24-42017-000_Addendum_1.pdf

STATE OF CALIFORNIA — DEPARTMENT OF STATE HOSPITALS GAVIN NEWSOM, GOVERNOR

DEPARTMENT OF STATE HOSPITALS – Napa 2100 Napa Vallejo Hwy.

Napa, CA 94558-6293

Addendum #1 December 17, 2024

IFB: 24-42017-000

“Generator Stack Extension”

The Department of State Hospitals (DSH) - Napa is issuing this Addendum for the following items, amendments to the IFB. Changes have been notated in bold, red font:

ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED

1. Key Action Dates:

Note: Unless otherwise indicated, all times noted in this solicitation are Pacific Time.

2. IFB 24-42017-000 updates:

a. Added DSH Logo on first page.

b. Revised ending page number.

c. Added Bidder’s Bond language under Attachment 6. (See Attachment A)

3. Questions and Answers:

1. Per Keynotes 14, 16, & 19 on Drawing M3.2, the existing baffle stacks are to be cleaned and painted. There appears to be limited access between existing baffles (approx. 12-15" clearance between baffles). We assume the commercial blast cleaning will require the existing baffle stack to be removed. What is the owner's expectation to do this work?

Event Date Time IFB available to prospective bidders December 05, 2024 11:00AM Due Date to Submit Request to Attend Conference

December 11, 2024 3:00PM

Bidder’s Conference December 12, 2024 10:00AM Deadline for Submission of Questions December 16, 2024 2:00PM Final Date for Bid Submission December 23, 2024 3:30PM Public Bid Opening December 23, 2024 3:30PM Notice of Intent to Award Posted December 30, 2024 - Anticipated Start Date January 01, 2025 -

a. JCCA Response: Do not remove or paint the existing baffles, just paint the exterior part of the existing stack to match the new extension. The intent of cleaning the inside of the existing stack is to make sure there are no obstructions blocking the air flow. Remove any external objects like dead animals. Blasting and vacuuming will be adequate. Paint inside and outside of the new extension per note 16.

2. If the existing baffle stack needs to be removed for painting and cleaning please provide procedures on how to remove (unbolt or cut or...) and reinstall (bolt or weld or...).

a. JCCA Response: Do not remove or paint the existing baffles, just paint the exterior part of the existing stack to match the new extension. The intent of cleaning the inside of the existing stack is to make sure there are no obstructions blocking the air flow. Remove any external objects

3. Appendix A Item 5 Summary of Work to be Performed states, "extend (2) existing co-generation baffles to reduce air turbulence and comply with EPA standards."

The Drawings show that the existing stack has baffles, but does not show the new extension stack including baffles. Please confirm the new extension stack does not include baffles.

a. JCCA response: New extension does not have baffles.

4. Drawing M3.1 includes "2022 CMC 301.3 Design of Equipment - The Installer or contractor shall furnish satisfactory evidence..." What is the intent of listing this code on the drawing?

a. JCCA response: This is a general note that was added per State Fire Marshal request to ensure that where applicable, the contractor complies with the code.

5. Drawing E1.1 includes "2022 CMC 301.3 Design of Equipment - The Installer or contractor shall furnish satisfactory evidence..." There's two receptacles being installed on this drawing. What is the intent of listing this code on the drawing?

a. JCCA response: This is a general note that was added per State Fire Marshal request to ensure that where applicable, the contractor complies with the code.

6. Can you please provide the compliance documents/contract, for the Prime

Contractor and its Subs?

a. PMU response: please Attachment B.

7. Can you please provide the corrected link for Standard Contract Language?

a. PMU response:

https://www.dgs.ca.gov/-/media/Divisions/OLS/Resources/GTC-April- 2017-FINAL.pdf

8. Is a bid bond is required? as it's not mentioned in the specification.

https://www.dgs.ca.gov/-/media/Divisions/OLS/Resources/GTC-April-2017-FINAL.pdf https://www.dgs.ca.gov/-/media/Divisions/OLS/Resources/GTC-April-2017-FINAL.pdf

a. PMU response: IFB updated to include Bidder’s Bond language on Attachment 6.

9. Who is to provide the new stack extension units? Owner or contractor?

a. JCCA response: Contractor provides and installs everything. Owner is not providing anything.

Call Rayan Keller of Durr Company, he can provide you with all materials and installation of the new stacks:

Durr Universal Inc. Clean Technology Systems 1925 US Highway 51 and 138 Stoughton, WI 53589 United States Phone +1 608 877-3284 Mobile +1 608 3549953 Fax +1 608-877-3314 MS Teams Chat/Call E-Mail ryan.keller@durrusa.com Internet www.durr.com

10. S0.1 structural notes specifies all steel exposed to weather shall be hot-dipped galvanized OR primed and painted. Which option would the owner like the contractor to include in their bid?

a. JCCA response: 1st choice is hot-dipped galvanized.

11. Picket railing is shown on M3.3. Structural drawings and details show horizontal pipe railing. Please advise which style we are to move forward with?

a. JCCA response: For this type of installation, picket railing is not the usual choice, but either is fine from a structural standpoint.

12. Will a set of specifications be released prior to bid? Or, are we to solely adhere to the IFB and drawing set?

a. PMU response: No Specifications, adhere to the IFB and drawing plan set.

13. Several of the links to the required bid forms are not working. Can you please provide a pdf document of all required bid forms for the contractor? Attachments 1 through 19.

a. PMU response: please Attachment B.

