846499roadHampt.pdf

ITB 27-15TM

BID PROPOSAL AND PROJECT MANUAL

Little Back River Road Reconstruction VDOT Project No.: U000-114-315 / UPC 109304

Federal Aid Project Numbers: STP-5A03(997) FHWA 534 No.: 45028

Bids Due: Tuesday, November 3, 2026 at 10:00 am ET to:

Consolidated Procurement Office (1 Franklin Street, Suite 345, Hampton, VA 23669) or Electronically via DemandStar

CITY OF HAMPTON

Procurement Office

Division of Finance Community, Municipal Services, Education

Hampton, Virginia

Issued: Tuesday, September 29, 2026

Non-Mandatory Pre-Bid Conference: Tuesday, October 13, 2026 at 10:00 am ET Zoom Meeting details in Bid Document

Pre-Bid Questions Due by: Tuesday, October 20, 2026 at 3:30 pm ET

INVITATION FOR BID PREPARED BY:

Name: Gary Sightler Title: Director of Procurement Telephone: 757-727-2206 Email: Gary.Sightler@Hampton.gov

ITB 27-15TM Little Back River Road Reconstruction VDOT Project No: U000-114-315 / UPC 109304 Federal Aid Project No.: STP-5A03(997)

TABLE OF CONTENTS

GENERAL:

NOTICE OF ADVERTISEMENT ............................................................................................. A-1

REQUIRED BID RESPONSE DOCUMENTS:

I. BID FORM ................................................................................................................ B-1

A. BID PROPOSAL & CONTRACTOR TABULATION SHEET…………….B-1

B. ADDENDA ACKNOWLEDGEMENT……………………………………….B-5

C. BIDDER COMPLIANCE……………………………………………..……...B-6

D. BIDDER SIGNATURE………………………………………………...….....B-7

E. BIDDER CONTACT INFORMATION……………………………..…..…...B-8

II. VIRGINIA CONTRACTOR’S LICENSE .................................................................... B-9 III. BID BOND .............................................................................................................. B-10 IV. CERTIFICATION REGARDING DEBARMENT ...................................................... B-11

V. ANTI-COLLUSION / NON-DISCRIMINATION / DRUG-FREE WORKPLACE ........ B-12

VI. VDOT FORMS: ..................................................................................................... B-14

FORM C-48 - SUBCONTRACTOR/SUPPLIER SOLICITATION AND UTILIZATION FORM

FORM C-49 - DBE GOOD FAITH EFFORTS DOCUMENTATION

FORM C-104 – BIDDER STATEMENT FEDERALLY FUNDED PROJECTS

FORM C-105 – BIDDER CERTIFICATION FEDERALLY FUNDED PROJECTS

FORM C-110 – DBE REGULAR DEALER/DISTRIBUTOR AFFIRMATION FORM

FORM C-111 – MINIMUM DBE REQUIREMENTS

FORM C-112 – CERTIFICATION OF BINDING AGREEMENT

OTHER FORMS:

I. PRE-BID QUESTION FORM .................................................................................... C-1 II. CONTRACTOR QUESTIONNAIRE FORM .............................................................. C-2 III. CONTRACT PERFORMANCE AND PAYMENT BOND ......................................... C-8 IV. INSURANCE CERTIFICATES ............................................................................. C-10

SAMPLE AGREEMENT TEMPLATE

PROJECT SPECIFIC PROVISIONS

VDOT ROAD & BRIDGE SPECIFICATIONS: SPECIAL PROVISION COPIED NOTES

(SPCNs), SPECIAL PROVISION (SPs), AND SUPPLEMENTAL SPECIFICATIONS (SSs):

DIVISION I (100 SERIES) – GENERAL PROVISIONS

DIVISION II (200 SERIES) – MATERIALS

DIVISION III (300 SERIES) – ROADWAY CONSTRUCTION

DIVISION IV (400 SERIES) – BRIDGES AND STRUCTURES

DIVISION V (500 SERIES) – INCIDENTAL CONSTRUCTION

DIVISION VI (600 SERIES) – ROADSIDE DEVELOPMENT

DIVISION VII (700 SERIES) – TRAFFIC CONTROL DEVICES

ATTACHMENTS:

PLAN SET

CROSS SECTIONS

QUALITY ASSURANCE PLAN

A-1

VDOT Project No: U000-114-315 / UPC 109304 Federal Aid Project No.: STP-5A03(997)

NOTICE OF ADVERTISEMENT

PROJECT: Little Back River Road Reconstruction

City Project No.: ITB 27-15TM VDOT Project No: U000-114-315 / UPC 109304 Federal Project No.: STP-5A03(997)

LOCATION: City of Hampton, Virginia

ISSUE DATE: Tuesday, September 29, 2026

A Non-Mandatory PRE-BID Conference will be held at 10:00 am ET on Tuesday, October 13, 2026 via Zoom.

