4._26YS0054_-_Bidder_s_Checklist_and_IFB_Attachments.pdf

State of California Solicitation Number: 26YS0054 Department of Veterans Affairs

BIDDER’S CHECKLIST

WINDOW FILM APPLICATION AND ON-CALL REPAIR SERVICES

The checklist below is a summary of documents to be submitted based on requirements in the Invitation for Bid. This checklist should be returned with your bid. Place a check-mark or “X” next to each document being submitted.

Signatures are required on the documents where specified.

The company name listed on all documents submitted (ex. licenses, permits, certifications, and insurance) must be identical to the company name on the Payee Data Record (STD 204). Failure to submit these documents in the manner prescribed may delay award of Agreements.

Bidder’s Checklist

Bidder Certification

Bid Rate Sheet

Signed Payee Data Record - STD 204

Bidder Declaration - GSPD-05-105

Commercially Useful Function (CUF) Certification, if applicable

Disabled Veteran Business Enterprise (DVBE) Declarations – DGS PD 843, if applicable

Iran, if applicable

Darfur Contracting Act

California Civil Rights Laws

Non-Collusion Affidavit (must be notarized)

State of Compliance (STD19)

Drug-free Workplace Certification (STD 21)

Small Business Preference and Certification Request (STD 811)

Standard Form of Guarantee

Contractor Certification Clauses (CCC-4/2017) - The CCC-4/2017 can be found on the Internet at https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List- Folder/Standard-Contract-Language

Valid California city or county business license; or, if a corporation located within the State of California, incorporation documents or letter from the Secretary of State; or, if not a California business, an affidavit that the business is in good standing with the State, Province, or Country in which the business is headquartered.

Submit all Licenses and Certificate of Insurance required by this solicitation with your bid package.

Department of Industrial Relations (D.I.R.) Registration

Sample Invoice

Department of Veterans Affairs TBD

BID/BIDDER CERTIFICATION SHEET

This Bid/Bidder Certification Sheet must be signed and returned along with all the "required attachments" as an entire package. The bid must be transmitted in accordance with IFB instructions.

A. I have read and understand the DVBE participation requirements and have included documentation demonstrating that I have met the participation goals, if goals are included.

B. The undersigned signature certifies under penalty of perjury that they are a duly authorized representative and in compliance with all the requirements of this bid document. The signature below authorizes the verification of this certification.

An Unsigned Bid/Bidder Certification Sheet May Be Cause For Rejection.

1. Company Name 2. Telephone Number 2a. Fax Number

2c. E-MAIL

3. Address

Indicate your organization type:

4. Sole Proprietorship 5. Partnership 6. Corporation

Indicate the applicable employee and/or corporation number:

7. Federal Employee ID No. (FEIN) 8. California Corporation No.

9. Bidder’s Name (Print) 10. Title

11. Signature 12. Date

13. Are you certified with the Department of General Services, Office of Small Business and Disabled Veteran Business Enterprise Services (OSDS) as:

a. California Small Business Yes No

If yes, enter certification number:

b. Disabled Veteran Business Enterprise Yes No If yes, enter your service code below:

NOTE: A copy of your Certification should be included if either of the above items is checked “Yes”.

Date application was submitted to OSDS, if an application is pending:

Department of Veterans Affairs TBD

Completion Instructions for Bid/Bidder Certification Sheet

Complete the numbered items on the Bid/Bidder Certification Sheet by following the instructions below.

Item

Numbers Instructions

1, 2, 2a, 3 Must be completed. These items are self-explanatory.

Check if your firm is a sole proprietorship. A sole proprietorship is a form of business in which one person owns all the assets of the business in contrast to a partnership and corporation. The sole proprietor is solely liable for all the debts of the business.

Check if your firm is a partnership. A partnership is a voluntary agreement between two or more competent persons to place their money, effects, labor, and skill, or some or all of them in lawful commerce or business, with the understanding that there shall be a proportional sharing of the profits and losses between them. An association of two or more persons to carry on, as co-owners, a business for profit.

Check if your firm is a corporation. A corporation is an artificial person or legal entity created by or under the authority of the laws of a state or nation, composed, in some rare instances, of a single person and his successors, being the incumbents of a particular office, but ordinarily consisting of an association of numerous individuals.

7 Enter your federal employee tax identification number.

Enter your corporation number assigned by the California Secretary of State’s Office. This information is used for checking if a corporation is in good standing and qualified to conduct business in California.

9, 10, 11, 12

Must be completed. These items are self-explanatory.

If certified as a California Small Business, place a check in the "Yes" box, and enter your certification number on the line. If certified as a Disabled Veterans Business Enterprise, place a check in the "Yes" box and enter your service code on the line. If you are not certified to one or both, place a check in the "No" box. If your certification is pending, enter the date your application was submitted to OSDS.

CERTIFICATION

CERTIFICATION

Department of Veterans Affairs

ATTACHMENT 12

CERTIFICATES OF INSURANCE

DATE (MM/DD/YY) / /

PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS

NO RIGHT UPON THE CERTIFICATE HOLDER. THIS COVERAGE DOES NOT AMEND,

EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW.

COMPANIES AFFORDING COVERAGE

COMPANY

A

INSURED COMPANY

B

COMPANY

C

COMPANY

D

COVERAGES

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDIDTION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH

POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

TYPE OF INSURANCE POLlCY NUMBER

POLICY

EFFECTIVE

DATE

(MM/DD/YY)

POLICY

EXPIRATION

DATE

(MM/DD/YY)

LIMITS

GENERAL LIABILITY GENERAL AGGREGATE $

COMMERCIAL GENERAL LIABILITY PRODUCTS - COMP/OP AGG $

CLAIMS

MADE

OCCUR PERSONAL & ADV INJURY $

PROT EACH OCCURRENCE $

FIRE DAMAGE (Any one fire) $ MED EXP (Any one person) $

AUTOMOBILE LIABILITY

COMBINED SINGLE LIMIT $

ANY AUTO

ALL OWNED AUTOS BODILY INJURY (Per person) $

SCHEDULED AUTOS

HIRED AUTOS BODILY INJURY (Per accident) $

NON-OWNED AUTOS

PROPERTY DAMAGE $

GARAGE LIABILITY

AUTO ONLY - EA ACCIDENT $

ANY AUTO OTHER THAN AUTO ONLY:

EACH ACCIDENT $

AGGREGATE $

EXCESS LIABILITY

EACH OCCURRENCE $

UMBRELLA FORM AGGREGATE $

OTHER THAN UMBRELLA FORM $

WORKERS COMPENSATION AND STATUTORY LIMITS

THE PROPRIETOR/ EACH ACCIDENT $

PARTNERS/ EXECUTIVE

OFFICERS ARE:

INCL DISEASE - POLICY LIMIT $

EXCL DISEASE - EACH EMPLOYEE $

OTHER

DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS

The State of California, its officers, agents, employees and servants are hereby named as additional insured but only with respect to work performed for the State of California.

CERTIFICATE HOLDER

ATTENTION:

BID NO.

STATE OF CALIFORNIA

P.O. Box 4038 Sacramento, CA 95812-4038

CANCELLATION

SHOULD ANY OF THE ABOVE-DESCRIBED POLICIES BE CANCELED BEFORE THE EXPIRATION DATE

THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE

CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE

NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR

RESPRESENTATIVES.

AUTHORIZED REPRESENTATIVE

I hereby certify under penalty of perjury that the foregoing is true and correct.

X