HomeMy WebLinkAboutSTEPHEN DORECK EQUIPMENT RENTALS, INC.I
Recording Requested By, Recorded in Official Records, Orange County
And When Recorded Mail To: Tom Daly, Clerk-Recorder
Clerk of the Council, City of Santa Ana I VIII I I IIIIII III VIII VIII VIII VIII VIII VIII VIII VIII VIII IIII I I III IIII
NO FEE
20 Civic Center Plaza, P.O. Box 1988
Santa Ana, CA 92702 * $ R O O O 4 8 9 5 6 3 7 $ *
2012000341966 9:03 am 06/18/12
217 4'13 N12 1
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I THIS SPACE FOR COUNTY RECORDERS USE ONLY
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s- ? !' - ` ° ! NOTICE OF COMPLETION
NOTICE IS HEREBY GIVEN that the undersigned City of Santa Ana, California, a
municipal corporation, with the address of City Hall, 20 Civic Center Plaza, Santa Ana,
California, 92701, is the owner of the property hereinafter described, that said owner has caused
construction of CATALINA STREET PUMP OWNER'S ASSOCIATION WATER SERVICE
W CONNECTIONS under contract entered into on NOVEMBER 28. 2011, with STEPHEN
a DORECK EQUIPMENT RENTALS_ INC., on which contract International FIDELITY
x ? INSURANCE COMPANY is surety. The property on which such work improvement was
? c placed is in the City of Santa Ana, County of Orange, State of California, and described as
m F Project No. 10-6403 located at: ROOSEVELT AVENUE. The work improvement on said
o w property was accepted as completed on JUNE 8. 2012.
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byTY O'xJ? ?-tihA ASIA, A Mi_JNICIPAL CORPORATION
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w ? Dated: ?O?L ??? Z Interim City Engineer
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VERIFICATION
I, the undersigned, say: I am the Interim City Engineer
of the City of Santa Ana, California; I executed the foregoing Notice of Completion acting on
behalf of the owner of the property therein described; I make this verification on behalf of said
corporation by authorization of the City Council of the City of Santa Ana; I have read said notice
and know the contents thereof; and I declare under penalty of perjury that the facts therein stated
are true.
Executed on ??? y''? (Z at Santa Ana, California
,.yj,.? _ ?l,l?/lEl/VV?,
(Signature of individual swearing that the
contents of Notice of Completion are true.)
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THIS NOTICE OF COMPLETION MUST BE RECORDED WITHIN TEN (10) DAVS AFTER COMPLETION
REQUEST FOR
COUNCIL ACTION
CITY COUNCIL MEETING DATE: CLERK OF COUNCIL USE ONLY:
NOVEMBER 28, 2011
TITLE: avPROVEJD /I• ?8•/?
CONTRACT AWARD FOR CATALINA M As Recommended d3 U
STREET PUMP OWNERS DAs Amended
ASSOCIATION WATER SERVICE f]ordioaoceonlaReading
CONNECTION (PROJECT N0,106403) 0 Implementing Resolut'wo
PROPOSITION 84 GRANT D setRubllcHeadrO Fy_
CONTINUED TO
FILE NUMBER
N CITY MANAGER
0 Ordinance on 2"° Reading
1. Al an appropriation adjusfinenf accepting funds in the amouof of $441,651 into the
Miscellaneous Revenue Funtl far Stale Grants (accounting unit 16417002.52025) and
appropriating $441,651 to the Public Works Wafer Quality and Control Expense Fund far
Wafer Capital Improvements (accounting unit 16417640.66301j.
2. Award a cenfract fo Stephen Doreck Equipment Rental, Inc., the lowest responsible bidder, in
accerdance with unit bid prices for the base bid plus In the eslimafetl ameunt of $169,120.45
(or construction of the Catalina Street Pump Owoers Association Water Service Connection
Project.
3. Approve a Fuuding Analysis with a total estimated construction cost of $245,200.
DISCUSSION
The Catalina Street Pump Owners Association (CSPOA) is a privately owned water system lhaf
provides domestic wafer service fo approximately 54 residences in the City (Exhibit 1j. The well
serving CSPOA is contam'mated with uranium and does not meet Title 22 drinking wafer standards.
In addition, CSPOA does not have cedlfied operators and ceooot afford to purchase a wafer
treatment system. Therefore, the State Department of Public Health and CSPOA are requesting
that water service be provided by the CltyImprovements include installation of new water services
and abandonment of the existing private well Once completed, the residents will have access to
Clry water.
In accordance with Safe Drinking Wafer, Wafer Quality and Supply, Flood Control, River and
Coastal Protection Act of 2006 (Proposition 84 Grano requirements, a resolution was adopted by
the City on July 18, 2011 allowing the City fo accept Stale Grant Funding, construct public water
system improvemeofs and provide service to former customers of CSPOAFollowing adoption of
the resolution, the Ciry received a Letter of Commitment that promises fund'mg and aufhoriies
ConfractAward For106403 CSPOAWater
Service Connections
November 28, 2011
Page 2
construction o(fhe wafer improvements for CSPGA while awaiting completion o(lhe Proposition 84
This project was previously bid in September 2011. Originally, a combination of Proposition 64
Granlfunds and a Sfafe Revolving Fund (SRF) loan were intended fo be used forthe project. SRF
loan required a Disadvantage Business Enterprise goal be applied to the project Since then,
Proposition 84 has been identified as the sole funding source for this project and the
disadvantaged business goal was no longer required. On this basis, the City Council rejected all
hills and directed staff to rebid with a revised hid package that excluded the SRF requirements
from this project.
Grant funding application.
The Notice Inviting Bids was advertised on October 19 and 21, 2011, and bids were opened on
November 9, 2011. A summary of the bid Invitations mailed, the bids received, and the bid results
follows.
Santa Ana Contractors receiving notices:
Contractors requesting bidding documents:
Bids received:
Bids received from Santa Ana Contractors:
While the City made outreach efforts fo Santa Ana contractors regarding the Notice Inviting Bids,
only one requested plans The five remaidmg plan holders were telephoned to inquire about intent
to bid. One Santa Ana firm'mdicaled they did not perform the type of work required, one Indicated
they didn't receive the notice, and the other firms could not be reached.
The bids received are as follows:
NAME OF RESPONSIVE BIDDER CITY BIDAMDUNT
1. Stephen Doreck Equipment Rental, Ina Pico Rivera $169,120.45
2. John T. Malloy, Inc Los Angeles $176,017.60
3. Garcia JuarezConsiruction,inc. Brea $171,898,00
4. DominguezGeneralEngineering,lnc. Rosemead $161,110.00
5. J. A. Salavar Construction & Supply Corp. La Habra $192,228.80
6. Paulus Engineering, Inc. Anaheim $ 219,265.00
1. T.BU.Inc. Beaumont $265,080.00
A total of seven bids were received and all were responsive The lowest bid was submiftetl by
Stephen Doreck Equipment Rental, Inc. for $169,120.45, which is below the engineers estimate of
$331,516. The low bid is a result of the downfum o(fhe economy and the competitive market and
the fact that the Engineer's Estimate was based on the original Sfafe Revolving Fund Grant
application
Contract Award For 106403 CSPOAWater
Service Connections
November 28, 2011
Page 3
ENVIRONMENTAL IMPACT
In Accordance with the California Environmental Quality Act, the recommended action is exempt
this project.