Join Zoom Meeting online:

https://us06web.zoom.us/j/87382443352?pwd=3bICHiXla1fcO0QvsTkbwVcmiQqOD1.1

Or by Conference Call: 888-475-4499 Meeting ID: 873 8244 3352 Passcode: 080095

PRE-BID QUESTIONS DUE: Tuesday, October 20, 2026 by 3:30 pm ET. Submit all pre-bid questions to Gary Sightler, Director of Procurement via email (Gary.Sightler@Hampton.gov).

Please utilize the form in this solicitation for all pre-bid questions.

The City of Hampton, Virginia will receive sealed Bids for the above titled project at the Procurement Office, located at 1 Franklin Street, Suite 345, Hampton, VA 23669, or electronically via DemandStar (http://www.demandstar.com) until at 10:00 am ET on Tuesday, November 3, 2026 at which time the Bids will be publicly opened and read aloud.

Faxed or emailed responses shall not be accepted. Any Bids received after the specified time and date will not be considered.

Bid Documents are available electronically via the City’s Procurement and eVA websites. Contact the Procurement Office, City of Hampton at (757) 727-2200 if assistance is needed.

The Project, ITB 27-15TM Little Back River Road Reconstruction, was developed under State / VDOT Project No: U000-114-315 / UPC 109304, and Federal Aid Project Numbers: STP-5A03(997).

The work under this Project generally consists of installing pedestrian facilities on both sides of Little Back River Road: an asphalt Shared-Use Path on the West side between Lamington Road and Oakville Road and a concrete sidewalk on the East side between Riverchase Drive and the existing sidewalk between Rosewood Drive and Westphal Drive.

This project shall be constructed in accordance with: AASHTO (American Association of State Highway and Transportation Officials) A Policy on Geometric Design of Highways and Streets, 7th Edition dated 2018, the Virginia Department of Transportation (VDOT) Road and Bridge (R&B) Specifications, dated 2020; and VDOT R&B Standards, dated 2016; the Virginia Manual on Uniform Traffic Control Devices (MUTCD) and the Virginia Work Area Protection Manual (WAPM), version 11.0 dated 2026; and the Project Specific Provisions and VDOT Supplemental Specifications, Special Provisions and Special Provision Copied Notes in this contract.

https://us06web.zoom.us/j/87382443352?pwd=3bICHiXla1fcO0QvsTkbwVcmiQqOD1.1 http://www.demandstar.com

A-2

VDOT Project No: U000-114-315 / UPC 109304 Federal Aid Project No.: STP-5A03(997)

In accordance with the Code of Virginia § 2.2-4336, a Bid Security in the amount of five percent (5% of the Bid shall be submitted with each Bid.

Contractor registration is required in accordance with the Code of Virginia Title 2.2 Chapter 43 and Title 54.1 Chapter 3.

Bidders shall be prequalified with VDOT, in accordance with Section 102.01 of the VDOT Road and Bridge Specifications and as listed at any prequalified level on VDOT’s List of Prequalified Vendors.

Restrictions for Subcontractor Only, Probationary, Currently Inactive, and Conditional prequalificated levels are waived for this project.

It is VDOT policy that Disadvantaged Business Enterprises (DBE) as defined in 49 CFR Part 26 must have the maximum opportunity to participate in the performance of federally funded contracts. A list of DBE firms certified by the SBSD and MWAA is maintained on SBSD’s website (http://www.SBSD.virginia.gov) under the DBE Directory of Certified Vendors. Contractors are encouraged to take all necessary and reasonable steps to ensure that DBE firms have the maximum opportunity to compete for and perform services on contract, including participation in any subsequent supplement contracts. If the contractor intends to subcontract a portion of the services on the project, the contractor is encouraged to seek out and consider DBEs as potential Sub-contractors. The contractor is encouraged to contact DBEs to solicit their interest, capability and qualifications. Any agreement between a contractor and a DBE whereby the DBE promises not to provide services to other contractors is prohibited. This project is federally funded with a DBE contract goal of zero percent (0%). VDOT Forms C-49, C-110, C-111, and C-112 are not required to be submitted. DBE participation will not count towards bid evaluations for responsiveness.