14. Can excavated spoils be stockpiled on-site? Do they need to be removed?

a. Plant Operations response: can be store onsite.

15. Is the stack support foundation plan on S2.1 and per Detail 18 on S3.2 existing or new? If new, are there any issues with the excavation and concrete demolition in the area shown on the drawings for the new 10'x12'x48" concrete footing?

a. JCCA response: The 10ft x 12ft concrete pads are new.

http://www.durr.com/

16. For Keynote 16 on M3.2, do you want SSPC-SP6 or SSPC-SP10? SP6 is a commercial blast and SP10 is a near white blast.

a. JCCA response: Use SP10.

17. Per our painting/coating sub, the existing baffles will need to be removed in order to blast, prime, and coat the inside of the existing stack. Is it possible to remove the existing baffles. If yes, how?

a. JCCA response: Do not remove or paint the existing baffles, just paint the exterior part of the existing stack to match the new extension. The intent of cleaning the inside of the existing stack is to make sure there are no obstructions blocking the air flow. Remove any external objects

18. What is the thickness of the existing concrete that needs to be demolished in order to pour the new concrete foundation pads? Is there rebar in the existing concrete?

a. JCCA response: As-built drawings were not made available so existing conditions are unknown.

19. Please confirm any existing equipment within the foot print of the stack supports and foundations will be removed prior to starting work.

a. Plant Operations response: All the equipment that is related to the turbines will stay in place such as pumps, battery station, nox system ect. The removable items such as pallets of salt, dunnage, and other containers will be moved.

20. Will exiting piping, utilities, etc... protruding from the heat exchanger conflict with the placement of the new steel structure? Has this been evaluated?

a. JCCA response: As-built drawings were not made available so existing conditions are unknown. If you come across existing utilities, please let the owner know.

21. Will the equipment behind the existing stack be removed by the owner prior to work commencing? It looks like it will conflict with the new pad (10'x12') and structure?

No description or information on this has been provided for the contractor to self perform.

a. Plant Operations response: All the equipment that is related to the turbines will stay in place such as pumps, battery station, nox system ect. The removable items such as pallets of salt, dunnage, and other containers will be moved.

22. How many Baffles are in the stack that need to be cleaned?

a. JCCA response: No need to clean the existing baffles, just make sure that the airway is clean and free of debris.

23. Do the stacks have removable socks or baffles that will need to be replaced? Are we just to clean the existing?

a. JCCA response: Just clean the inside of the stack to make sure nothing is blocking the air flow. Do not remove or paint the existing baffles, just paint the exterior part of the existing stack to match the new extension.

The intent of cleaning the inside of the existing stack is to make sure there are no obstructions blocking the air flow. Remove any external objects like dead animals. Blasting and vacuuming will be adequate.

Paint inside and outside of the new extension per note 16.

24. What type of fumes or contaminants are to be cleaned from the existing exhaust stacks? What type of particulate will be removed? This will determine what type of PPE is required.

a. JCCA response: Do not remove or paint the existing baffles, just paint the exterior part of the existing stack to match the new extension. The intent of cleaning the inside of the existing stack is to make sure there are no obstructions blocking the air flow. Remove any external objects

25. What permits, if any, will the contractor be required to obtain for this project?

a. Plant Operations response: Contractor not required to obtain any permits; Construction permit has been issued by the State Fire Marshall.

26. What is the expansion joint made out of? Do we purchase the expansion joint from the manufacturer?

a. JCCA response: Call Rayan Keller of Durr Company, he can provide you with all materials and installation of the new stacks:

Durr Universal Inc. Clean Technology Systems 1925 US Highway 51 and 138 Stoughton, WI 53589 United States Phone +1 608 877-3284 Mobile +1 608 3549953 Fax +1 608-877-3314 MS Teams Chat/Call

27. Is there enough of a working space for excavation and loading of excavation spoils?

a. Plant Operations response: yes, dependent on what kind of equipment you try to bring in.

28. Can excavated spoils be stored onsite or do they need to be loaded and removed offsite?

a. Plant Operations response: can be stored onsite.

29. Is there any concrete demo of (E ) site for new pads?

a. JCCA response: Yes….as a minimum, there is concrete flatwork in the area of the proposed pad footings. There’s insufficient as-built information to know if there are other subgrade obstacles.

30. Can both pads be poured in one placement?

a. JCCA response: Yes

31. At the job walk Skill and trained was mentioned. The documentation does not mention the skill and trained requirement. Please confirm if this project is subject to the skill and trained requirements.

a. PMU response: please in the IFB, Exhibit D, Special Terms and Conditions, 3.

32. At the job walk it was noted that the existing vault covers were bent, what is the weight capacity for these covers?

a. Plant Operations response: no equipment should be on these plates;

steel plates will need to be used over the existing vault covers.

33. Is there a sequencing timeline for the decommissioning of the equipment? (due to the limited room within the area)

a. Plant Operations response: Contractor to work with Owner on decommissioning timeline to meet hospital needs.

34. Is it possible to get access to both sides of the enclosure?

a. Plant Operations response: yes.

35. It states that the contractor is responsible for any permits. Can you please give us a list of the permits that we will need?

a. Plant Operations response: Contractor not required to obtain any permits; Construction permit has been issued by the State Fire Marshall.