FISCAL IMPACT
The funding analysis shows a total estimated cwsirucfion cost o($245,200 far the projec! (Exhibit
2) Upon approval of the appropriation adjustment, funds will be available in the Public Works
Water Quality and Control Expense Fwd (ar?owting uni116417640.66301j.
APPROVED AS TO FUNDS AND ACCOUNTS:
from further review. Categorical Exemption Environmental Review No.2009-19 has been filed for
Raul God'mei II
Executive Directo
Public Works Agency
Francisco Gufiemei
Executive Director
Finance & Management Services Agency
RGMJA
Exhibit 1: Project Location Map
2: Fund'mgAnalysis
NTS
VICINITY MAP
E%H?f 1
551" WATER SERVICES
p}IONF
sauraa?a Tlle? ?o? ,x?Rw?
np Cry CoUOCiI CATAllN4 STET PUlR ONMEFS ASWCIAiION
P? Agenda Dete WATER sE? oawErnar? ICI ?'
NOVEM?R2?2011 IPRO?ECfa-64m1
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1
FUNDINGANALYSIS
PROJECT N0.106403
CATALINA STREET PUMP OWNERS ASSOCIATION
WATER SERVICE CONNECTION
Construction ConUact $169,120
ConiracfAdministration $ 7344
Inspection and Testing $16,000
Contingencies $ 50,736
TOTAL ESTIMATED CONSTRUCTION COSTS 24$_?__Q2 Q
Eahlbif 2
PROJECT NO, IW03: CATALINA STREET PUMP OWNER'S ASSOCIATION WATER
SERVICE CONNECTIONS (REBID)
PROPOSAL & CONTRACT AGREE
BIDPROPOSAL
TO: CITYCOUNCBAFTRECMOFSANTAANA
PROM: Stephen Dereck Equipment Rentals, Inc
REQUIRBNIENI:
The wdersigaed dealaroa Ihu hdahe has ?eNpy examined Iho loealian of Qlepropoud wmk, that htlsha
hasexemNed the Plaoa and SpxificaGOna and Rid 6o auampanyvrg inshuclwa to BIDDERS, and hereby
pioposas to famish it material and do ell Ne warh rquimd to complete the said wad„ N auardarce with
followingachedula:
GlutioaStrutPemQ(feet'sAtaadadooWater ServireCo ooeetlnoa ebldl
Ire ?IS9 ? ?? M bill meal
1. Conshuct I" bhpper water Smvim pr EA y3 S ?? •UD S S •GU
?
? -?
Q
cicystdP?nNn•laol -
-
-
2 WnsWU2"BlowOfl'Asxmhlyp¢aCiry BA I $3,315•GD $?1S,oU
Sld. Plan No• 1414
1. I"Cold Mill SF 16,620 S •?? SI?2O
4. I"AC•Pavmnmf TN 223 $ NL2e? S I1 .2a
S, WeIlDesmmtion?Removal LS MY OF SANTA ANA
I SZl,oao.eOSZf,?.oU
said plans (deny), apaeifiadons and special pmviaiau, for de wit prir.Js) a lump wm(s) act forth in de
6. RepalrWwk LS f9 $5000 S3,pyQ__
Tolel S I I?2O• ?1?
PROJECT NO.10.6903 B,IQQF,R
Ca(al?eBprotPumPOv?r'sAssaaaiadon Fi>m sfaphwoorevkEquipme??kenialsfnc
WeteaServieeCors¢etlom(Rebfd) Addteas 9O95?OlegraphRoad
Pico Rivera, CA 90660
Phone(s) h62? 9494949 ?
Bidder
Si?lalmC
57e co L. Doterk Nice &?ideoc
TOBEMCL BDINB[DPACKAGE
BP I OF 13
CITY OF SANTA ANA
PROPOSAL AND CONTRACT AGREEMENT
LIST OF SUBCONFRACTORS
PROJECT NO, 10-6403
fmallsu6conuerawork exceeding lhetollowiogamount AA ?'
wltichevu is pm
Bwldia?, PBI?9? Ol6thef DIOJ&M91 Ill%Oh1A bld
EIDDERpropoare W suhontreet urfaN poniona of Ae woskso the tuna listed below;
Section GIW aL sxl of tbs Public ConGect Code requires Esdng of all subcontractors withlhc bld
NAME Q is -?
LOCATION ?
PHONE 9S?3b1 b5
TYPEOPWORI( IR s..S7,1h1C0)
NAME k + Y? ILOCATION Dl i ?Y?1
PHONE SII la6t• lD9
TYPEOFWORR hull' $(_G_gSl_W
0 uee18, Nghwsys including bddgeprojaNS; ll1%of No bid or SI0,000,
NAAtE
LCCpTION
PHONE
TYPEOFWORR _$_
NAME
LOCATION
PHONE _
TYPEOFWORR $
NAME
LOCATION
PHONE
1YPEOFWORK $
9ephe Dore?k &?uipmentRe fs, ln¢?
