605729 Addendum 1.pdf

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Massachusetts Department Of Transportation Highway Division Project No. 605729

00104 - 1

DOCUMENT 00104

NOTICE TO CONTRACTORS

Electronic proposals for the following project will be received through the internet using Bid Express until the date and time stated below and. will be posted on www.bidx.com forthwith after the bid submission deadline. No paper copies of bids will be accepted. Bidders must have a valid digital ID issued by MassDOT in order to bid on projects. Bidders need to apply for a Digital ID at least 14 days prior to a scheduled bid opening date with Bid Express.

TUESDAY, JUNE 24, 2014 at 2:00 P.M.

QUINCY

Federal Aid Project No. CM-002S(654)X

Roadway Reconstruction and Related Work (Including Signals) along Hancock, East and West Squantum Streets

(605729)

PROJECT VALUE = $3,891,000.00

Bidders must be pre-qualified by the Department in the HIGHWAY-CONSTRUCTION category to bid on the above project. An award will not be made to a Contractor who is not pre-qualified by the Department prior to the opening of Proposals.

Contractors intending to bid on this project must first complete a "Request for Proposal Form"(R-109 Form) and e-mail an electronic copy of this document to the MassDOT Director of Prequalification for approval. Please e-mail these documents to prequal.r109@state.ma.us .

Blank "Request for Proposal Forms"(R-109 Forms) can be obtained at http://www.massdot.state.ma.us/highway/Departments/PrequalificationofHorizontalConstructionFi rms.aspx Select the link “Request for Official Proposal Form (R-109 Form)”

Upon approval, the official bidder shall be entitled to receive an officially numbered Compact Disc (CD) containing the plans and specifications, free of charge. Other interested parties may also receive an informational copy of the CD containing the plans and specifications, free of charge. It should be noted that informational copies can not be used for bidding purposes. The bidding for and award of the contract for this project is to be in accordance with the requirements of Massachusetts General Laws Chapter 30 § 39M.

All parties who wish to have the CDs shipped to them must provide a completed mailing label with an approved carrier account number for overnight mail service (i.e. – Federal Express) to the MassDOT Office of the Cashier, Room 6261, 10 Park Plaza, Boston, MA 02116.

A Proposal Guaranty in the amount of 5% of the value of the bid is required either using BidX’s online form or by separately submitting an electronic copy of the Proposal Guaranty via e-mail to MassDOTBidBonds@dot.state.ma.us .

Project No. 605729

00104 - 2

Addendum No.1: May 27, 2014

NOTICE TO CONTRACTORS (Continued)

Bidders are on notice that this project is subject to the schedule of prevailing wage rates as determined by the Commissioner of the Massachusetts Department of Labor and Workforce Development, Division of Occupational, and the United States Department of Labor.

Plans will be on display and information will be available at the MassDOT Boston Office and at the District Office in BOSTON.

The Department, in compliance with Title 49 Code of Federal Regulations Part 21

(NONDISCRIMINATION IN FEDERALLY-ASSISTED PROGRAMS OF THE

DEPARTMENT OF TRANSPORTATION - EFFECTUATION OF TITLE VI OF THE CIVIL

RIGHTS ACT OF 1964), hereby notifies all bidders that it will affirmatively insure that in any contract entered into pursuant to this advertisement that minority business enterprises will be afforded full opportunity to submit bids in response to this invitation and will not be discriminated against on grounds of race, color, or national origin in consideration for an award.

This Proposal contains the "STANDARD FEDERAL EQUAL EMPLOYMENT OPPORTUNITY CONTRACT SPECIFICATIONS (EXECUTIVE ORDER 11246)". The goals and timetables applicable to this proposal for minority and female participation, expressed in percentage terms for the Contractor's aggregate work force in each trade on all work, are contained in Appendices A and B of the above Specifications.