36. Is there a manufacturer and model # for the expansion joints?

a. JCCA response: Call Rayan Keller of Durr Company, he can provide you with all materials and installation of the new stacks:

Durr Universal Inc. Clean Technology Systems 1925 US Highway 51 and 138 Stoughton, WI 53589 United States Phone +1 608 877-3284 Mobile +1 608 3549953 Fax +1 608-877-3314 MS Teams Chat/Call

37. Is there a list of attendees that attended the job walk?

a. PMU response: please see Attachment C.

38. Is the contractor responsible for procuring the stack extensions? If so are there fabrication drawings for the stack extensions? It gives the inner liner and outer liner dimensions but no thickness of the inner 409SS liner or the thickness of the outer liner.

a. JCCA response: Yes, the contractor is responsible for furnishing and installing the new extensions. Fabrication drawings can be obtained from the manufacturer of the stacks.

Call Rayan Keller of Durr Company, he can provide you with all materials and installation of the new stacks:

Durr Universal Inc. Clean Technology Systems 1925 US Highway 51 and 138 Stoughton, WI 53589 United States Phone +1 608 877-3284 Mobile +1 608 3549953 Fax +1 608-877-3314 MS Teams Chat/Call

39. On drawing S0.1 under the structural steel notes, under welding, it states that all welding shall be performed by a Building Department approved certified welders, do you have that list?

a. JCCA response: use IOR approved welders.

40. On drawing S0.1 under the structural steel notes, under welding it says it shall conform to the latest AWS D1.1, is ASME acceptable?

a. JCCA response: No

41. Is there a length of the belt for the expansion joint? Is there a length on keynote #1?

It just states that it is ¼” carbon steel flange.

a. JCCA response: The length must be field verified.

42. For bonding purposes, what is the Engineer's Estimate?

a. It is the policy of Department of State Hospitals Facilities Planning, Construction & Management Unit that Engineer Estimates are only utilized internally to determine if proposed Public Works Construction Projects fall under the Departments delegated authority or must be bid out as a Major Capital Outlay Project.

43. Is 3% DVBE Participation required?

a. This not required but the DVBE incentive is being offered.

44. There is electrical work shown on the drawings. Under which bid item on Attachment 5 should the electrical work be accounted for?

a. Electrical Work line item has been added to the rate sheet.

Attachment A

Name of Attachment Attachment

_____ Attachment 1

_____ Attachment 2

_____ Attachment 3

_____ Attachment 4

_____ Attachment 5

_____ Attachment 6

_____ Attachment 7

_____ Attachment 8

_____ Attachment 9

_____ Attachment 10

_____ Attachment 11

_____ Attachment 12

_____ Attachment 13

_____ Attachment 14

_____ Attachment 15

_____ Attachment 16

Copy of Business License

Printout from the California Secretary of State

Department of Industrial Relations Number:___________

Provide a copy of current Contractors State License

Copy of Quote

Bidder Declaration Form (GSPD 05-105)

Contractor Certification Clauses (CCC-4/2017)

Payee Data Record (Std. 204)

Insurance Certifications Bond Requirements

Darfur Contracting Act Certification

California Civil Right Certification

DVBE Declarations Form (Std. 843)

Labor Code Certification

Bidder’s Acknowledgment To Pay Prevailing Wage Rates

Nondiscrimination Compliance Statement (Std. 19)

GenAI Disclosure and Fact Sheet (STD. 1000)

Contract Documents Contractor:____________________________ Agreement Number:_____________________ IFB Service:_____________________

Attachment B

JAdamak Cross-Out

Attachment B

Contractor/Bidder Firm Name (Printed) Federal ID Number

Date Executed Executed in the County of

Contractor Certification Clauses

CCC 04/2017

CERTIFICATION

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized to legally bind the prospective Contractor to the clause(s) listed below. This certification is made under the laws of the State of California.

By (Authorized Signature)

Printed Name and Title of Person Signing

CONTRACTOR CERTIFICATION CLAUSES

1. STATEMENT OF COMPLIANCE: Contractor has, unless exempted, complied with the nondiscrimination program requirements. (Gov. Code §12990 (a-f) and CCR, Title 2, Section 11102) (Not applicable to public entities.)

2. DRUG-FREE WORKPLACE REQUIREMENTS: Contractor will comply with the requirements of the Drug-Free Workplace Act of 1990 and will provide a drug-free workplace by taking the following actions:

a. Publish a statement notifying employees that unlawful manufacture, distribution, dispensation, possession or use of a controlled substance is prohibited and specifying actions to be taken against employees for violations.

b. Establish a Drug-Free Awareness Program to inform employees about:

1) the dangers of drug abuse in the workplace;

2) the person's or organization's policy of maintaining a drug-free workplace;

3) any available counseling, rehabilitation and employee assistance programs; and,

4) penalties that may be imposed upon employees for drug abuse violations.

c. Every employee who works on the proposed Agreement will:

1) receive a copy of the company's drug-free workplace policy statement; and,

2) agree to abide by the terms of the company's statement as a condition of employment on the Agreement.

Failure to comply with these requirements may result in suspension of payments under the Agreement or termination of the Agreement or both and Contractor may be ineligible for award of any future State agreements if the department determines that any of the following has occurred: the Contractor has made false certification, or violated the certification by failing to carry out the requirements as noted above. (Gov. Code §8350 et seq.)

3. NATIONAL LABOR RELATIONS BOARD CERTIFICATION: Contractor certifies that no more than one (1) final unappealable finding of contempt of court by a Federal court has been issued against Contractor within the immediately preceding two-year period because of Contractor's failure to comply with an order of a Federal court, which orders Contractor to comply with an order of the National Labor Relations Board. (Pub. Contract Code §10296) (Not applicable to public entities.)

4. CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO BONO

REQUIREMENT: Contractor hereby certifies that Contractor will comply with the requirements of Section 6072 of the Business and Professions Code, effective January 1, 2003.

Contractor agrees to make a good faith effort to provide a minimum number of hours of pro bono legal services during each year of the contract equal to the lessor of 30 multiplied by the number of full time attorneys in the firm’s offices in the State, with the number of hours prorated on an actual day basis for any contract period of less than a full year or 10% of its contract with the State.

Failure to make a good faith effort may be cause for non-renewal of a state contract for legal services, and may be taken into account when determining the award of future contracts with the State for legal services.

5. EXPATRIATE CORPORATIONS: Contractor hereby declares that it is not an expatriate corporation or subsidiary of an expatriate corporation within the meaning of Public Contract Code Section 10286 and 10286.1, and is eligible to contract with the State of California.

6. SWEATFREE CODE OF CONDUCT:

a. All Contractors contracting for the procurement or laundering of apparel, garments or corresponding accessories, or the procurement of equipment, materials, or supplies, other than procurement related to a public works contract, declare under penalty of perjury that no apparel, garments or corresponding accessories, equipment, materials, or supplies furnished to the state pursuant to the contract have been laundered or produced in whole or in part by sweatshop labor, forced labor, convict labor, indentured labor under penal sanction, abusive forms of child labor or exploitation of children in sweatshop labor, or with the benefit of sweatshop labor, forced labor, convict labor, indentured labor under penal sanction, abusive forms of child labor or exploitation of children in sweatshop labor.

The contractor further declares under penalty of perjury that they adhere to the Sweatfree Code of Conduct as set forth on the California Department of Industrial Relations website located at www.dir.ca.gov, and Public Contract Code Section 6108.

b. The contractor agrees to cooperate fully in providing reasonable access to the contractor’s records, documents, agents or employees, or premises if reasonably http://www.dir.ca.gov/ required by authorized officials of the contracting agency, the Department of Industrial Relations, or the Department of Justice to determine the contractor’s compliance with the requirements under paragraph (a).

7. DOMESTIC PARTNERS: For contracts of $100,000 or more, Contractor certifies that Contractor is in compliance with Public Contract Code section 10295.3.

8. GENDER IDENTITY: For contracts of $100,000 or more, Contractor certifies that Contractor is in compliance with Public Contract Code section 10295.35.

DOING BUSINESS WITH THE STATE OF CALIFORNIA

The following laws apply to persons or entities doing business with the State of California.

1. CONFLICT OF INTEREST: Contractor needs to be aware of the following provisions regarding current or former state employees. If Contractor has any questions on the status of any person rendering services or involved with the Agreement, the awarding agency must be contacted immediately for clarification.

Current State Employees (Pub. Contract Code §10410):

1). No officer or employee shall engage in any employment, activity or enterprise from which the officer or employee receives compensation or has a financial interest and which is sponsored or funded by any state agency, unless the employment, activity or enterprise is required as a condition of regular state employment.

2). No officer or employee shall contract on his or her own behalf as an independent contractor with any state agency to provide goods or services.

Former State Employees (Pub. Contract Code §10411):

1). For the two-year period from the date he or she left state employment, no former state officer or employee may enter into a contract in which he or she engaged in any of the negotiations, transactions, planning, arrangements or any part of the decision-making process relevant to the contract while employed in any capacity by any state agency.

2). For the twelve-month period from the date he or she left state employment, no former state officer or employee may enter into a contract with any state agency if he or she was employed by that state agency in a policy-making position in the same general subject area as the proposed contract within the 12-month period prior to his or her leaving state service.

If Contractor violates any provisions of above paragraphs, such action by Contractor shall render this Agreement void. (Pub. Contract Code §10420)

Members of boards and commissions are exempt from this section if they do not receive payment other than payment of each meeting of the board or commission, payment for preparatory time and payment for per diem. (Pub. Contract Code §10430 (e))

2. LABOR CODE/WORKERS' COMPENSATION: Contractor needs to be aware of the provisions which require every employer to be insured against liability for Worker's Compensation or to undertake self-insurance in accordance with the provisions, and

Contractor affirms to comply with such provisions before commencing the performance of the work of this Agreement. (Labor Code Section 3700)

3. AMERICANS WITH DISABILITIES ACT: Contractor assures the State that it complies with the Americans with Disabilities Act (ADA) of 1990, which prohibits discrimination on the basis of disability, as well as all applicable regulations and guidelines issued pursuant to the ADA. (42 U.S.C. 12101 et seq.)

4. CONTRACTOR NAME CHANGE: An amendment is required to change the Contractor's name as listed on this Agreement. Upon receipt of legal documentation of the name change the State will process the amendment. Payment of invoices presented with a new name cannot be paid prior to approval of said amendment.

5. CORPORATE QUALIFICATIONS TO DO BUSINESS IN CALIFORNIA:

a. When agreements are to be performed in the state by corporations, the contracting agencies will be verifying that the contractor is currently qualified to do business in California in order to ensure that all obligations due to the state are fulfilled.

b. "Doing business" is defined in R&TC Section 23101 as actively engaging in any transaction for the purpose of financial or pecuniary gain or profit. Although there are some statutory exceptions to taxation, rarely will a corporate contractor performing within the state not be subject to the franchise tax.

c. Both domestic and foreign corporations (those incorporated outside of California) must be in good standing in order to be qualified to do business in California. Agencies will determine whether a corporation is in good standing by calling the Office of the Secretary of State.