N ims broi '
Si Me IBidda
Stephen L Oareck IViae Presidene
NAME
LOCATION
PHONE
TYPEOFWORK $_
NAME
LOCATION
PHONE
TYPEOFWORR $_
NAME
LOCATION
PHONE
TYPEOFWORK S_
TO BEINCIUDED M BID PACKAGE
BP20F17
CITY OF SMITA ANA
PROIECTNOIA6403
PROPOSAL & CDNTRACTA
BIDDER'S STATEMENT
BIDDER uadersands and agaas dial Us written proposal (or any part thereof spnoif(ahy
designated and mpfed by the Chy of Seem Ana, herunafer AGENCY) shall constitute the entire
a?eemembemenBIDDER ad doe AGENCY mlyafiait his been stunted bythe C4Counoil,
endorsed by it Clerk of the Conrail with her sipahueand official sal notitlg haven the action of
approval of fie Council, sued by the Public Works Agency Executive Director Of his duly
aolhoriud agen4 and aigoed by the City Attorney, deeofing his approval of We form of tiu's
document, and its execution, and When it or an exam copy of it has been either delivered tO
BIDDERordepo?itedwiththeDNmAStmesPasmlService propalyaddmsaddotheBIDDER with
BIDDER furrier agras Thai upon delivery (as defined above) of Pw epc¢ptpd agrameol hdsie wiR
famish AGENCY all required bonds and ap{ifioate of habiliry instuana wi+bin tun (10) data
(axaludMg Setardeys, Sundays atd'AGB(JCV'S legal holidays), oi'tNe foods, rook, dmR, or
BIDDERS bond aubsdtufeA in lief th?f aaompanying mis propnal shall Ixcane tie propany of
me AGENCY and all be ronsidetad u paymat of damage due W mC delay and other causes
suffered by AGENCY beeoua of the failuro to tiuoish fie nxasary bonds and Iwaua it is
distinmly aid that ? proof of demagos actudly sufTered is difficult to asceataln; olhernise said
funds, cheek, druBa, or BIDDER'S bond aubsiNled in lieu Ihorwf shall he remmed to Ne
wdasigned
BIDDER undaslandschatabidisraquirodfort6eeafirework,?atthaastimamdguantWesatfoCh
h thebid schedulean solsly for the pmpase of ampating bids, and that final ampansation undo
dte eonttam will be6aad upon tin salad quendbts of work mtisfaemrily aompleled,
All tams eontaln¢d in the SpaefflcationA dw Certification of NomDiscnadnedon by CeaneaWrs,
and m¢ Workers' Compeasadon Insurenae Cedifloade are tc he ineo?pare? 6y refaeme into>ltis
Agaementend arcmade spaifially as part of tNs bid,
Stephen Dore?k EquipmentRentals, IneNemeofRinm /1. rl n __
the wrtem posmge effiaad thercm,
SiguatmeofBidder WL ? I
Slephett L. Dorerk ie¢ President
Tide
(fanrndividual,soatate)
TO 8E WCLUDED M BID PACKAGE
BP7DF17
PRO?CTN0,10?6403
CITOFSANFAANA
PROPOSALANDCONTRACTAa RFMFNT
(U a firm or aaparNaahip, st* the 6nn name and give the names of all individual rq
aomppaing the firm If a corporation, state legal name of taryoretlnn, and names of Prcsidenh
Sacrdary? TttB9WEr BIIE MAGBBBf? I?E[¢Of.)
QMDER'S STATP,MENT • CONfMUED
Stephan Doraek Equipment Rentals, Inc. Corporation
Catharine R. Doreak President Slaphan L. Doraok Vioe President
Stephenl.IcDoceokvice President HollyL,Lewis-Corp, SecIry,/Treasurer
C ONOPCOUNCO,:
IIWWIfdBd t0 ??,
WIhB6iIGBOI RSfi00AGE?ld
ATIE
? CLERIS OF COIINC
APPROVED AS FO FORM:
?YATfO EY
ACCEPTED FORTHEGITY OP SANTA ANA'.
EXECUFIVEDCRC T R
PUBLfCWORKSA CY
TO BE INCLUDED M 81D PACIUGE
Dart
BP40F1S
PROIFxT NO 14403: CATATINA STREET PUMP OWNER'S ASSOCIATION
SERVICE CONNECfION9 (REBID)
CITY OF SANTA ANA
TMSPROPOS,44)
(THE BIDDERS ffECUT(ON ON THE SIGNATURE PORTION OF THIS
PROPOSAL SHALL dlb'OCONSTRUfEANENDOkSkMENT,4ND
FXECMON OF THOSE CERTIFICATIONS WHICH AREA PART OF
PheBIDDBR bfephen Unreel &quipmcnt Reolals, Inc
propoaedsubcantraolor j? iY?YUCOtM n?n? ,traehY
cetdfies0iathe hazx",hasnot_, pauicipafedinapreviousconuactorsu6canuactsubject b
(heequsl oppodwity clauses, as required by Eseuutlve Orders 10925, [1114, or 11246, and (hati
whererequired, he has fled ud>It Weloint RopoAing Commitlee, the Dhector of the Office of
Fedceal Conhacf Compliance, aFeAeml Govemmen(oontretl1g or a?uinistering agonvy, artht
Po®mkeaidmYsCommitteoonAqualBmploymcntOppadwiry,all?onsduewderthe
applicablefillingrequiremath,
EQUAL EMPLOYMENT OPPORTUNITY CERTMCAI ION
Nora; TheuhovecetUftcadouisrepuiredbytM1ePqualEmpbymontOppatAmityRe?ledaosoftlu
Suaelary of fabor(41 C?160d.1(b) (Ij), and mast ho su6miried by BIDDENS eud
proposed aubcentracfoas Duly inwnnecdon udlh eontreew cod au6eogtrads which are
subject to du equal appodunity clause. Conhecw and suhontracts w?ieh ere exempt Gam
lheequal oppoMoity clauseare sct fob N 41 CPR 60LS. (Oenbmllq only cantracta or
subrontraotsof$IO,000crundaareexempf.)
Curceutly, SisndmdPomt 100(EEO•I) islhe only reparlrequirtdbythe C?eeuliveOrders
or Iheu implemenfing2guladonsProposed Prime Contractors and Su6conkaclors who hava pmticipated in a previous wnhacl or
aubcontxt subject tothe E»ecufive (hders and have not filed the required mpo?s should Hole fat
41 CPR 60d.7(b) (I) prevents the award of cenkact5 audsubconhacts wiles such contractor
submits ateport covercag the dtlinquent period or such o?erperiod apeoified by the Federel
Highway Administration arby tht Director, OBice ofPederel Conhaet Compliance, U SDepamneat of labor,
TO BE WCGUDBDIN BID PACKAO6
BPfOFl9
CITY OF SANTA ANA
PROIEC'f N0. 1W03! CATALMA STREET PUMP OWNER'S RSSOCIATION WATER
s?avrc?DDnm>E?TIONS?B>D?
EXECUPIONOFTHOSE CERPIFICATIONSWHICHdREA?ART OF
TNISPROPOSA6)
EQUAL EMPLOYMENT'OPPOB'fUNIT1'CER'fIFICATION
(THE BIDDERSEXECUTION ON THE SIGNATURE PORTION OF THIS
PROPOSAL S1GdLlALSO CONSTffUTEANBNDORS&h16NTAND
Tho BIDDER Stephen Doreck Fgalpme?rt R¢otals, Inc.
proposedsubcontractor ?m cup ?ti hereby
aAiflusthathe hasXx,hasnotpazliaipaledin apaviouseonfrastorsub¢onlladsubjoo(to
lfieequal oppodunity clauses, as regalred by F,auudve0rders 10925, 11114, or 11246, and Ihah
where required, he has filed w{? the7eint Reporting Commitla¢, the Director oPthe Olfice of
Pedwal Conhaet Complian?, a PeAere(Govemmenl eonVaefing or edmininanng ¢ganuy, or the
former PresidenPs Commihea onAquel6mploymeal OppoMnily, all rgwtzs duewd¢r the
applicable filling regwr.ma?ts
Not¢, The above rRfiificsGon is r¢quN' by me Equal 8mploym¢nt pppoMnity RegWafions of th¢
S¢cretary of Labor (41 CFR 6D•1.1(b) (I)), and must bo submihed by 91DDERS and
proposed suboooNadora poly inconnection wiB? cootrae?a and su6eophac? which arc
subjecltothe¢qualopporNnityclause. Contrsctsendsuhconhaclswhichareeaempttrom
Ihetqual oppoAutity alause azo eel Rt<h al 41 CFR 60LS(G¢nolally only ¢ootrants or
subtronVaots of $10,00V or under are eaempl,)
Curtently, Standard Form IW (Fk0?1) is [h¢ only report rtquircd by the Eaeeutive Orders
ortheuimplamemUgroguletlona,
Proposed Prime Conhactors and Su6contraclors who hav¢ parlicipaled in a pr¢vious contract os
subcontract subjectto the Bzecutiv¢ Orders and hav¢ not filed R¢ required repods should noiethai
41 CPR 60?LT(b) (1) prevtnlslhe award of wntrects and subcontracts ualcas such convector
submitr arepod wvering (he ddinqueN paned or such other period specified by the Fcdernl
Highway AdminEVetian or by the Dirular, 08irao(Fedaal CankaM Compliance, U.S.
