1-.2026.05.19 MS-944 BLOOMFIELD BOROUGH STREET PAVING MAINTENANCE 2026 COMBINED.pdf
PDF 422 KB Posted
- Solicitation number
- Not on record
- Issued by
- Philadelphia County, Blawnox Borough, Pennsylvania
About this file
This is a proposal and contract form (MS-944) issued by Bloomfield Borough in Perry County, Pennsylvania for street paving and maintenance work scheduled for 2026. The project encompasses three distinct locations: South Church Street (approximately 210 linear feet and 5,040 square feet of roadway), South Apple Street (approximately 200 linear feet and 4,000 square feet of roadway), and Veterans Drive (approximately 6,480 square feet of roadway). Work includes variable depth milling, tack coat application, leveling courses, 1.5-inch wearing course asphalt paving, and joint sealing. Sealed proposals must be received by June 10, 2026 at 1:00 P.M. through PennBID, at which time bids will be publicly opened and read. Bidders must submit a certified check or bid bond equivalent to 10% of the proposal amount. The contractor must complete all work within a specified number of calendar days and is responsible for maintenance of permanent pavement repairs for one year following completion. Liquidated damages are assessed at $870.00 per additional working day if work is not completed by October 31, 2026, after which the rate increases to $975.00 per calendar day.
Contractors must submit unit prices for milling, tack coat, leveling course, and wearing course asphalt materials in tons and square yards as specified in the Schedule of Prices. The successful bidder must provide performance and payment bonds in accordance with the Public Works Contractors' Bond Law of 1967, with bond amounts ranging from 50% to 100% of the contract amount depending on contract value. All materials must comply with PennDOT Publication 408 specifications, with exceptions for prequalification and volumetric testing. Contractors must provide delivery tickets, certificates of compliance (Form CS-4171 and/or TR-465), design documentation five working days prior to project start, traffic control and safety devices, oil samples from distributor trucks, and random stone samples. The municipality reserves the right to inspect all work, limit work completion, procure materials deemed most suitable, and make awards based on aggregate totals for like items. Contractors are required to notify residents of pending work and review the proposed project with the municipality's representative prior to bidding.
View the file
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
MS-944 (4-22)
TIME
, on the above Letting Date. PROPOSALS MUST BE MAILED OR OTHERWISE
TIME DELIVERED TO THE ABOVE ADDRESS.
and specifications on file at as well as the supplements complete all work within calendar days.
3 Accompanying this proposal is a certified check or bid bond in the amount of made payable to the municipality as a proposal guarantee which, it is understood, will be forfeited in case the contractor fails to comply with the requirements of the proposal.
B. PROPOSAL OF:
1 The only person interested in the proposal as principal (s) is (are):
2 None of the above persons are employees of the municipality.
3 This proposal is made without collusion with any other person, firm or corporation.
New Bloomfield, PA 17068
1:00 P.M.
The contractor proposes to furnish and deliver all materials ( including Form CS-4171, CERTIFICATE OF COMPLIANCE and/ or TR-465 DAILY BITUMINOUS MIXTURE CERTIFICATION ) and to do and perform all work on the following project as more specifically set forth in the Schedule of Prices (Attachment), in accordance with drawings and special requirements contained herein and/ or attached hereto and current PennDOT Specifications (Publication 408), except (a) bidders need not be prequalified by PennDOT (Sec.102.01), and (b) Volumetric testing of bituminous paving materials is not required (Sec. 413).
(c) Bitumious Price Adjustments (Sec. 110.04)
INSTRUCTIONS ON PAGE 4
Bids will be opened and read at approximately
June 10, 2026
1:00 P.M.
Bloomfield Borough
MUNICIPALITY (NAME & TYPE)
If designated as the successful bidder, the contractor will begin work on the date specified in the notice to proceed, or as otherwise provided in the special requirements, and will
10%
Bloomfield Borough see attachment 1-A
-1-
It is hereby certified as follows:
NAME / ADDRESS OF CONTRACTOR
CONTRACTORS CERTIFICATION
All plans and specifications referred to above and the site of the work have been examined by the contractor. The contractor understands that the quantities indicated herein are approximate and are subject to change as may be required; and that all work is payable on the basis of the unit price listed on the Schedule of Prices. (Attachment 1).
