HomeMy WebLinkAboutSIEMENS INDUSTRY, INC. (2) I J�
Recording Requested By, Recorded in Official Records, Orange County
.And When Recorded Mail To: Hugh Nguyen, Clerk-Recorder
Clerk of the Council,City of Santa Ana II �1111
NO F E E20 Civic Center Plaza,P.O.Box 1988 IPI�+1I!11I�IPI 111�Il�fI III I II�1Santa Ana,cA 92702 RQI9O09s
2017000024224 9:32 am 01/19117
48 414 N12 1
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THIS SPACE FOR COUNTY RECORDERS USE ONLY
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1
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
a construction of PEDESTRIAN COUNTDOWN HEADS AND PUSH BUTTONS under
o contract entered into on JANUARY 19, 2016, with SIEMENS INDUSTRY, INC., on which
contract FEDERAL INSURANCE COMPANY AND FIDELITY AND DEPOSIT COMPANY
w a OF MARYLAND is surety. The property on which such work improvement was placed is in
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o w the City of Santa Ana, County of Orange, State of California, and described as Project No.
a 15-6830 located at: VARIOUS LOCATIONS, The work improvement on said property was
a
o ? accepted as completed on NOVEMBER 18, 2016.
CITY OF A,A MUNICIPAL CORPORATION
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Dated: r �a'I Principo&vil Engineer-Tyrone Chesanek
U 96 TITLE
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VERIFICATION
I, the undersigned, say: I am the City Engineer - Edwin "William" Galvez 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.
-_ J
Executed on 0 �l r , at Santa Ana, Calif rnia
(Signature of individ swearing that the
contents of Notice of Completion are true.)
THIS NOTICE OF COMPLETION MUST BE RECORDED WITHIN TEN(10)DAYS AFTER COMPLETION
REQUEST FOR
COUNCIL ACTION
CITY COUNCIL MEETING DATE:
JANUARY 19, 2016
TITLE:
AWARD CONTRACT FOR THE
INSTALLATION OF PEDESTRIAN
COUNTDOWN HEADS AND PUSH
BUTTONS (PROJECT NOS. 15-6830)
(STRATEGIC PLAN NO. 6 1B, & 1G)
1� lip
CITY MANAGE
RECOMMENDED ACTION
CLERK OF COUNCIL USE ONLY:
APPROVED ) 7�1 dlvp�
Ly As Recommended 1
❑ As Amended
❑ Ordinance on 1" Reading
❑ Ordinance on 2nd Reading
❑ Implementing Resolution
❑ Set Public Hearing For
CONTINUED TO
FILE NUMBER
1. Authorize the City Manager and Clerk of the Council to award a contract to Siemens Industry,
Inc., the lowest responsive bidder, in accordance with the bid in the amount of $596,076 for
the installation of pedestrian countdown heads and push buttons throughout the city, and
authorize the City Manager and Clerk of the Council to execute the contract, subject to non -
substantive changes approved by the City Manager and City Attorney.
2. Approve an appropriation adjustment recognizing $101,822 from the Highway Safety
Improvement Program funds into the Select Street Construction revenue account and
appropriating the same to the Select Street Construction Expenditure account.
3. Approve the Project Cost Analysis for a total estimated project delivery cost of $745,096,
which includes the contract base amount, administration, inspection, testing, and a 10
percent contractual contingency of $59,608, subject to non -substantive changes approved by
the City Manager and City Attorney.
DISCUSSION
The recommended action will improve pedestrian safety and enhance compliance with the
Americans with Disabilities Act. Traffic signals at selected intersections throughout the city
(Exhibit 1) will be upgraded with pedestrian countdown heads using the latest technology to
display a countdown of time remaining for pedestrians to complete crossing the roadway. In
addition, pedestrian push buttons will be lowered so that they are more accessible to all
pedestrians and easier to actuate. Once completed, these improvements will increase safety for
pedestrians while promoting more walking and bicycling throughout the city.
A Notice Inviting Bids was advertised on November 9 & 10, 2015, and bids were opened on
December 1, 2015. The following is a summary of the bid invitations made and the bids received:
Award Contract
Installation of Pedestrian Countdown Heads & Push Buttons
January 19, 2016
Page 2
Contractor Participation Data
Santa Ana contractors receiving notices
1
Contractors requesting bidding documents
15
Bids received
6
Bids received from Santa Ana contractors
0
Bid Results Summary
RANK
BIDDER'S NAME
LOCATION
BID
1
Siemens Industry, Inc.
Orange
$596,076.00
2
Asplundh Construction Corp.
Anaheim
$653,011.00
3
PTM General Engineering Service, Inc.
Riverside
$674,041.00
4
California Professional Engineering, Inc.
La Puente
$732,630.00
5
St. Francis Electric, LLC
Riverside
$741,970.50
6
Steiny and Company, Inc.
Baldwin Park
$790,907.00
Six bids were received and all were deemed responsive. Siemens Industry, Inc., submitted the
lowest responsive bid in the amount of $596,076. The Project Cost Analysis estimates the total
project delivery cost to be $745,096 (Exhibit 2). That amount is less than the engineer's estimate
of $827,820. Therefore, since there are sufficient funds to complete the project, staff
recommends award of a contract to Siemens Industry, Inc. The construction contract
incorporates the low bid and is ready for approval (Exhibit 3).
In July 2014, funding award from the Federal Highway Safety Improvement Program (HSIP) was
estimated at $989,700. In September 2015, the HSIP award was finalized at $1,091,522. The
appropriation adjustment in this Council action will recognize the additional $101,822 for
completion of this project.
STRATEGIC PLAN ALIGNMENT
Approval of this item supports the City's efforts to meet Goal #6 - Community Facilities &
Infrastructure, Objective #1 (establish and maintain a Community Investment Plan for all City
assets), Strategy B (equitably maintain existing streets and associated assets in a state of good
repair so they are clean, safe and aesthetically pleasing for all users) and Strategy G (develop
and implement the City's Capital Improvement Program in coordination with the Community
Investment and Deferred Maintenance Plans).
Award Contract
Installation of Pedestrian Countdown Heads & Push Buttons
January 19, 2016
Page 3
ENVIRONMENTAL IMPACT
In accordance with the California Environmental Quality Act, the recommended actions are
exempt from further review. Categorical Exemption Environmental Review No. 2014-20 was filed
for this project.
FISCAL IMPACT
The Project Cost Analysis estimates project expenditures to be $745,095.60, which includes
construction, contract administration, inspection, testing, surveying, and contingencies. Funding
is available in the Pedestrian Countdown Heads & ADA Push Button Upgrade project (No. 15-
6830) in the Federal Aid Safety Program Fund (Account No. 14717611-66220) and the Measure
M2 Local Fair Share Fund (Account No. 03217662-66220) using the following spending plan:
FY 2015-16 FY 2016-17
Federal Aid Safety Program Fund $335,293.02 $335.293.02
Measure M2 Local Fair Share Fund $37,254.78 $37,254.78
FY TOTAL $372,547.80 $372,547.80
PROJECT TOTAL
$745,095.60
An appropriation adjustment will be processed to recognize $101,822 from the Highway Safety
Improvement Program funds into the Select Street Construction revenue account (No. 14717002-
52001) and appropriating the same to the Select Street Construction Expenditure account (No.
14717611-66220).
Executive Director
Public Works Agency
FM/EWG/TC
Exhibits: 1. Location Map
2. Cost Analysis
3. Construction Contract with Bid
APPROVED ASITO FUNDS AND ACCOUNTS:
Executive Direct&
Finance & Management Services Agency
S`4 uu City Council
Agenda Date
S January 19.2016
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Project No. 15.6830: Pedestrian Countdown Heads and
Push Buttons
EXHIBIT 1
COST ANALYSIS
PROJECT NO. 15-6830: PEDESTRIAN COUNTDOWN HEADS AND PUSH BUTTONS
Construction Contract
$ 596,076.00
Contract Administration
$ 41,694.00
Inspection and Testing
$ 47,718.00
Survey
$ 0.00
Contingencies
$ 59,607.60
TOTAL ESTIMATED CONSTRUCTION COSTS
$ 745,095.60
EXHIBIT 2
CITY OF SANTA ANA EXHIBIT 3
Construction Contract
PROJECT NO. 15-6850
PEDESTRAN COUNTDOWN HEADS AND PUSH BUTTONS
This CONSTRUCTION CONTRACT is made and entered into this 19 day of January 2016, by
and between the CITY OF SANTA ANA, CALIFORNIA, a charter city and municipal
corporation organized and existing under the Constitution and laws of the State of California,
hereinafter referred to as "CITY" and Siemens Industry, Inc., hereinafter referred to as
"CONTRACTOR".
WITNESSETH:
The CITY and the CONTRACTOR, for the consideration hereinafter named, mutually agree as
follows:
1. CONTRACTOR agrees to perforin all the work and furnish all the materials at its own cost
and expense necessary to construct and complete in a good and workmanlike manner and to
the satisfaction of the City Engineer of the CITY, the Pedestrian Countdown Leads and Push
Buttons, hereinafter referred to as the "Work of Improvement", identified in and in
accordance with the Contract Documents prepared by the City's Public Works Agency and
approved by the City Council.
2. The complete Construction Contract consists of the "Contract Documents," as defined by the
Standard Specifications for Public Works Construction and which include the following:
• Notice Inviting Bids
• Information to Bidders
• Bid Proposal
• Bid Bond
• Contract Form
• Contract Bonds
• General Provisions
• Special Provisions
• Project Plans
• Required Contract Provisions Federal -Aid Construction Contracts
( Form FHWA 1273)
• Davis -Bacon Act and Wages
• Appendices
In case of conflict between the Contract Documents, the precedence of documents shall be as
established in the Standard Specifications for Public Works Construction.
3. CITY agrees to pay and CONTRACTOR agrees to accept in full payment to complete the
Work of Improvement the sunr total amount not to exceed $596,076.00, as set forth and
identified in the BID PROPOSAL, which is attached hereto and incorporated herein as
Exhibit "A'. The BID PROPOSAL contains a schedule of unit price(s) or lump sum(s)
based on approximate quantities only, and the City does not expressly or by implication
Page 1 of 3
CITY OF SANTA ANA
Construction Contract
PROJECT NO. 15-6830
PEDESTRAN COUNTDOWN HEADS AND PUSH BUTTONS
agree that the actual amount of work will correspond therewith, but reserves the right to
increase or decrease the amount of any class or portion of the work or to omit portions of the
work as may be deemed necessary or advisable.
4. CONTRACTOR agrees to complete the Work of Improvement within the time specified in
the 'Time for Completion of Improvements section of the BID PROPOSAL (Exhibit "A')
including commencing construction within the timeframe therein specified after issuance of a
Notice to Proceed.
5, The CONTRACTOR will pay, and will require all subcontractors to pay, all employees on
the Work of Improvement a salary or wage at least equal to the prevailing salary or wage
established for such work as set forth in the wage determinations for this work in accordance
with applicable State and Federal law.
6. CONTRACTOR shall, after award of this Contract, furnish two bonds to be approved by the
CITY, one in the amount of One Hundred Percent (100%) of the Contract price, to guarantee
the faithful performance of the work (Performance Bond), and one in the amount of One
Hundred Percent (100%) of the Contract price to guarantee payment of all claims for labor
and materials furnished (Payment Bond). This Contract shall not become effective until such
bonds are supplied to and approved by the CITY. CONTRACTOR shall, prior to the release
of the performance and payment bonds or the retention payment, furnish a warranty
performance and payment bond equal to at least ten (10%) percent of the final Contract price
or $1,000, whichever is greater (Warranty Bond).
CONTRACTOR shall, upon project completion as a condition of project acceptance, furnish
a Warranty Payment and Performance bond to be approved by the CITY, in the amount of
Twenty -Five Percent (25%) of the Contract price, to warrant the work done under said
Contract Agreement against material or quality defects for a period of one year after
acceptance by the AGENCY.
CONTRACTOR shall, after award of this Contract, furnish Certificates of Liability
Insurance and Worker's Compensation Insurance as outlined in the General Provisions, to be
approved by the CITY, u
Page 2 of 3
CITY OF SANTA ANA
Construction Contract
PROJECT N0. 15-6830
PEDESTRAN COUNTDOWN HEADS AND PUSH BUTTONS
IN WITNESS WHEREOF, the parties hereto have executed this Construction Contract on the
day and year first above written.
ATTEST:
MARIA D, HUIZAR
Clerk of the Council
APPROVED AS TO FORM:
SONIA R. CARVALHO
City Attorney
BY
JoSandoval
C of Assistant City Attorney
CITY OF SANTA ANA
DAVID CAVAZOS
City Manager
RECOMMENDED FOR APPROVAL:
Fred Mousavipour, P.E.
Executive Director, Public Works Agency
CONTRACTOR:
Siemens Industry, Inc
By:
Page 3 of 3
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
BID PROPOSAL
TO: CITY COUNCIL OF THE CITY OF SANTA ANA
FROM: SIEBMNS INDUSTRY, INC.
REQUIREMENT:
The undersigned bidder declares that they have carefully examined the location of the
proposed work, that they have examined the Contract Documents in its entirety and hereby
proposes to furnish all material and do all the work required to complete the said work in
accordance with said plans (if any) and the specifications for the unit price(s) or lump sum(s) set
forth in the following schedule:
Pro! ectp 15-6830
Item
Description
Qty
Unit
Unit Price
Amount
1
Replace Pedestrian Head Assembly with
734
EA
$
Countdown Head
2
Replace Pedestrian Head Module with
7
EA
Countdown Head
(�
3
Replace Pedestrian Push Button Assembly
948
EA
$ 00—
$ ) (pI j !`:
4
Replace Pedestrian Push Button
7.18
EA
5
Adjust Pedestrian Push Button Assembly to
831
EA
42 -Inch Above Finished Grade
6
Install New Pedestrian Push Button
52
EA
$.$r�
Assembly and Wiring
c -ate,
I
Total Base Bid For Project: 15-6830 $
The lowest responsible bidder shall be selected based on the total base bid. The City reserves
the right to award the Base Bid, and any, all, or none of the add -alternate bid items (if any).
The quantity for this bid item is shown for bid comparison only. This bid item shall not be
subject to the "25%" limit as stated in Section 3-2 of the Standard Specifications, The actual
amount for this item will be dictated by the actual quantity used, and the Agency reserves
the right to increase or decrease the quantity of this item accordingly.
1' This bid item is considered a Specialty Item per Section 2-3.2 of the Standard Specifications.
BP -1
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-8830: Pedestrian COUntdaWn pleads and Push Buttons
TIME FOR COMPLETION OF IMPROVEMENTS AND LIQUIDATED DAMAGES
The undersigned bidder hereby proposes to complete the Work for the total base bid amount
shown above, within eighty (80) working days after the commencement date stated in the
Notice to Proceed. The bidder also proposes to commence construction of the Work within ten
(10) days after issuance of a Notice to Proceed, and to continue in a diligent and workman -like
manner without interruption, and to complete the construction thereof within the time
specified above.
The liquidated damages amount in lieu of the amount specified in Subsection 6-9 of the
Standard Specifications, shall be $1,000 per calendar day.
Name of Firm SIEMENS INDUSTRY, INC.
Signature of BIDDER
Title LJ"i Ce c$�t r 7 }
�3C_f e tGC�
(if an individual, so state)
I3P-2
CITY OF SANTA ANA
PROPOSAL
PROJECT N0, 15-6830: Pedestrian Countdown Heads and Push Buttons
BIDDER'S STATEMENT
BIDDER understands and agrees that this Bid Proposal, Contract Documents and subsequent
Construction Contract Agreement shall constitute the entire agreement between BIDDER and
the AGENCY only after it has been accepted by the City Council, endorsed by the Clerk of the
Council with her signature and official seal noting hereon the action of approval of the Council,
signed by the Public Works Agency Executive Director or his/her duly authorized agent, and
signed by the City Attorney, denoting his approval of the form of this document, and its
execution, and when it or an exact copy of it has been either delivered to BIDDER or deposited
with the United States Postal Service properly addressed to the BIDDER with the correct
postage affixed thereto.
BIDDER further agrees that upon delivery (as defined above) of the accepted agreement he/she
will furnish AGENCY all required bonds and certificate of liability insurance within ten (10)
business days or the funds, check, draft, or BIDDERS bond substituted in lieu thereof
accompanying this proposal shall become the property of the AGENCY and shall be considered
as payment of damages due to the delay and other causes suffered by AGENCY because of the
failure to furnish the necessary bonds and because it is distinctly agreed that the proof of
damages actually suffered is difficult to ascertain; otherwise said funds, check, drafts, or
BIDDER'S bond substituted in lieu thereof shall be returned to the undersigned.
BIDDER understands that a bid is required for the entire work, the estimated quantities set
forth in the 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 BIDDER also certifies that the bid is a balanced bid.
In accordance with Section 7028.15 of the California Business and Professions Code, the
undersigned certifies under penalty of perjury that the foregoing is true and correct.
Name of Firm SIEMENS INDUSTRY, INC. (CORPORATION)
Signature of BIDDER
Title 7� Se(Q'kC:.-V—
(if an individual, so state)
(if a firm or co -partnership, state the firm name and give the names of all individual co-partners
composing the firm. If a corporation, state legal name of corporation, and names of President,
Secretary, Treasurer and Manager, thereof.)
President: CEO, Kevin Riddeu
Treasurer: CFO, Matthias Schielein
Secretary: Communication Officer, Franzislca Wagner
Address:
527 Madison Ave, 8th floor, New York NY10022
B P-3
Operations Manager: Mielmel Hutchens
2200 W Orangewood Ave, Orange, CA 92868
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-683(t Pedestrian Countdown Heads and Push Buttons
CONTRACTOR'S LICENSING and REGISTRATION STATEMENT
The undersigned contractor, or corporate officer, declares under penalty of perjury that he/she
and all his/her subcontractors are registered with the State of California Department of
Industrial Relations (DIR), and that the following is true and correct.
Contractor's Name: SIEMENS INDUSTRY INC
Business Address: 2200 w Orangewood Ave, orange, CA 92868
Business E -Mail MIC'HAEI,.IIUTCIIENS(i,),SIEMEN3.COM
Address: 2200 W Orangewood Ave, Orange, CA. 92868
Telephone: 714-448-6943
State Contractor's License No. and Class: 758796, C -10,C-20, C-1(,13
License
Expiration Date: 02/28/2017
State Dept. of Industrial Relations (DIR)
Registration No.: 1000002447
State Dept. of Industrial Relations (DIR)
Registration Expiration Date: 06/30/2016
Signed:
Title:
I ) i Ce.c ria c, 4, �e fo'k e.e
BP -4
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 75-6830: Pedestrian Countdown Heads and Push Huttons
PREVAILING WAGE COMPLIANCE AND MONITORING STATEMENT
Contractor is aware of the requirements of California Labor Code Section 1720, et seq., as well
as California Code of Regulations, Title 8, Section 16,000, et seq., ("Prevailing Wage Laws"),
which require the payment of prevailing wage rates and the performance of other
requirements on "public works" and "maintenance" projects. Since the services are being
performed as part of an applicable "public works" or "maintenance" project, as defined by the
Prevailing Wage Laws, and since the total compensation is $1,000 or more, Contractor agrees
to fully comply with such Prevailing Wage Laws.
City shall provide Contractor with a copy of the prevailing rates of per diem wages in effect at
the commencement of this Agreement. Contractor shall make copies of the prevailing rates of
per diem wages for each craft, classification or type of worker needed to execute the services
available to interested parties upon request, and shall post copies at the Contractor's principal
place of business and at the project site.
Contractor shall defend, indemnify and hold the City, its elected officials, officers, employees
and agents free and harmless from any claim or liability arising out of any failure or alleged
failure to comply with the Prevailing Wage Laws.
The undersigned certifies that the foregoing is true and correct,
Name of Firm SIEMENS INDUSTRY, INC.
Signature of BIDDER
Title C'z r {7at U
(if an individual, so state)
BP -5
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Ileads and Push Buttons
OWNERSHIP AFFIDAVIT
STATE OF CALIFORNIA )
COUNTY OF ORANGE )s5'.
CITY OF SANTA ANA }
that such a bid is genuine and not collusive or sham, and has not in any manner sought by
collusion to secure any advantage against the City of Santa Ana or any person interested in the
proposed contract, for himself or any other person. /
e
gnature er "a�T;s34aj "'�p,(,s aD401-Aror a& rvdc�c
Subscribed and sworn to before me this day of 20
Signature of officer Administering Oath (
BP -6
being duly sworn, deposes and says:
❑INDIVIDUAL
That he/she is the party making the foregoing proposal:
❑ PARTNERSHIP
That he/she is a member of the co -partnership firm designated as:
and who has been and is duly vested with the authority to make and execute
Instruments for the co -partnership by:
who constitute the other members of the co -partnership v
,'+]CORPORATION
That he is of:
SIEMENS INDUSTRY, INC.
a corporation which is making the foregoing proposal:
❑JOINT VENTURE
That he Is of:
one of the parties making the foregoing proposal as a joint venture, and the he/she has
been and Is duly vested with the authority to execute instruments for an on behalf of
the parties making said bid who are:
that such a bid is genuine and not collusive or sham, and has not in any manner sought by
collusion to secure any advantage against the City of Santa Ana or any person interested in the
proposed contract, for himself or any other person. /
e
gnature er "a�T;s34aj "'�p,(,s aD401-Aror a& rvdc�c
Subscribed and sworn to before me this day of 20
Signature of officer Administering Oath (
BP -6
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
STATE OF CALIFORNIA
County of_ Orange-__
On -\)K & ��t�efore me, Candace Gallaher - Nota v Public
Dale Here li Name ana Tiff of the Officar
personally appeared
CANDACEGALL�AHER C
Commission 8 2997338
zNotary public - California
zeMy
Orange County
Comm. Expires Jul 24, 20994
Place Notary Seal Above
who proved to me on the basis of satisfactory evidence to
be the persons}whose name.(s)-is/are-subscribed to the
within instrument and acknowledged to me that he/she/they—
executed the same in his/heritheir authorized capacity(ies),
and that by his/haritheir signatureayon the instrument the
person(zj,, or the entity upon behalf of which the person(s)-
acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of
the State of California that the foregoing paragraph is true
and correct.
n
Witness m and and official se I.
Signature�� -
Signature of Notary Public
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document:
Document Date:
Signers) Other Than Named
Capacity(les) Claimed by Signer(s)
Signer's Name: _...__
❑ Individual
❑ Corporate Officer—Title(s):�.___�.
❑ Partner— ❑ Limited ❑ General
CI Attorney In Fact
❑ Trustee
C7 Guardian or Conservator
❑ Other.
Signer is Representing:
Number of Pages: ..--.—_—.
Signer's Name:—.--------
0
ame:_,__________❑ Individual
❑ Corporate Officer—Title(s): _-,�
❑ Partner— ❑ Limited ❑ General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
CITY OF SANTA ANA
PROPOSAL
PR016CT NO. 156830: Pedestrian Countdown Heads and Push Buttons
KNOW ALL PRESENT that,
as BID
as SUf
are held and firmly bound unto the CITY OF SANTA ANA, as AGENCY, in the penal s �n of
Dollars ($ ), which is ten Sercent (10%)
of the total amount bid by BIDDER to AGENCY for the above -stated project, f the payment of
which sum, BIDDER and SURETY agree to be bound, jointly and severa firmly by these
presents.
THE CONDITIONS OF THIS OBLIGATION ARE SUCH that, whereas BI DER is about to submit a
bid to AGENCY for the above -stated project, if said bid is rejectedAr if said bid is accepted and
a contract is awarded and entered into by BIDDER in the man r and time specified, then this
obligation shall be null and void, otherwise it shall remain Wfull force and effect in favor of
AGENCY.
IN WITNESS WHEREOF the parties hereto have set the' names, titles, hands, and seal this
day of , 20_,
BIDDER*
SURETY*
Subscribed and sworn before me this day of
,200
Signature:
Nota/BIDDER/
and for the County of , State of
*ProSURETY name, address, and telephone number and the name, title, address,
and tumber of authorized representative.
13P-7
Document A310TM -2010
Conforms with The American Institute of Architects AIA Document 310
CONTRACTOR:
(Name, legal status anal address)
Siemens Industry Inc.
2250 Business Way
Riverside, CA 92501
OWNER:
(Name, legal status and address)
City of Santa Ana
20 Civic Center Plaza
Santa Ana, CA 92701
Bond Number: 79434433-CHU-15-22
SURETY:
(Name, legal.slalus and Inincipal place of business)
Federal Insurance Company
15 Mountain View Rd.
Warren, NJ 07061-1615
State of Inc: Indiana
BOND AMOUNT: Ten Percent of Amount Bid (10%)
This document has important legal
consequences. Consultation with
an attorney is encouraged with
respect to its completion or
modification.
Any singular reference to
Contractor, Surely, Owner or
other party shall be considered
plural where applicable.
PROJECT:
(Nanie, location or address, and Project number, if call-)
Pedestrian Countdown Heads and Push Buttons Replacement of Countdown Pedestrian Heads and PPB's City Wide
The Contractor and Surety are bound to the Owner in the amount set forth above, for the payment of which the
Contractor and Surety bind themselves, their heirs, executors, administrators, successors and assigns, jointly and
severally, as provided herein, The conditions of this Bond are such that if the Owner accepts the bid of the Contractor
within the time specific([ in the bid documents, or within such time period as may be agreed to by the Owner and
Contractor, and the Contractor either (1) enters into a contract with the Owner in accordance with the terms of such bid,
and gives such bond or bonds as may be specified in the bidding or Contract Documents, with a surety admitted in the
jurisdiction of the Project and otherwise acceptable to the Owner, for the faithful performance of such Contract and for
the prompt payment of labor and material furnished in the prosecution thereof; or (2) pays to the Owner the difference,
not to exceed the amount of this Bond, between the amount specified in said bid and such larger amount for which the
Owner may in good faith contract with another party to perform the work covered by said bid, then this obligation shall
be null and void, otherwise to remain in full force and effect. The Surety hereby waives any notice of an agreement
between the Owner and Contractor to extent) the time in which the Owner may accept the bid. Waiver of notice by the
Surety shall not apply to any extension exceeding sixty (60) days in the aggregate beyond the time for acceptance of bids
specified in the bid documents, and the Owner and Contractor shall obtain the Surety's consent for an extension beyond
sixty (60) days.
If this Bond is issued in connection with a subcontractor's bid to a Contractor, the term Contractor in this
deemed to be Subcontractor and the term Owner shall be deemed to be Contractor. 1
When this Bond has been furnished to comply with at statutory or other legal requirement in the to
any provision in this Bond conflicting with said statutory or legal requirement shall be deemed d
provisions conforming to such statutory or other legal requirement shall be deemed incorporated
furnished, the intent is that this Bond shall be construed as a statutory bond and not as a common It
Signed and sealed this 01st de n Deoem , 2015
/ r Siemens Inc
(Witness)/
'+lT
,u dJ,� / -� Federal Insurance Comber,
n�na ailX�N I f111 �� (Buret (Seal)
(Witness) Nan y L. Johnson
(Title) Sandra L. Ham, Attorney -In -Fact
ACKNOWLEDGMENT BY SURETY
S'I'A`I'E
OF Missouri
City of' St. Louis ss'
On this 01st
appeared
clay of December
Sandra L. Ham
Federal Insurance Company
2015 , before me personally
known to me to be the Auonie3-in-Fact of
_ the corporation
dial executed the within instrument, and acktiowledgcd to me that such corporation executed the same.