Depatlmwt of labor,
TO BB MCLWED M BID PACItAGfi
BPSOFI9
CffYOPSANTAANA
PROIECTN0.ID64W
CER11PICAf10N OF ODISMOATION BY CONTRACTOR
1}a wderaipsud entraota or aorporatr oar, during 6e performance of N& contact carnfes as
follows
L 11i¢ Contractor shall not discrimhate against any ¢mployce or applicant for employment
beauseofrece,color, religion, sex,araalionaiongin The hie affirmative acton
to ensure that applicant are employed, and diet employees art k¢alad during employment wilhou4
adveNaing, layoff or tam?aGmn; rotes of pay or other forms of componsatiu; and selection for
treiang, v?ludingappmnUceship. TheConkactor agrees to past in conspicuous pleas, available to
employee and applicants for employm¢ak notices to be provided setting fotrhthe provisions of his
nondiscnminaEonelause.
regard to their race, color, religion, six, of natlaoal origin. Such action shall Nclude, but not be
limited tm,UuPollowing, amployment,upgreding,demotion,or transfer, mantiknantor recwuneltt
2. Th¢ Conkacror s6sll, io all solieikfions or advaNstmEnls for employes placed by or on
hehCf of the Contiec4or, stele ? all qualified epplieanta will rtrxive Consideration far employment
wi0outregatd torace,color, roligioq s¢z, ornational origin.
7, TheConkacrorshallaedtoesChlabortioionorreaceenletlveofwarkemwifhwhiahhahes
a alleckve bergawng agrument or otheer contract or wdasranding, a nofia ro be provided
advhNg the said labor union or wcekem' reprasen?alives of d?¢ Contractor's Commitmenta wrier
Als saetiw, end shall post wpias of the notia N anspiauous pleas available to employes wd
applicaolsforemploymen
4. Th¢ContredorsVallamplywhballprovisionsofEzxutlve0rder11246afgeptember24,
1965,audm(14arBe,rogula?ons,androlavantorderacfNaSemelalyofLabor,
S, Toe Conkamor shell fwnfsh all Nformetlon and ¢ports requirod by P?au6ve Order 11246
of September 24,1965, and by ales, rcgulatiors, and orders of the Smmelery of isbmr, or pursueul
dwaem, and will permit aeasa ro hismbr books,records, and aaowb by ?C edminislceing agency
and (he Seretaty of labor for pmpoaes of invesdgatien, to emetlain oampliwaa vnlh such roles,
regulations, and orders,
6, (n the ¢vcet of the Comtte(mr's non?ompliena with the nondiscrimination clauses of tfus
antral or wish any of the aid Hiles, regulatiors, or ordets, the ankacl may b¢ canaled,
tceminated,arsuspedediowholeorinpattwdtheConnecrormaybed¢cluedin¢Vgibl¢for
TO BE TNCLWED M BlD PACKAGE
BP60F13
CITY OF SANTA ANA
PROJECT N0.10.6405
fuAhu Oovemmant contracts or fed¢relly assiskd wnsGucdan ¢omreGa in accordance wiE
may 6e impoud and remedim invoked es provided N Eueeutive OrdPx 11146 of Sapt¢m6er 24,
1965, or by rule, mguladona, ororder mike Sato of labor, or as ofherniae prouidad bylaw,
PROPOSAL AND CONTRACT AGREEMENT'
CERTIFICATION OFNONDISCNNilNATIONEYCONTRACT OR-CONTm'UEd
procedures authorized in Execution Order 11246 of S¢pt¢mbm 24,190, and s't¢h other sanctions
The contractor shell inr7ude>he poNOn of the sentence immediately preceding persgnaph
esa
(1) snd the proriai¢na of paregrapha Q) Ibroogh (1) N ¢vary sub¢onhaot of purchase ord¢r I'll
¢aemplbl by colas, regulators, or orders of the Secretary oflabor issued pursuaolro Section 204 of
Ekauhv¢ Order 11246 of S¢p1¢mber 74,1965, so Wet such provisions will be hioding upon each
aubtontred or purohaae ostler sa ?e administering agency may dual a9 moans of anfoming such
provisioma, inolud?g sanegona for non[rcmplianae; provided, however, tbef N ?e event tMe
Contractor becomes involved ia, of is0umtan¢d wi(h, IingNion with a auhaontraclnr or ueudrn as a
result of such dlrecfion by the admuiistenng agency, the Contrecmr may request That the Unit¢d
Stsks mler ium saeh Gtiga6on to protal the imu¢sts of the UniUA Sfetas.
g. Pursuant to Cslifomia fa6or Code S¢elion 1735, as added by Chapty 643 Slafg,1979, and
as amended,
Na discrimimtlon shall be med¢ in 4e employment otpersona upon public works because at rae¢,
religious oreeA, actor, oedonal origin, erweshg physical trendiraps, mds?l car?idoq manul stems,
or scz of such persons, ea¢ept as provided a SuRon 142D, and my canheomr a(publiu works
violaVngdtissx'nissubjattoallthepereltle' s¢dfora'Iadonof?eClmpuc
g?
Tid¢ '
Stephen Dore?k Equipment Ren[als, Ina.
Finn
Da,¢ ll ?Zo U
TO BE INCLUDED INBID PACKAGE
BF1 OF 1J
CIFV OF SANTA ANA
PROIECTN0.10?6405
WORKERS' COMPINSA180NMSVRANCErFRTIPICAIfON
Asrequired byCaBfomiaLaborCodaSecfian 1860and 1661,theCongaclorcerdfies asfollows
PROPOSAL ANDCONTRACTAGRF,EMENT
I am aware of Aa provisions of Sacfien 3100 of the Labor Code, which requires every employer to
be irsm¢d again liability for worker's compensation or to undertake self-insurance in arcordartce
wig she proviaioim of tGe Carlo, and 1 Al wmply with such provisions hefaro Wmmenaing the
pe?ormance of fha work of tltiseonhad,
If I, as rho Contractor, now or at any Bme during Ibc course of dtis agrcementi qualify as an
employer under Califamia Labor Code Salion 33W, wdess the hhed employee(s) is (arc) ptcsoms
eaoluded by sad Labor Codq 1 shill fomlah the Ciry of Santa Ana wlfh ao inauraoce euvfirate
Rom mp wodcem' compensation insuaaca coma cerdfyu>g That I carry such ?stuanca and Bmtt?
policy shell not be amceled nor the aovemgereduced except upon Thirty (30) days prior wnnen
no6cetoduCitycfSanlaAna ` A
Signed /,? ? r
Tme Ste hen DorB?k /Vice President
Fig Stephen Doreek Equipment Rentals, Inc.