6. RESOLUTION: A county, city, district, or other local public body must provide the State with a copy of a resolution, order, motion, or ordinance of the local governing body which by law has authority to enter into an agreement, authorizing execution of the agreement.

7. AIR OR WATER POLLUTION VIOLATION: Under the State laws, the Contractor shall not be: (1) in violation of any order or resolution not subject to review promulgated by the State Air Resources Board or an air pollution control district; (2) subject to cease and desist order not subject to review issued pursuant to Section 13301 of the Water Code for violation of waste discharge requirements or discharge prohibitions; or (3) finally determined to be in violation of provisions of federal law relating to air or water pollution.

8. PAYEE DATA RECORD FORM STD. 204: This form must be completed by all contractors that are not another state agency or other governmental entity.

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

Section 1 – Payee Information NAME (This is required. Do not leave this line blank. Must match the payee’s federal tax return)

BUSINESS NAME, DBA NAME or DISREGARDED SINGLE MEMBER LLC NAME (If different from above)

MAILING ADDRESS (number, street, apt. or suite no.) (See instructions on Page 2)

CITY, STATE, ZIP CODE E-MAIL ADDRESS

Section 2 – Entity Type Check one (1) box only that matches the entity type of the Payee listed in Section 1 above. (See instructions on page 2)

CORPORATION (see instructions on page 2)SOLE PROPRIETOR / INDIVIDUAL MEDICAL (e.g., dentistry, chiropractic, etc.)SINGLE MEMBER LLC Disregarded Entity owned by an individual

PARTNERSHIP

ESTATE OR TRUST

LEGAL (e.g., attorney services)

EXEMPT (e.g., nonprofit)

ALL OTHERS

Section 3 – Tax Identification Number Enter your Tax Identification Number (TIN) in the appropriate box. The TIN must match the name given in Section 1 of this form. Do not provide more than one (1) TIN.

The TIN is a 9-digit number. Note: Payment will not be processed without a TIN.

For Individuals, enter SSN.

If you are a Resident Alien, and you do not have and are not eligible to get an SSN, enter your ITIN.

Grantor Trusts (such as a Revocable Living Trust while the grantors are alive) may not have a separate FEIN. Those trusts must enter the individual grantor’s SSN.

For Sole Proprietor or Single Member LLC (disregarded entity), in which the sole member is an individual, enter SSN (ITIN if applicable) or FEIN (FTB prefers SSN).

For Single Member LLC (disregarded entity), in which the sole member is a business entity, enter the owner entity’s FEIN. Do not use the disregarded entity’s FEIN.

For all other entities including LLC that is taxed as a corporation or partnership, estates/trusts (with FEINs), enter the entity’s FEIN.

Social Security Number (SSN) or Individual Tax Identification Number (ITIN)

OR

Federal Employer Identification Number

(FEIN)

Section 4 – Payee Residency Status (See instructions)

CALIFORNIA RESIDENT – Qualified to do business in California or maintains a permanent place of business in California.

CALIFORNIA NONRESIDENT – Payments to nonresidents for services may be subject to state income tax withholding.

No services performed in California

Copy of Franchise Tax Board waiver of state withholding is attached.

Section 5 – Certification I hereby certify under penalty of perjury that the information provided on this document is true and correct.

Should my residency status change, I will promptly notify the state agency below.

NAME OF AUTHORIZED PAYEE REPRESENTATIVE TITLE E-MAIL ADDRESS

SIGNATURE DATE TELEPHONE (include area code)

Section 6 – Paying State Agency Please return completed form to:

FAX TELEPHONE (include area code)

CITY STATE ZIP CODE E-MAIL ADDRESS

STATE AGENCY/DEPARTMENT OFFICE UNIT/SECTION

MAILING ADDRESS

Print Form Reset Form

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

GENERAL INSTRUCTIONS

Type or print the information on the Payee Data Record, STD 204 form. Sign, date, and return to the state agency/department office address shown in Section 6.

Prompt return of this fully completed form will prevent delays when processing payments.

Information provided in this form will be used by California state agencies/departments to prepare Information Returns (Form1099).

NOTE: Completion of this form is optional for Government entities, i.e. federal, state, local, and special districts.

A completed Payee Data Record, STD 204 form, is required for all payees (non-governmental entities or individuals) entering into a transaction that may lead to a payment from the state. Each state agency requires a completed, signed, and dated STD 204 on file; therefore, it is possible for you to receive this form from multiple state agencies with which you do business.

Payees who do not wish to complete the STD 204 may elect not to do business with the state. If the payee does not complete the STD 204 and the required payee data is not otherwise provided, payment may be reduced for federal and state backup withholding. Amounts reported on Information Returns (Form 1099) are in accordance with the Internal Revenue Code (IRC) and the California Revenue and Taxation Code (R&TC).

Section 1 – Payee Information Name – Enter the name that appears on the payee's federal tax return. The name provided shall be the tax liable party and is subject to IRS TIN matching (when applicable).

Sole Proprietor/Individual/Revocable Trusts – enter the name shown on your federal tax return.