Withdrawal of Bids due to error shall be subject to and in accordance with Section 2.2-4330 of the Code of Virginia and the Contract Documents. The Owner reserves the right to reject any and all Bids and to waive any minor non-substantive errors in the Bid.

The City of Hampton does not discriminate in the solicitation or awarding of contracts on the basis of race, religion, faith-based organizations, color, national origin, age, disability or any other basis prohibited by state or federal law. FHWA policy prohibits the use of convict labor and material for projects located on this project.

All bids received in accordance with the terms of the advertisement shall be publicly opened and announced by total amount. If any bid received is not read aloud, the name of the bidder and the reason for not reading the bid aloud shall be publicly announced at the letting. Negotiation with contractors, during the period following the opening of bids and before the award of the contract shall not be permitted.

Unless otherwise provided in the Invitation to Bid, the name of a certain brand, make or manufacturer shall not restrict bidders to the specific brand, make or manufacturer named and shall be deemed to convey the general style, type, character, and quality of the article desired. Any article that the public body in its sole discretion determines to be the equal of that specified, considering quality, workmanship, economy of operation, and suitability for the purpose intended, shall be accepted.

By: Gary Sightler Director of Procurement City of Hampton Procurement Department http://www.sbsd.virginia.gov/

B-1

VDOT Project No: U000-114-315 / UPC 109304 Federal Aid Project No.: STP-5A03(997)

REQUIRED BID RESPONSE DOCUMENTS

I. BID FORM

Bids due:

Bids to be opened:

Contract time limit Performance Bond:

Payment Bond:

Bid Security:

Tuesday, November 3, 2026

10:00 am ET 550 Days 100% 100% 5%

To: City of Hampton, Virginia 1 Franklin Street, Suite 345 Hampton, VA 23669

A. BID PROPOSAL

In compliance with the Contract Documents, Back River Road Reconstruction, titled ITB 27-15TM Little VDOT Project No:

U000-114-315 / UPC 109304, Federal Aid Project No.: STP-5A03(997), and all Addenda issued to date all of which are part of this Bid, the undersigned hereby proposes to furnish all items including materials, supervision, labor, and equipment in strict accordance with, said Contract Documents, for the total base sum of:

SEE CONTRACTOR BID TABULATION SHEET(S), STARTING NEXT PAGE

Federal Aid Project No.: STP-5A03(997)

CONTRACTOR BID TABULATION SHEET

Item No. Description Quantity Unit Unit Price Extended Price

B-2

1 MOBILIZATION 1 LS $ $

2 MAINTENANCE OF TRAFFIC 1 LS $ $

3 CONSTRUCTION SURVEYING 1 LS $ $

4 CLEARING AND GRUBBING 1 LS $ $

5 EROSION AND SEDIMENT CONTROL 1 LS $ $

6 SOIL STABILIZATION 1 LS $ $

7 DEMOLITION OF PAVEMENT (RIGID/FLEXIBLE) 1,340 SY $ $

8 REGULAR EXCAVATION 2,250 CY $ $

9 UNDERCUT EXCAVATION (UNSUITABLE

MATERIAL) (AS NEEDED) 225 CY $ $

10 BEDDING MATL. AGGR. NO. 57 (AS NEEDED) 125 CY $ $

11 AGGR. MATERIAL NO. 3 (SUBGRADE

STABILIZATION) (AS NEEDED) 125 CY $ $

12 GEOTEXTILE (SUBGRADE STABILIZATION) (AS

NEEDED) 3,900 SY $ $

13 AGGR. MATERIAL NO. 25 OR 26 (AS NEEDED) 100 CY $ $

14 FLOWABLE BACKFILL (AS NEEDED) 18 CY $ $

15 SELECT MATERIAL (TYPE II) (CBR 20) 4,000 CY $ $

16 HYDR. CEMENT CONC. SIDEWALK (4") 1,454 SY $ $

17 HYDR. CEMENT CONC. SIDEWALK (7") (CURB

RAMPS) 490 SY $ $

18 CG-12 DETECTABLE WARNING SURFACE 104 SY $ $

19 STD. CURB CG-2 750 LF $ $

20 STD. COMB. CURB & GUTTER CG-6 4,700 LF $ $

21 ENTRANCE GUTTER CG-9A 255 SY $ $

22 ENTRANCE GUTTER VE-1 268 SY $ $

23 ENTRANCE GUTTER VE-3A 320 SY $ $

24 ENTRANCE GUTTER VE-5 236 SY $ $

Federal Aid Project No.: STP-5A03(997)