Qau I1?9?20?1
TO BE INCLUDEQ M BID PACKAGE
BP 80F 17
CITY OF SANTA ANA
PROICTNO IM403
RROROSALANDCONTRACTAOREEMENT
REFERENCES
BIDDER has pafomaed suinlar work within th¢test Nro years.
I City ofMooere? Park
Name and Address of Owner,
320 W. Newmark hve.,MonlereyPark,CA01764 Cesar Vega 62613071722
3777,191,00 WaIwL'melmprovemenls 812011
ContractAmawd Tyr of Work Date Compieled
The following an the ralnea, addresses, and telephone numbers for Ilueepublic agencies for which
Name and Addaess of ownu.
IGncCencedhdeRrea,CA92821 Jos¢Castto714)990.7600
Nerve and hf¢phon¢Numb¢raf p¢reon fmtiGar with proj¢at.
aIS0,00000 WatarMain lmprovemeols Gnrent
ConlmatMiOwl TypeofWotk DeteCompleted
long8¢arhWatu IBOOEWardlowOeplLongBea0rCP90807
Name and Addr¢ss of owner,
F6Rendon 562?S10174f
Nam¢endT¢IeQhaaeNumbmofpusanf¢miliarwithprojwl3is7,?7oa (asftronMam s72oii
CantractAmowt Type ofWotk DeteCompl¢ted
Name and Telephone Number of pewra familiar with project,
The foUawing are the dames, addresses, and telephone numbers of all 6rokms end sureties from
whom BIDDER invluda lopraure insuratue and bonds,
City of Brea
Commereial Surzly Bond Agency 1411 Batavia, Saitelll, Orange CP 9'2887 714647-Sfi80
OaNeaHaeka6ay
TO EE INCLUDEDlN EID RACKACE
BP90R13
C1TY OFSANTAANA
PROIECTNO. I0-6403
BIDDER'S STATEMENT REGARDBJG APPRENT1CESERP REOUIREM
PROPOSAL AND CONTRACT GREEMENT
N wdersiped Bidder is familiar wiN the nouiremenla of Section 1771.5 of the Slete Labor Code
agazd?g employment of apprentlom, and wdemlmds Ih¢t uonhaelom on ecnhanta uaeding
$30,OOdor20wmkingdsyaslmll;
I. Apply to the joint eppmntiecship aommittce edminismnng the uppreotlcesMp standards of
the nrafl or halo in the ama of Ih¢ sit¢ of Ihepublio work fora ¢eclifiwte approving the ooortaclor
wd¢r tha apprentic¢ahip dandarda fot the employment and (raining of apprentices m the area or
iadturtyaffected.
2. Employ ?enumh¢rofappe¢ndcesort6¢ratioofepprenficestojoum¢ymansgpulaledinfh¢
apprenhasWp standards.
S. Contribute to the fiord ar fords in raoh ecaft or trade N which he employe joumeymw or
apprenlirzs on the pubVc wok, N ti1a same amowt or upon IM same 6ssis snd in We same mamtr
ar the olhu wnhaalors, esctpf eonfrectom not amatory to ?e tmst agn¢emant shall pay a Bke
Signed I?' ? (/j/
Tiua 3tephay L. Dora?k /Vice President
E? Stephan Doreek Equipment Rentals, IneDam Itlgl2o
TG BEINCLUDED IN BID PACKAGE
BPIBOFI3
CITY OF SANTA ANA
PR07ECTNC.10.6407
PROPOSAL AND CONTRACT AGREEMENT
(Tide 23 United Slat¢sCode Section 112aud
PublicCoohacf Code Section 1106)
NON-COLLUSION AEDAVI
To Ne CITY OF SANTA ANA DBPARTh1ENT0P PUBLIC WORKS
U aceotdante with Title23 Unikd Smua Curio Sudon 112 awl PuNio ConfrcotCode1106N¢ bidder
dalaas Nat N¢ bid N cotmadein Neiuferesf af, or on behalf of, any undimlosed pereoq paNaersNp,
company, association, orgatdmdory m co?poralion; ? No bid is @ahuiua dnG not collusive or sham;
tlmt Ne bidder has not dirully or indirectly induced or solioiled any other bidder W put m a false or
sham bid, and has not tlimlly or Ndlrxdy colluded, conspired, cormivad or aped m1h any bidder or
arryoaa ola¢ to put N e ahem bid, or Ihal anyone "I tehdn from biddig,Nal toe bidder has not in
sny manger, dirccUy or indireotiy, w* by egretmanf, cammwi¢adoq of conference With anyone Po
puce, or of Net of any oNu bidder, ar to secure any adveoug¢ egalnu Nepublie body awarding Na
contrxx9 of agvona Nlerea(? in Ifie propoxd roruact, Nat all stalemems rondined N Ne bld aze hue;
and, fwlher, fat the bidder has no4 dlrcudy a udireuly, submihad ?S or hu bid prig or any
brakdown Nerenf, or the comenta thueof, or divvlgad Womudon u daN rel'efi4e tlumto, or ?itl,
end will not pay, enyfce fo any row<romtiaq paMersNp, company msocialion, or?nimdon, bid
depository, orto arty mambo aragent N¢nof to effaluele ecolludve or sham bid.
NOTE; The abovtNon?allusion Affidavit is pad of the Proposal. Signing fNs Pmpoml on
Ne si?eture portion thacof shell also coretimk sign?u?y of this uun<olluaion A?daviL
Biddus are ceutioned thal maldnR a false cedificauoa may aubiut the aatifiu m aiminal
signs ./lz(/rl'?t/? l y lT/'
I the bid price of die bidder or mY bidder or to ix my oa2ihced, proflb or cost element of die bid
$18[e oflallfefNa
C¢Ilnry Of WAog¢I¢s
Subsedbod and swum m (m ?'mced) hefor¢ ma on Ws 9?h day of Novemhw, 201,E by
Stephen L Dor¢ok proved to me on ? basic of sadsfadory midenae to be Ne porsor,(s)
whoapp¢aradbeforeme,
No blioSi NowyWblicSeal
Syha Sifuenrrs (Notary Pob6c)
TO BB N'CIUDED N' BID PACKAGE
BP IIDFI3
State n(California
Ctun7 of LOS ANGELES
SYlNN81fUfN1EX Suhs?ihed andawnmm(oto0irm')htfname
CarMINooM19091a? tfts 9? dayof Nouembee. 1DII__,bp
t StephenLDore?t prouedmme
XN112 PINX•CNXWNI if
IWMQIXICOYNy ? P10uedmmeanthehrslso(?fiafaeroryevideneem6eiM
XI Comm, ZONE, 2011 P¢iwu(s)who uppearedM1e[nrcme.