IN 1VI1'N1,',5S ),V11EREOF, I hate hereunto set my hand and affixed my official seal, at m}' office in the aforesaid
County, the day and year in this certificate lust above Written,
My Conunission Expires: September 16, 2019
(Seal) Bkiir%y r). C...'°`"""
Notory 1, 11c,, Notl t Seo[ !f
Store of Misso a �+
Louls County
MV Commissfo r ExpIrestS18tc 38336ef . 20
S-02301GEEF 2198
Brittany D. Clavin
Notary Public in the State of Missouri
County of St. Louis
Commission # 15638336
IcChubb POWER i Insurance Company n; ere Department
OF Vigilant Insurance Company 15 Mountain View Road
Surely ATTORNEY pacific Indemnity Company Warren, NJ 07059
Know All by These Presents, That FEDERAL INSURANCE COMPANY, an Indiana corporation, VIGILANT INSURANCE
COMPANY, a New York Corporation, and PACIFIC INDEMNITY COMPANY, a Wisconsin corporation, do each hereby constitute and
appoint Pamela A. Beelman, Cynthia L, Choren, Joann R. Frank, Sandra L. Ham, Nancy L. Johnson, Heidi A, Nothelsan,
Karen L. Roider and Debra C. Schneider of St. Louis, Missouri «----------'-- -- -- — — — ^ --^
each as bantam and lawful At cmey in. Feet to execute under such dnalgnallon In their names arid to affix their corporate seals to and deliver for alit oil their behalf as surely
thereon or atilemiso, bonds and undertakings and other wrhinga Obligatory in the nature thereof (other than ball bonds) given or executed In the course of business, and any
Instruments amending or Sharing the same, and onsenta to the modficakn or alteration of any htstnlment referred to to sold bonds or obtgagonal
In wmress YyhaRrof, said FEDERAL INSURANCE COMPA�1' VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY have each exocund and attested
these presants and arnxed their corporate seals on this 21 say of May, 2014.
VVAA PfesI
Oscan M CldrXos. A89�stant�Soc�m ry . I � D 9rti:4,. Jr„ Vtoe � �.
dYhhfAW" ,+
*0110,
STATE OF NEW JERSEY
ss.
County of Sonwrsot
on this 21m day Of May, 2014 before me, a Notary Public of New Jersey, paremally came Dawn M. Chloros, to rhe NnWM b mAsalalantamataryatFEDERAL
INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNNY COMPANY, the companleswhloh axacuied the foregoing PlemaltsAltomey, and the
Said Dawn M. Chiapas, being by me duly smm, did depose and say that she is Assistant Secretary of FED6RAL'IN5URANCIC COMPANY, VIGILANT INSURANCE
COMPANY, and PACIFIC INDEMNITY COMPANY and know$ Ira fwfponate seals thereof, that Ule seals affixed to the fbregoir 9 Povef N Attorney are such corporate seals
and were fhemlO aRaed by entreaty of the By- Laws of said Companies; and that she slgmo l Bald Power of Attorney as AssistantSecretay, of said Companies by like authadty,
and that she to acquainted with David B. Nuns, Jr., and knows him to be Vioe President of said Companies; and that the signature of David B. Noni$, Jr., subscribad to sold
Power of Ahornay Is in the genuine handvmting of David B. Nonls, Jr., and was thereto subsonbed by authority of sold By Lays and in deponent's presence.
Notarial Seal
a
KATHERINE i ADELAAR
NOTARYFUBLiCOFNEw1ERSEYNo 2918885
CdrTRniniorr E>aan►$ dDy 18, aria Tary""CERTIFICATION
rdract from the i Laws of FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY:
,All pawners of attorney for and on beholf of the Company may and shall be executed in the name and on What of the Company, either by the Chairman at the
President or a Mce Presldent or an Assistant Vie President, jointly With the secretary or an Asslstord Secretary, under mar respective designations, The
signature of such ofgoare may be engraved, annual or lilhogrephad. The signature of each of the fcIOkvk g officers; Chalman. President, any Vico President, any
Asalstantvice President, any Secretary, any Assistant Secretary and the seal of the Company may be affixed by facsimile to any power of attorney or to any
certificate refuting thereto Rppolrang Assistant Seraetame, or Attorneys- in- Fool for Purposes any of exaculbng and attesting bonds and undertakings end other
wribng9 obligatory to Lha rours thereof, and any such poker of attorney or canMcate bearing such facsimile elgnsture afacsimile anal shall be valid and binding
upon the Company and any such power so executed ami ceniked by such facsimile uignolure and facsimile seal shall be valid and birlding upon the Company
with For" to any bond or undertaking to which it Is attached,'
1, Dawn M. Chbros, Asalslent Secretary of FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY (the'Cempanoe
do hereby carry that
(I) the fcregoing toren l of the By- Lava of the Companies Is hue and co eat,
n the Companies are duty licensed and authodaed to ffansaon surety busbass in all 60 of the United Sums of America and the District of Columbia and ere
euthodzed by the U.S. Treasury Department; further, Federal and Vigilant ore licensed in the U.S. Virgin Islands, and Federal is licensed in American
Bamee, Guam, Puerto Rio, and each ofthe Provinces of Canada except Prince Edward Island; and
LOQ the foregoing Power of Attorney Is free, correct and In full form and effect.
Given under my hand and seals of said Companies at Waren, NJ this 01st day of December 2015.
'""'-"'ii�ivnin"�Tll�lne. Asstalaot sadramly
IN THE EVENT YOU 1M6H TO NOTIFY Ug On A CLAIM, yERIR( THE AUiHENTICRY OF THIS BOND OR NOTIFY US OFANY OTHER MATTER, REFACE CONTACT US AT ApoRF,Ba
Fam1&t'6 eTdfi&U GEN OONSFJYI'(ray. oa•1-01
Foun 15-10-0313A(Rm. 3/15)
FEDERAL INSURANCE COMPANY
STATEMENT OF ASSETS, LIABILITIES AND SURPLUS TO POLICYHOLDERS
Statutory Basis
DECEMBER 31, 2014
(in thousands of dollars)
LIABILITIES
AND
ASSETS SURPLUS TO POLICYHOLDERS
Cash and Short Term Investments ................ $ 110,484 Outstanding Losses and Loss Expenses..... $ 12,181,139
United States Government, State and Unearned Premiums ..................................... 3,654,861
Municipal Bonds— ...................................... 10,245,402 Ceded Reinsurance Premiums Payable....... 339,466
Other Bonds. ........ —...................................... 4,927,443 Provision for Reinsurance ............................ 46,470
Stocks........................................................... 1,066,355 Other Liabilities............................................. 1,434,018
Other Invested Assets ................................... 1,365,387
TOTAL INVESTMENTS ............................... 17,715,051 TOTAL LIABILITIES .................................... 17,655,954
Investments In Affiliates:
Chubb Investment Holdings, Ino ................ 3,565,038 Capital Stock ................................................ 20,980
Pacific Indemnity Company ....... ................ 2,922,214 Pald-In Surplus............................................. 3,106,809
Executive Risk Indemnity Inc.... .................. 1,258,019 Unassigned Funds....................................... 11,700,594
Chubb Insurance Investment Holdings Ltd.... 1,162,709 — --
CC Canada Holdings Ltd ............................ 652,880
Chubb Insurance Company of Australia Ltd. 480,068 SURPLUS TO POLICYHOLDERS .............. 14,828,383
Great Northern Insurance Company.......... 476,969
Vigilant Insurance Company ....................... 292,313
Chubb European Investment Holdings SLP.. 287,633
Other Affiliates ............................................ 517,330
Premiums Receivable ................................... 1,679,148
Other Assets ................................................. 1,474,965
TOTAL LIABILITIES AND SURPLUS
TOTAL ADMITTED ASSETS ...................... $ 32,484,337 TOPOLICYHOLDERS .......................... .,. $ 32,484,337
Investments are valued in accordance with requirements of the National Association of Insurance Commissioners,
At December 31, 2014, Investments with a carrying value of $618,199,884 were deposited with government authorities
as required by law.
State, County & City of New York, — ss:
Yvonne Baker, Assistant Secretary of the Federal Insurance Company
being duly sworn, deposes and says that the foregoing Statement of Assets, Liabilities and Surplus to Policyholders of said
Federal Insurance Company on December 31, 2014 is true and correct and is a true abstract of the Annual Statement of said
Company as filed with the Secretary of the Treasury of the United States for the 12 months ending December 31, 2014.
Subscribed and sworn to before me
this March 11, 2015. a .^.w...
j �
JEANETfE SHIPSEY Assistant Secretary
Notary Public, State of Now York
Notary Public No, 02SH5074142
Qualified In Nassau County
Commission Expires March 10, 2019
Foun 15-10-0313A(Rm. 3/15)
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
STATE OF CALIFORNIA
County of _Orange
On . 1_160f ibfore me, Candace Gallaher - Nolary_Public
ate Here Insert Name and Title of the Office,
personally appeared
CANDACEGAL AHER colnmisalon k 2117338 E
Notary Public - California n
z Orange County
aM Camm. Ex tires Jul 2A, 2019
Place Notary Seal Above
who proved to me on the basis of satisfactory evidence to
be the persou(s)`whose names) is/are-subscribed to the
within instrument and acknowledged to me that he/she/they-
executed the same in his/herAhoiPauthorized capacity(ies),
and that by his/herftair signature( ) -on the instrument the
psrson,(s• , or the entity upon behalf of which the person,(.a)-
acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of
the State of California that the foregoing paragraph Is true
and correct.
Witness my,, land a d official se I.
Signature
Signa ure of otary Public
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document:
Document Date:
Signer(s) Other Than Named
Capacity(ies) Claimed by Signer(s)
Signer's Name:
❑ Individual
❑ Corporate Officer—Title(s):____
❑ Partner --❑ Limited ❑ General
❑ Attorney in Fact
❑ Trustee
EI Guardian or Conservator
❑ Other:
Signer Is Representing:
Number of Pages:---
Signer's
ages:___
Signer's Name: _
❑ Individual
❑ Corporate Officer— Title(s)____.._.__.__
❑ Partner -- ❑ Limited ❑ General
❑ Attorney in Fact
Trustee
Guardian or Conservator
❑ Other:
Signer Is Representing:
REQUEST FOR APPROPRIATION ADJUSTMENT
2a6 -07-/
Appropnation Ad_7usun No:
Date: January 19, 2016
Department: Public Works
TYPE OF ADJUSTMENT
Transfer of Funds (No Council Action Required)
Transfer of Funds (Council Action Required)
From:
Unit
14717002 52001
aC>PV
Clerk of the Council
No
To: PUB SVS -STREET SAFETY PROJECTS
rrnuntina ITnit - Account # - Description Amount
Federal Grant -Indirect 101,8221 14717611 66220 Improvements Omer Than Building 101,822
Total 101,8221 Total 101,822
JUSTIFICATION FOR REQUEST: To recognize Highway Safety Improvement funds to install pedestrian
countdown heads and push buttons (15-6830) throughout the city which aligns with the City's Strategic Plan Goal #6 Community Facilities &
Infrastructure, Objective 41 (establish and maintain a Community Investment Plan for all city assets); Strategy B (equitably maintain existing
streets and associated assets in a state of good repair so they are clean safe and aesthetically pleaseing fo all users). RFCA 420A 01/19/2015
ss
Departrne Head Accdunting
APPROVED AS TO FUNDS AND ACCOUNTS: APPRO .
Assistant�D ector of Finance Date City Manager Date
PREPARATION:
Submit original with department head signature to Finance/Accounting M-17, and a control number will be assigned. Upon approval
from the Assistant Director of Finance and the City Manager, a photocopy of the signed original will be forwarded to the department
THE REGISTER This apace for Mims stamp only
625 N GRAND AVE, SANTA ANA, CA 92701
Telephone (714) 796-7000 / Fax (714) 796-6059
PROOF OF PUBLICATION
(2015.5 C.C.P.)
State of California )
County of ORANGE ) ss
Notice Type: BID - NOTICE INVITING BIDS
Ad Description:
PEDESTRN COUNTDWN HEADS & PUSH BUTTONS
I am a citizen of the United States and a resident of the Slate of California; I am
over the age of eighteen years, and not a party to or interested in the above
entitled matter. I am the principal clerk of the printer and publisher of the THE
REGISTER, a newspaper published in the English language in the city of
SANTA ANA, county of ORANGE, and adjudged a newspaper of general
circulation as defined by the laws of the State of California by the Superior
Court of the County of ORANGE, State of California, under date 11/19/1905,
Case No, A21046. That the notice, of which the annexed is a printed copy, has
been published In each regular and entire issue of said newspaper and not in
any supplement thereof on the following dates, to -wit:
11/09/2015, 11/16/2015
Executed on: 11/16/2015
At SANTA ANA ,CA
I certify (or declare) under penalty of perjury that the foregoing is true and
correct.
CNS#: 2810976
III III II II II II II III III III II I II
* A 0 0 0 0 0 3 9 1 7 4 1 1
MAYOR
Miguel A. Pulido
MAYOR PRO TEM
++
.`-
Sal Tirejero
"> t
COUNCIL MEMBERS
Angelica Arri
lkow-
P. David Benavides
Michele Martinez
Roman A. Reyna
Vincent F. Sarmiento
CITY OF SANTA ANA
PLANNING & BUILDING AGENCY
20 Civic Center Plaza (M-20)
P.O. BOX 1988 . Santa Ana, California 92702
(714) 667-2700 - Fax (714) 973-1461
w .sante-ana.org
NOTICE OF EXEMPTION
From the Requirements of the California Environmental
CITY MANAGER
David Cavazos
CITY ATTORNEY
Sonia R. Carvalho
CLERK OF THE COUNCIL
Maria D. Huizar
i
Fta
ORANGE COUNTY CLERK -REG RDER DEPARTMENT
BY:— / ,7�_DEPUTY
Quality Act (CCCE'�QA)
Fee Exemption per California Government Code Section 6103
To: COUNTY CLERK From: City of Santa Ana
County of Orange Planning & Building Agency
P.O. Box 238 20 Civic Center Plaza M-20
Santa Ana, CA 92702 Santa Ana, CA 92702
Project Title: Install pedestrian countdown h Date of Approval: 07/15/2013
Project Number(s): PWA -2014 -265 -CITY
Project Location: 1 CityWide (Partial)
City: Santa Ana County: Orange ER Number: ER -2014-20
Project Description: The construction will install new pedestrian countdown heads and ADA pedestrian pushbuttons.
Recorded in Official Records, Orange County
Hugh Nguyen, Clerk -Recorder
Applicant Name: City of Santa Ana I II $11111111111111111] 1 I 11$ I III II I II II. NO FEE
Applicant Address: 20 Civic Center Plaza M-43
SANTA ANA, CA 92702 *$ R 0 D 0 6 5 5 7 1 6 6 8
Name of Public Agency Approving Project: 201485000206 3.28 pm 03/11/14
City Council
214 304 Z01
Name of Person or Agency Carrying Out Project: Kekula, Zdenek 0.00 50.00 0.00 0.00 0.00 0.00 0.00 0.00
Exempt Status:
❑ Ministerial (Sec. 15268)
❑ Declared Emergency (Sec. 15269 (a))
❑ Emergency Project (Sec. 15269 (b through e))
❑ General Rule (Sec. 15061(b)(3)/(5))
❑ Statutory Exemption:
Q Categorical Exemption: 15301(b)
Reason(s) Why Project is Exempt From CEQA:
15301(b) consists of repair/maintenance of existing public facilities.
ORANOPCOUN'(YCLERK-RE RDERDEPARTMENT
3Y:....,-._.,.._, DEPUTY
City Contact: Zdenek Kekula Telephone: (714) 647-5606
Signature: Title: 4rT:�rz1r,.CI�I� E , Date: ��j_ilrl
SANTA ANA CITY COUNCIL
Miguel A. Pulido Sal Tinalero Vincent F. Sarmiento Michele Marline? Angelica Arnezcua P. David Benavides Roman Rayne
Mayor Mayor Pro Tern, Ward G Ward Ward Ward Ward ds
M ulids@santa-ana-grq ST' aieroaC t -anaore VVSamm,en}o(dlsanl -anal MManinez res nta-ane ora AAmezcuar�sarlta-ana.ora af,) en vides(®s ryta-ane ora R naroWarWar t -andD4
o*VPOO)
QW2JV01
CITY OF SANTA ANA
Construction Contract
PROJECT NO. 15-6830
PEDESTRAN COUNTDOWN HEADS AND PUSH BUTTONS
This CONSTRUCTION CONTRACT is made and entered into this 19 day of January 2016, by
and between the CITY OF SANTA ANA, CALIFORNIA, a charter city and municipal
corporation organized and existing under the Constitution and laws of the State of California,
hereinafter referred to as "CITI"' and Siemens Industry, Inc., hereinafter referred to as
"CONTRACTOR".
The CITY and the CONTRACTOR, for the consideration hereinafter named, mutually agree as
follows:
CONTRACTOR agrees to perform all the work and furnish all the materials at its own cost
and expense necessary to construct and complete in a good and workmanlike manner and to
the satisfaction of the City Engineer of the CITY, the Pedestrian Countdown Heads and Push
Buttons, hereinafter referred to as the "Work of Improvement", identified in and in
accordance with the Contract Documents prepared by the City's Public Works Agency and
approved by the City Council.
2. The complete Construction Contract consists of the "Contract Documents," as defined by the
Standard Specifications for Public Works Construction and which include the following:
• Notice Inviting Bids
• Information to Bidders
• Bid Proposal
• Bid Bond
• Contract Form
• Contract Bonds
• General Provisions
• Special Provisions
• Project Plans
• Required Contract Provisions Federal -Aid Construction Contracts
( Form FHWA 1273)
• Davis -Bacon Act and Wages
• Appendices
In case of conflict between the Contract Documents, the precedence of documents shall be as
established in the Standard Specifications for Public Works Construction,
3. CITY agrees to pay and CONTRACTOR agrees to accept in full payment to complete the
Work of Improvement the sum total amount not to exceed $596,076.00, as set forth and
identified in the BID PROPOSAL, which is attached hereto and incorporated herein. as
Exhibit "A". The BID PROPOSAL contains a schedule of unit price(s) or lump sum(s)
based on approximate quantities only, and the City does not expressly or by implication
Page 1 of 3
CITY OF SANTA ANA
Construction Contract
PROJECT NO. 15-6830,
PEDESTRAN COUNTDOWN HEADS AND PUSH BUTTONS
agree that the actual amount of work will correspond therewith, but reserves the right to
increase or decrease the amount of any class or portion of the work or to omit portions of the
work as may be deemed necessary or advisable.
4. CONTRACTOR agrees to complete the Work of Improvement within the time specified in
the Time for Completion of Improvements section of the BID PROPOSAL (Exhibit "A")
including commencing construction within the timeframe therein specified after issuance of a
Notice to Proceed.
5. The CONTRACTOR will pay, and will require all subcontractors to pay, all employees on
the Work of Improvement a salary or wage at least equal to the prevailing salary or wage
established for such work as set forth in the wage determinations for this work in accordance
with applicable State and Federal law.
6. CONTRACTOR shall, after award of this Contract, furnish two bonds to be approved by the
CITY, one in the amount of One Hundred Percent (100%) of the Contract price, to guarantee
the faithful performance of the work (Performance Bond), and one in the amount of One
Hundred Percent (100%) of the Contract price to guarantee payment of all claims for labor
and materials furnished (Payment Bond). This Contract shall not become effective until such
bonds are supplied to and approved by the CITY. CONTRACTOR shall, prior to the release
of the performance and payment bonds or the retention payment, furnish a warranty
performance and payment bond equal to at least ten (10%) percent of the final Contract price
or $1,000, whichever is greater (Warranty Bond).
7. CONTRACTOR shall, upon project completion as a condition of project acceptance, furnish
a Warranty Payment and Performance bond to be approved by the CITY, in the amount of
Twenty -Five Percent (25%) of the Contract price, to warrant the work done under said
Contract Agreement against material or quality defects for a period of one year after
acceptance by the AGENCY.
CONTRACTOR shall, after award of this Contract, furnish Certificates of Liability
Insurance and Worker's Compensation Insurance as outlined in the General Provisions, to be
approved by the CITY, u
Page 2 of 3
CITY OF SANTA ANA
Construction Contract
PROJECT NO. 15-6830
PEDESTRAN COUNTDOWN HEADS AND PUSH BUTTONS
IN WITNESS WHEREOF, the parties hereto have executed this Construction Contract on the
day and year first above written.
ATTEST: CITY OF SANTA
MA A D. HiJIZAR DAVID CAVAZOS
Clerk of the Council City Manager
APPROVED AS TO FORM: RECOMMENDED FOR APPROVAL:
SONIA R. CARVALHO
City Attorney
BY ��
JoSandoval ed Mousavipour, P.E.
Cif Assistant City Attorney xecutive Director, Public Works Agency
CONTRACTOR:
Siemens Indus
By
Title: Flr¢.a ora+P®ns PEana9e�-
Page 3 of 3
DELEGATION OF APPROVAL AUTHORITY FROM
PRESIDENT KEVIN RIDDETT AND VICE PRESIDENT FINANCE & BUSINESS
ADMINISTRATION MATTHIAS SCHL•ELEIN
Mobility Management
Urban Transport / Mainline Transport (RS)
Intelligent Traffic Systems
Rail Electrification
Customer Services
SIEMENS INDUSTRY, INC, — MOBILITY DIVISION
A. The undersigned Kevin Riddett, President and Matthias Schlelsin, Vice President, Finance and
Business Administration of the Mobility Division of Siemens Industry, Inc. (the "Corporation"), a
corporation duly organized and existing under the laws of the State of Delaware, by virtue of the
authority vested as President and Vice President Finance & Business Administration to sign or
countersign and otherwise execute in the name, or on behalf of the Corporation, any bids, projects,
contracts, agreements and any certificates, affidavits or ancillary documents In connection therewith
to the extent the foregoing instruments and are consistent with the limits of authority granted under
LoA guidelines and grants of release for and on behalf of the Corporation, do hereby delegate to and
acknowledge that the following person(s) may exercise such authority for and on our behalf up to $10
million.
AU—TtIORIZED SIGNATORIES
Business Operations
N e1Po i o
Finance/Central Supnort Function
a os t o
John Paljug
VP - MM
Marsha Smith
Senior Director, FBA - MM
Michael Cahill,
VP -R8
Christopher Halieus,
FBA— RS
Robin.Stimson
Vice President, RS MK&S
Michael Tyler
Senior Director CS
Chris Maynard
Senior Director RS CS
Madeline Rodriguez
Director RS LOC/BG
Steffen Moeller
VP—TPE
Christopher Giesch
FBA—TPE
Dave Ward
Vice President, RS LOC/BG
James Thomton,
Head of Procurement, MO
Marcus Weiz
ITS
Rajarshl Ghash
ITS BA
S. It is further acknowledged that the following individuals are hereby authorized to sign or countersign
and otherwise execute in the name or on behalf of the Corporation the same documents as
referenced in paragraph A, up to and including a transactional limit of $5 million. Any such delegation
extends to but is limited to the same scope, documents and subject matter as referenced and granted
in Paragraph A, limited to the monetary amount stated in this Paragraph.
AUTHORIZED IUNATO ES
Sales Onerstighs
am Pos' one/P
Finascl¢entralSu000ft Function
s 'on
Douglas Dreisbach
Director of Pro ects -MM'
Mary Rachel Pearce
Director of Finance & Administration -MM
Bradley Hall
Scott Carper
VP Sales
Manager, FBA—MM
Jack Wilson
Valerie Conway
MM Sales
Senior Director SCM RS
Steve Gitkin
Jessica Shaiegan
Sales Director- ITS
MM
C. It is further acknowledged that the following individuals are hereby authorized to signor countersign
and otherwiss execute in the name, or on behalf of the Corporation, the same documents as
referenced In paragraph A, up to and including a transactional limit of $3 million. Any such delegation
extends to but is limited to the same scope, documents and subject matter as referenced and granted
in Paragraph A, limited to the monetary amount stated in this Paragraph
UTHORiZED ElGtLATORIES
Business gnerations
a e/PSitio
Business Ooerations
a e/Po tion
Elnance/Central Sypoort j=gnctlon
os t o
Nikki Basal
Director, RS
David Gutierrez
Director RS UT
Tony Ritter
Director CSSe
Cathie Steele
mart Controller RS CS UT
Reiner,Martin
Director RS CS
Kim Swain
Segment Controller RS Metros & Coaches
Omid Akbarzadeh-Paydar
Business Manager Bogies, RS LOC BG
Fleur Gessner
Se ment Controller RS BG .
Mark Sennett
Vice President RS operations
Carrie Hernandez
SCC SPR RS
Raymond Ginnell .
General Project manager, RS
Michelle Picard
Director, RS
Jamie Doherty
Mirko Giese
DirectorRI HI BA
Armin Kick
Director RS HI
Claus us
Finance Director, ITS Services
Steve Teal
Director, ITS Services
D. It is further acknowledged that the following individuals are hereby authorized to sign or countersign
and otherwise execute In the name, or on behalf of the Corporation, the same documents as
referenced in paragraph A, up to and Including a transactional limit of $1 million. Any such delegation
extends to but is limited to the same scope, documents and subject matter as referenced and granted
in Paragraph A, limited to the monetary amount stated in this Paragraph,
A-U1:E1(2Rl7.EQ SIG TORIES
Business gnerations
a e/PSitio
Finaryo Ontrai Su000rt Function
Na a/Position
Stephen Klein,
Director MM
Tommy Charurat
Director Performance Controlling, RS
Paul Elias,
Director MM
Sandra Kluthausen,
Commercial Manager
David Costello,
DirectorMM
Gisela Kaufmann
Controller
Dave Jeanette
Manager, MM
Rudolf Wagner
Performance Controlling
Jim Lyons
Sr. Manager, MM
Gonstanze Kutschki
Mana er Order Management RS
Jeff Balogh
Sr. Director, MM
Kathrin Schicketanz
Commercial Prc'ect Manager, RS LOC
-George Lon
'Ronald Staggs
2
Director Engineering RS
Commercial Project Manager, RS UT
Greg Tindall
Mary Matos
Director Quality RS
Commercial Pro'act Manager, RS UT
Robert Mariner
Vesa Ventunen
Senior Project Manager, RS LOC
Commercial Pro ect Manager, RS UT
Jeffrey Curran
Alexander Jankowski
Pro ect Manager RS UT
Commercial Project Manager, RS UT
Duane Kopp
Christine Jaw
Project Manager, RS UT
Commercial Project Manager, CS
Ron VanHuuksloot
Steffen Hertel
Project Manager, RS UT
Commercial Project Manager, RS LOC
Thomas Stehlik
Larry Chen
Project Manager, RS UT
Commercial Project Manager, CS
Moral Aninoiu
Kavita Patel
Project Manager, RS UT
Commercial Project Manager, CS
Carsten Nabs
Paul Berquam,
Project Manager, RS UT
Director, Business Continuity RS
Mark Anderson
Patrick Blackburne
Project Manager, CS
Commercial Pro ect Manager, RS
Aaldrik Matting
Craig Debevoise
Pro act Manager, CS
Proacts Commercial
Jochen Woem
Christoph Hiigers
Project Manager, CS
Director Operations Controlling RS
Brad Bonn
Manuel Schimhofer
Pro eat Manager, CS
Commercial Project Manager, RS LOC
Chander Khanna,
Miriam Shear
Sr. Director, Manufacturing Processes RS
Commercial Project Manager, CS
Paul Aichholzer
Christopher Smith
Project Manager, RS LOC
Commercial Project Manager, RS UT
Digant Dave,
David Spence
Project Manager, CS
Commercial Pro act Manager
Ibrahim Kalender
Stefan Hofer
Project Manager, RS BG
Commercial Project Man er
Barry Sidler
Sabine Anddkos
Proram Manager, CS
Commercial Service Men er
Michael Diaz
Natalie Maga W
Projects
Commercial Project Manager, MM
Dlmkrios Andrlkos
Matthew Chalmers
Sales Operations
Commercial Project Man2ger MM
Christopher Romeo
Michael Danka
Operations manager
Commercial Project Manager. MIM
Mike Emmons
Operations Manager
Luis Correia
Project Manager, CS
Trine Boedker Jensen
Pro ect Manager, CS
Michael Hutchens
Operations Manager
William Tucker
Operations Mangger
Christopher Mcelroy
Service Acoount Maneer
E. It is further acknowledged that each of the signatures of the persons referred to In paragraphs A, B, C
and D are binding upon the Corporation.
F. It is further acknowledged that any document shall require the signature of two (2) of the above
Authorized Signatories, one each from Business Operations and from Finance/Central Support
Functions, whom shall have the requisite signature authority to be legally binding upon the
Corporation.
G. It is further acknowledged that each of the persons referred to herein Is authorized to delegate such
person's authority. hereunder to additional members of his or her management team up to the limit of
such person's delegation of authority, provided that such delegation is in written form signed by the
delegator and filed with the Legal Department.
H. It is further acknowledged that the Secretary or an Assistant Secretary of the Corporation is
authorized to issue certifications attesting to the Incumbency, authority and status of any of the
persons referred to in this resolution.
iN WITNESS WHEREOF, we have hereunto subscribed our names and affixed the corporate seal of the
said Corporation, as of the 1st day of January, 2016.
s Industry, Inc.
Division
ji v"1 eA ,
Matthias Schielein
Vice President, Finance and Business Administration
Siemens Industry, Inc.
Mobility Division
0
City # 15-6830
FED # HSIPL 5063(154)
Local Assistance Procedures Manual Exhibit 12-G
Required Federal -aid Contract Language
EXHIBIT 12-G REQUIRED FEDERAL -AID CONTRACT LANGUAGE
(For Local Assistance Construction Projects)
The following language must be incorporated into all Local Assistance Federal -aid construction
contracts. The following language, with minor edits, was taken from the 2010 Caltrans Standard
Specifications, Revised Standard Specifications issued by Caltrans Office Engineer, and the Code
of Federal Regulations.
Table of Contents
Section Page No.
1. DISADVANTAGED BUSINESS ENTERPRISES(DBE)......................................................................2
DBE COMMITMENT SUBMITTAL
GOOD FAITH EFFORTS SUBMITTAL..............................................................................................................3
EXHIBIT 15-G LOCAL AGENCY BIDDER DBE INFORMATION (CONSTRUCTION CONTRACTS).4
SUBCONTRACTOR AND DISADVANTAGED BUSINESS ENTERPRISE RECORDS ..............................4
PERFORMANCE OF DISADVANTAGED BUSINESS ENTERPRISES.........................................................4
2. BID OPENING.........................................................................................................................................................5
3. BID RIGGING.........................................................................................................................................................5
4. CONTRACT AWARD............................................................................................................................................5
5. CONTRACTOR LICENSE....................................................................................................................................5
6. DIFFERING SITE CONDITIONS.........................................................................................................................5
CONTRACTOR'S NOTIFICATION
ENGINEER'S INVESTIGATION AND DECISION
7. BEGINNING OF WORK, TIME OF COMPLETION AND LIQUIDATED DAMAGES...............................6
8. BUY AMERICA.......................................................................................................................................................6
9. QUALITY ASSURANCE........................................................................................................................................6
10. PROMPT PAYMENT OF FUNDS WITHIIELD TO SUBCONTRACTORS...................................................7
11. FORM FHWA-1.273 REQUIRED CONTRACT PROVISIONS FEDERAL -AID CONTRACTS ..................7
12. FEMALE AND MIONORITY GOALS...............................................................................................................I8
13. FEDERAL TRAINEE PROGRAM.....................................................................................................................19
14. TITLE VI ASSURANCES................................................................................................................. -- -z2
Page 1 of 22
DLA -OB 13-06 August 12, 2013
Local Assistance Procedures Manual
1. DISADVANTAGED BUSINESS ENTERPRISES (DBE)
Under 49 CFR 26.13(b):
City # 15-6830
FED # HSIPL 5063(154)
Exhibit 12-G
Required Federal -aid Contract Language
The contractor, subrecipient or subcontractor shall not discriminate on the basis of race, color,
national origin, or sex in the performance of this contract. The contractor shall carry out
applicable requirements of 49 CFR part 26 in the award and administration of DOT -assisted
contracts. Failure by the contractor to carry out these requirements is a material breach of this
contract, which may result in the termination of this contract or such other remedy as the recipient
deems appropriate.
Take necessary and reasonable steps to ensure that DBEs have opportunity to participate in the contract (49
CFR 26).
To ensure equal participation of DBEs provided in 49 CFR 26.5, the Agency shows a goal for DBEs
Make work available to DBEs and select work parts consistent with available DBE subcontractors and
suppliers.
Meet the DBE goal shown elsewhere in these special provisions or demonstrate that you made adequate good
faith efforts to meet this goal.
It is your responsibility to verify that the DBE firm is certified as DBE at date of bid opening. For a list of
DBEs certified by the California Unified Certification Program, go to:
http://www.dot.ca. oay/hq/bep/find certified hum.
All DBE participation will count toward the California Department of Transportation's federally mandated
statewide overall DBE goal.
Credit for materials or supplies you purchase from DBEs counts towards the goal in the following manner:
• 100 percent counts if the materials or supplies are obtained from a DBE manufacturer.
• 60 percent counts if the materials or supplies are obtained from a DBE regular dealer.
• Only fees, commissions, and charges for assistance in the procurement and delivery of
materials or supplies count if obtained from a DBE that is neither a manufacturer nor regular
dealer. 49 CFR 26.55 defines "manufacturer" and "regular dealer."
You receive credit towards the goal if you employ a DBE trucking company that performs a commercially
useful function as defined in 49 CFR 26.55(d)(1) through (4) and (6).
a. DBE Commitment Submittal
Submit the Exhibit 15-G Local Agency Bidder DBE Commitment (Construction Contracts) form, included in
the Bid book. If the form is not submitted with the bid, remove the form from the Bid book before submitting
your bid.
If the DBE Commitment form is not submitted with the bid, the apparent low bidder, the 2nd low bidder, and
the 3rd low bidder must complete and submit the DBE Commitment form to the Agency. DBE Commitment
form must be received by the Agency no later than 4:00 p.m. on the 4th business day after bid opening.
Other bidders do not need to submit the DBE Commitment form unless the Agency requests it. If the Agency
requests you to submit a DBE Commitment form, submit the completed form within 4 business days of the
request.
Submit written confirmation from each DBE stating that it is participating in the contract. Include
confirmation with the DBE Commitment form. A copy of a DBE's quote will serve as written confirmation
that the DBE is participating in the contract.
If you do not submit the DBE Commitment form within the specified time, the Agency will find your bid
nonresponsive.
Page 2 of 22
DLA -OR 13-06 August 12, 2013
City # 15-6830
FED # HSIPL 5063(154)
Local Assistance Procedures Manual Exhibit 12-G
Required Federal -aid Contract Language
b. Good Faith Efforts Submittal
If you have not met the DBE goal, complete and submit the DBE Information - Good Faith Efforts, Exhibit
15-H, form with the bid showing that you made adequate good faith efforts to meet the goal. Only good faith
efforts directed towards obtaining participation by DBEs will be considered. If good faith efforts
documentation is not submitted with the bid, it must be received by the Agency no later than 4:00 p.m. on the
4th business day after bid opening.
If your DBE Commitment form shows that you have met the DBE goal or if you are required to submit the
DBE Commitment form, you must also submit good faith efforts documentation within the specified time to
protect your eligibility for award of the contract in the event the Agency finds that the DBE goal has not been
met.
Good faith efforts documentation must include the following information and supporting documents, as
necessary:
1. Items of work you have made available to DBE firms. Identify those items of work you
might otherwise perform with your own forces and those items that have been broken down
into economically feasible units to facilitate DBE participation. For each item listed, show
the dollar value and percentage of the total contract. It is your responsibility to demonstrate
that sufficient work to meet the goal was made available to DBE firms.
2. Names of certified DBEs and dates on which they were solicited to bid on the project.
Include the items of work offered. Describe the methods used for following Lip initial
solicitations to determine with certainty if the DBEs were interested, and the dates of the
follow-up. Attach supporting documents such as copies of letters, memos, facsimiles sent,
telephone logs, telephone billing statements, and other evidence of solicitation. You are
reminded to solicit certified DBEs through all reasonable and available means and provide
sufficient time to allow DBEs to respond.
3. Name of selected firm and its status as a DBE for each item of work made available. Include
name, address, and telephone number of each DBE that provided a quote and their price
quote. If the firm selected for the item is not a DBE, provide the reasons for the selection.
4. Name and date of each publication in which you requested DBE participation for the project.
Attach copies of the published advertisements.
5. Names of agencies and dates on which they were contacted to provide assistance in
contacting, recruiting, and using DBE firms. If the agencies were contacted in writing,
provide copies of supporting documents.
6. List of efforts made to provide interested DBEs with adequate information about the plans,
specifications, and requirements of the contract to assist them in responding to a solicitation.
If you have provided information, identify the name of the DBE assisted, the nature of the
information provided, and date of contact. Provide copies of supporting documents, as
appropriate.
7. List of efforts made to assist interested DBEs in obtaining bonding, lines of credit, insurance,
necessary equipment, supplies, and materials, excluding supplies and equipment that the DBE
subcontractor purchases or leases from the prime contractor or its affiliate. If such assistance
is provided by you, identify the name of the DBE assisted, nature of the assistance offered,
and date assistance was provided. Provide copies of supporting documents, as appropriate.
8. Any additional data to support demonstration of good faith efforts.
The Agency may consider DBE commitments of the 2nd and 3rd bidders when determining whether the low
bidder made good faith efforts to meet the DBE goal.
Page 3 of 22
DLA -OB 13-06 August 12, 2013
City # 15-6830
FED # HSIPL 5063(154)
Local Assistance Procedures Manual Exhibit 12-G
Required Federal -aid Contract Language
c. Exhibit 15-G -Local Agency Bidder DBE Information (Construction Contracts)
Complete and sign Exhibit 15-G Local Agency Bidder DBE Commitment (Construction Contracts) included
in the contract documents regardless of whether DBE participation is reported.
Provide written confirmation from each DBE that the DBE is participating in the Contract. A copy of a DBE's
quote serves as written confirmation. If a DBE is participating as a joint venture partner, the Agency
encourages you to submit a copy of the joint venture agreement.)
d. Subcontractor and Disadvantaged Business Enterprise Records
Use each DBE subcontractor as listed on Exhibit 12-B Bidder's List of Subcontractors (DBE and Non -DBE)
and Exhibit 15-G Local Agency Bidder DBE Commitment (Construction Contracts) form unless you receive
authorization for a substitution.
The Agency requests the Contractor to:
1. Notify the Engineer of any changes to its anticipated DBE participation
2. Provide this notification before starting the affected work
3. Maintain records including:
• Name and business address of each I` -tier subcontractor
Name and business address of each DBE subcontractor, DBE vendor, and DBE trucking
company, regardless of tier
Date of payment and total amount paid to each business
If you are a DBE contractor, include the date of work performed by your own forces and the corresponding
value of the work.
Before the 15th of each month, submit a Monthly DBE Trucking Verification form.
If a DBE is decertified before completing its work, the DBE must notify you in writing of the decertification
date. If a business becomes a certified DBE before completing its work, the business must notify you in
writing of the certification date. Submit the notifications. On work completion, complete a Disadvantaged
Business Enterprises (DBE) Certification Status Change, Exhibit 17-0, form. Submit the form within 30 days
of contract acceptance.
Upon work completion, complete Exhibit 17-F Final Report— Utilization of Disadvantaged Business
Enterprises (DBE), First -Tier Subcontractors. Submit it within 90 days of contract acceptance. The Agency
will withhold $10,000 until the form is submitted. The Agency releases the withhold upon submission of the
completed form.
e. Performance of Disadvantaged Business Enterprises
DBEs must perform work or supply materials as listed in the Exhibit 15-G Local Agency Bidder DBE
Commitment (Construction Contracts) form, included in the Bid.
Do not terminate or substitute a listed DBE for convenience and perform the work with your own forces or
obtain materials from other sources without authorization from the Agency.
The Agency authorizes a request to use other forces or sources of materials if it shows any of the following
justifications:
1. Listed DBE fails or refuses to execute a written contract based on plans and specifications for
the project.
2. You stipulated that a bond is a condition of executing the subcontract and the listed DBE fails
to meet your bond requirements.
Page 4 of 22
DLA -OB 13-06 August 12, 2013
City # 15-6830
FED # HSIPL 5063(154)
Local Assistance Procedures Manual Exhibit 12-G
Required Federal -aid Contract Language
3. Work requires a contractor's license and listed DBE does not have a valid license under
Contractors License Law.
4. Listed DBE fails or refuses to perform the work or furnish the listed materials.
5. Listed DBE's work is unsatisfactory and not in compliance with the contract.
6. Listed DBE is ineligible to work on the project because of suspension or debarment.
7. Listed DBE becomes bankrupt or insolvent.
8. Listed DBE voluntarily withdraws with written notice from the Contract
9. Listed DBE is ineligible to receive credit for the type of work required.
10. Listed DBE owner dies or becomes disabled resulting in the inability to perform the work on
the Contract.
11. Agency determines other documented good cause.
Notify the original DBE of your intent to use other forces or material sources and provide the reasons.
Provide the DBE with 5 days to respond to your notice and advise you and the Agency of the reasons why the
use of other forces or sources of materials should not occur. Your request to use other forces or material
sources must include:
1. One or more of the reasons listed in the preceding paragraph
2. Notices from you to the DBE regarding the request
3. Notices from the DBEs to you regarding the request
If a listed DBE is terminated or substituted, you must make good faith efforts to find another DBE to
substitute for the original DBE. The substitute DBE must perform at Least the same amount of work as the
original DBE under the contract to the extent needed to meet the DBE goal.
The substitute DBE must be certified as a DBE at the time of request for substitution.
Unless the Agency authorizes (1) a request to use other forces or sources of materials or (2) a good faith effort
for a substitution of a terminated DBE, the Agency does not pay for work listed on the Exhibit 15-G Local
Agency Bidder DBE Commitment (Construction Contracts) form unless it is performed or supplied by the
listed DBE or an authorized substitute.
2. BID OPENING
The Agency publicly opens and reads bids at the time and place shown on the Notice to Bidders.
3. BID RIGGING
The U.S. Department of Transportation (DOT) provides a toll-free hotline to report bid rigging activities. Use
the hotline to report bid rigging, bidder collusion, and other fraudulent activities. The hotline number is
(800) 424-9071. The service is available 24 hours 7 days a week and is confidential and anonymous.. The
hotline is part of the DOT's effort to identify and investigate highway construction contract fraud and abuse
and is operated under the direction of the DOT Inspector General.
4. CONTRACTAWARD
If the Agency awards the contract, the award is made to the lowest responsible bidder.
5. CONTRACTOR LICENSE
The Contractor must be properly licensed as a contractor from contract award through Contract acceptance
(Public Contract Code § 10164).
6. DIFFERING SITE CONDITIONS
a. Contractor's Notification
Promptly notify the Agency's Engineer if you find either of the following conditions:
1. Physical conditions differing materially from either of the following:
Page 5 of 22
DLA -OB 13-06 August 12, 2013
Local Assistance Procedures Manual
• Contract documents
• Job site examination
City # 15-6830
FED # HSIPL 5063(154)
Exhibit 12-G
Required Federal -aid Contract Language
2. Physical conditions of an unusual nature, differing materially from those ordinarily
encountered and generally recognized as inherent in the work provided for in the
Contract
Include details explaining the information you relied on and the material differences you discovered.
If you fail to promptly notify the Engineer, you waive the differing site condition claim for the period
between your discovery of the differing site condition and your notification to the Engineer.
If you disturb the site after discovery and before the Engineer's investigation, you waive the differing site
condition claim.
b. Engineer's Investigation and Decision
Upon your notification, the Engineer investigates job site conditions and:
1. Notifies you whether to resume affected work
2. Decides whether the condition differs materially and is cause for an adjustment of time,
payment, or both
7. BEGINNING OF WORK, TIME OF COMPLETIONAND LIQUIDATED DAMAGES
The Contractor shall begin work within 15 calendar days after the contract has been approved by the attorney
appointed and authorized to represent the City/County of
This work shall be diligently prosecuted to completion before the expiration of WORKING DAYS
beginning on the fifteenth calendar day after approval of the contract.
(Insert amount of Liquidated Damages)
The Contractor shall pay to the City/County of the sum of $ per day, for each and
every calendar day's delay in finishing the work in excess of the number of working days prescribed above.
8. BUYAMERICA
Furnish steel and iron materials to be incorporated into the work with certificates of compliance. Steel and
iron materials must be produced in the U.S. except:
1. Foreign pig iron and processed, pelletized, and reduced iron ore may be used in the domestic
production of the steel and iron materials [60 Fed Reg 15478 (03/24/1995)];
2. If the total combined cost of the materials does not exceed the greater of 0.1 percent of the
total bid or $2,500, materials produced outside the U.S. may be used.
Production includes:
1. Processing steel and iron materials, including smelting or other processes that alter the
physical form or shape (such as rolling, extruding, machining, bending, grinding, and
drilling) or chemical composition;
2. Coating application, including epoxy coating, galvanizing, and painting, that protects or
enhances the value of steel and iron materials.
9. QUALITYASSURANCE
The Agency uses a Quality Assurance Program (QAP) to ensure a material is produced to comply with the
Contract.
You may examine the records and reports of tests the Agency performs if they are available at the job site.
Page 6 of 22
DLA -OB 13-06 August 12, 2013
City # 15-6830
FED # HSIPL 5063(154)
Local Assistance Procedures Manual Exhibit 12-G
Required Federal -aid Contract Language
Schedule work to allow time for QAP.
10. PROMPT PAYMENT OF FUNDS WITHHELD TO SUBCONTRACTORS
(The local agency must include one of the following three provisions to ensure prompt and full payment of
any retainage from the prime contractor, or subcontractor, to a subcontractor. Remove or strike out the
methods not used.)
(EITHER)
No retainage will be withheld by the agency from progress payments due the prime contractor. Retainage by
the prime contractor or subcontractors is prohibited and no retainage will be held by the prime contractor from
progress due subcontractors. Any violation of this provision shall subject the violating prime contractor or
subcontractor to the penalties, sanctions and other remedies specified in Section 7108.5 of the California
Business and Professions Code. This requirement shall not be construed to limit or impair any contractual,
administrative, or judicial remedies otherwise available to the prime Contractor or subcontractor in the event
of a dispute involving late payment or nonpayment by the prime contractor or deficient subcontract
performance, or noncompliance by a subcontractor.
Iffiff
No retainage will be held by the agency from progress payments due the prime contractor. Any retainage
held by the prime contractors or subcontractors from progress payments due subcontractors shall be promptly
paid in full to subcontractors within 30 days after the subcontractor's work is satisfactorily completed.
Federal law (49CFR26.29) requires that any delay or postponement of payment over the 30 days may take
place only for good cause and with the agency's prior written approval. Any violation of this provision shall
subject the violating prime contractor or subcontractor to the penalties, sanctions and other remedies specified
in Section 7108.5 of the Business and Professions Code. These requirements shall not be construed to limit or
impair any contractual, administrative, orjudicial remedies otherwise available to the prime Contractor or
subcontractor in the event of a dispute involving late payment or nonpayment by the prime contractor,
deficient subcontract performance, or noncompliance by a subcontractor.
(OR)
The agency shall hold retainage from the prime contractor and shall make prompt and regular incremental
acceptances of portions, as determined by the agency, of the contract work, and pay retainage to the prime
contractor based on these acceptances. The prime contractor, or subcontractor, shall return all monies
withheld in retention from a subcontractor within 30 days after receiving payment for work satisfactorily
completed and accepted including incremental acceptances of portions of the contract work by the agency.
Federal law (49CFR26.29) requires that any delay or postponement of payment over 30 days may take place
only for good cause and with the agency's prior written approval. Any violation of this provision shall
subject the violating prime contractor or subcontractor to the penalties, sanctions and other remedies specified
in Section 7108.5 of the Business and Professions Code. These requirements shall not be construed to limit or
impair any contractual, administrative, or judicial remedies otherwise available to the prime contractor or
subcontractor in the event of a dispute involving late payment or nonpayment by the prime contractor,
deficient subcontract performance, or noncompliance by a subcontractor.
11. FORM FHWA-1273 REQUIRED CONTRACT PROVISIONS FEDERAL AID CONTRACTS (Excluding
ATTACHMENT A - EMPLOYMENT AND MATERIALS PREFERENCE FOR APPALACHIAN
DEVELOPMENT HIGHWAY SYSTEM OR APPALACHIAN LOCAL ACCESS ROAD CONTRACTS)
[The following 10 pages must be physically inserted into the contract without modification.]
Page 7 of 22
DLA -013 13-06 August 12, 2013
City # 15-6830
FED # HSIPL 5063(154)
Local Assistance Procedures Manual Exhibit 12-G
Required Federal -aid Contract Language
FHWA-1273 -- Revised May 1, 2012
REQUIRED CONTRACT PROVISIONS
FEDERAL -AID CONSTRUCTION CONTRACTS
I. General
II. Nondiscrimination
III. Nonsegregated Facilities
IV. Davis -Bacon and Related Act Provisions
V. Contract Work Hours and Safety Standards Act Provisions
VI. Subletting or Assigning the Contract
VII. Safety: Accident Prevention
VIII. False Statements Concerning Highway Projects
IX. Implementation of Clean Air Act and Federal Water Pollution
Control Act
X. Compliance with Governmentwide Suspension and Debarment
Requirements
XI. Certification Regarding Use of Contract Funds for Lobbying
ATTACHMENTS
A. Employment and Materials Preference for Appalachian Development
Highway System or Appalachian Local Access Road Contracts (included
in Appalachian contracts only)
I. GENERAL
1. Form FHWA-1273 must be physically incorporated in each
construction contract funded under Title 23 (excluding emergency
contracts solely intended for debris removal). The contractor (or
subcontractor) must insert this form in each subcontract and further
require its inclusion in all lower tier subcontracts (excluding purchase
orders, rental agreements and other agreements for supplies or
services).
The applicable requirements of Form FHWA-1273 are incorporated by
reference for work done under any purchase order, rental agreement or
agreement for other services, The prime contractor shall be responsible
for compliance by any subcontractor, lower -tier subcontractor or service
provider.
Form FHWA-1273 must be included in all Federal -aid design -build
contracts, in all subcontracts and In lower tier subcontracts (excluding
subcontracts for design services, purchase orders, rental agreements
and other agreements for supplies or services). The design -builder shall
be responsible for compliance by any subcontractor, lower -tier
subcontractor or service provider.
Contracting agencies may reference Form FHWA-1273 in bid proposal
or request for proposal documents, however, the Form FHWA-1273 must
be physically incorporated (not referenced) in all contracts, subcontracts
and lower -tier subcontracts (excluding purchase orders, rental
agreements and other agreements for supplies or services related to a
construction contract).
2. Subject to the applicability criteria noted in the following sections,
these contract provisions shall apply to all work performed on the
contract by the contractor's own organization and with the assistance of
workers under the contractor's immediate superintendence and to all
work performed on the contract by piecework, station work, or by
subcontract.
3. A breach of any of the stipulations contained in these Required
Contract Provisions may be sufficient grounds for withholding of progress
payments, withholding of final payment, termination of the contract,
suspension I debarment or any other action determined to be appropriate
by the contracting agency and FHWA.
4. Selection of Labor: During the performance of this contract, the
contractor shall not use convict labor for any purpose within the limits of
a construction project on a Federal -aid highway unless it is labor
performed by convicts who are on parole, supervised release, or
probation, The term Federal -aid highway does not include roadways
functionally classified as local roads or rural minor collectors.
DLA -OB 13-06
II. NONDISCRIMINATION
The provisions of this section related to 23 CFR Part 230 are applicable
to all Federal -aid construction contracts and to all related construction
subcontracts of $10,000 or more. The provisions of 23 CFR Part 230 are
not applicable to material supply, engineering, or architectural service
contracts.
In addition, the contractor and all subcontractors must comply with the
following policies: Executive Order 11246, 41 CFR 60, 29 CFR 1625-
1627, Title 23 USC Section 140, the Rehabilitation Act of 1973, as
amended (29 USC 794), Title VI of the Civil Rights Act of 1964, as
amended, and related regulations including 49 CFR Parts 21, 26 and 27;
and 23 CFR Parts 200, 230, and 633.
The contractor and all subcontractors must comply with: the
requirements of the Equal Opportunity Clause in 41 CFR 60-1.4(b) and,
for all construction contracts exceeding $10,000, the Standard Federal
Equal Employment Opportunity Construction Contract Specifications in
41 CFR 60-4.3.
Note: The U.S. Department of Labor has exclusive authority to determine
compliance with Executive Order 11246 and the policies of the Secretary
of Labor including 41 CFR 60, and 29 CFR 1625-1627. The contracting
agency and the FHWA have the authority and the responsibility to
ensure compliance with Title 23 USC Section 140, the Rehabilitation Act
of 1973, as amended (29 USC 794), and Title VI of the Civil Rights Act of
1964, as amended, and related regulations including 49 CFR Parts 21,
26 and 27; and 23 CFR Parts 200, 230, and 633.
The following provision is adopted from 23 CFR 230, Appendix A, with
appropriate revisions to conform to the U.S. Department of Labor (US
DOL) and FHWA requirements.
1. Equal Employment Opportunity: Equal employment opportunity
(EEO) requirements not to discriminate and to take affirmative action to
assure equal opportunity as set forth under laws, executive orders, rules,
regulations (28 CFR 35, 29 CFR 1630, 29 CFR 1625-1627, 41 CFR 60
and 49 CFR 27) and orders of the Secretary of Labor as modified by the
provisions prescribed herein, and imposed pursuant to 23 U, S.C. 140
shall constitute the EEO and specific affirmative action standards for the
contractor's project activities under this contract, The provisions of the
Americans with Disabilities Act of 1990 (42 U.S.C. 12101 at seq.) set
forth under 28 CFR 35 and 29 CFR 1630 are incorporated by reference
In this contract. In the execution of this contract, the contractor agrees to
comply with the following minimum specific requirement activities of
EEO:
a. The contractor will work with the contracting agency and the Federal
Government to ensure that it has made every goad faith effort to provide
equal opportunity with respect to all of its terms and conditions of
employment and in their review of activities under the contract.
b. The contractor will accept as its operating policy the following
statement:
"It Is the policy of this Company to assure that applicants are
employed, and that employees are treated during employment, without
regard to their race, religion, sex, color, national origin, age or
disability. Such action shall include: employment, upgrading,
demotion, or transfer; recruitment or recruitment advertising; layoff or
termination; rates of pay or other forms of compensation; and selection
for training, including apprenticeship, pre -apprenticeship, and/or on-
the-job training."
2. EEO Officer: The contractor will designate and make known to the
contracting officers an EEO Officer who will have the responsibility for
and must be capable of effectively administering and promoting an
active EEO program and who must be assigned adequate authority and
responsibility to do so
Page 8 of 22
August 12, 2013
City # 15-6830
FED # HSIPL 5063(154)
Local Assistance Procedures Manual Exhibit 12-G
Required Federal -aid Contract Language
3. Dissemination of Policy: All members of the contractor's staff
who are authorized to hire, supervise, promote, and discharge
employees, orwho recommend such action, or who are substantially
involved in such action, will be made fully cognizant of, and will
implement, the contractor's EEO policy and contractual
responsibilities to provide EEO in each grade and classification of
employment. To ensure that the above agreement will be mel, the
following actions will be taken as a minimum:
a. Periodic meetings of supervisory and personnel office
employees will be conducted before the start of work and then not
less often than once every six months, at which time the contractor's
EEO policy and its implementation will be reviewed and explained.
The meetings will be conducted by the EEO Officer.
b. All new supervisory or personnel office employees will be given
a thorough indoctrination by the EEO Officer, covering all major
aspects of the contractor's EEO obligations within thirty days
following their reporting for duty with the contractor.
c. All personnel who are engaged in direct recruitment for the
project will be instructed by the EEO Officer in the contractor's
procedures for locating and hiring minorities and women.
d. Notices and posters setting forth the contractor's EEO policy
will be placed in areas readily accessible to employees, applicants
for employment and potential employees.
e. The contractor's EEO policy and the procedures to implement
such policy will be brought to the attention of employees by means
of meetings, employee handbooks, or other appropriate means.
4. Recruitment: When advertising for employees, the contractor will
include in all advertisements for employees the notation: "An Equal
Opportunity Employer." All such advertisements will be placed in
publications having a large circulation among minorities and women
in the area from which the project work force would normally be
derived.
a. The contractor will, unless precluded by a valid bargaining
agreement, conduct systematic and direct recruitment through public
and private employee referral sources likely to yield qualified
minorities and women. To meet this requirement, the contractor will
identify sources of potential minority group employees, and establish
wth such identified sources procedures whereby minority and
women applicants may be referred to the contractor for employment
consideration.
b. In the event the contractor has a valid bargaining agreement
providing for exclusive hiring hall referrals, the contractor is
expected to observe the provisions of that agreement to the extent
that the system meets the contractor's compliance with EEO
contract provisions. Where implementation of such an agreement
has the effect of discriminating against minorities or women, or
obligates the contractor to do the same, such implementation
violates Federal nondiscrimination provisions.
c. The contractor will encourage its present employees to refer
minorities and women as applicants for employment. Information
and procedures with regard to referring such applicants will be
discussed with employees.
5. Personnel Actions: Wages, working conditions, and employee
benefits shall be established and administered, and personnel
actions of every type, including hiring, upgrading, promotion,
transfer, demotion, layoff, and termination, shall be taken without
regard to race, color, religion, sex, national origin, age or disability.
The following procedures shall be followed:
a. The contractor will conduct periodic inspections of project sites
to insure that working conditions and employee facilities do not
indicate discriminatory treatment of project site personnel.
DLA -OB 13-06
b. The contractor will periodically evaluate the spread of wages
paid within each classification to determine any evidence of
discriminatory wage practices.
c. The contractor will periodically review selected personnel
actions in depth to determine whether there is evidence of
discrimination. Where evidence is found, the contractor will
promptly take corrective action. If the review indicates that the
discrimination may extend beyond the actions reviewed, such
corrective action shall include all affected persons.
d. The contractor will promptly investigate all complaints of
alleged discrimination made to the contractor in connection with its
obligations under this contract, will attempt to resolve such
complaints, and will take appropriate corrective action within a
reasonable time. If the investigation indicates that the discrimination
may affect persons other than the complainant, such corrective
action shall include such other persons. Upon completion of each
investigation, the contractor will inform every complainant of all of
their avenues of appeal.
6. Training and Promotion:
a. The contractor will assist in locating, qualifying, and increasing
the skills of minorities and women who are applicants for
employment or current employees. Such efforts should be aimed at
developing full journey level status employees in the type of trade or
job classification involved.
b. Consistent with the contractor's work force requirements and
as permissible under Federal and State regulations, the contractor
shall make full use of training programs, i.e., apprenticeship, and on-
the-job training programs for the geographical area of contract
performance. In the event a special provision for training is provided
under this contract, this subparagraph Will be superseded as
indicated in the special provision. The contracting agency may
reserve training positions for persons who receive welfare
assistance in accordance with 23 U.S.C. 140(a).
c. The contractor will advise employees and applicants for
employment of available training programs and entrance
requirements for each.
d. The contractor will periodically review the training and
promotion potential of employees who are minorities and women
and will encourage eligible employees to apply for such training and
promotion.
7. Unions: If the contractor relies in whole or in part upon unions as
a source of employees, the contractor will use good faith efforts to
obtain the cooperation of such unions to increase opportunities for
minorities and women. Actions by the contractor, either directly or
through a contractor's association acting as agent, will include the
procedures set forth below:
a. The contractor will use good faith efforts to develop, in
cooperation with the unions, joint training programs aimed toward
qualifying more minorities and women for membership in the unions
and increasing the skills of minorities and women so that they may
qualify for higher paying employment.
b. The contractor will use good faith efforts to incorporate an EEO
clause into each union agreement to the end that such union will be
contractually bound to refer applicants without regard to their race,
color, religion, sex, national origin, age or disability.
c. The contractor is to obtain information as to the referral
practices and policies of the labor union except that to the extent
such information is within the exclusive possession of the labor
union and such labor union refuses to furnish such information to the
contractor, the contractor shall so certify to the contracting agency
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FED # HSIPL 5063(154)
Local Assistance Procedures Manual Exhibit 12-G
Required Federal -aid Contract Language
and shall set forth what efforts have been made to obtain such
information.
d. In the event the union is unable to provide the contractor with a
reasonable flow of referrals within the time limit set forth in the
collective bargaining agreement, the contractor will, through
independent recruitment efforts, fill the employment vacancies
without regard to race, color, religion, sex, national origin, age or
disability; making full efforts to obtain qualified and/or qualifiable
minorities and women. The failure of a union to provide sufficient
referrals (even though it is obligated to provide exclusive referrals
under the terms of a collective bargaining agreement) does not
relieve the contractor from the requirements of this paragraph. In
the event the union referral practice prevents the contractor from
meeting the obligations pursuant to Executive Order 11246, as
amended, and these special provisions, such contractor shall
immediately notify the contracting agency.
6. Reasonable Accommodation for Applicants / Employees
with Disabilities: The contractor must be familiar with the
requirements for and comply with the Americans with Disabilities Act
and all rules and regulations established there under. Employers
must provide reasonable accommodation in all employment
activities unless to do so would cause an undue hardship.
9. Selection of Subcontractors, Procurement of Materials and
Leasing of Equipment: The contractor shall not discriminate on the
grounds of race, color, religion, sex, national origin, age or disability
in the selection and retention of subcontractors, including
procurement of materials and leases of equipment. The contractor
shall take all necessary and reasonable steps to ensure
nondiscrimination in the administration of this contract.
a. The contractor shall notify all potential subcontractors and
suppliers and lessors of their EEO obligations under this contract.
b. The contractor will use good faith efforts to ensure
subcontractor compliance with their EEO obligations.
10. Assurance Required by 49 CFR 26.13(b):
a. The requirements of 49 CFR Part 26 and the State DOT's U.S.
DOT -approved DBE program are incorporated by reference.
b. The contractor or subcontractor shall not discriminate on the
basis of race, color, national origin, or sex in the performance of this
contract. The contractor shall carry out applicable requirements of
49 CFR Part 26 in the award and administration of DOT -assisted
contracts. Failure by the contractor to carry out these requirements
is a material breach of this contract, which may result in the
termination of this contract or such other remedy as the contracting
agency deems appropriate.
11. Records and Reports: The contractor shall keep such records
as necessary to document compliance with the EEO requirements.
Such records shall be retained for a period of three years following
the date of the final payment to the contractor for all contract work
and shall be available at reasonable times and places for inspection
by authorized representatives of the contracting agency and the
FHWA.
a. The records kept by the contractor shall document the
following:
(1) The number and work hours of minority and non -minority
group members and women employed in each work classification
on the project;
(2) The progress and efforts being made in cooperation with
unions, when applicable, to increase employment opportunities for
minorities and women; and
(3) The progress and efforts being made in locating, hiring,
training, qualifying, and upgrading minorities and women;
b. The contractors and subcontractors will submit an annual
report to the contracting agency each July for the duration of the
project, indicating the number of minority, women, and non -minority
group employees currently engaged in each work classification
required by the contract work. This information is to be reported on
Form FHWA-1391. The staffing data should represent the project
work force on board in all or any part of the last payroll period
preceding the end of July. If on-the-job training is being required by
special provision, the contractor will be required to collect and report
training data. The employment data should reflect the work force on
board during all or any part of the last payroll period preceding the
end of July.
III. NONSEGREGATED FACILITIES
This provision is applicable to all Federal -aid construction contracts
and to all related construction subcontracts of $10,000 or more.
The contractor must ensure that facilities provided for employees
are provided in such a manner that segregation on the basis of race,
color, religion, sex, or national origin cannot result. The contractor
may neither require such segregated use by written or oral policies
nor tolerate such use by employee custom. The contractor's
obligation extends further to ensure that its employees are not
assigned to perform their services at any location, under the
contractor's control, where the facilities are segregated. The term
"facilities" includes waiting rooms, work areas, restaurants and other
eating areas, time clocks, restrooms, washrooms, locker rooms, and
other storage or dressing areas, parking lots, drinking fountains,
recreation or entertainment areas, transportation, and housing
provided for employees. The contractor shall provide separate or
single -user restrooms and necessary dressing or sleeping areas to
assure privacy between sexes.
IV. DAVIS-BACON AND RELATED ACT PROVISIONS
This section is applicable to all Federal -aid construction projects
exceeding $2,000 and to all related subcontracts and lower -tier
subcontracts (regardless of subcontract size). The requirements
apply to all projects located within the right-of-way of a roadway that
is functionally classified as Federal -aid highway. This excludes
roadways functionally classified as local roads or rural minor
collectors, which are exempt. Contracting agencies may elect to
apply these requirements to other projects.
The following provisions are from the U.S. Department of Labor
regulations in 29 CFR 5.5 "Contract provisions and related matters'
with minor revisions to conform to the FHWA-1273 format and
FHWA program requirements.
1. Minimum wages
a. All laborers and mechanics employed or working upon the site
of the work, will be paid unconditionally and not less often than once
a week, and without subsequent deduction or rebate on any account
(except such payroll deductions as are permitted by regulations
Issued by the Secretary of Labor under the Copeland Act (29 CFR
part 3)), the full amount of wages and bona fide fringe benefits (or
cash equivalents thereof) due at time of payment computed at rates
not less than those contained in the wage determination of the
Secretary of Labor which is attached hereto and made a part hereof,
regardless of any contractual relationship Which may be alleged to
exist between the contractor and such laborers and mechanics.
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City # 15-6830
FED # HSIPL 5063(154)
Local Assistance Procedures Manual Exhibit 12-G
Required Federal -aid Contract Language
Contributions made or costs reasonably anticipated for bona fide
fringe benefits under section 1(b)(2) of the Davis -Bacon Act on
behalf of laborers or mechanics are considered wages paid to such
laborers or mechanics, subject to the provisions of paragraph 1.d. of
this section; also, regular contributions made or costs incurred for
more than a weekly period (but not less often than quarterly) under
plans, funds, or programs which cover the particular weekly period,
are deemed to be constructively made or incurred during such
weekly period. Such laborers and mechanics shall be paid the
appropriate wage rate and fringe benefits on the wage determination
for the classification of work actually performed, without regard to
skill, except as provided in 29 CFR 5.5(a)(4). Laborers or mechanics
performing work in more than one classification may be
compensated at the rate specified for each classification for the time
actually worked therein: Provided, That the employer's payroll
records accurately set forth the time spent in each classification in
which work is performed. The wage determination (including any
additional classification and wage rates conformed under paragraph
1.b. of this section) and the Davis -Bacon poster (WH -1321) shall be
posted at all times by the contractor and its subcontractors at the
site of the work in a prominent and accessible place where it can be
easily seen by the workers.
b. (1) The contracting officer shall require that any class of
laborers or mechanics, including helpers, which is not listed in the
wage determination and which is to be employed under the contract
shall be classified in conformance with the wage determination. The
contracting officer shall approve an additional classification and
wage rate and fringe benefits therefore only when the following
criteria have been met:
(i) The work to be performed by the classification requested is
not performed by a classification in the wage determination; and
(ii) The classification is utilized in the area by the construction
industry; and
(iii) The proposed wage rate, including any bona fide fringe
benefits, bears a reasonable relationship to the wage rates
contained in the wage determination.
(2) If the contractor and the laborers and mechanics to be
employed in the classification (if known), or their representatives,
and the contracting officer agree on the classification and wage
rate (including the amount designated forfringe benefits where
appropriate), a report of the action taken shall be sent by the
contracting officer to the Administrator of the Wage and Hour
Division, Employment Standards Administration, U.S. Department
of Labor, Washington, DC 20210. The Administrator, or an
authorized representative, will approve, modify, or disapprove
every additional classification action within 30 days of receipt and
so advise the contracting officer or will notify the contracting officer
within the 30 -day period that additional time is necessary.
(3) In the event the contractor, the laborers or mechanics to be
employed in the classification or their representatives, and the
contracting officer do not agree on the proposed classification and
wage rate (including the amount designated for fringe benefits,
where appropriate), the contracting officer shall refer the
questions, including the views of all interested parties and the
recommendation of the contracting officer, to the Wage and Hour
Administrator for determination. The Wage and Hour
Administrator, or an authorized representative, will issue a
determination within 30 days of receipt and so advise the
contracting officer or will notify the contracting officerwithin the 30 -
day period that additional time is necessary.
(4) The wage rale (including fringe benefits where appropriate)
determined pursuant to paragraphs 1.b.(2) or 1.b.(3) of this
section, shall be paid to all workers performing work in the
classification under this contract from the first day on which work
is performed in the classification.
c. Whenever the minimum wage rate prescribed in the contract for
a class of laborers or mechanics includes a fringe benefit which is
not expressed as an hourly rate, the contractor shall either pay the
benefit as stated in the wage determination or shall pay another
bona fide fringe benefit or an hourly cash equivalent thereof.
J. If the contractor does not make payments to a trustee or other
third person, the contractor may consider as part of the wages of
any laborer or mechanic the amount of any costs reasonably
anticipated in providing bona fide fringe benefits under a plan or
program, Provided, That the Secretary of Labor has found, upon the
written request of the contractor, that the applicable standards of the
Davis -Bacon Act have been met. The Secretary of Labor may
require the contractor to set aside in a separate account assets for
the meeting of obligations under the plan or program.
2. Withholding
The contracting agency shall upon its own action or upon written
request of an authorized representative of the Department of Labor,
withhold or cause to be withheld from the contractor under this
contract, or any other Federal contract with the same prime
contractor, or any other federally -assisted contract subject to Davis -
Bacon prevailing wage requirements, which is held by the same
prime contractor, so much of the accrued payments or advances as
may be considered necessary to pay laborers and mechanics,
including apprentices, trainees, and helpers, employed by the
contractor or any subcontractor the full amount of wages required by
the contract. In the event of failure to pay any laborer or mechanic,
including any apprentice, trainee, or helper, employed or working on
the site of the work, all or part of the wages required by the contract,
the contracting agency may, after written notice to the contractor,
take such action as may be necessary to cause the suspension of
any further payment, advance, or guarantee of funds until such
violations have ceased.
3. Payrolls and basic records
a. Payrolls and basic records relating thereto shall be maintained
by the contractor during the course of the work and preserved for a
period of three years thereafter for all laborers and mechanics
working at the site of the work. Such records shall contain the name,
address, and social security number of each such worker, his or her
correct classification, hourly rates of wages paid (including rales of
contributions or costs anticipated for bona fide fringe benefits or
cash equivalents thereof of the types described in section 1(b)(2)(B)
of the Davis -Bacon Act), daily and weekly number of hours worked,
deductions made and actual wages paid. Whenever the Secretary of
Labor has found under 29 CFR 5.5(a)(1)(iv) that the wages of any
laborer or mechanic include the amount of any costs reasonably
anticipated in providing benefits under a plan or program described
in section 1(b)(2)(B) of the Davis -Bacon Act, the contractor shall
maintain records which show that the commitment to provide such
benefits is enforceable, that the plan or program is financially
responsible, and that the plan or program has been communicated
in writing to the laborers or mechanics affected, and records which
show the costs anticipated or the actual cost incurred in providing
such benefits. Contractors employing apprentices or trainees under
approved programs shall maintain written evidence of the
registration of apprenticeship programs and certification of trainee
programs, the registration of the apprentices and trainees, and the
ratios and wage rates prescribed in the applicable programs.
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Local Assistance Procedures Manual
b. (1) The contractor shall submit weekly for each week in which
any contract work is performed a copy of all payrolls to the
contracting agency. The payrolls submitted shall set out accurately
and completely all of the information required to be maintained
under 29 CFR 5.5(a)(3)(i), except that full social security numbers
and home addresses shall not be included on weekly transmittals.
Instead the payrolls shall only need to include an individually
identifying number for each employee ( e.g. , the last four digits of
the employee's social security number). The required weekly payroll
information may be submitted in any form desired. Optional Form
WH -347 is available for this purpose from the Wage and Hour
Division Web site at
http://www.dol.gov/esa/whd/forms/wh347!nstr.htm or its successor
site. The prime contractor is responsible for the submission of
copies of payrolls by all subcontractors. Contractors and
subcontractors shall maintain the full social security number and
current address of each covered worker, and shall provide them
upon request to the contracting agency for transmission to the State
DOT, the FHWA or the Wage and Hour Division of the Department
of Labor for purposes of an investigation or audit of compliance with
prevailing wage requirements. It is not a violation of this section for a
prime contractor to require a subcontractor to provide addresses
and social security numbers to the prime contractor for its own
records, without weekly submission to the contracting agency..
(2) Each payroll submitted shall be accompanied by a "Statement of
Compliance," signed by the contractor or subcontractor or his or her
agent who pays or supervises the payment of the persons employed
under the contract and shall certify the following:
(i) That the payroll for the payroll period contains the
information required to be provided under §5.5 (a)(3)(ii) of
Regulations, 29 CFR part 5, the appropriate information is being
maintained under §5.5 (a)(3)(1) of Regulations, 29 CFR part 5,
and that such information is correct and complete;
(ii) That each laborer or mechanic (including each helper,
apprentice, and trainee) employed on the contract during the
payroll period has been paid the full weekly wages earned,
without rebate, either directly or indirectly, and that no
deductions have been made either directly or indirectly from the
full wages earned, other than permissible deductions as set forth
in Regulations, 29 CFR part 3;
(iii) That each laborer or mechanic has been paid not less
than the applicable wage rates and fringe benefits or cash
equivalents for the classification of work performed, as specified
in the applicable wage determination incorporated into the
contract.
(3) The weekly submission of a properly executed certification
set forth on the reverse side of Optional Form WH -347 shall
satisfy the requirement for submission of the "Statement of
Compliance" required by paragraph 3.b.(2) of this section.
(4) The falsification of any of the above certifications may
subject the contractor or subcontractor to civil or criminal
prosecution under section 1001 of title 18 and section 231 of title
31 of the United States Code.
c. The contractor or subcontractor shall make the records required
under paragraph 3.a. of this section available for inspection,
copying, or transcription by authorized representatives of the
contracting agency, the State DOT, the FHWA, or the Department
of Labor, and shall permit such representatives to interview
employees during working hours on the job. If the contractor or
subcontractor fails to submit the required records or to make them
available, the FHWA may, after written notice to the contractor, the
DLA -OB 13-06
City # 15-6830
FED # HSIPL 5063(154)
Exhibit 12-G
Required Federal -aid Contract Language
contracting agency or the State DOT, take such action as may be
necessary to cause the suspension of any further payment,
advance, or guarantee of funds. Furthermore, failure to submit the
required records upon request or to make such records available
may be grounds for debarment action pursuant to 29 CFR 5.12.
4. Apprentices and trainees
a. Apprentices (programs of the USDOL).
Apprentices will be permitted to work at less than the predetermined
rate for the work they performed when they are employed pursuant
to and individually registered in a bona fide apprenticeship program
registered with the U.S. Department of Labor, Employment and
Training Administration, Office of Apprenticeship Training, Employer
and Labor Services, or with a State Apprenticeship Agency
recognized by the Office, or if a person is employed in his or her first
90 days of probationary employment as an apprentice in such an
apprenticeship program, who is not individually registered in the
program, but who has been certified by the Office of Apprenticeship
Training, Employer and Labor Services or a State Apprenticeship
Agency (where appropriate) to be eligible for probationary
employment as an apprentice.
The allowable ratio of apprentices to journeymen on the jab site in
any craft classification shall not be greater than the ratio permitted to
the contractor as to the entire work force under the registered
program. Any worker listed on a payroll at an apprentice wage rate,
who is not registered or otherwise employed as stated above, shall
be paid not less than the applicable wage rate on the wage
determination for the classification of work actually performed. In
addition, any apprentice performing work on the job site in excess of
the ratio permitted under the registered program shall be paid not
less than the applicable wage rate on the wage determination for the
work actually performed. Where a contractor is performing
construction on a project in a locality other than that in which its
program is registered, the ratios and wage rates (expressed in
percentages of the journeyman's hourly rate) specified in the
contractor's or subcontractor's registered program shall be
observed.
Every apprentice must be paid at not less than the rate specified in
the registered program for the apprentice's level of progress,
expressed as a percentage of the journeymen hourly rate specified
in the applicable wage determination. Apprentices shall be paid
fringe benefits in accordance with the provisions of the
apprenticeship program. If the apprenticeship program does not
specify fringe benefits, apprentices must be paid the full amount of
fringe benefits listed on the wage determination for the applicable
classification. If the Administrator determines that a different practice
prevails for the applicable apprentice classification, fringes shall be
paid in accordance with that determination.
In the event the Office of Apprenticeship Training, Employer and
Labor Services, or a State Apprenticeship Agency recognized by the
Office, withdraws approval of an apprenticeship program, the
contractor will no longer be permitted to utilize apprentices at less
than the applicable predetermined rate for the work performed until
an acceptable program is approved.
b. Trainees (programs of the USDOL).
Except as provided in 29 CFR 5.16, trainees will not be permitted to
work at less than the predetermined rate for the work performed
unless they are employed pursuant to and individually registered in
a program which has received prior approval, evidenced by formal
certification by the U.S. Department of Labor, Employment and
Training Administration.
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Local Assistance Procedures Manual
The ratio of trainees to journeymen on the job site shall not be
greater than permitted under the plan approved by the Employment
and Training Administration.
Every trainee must be paid at not less than the rate specified in the
approved program for the trainee's level of progress, expressed as a
percentage of the journeyman hourly rate specified in the applicable
wage determination. Trainees shall be paid fringe benefits in
accordance with the provisions of the trainee program. If the trainee
program does not mention fringe benefits, trainees shall be paid the
full amount of fringe benefits listed on the wage determination
unless the Administrator of the Wage and Hour Division determines
that there is an apprenticeship program associated with the
corresponding journeyman wage rate on the wage determination
which provides for less than full fringe benefits for apprentices. Any
employee listed on the payroll at a trainee rate who is not registered
and participating in a training plan approved by the Employment and
Training Administration shall be paid not less than the applicable
wage rate on the wage determination for the classification of work
actually performed. In addition, any trainee performing work on the
job site in excess of the ratio permitted under the registered program
shall be paid not less than the applicable wage rate on the wage
determination for the work actually performed.
In the event the Employment and Training Administration withdraws
approval of a training program, the contractor will no longer be
permitted to utilize trainees at less than the applicable
predetermined rate for the work performed until an acceptable
program is approved.
c. Equal employment opportunity. The utilization of apprentices,
trainees and journeymen under this part shall be in conformity, with
the equal employment opportunity requirements of Executive Order
11246, as amended, and 29 CFR part 30.
J. Apprentices and Trainees (programs of the U.S. DOT).
Apprentices and trainees working under apprenticeship and skill
training programs which have been certified by the Secretary of
Transportation as promoting EEO in connection with Federal -aid
highway construction programs are not subject to the requirements
of paragraph 4 of this Section IV. The straight time hourly wage
rates for apprentices and trainees under such programs will be
established by the particular programs. The ratio of apprentices and
trainees to journeymen shall not be greater than permitted by the
terms of the particular program.
5. Compliance with Copeland Act requirements. The contractor
shall comply with the requirements of 29 CFR part 3, which are
incorporated by reference in this contract.
6. Subcontracts. The contractor or subcontractor shall insert Form
FHWA-1273 in any subcontracts and also require the subcontractors
to include Form FHWA-1273 in any lower tier subcontracts. The
prime contractor shall be responsible for the compliance by any
subcontractor or lower tier subcontractor with all the contract
clauses in 29 CFR 5.5.
7. Contract termination: debarment. A breach of the contract
clauses in 29 CFR 5.5 may be grounds for termination of the
contract, and for debarment as a contractor and a subcontractor as
provided in 29 CFR 5.12.
8. Compliance with Davis -Bacon and Related Act requirements.
All rulings and interpretations of the Davis -Bacon and Related Acts
contained in 29 CFR parts 1, 3, and 5 are herein incorporated by
reference in this contract.
DLA -OB 13-06
City # 15-6830
FED # HSIPL 5063(154)
Exhibit 12-G
Required Federal -aid Contract Language
9. Disputes concerning labor standards. Disputes arising out of
the labor standards provisions of this contract shall not be subject to
the general disputes clause of this contract. Such disputes shall be
resolved in accordance with the procedures of the Department of
Labor set forth in 29 CFR parts 5, 6, and 7. Disputes within the
meaning of this clause include disputes between the contractor (or
any of its subcontractors) and the contracting agency, the U.S.
Department of Labor, or the employees or their representatives.
10. Certification of eligibility.
a. By entering into this contract, the contractor certifies that neither it
(nor he or she) nor any person or firm who has an interest in the
contractor's firm is a person or firm ineligible to be awarded
Government contracts by virtue of section 3(a) of the Davis -Bacon
Act or 29 CFR 5.12(a)(1).
b. No part of this contract shall be subcontracted to any person or
firm ineligible for award of a Government contract by virtue of
section 3(a) of the Davis -Bacon Act or 29 CFR 5.12(a)(1).
c. The penalty for making false statements is prescribed in the U.S.
Criminal Code, 18 U.S.C. 1001.
V. CONTRACT WORK HOURS AND SAFETY STANDARDS ACT
The following clauses apply to any Federal -aid construction contract
in an amount in excess of $100,000 and subject to the overtime
provisions of the Contract Work Hours and Safety Standards Act.
These clauses shall be inserted in addition to the clauses required
by 29 CFR 5.5(a) or 29 CFR 4.6. As used in this paragraph, the
terms laborers and mechanics include watchmen and guards.
1. Overtime requirements. No contractor or subcontractor
contracting for any part of the contract work which may require or
involve the employment of laborers or mechanics shall require or
permit any such laborer or mechanic in any workweek in which he or
she is employed on such work to work in excess of forty hours in
such workweek unless such laborer or mechanic receives
compensation at a rate not less than one and one-half times the
basic rate of pay for all hours worked in excess of forty hours in such
workweek.
2. Violation; liability for unpaid wages; liquidated damages. In
the event of any violation of the clause set forth in paragraph (1.) of
this section, the contractor and any subcontractor responsible
therefor shall be liable for the unpaid wages. In addition, such
contractor and subcontractor shall be liable to the United States (in
the case of work done under contract for the District of Columbia or
a territory, to such District or to such territory), for liquidated
damages. Such liquidated damages shall be computed with respect
to each individual laborer or mechanic, including watchmen and
guards, employed in violation of the clause set forth in paragraph
(1.) of this section, in the sum of $10 for each calendar day on which
such individual was required or permitted to work in excess of the
standard workweek of forty hours without payment of the overtime
wages required by the clause set forth in paragraph (1.) of this
section.
3. Withholding for unpaid wages and liquidated damages. The
FHWA or the contacting agency shall upon its own action or upon
written request of an authorized representative of the Department of
Labor withhold or cause to be withheld, from any moneys payable
on account of work performed by the contractor or subcontractor
under any such contract or any other Federal contract with the same
Page 13 of 22
August 12, 2013
City # 15-6830
FED # HSIPL 5063(154)
Local Assistance Procedures Manual Exhibit 1.2-G
Required Federal -aid Contract Language
prime contractor, or any other federally -assisted contract subject to
the Contract Work Hours and Safely Standards Act, which is held by
the same prime contractor, such sums as may be determined to be
necessary to satisfy any liabilities of such contractor or
subcontractor for unpaid wages and liquidated damages as provided
in the clause set forth in paragraph (2.) of this section.
4. Subcontracts. The contractor or subcontractor shall insert in any
subcontracts the clauses set forth in paragraph (1.) through (4.) of
this section and also a clause requiring the subcontractors to include
these clauses in any lower tier subcontracts. The prime contractor
shall be responsible for compliance by any subcontractor or lower
tier subcontractor with the clauses set forth in paragraphs (1.)
through (4.) of this section.
VI. SUBLETTING OR ASSIGNING THE CONTRACT
This provision is applicable to all Federal -aid construction contracts
on the National Highway System.
1. The contractor shall perform with its own organization contract
work amounting to not less than 30 percent (or a greater percentage
if specified elsewhere in the contract) of the total original contract
price, excluding any specially items designated by the contracting
agency. Specialty items may be performed by subcontract and the
amount of any such specialty items performed may be deducted
from the total original contract price before computing the amount of
work required to be performed by the contractor's own organization
(23 CFR 635.116).
a. The term "perform work with its own organization" refers to
workers employed or leased by the prime contractor, and equipment
owned or rented by the prime contractor, with or without operators.
Such term does not include employees or equipment of a
subcontractor or lower tier subcontractor, agents of the prime
contractor, or any other assignees. The term may include payments
for the costs of hiring leased employees from an employee leasing
firm meeting all relevant Federal and State regulatory requirements.
Leased employees may only be included in this term if the prime
contractor meets all of the following conditions:
(1) the prime contractor maintains control over
the supervision of the day-to-day activities of the leased employees;
(2) the prime contractor remains responsible for the quality of
the work of the leased employees;
(3) the prime contractor retains all power to accept or exclude
individual employees from work on the project; and
(4) the prime contractor remains ultimately responsible for the
payment of predetermined minimum wages, the submission of
payrolls, statements of compliance and all other Federal
regulatory requirements.
b. "Specialty Items" shall be construed to be limited to work that
requires highly specialized knowledge, abilities, or equipment not
ordinarily available in the type of contracting organizations qualified
and expected to bid or propose on the contract as a whole and in
general are to be limited to minor components of the overall
contract.
2. The contract amount upon which the requirements set forth in
paragraph (1) of Section VI is computed includes the cost of material
and manufactured products which are to be purchased or produced
by the contractor under the contract provisions.
3. The contractor shall furnish (a) a competent superintendent or
supervisor who is employed by the firm, has full authority to direct
performance of the work in accordance with the contract
requirements, and is in charge of all construction operations
(regardless of who performs the work) and (b) such other of its own
organizational resources (supervision, management, and
engineering services) as the contracting officer determines is
necessary to assure the performance of the contract.
4. No portion of the contract shall be sublet, assigned or otherwise
disposed of except with the written consent of the contracting officer,
or authorized representative, and such consent when given shall not
be construed to relieve the contractor of any responsibility for the
fulfillment of the contract. Written consent will be given only after
the contracting agency has assured that each subcontract is
evidenced in writing and that it contains all pertinent provisions and
requirements of the prime contract.
5. The 30% self -performance requirement of paragraph (1) is not
applicable to design -build contracts; however, contracting agencies
may establish their own self -performance requirements.
VII. SAFETY: ACCIDENT PREVENTION
This provision is applicable to all Federal -aid construction contracts
and to all related subcontracts.
1. In the performance of this contract the contractor shall comply
with all applicable Federal, State, and local laws governing safety,
health, and sanitation (23 CFR 635). The contractor shall provide all
safeguards, safety devices and protective equipment and take any
other needed actions as it determines, or as the contracting officer
may determine, to be reasonably necessary to protect the life and
health of employees on the job and the safety of the public and to
protect property in connection with the performance of the work
covered by the contract.
2. It is a condition of this contract, and shall be made a condition of
each subcontract, which the contractor enters into pursuant to this
contract, that the contractor and any subcontractor shall not permit
any employee, in performance of the contract, to work in
surroundings or under conditions which are unsanitary, hazardous
or dangerous to his/her health or safety, as determined under
construction safety and health standards (29 CFR 1926)
promulgated by the Secretary of Labor, in accordance with Section
107 of the Contract Work Hours and Safety Standards Act (40
U.S.C. 3704).
3. Pursuant to 29 CFR 1926.3, it is a condition of this contract that
the Secretary of Labor or authorized representative thereof, shall
have right of entry to any site of contract performance to inspect or
investigate the matter of compliance with the construction safety and
health standards and to carry out the duties of the Secretary under
Section 107 of the Contract Work Hours and Safety Standards Act
(40 U.S.C.3704).
VIII. FALSE STATEMENTS CONCERNING HIGHWAY PROJECTS
This provision is applicable to all Federal -aid construction contracts
and to all related subcontracts.
In order to assure high quality and durable construction in
conformity with approved plans and specifications and a high degree
of reliability on statements and representations made by engineers,
contractors, suppliers, and workers on Federal -aid highway projects,
it is essential that all persons concerned with the project perform
their functions as carefully, thoroughly, and honestly as possible.
Willful falsification, distortion, or misrepresentation with respect to
any facts related to the project is a violation of Federal law. To
prevent any misunderstanding regarding the seriousness of these
and similar acts, Form FHWA-1022 shall be posted on each
Federal -aid highway project (23 CFR 635) in one or more places
Page 14 of 22
DLA -OB 13-06 August 12, 2013
City # 15-6830
FED # HSIPL 5063(154)
Local Assistance Procedures Manual Exhibit 12-G
Required Federal -aid Contract Language
where it is readily available to all persons concerned with the
project:
18 U.S.C. 1020 reads as follows:
"Whoever, being an officer, agent, or employee of the United
States, or of any State or Territory, or whoever, whether a person,
association, firm, or corporation, knowingly makes any false
statement, false representation, or false report as to the character,
quality, quantity, or cost of the material used or to be used, or the
quantity or quality of the work performed or to be performed, or the
cost thereof in connection with the submission of plans, maps,
specifications, contracts, or costs of construction on any highway or
related project submitted for approval to the Secretary of
Transportation; or
Whoever knowingly makes any false statement, false
representation, false report or false claim with respect to the
character, quality, quantity, or cost of any work performed or to be
performed, or materials furnished or to be furnished, in connection
with the construction of any highway or related project approved by
the Secretary of Transportation; or
Whoever knowingly makes any false statement or false
representation as to material fact in any statement, certificate, or
report submitted pursuant to provisions of the Federal -aid Roads Act
approved July 1, 1916, (39 Stat. 355), as amended and
supplemented;
Shall be fined under this title or imprisoned not more than 5 years
or both."
IX. IMPLEMENTATION OF CLEAN AIR ACT AND FEDERAL
WATER POLLUTION CONTROL ACT
This provision is applicable to all Federal -aid construction contracts
and to all related subcontracts.
By submission of this bid/proposal or the execution of this contract,
or subcontract, as appropriate, the bidder, proposer, Federal -aid
construction contractor, or subcontractor, as appropriate, will be
deemed to have stipulated as follows:
1. That any person who is or will be utilized in the performance of
this contract is not prohibited from receiving an award due to a
violation of Section 508 of the Clean Water Act or Section 306 of the
Clean Air Act.
2. That the contractor agrees to include or cause to be included the
requirements of paragraph (1) of this Section X in every subcontract,
and further agrees to take such action as the contracting agency
may direct as a means of enforcing such requirements.
X. CERTIFICATION REGARDING DEBARMENT, SUSPENSION,
INELIGIBILITY AND VOLUNTARY EXCLUSION
This provision is applicable to all Federal -aid construction contracts,
design -build contracts, subcontracts, lower -tier subcontracts,
purchase orders, lease agreements, consultant contracts or any
other covered transaction requiring FHWA approval or that is
estimated to cost $25,000 or more — as defined in 2 CFR Parts 180
and 1200.
1. Instructions for Certification — First Tier Participants
a. By signing and submitting this proposal, the prospective first
tier participant is providing the certification set out below.
DLA -OB 13-06
b. The inability of a person to provide the certification set out
below will not necessarily result in denial of participation in this
covered transaction. The prospective first tier participant shall
submit an explanation of why it cannot provide the certification set
out below. The certification or explanation will be considered in
connection with the department or agency's determination whether
to enter into this transaction. However, failure of the prospective first
tier participant to furnish a certification or an explanation shall
disqualify such a person from participation in this transaction.
c. The certification in this clause is a material representation of
fact upon which reliance was placed when the contracting agency
determined to enter into this transaction. If it is later determined that
the prospective participant knowingly rendered an erroneous
certification, in addition to other remedies available to the Federal
Government, the contracting agency may terminate this transaction
for cause of default.
d. The prospective first tier participant shall provide immediate
written notice to the contracting agency to whom this proposal is
submitted if any time the prospective first tier participant learns that
its certification was erroneous when submitted or has become
erroneous by reason of changed circumstances.
e. The terms "covered transaction," "debarred," "suspended,"
"ineligible; "'participant," "person," "principal;' and "voluntarily
excluded," as used in this clause, are defined in 2 CFR Parts 180
and 1200. "First Tier Covered Transactions' refers to any covered
transaction between a grantee or subgrantee of Federal funds and a
participant (such as the prime or general contract). "Lower Tier
Covered Transactions" refers to any covered transaction under a
First Tier Covered Transaction (such as subcontracts). "First Tier
Participant" refers to the participant who has entered into a covered
transaction with a grantee or subgrantee of Federal funds (such as
the prime or general contractor). "Lower Tier Participant" refers any
participant who has entered into a covered transaction with a First
Tier Participant or other Lower Tier Participants (such as
subcontractors and suppliers).
f. The prospective first tier participant agrees by submitting this
proposal that, should the proposed covered transaction be entered
into, it shall not knowingly enter into any lower tier covered
transaction with a person who is debarred, suspended, declared
ineligible, or voluntarily excluded from participation in this covered
transaction, unless authorized by the department or agency entering
into this transaction.
g. The prospective first tier participant further agrees by
submitting this proposal that it will include the clause titled
"Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusion -Lower Tier Covered Transactions," provided by
the department or contracting agency, entering into this covered
transaction, without modification, in all lower tier covered
transactions and in all solicitations for lower tier covered
transactions exceeding the $25,000 threshold.
h. A participant in a covered transaction may rely upon a
certification of a prospective participant in a lower tier covered
transaction that is not debarred, suspended, ineligible, or voluntarily
excluded from the covered transaction, unless it knows that the
certification is erroneous. A participant is responsible for ensuring
that its principals are not suspended, debarred, or otherwise
ineligible to participate in covered transactions. To verify the
eligibility of its principals, as well as the eligibility of any lower tier
prospective participants, each participant may, but is not required to,
check the Excluded Parties List System website
https://www.eols.eov/), which is compiled by the General Services
Administration.
1. Nothing contained in the foregoing shall be construed to require
the establishment of a system of records in order to render in good
faith the certification required by this clause. The knowledge and
Page 15 of 22
August 12, 2013
Local Assistance Procedures Manual
information of the prospective participant is not required to exceed
that which is normally possessed by a prudent person in the
ordinary course of business dealings.
j. Except for transactions authorized under paragraph (t) of these
instructions, if a participant in a covered transaction knowingly
enters into a lower tier covered transaction with a person who is
suspended, debarred, ineligible, or voluntarily excluded from
participation in this transaction, in addition to other remedies
available to the Federal Government, the department or agency may
terminale this transaction for cause or default.
2. Certification Regarding Debarment, Suspension, Ineligibility
and Voluntary Exclusion — First Tier Participants:
a. The prospective first tier participant certifies to the best of its
knowledge and belief, that it and its principals:
(1) Are not presently debarred, suspended, proposed for
debarment, declared ineligible, or voluntarily excluded from
participating in covered transactions by any Federal department or
agency;
(2) Have not within a three-year period preceding this proposal
been convicted of or had a civil judgment rendered against them for
commission of fraud or a criminal offense in connection with
obtaining, attempting to obtain, or performing a public (Federal,
State or local) transaction or contract under a public transaction;
violation of Federal or State antitrust statutes or commission of
embezzlement, theft, forgery, bribery, falsification or destruction of
records, making false statements, or receiving stolen property;
(3) Are not presently indicted for or otherwise criminally or civilly
charged by a governmental entity (Federal, State or local) with
commission of any of the offenses enumerated in paragraph (a)(2)
of this certification; and
(4) Have not within a three-year period preceding this
application/proposal had one or more public transactions (Federal,
State or local) terminated for cause or default.
b. Where the prospective participant is unable to certify to any of
the statements in this certification, such prospective participant shall
attach an explanation to this proposal.
2. Instructions for Certification - Lower Tier Participants:
(Applicable to all subcontracts, purchase orders and other lower tier
transactions requiring prior FHWA approval or estimated to cost
$25,000 or more - 2 CFR Parts 180 and 1200)
a. By signing and submitting this proposal, the prospective lower
tier is providing the certification set out below.
b. The certification in this clause is a material representation of
fact upon which reliance was placed when this transaction was
entered into. If it is later determined that the prospective lower tier
participant knowingly rendered an erroneous certification, in addition
to other remedies available to the Federal Government, the
department, or agency with which this transaction originated may
pursue available remedies, including suspension and/or debarment.
c. The prospective lower tier participant shall provide immediate
written notice to the person to which this proposal is submitted if at
any time the prospective lower tier participant learns that its
certification was erroneous by reason of changed circumstances.
d. The terms "covered transaction," "debarred," "suspended,"
"Ineligible," "participant," "person," "principal," and "voluntarily
excluded," as used in this clause, are defined in 2 CFR Parts 180
City # 15-6830
FED # HSIPL 5063(154)
Exhibit 12-G
Required Federal -aid Contract Language
and 1200. You may contact the person to which this proposal is
submitted for assistance in obtaining a copy of those regulations.
"First Tier Covered Transactions" refers to any covered transaction
between a grantee or subgrantee of Federal funds and a participant
(such as the prime or general contract). "Lower Tier Covered
Transactions' refers to any covered transaction under a First Tier
Covered Transaction (such as subcontracts). "First Tier Participant'
refers to the participant who has entered into a covered transaction
with a grantee or subgrantee of Federal funds (such as the prime or
general contractor). "Lower Tier Participant" refers any participant
who has entered into a covered transaction with a First Tier
Participant or other Lower Tier Participants (such as subcontractors
and suppliers).
e. The prospective lower tier participant agrees by submitting this
proposal that, should the proposed covered transaction be entered
into, it shall not knowingly enter into any lower tier covered
transaction with a person who is debarred, suspended, declared
ineligible, or voluntarily excluded from participation in this covered
transaction, unless authorized by the department or agency with
which this transaction originated.
f. The prospective lower tier participant further agrees by
submitting this proposal that it will include this clause titled
"Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusion -Lower Tier Covered Transaction," without
modification, in all lower tier covered transactions and in all
solicitations for lower tier covered transactions exceeding the
$25,000 threshold.
g. A participant in a covered transaction may rely upon a
certification of a prospective participant in a lower tier covered
transaction that is not debarred, suspended, ineligible, or voluntarily
excluded from the covered transaction, unless it knows that the
certification is erroneous. A participant is responsible for ensuring
that its principals are not suspended, debarred, or otherwise
ineligible to participate in covered transactions. To verify the
eligibility of its principals, as well as the eligibility of any lower tier
prospective participants, each participant may, but is not required to,
check the Excluded Parties List System website
(https://www.epls.gov/), which is compiled by the General Services
Administration.
h. Nothing contained in the foregoing shall be construed to require
establishment of a system of records in order to render in good faith
the certification required by this clause. The knowledge and
information of participant is not required to exceed that which is
normally possessed by a prudent person in the ordinary course of
business dealings.
i. Except for transactions authorized under paragraph a of these
instructions, if a participant in a covered transaction knowingly
enters into a lower tier covered transaction with a person who is
suspended, debarred, ineligible, or voluntarily excluded from
participation in this transaction, in addition to other remedies
available to the Federal Government, the department or agency with
which this transaction originated may pursue available remedies,
including suspension and/or debarment.
Certification Regarding Debarment, Suspension, Ineligibility
and Voluntary Exclusion --Lower Tier Participants:
1. The prospective lower tier participant certifies, by submission of
this proposal, that neither it nor its principals is presently debarred,
suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from participating in covered transactions by
any Federal department or agency.
Page 16 of 22
DLA -OB 13-06 August 12, 2013
Local Assistance Procedures Manual
2. Where the prospective lower tier participant is unable to certify to
any of the statements in this certification, such prospective
participant shall attach an explanation to this proposal.
XI. CERTIFICATION REGARDING USE OF CONTRACT FUNDS
FOR LOBBYING
This provision is applicable to all Federal -aid construction contracts
and to all related subcontracts which exceed $100,000 (49 CFR 20).
1. The prospective participant certifies, by signing and submitting
this bid or proposal, to the best of his or her knowledge and belief,
that:
a. 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.
b. If any funds other than Federal appropriated funds have been
paid or will be paid to any person for influencing or attempting to
influence an officer or employee of any 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 Form to
Report Lobbying," in accordance with its instructions.
2. 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 31 U.S.C. 1352. 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.
3. The prospective participant also agrees by submitting its bid or
proposal that the participant shall require that the language of this
certification be included in all lower tier subcontracts, which exceed
$100,000 and that all such recipients shall certify and disclose
accordingly.
City # 15-6830
FED # HSIPL 5063(154)
Exhibit 12-G
Required Federal -aid Contract Language
Page 17 of 22
DLA -OB 13-06 August 12, 2013
Local Assistance Procedures Manual
12. FEMALE AND MIONORITY GOALS
City # 15-6830
FED # HSIPL 5063(154)
Exhibit 12-G
Required Federal -aid Contract Language
To comply with Section II, "Nondiscrimination," of "Required Contract Provisions Federal -Aid Construction
Contracts," the following are goals for female and minority utilization goals for Federal -aid construction
contracts and subcontracts that exceed $10,000:
The nationwide goal for female utilization is 6.9 percent.
The goals for minority utilization [45 Fed Reg 65984 (10/3/1980)] are as follows:
MINORITY UTILIZATION GOALS
Page 18 of 22
I)LA-OB 13-06 August 12, 2013.
Goal
Economic Area
(Percent
Redding CA:
174
Non -SMSA (Standard Metropolitan Statistical Area) Counties:
6.8
CA Lassen; CA Modoc; CA Plumas; CA Shasta; CA Siskiyou; CA Tehama
Eureka, CA
175
Non -SMSA Counties:
6.6
CA Del Norte; CA Humboldt; CA Trinity
San Francisco -Oakland -San Jose, CA:
SMSA Counties:
7120 Salinas -Seaside -Monterey, CA
28.9
CA Monterey
7360 San Francisco -Oakland
25.6
CA Alameda; CA Contra Costa; CA Marin; CA San Francisco; CA San Mateo
7400 San Jose, CA
176
CA Santa Clara, CA
19.6
7485 Santa Cruz, CA
CA Santa Cruz
14.9
7500 Santa Rosa
CA Sonoma
9.1
8720 Vallejo -Fairfield -Napa, CA
CA Napa; CA Solano
17.1
Non -SMSA Counties:
CA Lake; CA Mendocino; CA San Benito
23.2
Sacramento, CA:
SMSA Counties:
6920 Sacramento, CA
16.1
177
CA Placer; CA Sacramento; CA Yolo
Non -SMSA Counties
14.3
CA Butte; CA Colusa; CA El Dorado; CA Glenn; CA Nevada; CA Sierra; CA Sutter; CA
Yuba
Stockton -Modesto, CA:
SMSA Counties:
5170 Modesto, CA
12.3
178
CA Stanislaus
8120 Stockton, CA
24.3
CA San Joaquin
Non -SMSA Counties
19.8
CA Alpine; CA Amador; CA Calaveras; CA Mariposa; CA Merced; CA Tuolumne
Page 18 of 22
I)LA-OB 13-06 August 12, 2013.
City # 15-6830
FED # HSIPL 5063(154)
Local Assistance Procedures Manual Exhibit 12-G
Required Federal -aid Contract Language
179
Fresno -Bakersfield, CA
SMSA Counties:
0680 Bakersfield, CA
CA Kern
2840 Fresno, CA
CA Fresno
Non -SMSA Counties:
CA Kings; CA Madera; CA Tulare
19.1
26.1
23.6
Los Angeles, CA:
SMSA Counties:
0360 Anaheim -Santa Ana -Garden Grove, CA
11.9
CA Orange
4480 Los Angeles -Long Beach, CA
28.3
CA Los Angeles
180
6000 Oxnard -Simi Valley -Ventura, CA
21.5
CA Ventura
6780 Riverside -San Bernardino -Ontario, CA
19.0
CA Riverside; CA San Bernardino
7480 Santa Barbara -Santa Maria -Lompoc, CA
19.7
CA Santa Barbara
Non -SMSA Counties
24.6
CA In o; CA Mono; CA San Luis Obispo
San Diego, CA:
SMSA Counties
181
7320 San Diego, CA
16.9
CA San Diego
Non -SMSA Counties
18.2
CA Imperial
For each July during which work is performed under the contract, you and each non material -supplier
subcontractor with a subcontract of $10,000 or more must complete Form FHWA PR -1391 (Appendix C to
23 CFR 230). Submit the forms by August 15.
13. FEDERAL TRAINEE PROGRAM
For the Federal training program, the number of trainees or apprentices is
This section applies if a number of trainees or apprentices is specified in the special provisions.
As part of your equal opportunity affirmative action program, provide on-the-job training to develop full
journeymen in the types of trades or job classifications involved.
You have primary responsibility for meeting this training requirement.
tf you subcontract a contract part, determine how many trainees or apprentices are to be trained by the
subcontractor.
Include these training requirements in your subcontract.
Where feasible, 25 percent of apprentices or trainees in each occupation must be in their 1st year of
apprenticeship or training.
Distribute the number of apprentices or trainees among the work classifications on the basis of your needs and
the availability ofjourneymen in the various classifications within a reasonable recruitment area.
Before starting work, submit to the City/County of
Page 19 of 22
DLA -06 13-06 August 12, 2013.
Local Assistance Procedures Manual
City # 15-6830
FED # HSIPL 5063(154)
Exhibit 12-G
Required Federal -aid Contract Language
1. Number of apprentices or trainees to be trained for each classification
2. Training program to be used
3. Training starting date for each classification
Obtain the City/County's of approval for this submitted information before you start work. The
City/County of credits you for each apprentice or trainee you employ on the work who is
currently enrolled or becomes enrolled in an approved program.
The primary objective of this section is to train and upgrade minorities and women toward journeymen status.
Make every effort to enroll minority and women apprentices or trainees, such as conducting systematic and
direct recruitment through public and private sources likely to yield minority and women apprentices or
trainees, to the extent they are available within a reasonable recruitment area. Show that you have made the
efforts. In making these efforts, do not discriminate against any applicant for training.
Do not employ as an apprentice or trainee an employee:
1. In any classification in which the employee has successfully completed a training course leading to
journeyman status or in which the employee has been employed as a journeyman
2. Who is not registered in a program approved by the US Department of Labor, Bureau of
Apprenticeship and Training
Ask the employee if the employee has successfully completed a training course leading to journeyman status
or has been employed as ajourneyman. Your records must show the employee's answers to the questions.
In your training program, establish the minimum length and training type for each classification. The
City/County of and FHWA approves a program if one of the following is met:
1. It is calculated to:
Meet the your equal employment opportunity responsibilities
• Qualify the average apprentice or trainee for journeyman status in the classification involved
by the end of the training period
2. It is registered with the U.S. Department of Labor, Bureau of Apprenticeship and Training, and it
is administered in a way consistent with the equal employment responsibilities of Federal -aid
highway construction contracts
Obtain the State's approval for your training program before you start work involving the classification
covered by the program.
Provide training in the construction crafts, not in clerk -typist or secretarial -type positions. Training is
allowed in lower level management positions such as office engineers, estimators, and timekeepers if the
training is oriented toward construction applications. Training is allowed in the laborer classification if
significant and meaningful training is provided and approved by the division office. Off-site training is
allowed if the training is an integral part of an approved training program and does not make up a
significant part of the overall training.
The City/County of reimburses you 80 cents per hour of training given an employee on this
contract under an approved training program:
1. For on-site training
2. For off-site training if the apprentice or trainee is currently employed on a Federal -aid project and
you do at least one of the following:
• Contribute to the cost of the training
• Provide the instruction to the apprentice or trainee
• Pay the apprentice's or trainee's wages during the off-site training period
3. If you comply this section.
Page 20 of 22
DLA -OB 13-06 August 12, 2013
city # 15-6830
FED # HSIPL 5063(154)
Local Assistance Procedures Manual Exhibit 12-G
Required Federal -aid Contract Language
Each apprentice or trainee must:
1. Begin training on the project as soon as feasible after the start of work involving the apprentice's
or trainee's skill
2. Remain on the project as long as training opportunities exist in the apprentice's or trainee's work
classification or until the apprentice or trainee has completed the training program
Furnish the apprentice or trainee:
1. Copy of the program you will comply within providing the training
2. Certification showing the type and length of training satisfactorily completed
14. TITLE VIASSURANCES
During the performance of this Agreement, the contractor, for itself, its assignees and successors in
interest (hereinafter collectively referred to as CONTRACTOR) agrees as follows:
(1) Compliance with Regulations: CONTRACTOR shall comply with the regulations relative to
nondiscrimination in federally assisted programs of the Department of Transportation, Title 49, Code
of Federal Regulations, Part 21, as they may be amended from time to time, (hereinafter referred to as
the REGULATIONS), which are herein incorporated by reference and made a part of this agreement.
(2) Nondiscrimination: CONTRACTOR, with regard to the wort, performed by it during the
AGREEMENT, shall not discriminate on the grounds of race, color, sex, national origin, religion,
age, or disability in the selection and retention of sub -applicants, including procurements of materials
and leases of equipment. CONTRACTOR shall not participate either directly or indirectly in the
discrimination prohibited by Section 21.5 of the Regulations, including employment practices when
the agreement covers a program set forth in Appendix B of the Regulations.
(3) Solicitations for Sub -agreements, Including Procurements of Materials and Equipment: In all
solicitations either by competitive bidding or negotiation made by CONTRACTOR for work to be
performed under a Sub -agreement, including procurements of materials or leases of equipment, each
potential sub -applicant or supplier shall be notified by CONTRACTOR of the CONTRACTOR'S
obligations under this Agreement and the Regulations relative to nondiscrimination on the grounds of
race, color, or national origin.
(4) Information and Reports: CONTRACTOR shall provide all information and reports required by the
Regulations, or directives issued pursuant thereto, and shall permit access to its books, records,
accounts, other sources of information, and its facilities as may be determined by the California
Department of Transportation or FHWA to be pertinent to ascertain compliance with such
Regulations or directives. Where any information required of CONTRACTOR is in the exclusive
possession of another who fails or refuses to furnish this information, CONTRACTOR shall so
certify to the California Department of Transportation or the FHWA as appropriate, and shall set forth
what efforts CONTRACTOR has made to obtain the information.
(5) Sanctions for Noncompliance: In the event of CONTRACTOR's noncompliance with the
nondiscrimination provisions of this agreement, the California Department of Transportation shall
impose such agreement sanctions as it or the FHWA may determine to be appropriate, including, but
not limited to:
(a) withholding of payments to CONTRACTOR under the Agreement within a reasonable period of
time, not to exceed 90 days; and/or
(b) cancellation, termination or suspension of the Agreement, in whole or in part.
(6) Incorporation of Provisions: CONTRACTOR shall include the provisions of paragraphs (1) through
(6) in every sub -agreement, including procurements of materials and leases of equipment, unless
exempt by the Regulations, or directives issued pursuant thereto.
Page 21 of 22
DLA -OB 13-06 August 12, 2013
City # 15-6830
FED # HSIPL 5063(154)
Local Assistance Procedures Manual Exhibit 12-G
Required Federal -aid Contract Language
CONTRACTOR shall take such action with respect to any sub -agreement or procurement as the
California Department of Transportation or FHWA may direct as a means of enforcing such provisions
including sanctions for noncompliance, provided, however, that, in the event CONTRACTOR becomes
involved in, or is threatened with, litigation with a sub -applicant or supplier as a result of such direction,
CONTRACTOR may request the California Department of Transportation enter into such litigation to
protect the interests of the State, and, in addition, CONTRACTOR may request the United States to enter
into such litigation to protect the interests of the United States.
MAINTAIN RECORDS AND SUBMIT REPORTS DOCUMENTING YOUR PERFORMANCE UNDER THIS SECTION
Page 22 of 22
DLA -OB 13-06 August 12, 2013
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
BID PROPOSAL
TO: CITY COUNCIL OF THE CITY OF SANTA ANA
FROM: SIEMENS INDUSTRY, INC.
REQUIREMENT:
The undersigned bidder declares that they have carefully examined the location of the
proposed work, that they have examined the Contract Documents in its entirety and hereby
proposes to furnish all material and do all the work required to complete the said work in
accordance with said plans (if any) and the specifications for the unit price(s) or lump sums) set
forth in the following schedule:
Project # 15-6830
Item
Description
Qty
Unit
Unit Price
Amount
1
Replace Pedestrian Head Assembly with
Countdown Head
734
EA
$ q8o, ®
5z,ry o
$ 35_? V
J
2
Replace Pedestrian Head Module with
7
EA
Countdown Head
`
3
Replace Pedestrian Push Button Assembly
948
EA
$
$ (PI, W`
4
Replace Pedestrian Push Button
118
EA
$
"
-1-2--
8 L) ao
5
Adjust Pedestrian Push Button Assembly to
831
EA
42 -inch Above Finished Grade
6
Install New Pedestrian Push Button
52
EA
gg
Assembly and Wiring
t c ®
Total Base Bid For Project: 15-6830 $
The lowest responsible bidder shall be selected based on the total base bid. The City reserves
the right to award the Base Bid, and any, all, or none of the add -alternate bid items (if any).
* The quantity for this bid item is shown for bid comparison only. This bid item shall not be
subject to the "25%" limit as stated in Section 3-2 of the Standard Specifications. The actual
amount for this item will be dictated by the actual quantity used, and the Agency reserves
the right to increase or decrease the quantity of this item accordingly.
t This bid item is considered a Specialty Item per Section 2-3.2 of the Standard Specifications.
BP-]
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
TIME FOR COMPLETION OF IMPROVEMENTS AND LIQUIDATED DAMAGES
The undersigned bidder hereby proposes to complete the Work for the total base bid amount
shown above, within eighty (80) working days after the commencement date stated in the
Notice to Proceed. The bidder also proposes to commence construction of the Work within ten
(10) days after issuance of a Notice to Proceed, and to continue in a diligent and workman -like
manner without interruption, and to complete the construction thereof within the time
specified above.
The liquidated damages amount in lieu of the amount specified in Subsection 6-9 of the
Standard Specifications, shall be $1,000 per calendar day.
Name of Firm SIEMENS INDUSTRY, INC.
Signature of BIDDER
s46exrda
Title la I f e- C to r O2 2 sey\Ce
(if an individual, so state)
BP -2
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
BIDDER'S STATEMENT
BIDDER understands and agrees that this Bid Proposal, Contract Documents and subsequent
Construction Contract Agreement shall constitute the entire agreement between BIDDER and
the AGENCY only after it has been accepted by the City Council, endorsed by the Clerk of the
Council with her signature and official seal noting hereon the action of approval of the Council,
signed by the Public Works Agency Executive Director or his/her duly authorized agent, and
signed by the City Attorney, denoting his approval of the form of this document, and its
execution, and when it or an exact copy of it has been either delivered to BIDDER or deposited
with the United States Postal Service properly addressed to the BIDDER with the correct
postage affixed thereto.
BIDDER further agrees that upon delivery (as defined above) of the accepted agreement he/she
will furnish AGENCY all required bonds and certificate of liability insurance within ten (10)
business days or the funds, check, draft, or BIDDERS bond substituted in lieu thereof
accompanying this proposal shall become the property of the AGENCY and shall be considered
as payment of damages due to the delay and other causes suffered by AGENCY because of the
failure to furnish the necessary bonds and because it is distinctly agreed that the proof of
—damages- actually —suffered—is—difficuirto—ascertain; otherwise—said—funds, check, drafts,--ar
BIDDER'S bond substituted in lieu thereof shall be returned to the undersigned.
BIDDER understands that a bid is required for the entire work, the estimated quantities set
forth in the 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 BIDDER also certifies that the bid is a balanced bid.
In accordance with Section 7028.15 of the California Business and Professions Code, the
undersigned certifies under penalty of perjury that the foregoing is true and correct.
Name of Firm SIEMENS INDUSTRY, INC. (CORPORATION)
Signature of BIDDER
Title UeCe4-A0a- 0V Se—CykceQ.
(if an individual, so state)
(If a firm or co -partnership, state the firm name and give the names of all individual co-partners
composing the firm. If a corporation, state legal name of corporation, and names of President,
Secretary, Treasurer and Manager, thereof.)
President: CEO, Kevin Riddett
Treasurer: CPO, Matthias Schlelein
Secretary: Communication Officer, Pranzislca Wagner
Address:
527 Madison Ave, 8th floor, New YorkNY10022
IM,
Operations Manager: Michael I3utchens
2200 W Orangewood Ave, Orange, CA 92868
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
CONTRACTOR'S LICENSING and REGISTRATION STATEMENT
The undersigned contractor, or corporate officer, declares under penalty of perjury that he/she
and all his/her subcontractors are registered with the State of California Department of
Industrial Relations (DIR), and that the following is true and correct.
Contractor's Name: SIEMENS INDUSTRY INC
Business Address: 2200 W Orangewood Ave, Orange, CA 92868
Business E -Mail MICHAELMUTCHENSaSIEMENS.COM
Address: 2200 W Orangewood Ave, Orange, CA 92868
Telephone: 714-448-6943
State Contractor's License No. and Class: 758796, C-I0,C-20, C-16, B
License
Expiration Date: 02/28/2017
State Dept. of Industrial Relations (DIR)
Registration No.: 1000002447
State Dept. of Industrial Relations (DIR)
Registration Expiration Date: 06/30/2016
Signed:
Title:
BP -4
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
PREVAILING WAGE COMPLIANCE AND MONITORING STATEMENT
Contractor is aware of the requirements of California Labor Code Section 1720, et seq., as well
as California Code of Regulations, Title 8, Section 16,000, et seq., ("Prevailing Wage Laws"),
which require the payment of prevailing wage rates and the performance of other
requirements on "public works" and "maintenance" projects. Since the services are being
performed as part of an applicable "public works" or "maintenance' project, as defined by the
Prevailing Wage Laws, and since the total compensation is $1,000 or more, Contractor agrees
to fully comply with such Prevailing Wage Laws.
City shall provide Contractor with a copy of the prevailing rates of per diem wages in effect at
the commencement of this Agreement. Contractor shall make copies of the prevailing rates of
per diem wages for each craft, classification or type of worker needed to execute the services
available to interested parties upon request, and shall post copies at the Contractor's principal
place of business and at the project site.
Contractor shall defend, indemnify and hold the City, its elected officials, officers, employees
and agents free and harmless from any claim or liability arising out of any failure or alleged
failure to comply with the Prevailing Wage Laws.
The undersigned certifies that the foregoing is true and correct.
Name of Firm SIEMENS INDUSTRY, INC.
Signature of BIDDER
Title { &9-r` hr o -t' Se-ryice.
(if an individual, so state)
-
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
OWNERSHIP AFFIDAVIT
STATE OF CALIFORNIA )
COUNTY OF ORANGE )SS:
CITY OF SANTA ANA )
that such a bid is genuine and not collusive or sham, and has not in any manner sought by
collusion to secure any advantage against the City of Santa Ana or any person interested in the
proposed contract, for himself or any other person.
ature�Bf dimer SiWL., pi, I
ib �r�ic�
Subscribed and sworn to before me thisday of -----2�O
Signature of officer Administering Oath
:.,
, being duly sworn, deposes and says:
❑ INDIVIDUAL
That he/she is the party making the foregoing proposal:
❑ PARTNERSHIP
That he/she is a member of the co -partnership firm designated as:
and who has been and is duly vested with the authority to make and execute
instruments for the co -partnership by;
who constitute the other members of the co -partnership.
® CORPORATION
That he is of:
SIEMENS INDUSTRY, INC.
a corporation which is makingthe foregoing proposal:
[-]JOINT VENTURE
That he is of:
one of the parties making the foregoing proposal as a joint venture, and the he/she has
been and is duly vested with the authority to execute instruments for an on behalf of
the parties making said bid who are:
that such a bid is genuine and not collusive or sham, and has not in any manner sought by
collusion to secure any advantage against the City of Santa Ana or any person interested in the
proposed contract, for himself or any other person.
ature�Bf dimer SiWL., pi, I
ib �r�ic�
Subscribed and sworn to before me thisday of -----2�O
Signature of officer Administering Oath
:.,
CITY OF SANTA ANA
PROPOSAL
PROJECT N0, 15-6830: Pedestrian Countdown Heads and Push Buttons
*SIEMENS INDUSTRY, INC. DOES NOT INTEND TO SUBCONTRACT ANY
PORTION OF WORK FOR THIS CONTRACT*
LIST OF SUB -CONTRACTORS
Section 4100 et. seq. of the Public Contract Code requires listing of all subcontractors with the bidfor I
subcontract work exceeding the following amount:
o Streets, highways including bridge projects: %% of the bid or $10,000, whichever is g, eater
o Buildings, parks, or other projects: Y2% of the bid
Section 1725.5 of the Public Contract Code requires all Subcontractors be registered ith the State
Department of Industrial Relations (DIR).
BIDDER proposes to subcontract certain portions of the work to the firms listed
71 "1
License #/Exp.
DIR Reg.#/Exp.
Location
Phone
Type Of Work
Amount $
FGM
License #/Exp.
DIR Reg.#/Exp.
License #
Location _
Phone
Type Of Work
Amount $
License #/Exp.
DIR Reg.#/Exp.
License # _
Location
Phone
Type Of V� rk
Amoug $
Signature
Name
License #/Exp.
DIR Reg.#/Exl
Location /
Phone /
Type Of Work
License #/Exp.
DIR Reg.#/Exp.
License # _
Location _
Phone _
Type Of Work
Amount $
P=
License #/Exp.
DIR Reg.#/Exp.
License # _
Location _
Phone
Type Of Work
Amount $
��ilL°wioa of ,¢r�21x
BP -8
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830; Pedestrian Countdown Heads and Push Buttons
REFERENCES
The following are the names, addresses, and telephone numbers for THREE public agencies for
which BIDDER has performed similar work within the past three years.
1 CITY OF DOWNEY, CA 11.111 Brookshire Ave, Downey, CA 90241
Name and Address of Owner.
EDWARD TORRESS 562 904 7114
Name and Telephone Number of person familiar with project.
$80,438.00 PEDESTRIAN COUNTDOWN HEADS PROJECT- PHASE 2 MAY 2015
Contract Amount Type of Work
Date Completed
2. CITY OF IRVINE, CA 6427 Oak Canyon, #3 Irvine, CA 92618
Name and Address of owner.
DAVE FLANAGAN (770) 206-2534
Name and Telephone Number of person familiar withopro�ect.
PIC ESTRIAN
HEAD REPLA EM NCS
$643,215.00 WITHIN SERVICE CONTRACT
JULY , 2015
Contract Amount Type of Work
Date Completed
3. CITY OF ONTARIO, CA 303 E B St, Ontario, CA 91764
Name and Address of owner.
MORICIO DIAZ 909-395-2000
Name and Telephone Number of person familiar with project.
$1,568 328.00 SERVICE AGREEMENT GROUP LED REPLACEMENT
OCTOBER, 2015.
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 and bonds.
Surety Company:
Liberty Mutual Holding CO., 450 Plymouth Rd., Suite 400, Plymouth Meeting, PA. 19462 610-832-8240 206473-6700
Insurance Company(s)
HDI -Gerling America, Travelers Property Casualty Company of America and the Charter Oak Fire Insurance
161 North Clark St. 48th Floor, Chicago, IL 60601 ; One Tower Square Hartford, CT 06183;/
312-580-1900;860-277.0111;
Broker
MARSH 445 South St. Morristown, NJ. 07962 973-401-5024
BP -9
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
ADDITIONAL REFERENCES
The following are the names, addresses, and telephone numbers for THREE public agencies for
which the BIDDER or Subcontractor has performed traffic signal installation and/or modification
in the past 5 years.
1 CITY OF IRVINE, CA 6427 Oak Canyon, #3 Irvine, CA 92618
Name and Address of Owner.
DAVE FLANACAN (949) 724-7684
Name and Telephone Number of person familiar with project.
$643,215.00 TS ROUTINE AND EMERGENCY SERVICES JULY 2015
Contract Amount Type of Work Date Completed
2 CITY OF YORBA LINDA, CA 4845 Casa Loma Avenue, Yorba Linda, Ca 92885
Name and Address of owner.
Armando Jaime (714) 961-7100
Name and Telephone Number of person familiar with project.
,+� Traffic Signal Preventative Maintenance, 1 1
1 Q 2,s^),"1n. LLD upgrade, signal head replacement l�,l^'CeAc�t
Contract Amount Type of Work Date Completed
3. CITY OF ANAHEIM 200 South Anaheim Blvd Anaheim, CA 92805
Name and Address of owner.
Christpher Dahl (714 ) 765-6908
Name and Telephone Number of person familiar with project.
'rrarfic Signal Preventative Maintenance Sq
oc-X'3 '"-' and emergency response �.+1. f f -,RV-,
Contract Amount Type of Worl<
Date Completed
The following are the names, addresses, and telephone numbers of all brokers and sureties
from whom BIDDER intends to procure insurance and bonds.
Surety Cumpmuy:
Liberty Mutual 1111a6rlln0 CO.. 4501ilymouth Rd., Sake 400, Plytnrmth hl" ln8,11A.19462 610.832-8240'206-473.6700
Insurance Ctmtpany(s)
61D11-Ceriht r America, Travelers Property CasualIX Company of Amerlon and the Charier Oak Fire Insurance
661 INor1h Clark S1, 48th Fleur, Chicago, 111,60601 „ One `]rawer $Hoare Hartford, CI 06183^1
(2-580-1900;860-231-0111„
Broker
[NIARSII 445 Soulb St. Morristown, ,NJ. 07962 +97340t-5024
BP -10
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
NON -COLLUSION AFFIDAVIT
(Title 23 United States Code Section 112 and
Public Contract Code Section 7106)
In accordance 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
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.
Note: The above Non -collusion Affidavit is part of the Proposal. Signing this Proposal on
the signature portion thereof shall also constitute signature of this Non -collusion Affidavit.
BIDDERS are cautioned that making a false certification may subject the certifier to criminal
prosecution.
Signed
State of California
County of
Subscribed and sworn to (or affirmed) before me on this y of20_, by
proved to me on the basis o tisfactory evidence to be the
person(s) who appeared before me
Notary Public Signature Notary Public Seal
BP -11
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
STATE OF CALIFORNIA
County of Orange }
On �Il�l Ony L� X6 before me, Candace Gallaher - Nott
Date Here
personally appeared
Capacity(ies) Claimed by Signer(s)
Signer's Name
❑ Individual
❑ Corporate Officer —Title(s):_
❑ Partner— ❑ Limited ❑ General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
Signer's Name
❑ Individual
❑ Corporate Officer —Title(s)_
❑ Partner —❑ Limited ❑ General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
who proved to me on the basis of satisfactory evidence to
be the persoriW whose name(€) is/awe-subscribed to the
within instrument and acknowledged to me that he/sem
executed the same in his/heOthOr authorized capacity('
R
CAN DACE OALLAHEN
and that by his/barAheir signature(e) on the instrument the
commission # 2117
person(,, or the entity upon behalf of which the person(s)-
acted, executed the instrument.
�. Notary Public - California
orange County
I certify under PENALTY OF PERJURY under the laws of
Comm, Ex irea Jul 24, 2019
the State of California that the foregoing g paragraph is true
and correct.
Witness my hind and (ficial seal.
Signature � ti
Place Notary Seal Above
Slgna ure of Notary Public
�/
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document:
Document Date:
Number of Pages:
Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name
❑ Individual
❑ Corporate Officer —Title(s):_
❑ Partner— ❑ Limited ❑ General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
Signer's Name
❑ Individual
❑ Corporate Officer —Title(s)_
❑ Partner —❑ Limited ❑ General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-68M Pedestrian Countdown Heads and Push Buttons
NON-DISCRIMINATION CERTIFICATE
The undersigned contractor or corporate officer, during the performance of this contract,
certifies as follows:
1. The Contractor shall not discriminate against any employee or applicant for employment
because of race, color, religion, sex, or national origin. The Contractor shall take affirmative
action to ensure that applicants are employed, and that employees are treated during
employment without, regard to their race, color, religion, sex, or national origin. Such
action shall include, but not be limited to, the following: employment, upgrading,
demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates
of pay or other forms of compensation; and selection for training, including apprenticeship.
The Contractor agrees to post in conspicuous places, available to employees and applicants
for employment, notices to be provided setting forth the provisions of this
nondiscrimination clause.
2. The Contractor shall, in all solicitations or advertisements for employees placed by or on
behalf of the Contractor, state that all qualified applicants will receive consideration for
employment without regard to race, color, religion, sex, or national origin.
3. The Contractor shall send to each labor union or representative of workers with which
he/she has a collective bargaining agreement or other contract or understanding, a notice
to be provided advising the said labor union or workers' representatives of the Contractor's
commitments under this section, and shall post copies of the notice in conspicuous places
available to employees and applicants for employment.
4. The Contractor shall comply with all provisions of Executive Order 11246 of September 24,
1965, and of the rules, regulations, and relevant orders of the Secretary of Labor.
5. The Contractor shall furnish all information and reports required by Executive Order 11246
of September 24, 1965, and by rules, regulations, and orders of the Secretary of Labor, or
pursuant thereto, and will permit access to his/her books, records, and accounts by the
administering agency and the Secretary of Labor for purposes of investigation, to ascertain
compliance with such rules, regulations, and orders.
6. In the event of the Contractor's non-compliance with the nondiscrimination clauses of this
contract or with any of the said rules, regulations, or orders, the contract may be canceled,
terminated, or suspended in whole or in part and the Contractor may be declared ineligible
for further Government contracts or federally assisted construction contracts in accordance
with procedures authorized in Execution Order 11246 of September 24, 1965, and such
other sanctions may be imposed and remedies invoked as provided in Executive Order
11246 of September 24, 1965, or by rule, regulations, or order of the Secretary of Labor, or
as otherwise provided by law.
BP -12
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
7. The Contractor shall include the portion of the sentence immediately preceding paragraph
(1) and the provisions of paragraphs (1) through (7) in every subcontract or purchase order
unless exempted by rules, regulations, or orders of the Secretary of Labor issued pursuant
to Section 204 of Executive Order 11246 of September 24, 1965, so that such provisions will
be binding upon each subcontract or purchase order as the administering agency may direct
as means of enforcing such provisions, including sanctions for noncompliance; provided,
however, that in the event the Contractor becomes involved in, or is threatened with,
litigation with a subcontractor or vendor as a result of such direction by the administering
agency, the Contractor may request that the United States enter into such litigation to
protect the interests of the United States.
8. Pursuant to California Labor Code Section 1735, as added by Chapter 643 Stats. 1939, and
as amended,
No discrimination shall be made in the employment of persons upon public works because of
race, religious creed, color, national origin, ancestry, physical handicaps, mental condition,
marital status, or sex of such persons, except as provided in Section 1420, and any contractor of
public works violating this Section is subject to all the penalties imposed for a violation of the
Chapter.
Signed:
Title:1f�c°�Uc p �J�CV9Cs
Firm: SIEMENS INDUSTRY, INC.
Date: 1 L- 1- 201 S
BP -13
CITY OF SANTA ANA
PROPOSAL
PROJECT N0, 15-6830: Pedestrian Countdown Heads and Push Buttons
STATEMENT REGARDING APPRENTICESHIP REQUIREMENTS
The undersigned BIDDER is familiar with the requirements of Section 1777.5 of the State Labor
Code regarding employment of apprentices, and understands that contractors on contracts
exceeding $30,000 or 20 working days shall:
1. Apply to the joint apprenticeship committee administering the apprenticeship standards
of the craft or trade in the area of the site of the public work for a certificate approving the
contractor under the apprenticeship standards for the employment and training of apprentices
in the area or industry affected.
2. Employ the number of apprentices or the ratio of apprentices to journeymen stipulated
in the apprenticeship standards.
3. Contribute to the fund or funds in each craft or trade in which he/she employs
journeymen or apprentices on the public work, in the same amount or upon the same basis and
in the same manner as the other contractors, except contractors not signatory to the trust
agreement shall pay a like amount to the California Apprenticeship Council.
Signed:
Title: 1 JIC¢c�cC c� �e�^J1
Firm: SIEMENS INDUSTRY, INC.
Date: 17--- l— 2o15
BP -14
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
STATEMENT REGARDING "ANTI -KICKBACK" REQUIREMENTS
The undersigned is submitting this proposal for performing by contract the work required by
these bid documents, agrees to comply with the Copeland "Anti -Kickback" Act (18 USC 74) as
supplemented in the Department of Labor regulations (29 CFR, Part 3). This act provides that
each contractor or subcontractor shall be prohibited from inducing, by any means, any person
employed in the construction or repair of public work, to give up any part of the compensation
to which he/she is otherwise entitled.
Signed: ✓/�
1575r
Title:
Firm: SIEMENS INDUSTRY. INC.
Date: 12 - I- 20 t s
BP -15
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
PUBLIC CONTRACT CODE SECTION 10162 QUESTIONNAIRE
In conformance with Public Contract Code Section 10162, the BIDDER shall complete, under
penalty of perjury, the following questionnaire:
Has the BIDDER, any officer of the BIDDER, or any employee of the BIDDER who has a
proprietary interest in the BIDDER, ever been disqualified, removed, or otherwise prevented
from bidding on, or completing a federal, state, or local government project because of a
violation of law or a safety regulation?
Yes No X
If the answer is yes, explain the circumstances in the following space.
****At present Siemens ITS business unit, of Siemens Industry, Inc. has no pending criminal, civil or administrative litigations.
Please note that this certification primarily reflects information related only to the ITS Mobility business unit and not to its affiliates.
ITS is a part of a large corporate enterprise, with numerous directly or indirectly controlled or controlling affiliates, conducting various
disparate businesses in multiple jurisdictions, and employing over 60,000 employees in the United States. Information from
Siemens Industry, Inc, affiliates regarding issues not material to the business of Siemens Industry, Inc. is generally not centrally
maintained by Siemens Industry, Inc. SII performs tens of thousands of projects annually through over one hundred offices.
As such SII has been involved in miscellaneous litigations and disputes arising out of its business none of which are of a material
nature as to adversely impact its ability to completely and satisfactorily perform any of its projects. As a result, Siemens Industry, Inc.
cannot ensure the completeness of such information. Consequently a material risk of insolvency to either tine Service Provider or
Guarantor or materially affect the Service Provider's or Guarantor's ability to perform their obligations due to pending litigation
is not apparent.***
BP -16
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
BIDDER'S STATEMENT REGARDING REQUIRED FEDERAL CONTRACT PROVISIONS (Form FHWA-
1273
The undersigned, is submitting this proposal for performing by contract the work required by
these bid documents, agrees to comply with the required Federal Contract Provision (Form
FHWA-1273) as shown in the Agpeendix F of the special provisions of this project.
Signed
'' • rer V
Title ►_.J j q c -b -c- u l� Sais1�c
Firm SIEMENS INDUSTRY, INC.
Date I7_— I —
BP -17
CITY OF SANTA ANA
PROPOSAL
PROJECT N0, 15-58M Pedestrian Countdown Heads and Push Buttons
EQUAL EMPLOYMENT OPPORTUNITY CERTIFICATION
The bidder SIEMENS INDUSTRY, INC.
proposed subcontractor NSA hereby
certifies that he has X has not _, participated in a previous contract or subcontract
subject to the equal opportunity clauses, as required by Executive Orders 10925, 11114, or
11246, and that, where required, he has filed with the Joint Reporting Committee, the Director
of the Office of Federal Contract Compliance, a Federal Government contracting or
administering agency, or the former President's Committee on Equal Employment Opportunity,
all reports due under the applicable filling requirements.
Note: The above certification is required by the Equal Employment Opportunity Regulations 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. Contracts and subcontracts which are exempt
from the equal opportunity clause are set forth in 41 CFR 60-1.5. (Generally only
contracts or subcontracts of $10,000 or under are exempt.)
Currently, 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.
BP -18
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
PUBLIC CONTRACT CODE SECTION 10285.1 STATEMENT
In conformance with Public Contract Code Section 10285.1 (Chapter 376, Stats. 1985), the
bidder hereby declares under penalty of perjury under the laws of the State of California that
the bidder has _, has not X been convicted within the preceding three years of any
offenses referred to in that section, including any charge of fraud, bribery, collusion, conspiracy,
or any other act in violation of any state or Federal antitrust law in connection with the bidding
upon, award of, or performance of, any public works contract, as defined in Public Contract
Code Section 1101, with any public entity, as defined in Public Contract Code Section 1100,
including the Regents of the University of California or the Trustees of the California State
University. The term "bidder" is understood to include any partner, member, officer, director,
responsible managing officer, or responsible managing employee thereof, as referred to in
Section 10285.1,
Note: The bidder must place a check mark after "has" or "has not" in one of the blank spaces
provided. The above Statement is part of the Proposal. Signing this Proposal on the
signature portion thereof shall also constitute signature of this Statement. Bidders are
cautioned that making a false certification may subject the certifier to criminal
prosecution.
Signed
Title ' ) k -cc -A -Dc- Q-• Eaac, n -e-
Firm SIEMENS INDUSTRY INC
Date
****At present Siemens ITS business unit, of Siemens Industry, Inc. has no pending criminal, civil or administrative litigations.
Please note that this certification primarily reflects information related only to the ITS Mobility business unit and not to its affiliates.
ITS is a part of a large corporate enterprise, with numerous directly or indirectly controlled or controlling affiliates, conducting various
disparate businesses in multiple jurisdictions, and employing over 60,000 employees in the United States. Information from
Siemens Industry, Inc. affiliates regarding issues not material to the business of Siemens Industry, Inc. is generally not centrally
maintained by Siemens Industry, Inc. SII performs tens of thousands of projects annually through over one hundred offices.
As such SII has been involved in miscellaneous litigations and disputes arising out of its business none of which are of a material
nature as to adversely impact its ability to completely and satisfactorily perform any of its projects. As a result, Siemens Industry, Inc.
cannot ensure the completeness of such information. Consequently a material risk of insolvency to either the Service Provider or
Guarantor or materially affect the Service Provider's or Guarantor's ability to perform their obligations due to pending litigation
is not apparent.***
BP -19
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
PUBLIC CONTRACT CODE SECTION 10232 STATEMENT
In conformance with Public Contract Code Section 10232, the Contractor, hereby states under
penalty of perjury, that no more than one final unappealable finding of contempt of court by a
federal court has been issued against the Contractor within the immediately preceding two
year period because of the Contractor's failure to comply with an order of a federal court which
orders the Contractor to comply with an order of the National Labor Relations Board.
Note: The above Statement and Questionnaire are part of the Proposal. Signing this
Proposal on the signature portion thereof shall also constitute signature of this
Statement and Questionnaire.
Bidders are cautioned that making a false certification may subject the certifier
to criminal prosecution.
Signed
Title t Cn�r n-� i C.,e-
Firm SIEMENS INDUSTRY, INC.
Date \ ") , — � —
C' 1
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
TITLE 49 CODE OF FEDERAL REGULATIONS PART 29 DEBARMENT AND SUSPENSION
CERTIFICATION
The bidder under penalty of perjury, certifies that except as noted below, he/she or any person
associated therewith in the capacity of owner, partner, director, officer, manager:
is not currently under suspension, debarment, voluntary exclusion, or determination of
ineligibility by any federal agency;
has not suspended, debarred, voluntarily excluded, or determined ineligible by any federal
agency within past three years;
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.
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.
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.
Name of Bidder SIEMENS INDUSTRY INC
Signature of Bidd
Date
****At present Siemens ITS business unit, of Siemens Industry, Inc. has no pending criminal, civil or administrative litigations.
Please note that this certification primarily reflects information related only to the ITS Mobility business unit and not to its affiliates.
.ITS is a part of a large corporate enterprise, with numerous directly or indirectly controlled or controlling affiliates, conducting various
disparate businesses in multiple jurisdictions, and employing over 60,000 employees in the United States. Information from
Siemens Industry, Inc. affiliates regarding issues not material to the business of Siemens Industry, file, is generally not centrally
maintained by Siemens Industry, Inc. SII performs tens of thousands of projects annually through over one hundred offices.
As such SIl has been involved in miscellaneous litigations and disputes arising out of its business none of which are of a material
nature as to adversely impact its ability to completely and satisfactorily perform any of its projects. As a result, Siemens Industry, Inc.
cannot ensure the completeness of such information. Consequently a material risk of insolvency to either the Service Provider or
Guarantor or materially affect the Service Provider's or Guarantor's ability to perform their obligations due to pending litigation
is not apparent.***
BP -21
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
NON -LOBBYING CERTIFICATION FOR FEDERAL AID CONTRACTS
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 influence or attempting to influence 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 appropriate 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 accordance 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 $100,000 and that all such sub -recipients shall certify and disclose
accordingly.
Bidder's i n x8u6nl iEe`jb, .✓e'c t
SIEMENS INDUSTRY, INC.
Firm
Date
Standard Form LLL may be obtained from Caltrans and FHWA offices.
BP -22
*SIEMENS INDUSTRY INC HAS NOT PARTICIPATED IN ANY LOBBYING ACTIVITES PURSUIENT TO THIS PROJECT TO
THE BEST OF OUR KNOWLEDGE*
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
DISCLOSURE OF LOBBYING ACTIVITIES
Complete this farm to disclose lo'L6ying aavigea pursuant to 131 U.S.C- 1352
i(.mina vau+ .- F m.J{J:m k...^.r-- s- e.
Appaavea by QM5
ONR-=6
1.Type of lFederafAtiw
'g. Status of Federal] Action: •..�•�••,��•
3. Report Type:
❑ a_ contract
❑a hadAdlerdapplicatiom
❑ a.. indiak filing
las grant
h. imgal
sward
la.. malerial. change
c. cooperative agreement
o post,award
O
Four Materiel lC'3hange f3nfy.
d. duan
year quarlei
/
a. ow guarantee
data of last report
fi loan iasuraerce
�—
d. Name and Addlress of Reporting.., Entity:
S -'IF Reporting) En6Bty in�He,..�d is. a Sub � e,a�, Ente�€Riame
❑ Erma ❑ suuswaaee
ann] Address sof Prima::
Tarr . ifImouwr:
cdn' resslanal', DistRmt. ffdrmowm:
ra'SSHUStlat District.wa:
7. Faadaral program Description .
5i Federal fiajpartumentrftgerrcy:
rCFDA Numb de:
8, Federal ActionNumber, ifltnowm:
S, Award A nt,. Wknown:
S
I& a_ Hafnia and pAddiaof Lobbying Entity
tr. Indaidpata Perforroiog Semiues diorhrding addrrass rrf
(ifiadfvidaal. Mast name, first name, M)-.
d'Nerx4af from No. f Ipal
{feyP name. fiestmaune. tiff):.
Rift MUM 4cia)S/,VLUA;raeue
11, Amount of Payment (check aff a@afapply):
113. Type of:Payment Ichefalr�al'81@,raf a.W1Ri}rI:
El acoria Elp
Ela falana
❑ tkore;$an No
❑o: eornrNrtlan
1!2.IForm of Payment(cJheA addthat , apply
❑ a:cwh
❑ d-CCXrti 1pmtiBe.
❑ tkAnt tmiy'"cur Inalraie
❑ e�aararmd
orbs
❑ r. rats; urpBCRy:.
'
fdl. D:rief Desoriptdwmr of Se s Performed or to be Performed and Datels) of Servicecl ..
, inud7na o�fficeri[s,�,
employeelsp, or Miam6 sI contaofed', for Payment'. Indicated in, Bem f 1-
af'faa7 tbtJdllctalYad
SFLHq�rirtear�.
1S. �Cantinua n SPoee$ s SF-I-L'd attachedi:.
Yea
rV re. so. WAC.,_.....mulgnfltoTEVEN
,.mow w•+rK m v osc. ns, re`
EAL
Print Name.itle:.aPt'diw
XK—
Gw �a soar. wd nxmr. arw%itaeoGM
Telephome No.: !ll _
,./.Y.-, 1"'t�i 1[fata.
Federal Use Only:
Airloa3ed fart Loma Rapm anon
Stm�d'ao'. Ebim LLL Ray.7-a
BP -23
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
EXHIBIT 15-G CONSTRUCTION CONTRACT DBE COMMITMENT
1, Local Agency: City of Santa Ana
2. Contract DBE Goal:
3. Project Description: Replace exist no pedestrian heada to Countdown heads and push br tions
4. Project Location: Vadlaus Incations throuaho d the Cfy of Santa Ana
5. Bidder's Name: SIEMENS INDUSTRY, INC.
6. Prime Certified DBE:
❑ 7. Bid Amount:
8. Total Dollar Amount for ALL Subcontractors: 0 9. Total Number of ALL Subcontractors: 0
10. Bid
Item
Number
11. Description of Work, Service, or Materials
Supplied
12. DBE
Certification
Number
13. DBE Contact Information
(Must be certified on the date bids are
opened)
14. DBE
Dollar
Amount
Local Agency to Complete this Section
$ 0
21. Local Agency Contract Number:
22. Federal -Aid Project Number: HSIPL 5063(154)
15. TOTAL CLAIMED DBE PARTICIPATION
23. Bid Opening Date:
24. Contract Award Date:
IMPORTANT: Identify all DBE firms being claimed for credit,
regardless of tier. Names of the First Tier DBE
Subcontractors and their respective items) of work listed
above must be consistent, where applicable with the names
and items of the work in the "Subcontractor List" submitted
Local Agency certifies that all DBE certifications are valid and information on
with your bid. Written confirmation of each listed DBE is
this form is complete and accurate.
required. _
o ei
16. Preparets.Siq9ture 11. Date
25. Local Agency Representative's Signature H. Date
STEVEN TEAL -Jj` _+'D j 6
27. Local Aqency Representative's Name 28. Phone
s Name .�
1188`. 117,9. Phone
29. Local Agency Representative's Title
�Prepare
�j �� 7 �-X
��\C
20. Pre arer's Title
DISTRIBUTION: 1. Original - Lo cal Agency
2. Copy- Caltrans District Local Assistance Engineer (DLAE). Failure to submit to CLAP within 30 days
of contract execution may result in de -obligation of federal funds on contract. Include additional copy
with award package.
ADA Notice: For individuals with sensory disabilities, this document is available In alternate formats. For Information call (916) 654-6419
or TDD (918) 654-3889 or write Records and Forms Management, 1129 N Street, MS -89, Sacramento, CA 95814.
BP -25
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
EXHIBIT 15-H DBE INFORMATION—GOOD FAITH EFFORTS
DBE INFORMATION - GOOD FAITH EFFORTS
Federal -aid Project No. HSIPL 5063 (154) Bid Opening Date 12/1/2015
CITY OF SANTA ANA
The (City/County of) established a Disadvantaged Business Enterprise (DBE) goal of 0 % for this
project. The information provided herein shows that a good faith effort was made.
Lowest, second lowest and third lowest bidders shall submit the following information to document adequate good faith
efforts. Bidders should submit the following information even if the "Local Agency Bidder DBE Commitment" form
indicates that the bidder has met the DBE goal. This will protect the bidder's eligibility for award of the contract if the
administering agency determines that the bidder failed to meet the goal for various reasons, e.g., a DBE firm was not certified
at bid opening, or the bidder made a mathematical error.
Submittal of only the "Local Agency Bidder DBE Commitment" form may not provide sufficient documentation to
demonstrate that adequate good faith efforts were made.
The following items are listed in the Section entitled "Submission of DBE Commitment" of the Special Provisions
A. The names and dates of each publication in which a request for DBE participation for this project was
placed by the bidder (please attach copies of advertisements or proofs of publication):
Publications Dates of Advertisement
N/A
B. The Dames and dates of written notices sent to certified DBEs soliciting bids for this project and the dates
and methods used for following up initial solicitations to determine with certainly whether the DBEs were
interested (please attach copies of solicitations, telephone records, fax confirmations, etc.):
Names of DBEs Solicited Date of Initial Follow Up Methods and Dates
N/A
BP -27
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-68M Pedestrian Countdown Heads and Push Buttons
C. The items of work which the bidder made available to DBE firms including, where appropriate, any
Breaking down of the contract work items (including those items normally performed by the bidder with its
own forces) into economically feasible units to facilitate DBE participation. It is the bidder's responsibility to
demonstrate that sufficient work to facilitate DBE participation was made available to DBE firms.
Items of Work Bidder Normally Breakdown of Amount Percentage
Performs Item Items M Of
N/A
D. The names, addresses and phone numbers of rejected DBE firms, the reasons for the bidder's rejection of
the DBEs, the firms selected for that work (please attach copies of quotes from the firms involved), and the
price difference for each DBE if the selected firm is not a DBE:
Names, addresses and phone numbers of rejected DBEs and the reasons for the bidder's rejection of the
DBEs:
N/A
Names, addresses and phone numbers of firms selected for the work above:
N/A
E. Efforts made to assist interested DBEs in obtaining bonding, lines of credit or insurance, and any technical
assistance or information related to the plans, specifications and requirements for the work which was
provided to DBEs:
N/A
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
F. Efforts made to assist interested DBEs in obtaining necessary equipment, supplies, materials or related
assistance or services, excluding supplies and equipment the DBE subcontractor purchases or leases from
the prime contractor or its affiliate:
G. The names of agencies, organizations or groups contacted to provide assistance in contacting, recruiting
and using DBE firms (please attach copies of requests to agencies and any responses received, i.e., lists,
Internet page download, etc.):
Name of Agency/Organization Method/Date of Contact Results
N/A
H. Any additional data to support a demonstration of good faith efforts (use additional sheets if necessary):
NOTE: USE ADDITIONAL SHEETS OF PAPER IF NECESSARY.
*SIEMENS INDUSTRY INC DOES NOT INTEND TO SUBCONTRACT ANY
PORTION OF WORK FOR THIS CONTRACT. HOWEVER, IF DURING EXICUTION OF CONTRACT A PORTION
OF THE CONTRACT IS IDENTIFIED TO BE SUBCONTRACT, SIEMENS INDUSTRY INC IS COMMITTED TO
SUPPORTING ALL FEDERAL AND LOCAL DBE GOALS AND EFFORTS
BP -29
i°SIEMENS INDUSTRY INC DOES NOT INTEND TO SUBCONTRACT ANY PORTION OF WORK FOR THIS
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
EXHIBIT 12-B BIDDER'S LIST OF SUBCONTRACTORS (DBE AND NON -DBE)
PARTI
The bidder shall list all subcontractors (both DBE and non -DBE) in accordance with Section 2- .054 of the Standard
Specifications and per Title 49, Section 26.11 of the Code of Federal Regulations. This listh is required in
addition to listing DBE Subcontractors elsewhere in the proposal. Photocopy this form f additional firms.
Firm Name/ phone/
Address/ Fax Annual Gross Description of Portion of Wo r to be Local Aeency Use -
City, State, Receipts Performed O^]v -
ZIP (Certified DBE?)
Name _ Phone ❑ <$1 million f—Iv>~c;..� _...
BP -30
Fax
LJ <$15 million
City State ZIP
❑ > $15 million
A' a sof Ftrra .Yrs;
Name
Phone
❑ <$lmillion
X'ES
❑ <$5 millionEl
Address
❑ <$I 0 million
=7 YE,S dist DBS;
Fax
❑ <$15 million
-
City State ZIP
❑ > $15 million
A e of,Flrm
'
Name
Phone
❑ < $1 million
❑ <$5 million
-p-_
Address
❑<$10million
1;$ SdistDBE#
Fax
❑ < $15 million
City State ZIP❑
> $15 milliFirm
Yrs. -
Name
Phone
❑ < $1 mij, ion
❑<$5 tllion-
Address
❑ < $ 0 million
I YT S list DBE
Fax
❑ < 15 million
City State ZIP
❑ $15 million
Ace of Firm (Yrs_) �.
BP -30
*SIEMENS INDUSTRY INC DOES NOT INTEND TO SUBCONTRACT ANY PORTION OF WORK FOR THIS CONTRACT
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
EXHIBIT 12-B BIDDER'S LIST OF SUBCONTRACTORS (DBE AND NON -DBE)
PART II
The bidder shall list all subcontractors who provided a quote or bid but were not selected to p,
subcontractor on this project. This is required for compliance with Title 49, Section 26 of the
Regulations. Photocopy this form for additional firms.
Firm Name/ Phone/
Address/ Annual Gross Description of Portion of Wor/be
City, State, Fax Receipts Performed
ZIP
Name Phone ❑ <$1 million
❑ < $5 million
Address ❑ <$10 million
Fax ❑ <$15 million
City State ZIP ❑> $$15 million
Name Phone ❑ <$1 million
❑ < $5 million
Address ❑<$10million
Fax ❑ <$15 million
City State ZIP ❑ > $15 million
Name Phone I_I <$1 million
❑ <$5 million
Address ❑<$10million
Fax ❑ <$15 million
City State 7.1P ❑ > $15 millioxf
Name Phone ❑ <
❑<
Address ❑ <
Fax ❑ <
City State ZIP ❑
BP -31
ate as a
of Federal
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
PROMPT PAYMENT OF FUNDS WITHHELD TO SUBCONTRACTORS
The undersigned, is submitting this proposal for performing by contract the work required by
these bid documents, certify to comply with the following:
The agency shall hold retainage from the prime contractor and shall make prompt and
regular incremental acceptances of portions, as determined by the agency, of the
contract work, and pay retainage to the prime contractor based on these acceptances.
The prime contractor, or subcontractor, shall return all monies withheld in retention
from a subcontractor within 30 days after receiving payment for work satisfactorily
completed and accepted including incremental acceptances of portions of the contract
work by the agency. Federal law (49CFR26.29) requires that any delay or postponement
of payment over 30 days may take place only for good cause and with the agency's
prior written approval. Any violation of this provision shall subject the violating prime
contractor or subcontractor to the penalties, sanctions and other remedies specified in
Section 7108.5 of the Business and Professions Code. These requirements shall not be
construed to limit or impair any contractual, administrative, or judicial remedies
otherwise available to the prime contractor or subcontractor in the event of a dispute
involving late payment or nonpayment by the prime contractor, deficient subcontract
performance, or noncompliance by a subcontractor.
Signed
Title
Firm SIEMENS INDUSTRY, INC.
Date
BP -32
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
DIFFERING SITE CONDITIONS
The undersigned, is submitting this proposal for performing by contract the work required by
these bid documents, certify to comply with the following:
Signed
Title
a. Contractor's Notification
Promptly notify the Agency's Engineer if you find either of the following conditions:
1. Physical conditions differing materially from either of the following:
• Contract documents
• Job site examination
2. Physical conditions of an unusual nature, differing materially
from those ordinarily encountered and generally recognized as
inherent in the work provided for in the Contract
Include details explaining the information you relied on and the material
differences you discovered. If you fail to promptly notify the Engineer, you waive
the differing site condition claim for the period between your discovery of the
differing site condition and your notification to the Engineer.
If you disturb the site after discovery and before the Engineer's investigation, you
waive the differing site condition claim.
b. Engineer's Investigation and Decision
Upon your notification, the Engineer investigates job site conditions and:
1. Notifies you whether to resume affected work
2. Decides whether the condition differs materially and is cause for an
adjustment of time, payment, or both
"w0a lk t�\C2
Firm SIEMENS INDUSTRY, INC.
Date
BP -33
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
BIDDER'S CERTIFICATE OF COMPLIANCE REGARDING "BUY AMERICA" REQUIREMENTS FOR
STEEL OR MANUFACTURED PRODUCTS
The undersigned, is submitting this proposal for performing by contract the work required by
these bid documents, certify to comply with the " Buy America" requirements of Section 165 of
the Surface Transportation Assistance Act of 1982 and as shown in the special provisions of this
project.
Signed
Title
Firm SIEMENS INDUSTRY, INC.
Date
BP -34
MAYOR
Miguel A. Pulido
MAYOR PRO TEM
Vincent F. Sarmiento
COUNCILMEMBERS
Angelica Amezcua
P. David Benavides
Michele Martinez
Roman Reyna
Sal Tinajero
November 24, 2015
ADDENDUM No. Two
CITY OF SANTA ANA
20 Civic Center Plaza . P.O. Box '1988, M-43
Santa Ana, California 92702.
(714)647-5019
www Santa-ana ora
CITY MANAGER
David Cavazos
CITY ATTORNEY
Sonia R. Carvalho
CLERK OF THE COUNCIL
Maria D. Huizar
SUBJECT: PROJECT No. 15-6830: Pedestrian Countdown Heads and Push
Buttons
The following clarifications have been made to the subject project:
1) What are the acceptable methods for patching the visible holes on the signal pole
as a result of the removal or relocation of the existing pedestrian push button
assembly?
The acceptable method is to install a Steel Knockout Seal with Screw Bar
or Snap -in Steel Knockout Seal.
2) Is it allowable to install the new 3 conductor cable in existing conduit without
removing existing conductors?
Yes, the new 3 conductor signal cable may be installed without removing
other conductors.
All other terms and conditions remain the same.
FOR THE CITY OF SANTA ANA
f �1 in "William" Galvez, P.E.
v.
City Engineer
SANTA ANA CITY COUNCIL
Miguel A-Pulido vincenf F. Sarmiento Michele. Martinez An9alica Amezrue P- Devid Banevides Roman Rayna Sal nna,aro
Mayor Mayor Pm Tem, Ward 1 Ward Wa,d3 Ward WartlS Ward6
msulitlo(aJsanla-ana on vaanniento(NSanfa-ana om mmarlineiC�Jsan4a-ana orq aamezcua(Nsai�fa-ana,orq dhenavides_Qsanta-ana ort rre na sanfaana orq slinaieroLsanlB-ana oy
MAYOR
Miguel A. Pulido
MAYOR PRO TEM
Vincent F. Sarmiento
COUNCILMEMBERS
Angelica Amezcua
P. David Benavides
Michele Martinez
Roman Reyna
Sal Tinaiena
November 19, 2015
ADDENDUM No. One
CITY OF SANTA ANA
20 Civic Center Plaza • P.O. Box 1988, M-43
Santa Ana, California 92702
(714) 847-5019
www Santa -ane ora
CITY MANAGER
David Cavazos
CITY ATTORNEY
Sonia R. Carvalho
CLERK OF THE COUNCIL
Maria D. Huizar
SUBJECT: PROJECT No. 15-6830: Pedestrian Countdown Heads and Push
Buttons
The following changes have been made to the plans and specifications of the subject
project.
1. Replace sheet 14 with attached revised sheet 14. Corrected total Replace
Assembly quantity in Pedestrian Push Button table. However, the total quantity in
the bid proposal remains the same,
Specifications:
1. Page 59, Delete section 3.04 "ADVANCE WARNING SIGNS' in its entirety.
All other terms and conditions remain the same.
FOR THE CITY OF SANTA ANA
""William
z, P.E.
City Engineer
SANTA ANA CITY COUNCIL
Mlyuel A. Pulido Vincent F. Sarmiento Michale Martinez Angelica Amezcua P. David aenavidec
Mayor Mayor Pro rem, Ward 1 Ward 2 Ward 3 Ward 4
m ulidoa s�anle-ana.ora varmienlo Santa-ana as, mmar Inez o7sanla-anew aamezcua(edsant-ana.oej dl>b n vig�ganta-anaoro
Roman Reyna Sal Tmajero
Ward Ward
IIp na San eaLaa_gg eti aero ala -ane o,
Chubb—� POWER Federal Insurance Company Attn: Surety Department
OF Vigilant Insurance Company 15 Mountain View Road
Surety ATTORNEY Pacific Indemnity Company Warton, NJ 07059
Know Alit by These Presents, That FEDERAL INSURANCE COMPANY, an Indiana corporation, VIGILANT INSURANCE
COMPANY, a New York corporation, and PACIFIC INDEMNITY COMPANY, a Wisconsin corporation, do each hereby constitute and
appoint Pamela A. Beelman, Cynthia L. Choren, Joann R. Frank, Sandra L. Ham, Nancy L. Johnson, Heidi A. Notheisen,
Karen L. Rolder and Debra C. Schneider of St. Louis, Missouri — ----- — --- — -------
each as their true and lawful Attorney. In- Fad to execute under such designation in their names and to affix their corporate seals to and deliver for and on their behalf as surety
thereon or otherwise, bonds and undertakings and other wrilirgs obligatory In the nature thereof (other than bail bonds) given a executed in the mum of business, and any
instruments amending or altering the same, and consents to the mod5dation or atterellon of any InMment rammed to in said bonds or obligations.
In witness whereof, mid FEDERAL INSURANCE COMPAf Y VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY have each executed and attested
these presents and affixed their corporate seals on this 21 day or May, 2014.
Lnm.:Ohloros, 66'tant 5®arelary a or ~Jr -,Vim i
* 0 9) *
STATE OF NEW JERSEY
as.
County of Somerset
On this 21th day of May, 2014 before me, a Notary Public of New Jersey, personally came Dawn M. Chloros, tome known to ba Assesont Smartary of FEDERAL
INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY, the companies which nxamtedthbiorogolpg:Power ofAttorney, and the
said Daum M. Chloros, being by me duly sworn, did depose and Say that she is Assistant Secretary of FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE
COMPANY, and PACIFIC INDEMNITY COMPANY and knows the corporate seals thereof, that the Seals affixed to the foregoing Power of Ahomey ars such corporate seals
and were thereto a0wed by authority of the By- Laws of said Companies; and that she signed said Power of Attomey as Assistant Secretary of said Companies by Ilke authody;
and that she is acquainted with David B. Norris, Jr., and knows him to be Vice President of said Companies; and that the signature of David B. Norris, Jr., subscribed to said
Powef orAttomay fa in the genuine handwriting of David B. Noms, Jr., end was thereto Subscribed by authorityof said By- Laws and in deponent's presence.
Notarial Seal
KATHERINE A RAM F E NEW
G LLQ
AAR
m
NOTARY OF NEW JERSEY i^
No 2316685 G'h„�
Commission Eepim July 16, 2014 No cry adbi c
CERTIFICATION
Extract from the By- Lavers of FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY:
'All powers of attorney for and on behalf of the Company may and shall be executed in the name and on behalf of the Company, either by the Chairman or the
President or a Vice President or an Assistant Vice President, jolntiy with the Secretary or an Assistant Secretary, under their respective designations. The
signature of such officers may be engraved, printed or Lithographed. The signature of each of the following officers; Chairman, President, any Vice President, any
Assistant Vim President, any Secretary, any Assistant Secretary and the seal of the Company may be affixed by facsimile to any power of attorney or to any
certificate relating thereto appolnting Assistant Secretaries or Atiomeys- in- FOCI for purposes only of executing and attesting bonds and undertakings and otter
writings obligatory in the nature thereof, and any such power of adomey or certificate bearing such facsimile signature or facsimile seal shall be valid and binding
upon the Company and any such power so executed and cenifled by such facsimile signature and facslmlle seal shall be valid and binding upon the Company
with respect to any bond or undertaking to which it Is atlached.'
I, Dawn M. Chloros, Assistant Secretary of FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY (the "Companles)
do hereby certify that
(i) the foregoing extract of the By- Laws of the Companies is true and correct,
(i) the Companies are duly licensed and authorized to transact surety business in all 50 of the United States of America and the District of Columbia OM are
authorized by the U.S. Treasury Department; further, Federal and Vigilant are Iimined In the U.S. Virgin Islands, and Federal Is licensed in Amedcan
Samoa, Guam, Puerto Rico, and each of the Provinces of Canada except Prince Edward Island; and
(ii) the foregoing Power of Attorney is true, correct and in full force and effect,
Given under my hand and seals of said Companies at Waren, NJ this 01 st day of December 2015.
NWIw f?`ChlornS Assistant5eoretaly
IN THE EVENT YOU WISH TO NOTIFY US OF A CLAIM, VERIFY THE AUTHENTIC" OF THIS BOND OR NOTIFY US OF ANY OTHER MATTER, PLEASE CONTACT US AT ADDRESS
Form 1610.0226& U GEN CONSENT (rev. MAO
Form 15-10-0313A (Rev. 3/15)
FEDERAL INSURANCE COMPANY
STATEMENT OF ASSETS, LIABILITIES AND SURPLUS TO POLICYHOLDERS
Statutory Basis
DECEMBER 31, 2014
(in thousands of dollars)
LIABILITIES
AND
ASSETS SURPLUS TO POLICYHOLDERS
Cash and Short Term Investments................ $ 110,484 Outstanding Losses and Loss Expenses..... $ 12,181,139
United States Government, State and Unearned Premiums..................................... 3,654,861
Municipal Bonds......................................... 10,245,402 Ceded Reinsurance Premiums Payable....... 339,466
Other Bonds.................................................. 4,927,443 Provision for Reinsurance ............................ 46,470
Stocks........................................................... 1,066,355 Other Liabilities............................................. 1,434,018
Other Invested Assets................................... 1,365,367
TOTAL INVESTMENTS ............................... 17,715,051 TOTAL LIABILITIES.................................... 17,655,954
Investments in Affiliates:
Chubb Investment Holdings, Inc................ 3,565,038 Capital Stock................................................ 20,980
Pacific Indemnity Company ........................ 2,922,214 Paid-In Surplus............................................. 3,106,909
Executive Risk Indemnity Inc...................... 1,258,019 Unassigned Funds....................................... 11,700,594
Chubb Insurance Investment Holdings Ltd.... 1,162,709
CC Canada Holdings Ltd ............................ 652,880
Chubb Insurance Company of Australia Ltd. 480,068 SURPLUS TO POLICYHOLDERS.............. 14,828,383
Great Northern Insurance Company.......... 476,969
Vigilant Insurance Company ....................... 292,313
Chubb European Investment Holdings SLP.. 287,633
Other Affiliates............................................ 517,330
Premiums Receivable................................... 1,679,148
Other Assets................................................. 1,474,965
TOTAL LIABILITIES AND SURPLUS
TOTAL ADMITTED ASSETS ...................... $ 32,484,337 TO POLICYHOLDERS............................. $ 32,484,337
Investments are valued in accordance with requirements of the National Association of Insurance Commissioners.
At December 31, 2014, investments with a carrying value of $518,199,884 were deposited with government authorities
as required by law.
State, County & City of New York, — as:
Yvonne Baker, Assistant Secretary of the Federal Insurance Company
being duly sworn, deposes and says that the foregoing Statement of Assets, Liabilities and Surplus to Policyholders of said
Federal Insurance Company on December 31, 2014 is true and correct and is a true abstract of the Annual Statement of said
Company as filed with the Secretary of the Treasury of the United States for the 12 months ending December 31, 2014.
Subscribed and sworn to before me
this March 11, 2015.
_
JEANETTE SHIPSEY Assistant Secretary
_ Notary Public, State of New York
Notary Public No. 02SH5074142
Qualified in Nassau County
Commission Expires March 10, 2019
Form 15-10-0313A (Rev. 3/15)
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
STATE OF CALIFORNIA
County of Orange
On((i �1 J bfore me, Candace Gallaher -Notary Public
Date Here Insert Name and Title of the Officer
personally appeared
----CANDACEAHE,
Commission M 2117338
Notary Public • California a
Orange County
Ex Ires Jul 24, 2019
who proved to me on the basis of satisfactory evidence to
be the persory(ej'whose name(w) is/axe-subscribed to the
within instrument and acknowledged to me that he/ahe4h.sy-
executed the same in hlsi44@ lthja[P authorized capacity(las)7
and that by his/her4heir signature(qn the instrument the
person*, or the entity upon behalf of which the personJ*
acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of
the State of California that the foregoing paragraph is true
and correct.
Witness my, land a d official se I.
AU),
Signature /
Place Notary Seal Above Signature of otary Public
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document:
Document Date:
Signer(s) Other Than Named Above:
Capacity(les) Claimed by Signer(s)
Signer's Name:
❑ Individual
❑ Corporate Officer --Title(s):_
❑ Partner— ❑ Limited ❑ General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
Number of Pages:_
Signer's Name:
❑ Individual
❑ Corporate Officer —Title(s)_
❑ Partner— ❑ Limited ❑ General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
STATE OF CALIFORNIA
Countyof Orange
Q l' CJb b fore me, Candace Gallaher - Notary Public
On 0 Here Insert Name and Title of the Officer '
personally appeared
]�+�r+-+CANDACEE GALLA ER E
Commission #2111733111
a Notary Public - California z
z Orange County '
s�My Comm. Ex fires Jul 24, 2019+
Place Notary Seal Above
who proved to me on the basis of satisfactory evidence to
be the person - whose name.(s)-is/ar-e-subscribed to the
within instrument and acknowledged to me that he/sheAhW-_
executed the same in his/h®r6their authorized capacity(les),
and that by his/her-lttheir signature(s)-on the instrument the
person(o,, or the entity upon behalf of which the person(e)-
acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of
the State of California that the foregoing paragraph is true
and correct.
Witness m and an � official seal. �
Signature
Signature of Notary Public
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document:
Document
Signer(s) Other Than Named Above:
Capacity(les) Claimed by Signer(s)
Signer's Name:
❑ Individual
❑ Corporate Officer —Title(s):_
❑ Partner — ❑Limited❑General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
Number of
Signer's Name:
❑ Individual
❑ Corporate Officer —Title(s)_
❑ Partner— ❑ Limited ❑ General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
CITY OF SANTA ANA
PROPOSAL
PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons
KNOW ALL PRESENT that,
itL&%.-Ve+e-ft ,as BIDDER, nd
, as SURET ,
are held and firmly bound unto the CITY OF SANTA ANA, as AGENCY, in the penal
sufn of
Dollars ($ ), which is ten ercent (10%)
of the total amount bid by BIDDER to AGENCY for the above -stated project, f the payment of
which sum, BIDDER and SURETY agree to be bound, jointly and severa y! firmly by these
presents.
THE CONDITIONS OF THIS OBLIGATION ARE SUCH that, w/nD
ER is about to submit a
bid to AGENCY for the above -stated project, if said bid is rsaid bid is accepted and
a contract is awarded and entered into by BIDDER in the time specified, then this
obligation shall be null and void, otherwise it shall remaice and effect in favor of
AGENCY.
IN WITNESS WHEREOF the parties hereto have set the .(names, titles, hands, and seal this
day of , 20_.
BIDDER*
SURETY*
Subscribed and sworn p6 before me this day of
20_
Signature:
Notary Publ' in and for the County of , State of
*Provid BIDDER/ SURETY name, address, and telephone number and the name, title, address,
and t ephone number of authorized representative.
BP -7
Document A31®TM .2010
Conforms with The American Institute of Architects AIA Document 310
CONTRACTOR:
(Name, legal status and address)
Siemens Industry Inc.
2250 Business Way
Riverside, CA 92501
OWNER:
(Name, legal status and address)
City of Santa Ana
20 Civic Center Plaza
Santa Ana, CA 92701
Bond Number: 79434433-CHU-15-22
SURETY:
(Name, legal status and principal place of business)
Federal Insurance Company
15 Mountain View Rd.
Warren, NJ 07061-1615
State of Inc: Indiana
BOND AMOUNT: Ten Percent of Amount Bid (10%)
This document has important legal
consequences. Consultation with
an attorney is encouraged with
respect to its completion or
modification.
Any singular reference to
Contractor, Surety, Owner or
other party shall be considered
plural where applicable.
PROJECT:
(Name, location or address, and Project number, ff any)
Pedestrian Countdown Heads and Push Buttons Replacement of Countdown Pedestrian Heads and PPB's City Wide
The Contractor and Surety are bound to the Owner in the amount set forth above, for the payment of which the
Contractor and Surety bind themselves, their heirs, executors, administrators, successors and assigns, jointly and
severally, as provided herein. The conditions of this Bond are such that if the Owner accepts the bid of the Contractor
within the time specified in the bid documents, or within such time period as may be agreed to by the Owner and
Contractor, and the Contractor either (1) enters into a contract with the Owner in accordance with the terms of such bid,
and gives such bond or bonds as may be specified in the bidding or Contract Documents, with a surety admitted in the
jurisdiction of the Project and otherwise acceptable to the Owner, for the faithful performance of such Contract and for
the prompt payment of labor and material furnished in the prosecution thereof; or (2) pays to the Owner the difference,
not to exceed the amount of this Bond, between the amount specified in said bid and such larger amount for which the
Owner may in good faith contract with another party to perform the work covered by said bid, then this obligation shall
be null and void, otherwise to remain in full force and effect. The Surety hereby waives any notice of an agreement
between the Owner and Contractor to extend the time in which the Owner may accept the bid. Waiver of notice by the
Surety shall not apply to any extension exceeding sixty (60) days in the aggregate beyond the time for acceptance of bids
specified in the bid documents, and the Owner and Contractor shall obtain the Surety's consent for an extension beyond
sixty (60) days.
If this Bond is issued in connection with a subcontractor's bid to a Contractor, the term Contractor in this
deemed to be Subcontractor and the term Owner shall be deemed to be Contractor. -t
When this Bond has been furnished to comply with a statutory or other legal requirement in the tocat�
any provision in this Bond conflicting with said statutory or legal requirement shall be deemed del
provisions conforming to such statutory or other legal requirement shall be deemed incorporated 15
furnished, the intent is that this Bond shall be construed as a statutory bond and not as a common Is
,
Signed and sealed this 01st eror Decem e , 2015
Siemens
(Principal)
(Witness -
5"Al
Federal Insurance Com ani_ -____i
��(�l/�`. (Suret (Seal)
(WitneSS) Nan y L. Johnson
(Title) Sandra L. Ham, Attorney -In -Fact
ACKNOWLEDGMENT BY SURETY
STATE
OF Missouri
City of St. Louis } ss.
On this 01st
appeared
day of December.
Sandra L. Ham
Federal Insurance Company
2015 , before me personally
, luiown to me to be the Attorney -in -Fact of
, the corporation
that executed the within instrument, and acknowledged to me that such corporation executed the same.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal, at my office in the aforesaid
County, the day and year in this certificate first above writ[cn.
My Commission Expires: September 16, 2019
(Seal)
Nato�r ..."y u. CLAY[N —
V obllc, Notary Seal
St
St. Lowq r ---Missouri
S-0230/GEEF 2/98
201,;
Brittany D. Clavin
Notary Public in the State of Missouri
County of St. Louis
Commission # 15638336
SIEMENS
=04, 111791 W W.
Orange, Ca .i
City of Santa Ana
City Hall — Ross Annex
20 Civic Center Plaza, M-22
Santa Ana, Ca 92701
"SEALED BID — DO NOT OPEN WITH REGULAR MAIL"
Project No. 15-6830: Pedestrian Countdown Heads and Push Buttons
December 1, 2015 at 2:00:59 P.M.
Bond Number: 8244-17-76MI13211106M
CITY OF SANTA ANA
BONDS
PROJECT NO,: XX,XXXX
PROJECT TITLE
H Ty PES'' Cllr An PAYM)GNT BOND
(To be submitted upon project completion as a condition of project acceptance)
KNOW ALL MEN BY THESE PRESENTS that Siemens Industry Inc.
as CONTRACTOR, and Federal Insurance Company and Fidelity and Deposit ompany o ary an '
a corporation, organized and existing under the laws of the State, and duly authorized to transact
business Under Etre laws of the State, of CaIifornda, as SURETY, are held and firmly bound unto
the City of Santa Ana, as AGR9CY, in the penal sum of One Hundred Forty -Nine Thousand
Nineteenand 001100 ---------------------------------- --------------------------------------------------
149,o19.oa Dollars
which is 25 percent of the #final contract amount for the above stated
project, for the payment of which sum, CONTRACTOR and SURETY agree to be bound, jointly
and severally, firmly by these presents.
THE CONDITIONS OF THIS OBLIGATION ARE SUCH that, whereas CONTRACTOR has
been awarded and is about to enter into the annexed Contract Agreement with AGENCY dated
March 24, 2016 for
Project 15-6830 (Federal Project HSIPL 5063 154)) Pedestrian Countdown Heads & Push Buttons
If CONTRACTOR faithfully warrants the work done under said Contract Agreement against
material or quality defects for a period of one year after acceptance by the AGENCY, then dials
obligation shall be null and void, otherwise it shall remain in fall force and effect in favor of
AGENCY; provided that any alterations in the obligations or time for completion made pursuant
to the terms of the contract documents shall not in any way release either CONTRACTOR or
SURETY, and notice of such alterations is hereby waived by SURETY.
IN WITNESS WHEREOF the parties hereto have set their names, titles, hands, and seal this
26th day of September 20 16
CONTRACTOR* Siemens Industry Inc. 2200 VV Orangewood Ave. Suite 210,' Orange, CA 92868 (714)456-9902
By:
a�rrr ttb t1 �Y Federal insurance Company 15 Mountain Vlew Rd, Warren, NJ 07059 (908)903-3493
SU n r'T 1l * Fidelit and Deposit Com an of Maryland 1400 American Lane, Schaumburg, IL 60106 (800)962-2557
By!� i ],ctl ] n I)in
Subscribed and sworn to before roe, Cynthia t_. Chorea this 26th day of
September 20 16
i L vire
Signature: yu r 0 o ',js„c ,rl
'
'51 i_Cuis l;Ql,Ji,k'
�i
Notal Public, it) orad for t c Count of St. Louis , t f 1 t�k"�s
Notary y r.a e o ����:,�,�I �Irca :;�.• , I; ,'�. ) r, zU V
Rate of premium on this bond is $ N/A per thousand.
Total amount of premium charge is $ N/A — _ . To belled in by Surely
*Provide CON -TRACTOR f ADMYTED SURETYname, address, and telephone number and the
name, title, address, and telephone number of authorized representative.
3 of 3
Chubb DOWER Federal insurance COMPAny Attn: Surety Department
SuretyOF A- , ORNEY Vigilant Insurance Com', +Y 15 Mountain View Road
e Pacific Indemnity Company Warren, NJ 07059
Know All by These Presents, That FEDERAL INSURANCE COMPANY, an Indiana c0rporati0n, VIGILANT INSURANCE
COMPANY, a New York corporation, and PACIFIC INDEMNITY COMPANY a Wisconsin corporation, do each hereby constitute and
appoint Pamela A. Beellinn Cynthia L. Choren, Brittany D. Clavin, Joann R. Frank, Sandra L. Ham, Heidi A. Nothelsen,
Karen L. Roider and Debra C, Schneider of St. Louis, Missouri - — — ----------
each as their true and lawful Attorney- in- Fact to execute under such designation in their names and to affix their corporate seals to and deliver for and m their behe ccursL, of businhalf as surety
thereon or otherwise, bonds and undertakings and other writings obligatory In the nature thereof (other than bail fronds
Instruments amending or altering the same, and consents to the modificaticn or aiteratlon of any instrument referred to in said bonds or obligations.
In Witness Whereof, said FEDERAL INSURANCE COMas
ftANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEM•NITYgiven tCOMPANY hexecuted in tave each executed and attested
any
these presents and affixed their corporate seals on this 1 day of March, 2016.
ested
Daw M. Chlaras, Asslstant Secretary
• oms, Jr„ Vice Presld
�t►HT' i�</ Yom' �S .�
STATE OF NEW JERSEY
County of Somerset ss.
On this I et day of March, 2016 before mega Notary Public of New Jersey. Personally came Dawn M. Ci to me known to be Asslstant Secretary of FEDERAL
INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY, the companies which executed the roregeing Power of Attorney, and the
safd Dawn M. Chloros, being by me duly swam, did depose and say that she Is Assistant Secretary of FEDERAL INSiJRANCE COMPANY, VIGILANT INSURANCE
COMPANY, and PACIFIC INDEMNITY COMPANY and knows the Corporate seals thereof, that the seals affixed to the foregoing Power of Attorney are such corporate seals
and were thereto affixed by authority of the By- Laws of said Companies; and that she signed said Power of Attorney as Assistant Secretary of said Companies by like authority;
and that she is acquainted with David i Norris, Jr., and knows him to be Vice President of said Companies; and that the signature of David B. Norns, Jr„ subscribed to said
Power of Attorney is in the genuine handwriting or David B. Norris, Jr., and was thereto subscribed by authority of said By Laws and In deponent's presence.
Notarial Seal
OTAl�y KATHERINE J. ADELAAR
�.
r�� NOTARY PUBLIC Off' NEW r•• No, 231JERSEY r
PUBi Cornmisstan Expires July 1e 2t]19
��'JEflg� Notary Public
CERTIFICATION
Extract from the By- Laws of FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMN{TY COMPANY:
"Except as otherwise Provided in these By -Laws or by law or as otherwise directed by the Board of Directors, the President or any Vice President shall be authorized to
execute and deliver, in the name and on behalf of the Corporation, all agreoments, bands, contracts, deeds, mortgages, and other instruments, either for the Corporation's
own account or in a fiduciary or other capacity, and the seal of the Corporation, if appropriate, shall be affixed thereto by any or such officers or the Secretary or an Assistant
Secretary. The Board of Directors, the President or any Vice President designated by the Board of Directors may authorize any other officer, employee or agent to execute
and deliver, in the name and on behalf of the Corporation, agreements, bonds, contracts, deeds, mortgages, and other Instruments, either for the Cor
account or in a confined
t or other capacity, and, if appropriate, to affix the seal of the Corporation thereto. The grant of such authority by the Board or any such officer may
be general yr a fidudd to r other instances." poratlon's own:
I, Dawn M, Chloros, Assistanl Secretary of FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY (the 'Companies')
do hereby certify that
(1) the foregoing extract of the Sy- Laws of the Companies is true and correct,
the Companies are duly licensed and authorized to transact surety business in all 50 of the United States of America and the District of Columbia and are
authorized by the U.S. Treasury Department; further, Federal and Vigilant are licensed in the U.S, Virgin Islands, and Federal Is licensed fn Guam, Puerto
Rica, and each of the Provinces of Canada except Prince Edward Island; and
flit) the foregoing Power of Attorney is true, correct and in full force and effect.
Given under my hand and seals of said Companies at Warren, NJ this
26th day of September, 2076,
�1 r
F Dawn h1. Chloros, Assistant Secretary
IN THE EVENT YOU vvISH Td No-ni US OF A CLAIM, VERIFY THE AUTHENTICITY OF THIS BOND OR NOTIFY US OF ANY OTHER MATTER, PLEASE CONTACT US AT ADDRESS
LISTED ABOVE OR BY Tele hone 905 903- 3493 Fax Wei qna SAA - --. . - .
Fam115-10- 02256- U GEN CONSENT (rev. 07-15)
F=MERAL INSURANCE COMPt Y
STATEMENT OF ASSETS, LIABILITIES AND SURPLUS TO POLICYHOLDERS
Statutory Basis
DECEMBER 31, 2014
(in thousands of dollars)
ASSETS
Cash and Short Term Investments ................ $ 110,464
United States Government, State and
Municipal Bonds ......................................... 10,245,402
Other Bonds .....................................
........
....... .._ 4,927,443
.....................
Stocks...................................................... 1,066,355
Other Invested Assets ................................. 1,365,367
TOTAL INVESTMENTS ............................... 17,715,051
Investments in Affiliates:
Chubb Investment Holdings, Inc ................
3,565,038
Pacific Indemnity Company ..................
2,922,214
Executive Risk Indemnity Inc ......................
1,258,019
Chubb Insurance Investment Holdings Ltd....
1,162,709
CC Canada Holdings Ltd
............................
Chubb Insurance Company of Australia Ltd.
652,880
480,068
Great Northern Insurance Company .........,
476,969
Vigilant Insurance Company
...............
Chubb European Investment Holdings SLP..
9
292,315
287,633
Other Affiliates
........................................
Premiums Receivable
517,330
.................... ..........
Other Assets
1,679,148
..........................................
1,474,965
LIABILITIES
AND
SURPLUS TO POLICYHOLDERS
Outstanding Losses and Loss Expenses..... $ 12,181 139
Unearned Premiums.— ............ 3,654,861
Ceded Reinsurance Premiums Payable,...,.. 339,466
Provlsion for Reinsurance ......... I ..... ............. 46,470
OtherLiabilities ............................................ .......................... 1,434,018
TOTAL LIABILITIES .................................... 17,655,954
Capital Stock ................................ 20,980
Paid -In Surplus ............................................. 3,106,809
Unassigned Funds ....................................... 11,700,594
SURPLUS TO POLICYHOLDERS .............. 14,828,383
TOTAL ADMITTED ASSETS.— ........... TOTAL LIABILITIES AND SURPLUS
...... $ 32,484,337 TO POLICYHOLDERS
---= —............................. $ 32,4$4,337
Investments are valued in accordance with requirements of the National Association of Insurance Commissioners.
At December 31, 2014, investments with a carrying value of $518,199,884 were deposited with government authorities
as required by law,
State, County & City of New York, — ss:
Yvonne Baker, Assistant Secretary
of the Feeraibeing duly sworn, deposes and says that the foregoing Statement of Assets, Liabilit es andlSurpiusto Po ipiders of said
cyho
Federal insurance Company on December 31, 2014 is true and correct and is a true abstract of the Annual Statement of said
Company as filed with the Secretary of the Treasury of the United States for the 12 months ending December 31, 2014.
Subscribed and sworn to before me
tnis March 11, 2015.
JEANETTE SHEPSEY Assistant Secretary
Notary Public Notary Public, State of New York
No. 02S45074142
Qualified in Nassau County
Commission Fxnima NA—H ,n ., _
,, w-iu-us iaa, �FBV 31151
ZURICH AMERICAN INSURANCE COMPANY
COLONIAL AMERICAN CASUALTY AND SURETY COMPANY
FIDELITY AND DEPOSIT COMPANY OF MARYLAND
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS: That the ZURICH AMERICAN INSURANCE COMPANY, a corporation of the State of New
York, the COLONIAL AMERICAN CASUALTY AND SURETY COMPANY, a corporation of the State of Maryland, and the FIDELITY
AND DEPOSIT COMPANY OF MARYLAND a corporation of the State of Maryland (herein collectively called the "Companies"), by
Thomas O. McClellan, Vice President, in pursuance of authority granted by Article V, Section 8, of the By -Laws of said Companies, which
are set forth on the reverse side hereof and are hereby certified to be in full force and effect on the date hereof, do hereby nominate,
constitute, and appoint Cynthia L. Choren of St. Louis, Missouri , its true and lawful agent and Attorney -
in -Fact, to make, execute, seal and deliver, for, and on its behalf as surety, and as its act and deed: any and all bonds and undertakings,
and the execution of such bonds or undertakings in pursuance of these presents, shall be as binding upon said Companies, as fully and amply,
to all intents and purposes, as if they had been duly executed and acknowledged by the regularly elected officers of the ZURICH
AMERICAN INSURANCE COMPANY at its office in New York, New York., the regularly elected officers of the COLONIAL
AMERICAN CASUALTY AND SURETY COMPANY at its office in Owings Mills, Maryland., and the regularly elected officers of the
FIDELITY AND DEPOSIT COMPANY OF MARYLAND at its office in Owings Mills, Maryland., in their own proper persons.
The said Vice President does hereby certify that the extract set forth on the reverse side hereof is a true copy of Article V, Section 8, of
the By -Laws of said Companies, and is now in force.
IN WITNESS WHEREOF, the said Vice -President has hereunto subscribed his/her names and affixed the Corporate Seals of the said
ZURICII AMERICAN INSURANCE COMPANY, COLONIAL AMERICAN CASUALTY AND SURETY COMPANY, and
FIDELITY AND DEPOSIT COMPANY OF MARYLAND, this l4th day of October, A.D. 2015,
- -ff, " )-, W -,, K, (�, Z,- -, (
ATTEST:
ZURICI'I AMERICAN INSURANCE COMPANY
COLONIAL AMERICAN CASUALTY AND SURETY COMPANY
FIDELITY AND DEPOSIT COMPANY OF MARYLAND
By: Thomas O, McClellan By: Eric D, Barnes
Vice President Secretary
State of Maryland
County of Baltimore
On this 14th day of October, A.A. 2015, before the subscriber, a Notary Public of the State of Maryland, duly commissioned and qualified, Thomas O.
McClellan, Vice President and Eric 1). Barnes, Secretary of the Companies, to me personally known to be the individuals and officers described in and who
executed the preceding instrument, and acknowledged the execution of same, and being by me duly sworn, deposeth and saith, that he/she is the said officer of
the Company aforesaid, and that the seals affixed to the preceding instrument arc the Corporate Seals of said Companies, and that the said Corporate Seals and
the signature as such officer were duly affixed and subscribed to the said instrument by the authority and direction of the said Corporations.
IN TESTIMONY WHEREOF, l have hereunto set my hand and affixed my Official Seal the day and year first above written.
''y�gea�ayad�t apps.
By: Constance A. Dunn, Notary Public
My Commission Expires: July 9, 2019
EXTRACT FROM BY-LAWS OF THE COMPANIES
"Article V, Section 8, Attorneys -in -Fact, The Chief Executive Officer, the President, or any Executive Vice President or Vice President
may, by written instrument under the attested corporate seal, appoint attorneys -in -fact with authority to execute bonds, policies,
recognizances, stipulations, undertakings, or other like instruments on behalf of the Company, and may authorize any officer or any such
attorney-in-fact to affix the corporate seal thereto; and may with or without cause modify of revoke any such appointment or authority at any
time."
CERTIFICATE
I, the undersigned, Vice President of the ZURICH AMERICAN INSURANCE COMPANY, the COLONIAL AMERICAN
CASUALTY AND SURETY COMPANY, and the FIDELITY AND DEPOSIT COMPANY OF MARYLAND, do hereby certify that the
foregoing Power of Attorney is still in full force and effect on the date of this certificate; and I do further certify that Article V, Section 8, of
the By -Laws of the Companies is still in force.
This Power of Attorney and Certificate may be signed by facsimile under and by authority of the following resolution of the Board of
Directors of the ZURICH AMERICAN INSURANCE COMPANY at a meeting duly called and held on the 15th day of December 1998.
RESOLVED: "That the signature of the President or a Vice President and the attesting signature of a Secretary or an Assistant Secretary
and the Seal of the Company may be affixed by facsimile on any Power of Attorney.., Any such Power or any certificate thereof bearing such
facsimile signature and seal shall be valid and binding on the Company."
This Power of Attorney and Certificate may be signed by facsimile under and by authority of the following resolution of the Board of
Directors of the COLONIAL AMERICAN CASUALTY AND SURETY COMPANY at a meeting duly called and held on the 5th day of
May, 1994, and the following resolution of the Board of Directors of the FIDELITY AND DEPOSIT COMPANY OF MARYLAND at a
meeting duly called and held on the 10th day of May, 1990.
RESOLVED; "That the facsimile or mechanically reproduced seal of the company and facsimile or mechanically reproduced signature
of any Vice -President, Secretary, or Assistant Secretary of the Company, whether made heretofore or hereafter, wherever appearing upon a
certified copy of any power of attorney issued by the Company, shall be valid and binding upon the Company with the same force and effect
as though manually affixed.
IN TESTIMONY WHEREOF, I have hereunto subscribed my name and affixed the corporate seals of the said Companies,
this 26th day of September 2016
,�Fa nioof�
awl C)
By: Gerald F. Haley, Vice President
FIDELITY AND DEPOSIT COMPANY
OF MARYLAND
600 Red 13rook Blvd,, Suite 600, Owings Mills, MD 21117
Statement of Financial Condition
As Of December 31, 2015
Bonds.............................ASSETS
Stocks................................
............................ .....................................
...,........ .............................. ..................... ........ $ 142,878,497
Investments ..........................1.,......,...................,.....,,..,.......... .................... 22,315,096
Cash and Short Term luvest
........................................................................ 337,835
ReinsuranceRecoverable .................. ......... .............—.... ...............................,.........,....,..,............. 24,731,651
Other Accounhs Receivable ............ .. ,..
TOTAL A�lv1i11EI7 ASSETS .............................................................................................. 19,935,844
......... .
....... $ 210,198,923
LIABILITIES, SURPLUS AND OTHER FUNDS
Reserve for Taxes and Expenses...,....
............................................................. $ 46,436
Ceded Reinsurance Premiums Payable .......................................40,456,309
Securities Lending Collateral Liability ............ 0
T'�TALIjlABIhIT1E5.................. ......,........,..,..........,....,...,..............,.......................
Capital Stock, Paid U....................................................................................... $ 40,502,745
.................
,......... ............................. $ 5,000,000
smplus................................................................................................... 164,696,178
Surplus as regards Policyholders .................................. 169,696,178
TOTAL.........................I......I...
................................................................................................................... $ 210,19$,923
Securities carried at $57,996,983 in the above statement are deposited with various states as required by law.
Securities carried on the basis prescribed by the National Association of Insurance Commissioners. On the basis of
market quotations for all bonds and stocks owned, the Company's total admitted assets at December 31, 2015 would
be $212,137,795 and surplus as regards policyholders $171,635,049.
1, DENNIS F.1<.E1WGAN, ConEorate Secretary of the FIDELITY AND DF-PosfI' COMPANY oF MARYLAND, do hereby
certify that the faiegoing statement is a confect exhibit of the assets and liabilities of the said Company on the 31st
day of December, 2015.
Ca paste Secretary
State of Illinois
City of Schaumburg SS:
Subscribed acid sworn to, before me, a Notary Public of the State of Iflmois, in lite City of Schaumburg, t1iis 15th day of March, 2016,
W 5�
DARRYL JOINER !1 lvotaty PtWia
OFFICIAL 9EAL
Nolary PvnGc - Stafn of Illinois
My GOMIr1ISS[0l1 rxplres
Februaty 24, 201u