THIS PROPOSAL INCLUDES
INSTRUCTIONS TO BIDDERS
ADDRESS
A. DEPOSIT OF PROPOSALS.
Sealed Proposals will be received on or before
All envelopes containing Bid proposals shall be clearly marked “Bid Proposal for letting of
PROPOSAL AND CONTRACT
( WHEN EXECUTED )
Danielle L. Shope
SECRETARY
DATE
on the above Letting Date. 25 E. McClure Street
BY: DATE:
TITLE:
DATE:
TITLE:
TITLE:
BY:
TITLE:
BY:
TITLE:
TITLE:
DATE
Bloomfield Borough
The contractor will comply with all requirements of the laws and implementing regulations of the Commonwealth of Pennsylvania and the United States relating to human relations, equal opportunity and non-discrimination in employment, and will pay to workmen employed in the performance of the contract the wages to which they may be entitled.
The contractor will provide the municipality with a performance bond, conditioned upon the faithful performance of the contract in accordance with the plans, specifications and conditions thereof, and a payment bond, conditioned on the prompt payment of all material furnished and labor supplied or performed in the prosecution of the work, in accordance with the Public Works Contractors’ Bond Law of 1967; and an affidavit accepting the provisions of the Workmen’s Compensation Act of 1915, as amended.
CONTRACTOR
WITNESSED OR ATTESTED BY:
TO BE EXECUTED ONLY IN THE EVENT THE ABOVE PROPOSAL IS ACCEPTED
ACCEPTED ON :
-2-
ATTESTED BY:
MUNICIPALITY
BY:
SEAL
County:
TON
TON
SY
SY
SUBTOTAL
EACH MUST BE INCLUDED.
- 3 -
OPTION 3 OR PHASE 3 BID TOTAL
ATTACHMENT 1
TO MS - 944 ( PROPOSAL AND CONTRACT MS - 944 )
Perry Municipality: Bloomfield Borough
LOCATION OF WORK:
TH
IS
P O
R
TI
O N
T O
B E
C O
M
PL
ET
ED
BY
T
H E
M U
N
IC
IP
AL
IT
Y
Unit
SCHEDULE OF PRICES
*Description
Project Number:
DESCRIPTION OF WORK:
Location #1: South Church Street (approximately 210 linear feet between Barnett St. and Farmers Alley)
Approximate 2 Quantities
0413-2059
0413-0205
A. Perform variable depth milling within the center 20 feet of the roadway (0" at the limits of milling, 1"–1.5" at the roadway centerline). Adjust milling depths in the field as needed or directed, including at structures and tie-ins.
B. Apply tack coat adhesive to the entire roadway for proper adhesion.
C. Correct surface irregularities by placing a leveling course as directed to achieve a uniform riding surface and proper grade.
D. Pave the entire roadway with 1.5” wearing course asphalt and install any rolled curb edges as may be needed to contain water run off accordingly. The total is approximately 5,040 sq/ft.
E. Compact in place with vibrating rollers and apply AC20 (or equivalent) hot tar joint sealer to roadway as needed at any structures or joints to existing paving.
Total
SUPERPAVE ASPHALT MIXTURE DESIGN,
WEARING COURSE, PG 64S-22, < 0.3
MILLION ESALS, 9.5 MM MIX, SRL-L
0460-0001
0491-0019
BID TOTAL FOR A NON OPTION / PHASE BID
ESCALATOR CLAUSE:( if adopted by Municipality.)
Unit 5 Price
Item 1 No.
1,027
SUBTOTAL FROM OTHER ATTACHMENTS
* DESCRIPTION:
Must include ADT on wearing surfaces
USE OF CUTBACK ASPHALT IS PROHIBITED
BETWEEN MAY 1st AND OCTOBER 31st, EXCEPT
AS NOTED IN BULLETIN NO. 25.