(?I; Signa .
CITY OF SANTA ANA
ROROSAG AND CONTRACT ACRFiEMENT
IDDER'SSTATE MR T?G9Rp1NG"ANT6KIg4BACK"RE
PROJECT NO 10-RO
The wdersiga¢d is suhmitwg Uds proposal ?t p¢tfomting by can Genl the walk requimd by these
bid doeum¢ata, agrces N ramply with the Copeland "Mfi•Kickhack" Aef (18 USC 74) es
supplemented in th¢ Dapattraeot ntLahor rcgNadona (29 CRR, Pad 3). 7Nis acf proNd¢s that each
eonhador of subraamac(os sVall be praNbit¢d 6om iadue?g, by any mans, any peason employed
in Uu conaWouon or mpau of public wotk, to giv¢ up any paA of the compenaedon m which helshe
is otb¢nvise endtl
Signed
Tih¢ Stephen Doce?k/Vi¢ePresideot
ply Stephen Doreck Equipment Rentals, Inc.
Dam ht?q?2pU
TO BE INCLUDED M BD PACIUGE
BP 120813
CITY of SANTA M'A
PROJECTN0.1g6407
PROPOSAL AND CONTRACT AGREEMENT
COMRACTOR'S1ICENBA'GSTATEMENT
Tlu undersigned rantreelot, orooTomte officet, deoleaesundor penalty ofpequry Thal & following
is Waand eortera.
Genkaotor'sNeme; Stephen Doreek Equipment Rentals, ln?.
Bnsineaakadr?s: 9096 Telegraph Road, PICO Rivera, CR 90660
Teiwhnae, 562) 949-4949
StaleContrawaor's
Ll?seN°.? 665471-A
Glasa.
EapuaGonDate: x/29 012
Signal:
rue, 3t phe Dareek I Vice P?2sident
TO BE MCLUDED W BB) PACKAGE
BP 13 OF 13
State of California
C¢unry of Los Angeles I
YbIAW NMBAMr04pNB(IRYf.I
personally appeared Stephen L 0oreck
NBAe?6fA00oP?6
who proved to ma on the basis of satisfactory euibance to be the pemon(si whose
nam¢is) islare subscribed to the within instrument and acknowledged to me tlnal helsheldey
a><acutetl the same in his)herl autoniad rspaciryi?s), end Ihat by hislharNhwr
aigoatureia) on the instrumantihe pemonisi, ortha a¢tlry upon hehalf of which Iha pamonisi
111912011 before me, Sylvia 81fuenteis, Notary Public,
I cehity under PENALTY OF PERJURY uncle? 0?e laws of die State of Califomia that tl?e
WITNESS my hand and ohlcial seal, OYLVIk OIYUEX1Ea
CaaNuk¢ / 1f0Y1Pt
XoIxYPoll •CeNwNr ?
LxAvis COam
Cantu. fr Im Oel Y, 7011
Signature ? (Seal)
spna eoNNrewwoi'r
OPTIONAL
TNWnNNBIN01R18N00 NBOWBIIOf?IIIBN E?aW,RIBNpIWOVBXIBEBLm pBR1N61B'jFIg ONNBELGIRI&NdNEfpM mfiVBN
M120dONfN IBIfNY8BN41BA3Ch0M?0?N$bIR108N0h81NWN0BN,
Description of Attached Document
IDla or Type of Document
acted, executed to instrument
foregoing paragraph is sue and conrecl
Document Oriue:
Signeris) Other Theo Named Abou¢
Capaeify(ies) Claimed by Signer
Sig¢er'sName
p Inbividual ? ?
? p Co?pomte0fh'cerTltla(s?, roemmumosere ?
? p PaMer- p Limited p General
p Atlamey io-Fact ?
p Tmstee ?
? p Gua?tliano?Conservator ?
? p Other. ?
? SignerlsRepresendng, ?
I I
I I
Company &ofile
COMPANY PROFILE
Company Profile
Company Search Company Information
Ltmpany Gearch
Company INTERNATIONAL FIDELITY INSURANCE COMPANY
Names
Old Company Names Effective
Date
Reference
lofomlatian
NAICGIOUp llst hark to tap
tines of Business
.Agent FOrService
Flnantial5lalemeols
PDf's DOROTHY O'CDNNDRMANSUN
Annual5rztements 1999 OAK ROAD
Company Complaint hatN to top
Company
Performances Relerenteinformation
ompprisao Data Results
Information ONE NEWARK CENTER 10TH FL
Old Company NEWARN, N107101-5107
Agent for Service
Company
EoMmement Acllon
LLmposlte
Complaints Studies;
Additlonal Info
FiodACompany
Repreualativeln
Your Area
View Financial
Disclaimer
NAIL#, 1691
California Company lD#, 43414
Date AUfhariaed In Lallfarnla, Otf09f1996
Uaose Glatus, UNtIM11ED?NORMAL
Company iype, PropertysCasually
State of DOmicile, NEW]FRSEY
bark to tap
NAILGroup List
NNC Group#, 4IDS AIA Holdings lnrf,rp
hark torop
Quarterly SUITE 02D
Statements WALNUT CREEK CA 94597
Lines OF Business
the company Is authoriaed to transact husloess within Nese Ilnesof Insuraore,
for an ezpNnadon of any of These t;rms, please refer Io the glossary,
SURELY
6atNrotop
p 1088 Callfomla Depanmen! of Insumote
Page 1 of I
hl[p:IlinteraGive,web.insurance.Da.govlcompanyprofileloompanyprofile?event=company... 1111012011
CITY OF SANTA ANA
PUBLIC WORKS AGENCY
20 CIVIC CENTER PLAZA (M•65)
SANTA ANA, CA 92701
TRANSMITTAL COVER SIFT
DATE: October 25, 2011
SUBJECT: ADDENDUM NO: ONE PROJECT NO; 1x6403
REMARKS: PAGESATTACHED; 2 MAIL STATION: M•65
PLEASE FAX THIS PAGE ONLY T0. Armando Fernandes
? FAX NO,; (114)647.3345 ?
PNONENO„ (714164)3321
NOTE: UPONRECEIPiOFADDENDUM,PLEASESIGNiNISSHEETANDREPLYVIAE•
MAIL i0; AFERNANDE2(dSANTA•ANA,ORG OR FAR 10114641,3145
ATTENTION; Armando Fernandez
I HEREBY ACHNOWLEDGE RECEIPT Of ADDENDUM NUMBER; ONE
PROJECTNO.. 11.6403 /?