CONTRACTOR BID TABULATION SHEET

B-3

25 FLEXIBLE PAVE.PLANING 0"-2" 7,000 SY $ $

26 ASPHALT CONC. SURFACE COURSE TYPE SM-

9.5A (1"-3") 7,000 SY $ $

27 ASPHALT CONC. BASE COURSE TYPE BM-

25.0A (8") 180 SY $ $

28 AGGR. BASE MATERIAL NO. 21B (8") 180 SY $ $

29 ASPHALT CONC. SURFACE COURSE TYPE SM-

9.5A (2") (PATH) 225 SY $ $

30 AGGR. BASE MATERIAL NO. 21B (6") (PATH) 225 SY $ $

31 A3 MISC. CONCRETE (BUS STOP PAD) 4 CY $ $

32 YARD DRAIN YD 8 EA $ $

33 DROP INLET DI-1 7 EA $ $

34 DROP INLET DI-2A 1 EA $ $

35 DROP INLET DI-5 6 EA $ $

36 DROP INLET DI-9 12 EA $ $

37 MANHOLE MH-1 OR 2 8 EA $ $

38 MANHOLE FRAME AND COVER MH-1 OR MH-1A 11 EA $ $

39 TRENCH DRAIN 7 EA $ $

40 12" CONC. PIPE 10 LF $ $

41 15" CONC. PIPE 902 LF $ $

42 18" CONC. PIPE 358 LF $ $

43 24" CONC. PIPE 1,545 LF $ $

44 12" END SECTION ES-1 OR 2 1 EA $ $

45 15" END SECTION ES-1 OR 2 3 EA $ $

46 REMOVE EXIST. STRUCTURE 14 EA $ $

47 MODIFY EXIST. STRUCTURE 9 EA $ $

48 ADJUST EXIST. FRAME AND COVER 8 EA $ $

Federal Aid Project No.: STP-5A03(997)

CONTRACTOR BID TABULATION SHEET

B-4

49 ADJUST EXIST. SEWER CLEANOUT 2 EA $ $

50 ADJUST EXIST. METER/VALVE BOX 14 EA $ $

51 RELOCATE EXIST. MAILBOX 5 EA $ $

52 RELOCATE EXIST. SIGN PANEL 26 EA $ $

53 3/4" WATER SERVICE LATERAL, COPPER 162 LF $ $

54 1" WATER SERVICE LATERAL, COPPER 13 LF $ $

55 SIGN PANEL 141 SF $ $

56 SIGN POST STP-1, 2 3/16", 10 GAUGE 23 EA $ $

57 SIGN POST STP-1, 2 1/2", 10 GAUGE 23 EA $ $

58 CONCRETE FOUNDATION STP-1 TYPE B 23 EA $ $

59 TYPE B CLASS 1 PAVEMENT LINE MARKING 4" 6,700 LF $ $

60 TYPE B CLASS 1 PAVEMENT LINE MARKING 24" 1,000 LF $ $

61 RECTANGULAR RAPID FLASHING BEACON

ASSEMBLY 6 EA $ $

62 PROJECT IDENTIFICATION SIGN 2 EA $ $

TOTAL CONSTRUCTION BASE BID $

Bidder acknowledges that estimated quantities are not guaranteed, and are solely for the purpose of comparison of Bids, and final payment for all Unit Price Bid items will be based on actual quantities provided, determined as provided in the Contract Documents.

The prices quoted shall include without exception all materials, supervision, labor, equipment, appliances, clean-up, incidental items, applicable sales, use and other taxes, insurance, building permit or fees, and the Contractor's labor, overhead, profit, mobilization and other mark-ups, and in full accordance with the Contract Documents. Include allowance for waste where appropriate. The unit prices shall be maintained throughout the Contract Time.