Single Member Limited Liability Companies (LLCs) that is disregarded as an entity separate from its owner for federal tax purposes - enter the name of the individual or business entity that is tax liable for the business in section 1. Enter the DBA, LLC name, trade, or fictitious name under Business Name.

Note: for the State of California tax purposes, a Single Member LLC is not disregarded from its owner, even if they may be disregarded at the Federal level.

Partnerships, Estates/Trusts, or Corporations – enter the entity name as shown on the entity’s federal tax return. The name provided in Section 1 must match to the TIN provided in section 3. Enter any DBA, trade, or fictitious business names under Business Name.

Business Name – Enter the business name, DBA name, trade or fictitious name, or disregarded LLC name.

Mailing Address – The mailing address is the address where the payee will receive information returns. Use form STD 205, Payee Data Record Supplement to provide a remittance address if different from the mailing address for information returns, or make subsequent changes to the remittance address.

Section 2 – Entity Type If the Payee in Section 1 is a(n)… THEN Select the Box for…

Grantor (Revocable Living) Trust disregarded for federal tax purposes Sole Proprietor/Individual Limited Liability Company (LLC) owned by an individual and is disregarded for federal tax purposes Single Member LLC-owned by an individual Partnerships Limited Liability Partnerships (LLP) and, LLC treated as a Partnership Partnerships Estate Trust (other than disregarded Grantor Trust) Estate or Trust Corporation that is medical in nature (e.g., medical and healthcare services, physician care, nursery care, dentistry, etc. LLC that is to be taxed like a Corporation and is medical in nature

Corporation-Medical

Corporation that is legal in nature (e.g., services of attorneys, arbitrators, notary publics involving legal or law related matters, etc.) LLC that is to be taxed like a Corporation and is legal in nature

Corporation-Legal

Corporation that qualifies for an Exempt status, including 501(c) 3 and domestic non-profit corporations. Corporation-Exempt Corporation that does not meet the qualifications of any of the other corporation types listed above LLC that is to be taxed as a Corporation and does not meet any of the other corporation types listed above

Corporation-All Other

Section 3 – Tax Identification Number The State of California requires that all parties entering into business transactions that may lead to payment(s) from the state provide their Taxpayer Identification Number (TIN). The TIN is required by R&TC sections 18646 and 18661 to facilitate tax compliance enforcement activities and preparation of Form 1099 and other information returns as required by the IRC section 6109(a) and R&TC section 18662 and its regulations.

Section 4 – Payee Residency Status Are you a California resident or nonresident?

A corporation will be defined as a "resident" if it has a permanent place of business in California or is qualified through the Secretary of State to do business in California.

A partnership is considered a resident partnership if it has a permanent place of business in California.

An estate is a resident if the decedent was a California resident at time of death.

A trust is a resident if at least one trustee is a California resident.

o For individuals and sole proprietors, the term "resident" includes every individual who is in California for other than a temporary or transitory purpose and any individual domiciled in California who is absent for a temporary or transitory purpose. Generally, an individual who comes to California for a purpose that will extend over a long or indefinite period will be considered a resident. However, an individual who comes to perform a particular contract of short duration will be considered a nonresident.

For information on Nonresident Withholding, contact the Franchise Tax Board at the numbers listed below:

Withholding Services and Compliance Section: 1-888-792-4900 E-mail address: wscs.gen@ftb.ca.gov For hearing impaired with TDD, call: 1-800-822-6268 Website: www.ftb.ca.gov

Section 5 – Certification Provide the name, title, email address, signature, and telephone number of individual completing this form and date completed. In the event that a SSN or ITIN is provided, the individual identified as the tax liable party must certify the form. Note: the signee may differ from the tax liable party in this situation if the signe e can provide a power of attorney documented for the individual.

Section 6 – Paying State Agency This section must be completed by the state agency/department requesting the STD 204.

Privacy Statement Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, state, or local governmental agency, which requests an individual to disclose their social security account number, shall inform that individual whether that disclosure is mandatory or voluntary, by which statutory or other authority such number is solicited, and what uses will be made of it. It is mandatory to furnish the information requested. Federal law requires that payment for which the requested information is not provided is subject to federal backup withholding and state law imposes noncompliance penalties of up to $20,000. You have the right to access records containing your personal information, such as your SSN. To exercise that right, please contact the business services unit or the accounts payable unit of the state agency(ies) with which you transact that business.

All questions should be referred to the requesting state agency listed on the bottom front of this form.

INSURANCE CERTIFICATION

This form reminds bidders of the insurance requirements that may be imposed by this solicitation and provides samples of some of the forms that they may be required to produce prior to being awarded an agreement.

Initial Certification

Bidder acknowledges that they have reviewed and understands the insurance requirements for this solicitation as described in Attachment 18, Sample Contract, Exhibit G, Insurance Requirements.

Bidder acknowledges that they have reviewed and understands the sample insurance forms provided with this attachment.

Bidder certifies that, if awarded an agreement, the bidder shall provide the DSH with all required insurance documents as may be applicable, in a timely manner. This includes, but may not be limited to:

Certificates of insurance showing the bidder’s insurance coverage types and limitations, Proof that the bidder has insured the State of California, its officers, employees, and agents. Bidder further understands that this proof shall come in the form of either:

An endorsement to the bidder’s insurance policy (Form CG 20 10 11 85 or as broad as), A copy of the bidder’s current insurance policy that shows that the policy already insures all parties required to be insured by this Agreement.