FOR OPTION OR PHASE BIDS THE TOTALS FOR
OPTION 1 OR PHASE 1 BID TOTAL
OPTION 2 OR PHASE 2 BID TOTAL
SUPERPAVE ASPHALT MIXTURE DESIGN,
WEARING COURSE (LEVELING), PG 64S-
22, < 0.3 MILLION ESALS, 9.5 MM MIX, SRL-
L (AS DIRECTED)
MILLING OF ASPHALT PAVEMENT
SURFACE, VARIABLE DEPTH, MILLED
MATERIAL RETAINED BY CONTRACTOR
ASPHALT TACK COAT
TON
SY
SY
SUBTOTAL
EACH MUST BE INCLUDED. OPTION 3 OR PHASE 3 BID TOTAL
- 3 -
* DESCRIPTION:
Must include ADT on wearing surfaces
USE OF CUTBACK ASPHALT IS PROHIBITED
BETWEEN MAY 1st AND OCTOBER 31st, EXCEPT
AS NOTED IN BULLETIN NO. 25.
FOR OPTION OR PHASE BIDS THE TOTALS FOR
SUBTOTAL FROM OTHER ATTACHMENTS
BID TOTAL FOR A NON OPTION / PHASE BID
OPTION 1 OR PHASE 1 BID TOTAL
OPTION 2 OR PHASE 2 BID TOTAL
0460-0001 889 ASPHALT TACK COAT
0491-0019 445
MILLING OF ASPHALT PAVEMENT
SURFACE, VARIABLE DEPTH, MILLED
MATERIAL RETAINED BY CONTRACTOR
0413-0205 37
SUPERPAVE ASPHALT MIXTURE DESIGN,
WEARING COURSE, PG 64S-22, < 0.3
MILLION ESALS, 9.5 MM MIX, SRL-L
0413-2059 12
SUPERPAVE ASPHALT MIXTURE DESIGN,
WEARING COURSE (LEVELING), PG 64S-
22, < 0.3 MILLION ESALS, 9.5 MM MIX, SRL-
L (AS DIRECTED)
SCHEDULE OF PRICES
Item 1 No.
Approximate 2 Quantities
Unit
*Description
Unit 5 Price
Total
Project Number:
LOCATION OF WORK:
TH
IS
P O
R
TI
O N
T O
B E
C O
M
PL
ET
ED
BY
T
H E
M U
N
IC
IP
AL
IT
Y
Location #2: South Apple Street (approximately 200 linear feet South from Barnett St.)
DESCRIPTION OF WORK:
A. Perform variable depth milling within the center 20 feet of the roadway (0" at the limits of milling, 1"–1.5" at the roadway centerline). Adjust milling depths in the field as needed or directed, including at structures and tie-ins.
B. Apply tack coat adhesive to the entire roadway for proper adhesion.
C. Correct surface irregularities by placing a leveling course as directed to achieve a uniform riding surface and proper grade.
D. Pave the entire roadway with 1.5” wearing course asphalt and install any rolled curb edges as may be needed to contain water run off accordingly. The total is approximately 4,000 sq/ft.
E. Compact in place with vibrating rollers and apply AC20 (or equivalent) hot tar joint sealer to roadway as needed at any structures or joints to existing paving.
ESCALATOR CLAUSE:( if adopted by Municipality.)
ATTACHMENT 1
TO MS - 944 ( PROPOSAL AND CONTRACT MS - 944 )
Perry Municipality: Bloomfield Borough
TON
SY
SUBTOTAL
EACH MUST BE INCLUDED. OPTION 3 OR PHASE 3 BID TOTAL
- 3 -
* DESCRIPTION:
Must include ADT on wearing surfaces
USE OF CUTBACK ASPHALT IS PROHIBITED
BETWEEN MAY 1st AND OCTOBER 31st, EXCEPT
AS NOTED IN BULLETIN NO. 25.
FOR OPTION OR PHASE BIDS THE TOTALS FOR
SUBTOTAL FROM OTHER ATTACHMENTS
BID TOTAL FOR A NON OPTION / PHASE BID
OPTION 1 OR PHASE 1 BID TOTAL
OPTION 2 OR PHASE 2 BID TOTAL
0460-0001 1,440 ASPHALT TACK COAT
0413-0205 59
SUPERPAVE ASPHALT MIXTURE DESIGN,
WEARING COURSE, PG 64S-22, < 0.3
MILLION ESALS, 9.5 MM MIX, SRL-L
0413-2059 20
SUPERPAVE ASPHALT MIXTURE DESIGN,
WEARING COURSE (LEVELING), PG 64S-
22, < 0.3 MILLION ESALS, 9.5 MM MIX, SRL-
L (AS DIRECTED)
SCHEDULE OF PRICES
Item 1 No.
Approximate 2 Quantities
Unit
*Description
Unit 5 Price
Total
Project Number:
LOCATION OF WORK:
TH
IS
P O
R
TI
O N
T O
B E
C O
M
PL
ET
ED
BY
T
H E
M U
N
IC
IP
AL
IT
Y
Location #3: Veterans Drive (Extending East from the intersection of East Main St.)
DESCRIPTION OF WORK:
A. Mill tie in notch at intersection of East Main Street in its entirety. Mill notch at secondary tie in location 140 ft up Veterans Drive. (as measured on the North Side of Roadway) B. Mill tie in notch at both ends, and center line of a second location in the westbound travel lane as directed for a distance of 150 ft x 13 ft wide.
C. Apply tack coat adhesive to the entire roadway for proper adhesion.
D. Correct surface irregularities by placing a leveling course as directed to achieve a uniform riding surface and proper grade.
E. Pave the entire roadway with 1.5” wearing course asphalt and install any rolled curb edges as may be needed to contain water run off accordingly. The total is approximately 6,480 sq/ft.
F. Compact in place with vibrating rollers and apply AC20 (or equivalent) hot tar joint sealer to roadway as needed at any structures or joints to existing paving.
ESCALATOR CLAUSE:( if adopted by Municipality.)
ATTACHMENT 1
TO MS - 944 ( PROPOSAL AND CONTRACT MS - 944 )
Perry Municipality: Bloomfield Borough x Traffic Control and Safety Devices to be provided by the Contractor.
x Delivery tickets for all materials.
x CS-4171 Certificate of Compliance and/ or TR-465 Daily Bituminous Mixture Certification required for all materials.
x five (5) working days prior to start of project.
x 10/31/2026 . After 10/31/2026 the rate of $ 975.00 per calendar day.
x Roadway to be power broomed by (contractor x municipality )prior to start of project.
x Excess material to be removed by (contractor x municipality .)
x Municipality to inspect project.
x Need Bill of Lading for each shipment of bituminous material per Section 702.1(c) of Specifications 408.
x Tack Coat required per Section 460, or 413 for superpave, of Specifications 408 and is incidental to paving item unless noted otherwise.
Prime Coat required per Section 461 of Specifications 408.
x Bituminous Seal on all abutting pavement and curbs required.
x Saw cut or Milled Paving Notch required and incidental to paving item unless noted otherwise.
x Scratch/ Leveling Courses to be placed at the discretion of appointed inspector(s).
x Municipality reserves the right to limit work completed.
Taper pavement the last 3 feet to curb.
For FOB Source bids, hauling distance will determine selection of bid award.
Municipality reserves the right to procure material which best suits their requirements after all bids and items are reviewed.
x Incidental Preparation and clean up required. ( Project Construction Materials ) x The municipality reserves the right to make an award on the basis of the aggregate total for all like items on which quotations are received.
Provide design, which meets Specifications Form 408 to the municipality 5 days prior to start of work.
x Contractor responsible for defects that occur within one year of applications.
x Contractor required to review proposed project with Municipality’s Representative prior to bidding.
Oil Samples required from each distributor truck by contractor (1) one quart : A.M. & P.M. and witnessed by municipality and retained by municipality. (Oil samples must be placed in an approved type container that is compatible with oil sample.)
At least three random stone samples to be taken by contractor on project site witnessed by municipality and retained by municipality.
Complete all testing in accordance with Specification Form 408 Section 413 except for superpave volumetric testing.
Notice to Proceed will be the date of Contract acceptance.
x Final Completion Certificate & Notice of Completion required.
x Future award of Contract will be based on quality of work as determined by the municipality.
Contractor, notify all residents of pending work to be performed.
x
My signature signifies that I have read and understand the above special provisions to this contract, and by being authorized by this company to act as their authorized representative, and on their behalf hereby agree to adhere to any and all of the provisions pertaining to this contract.
Date
Work to be completed on or before
Bloomfield Borough
Liquidated damages apply at
Full width pavement with one pass required.
Rolled asphalt curb edges incidental to wearing course.
Company Municipality
Contractor's Representative Municipality's Representative Date
Notify the Municipality
(5-06) SPECIAL PROVISIONS TO CONTRACT MS-944 ( Attachment 1-A )
CONTAINS IMPORTANT INFORMATION FOR THE CONTRACTOR
The Prime Contractor and subcontractors must comply with all of the following provisions that are marked with an "X".
( Maintenance and Protection of Traffic to comply with current MUTCD, Publication 212 and Publication 213.)
2 If more than one proposal on any project is submitted by an individual, firm or partnership, corporation or association under the same or different names, only one lowest proposal will be considered.
3 Description of Work- - -
A. If additional space is needed, insert appropriately numbered attachment and note “Continued on attached work sheets."
4 Part A of Page 1 to be completed by municipality. Part B of Page 1 to be completed by contractor.
Schedule of Prices - Column #1 (Item), #2 (Approximate quantities), #3 (Unit, i.e., ton, square yard, linear feet, etc.) And #4 (Description, i.e. , bituminous materials - 9.5 mm S & L, 12.5 mm Wearing,
25.0 mm Base Course, etc.) Must be filled in by the municipality to insure equitable bidding.
Columns #5 (Unit Price), #6 (Total) and total amount of bid, must be filled in by the contractor.
If more space is needed, add note at the bottom of the page; “Continued on Attachment No. 1-A”, and add additional sheet designated as Attachment No. 1-A, 1-B, etc.. Repeat for each additional sheet required.
As required by Publication 408, Section 102.06(e),each bidder must submit a completed Form 7126 - Anti-Collusion Affidavit with its bid proposal.
5 If liquidated damages are to be assessed, add the following sentence to Part A #2. If all work is not completed on time, liquidated damages will be assessed at the rate of $870.00 per additional working day.
(OR “. . . as set forth in the attached schedule.”)
6 Payment and Performance bonds are provided only by the successful bidder. Contracts from $4,000.00 up to $5,000.00 in Second Class Townships - performance bond must be not less than 10% or greater than 100% of amount of contract.
Contracts greater than $1,500.00 up to $10,000.00 in First Class Townships, Boroughs and Third Class Cities - bonds must be between 50 % to 100% of the contract amount. Contracts in excess of $5,000.00 in Second Class Townships and in excess of $10,000.00 in First Class Townships, Boroughs and Third Class Cities - bonds must be in 100% of the amount of the contract. Bond Forms MS-944 Attachments 2 and 3 and Workmen’s Compensation Affidavit - Attachment 4 must be submitted by the successful bidder within 20 days of the contract award. Failure to submit the bonds shall constitute grounds to cancel the contract.
7 *Construction projects, where the estimated cost of the total project exceeds $100,000, are subject to the provisions of the Pennsylvania Prevailing Wage Act 442 and amended by Act 89 of 2013. It is the responsibility of the municipality to request the Prevailing Wage Scale for the area and include it in the proposal. If the Prevailing Wage Act applies, this fact shall be noted in the advertisement.