This Contract contains price adjustments for hot mix asphalt and Portland cement mixtures, diesel fuel, and gasoline. For this project the base prices are as follows: asphalt cement $615.00 per ton, Portland cement $112.15 per ton, diesel fuel $3.456 per gallon, and gasoline $3.289 per gallon. MassDOT posts the Price Adjustments on their Highway Division’s website at http://www.massdot.state.ma.us/Highway/ under the following link sequences:

Doing Business With Us Construction Price Adjustments

STEEL PRICE ADJUSTMENT

This Contract contains Price Adjustments for steel. See Document 00813 - PRICE ADJUSTMENT FOR STRUCTURAL STEEL AND REINFORCING STEEL of the Special Provisions for their application.

The Base Prices for these items on this project are as follows:

Castings ASTM A27 (AASHTO M103) Steel Castings = $0.37 per pound

Project File No. 605729

A00801 - 1

SPECIAL PROVISIONS

QUINCY

Federal Aid No. CM-002S(654)X

Roadway Reconstruction and Related Work (Including Signals) along Hancock, East and West Squantum Streets

Labor participation goals for this project shall be 15.3% for minorities and 6.9% for women for each job category. The goals are applicable to both contractor’s and subcontractor’s on-site construction workforce. Refer to document 00820 for details.

SCOPE OF WORK

The work under this Contract consists of intersection and signal improvements to the Hancock Street and East/West Squantum Street intersection in Quincy. The work includes pavement milling and resurfacing of existing pavement, full depth construction at roadway widenings at the northwest and southeast corners of the intersection, cement concrete sidewalks, granite curb, full upgrade of the traffic signal systems at the intersections at Hancock Street/MBTA Driveway/Hunt Street, Hancock Street and East/West Squantum Street, and Hancock Street/Glover Street, installation of a pedestrian signal at the mid block crosswalk between McDonalds and North Quincy High School (just north of East/West Squantum Streets), video monitoring system at each of the four intersections, fiber optic installation, integration of the existing closed loop traffic signal software and the City Police Station video monitoring system, signal interconnection between all of the traffic signals shown in the plan, proposed landscape/streetscape along Hancock Street, lighting, minor drainage modifications, minor guardrail modifications, pavement markings, signing, the provision of safety controls and signing for construction operations and other incidental items included in the contract documents.

All work under this contract shall be done in conformance with the Massachusetts Highway Department Standard Specifications for Highways and Bridges dated 1988, the Supplemental Specifications dated June 15, 2012, and the Interim Supplemental Specifications contained in this book; the 2012 Construction Standard Details, the 1990 Standard Drawings for Signs and Supports; the 2009 Manual on Uniform Traffic Control Devices (MUTCD) with Massachusetts Amendments and the Standard Municipal Traffic Code; the 1968 Standard Drawings for Traffic Signals and Highway Lighting; the latest edition of American Standard for Nursery Stock; the Plans and these Special Provisions.

A00801 - 2

CONTRACTOR QUESTIONS AND ADDENDUM ACKNOWLEDGEMENTS

Prospective bidders are required to submit all questions to the Construction Contracts Engineer by 1:00 P.M. on the Thursday before the scheduled bid opening date. Any questions received after this time will not be considered for review by the Department.

Contractors should email questions and addendum acknowledgements to the following email address massdot-specifications@dot.state.ma.us. Please put the MassDOT project file number and municipality in the subject line.

MASSHIGHWAY TO MASSDOT NAME CHANGE

The following definitions in Section 100 of the Standard Specifications for Highways and Bridges are revised as follows:

(Amend definition of Department)

1.17 –Department .....Effective November 1, 2009, St. 2009, c. 25 abolishes the Massachusetts

Department of Highways and all assets, liabilities, and obligations become those of the Massachusetts Department of Transportation (“MassDOT). Anywhere in this contract the terms Commission, Commonwealth, Department of Public Works, Department, Massachusetts Highway Department, MassHighway, Party of the First Part, or any other term intending to mean the former Massachusetts Department of Highways is used, it shall be interpreted to mean MassDOT or applicable employee of MassDOT unless the context clearly requires otherwise. Furthermore, MassDOT by operation of law inherited all rights and obligations pursuant to any contract, and therefore parties to this contract hereby acknowledge and agree that its terms shall be liberally construed and interpreted to maintain the rights and obligations of MassDOT. Furthermore, the parties hereby acknowledge and agree that the transfer of all rights and obligations from the Massachusetts Department of Highways to MassDOT shall not have the effect of altering or eliminating any provision of this contract in a manner that inures to the detriment of MassDOT.