Bidder certifies that, should Commercial General Liability insurance be required, and should the bidder use a subcontractor to complete a portion of this Agreement, the bidder shall either:

Include the subcontractor as an additional named insured under the bidder’s policy, Ensure that each subcontractor is insured under their own Commercial General

Liability policy.

Bidder acknowledges that they understand that the DSH reserves the right, at its sole discretion, to cancel a proposed award to a bidder who does not submit the required documentation described herein.

Bidder acknowledges that a Payment Bond will be required if the quoted amount is over $25,000. Bidder agrees to complete the STD807 provided bond form upon award.

Bidder acknowledges that a Performance Bond will be required if the quoted amount exceeds $10,000.00 and progress payments will be made. Bonds must be issued by a California-admitted surety per CCP§995.311.

ACORD CERTIFICATE

This is a sample insurance certificate.

ENDORSEMENT

Language on this certificate indicating that the State is an additional insured is not sufficient to meet the requirements of Exhibit G.

INSURED

The name in this box MUST match the name listed in the PAYEE’S LEGAL BUSINESS NAME field on the Std. 204.

TYPE OF INSURANCE and LIMITS Each required insurance type, with the exception of Worker’s Compensation and Professional Liability, must be listed on the certificate.

POLICY EXP.

All required insurance types must be active (not expired). If an insurance policy expiration date is impending, awarded firms are advised to be ready to submit an updated certificate with the renewal dates.

CERTIFICATE HOLDER

This box must be completed as indicated in Exhibit G, section 4.

“BLANKET ENDORSEMENT”

Section g. is an example of an existing insurance policy that contains a provision naming a contracted party an additional insured.

POLICY OR FORM NUMBER

Like a blanket endorsement, this traditional endorsement must be reconcilable to the insurance certificate.

A policy or form number that is also referenced on the insurance certificate must be present on the endorsement.

ADDITIONAL INSURED LANGUAGE

As required in Exhibit G, the “State of California, its officers, employees, and agents” must be listed as the additional insured parties. However, this endorsement may be limited to just the operations under the Agreement.

Darfur Contracting Act Certification

Public Contract Code sections 10475 - 10481 applies to any company that currently or within the previous three years has had business activities or other operations outside of the United States. For such a company to bid on or submit a proposal for a State of California contract, the company must certify that it is either a) not a scrutinized company; or b) a scrutinized company that has been granted permission by the Department of General Services to submit a proposal or bid.

If your company has not, within the previous three years, had any business activities or other operations outside of the United States, you do not need to complete this form.

OPTION #1 - CERTIFICATION

If your company, within the previous three years, has had business activities or other operations outside of the United States, in order to be eligible to submit a bid or proposal, please insert your company name and Federal ID Number and complete the certification below.

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that a) the prospective proposer/bidder named below is not a scrutinized company per Public Contract Code section 10476; and b) I am duly authorized to legally bind the prospective proposer/bidder named below. This certification is made under the laws of the State of California.

Company/Vendor Name (Printed) Federal ID Number

By (Authorized Signature)

Printed Name and Title of Person Signing

Date Executed Executed in the County and State of

OPTION #2 – WRITTEN PERMISSION FROM DGS

Pursuant to Public Contract Code section 10477, subsection (b), the Director of the Department of General Services may permit a scrutinized company, on a case-by-case basis, to bid on or submit a proposal for a contract with a state agency for goods or services, if it is in the best interests of the state. If you are a scrutinized company that has obtained written permission from the DGS to submit a bid or proposal, complete the information below.

We are a scrutinized company as defined in Public Contract Code section 10476, but we have received written permission from the Department of General Services to submit a bid or proposal pursuant to Public Contract Code section 10477, subsection (b). A copy of the written permission from DGS is included with our bid or proposal.

Company/Vendor Name (Printed) Federal ID Number

Initials of Submitter

Printed Name and Title of Person Initialing

STATE OF CALIFORNIA DEPARTMENT OF GENERAL SERVICES

CALIFORNIA CIVIL RIGHTS LAWS ATTACHMENT OFFICE OF LEGAL SERVICES

DGS OLS 04 (Rev. 01/17)

Pursuant to Public Contract Code section 2010, a person that submits a bid or proposal to, or otherwise proposes to enter into or renew a contract with, a state agency with respect to any contract in the amount of $100,000 or above shall certify, under penalty of perjury, at the time the bid or proposal is submitted or the contract is renewed, all of the following:

1. CALIFORNIA CIVIL RIGHTS LAWS: For contracts executed or renewed after January 1, 2017, the contractor certifies compliance with the Unruh Civil Rights Act (Section 51 of the Civil Code) and the Fair Employment and Housing Act (Section 12960 of the Government Code); and

2. EMPLOYER DISCRIMINATORY POLICIES: For contracts executed or renewed after January 1, 2017, if a Contractor has an internal policy against a sovereign nation or peoples recognized by the United States government, the Contractor certifies that such policies are not used in violation of the Unruh Civil Rights Act (Section 51 of the Civil Code) or the Fair Employment and Housing Act (Section 12960 of the Government Code).

CERTIFICATION

I, the official named below, certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

By (Authorized Signature)

Printed Name and Title of Person Signing

Executed in the County of Executed in the State of

Date Executed

Proposer/Bidder Firm Name (Printed) Federal ID Number

STATE OF CALIFORNIA – DEPARTMENT OF GENERAL SERVICES PROCUREMENT DIVISION

DISABLED VETERAN BUSINESS ENTERPRISE DECLARATIONS

(Rev. /20 )

Instructions: The disabled veteran (DV) owner(s) and DV manager(s) of the Disabled Veteran Business Enterprise (DVBE) must complete this declaration when a DVBE contractor or subcontractor will provide materials, supplies, services or equipment [Military and Veterans Code Section 999.2]. Violations are misdemeanors and punishable by imprisonment or fine and violators are liable for civil penalties. All signatures are made under penalty of perjury.