On projects utilizing Federal Revenue Sharing Funds, if the project cost exceeds $2,000 and is financed with 25% or more Federal Revenue Sharing Funds, the Davis Bacon Act applies. Again, it is the responsibility of the municipality to obtain the Davis Bacon Wage Rates, include them in the proposal and note the fact in the advertisement. If both acts are applicable, The Davis Bacon Act has preference over the Pennsylvania Prevailing Wage Act.
8 An ESCALATOR CLAUSE is optional; if used, it must be included in the proposal prepared by the municipality. An escalator clause may not be inserted by the contractor.
*(1961, Aug. 15, P.L. 987; 43 P.S. 165)
-4-
PROPOSAL AND CONTRACT INSTRUCTIONS- FORM 944 (Rev. 1/2014)
The proposal must be typewritten or printed.
Attachment 2
($ ) dollars
WHEREAS, the above bounden Principal has entered into a contract with the above Municipality, bearing even date herewith, for
It is further provided that any alteration which may be made in the terms of the contractor or its specifications with the express authorizing the same to be done on .
BY
TITLE:
TITLE:
TITLE:
TITLE:
- 1 -
CONTRACTOR
SURETY COMPANY
Attest / Witness:
(DATE OF BOND)
(With Corporate Surety)
Attest / Witness:
IN WITNESS WHEREOF, the said Principal and Surety have duly executed this Bond under Seal, pursuant to due and legal action
NOW, THEREFORE, the condition of this obligation is such that if the above bounden Principal, as Contractor, shall in all lawful money to the United States of America, to be paid to the above Municipality or its assigns, to which payment well and truly to be made, we bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents.
forebearance being hereby waived.
shall be and remain in full force, virtue and effect.
approval of the Municipality or the Principal to the other, shall not in any way release the Principal and the Surety or either or any of them, to and made a part thereof, and such alterations as may be made in said Specifications as therein provided, and shall well and truly, and in a manner satisfactory to the municipality fulfill all obligations as therein set forth, then this Obligation shall be void, but otherwise the same the undertaking of certain obligations as therein set forth.
respects comply with and faithfully perform the terms and conditions of said Contract, including the Specifications and conditions referred their heirs, executors, administrators, successors or assigns from their liability hereunder, notice to the surety of any such alteration or
PERFORMANCE BONDMS-944-S (7-09)
(NAME OF MUNICIPALITY)
Bloomfield Borough in the full and just sum of
(NAME OF STATE)
are held and firmly bound unto
KNOW ALL MEN BY THESE PRESENTS, That we, as Surety as Principal and a corporation incorporated under the laws of the State of
(SURETY COMPANY)
(NAME AND ADDRESS OF CONTRACTOR)
PLACE
SEAL
HERE
PLACE
HERE
MS-944S
KNOW ALL MEN BY THESE PRESENTS, that we a corporation incorporated under the laws of the State of as SURETY, are held and firmly bond unto the , in the full and just sum of
($ )dollars, lawful money of the United States of America, to be paid to the said or its assigns, to which payment well and truly to be made, we bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents.
WHEREAS, the above bounden Principal has entered into a contract with the above municipality hereinafter called Obligee, bearing even date herewith, for the improvement of a certain section of highway or bridge in said Municipality consisting of:
for approximately the sum of: ($ ) dollars.
NOW, THEREFORE, the condition of this obligation is such that if the above bounden PRINCIPAL shall and will promptly pay or cause to be paid in full all sums of money which may be due by contract or otherwise, to any individual, firm, partnership, association or corporation, for all material furnished or labor supplied or performed in the prosecution of the work, whether or not the said for material or labor entered into and became component parts of the work and for rental of the equipment used and services rendered by public utilities in, or in connection with the prosecution of such work, then this obligation to be void, otherwise to remain in full force and effect.
The PRINCIPAL and SURETY, hereby, jointly and severally, agree with the Obligee herein that any individual firm, partnership, association or corporation, which has performed labor or furnished material in the prosecution of the work as provided, and any public utility which has not been paid in full therefor, may sue in assumpsit on this Payment Bond in his, their, or its own name and may prosecute the same to final for such sum or sums as may be justly due him, them or it, and have execution thereon. Provided, however, that the Obligee shall not be liable for the payment of any costs of expenses of such suit.
RECOVERY by any individual, firm, partnership, association or corporation hereunder shall be subject to the provisions of the “Public Works Contractors’ Bond Law of 1967", Act No. 385, approved December 20, 1967,P.L. 869, which Act shall be incorporated herein and made a part hereof, as fully and completely as though its provisions were fully and at length herein recited.
It is further provided that any alterations which may be made in the terms of the contract or in the work to be done or materials to be furnished or labor to be supplied or performed under it or the giving by the Obligee of any extension of time for the performance of the contract or any other forebearance on the part of either the Obligee or the Principal to the other, shall not in any way release the PRINCIPAL and the SURETY or SURETIES of any such alteration, extension of forebearance being hereby waived.
IN WITNESS WHEREOF, the said PRINCIPAL and SURETY have duly executed this Bond under seal this ,20 .
WITNESS:
CONTRACTOR
BY:
TITLE:
SURETY COMPANY
TITLE: TITLE:
Bloomfield Borough
TITLE:
- 2 -
WITNESS:
day of
PAYMENT BOND Attachment 3 as PRINCIPAL and
Bloomfield Borough
PLACE
SEAL
HERE
PLACE
HERE
Attachment 4
State of ) ) ss:
County of ) he has being duly sworn according to law deposes and says that they have it has accepted the provisions of the Workmen’s Compensation Act of 1915 of the Commonwealth of Pennsylvania, with has his its supplements and amendments, and have insured their liability thereunder in accordance with the terms of said its
Act with .
( TYPE OR PRINT)
BY
day of A.D. 20 .
My Commission Expires
- 3 -
CONTRACTOR
SIGNATURE
Sworn to and subscribed before me this
( DATE )
SIGNATURE
(SURETY COMPANY)
AFFIDAVIT RE
ACCEPTING PROVISIONS OF THE WORKMEN’S COMPENSATION ACT
Pennsylvania
Perry
D-7126 ( 7-09 )
County
Municipality
Project Number
State of Fed. Project No.
( If Applicable )
The undersigned deponent deposes and says that he is the of the
BY
Sworn to and subscribed before me the undersigned notary public this day of , .
Notary Public
My Commission expires
(Contractor) competitive bidding in connection with such contract.
into any agreement, participated in any collusion, or otherwise taken any action in restraint of free
Company; that he is authorized to make this
Publication 408, as amended and that the said company has not, either directly or indirectly, entered affidavit on behalf of said company in compliance with section 102.06 (e) of Department Specifications, PerryCounty of
ANTI-COLLUSION AFFIDAVIT
Perry
Bloomfield Borough
Pennsylvania
MS-NCP
MUNICIPALITY
Name of Contractor
Performance of work as specified on the above numbered contract is completed and final pavement inspection has been made by the contractor and municipality in accordance with the terms of the contract awarded.
DATE OF AWARD
Both copies of this form to be filled by the Contractor-Municipality on completion of final pavement restoration.
*DATE
period of one year from this date.
* The contractor is responsible for maintenance of permanent pavement repairs for a
By the affixing of my signature I hereby certify that final
NOTICE OF COMPLETION
IN REFERENCE TO PROJECT #
accordance with the above contract # and is hereby accepted inspection has been made and all work has been performed in
FINAL COMPLETION CERTIFICATE
THIS PORTION TO BE COMPLETED BY MUNICIPALITY
Authorized Agent for the Municipality by the municipality as completed.
Bloomfield Borough
Signature of Contractor
Signature of Municipality
File details come from the government source that posted it. Updated .