(Add a definition for MassDOT)

1.46 – MassDOT........The Massachusetts Department of Transportation, a body politic and corporate, under St. 2009, c. 25 “An Act Modernizing the Transportation Systems of the Commonwealth”, as amended.

A00801 - 19

SUBSECTION 8.14 (Continued)

In order to demonstrate that a critical path delay has been caused by a third-party Utility, the Contractor must demonstrate, through the requirements of the monthly Progress Schedule submissions and the supporting contract records associated with Subsection 8.02, 8.10 and 8.14, that the delays were beyond the control of the Contractor.

All documentation provided in this section is subject to the review and verification of the Engineer and, if required, the Utility Owner. In accordance with MassDOT Specifications, Division I, Subsection 8.10, a Time Extension will be granted for a delay caused by a Utility, only if the actual duration of the utility work is in excess of that shown on the Project Utility Coordination Form, and only if;

1) proper Notification of Delay was provided to MassDOT in accordance with the time requirements that are specified in this Section

2) the utility delay is a critical path impact to the Baseline Schedule (or most recently approved Progress Schedule)

E. - LOCATION OF UTILITIES

The locations of existing utilities are shown on the Contract drawings as an approximation only.

The Contractor shall perform a pre-construction utility survey, including any required test pits, to determine the location of all known utilities no later than thirty (30) calendar days before commencing physical site work in the affected area.

F. - POST UTILITY SURVEY – NOTIFICATION

Following completion of a utility survey of existing locations, the Contractor will be responsible to notify the Engineer of any known conflicts associated with the actual location of utilities prior to the start of the work. The Engineer and the Contractor will coordinate with any utility whose assets are to be affected by the Work of this Contract. A partial list of utility contact information is provided in the Project Utility Coordination Form.

G. - MEETINGS AND COOPERATION WITH UTILITY OWNERS

The Contractor shall notify the Engineer in advance of any meeting they initiate with a Utility Owner’s representative to allow MassDOT to participate in the meeting if needed.

Prior to the Pre-Construction Meeting, the Contractor should meet with all Utility Owners who will be required to perform utility relocations within the first 6 months of the project, to update the affected utilities of the Project Utility Coordination Form and all other applicable Contract requirements that impact the Utilities. The Contractor shall copy the Engineer on any correspondence between the Utility Owner and the Contractor.

H. - FORCE ACCOUNT / UTILITY MONITORING REQUIREMENTS

The Engineer will be responsible for recording daily Utility work force reports. The start, suspension, re-start, and completion dates of each of the Utilities, within each phase of the utility relocation work, will be monitored and agreed to by the Engineer and the Contractor as the work progresses.

A00801 - 20

SUBSECTION 8.14 (Continued)

I. - ACCESS AND INSPECTION

The Contractor shall be responsible for allowing Utility owners access to their own utilities to perform the relocations and/or inspections. The Contractor shall schedule their work accordingly so as not to delay or prevent each utility from maintaining their relocation schedule.

CONTRACT AWARD AND NOTICE TO PROCEED PROCEDURES

(Amending and Supplementing Subsections 3.03 and 3.05)

The prepared Contract package which will be e-mailed the day following the bid opening is to be completed in duplicate by the successful Bidder who shall execute and deliver the Contract package and furnish the required surety to the Department on the third day after the date of bid opening by 2:00 pm. For this project the date of contract will be the Wednesday of the week following the date of bid opening (i.e. generally eight days after the bid opening) and this date of contract will be typed on all forms by MassDOT.