SECTION 1

Name of certified DVBE: DVBE Ref. Number:

Description (materials/supplies/services/equipment proposed):

Solicitation/Contract Number: SCPRS Ref. Number:__________________________

(FOR STATE USE ONLY)

SECTION 2

APPLIES TO ALL DVBEs. Check only one box in Section 2 and provide original signatures.

I (we) declare that the DVBE is not a broker or agent, as defined in Military and Veterans Code Section 999.2 (b), of materials, supplies, services or equipment listed above. Also, complete Section 3 below if renting equipment.

Pursuant to Military and Veterans Code Section 999.2 (f), I (we) declare that the DVBE is a broker or agent for the principal(s) listed below or on an attached sheet(s). (Pursuant to Military and Veterans Code 999.2 (e), State funds expended for equipment rented from equipment brokers pursuant to contracts awarded under this section shall not be credited toward the 3-percent DVBE participation goal.)

All DV owners and managers of the DVBE (attach additional pages with sufficient signature blocks for each person to sign):

(Printed Name of DV Owner/Manager) (Signature of DV Owner/ Manager) (Date Signed)

(Printed Name of DV Owner/Manager) (Signature of DV Owner/Manager) (Date Signed)

Firm/Principal for whom the DVBE is acting as a broker or age nt:

(If more than one firm, list on extra sheets.) (Print or Type Name)

Firm/Principal Phone: Address:

SECTION 3

APPLIES TO ALL DVBEs THAT RENT EQUIPMENT AND DECLARE THE DVBE IS NOT A BROKER.

Pursuant to Military and Veterans Code Section 999.2 (c), (d) and (g), I am (we are) the DV(s) with at least 51% ownership of the DVBE, or a DV manager(s) of the DVBE. The DVBE maintains certification requirements in accordance with Military and Veterans Code Section 999 et. seq.

The undersigned owner(s) own(s) at least 51% of the quantity and value of each piece of equipment that will be rented for use in the contract identified above. I (we), the DV owners of the equipment, have submitted to the administering agency my (our) personal federal tax return(s) at time of certification and annually thereafter as defined in Military and Veterans Code 999.2, subsections (c) and (g). Failure by the disabled veteran equipment owner(s) to submit their personal federal tax return(s) to the administering agency as defined in Military and Veterans Code 999.2, subsections

(c) and (g), will result in the DVBE being deemed an equipment broker.

Disabled Veteran Owner(s) of the DVBE (attach additional pages with signature blocks for each person to sign):

(Printed Name) (Signature) (Date Signed)

(Address of Owner) (Telephone) (Tax Identification Number of Owner)

Disabled Veteran Manager(s) of the DVBE (attach additional pages with sufficient signature blocks for each person to sign):

(Printed Name of DV Manager) (Signature of DV Manager) (Date Signed)

Page of

Labor Code Certification

By my signature hereunder, as Contractor, I certify to the following, under the penalty of perjury under the laws of the State of California:

A. I am aware of the provisions of Section 3700 of the Labor Code, which require every employer to be insured against liability for workers' compensation or to undertake self-insurance in accordance with the provisions of that Code, and I will comply with such provisions before commencing the performance of the work of this contract.

B. It is hereby mutually agreed that the Contractor shall forfeit to the State a penalty of two hundred dollars for each calendar day, or portion thereof, for each worker paid by him or her, or subcontractor under him or her, less than the prevailing wage so stipulated and in addition the Contractor further agrees to pay to each worker the difference between the actual amount paid for each calendar day, or portion thereof, and the stipulated prevailing wage rate for the same. This provision shall not apply to properly registered apprentices.

C. It is further agreed that the maximum hours a worker is to be employed is limited to eight hours a day and 40 hours a week and the Contractor shall forfeit, as a penalty to the State, Twenty-Five Dollars for each worker employed in the execution of the contract for each calendar day during which a worker is required or permitted to labor more than eight hours in any calendar day or more than 40 hours in any calendar week, in violation of Labor Code Sections 1810-1815, inclusive.

D. Travel and subsistence payments shall be paid to each worker needed to execute the work, as such travel and subsistence payments are defined in the applicable collective bargaining agreements filed in accordance with Labor Code Section 1773.8.

E. Properly registered apprentices may be employed in the prosecution of the work. Every such apprentice shall be paid the standard wage paid to apprentices under the regulations of the craft or trade at which he or she is employed, and shall be employed only at the work of the craft or trade to which he or she is registered. The contractor and each subcontractor must comply with the requirements of Labor Code Section 1777.5 and any related regulations regarding the employment of registered apprentices.

F. Each Contractor and subcontractor shall comply with Labor Code Section 1776 regarding record keeping.

Contractor name: License No.:

Address: City___________________________

Signature: Federal Employer I.D. No.:

(For bid over $25,000.00)

BIDDER’S ACKNOWLEDGEMENT TO PAY PREVAILING WAGE RATES

________________________________________acknowledges that State General Prevailing Wage

Print Name of Bidder

Rates will apply for the County in which the work…