CONPANY: ?? C f?,?, /?,, f ?, 310NANRE,
TNLE:
DAIS (? 01 ? PRIMNAME ?hti
MAYOR
11 IA NI do
MAYOR PROIEM
GwdieC. Alvmz
COUkCnM1ff.MBERS
Cula Bulonwle
DwidBuleuida
M0skMedina
Stl iNejoo
Vinwil F. SmNmfo
October2S,2011
ADDENDUM Nl
CITY OF SANTA ANA
PUBIJCWORESAGENCY
220S,DuryAn., MAf • FO.Bw.1988
SwOAn;Glifamie92101
MIERA1CnY MANAGBA
Pwl Wdln
IMERPMGiYAIIORNEY
IaSoete
G,EAXOF711ECON4Ca
MvieD, Huiw
SUBJECT; PROJECTN0,10.6403-CATALDlASTREET PUMP OW'N'ER'SASSOCIATION
The fDllovnngaddiUonsarAchanges have twwmedetolheslanderdspeGificetionsoflheaubjectprojeet:
Slaadard Soaificatiaos
I. BidOpeaiagDate
TheBid Opening Dafehasbeea extended tD WednesdayNovember9%, 2011 at2:00PM
All alder terms and conditionsremain the same
FORTHECITYOFSANTAANA
CesarE.B ,PE.
Principal Civil Engineer
Ylriajor0l AdinIIB6WiCSPOAWdpSevrzCa?eclianNawardatiooL4ddmdmn I hgat 10840JCddiruShatPmopPwdsAUacudmWga
SmiaCannadars,doa
THE AMERICAN INSTITUTE OF ARCHITECTS
Emd NumCe.5iED097
V
AIAOaumaolA3f0
Bid Bond
KNOW ALL MEN BY THESE PRESENTS. tal we
SYepkeo Coreck Equipment Reolaw, loc.
809E Telegraph Road
Pim Rivera CA 9CUv0
iC4GR Sabre Sptlr?s Padwey, Suae YID
Sgo Clio , CA 82128
awrporallon dutyargao¢¢d wd¢r6?a laws of 9fe Slate G Aexdersry
as Surety, harelrah¢rak 9se5urery, are held and fimly 6owd unlo
CRyafSeoteAOe
ZO CMc Curler Plata, how Ma, CABYIDi
as ON gee, he2inafterralled m¢ 0Agee, in Ge sum of
ten Pereent of Amounteld gears ($ to%dAmouoi elE?
for the paymeG Gwhfih sum wall and bury to be rrad2, tha said PoncipG aed tha said Surety, God aurs¢Nes, our
heirs, eeecumrs, atlmiaidratars, successors and assigns, joinfy and seuemlN, firtnN by Ih¢s¢ pleseoG.
WHEREAS, Ih¢ Principal hss suhmN¢da bld (or:
Celelim SVeel Pump Oamefa A9soclalloo Wafer?v'm Conoecfions Rehld ? PrajedNa. in6W3
as Prixipel, hateioaftaroalla9 the Priodoal,aod
International Fdd4 (Nuance Company
NOW, THEREFORE, if the 06fige¢ shall exept th¢ Gd of die P?Gpel end ge Pdoeipal shah ¢n(er Ind a C?neac(
wN?theOhggeeicauemar?cewiG?Getermsofsuohdfgandgrv¢suchdondorhatdsasmayf>eapeahediethe
hiddmgar Conhad gaumao(s wish gocA and soff?deol sur¢ylor the haVMul p¢r<Or of soh Cantmct and for
the prompt paym¢G of lade end ma(adal Nmishad ? Aa pmseoufion Nsreof, or In rye event of rye (enure of the
Pdodpal ? erAersuch CooVad antlgrve such bond or Eonds'rfhe Prlndpal shall pay to the Odlgee the d'deance
nG to exceed N¢ peoaly hereof heMz2n ? ameuot sp¢atlatl In sad did and such Wrger amount far which the
OG'g¢e may in good f? ran(md with another patly b padoml rye Wak avrered 6y said hid, then Nls obligation
shall6e null and void, othenuise b remain in Nllhme and a(fed.
Signedandsealedlhis tst day of November,YCn
elephen DaierAt Equipment Remal6,loc.
(PhhiessJ
Ael
lowroetiooel FldellrylreurenceComparry
ly f
Mum Ayala ly Iomeµlo?Fact
w oocuu¢aruta ? alo aoxo ? Aw m ? raeauartr ims so, nff ahamaN
i?unnrtsaaacnnECtSnsSnravE,kw,wA.¢tictowocmm5
CALIFORNIA ALL•PUAPOSE ACKNOWLEDGMENT
STATEOFCAbIFORNIA
Countyof Orange I
On 1111111 belomme,Susan Fluor, Nolary publlc ,
petsonallyappeared ArlumAyala
Namdst olSNo¢Qat
who proved to me on the basis of saVsfaboly evidence to
be the parson(s) whose name( Ii subscribed to the
Minn instrument and acknowledged to me that Pal
executed (he same in hislh rauthodaed capal
' ?pNP°eN
P342:9 n
7
r?
fAM
? antlthatbyhislhrsignature(s)onthelnstrumentlhe
.
, .
s
L
p
'
' per6on[?, of the Bratty Open hehat of WhCh thB perBOn(5?
mLa6fomta
r No ?m Pu61
016xNCECWNfY a abed, executed the instrument.
! >... M,reomm,hplmsNpix9Yeta
I certify under PENALTY OF PERJURY under the laws of
m0 State of CatllOmla that he foregoing paragraph is Ne
and Correct
Witness my hand and oflldal seal.