The company’s corporate seal should be affixed to both the contract and bonds.

The Contract Package consists of the following documents all of which must be returned:

Contract Page (Two Originals) Performance Bond (Two Originals) (Power Of Attorney should be in the return package) Payment Bond (Two Originals) (Power Of Attorney should be in the return package) Statement Of State Tax Compliance (Two Originals) Certificate Of Compliance With Massachusetts Employment Security Law (Two Originals) Board Of Directors Vote (Two Originals) Certification Of Contractor (Two Originals) Certificates Of Insurance (Two Originals) Insurer's Affidavit For Worker's Compensation (Two Originals) Out Of State Certificate (If incorporated outside of Massachusetts) (Two Originals) Certification Of Construction Equipment Standard Compliance Requirements (Two Originals) Diesel Retrofit Data (Two Originals) Executive Order 481 – Contractor Certification (Two Originals)

These documents are attached.

The board of director’s vote will indicate who is authorized to sign and execute the contract and bonds and affix the corporate seal. The vote shall show that said vote is in full force and effect and has not been amended or rescinded. The vote of the board of directors should be dated the same date as indicated on the contract form and should bear the imprint of the company’s corporate seal.

THE COMMONWEALTH OF MASSACHUSETTS

Massachusetts Highway Department

Office of Construction Contract Ten Park Plaza, Boston, MA 02116

(617) 973-7620

CONTRACTOR'S CHECK LIST

BEFORE YOU RETURN YOUR PAPERWORK, PLEASE CHECK THE FOLLOWING:

CONTRACT PAGE (Two Originals) � Page 1: Fill in the date of the Contract Date of contract coincide with the date on the Bond.

� Page 2: Sign Contract page with Title (original signature).

� If your company is a corporation, affix your Corporate Seal where indicated on page.

PERFORMANCE BOND (Two Originals) � Have the Insurance Company complete the first paragraph.

� Fill in the date of the contract in the second paragraph.

� Sign the bottom portion and affix your corporate seal (If applicable) where indicated on page.

� Have Surety Company sign and affix the Surety Seal - where indicated on page.

PAYMENT BOND (Two Originals) � Have Insurance Company complete the first paragraph.

� Fill in the date of the contract in the second paragraph.

� Fill in the date of the fourth paragraph.

� Contractor to sign bottom portion and affix the Corporate Seal (if applicable).

� Licensed Massachusetts Resident Agent to sign and affix the Surety Seal (If the bond is not signed by a

Licensed Agent, the bonds must be co-signed on the bottom left.)

STATEMENT OF STATE TAX COMPLIANCE (Two Originals) � Complete and sign with the date of the contract.

CERTIFICATE OF COMPLIANCE WITH MASSACHUSETTS EMPLOYMENT SECURITY

LAW (Two Originals) � Complete and sign with the date of the contract. Have notarized.

POWER OF ATTORNEY

� Two Copies to be provided by the Insurance Company. Same must appear on Power of Attorney as on the Performance and Payment Bonds.

Project No. 605729 Addendum No.1 :May 27, 2014

BOARD OF DIRECTORS VOTE (SAMPLE)

� Follow the sample sent to you with original paperwork. Also affix the Corporate Seal. Make sure the

Board of Directors Vote, authorizing whomever with signatory powers, coincides with the signature on the Contract Pages, Bonds and Statement of Tax Compliance. Return Two (2) Original Board Votes.

CERTIFICATION OF CONTRACTOR (If provided with initial paperwork) (Two Originals)

(ONLY ON FEDERAL AID PROJECTS)

� Complete top portion of this page with original signatures and dates.

CERTIFICATES OF INSURANCE (Two Originals) � If you are using either white or blue set, please have your insurance agent complete the set with original signatures on both copies. RUBBER STAMPS ARE NOT ACCEPTABLE. IMPORTANT: DO NOT CHANGE OR ALTER THE FORMS IN ANY WAY. If your coverage is different from what is requested on the white forms, please have your agent complete the blue forms with original signatures.

Return all forms with your paperwork.

INSURER'S AFFIDAVIT FOR WORKER'S COMPENSATION (Two Originals) � Have both affidavits completed with original signatures and notarized.

OUT OF STATE CERTIFICATE

� If your corporation is not located in Massachusetts, an Out of State Certificate certifying that you are eligible to do business in the Commonwealth of Massachusetts must be submitted with your paperwork.

This certificate is obtained at the Secretary of State's office, One Ashburton Place, 17th Floor, Boston, MA 02108, (617) 727-9640.

CERTIFICATION OF CONSTRUCTION EQUIPMENT STANDARD COMPLIANCE

REQUIREMENTS (two Originals) � Complete and sign (authorized signatory required) the attached Form verifying compliance with

MassHighway’s specification 3.041

DIESEL RETROFIT DATA (two Originals) � List and certify all large non-road diesel construction equipments (greater than 50 horsepower) used on this contract

EXECUTIVE ORDER 481 – CONTRACTOR CERTIFICATION (two Originals) � Complete and sign (authorized signatory required) the attached Form

NOTE:

Please make sure that all signatures are originals, that all seals are affixed and that your paperwork is returned within fourteen (14) calendar days. Failure to do so will result in a delay of Execution of your contract. "Section 3.05 of the Standard Specifications of Highways and Bridges states: the prepared Contract forms, bond forms and certificate of insurance forms will be sent with notification of award to the successful bidder who shall execute and deliver the Contract and furnish the required surety to the Department within fourteen calendar days after the date of the notice of award.

THE COMMONWEALTH OF MASSACHUSETTS

MASSACHUSETTS HIGHWAY DEPARTMENT

CONTRACT

Clause 1. This agreement made this day of in the year of two thousand nine, between the Commonwealth of Massachusetts, by the Massachusetts Highway Department, for the said Commonwealth, and

, a Corporation duly organized under the laws of the and having a usual place of business in , herein called the Contractor.

Clause 2. Witnesseth, That the parties to this agreement, each in consideration of the agreements on the part of the other herein contained, do hereby agree, the Commonwealth of Massachusetts for itself, and said Contractor for itself and its successors and assigns as follows:

The contractor agrees to furnish all equipment, machinery, tools and labor and furnish and deliver all materials required to be furnished and delivered in and about the improvement and to do and perform all work in in strict conformity with the provisions herein contained and of the Notice to Contractors, Proposal and Special Provisions hereto attached, and the applicable Standard Specifications for Highways and Bridges with the plans referred to herein. All said plans, Standard Specifications, Supplemental Specifications, Special Provisions, Notice to Contractors and Proposal are hereby made a part of this contract.

Clause 3. In consideration of the foregoing premises the Commonwealth agrees to pay and the Contractor agrees to receive as full compensation for everything furnished and done by the Contractor under this contract, including all work required but not shown on the plans for the items herein mentioned, and also for all loss or damage arising out of the nature of the work aforesaid, or from the action of the elements, or from any delay or from any unforeseen obstruction or difficulty encountered in the prosecution of the work, and for all risks of every description connected with the work, and for all expenses incurred by or in consequence of the suspension or discontinuance of the work as herein specified, and for well and faithfully completing the work, and the whole thereof, as herein provided, such unit prices are set out in the accompanying proposal, and for all work required, for which there is no item in the proposal, such compensation as is provided for in the aforesaid specifications.

In witness whereof, the said Contractor has caused these presents to be signed in its name and behalf and its corporate seal to be hereto affixed by

Its and its thereto duly authorized, and the said Commonwealth has executed these presents by its Highway Department on the year and day above written.

Commissioner, Massachusetts Highway Department

BY Contractor Corporate Seal

PERFORMANCE BOND

Know all men by these presents, that , a Corporation dully organized under the laws of and having a usual place of business in as principal, and as surety, are held and firmly bound upon the Commonwealth of Massachusetts in the sum of lawful money of the United States of America, to be paid to the Commonwealth of Massachusetts, for which payments, well and truly to be made, we bind ourselves, our respective heirs, executors, administrators, successors and assigns, jointly and severally, firmly be these presents.

Whereas, the said principal has made contract with the Commonwealth, acting through the Highway Department, bearing date of 2009, for the construction of Contract Number for

Now the condition of this obligation is such that if the principal shall well and truly keep and perform all the undertakings, covenants, agreements, terms and conditions of said contract on its part to be kept and performed during the original term of said contract and any extensions thereof that may be granted by the Commonwealth, with or without notice to the surety, and during the life of any guaranty required under the contract, and shall also well and truly keep and perform all the undertakings, covenants, agreements, terms and conditions of any and all duly authorized modifications, alterations, changes or additions to said contract that may hereafter be made, notice to the surety of such modifications, alterations, changes or additions being hereby waived, then this obligation shall become null and void; otherwise it shall remain in full force and virtue.

In the event that the contract is abandoned by the Contractor, or is terminated by the Commonwealth, under the provisions of Sec. 8.12 of the Standard Specifications for Highways and Bridges, said surety hereby further agrees that, if required in writing by the Commonwealth, said surety shall take such action as is necessary to complete said contract.

In witness whereof we hereunto set our hands and seals this day of , 2009

Principal

Corporate Seal

Surety Corporate Seal

PAYMENT BOND

Know all men by these presents, that , a Corporation organized under the laws of the and having a usual place of business in , , as principal, and as surety, are held and firmly bound unto the Commonwealth of Massachusetts in the sum of lawful money of the United States of America, to be paid to the Commonwealth of Massachusetts, for which payments, well and truly to be made, we bind ourselves, our respective heirs, executor administrators, successors and assigns, jointly and severally, firmly by these presents.

Whereas, the said principal has made a contract with the Commonwealth, acting through the Highway Department bearing date of 2009, for the construction of Contract Number for

Now the condition of this obligation is such that if the principal shall pay for all labor performed or furnished and for all materials used or employed in said contract and in any and all duly authorized modifications, alterations, extensions of time, changes or additions to said contract that may hereafter be made, notice to the surety of such modifications, alterations, extensions of time, changes or additions being hereby waived, the foregoing to include any other purposes or items set out in, and to be subject to, the provisions of Massachusetts General Laws, (Ter. Ed.), Chapter 30, Section 39A as amended and Chapter 149, Section 29 as amended, then this obligation shall become null and void; otherwise it shall remain in full force and virtue.

In witness whereof we hereunto set our hands and seals this day of , A.D. 2009

. Principal

BY Corporate Seal

Surety Corporate Seal

1. Name and Address of Agent or Agency receiving commission on this Performance and Payment Bond.

2. Name and Address of Resident Agent, if any, of Surety, or other Agent appointed by Surety to Whom Notice should be sent (Must be completed by Attorney-in-Fact of Surety.

Surety Corporate Seal

STATEMENT OF STATE TAX COMPLIANCE

PROJECT - - CONTRACT #

Pursuant to Section 36 of Chapter 233 of the Acts of 1983, Amending Section of 49A (b), of Chapter 62C, General Laws, I, authorized signatory for whose principal place of business is at do hereby certify under the pains and penalties of perjury that has complied with all laws of the Commonwealth relating to taxes.

Authorized Signature

Date

CERTIFICATE OF COMPLIANCE WITH

MASSACHUSETTS EMPLOYMENT SECURITY LAW

Pursuant to G. L. c. 151A, s. 19A (b), I

(Name & Title) signing on behalf of

(Name of Employer) hereby certify that the aforementioned employer has complied with all employment security laws of the Commonwealth relating to contributions and payments in lieu of contributions.

Signed under the penalties of perjury this day of , (Signature)

Notary Public

My Commission Expires on

State Contract No.

Federal Aid Project State MASSACHUSETTS

CERTIFICATION OF CONTRACTOR

I hereby certify that I am the and duly authorized representative of the firm of whose address is and that neither I nor the above firm I here represent has:

(a) employed or retained for a commission, percentage, brokerage contingent fee, or other consideration, any firm or person (other than a bona fide employee working solely for me or the above contractor) to solicit or secure this contract,

(b) agreed, as an express or implied condition for obtaining this contract to employ or retain the services of any firm or person in connection with carrying out the contract; except as here expressly stated (if any):

I acknowledge that this certificate is to be furnished to the State Highway Department and the Federal Highway Administration U.S. Department of Transportation in connection with this contract involving participation of Federal Aid Highway Funds, and is subject to applicable, State and Federal Laws, both criminal and civil.

Date Signature

CERTIFICATION OF STATE HIGHWAY DEPARTMENT

I hereby certify that I am the Chief Engineer of the Highway Department of the Commonwealth of Massachusetts and the above contracting firm or his representative has not been required, directly or indirectly as an express or implied condition in connection with obtaining and carrying out this contract to

(a) employ or retain, or agree to employ or retain, any firm or person or

(b) pay, or agree to pay, to any firm or person, or organization, any fee, contribution, donation or consideration of any kind;

except as here expressly state (if any):

I acknowledge that this certificate is to be furnished to the Federal Highway Administration U.S. Department of Transportation in connection with this contract involving participation of Federal Aid Highway Funds, and is subject to applicable State and Federal Laws, both criminal and civil.

Date Signature

CERTIFICATE OF INSURANCE

TO: THE COMM.OF MASS., MASS. HIGHWAY DEPT., 10 PARK PLAZA, RM 6260, BOSTON, MA 02116

NOTE: THIS CERTIFICATE MUST BE FILLED OUT BY AN AUTHORIZED REPRESENTATIVE OF THE

INSURANCE COMPANY ONLY.

This is to certify that (INSURED)

(ADDRESS)

is at the date of this certificate, insured by the Insurance Company (ies) listed below with respect to the types of Insurance required under Contract No.

dated between the Commonwealth of Massachusetts by its Highway Department and the above named insured for work in (LOCATION)

NAME & ADDRESS OF

INSURANCE CO.

POLICY NO. TYPE OF POLICY LIMITS OF LIABILITY INCLUSIVE DATES

MASS. WORKERS

COMPENSATION X

PUBLIC LIABILITY PER

PERSON/PER ACCIDENT X

1,000,000 – 2,000,000

PROPERTY DAMAGE

LIABILITY PER ACCIDENT

PER POLICY PERIOD X

1,000,000 – 2,000,000

PROTECTIVE PUBLIC

LIABILITY PER PERSON/PER

ACCIDENT X

1,000,000 – 2,000,000

PROTECTIVE PROPERTY

DAMAGE LIABILITY PER

ACCIDENT PER POLICY

PERIOD X

1,000,000 – 2,000,000

R. R. PROTECTIVE PULBIC

LIABILITY

R. R. PROTECTIVE

PROPERTY DAMAGE

LIABILITY

ASBESTOS LIABILITY

Before the above stated expiration date the Company will not cancel or reduce the insurance afforded under the above numbered policies prior to Ten (10) days after notice of such cancellation has been mailed to the Massachusetts Highway Department, 10 Park Plaza, Boston, MA 02116.

Attention is directed to Amendment Sec. 7.05 of the Standard Specifications for Highways, Bridges wherein it stipulates that the Insurance shall cover all damages to property whether above or below ground.

List Name, Address and Title of person or persons in Massachusetts authorized to accept service or notice on behalf of above insurance company(ies).

DATED AT X

AUTHORIZED REPRESENTATIVE OF INSURANCE COMPANY

SAMPLE

At a meeting of the Board of Directors of the (name of corporation) held on (date) , at which all the Directors were present or waived notice, it was or

At a regularly called meeting of the Board of Directors of the (name of corporation) held on (date) , at which a quorum was present, it was

VOTED, that (name) , (officer) of this company, and he is hereby authorized to execute contracts and bonds in the name and behalf of said company, and affix its corporate seal thereto; and such execution of any contract or obligation in this company's name on its behalf by such (officer) under seal of this company shall be valid and binding upon this company.

A True Copy Attest:

Clerk:

(signature)

(print name)

(Place of business)

(Date of this contract)

I, (name) hereby certify that I am the clerk of the (name of corporation) and that (name) is the duly elected (officer) of said company, and that the above vote has not been amended or rescinded and remains in full force and as of this date.

Clerk (Corporate Seal)

SAMPLE

INSURER'S AFFIDAVIT AS TO WORKER'S COMPENSATION INSURANCE

I, (NAME, TITLE AND ADDRESS)

authorized representative of

(INSURANCE COMPANY)

do hereby affirm that effective

(DATE)

(CONTRACTOR)

is insured by said Insurance Company with Policy Number for WORKER'S COMPENSATION in accordance with Massachusetts General Laws Chapter 152, and Subsection 7.05A of the Standard Specifications for Highways and Bridges of the Massachusetts Highway Department. Any discrepancies between the Massachusetts General Laws, Chapter 152 and Subsection 7.05A of the Standard Specifications for Highways, Bridges of the Massachusetts Highway Department shall be resolved in favor of M.G.L.A.

c 152.

(SIGNED)

Subscribed and Sworn to before me this day of , at

Notary Public

My Commission expires

State Contract No.

CERTIFICATION OF CONSTRUCTION EQUIPMENT STANDARD COMPLIANCE

I, __________________________________ authorized signatory for

______________________________________ whose principal place of business is at do hereby certify that any and all large non-road (greater than 50 horsepower) diesel construction equipment (DCE) to be used in this contract has emission control devices installed, such as oxidation catalysts or particulate filters, on the exhaust system side of the diesel combustion engine equipment.

I also hereby agree on behalf of ________________________ to provide a list of said DCE to the Massachusetts Highway Department prior to its actual use in connection with this contract, including but not limited to the number of vehicles subject to this certification and the number of vehicles retrofitted by vehicle type.

I acknowledge that this certificate is being furnished as a requirement under this contract, and is subject to applicable, State and Federal Laws, both criminal and civil.

Date Signature

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E m is si on C on tro l D ev ic e.

INSTRUCTIONS:

Executive Order 481 applies to all state agencies in the Executive Branch, including all executive offices, boards, commissions, agencies, departments, divisions, councils, bureaus, and offices, now existing and hereafter established. As it is the policy of the Executive Branch to prohibit the use of undocumented workers in connection with the performance of state contracts, all contracts entered into after February 23, 2007 require that contractors, as a condition of receiving Commonwealth funds under any Executive Branch contract, make the following certification:

CONTRACTOR CERTIFICATION:

As evidenced by the signature of the Contractor’s Authorized Signatory below, the Contractor certifies under the pains and penalties of perjury that the Contractor shall not knowingly use undocumented workers in connection with the performance of all Executive Branch contracts;

that pursuant to federal requirements, the Contractor shall verify the immigration status of all workers assigned to such contracts without engaging in unlawful discrimination; and that the Contractor shall not knowingly or recklessly alter, falsify, or accept altered or falsified documents from any such worker(s). The Contractor understands and agrees that breach of any of these terms during the period of each contract may be regarded as a material breach, subjecting the Contractor to sanctions, including but not limited to monetary penalties, withholding of payments, contract suspension or termination.

_____________________________________________ Date:

Contractor Authorizing Signature

Print Name

Title: Telephone:

Fax: Email:

The Contractor is required to sign this Certification only once and may provide a copy of the signed Certification for any contract executed with an Executive Branch Department. A copy of this signed Certification must be attached to the “record copy” of all contracts with this Contractor that are filed with the contracting Department.

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