Discrepancies between multiplication of units of work and unit prices will be resolved in favor of unit prices. Discrepancies between the indicated sum of any column of figures and the correct sum thereof will be resolved in the favor of the correct sum. Discrepancies between words and figures will be resolved in favor of words.

B-5

VDOT Project No: U000-114-315 / UPC 109304 Federal Aid Project No.: STP-5A03(997)

B. ADDENDA ACKNOWLEDGEMENT

The undersigned acknowledges receipt of the following addenda (if applicable):

Addendum No. __ Dated: __________

Addendum No. __ Dated: __________

Addendum No. __ Dated: __________

Addendum No. __ Dated: __________

Addendum No. __ Dated: __________

Federal Aid Project No.: STP-5A03(997)

B-6

C. BIDDER COMPLIANCE

1. Bidder agrees that the City of Hampton, Virginia shall have the right to waive any informalities or minor non-substantive errors in the Bid. Award shall be based on the lowest responsive and responsible Bid for Base Bid.

2. Bidder agrees that all prices stated herein shall be Firm for a period of 120 Calendar Days.

3. Bidder has carefully examined the Plans, Specifications, and all other documents pertaining thereto and thoroughly understand the contents thereof.

4. Bidder has examined the location of the proposed Work and source of supply of materials.

5. Bidder is prequalified with VDOT, in accordance with Section 102.01 of the VDOT Road and

Bridge Specifications and as listed at any prequalified level on VDOT’s List of Prequalified Vendors under VDOT Vendor ID:___________________________.

6. Bidder agrees to bind himself upon award of the City of Hampton, Virginia under this proposal to a contract with necessary surety bond to start work within ten (10) calendar days of Notice to Proceed or as excepted by other contract language permitted by the Specifications, and to complete all Work in accordance with the Plans and Specifications within the Contract Time Limit.

7. Upon acceptance of Bidder’s response, the Bidder will be asked to execute a formal Contract and required to furnish a payment bond and a performance bond (per Code of Virginia § 2.2-4337) and a certificate of insurance (per Code of Virginia § 2.2-4332). Bidder will execute and furnish the same within ten (10) calendar days of such notice. Failure to do so will mean forfeiture of any Surety Bidder may have been required to post as part of Bidder’s response.

8. Bidder’s Business, whether organized as a stock or non-stock Corporation, limited liability company, Business trust, limited partnership, or registered as a registered limited liability partnership, is authorized to transact business in the Commonwealth of Virginia as a domestic or foreign Business entity if so required by Title 13.1 or Title 50 of the Code of Virginia, as amended, or as otherwise required by law. Bidder shall include in his proposal the identification number issued to it by the State Corporation Commission or a statement describing why the Bidder is not required to be so authorized.

9. Bidder meets all licensing and permit requirements to conduct business in the City of Hampton, Virginia.

10. CONTRACTOR'S REGISTRATION:

Registered Virginia Contractor Class and No. ______________________________ (issued to Contractor by DPOR)

State Corporation Commission Registration No. _____________________________ (issued to Contractor by the SCC)

***In Accordance with 23 CFR 635.110 of the Code of Federal Regulations, Bidder shall provide a copy of Contractors License upon Notice of Intent (NOI) of Award of contract.***

(NOTE: FAILURE TO PROVIDE CONTRACTOR’S REGISTRATION NUMBER AT NOI TO AWARD IS

GROUNDS FOR REJECTION OF THE BID)

Federal Aid Project No.: STP-5A03(997)

B-7

D. BIDDER SIGNATURE

Name of Contractor:

Authorized Signature:

Printed Name:

Title:

Date:

(NOTE: If Bidder is a corporation, write state of incorporation next to Name of Contractor.)

Vendor / Federal ID Number (FIN):

DUNS Number:

Is Bidder SWaM certified? Yes No Is Bidder DBE certified? Yes No

Is Bidder a Minority-Owned Business? Yes No

If yes, please indicate the “minority” classification below:

African American Hispanic American Native American Asian American Other: _________________

Please Explain:

Is Bidder Woman Owned? Yes No Is Bidder a Small Business? Yes No Is Bidder a Faith-Based Organization? Yes No

Federal Aid Project No.: STP-5A03(997)

B-8

E. BIDDER CONTACT INFORMATION

MAILING ADDRESS, TELEPHONE NUMBER, FAX NUMBER & EMAIL ADDRESS OF BIDDER:

IF CORPORATION, PROVIDE NAME AND MAILING ADDRESS AS REQUIRED BELOW:

PRESIDENT SECRETARY TREASURER

IF PARTNERSHIP, PROPRIETORSHIP, LIMITED LIABILITY COMPANY OR OTHER FIRM,

PROVIDE NAME AND MAILING ADDRESS OF EACH PARTNER, PROPRIETOR, OR MEMBER

OF FIRM.