Signature ?-n
PB4B NOR SadI PffN2 SeIIBWIB0 J9al'f PWIY. SII II PII
OPTIONAL
Though fhe in(ormalioo below is not required by law, it mayproue valuable to persons relying on fhe tlccumenl
and soultlprevenl fraudulent remoualaod rashaahmeof of Ihis form to anolhardocomeot
Description of Attached Document
TitlsorTypaofDocumeoC BidSond
DooumentDale:1111111 NumberofPages, One
Sigoer?s?0lherThaoNametlAboue, None Dole Nate loaatl Nalna aodIDlaoll¢aOHmar
Capacity?i¢s? Claimed by Signers)
SignersNama, AtluroAyala
D Ind'midual
D Corporale0ffm¢r-Tille(s?:
Q Partner-OLlmiletlOGeneral
Atlomay In Fab
0 Trustee '
O Guardlao or Cnnaeruetor Tap of ihumbhere
D Other:
Sign¢r Is Representing:
Signers Name,
D lotlividual
D Corporela0(nner-TIIle?S)
D Partner-Olimiletl?General
D Atlom¢y in Fad
Q Trustee '
?GuardlenorCooseruator Topolihumbhere
? Other,
SigoerlsRepreseoting:
®4g0Nalonal NOlary Pssmatlommmee¢olo Pre., ePBm¢4?1•Clah!relp U91?152dp1?wwr?,NaIk?INAary,ory I@m PSB01 ReoAre'.@IItoIVFae 18M1616e¢7I
ENOWALLMENBYTHMPRESeNTS THE WTERNATIONUIDELI'fY.INSURANCE COMPANY, arorprmEon o[gan%ud aid eaispug
fewao(he ShleofNew lprmy, and h ing in pnnpipal ol'm me Cry of Newark', New forty, does humpy creature and Api
DWIGHT REILLY, ARTURO AYALA DANIEL HUCKAEAY
Orange, CA
Ire rue and awful Rimini m tam to wDus, sal and deliver broad on usheHffrs vureryrany and all Foods and undertakings eom acuedudemnily and
rimer wnhngsobliparD in the oamre hi whibe are or may It al td rNwred or pCommit by law Hmre ml¢, re@Wauon oonhaG Or odunuls and
_ 0e €rauhot of such mslmmad(s) m pursuame of most pmtanls shall it as dialing upon the said INTERNATIONAL FIDELITY INSURANCE
COMPANY, asfddy anddandi m all inlems and purpoms, as if me me had been duly exeNded and arknow edged by is regularly el l officers if ifa
pridcipal'dDwe
meBomdof
1Morrof ERNA NALFIDELITYLYSORANCITYyb?e EARJNCE COMPANY h aIe reading meminging adly called and and ithdap on' LOh day ofy 4La6ruaryumi , 1971
74
Dueu9hrs oflNfERNA ONALRID
h
The Preudenf or any Via Prisci ErumrveVice Preaem, Serraary or AHmed{S¢muary, hall Hve gowerand fluhonry
ill To appoml Afomeya to fads, Rod h Rwanda mem m ex¢sumon Nhalf of me Company, and alanh (he Seal of me Company herein, fonds and
und¢rmkmga, mnaanmo[indemnity and Omer writings ofligamry in lhoinnim di add,
(N To remove al anyGre, any such ahorrey infawand rcoe the armory given,
Fmifienmis PowerofAdowyls dgmdand sealwl byy hu'imifepumuamwriwlulion o[IMBOanlufOlregon'nfsaidEompaoy adopted olameeliog
dolt' relied and held an k 29h dey afApnl, IH2 of whuh mefopowing'w awemewpf
Now merefore me signal of sum oRicons and he Real of the Company may be affixed m any such power of auomey or any vrifl ruling of by
feaimhe; and any Wen, power ofanamey or uHfieam hearing Wchmudmllewgnalures or fuaimdes¢al shall fevalld anJbmhnggupon the COmpgny and any.
si?poAeeW eauuled and eeNRul byfacsmldesigmNresand faosunilereafshallb¢uabd abe binding upon meCommlwoy hh¢fuNre wimreyp?m loany
hood or urdutad'ngla whiHf Waled.
'?pp??????, 1N T?17MONY WRLREOk,IN'fENNATIONAL RIDEhITY INSURANCT COMPANY ha<naustQmis mtlrnnmol ra he
V ? sigu¢daH ita norpummsialmboaPu16yilsaumons¢d oHaer hu 161h HyafONohet AD 2047
O???J ?J, IN'fERNA170NALFID$LITYINIYIRANCECOMPANY.
e ?SEAI'? m
srgreoPNLwl?tseY ??? ??
r y 19?J4?, ? Caunryo[ESses ?,r?
se?mry
OnrhIel6N daYafOcro6¢r2m'Yl, before rtemme me'mdividual wfo eM¢nul¢d h¢ prewlu??gmslwnen4mme perwnally$mum, and, being by me duly
roam HidHeH lsmelHrem dehr'HJ andaulhonudaRiberd(IH INTERNA170NALRIDEGTYINBUNANCE COMPANY; mar mes¢alaffnwfm
mid inWum¢nl lame.Corydiafe&al of said Company', IDal ulereidCnrpom¢Seel and fusigoamre Wmedmy affu¢tlpy ordw of the Boanl of9irWOmol
Reid.Company
?rraryVm"b INTESTIMONYWHEREOF,IhaveReaunlorelmyhandaffuedmyOEmalSeal,
fd AZ °a,
Pn UP`s iq 'k slime CiDa[Newark New lermy heday and yearfim aNov¢wnhwr
a , ?0 RA
a r?
FAc'?, PW ANOPARYPlIBL1C0FNEWlERSEY
MnrnrxunAd My COmmiWion ?.plrcs Marti 29 'NI4
CFRTIFiCATIDN
I mewd¢mmn¢d ofic¢rofNTFANATIONAL RIDELI11'INS?NCB WMPANYAo hereby reHfy lhmlheverompared NePnregoinywpym[me
Power ofAdomey WdaEnlaVil, andlhe fnpyofineSeGlon ofineEylawsofsah C,thpaoyas Rel NAllnreid POwcEOfAaomey win Ne ORIGINAISON
INTtIEHOMEOFFICEOPSAID COMPANYaud lhallfie9meare cort¢I lmasrellnsmm¢oGand aflhewhohofhe?d ongnmis and Ual Neaaid Powrr
ofAWmN'Ms not been revoker pbeesaowm full (orceard el[e¢I.
INTETfIMONY WHERfNF IIwVGhereunm wamy hardmis?l9t Hyor Na?imbec, 2011
Stete of Callfomia
County of LoB Angeles
On 11f9?2011 62foreme, SyIvleSituentea "M,
I
personally appeared Stephen L Domck ?
I&rtaslm?oaipl r
who proved to m¢ on the basis of satisfactory evidence to be the pereoaisi whose
nemeis) Islare suhsc?lded to tl?a with'm Instmmant end aolmawledged to ma Ihat halsey
executed the same is hlslharphair eulhoriiatl oape¢ityhsl, and tl?at by hls@eH?r
signature(s) on tha'mstrument to parson(s), e? tl?e entity upon behalf of which tl?e pemonis)
acted, executed the instrument.
thelawsofth¢SlaleofCalifomiathatthe
? Icarry under PENALTY OF PERJURY under
? fonagoingparagraph is truaand comect.
Smy hand and oHicialseal
{ WITNES
Signature (SeaQ
Signal NohryPuNc
7. Irmb Nime eM i?b of Ne %fcei
6YENltSIN1EX1'fS
Comdubc / IW91?
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CommE ImOdE201d+
OPTIONAL
ihouab Nelnbimetloo beowlsoolaquiial by Aw,Nmaypmuevalrahlalo paiccmiaryfog oa Neb?umaoleModN pre+ml
M1auOObmiemmalaoGreaRrAm?tofN¢hnnloarptlsibaiumaol.
Description of Attached Document
Titleo?TypeofDocumenf:
Document Otlve,
Slgne?(si0the?ThanNemedAbove, _
Capacity(ies) Claimed by Signer
Signer's Name
0
0
0
0
0
0
0
Individual
Corporate OMice? rtleisi.
PaMer-- p
AtromeyiaFacl
Tmslee
Gua?tlian or Conservator
Olh¢r.
Limited p General
Signer Is Representing: