04-_Mispah_Parking_Lot_Replacement-_Grant_Forms.pdf

City of Leesburg, Florida 250301- Mispah Parking Lot Replacement-Rebid

CITY FORMS

Page CF-1 of 14

DISADVANTAGED BUSINESS ENTERPRISE PROGRAM

The undersigned bidder/offeror has satisfied the requirements of the DBE specification in the following manner (please check the appropriate space):

_____ The bidder/offeror is committed to a minimum of ______% W/DBE utilization on this contract.

_____ The bidder/offeror (if unable to meet the M/DBE goal of 14.9 %) is committed to a minimum of ______% M/DBE utilization on this contract and submits documentation demonstrating good faith efforts.

_____ The bidder/offeror is committed to a minimum of ______% M/DBE utilization on this contract.

_____ The bidder/offeror (if unable to meet the W/DBE goal of 6.9 %) is committed to a minimum of ______% W/DBE utilization on this contract and submits documentation demonstrating good faith efforts.

Name of Offeror/bidder firm: _____________________________________________

State Registration No. ___________________________________________________

By: ______________________________ ________________________________ Bidder’s (Signature) (Title)

DISADVANTAGED BUSINESS ENTERPRISE SUBCONTRACTS

* DBE Subcontractors Subcontract Work Item Dollar Value Names/Addresses/ Phone Numbers

*Submit “Letter of Intent” for each DBE subcontractor as a condition of responsiveness.

Page CF-2 of 14

Letter of Intent

Name of Offeror/bidder firm: __________________________________________________ Address: ___________________________________________________________________ City: _______________________ State: __________________ Zip: ______________

Name of DBE firm (Subcontractor):

Address: City: ______________________ State: _________________ Zip:______________ Telephone: ________________________

Description of work to be performed by DBE firm:

The bidder/offeror is committed to utilizing the above-named DBE firm for the work described above. The estimated dollar value of this work is $________________.

Affirmation

The above-named DBE firm affirms that it will perform the portion of the contract for the estimated dollar value as stated above.

By: ________________________________ _____________________________ Subcontractor Signature (Title)

If the bidder/offeror does not receive award of the prime contract, any and all representations in this Letter of Intent and Affirmation shall be null and void.

CITY FORMS

Page CF-3 of 14

Special EEO Provisions

TABLE A.

PROPOSED SUBCONTRACTS BREAKDOWN

FOR THE PERIOD COVERING ________________ 202__ THROUGH _________ 202__.

(DURATION OF THE CDBG-ASSISTED PROJECT)

COLUMN 1 COLUMN 2 COLUMN 3 COLUMN 4 COLUMN 5

TYPE OF CONTRACT TOTAL NUMBER TOTAL APPROXIMATE ESTIMATED ESTIMATED

DOLLAR AMOUNT NUMBER OF DOLLAR AMT (BUSINESS OR PRO- OF CONTRACTS

FESSIONAL) CONTRACTS PROJECT AREA

AREA

BUSINESSES*

*The Project Area is coextensive with the physical boundaries of City of Leesburg, Florida

Company

Project Name Project Number

EEO Officer (Signature) Date

Page CF-4 of 14

Special EEO Provisions

TABLE B.

ESTIMATED PROJECT WORKFORCE BREAKDOWN

TRADES:

*Lower Income Project Areas Residents:

Individuals residing within the City of Leesburg whose family income does not exceed 80% of the median income in the State

Job Category Total Estimated Positions

# Positions Currently Occupied by Permanent Employees

# Positions Not Currently Occupied

# Positions to be Filled with

L.I.PA.R *

Officers Supervisors

Professionals

Technicians

Housing/Sales Rental/Mgmt

Office Clerical

Service Workers

Others

Journeyman

Helpers

Apprentices

Maximum # Trainees

Others

Totals

Page CF-5 of 14

CERTIFICATION BY BIDDER

This certification is required pursuant to Executive Order 11246 (30 F.R. 12319-25). The implementing rules and regulations provide that any bidder or prospective contractor, or any of their proposed subcontractors, shall state as an initial part of the bid or negotiations of the contract whether it has participated in any previous contract or subcontract subject to the equal opportunity clause; and if so, whether it has filed all compliance reports due under applicable instructions.

Where the certification indicates that the bidder has not filed a compliance report due under applicable instructions, such bidder shall be required to submit a compliance report within seven calendar days after bid opening. No contract shall be awarded unless such report is submitted.

NAME AND ADDRESS OF BIDDER (include ZIP Code):

1. Bidder has participated in a previous contract or subcontract subject to the Equal

Opportunity Clause. Yes [ ] No [ ]

2. Compliance reports were required to be filed in connection with such contract or subcontract. Yes [ ] No [ ]

3. Bidder has filed all compliance reports due under applicable instructions.

Yes [ ] No [ ]

4. Have you ever been or are you being considered for sanction due to violation of Executive Order 112246, as amended? Yes [ ] No [ ]

NAME AND TITLE OF SIGNER (Please type):

SIGNATURE DATE

Page CF-6 of 14

CONTRACTOR: ________________________________

Section 3 Plan Format

______________________________ agrees to implement the following specific affirmative action steps directed at increasing the utilization of lower income residents and businesses within City of Leesburg.

A. To ascertain from the locality's CDBG program official the exact boundaries of the Section 3 covered project area and where advantageous, seek the assistance of local officials in preparing and implementing the affirmative action plan.

B. To attempt to recruit from within the City the necessary number of lower income residents through: Local advertising media, signs placed at the proposed site for the project, and community organizations and public or private institutions operating within or serving the project area such as Service Employment and Redevelopment (SER), Opportunities Industrialization Center (OIC), Urban League, Concentrated Employment Program, Home County Plan or the U. S. Employment Service.

C. To maintain a list of all lower income residents who have applied either on their own or on referral from any source, and to employ such persons, if otherwise eligible and if a vacancy exists.

*D. To insert this Section 3 plan in all bid documents, and to require all bidders on subcontracts to submit a Section 3 affirmative action plan including utilization goals and the specific steps planned to accomplish these goals.

*E. To insure that subcontracts which are typically let on a negotiated rather than a bid basis in areas other than Section 3 covered project areas are also let on a negotiated basis, whenever feasible, when let in a Section 3 covered project area.

F. To formally contact unions, subcontractors, and trade associations to secure their cooperation for this program.

G. To insure that all appropriate project area business concerns are notified of pending sub contractual opportunities.

H. To maintain records, including copies of correspondence, memoranda, etc., which document that all of the above affirmative action steps have been taken.

I. To appoint or recruit an executive official of the company or agency as Equal Opportunity Officer to coordinate the implementation of this Section 3 plan.

* Loans, grants, contracts, and subsidies for less than $10.000 will be exempt.

Page CF-7 of 14

J. To list on Tabe A, information related to subcontracts to be awarded.

K. To list on Table B, all projected workforce needs for all phases of this project by occupation, trade, skill level, and number of positions.

As officers and representatives of _______________________________________ (Name of Contractor)

We the undersigned have read and fully agree to this Affirmative Action Plan, and become a party to the full implementation of this program.

Signature

Title Date

Signature

Title Date

CITY FORMS

Page CF-8 of 14

Federal Labor Standards Provisions

CONTRACTOR' CERTIFICATION

CONCERNING LABOR STANDARDS AND PREVAILING WAGE REQUIREMENTS

To: City of Leesburg, Florida DATE:

PROJECT NUMBER: IFB 250301

PROJECT NAME: Mispah Parking Lot Replacement Rebid

1. The undersigned, having executed a contract with _________________________________ _______________________________________ (or the construction of the above identified project), acknowledges that

(a) The Labor Standards provisions are included in the aforesaid contract:

(b) Correction of any infractions of the aforesaid conditions, including infractions by any of his subcontractors and any lower tier subcontractors, is his responsibility:

2. He certifies that:

(a) Neither he nor any firm, partnership or association in which he has substantial interest is designated as an ineligible contractor by the Comptroller General of the United States pursuant to Section 5.6(b) of the Regulations of the Secretary of Labor, Part 5 (29 CFR, Part

5) or pursuant to Section 3(a) of the Davis-Bacon Act, as amended (40 U.S.C. 276a-2(a))

(b) No part of the aforementioned contract has been or will be subcontracted to any subcontractor if such subcontractor or any firm, corporation, partnership or association in which such subcontractor has a substantial interest is designated as an ineligible contractor pursuant to any of the aforementioned regulatory or statutory provisions.

3. He agrees to obtain and forward to the aforementioned recipient within ten days after the execution of any subcontract, including those executed by his subcontractors and any lower tier subcontractors, a Subcontractor's Certification Concerning Labor Standards and Prevailing Wage Requirements executed by the subcontractors.

4. He certifies that:

(a) The legal name and the business address of the undersigned are:

(b) The undersigned is:

(1) A SINGLE PROPRIETORSHIP (2) A PARTNERSHIP

(3) A CORPORATION ORGANIZED (4) OTHER ORGANIZATION (Describe)

IN THE STATE OF

Page CF-9 of 14

(c) The name, title and address of the owner, partners or officers of the undersigned are:

NAME TITLE ADDRESS

(d) The names and address of all persons, both natural and corporate, having a substantial interest in the undersigned, and the nature of the interest are: (if name, so state)

NAME TITLE NATURE OF INTEREST

(e) The names, addresses and trade classification of all other building construction contractors in which the undersigned as a substantial interest are: (if name, so state)

(Contractor) Date ________________________

WARNING

U.S. Criminal Code Section 1010, Title 18, U.S.C., provides in part: "Whoever,..makes, passes, utters or publishes any statement, knowing the same to be false...shall be fined not more than $5,000 or imprisoned not more than two years, or both".

Page CF-10 of 14

FORM 950.1

CERTIFICATION OF BIDDER

Name of Prime Contractor Project Name & Number

The undersigned hereby certifies that:

(a) Section 3 provisions are included in the Contract.

(b) A written Section 3 plan was prepared and submitted as part of the bid proceedings (if bid equals or exceeds $10,000).

(c) No segregated facilities will be maintained. Name and Title of Signer:

Signature Date

Page CF-11 of 14

CERTIFICATION BY PROPOSED SUBCONTRACTOR REGARDING

EQUAL EMPLOYMENT OPPORTUNITY

NAME OF CONTRACTOR PROJECT NUMBER

INSTRUCTIONS

This certification is required pursuant to executive Order 11246 (30 F. R.12319-25). The implementing rules and regulations provide that any bidder or prospective contractor, or any of their proposed subcontractors, shall state as an initial part of the bid or negotiations of the contract whether it has participated in any previous contract or subcontract subject to the equal opportunity clauses; and, if so, whether it has filed all compliance reports due under applicable instructions.

Where the certification indicates that the subcontractor has not filed a compliance report due under applicable instructions, such subcontractor shall be required to submit a compliance report before the owner approves the subcontract or permits work to begin under the subcontract.

SUBCONTRACTORS CERTIFICATION

NAME AND ADDRESS OF SUBCONTRACTOR (Include Zip Code)

1. Bidder has participated in previous contract subject to the Equal Opportunity Clause.

Yes [ ] No [ ]

2. Compliance reports were required to be filed in connection with such contract or subcontractor.

Yes [ ] No [ ]

3. Bidder has filed all compliance reports due under applicable instructions, including SF-100.

Yes [ ] No [ ]

4. Have you ever been or are you being considered for sanction due to violation of Executive Order 11246, as amended?

Yes [ ] No [ ] NAME AND TITLE OR SIGNER (Please type):

SIGNATURE DATE

Page CF-12 of 14

CERTIFICATION OF PROPOSED SUBCONTRACTOR REGARDING

SECTION 3 AND SEGREGATED FACILITIES

NAME OF SUB CONTRACTOR PROJECT NAME & NUMBER

The undersigned hereby certifies that:

(a) Section 3 provisions are included in the Contract.

(b) A written Section 3 plan was prepared and submitted as part of the bid proceedings (if bid equals or exceeds $10,000).

(c) No segregated facilities will be maintained as required by Title VI of the Civil Rights Act of 1964.

Name and Title of Signer:

Signature Date

CITY FORMS

Page CF-13 of 14

Federal Labor Standards Provisions

SUBCONTRACTOR CERTIFICATION

CONCERNING LABOR STANDARDS AND PREVAILING WAGE REQUIREMENTS

To: City of Leesburg, Florida DATE:

PROJECT NUMBER: IFB 250301

PROJECT NAME: Mispah Parking Lot Replacement-Rebid

1. The undersigned, having executed a contract with _________________________________ _______________________________________ (or the construction of the above identified project), acknowledges that

(a) The Labor Standards provisions are included in the aforesaid contract:

(b) Correction of any infractions of the aforesaid conditions, including infractions by any of his subcontractors and any lower tier subcontractors, is his responsibility:

2. He certifies that:

(a) Neither he nor any firm, partnership or association in which he has substantial interest is designated as an ineligible contractor by the Comptroller General of the United States pursuant to Section 5.6(b) of the Regulations of the Secretary of Labor, Part 5 (29 CFR, Part

5) or pursuant to Section 3(a) of the Davis-Bacon Act, as amended (40 U.S.C. 276a-2(a))

(b) No part of the aforementioned contract has been or will be subcontracted to any subcontractor if such subcontractor or any firm, corporation, partnership or association in which such subcontractor has a substantial interest is designated as an ineligible contractor pursuant to any of the aforementioned regulatory or statutory provisions.

3. He agrees to obtain and forward to the aforementioned recipient within ten days after the execution of any subcontract, including those executed by his subcontractors and any lower tier subcontractors, a Subcontractor's Certification Concerning Labor Standards and Prevailing Wage Requirements executed by the subcontractors.

4. He certifies that:

(a) The legal name and the business address of the undersigned are:

(b) The undersigned is:

(1) A SINGLE PROPRIETORSHIP (2) A PARTNERSHIP

(3) A CORPORATION ORGANIZED (4) OTHER ORGANIZATION (Describe)

IN THE STATE OF

Page CF-14 of 14

(c) The name, title and address of the owner, partners or officers of the undersigned are:

NAME TITLE ADDRESS

(d) The names and address of all persons, both natural and corporate, having a substantial interest in the undersigned, and the nature of the interest are: (if name, so state)

(e) The names, addresses and trade classification of all other building construction contractors in which the undersigned as a substantial interest are: (if name, so state)

(Contractor) Date ________________________

WARNING

U.S. Criminal Code Section 1010, Title 18, U.S.C., provides in part: "Whoever,..makes, passes, utters or publishes any statement, knowing the same to be false...shall be fined not more than $5,000 or imprisoned not more than two years, or both".