, loan e. loan guarantee f. loan insurance 2. Status of Federal Action: ❑ a. bid/offer/application b. initial award c. post -award 4. Name and Address of Reporting Entity Prime Subawardee Tier if known Congressional District, if known 6. Federal Department/Agency: 8. Federal Action Number, if known: 3. Report Type: Ela. initial b. material change For Material Change Only: year quarter date of last report 5. If Reporting Entity in No. 4 is Subawardee, Enter Name and Address of Prime: 0ressional District, if known Fed 1 Program Name/Description: A Number, if applicable 9. Award Amount, if known: 10. a. Name d Add of Lo E b. It gals Tlf�tr' (If in idual, a lame, F na e, M add ss if di{la. ame, f 11. 12. 14. (attach Continuation Sheet(s) if necessary) Amount of Payment (check all that apply) 13. Type of Payment (check all that apply) $ actual planned a. retainer b. one-time fee Form of Payment (check all that apply): c. commission ea. cash d. contingent fee b. in-kind; specify: nature a deferred value f. other, specify Brief Description of Services Performed or to be performed and Date(s) of Service, including officer(s), employee(s), or member(s) contacted, for Payment Indicated in Item 11: (attach Continuation Sheet(s) if necessary) 15. Continuation Sheet(s) attached: Yes ❑ No ❑ I& Information requested through this form is authorized by Title 31 U.S.C. Section 1352. This disclosure of lobbying reliance Signature: was placed by the tier above when his transaction was made or entered into. This disclosure is required pursuant to 31 Print Name: U.S.C. 1352. This information will be reported to Congress semiannually and will be available for public inspection. Any Title: person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Telephone No.: Date: Authorized for Local Reproduction Federal Use Only: Standard Form - LLL M0101 FY 14-15 Bridge Maintenance Program Federal Project BPMPL-5450(086) C-19 INSTRUCTIONS FOR COMPLETION OF SF -LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of covered Federal action or a material change to previous filing pursuant to title 31 U.S.C. section 1352. The filing of a form is required for such payment or agreement to make payment to lobbying entity 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 a covered Federal action. Attach a continuation sheet for additional information if the space on the form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence, the outcome of a covered Federal action. 2. Identify the status of the covered Federal action. 3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last, previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District if known. Check the appropriate classification of the reporting entity that designates if it is or expects to be a prime or subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the first tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in Item 4 checks "Subawardee" then enter the full name, address, city, state and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organization level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action identification in item 1 (e.g., Request for Proposal (RFP) number, Invitation for Bid (IFB) number, grant announcement number, the contract grant. or loan award number, the application/proposal control number assigned by the Federal agency). Include prefixes, e.g., "RFP -DE -90-001." 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitments for the prime entity identified in item 4 or 5. 10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity identified in item 4 to influenced the covered Federal action. (b) Enter the full names of the individual(s) performing services and include full address if different from 10 (a). Enter Last Name, First Name and Middle Initial (MI). 11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (item 4) to the lobbying entity (item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that apply. If this is a material change report, enter the cumulative amount of payment made or planned to be made. 12. Check the appropriate box(es). Check all boxes that apply. If payment is made through an in-kind contribution, specify the nature and value of the in-kind payment. 13. Check the appropriate box(es). Check all boxes that apply. If other, specify nature. 14. Provide a specific and detailed description of the services that the lobbyist has performed or will be expected to perform and the date(s) of any services rendered. Include all preparatory and related activity not just time spent in actual contact with Federal officials. Identify the Federal officer(s) or employee(s) contacted or the officer(s) employee(s) or Member(s) of Congress that were contacted. 15. Check whether or not a continuation sheet(s) is attached. 16. The certifying official shall sign and date the form, print his/her name title and telephone number. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instruction, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, D.C. 20503. SF -UL -Instructions Rev. 06-04-90<<ENDIFu C-20 M0101 FY 14-15 Bridge Maintenance Program Federal Project BPMPL-5450(066) T m 0 m D r 0 rn W r in ttn O O 00 0) 0 m O N O N W, W z 0 m z i I-, V F� 00 O FA O N D G) m m m z m D_ z m z D z C) m 0 G) D G1 N m D r m v co 0 n m T N N Ul G1 m z MM rn� w � r m nz O G1 � Lo s -4M M rr�� CS �x