B-9

VDOT Project No: U000-114-315 / UPC 109304 Federal Aid Project No.: STP-5A03(997)

II. VIRGINIA CONTRACTOR’S LICENSE

This Federally funded project shall be in accordance with 23 CFR 635: requiring the Contractor to provide its Contractors License upon award of contract. This, however, is not intended to preclude requirements for the licensing of a contractor subsequent to the award of the contract.

NOW, THEREFORE,

(a) If said BID shall be accepted, the Principal shall deliver a copy of Contractors License, or

(b) If said BID shall be rejected then this obligation shall be void, otherwise the same shall remain in force and effect.

IN WITNESS WHEREOF, the Principal and the Surety have here unto set their hands and seals, and such of them as are corporations have caused their corporate seals to be hereto affixed and these presents to be signed by their proper officers, the day and year set forth above.

Principal

By: ___________________________________________ Attorney-in-Fact

B-10

ITB 27-15TM, Little Back River Road Reconstruction VDOT Project No: U000-114-315 / UPC 109304 Federal Aid Project No.: STP-5A03(997)

III. BID BOND

KNOW ALL MEN BY THESE PRESENTS, that we, the undersigned, __________________________ as Principal, and __________________________________________ as Surety, are hereby held and firmly bound unto City of Hampton, Virginia as OWNER in the penal sum of _____________________ (Five Percent) for the payment of which, well and truly to be made, we hereby jointly and severally bind ourselves, successors and assigns.

Signed, this ______day of___________, 20___.

The Condition of the above obligation is such that whereas the Principal has submitted to the OWNER a certain BID, attached hereto and hereby made a part hereof to enter into a Contract in writing, for the project entitled: ITB 27-15TM, Little Back River Road Reconstruction, VDOT Project No: U000-114-315 / UPC 109304, Federal Aid Project No.: STP-5A03(997)

NOW, THEREFORE,

(a) If said BID shall be rejected, or

(b) If said BID shall be accepted and the Principal shall execute and deliver a Contract in the attachment hereto (properly completed in accordance with said BID) and shall furnish a BOND for faithful performance of said Contract, and for the payment of all persons performing labor or furnishing materials in connection therewith, then this obligation shall be void, otherwise the same shall remain in force and effect; it being expressly understood and agreed that the liability of the Surety for any and all claims hereunder shall, in no event, exceed the penal amount of this obligation as herein stated.

The Surety, for value received, hereby stipulates and agrees that the obligations of said Surety and its BOND shall be in no way impaired or affected by any extension of the time within which the OWNER may accept such BID; and said Surety does hereby waive notice of any such extension.

IN WITNESS WHEREOF, the Principal and the Surety have hereunto set their hands and seals, and such of them as are corporations have caused their corporate seals to be hereto affixed and these presents to be signed by their proper officers, the day and year set forth above.

Principal

Surety

By: ___________________________________________ Attorney-in-Fact

IMPORTANT - Surety companies executing BONDS shall appear on the Treasury Department's most current list (Circular 570 as amended) and be authorized to transact business in the Commonwealth of Virginia.

B-11

VDOT Project No: U000-114-315 / UPC 109304 Federal Aid Project No.: STP-5A03(997)

IV. CERTIFICATION REGARDING DEBARMENT

This is to certify that this person/firm/corporation is not now debarred by the Federal Government or by the Commonwealth of Virginia or by any other state, or by any town, city, or county, from submitting Bids on contracts for construction covered by this solicitation, nor are they an agent of any person or entity that is now so debarred.

Each covered contractor must also screen each of its covered subcontractors. In this certification “contractor” refers to both contractor and subcontractor; “contract” refers to both contract and subcontract.

Signature of Official

Name of Official

Title

Firm or Corporation

Date

Federal Aid Project No.: STP-5A03(997)

B-12

V. ANTI-COLLUSION/NON-DISCRIMINATION/DRUG-FREE

WORKPLACE REQUIREMENTS STATEMENT

ANTI-COLLUSION CLAUSE:

In the preparation and submission of this proposal, said bidder did not either directly or indirectly enter into any combination or arrangement with any person, firm or corporation, or enter into any agreement, participate in any collusion, or otherwise take any action in violation of the Sherman Act (15 U.S.C.

Section 1), Sections 59.1-9.1 through 59.1-9.17 or Sections 59.1-68.6 through 59.1-68.8 of the code of Virginia.

The undersigned bidder hereby certifies that this agreement, or any claims resulting therefrom, is not the result of, or affected by, any act of collusion with, or any act of, another person or persons, firm or corporation engaged in the same line of business or commerce; and, that no person acting for, or employed by, has an interest in, or is concerned with, this proposal; and, that no person or persons, firm or corporation other than the undersigned, have, or are, interested in this proposal.

DRUG-FREE WORKPLACE:

During the performance of this contract, the successful bidder agrees to (i) provide a drug-free workplace for the successful bidder’s employees; (ii) post in conspicuous places, available to employees and applicants for employment, a statement notifying employees that the unlawful manufacture, sale, distribution, dispensation, possession, or use of a controlled substance or marijuana is prohibited in the successful bidder’s workplace and specifying the actions that will be taken against employees for violations of such prohibition; (iii) state in all solicitations or advertisements for employees placed by or on behalf of the successful bidder that the successful bidder maintains a drug-free workplace; and (iv) include the provisions of the foregoing clauses in every subcontract or purchase order of over $10,000, so that the provisions will be binding upon each successful bidder or vendor.

For the purpose of this section, “drug-free workplace” means a site for the performance or work done in connection with a specific contract awarded to a successful bidder in accordance with federal law, the employees of whom are prohibited from engaging in the unlawful manufacture, sale, distribution, dispensation, possession or use of any controlled substance or marijuana during the performance of the contract.

EMPLOYMENT DISCRIMINATION BY THE SUCCESSFUL BIDDER SHALL BE

PROHIBITED:

1. During the performance of this contract, the successful bidder agrees as follows:

a. The bidder shall not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, disability, or any other basis prohibited by state law relating to discrimination in employment, except where there is a bona fide occupational qualification reasonably necessary to the normal operation of the successful bidder. The successful bidder agrees to post in conspicuous places, available to employees and applicants for employment, notices setting forth the provisions of this nondiscrimination clause.

Federal Aid Project No.: STP-5A03(997)

B-13

b. The successful bidder, in all solicitations or advertisements for employees placed by or on behalf of the successful bidder, shall state that such successful bidder is an equal opportunity employer.

c. Notices, advertisements, and solicitations placed in accordance with federal law, rule or regulation shall be deemed sufficient for the purpose of meeting the requirements of this section.

2. The successful bidder will include the provisions of the foregoing paragraphs a, b, and c in every subcontract or purchase order of over $10,000, so that the provisions will be binding upon each subcontractor or vendor.

Name of Contractor:

Authorized Signature:

Printed Name:

Title:

Date:

Federal Aid Project No.: STP-5A03(997)

B-14

VI. VDOT FORMS

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

Form C-48 Rev. 10-03-25

SUBCONTRACTOR/SUPPLIER SOLICITATION AND UTILIZATION,

AND VENDOR SURVEY FORM (ALL VENDORS)

PROJECT

NO.

CONTRACT I.D.

NO.

FHWA NO. DATE SUBMITTED

All vendors submitting a bid as a Prime Contractor shall complete and submit with their bids the following information as requested for (1) Subcontractor/Supplier Solicitation, and Utilization, and (2) for Vendor Survey.

The vendor certifies this form accurately represents its solicitation and utilization or non-utilization, as indicated, of the firms listed below for performance of work on this contract. The vendor also certifies he/she has had direct contact with the named firms regarding participation on this project.

Vendor Signature:

Vendor ID No. Title:

Vendor’s Address: ____________________________________

City: __________________

State: __________________ Zip Code: _________

SUBCONTRACTOR/SUPPLIER SOLICITATION AND UTILIZATION (ALL)

VENDOR

NUMBER

NAME OF SUBCONTRACTOR/SUPPLIER TELEPHONE

NUMBER

UTILIZED

(Y/N)

NOTE: ATTACH ADDITIONAL PAGES, IF NECESSARY.

BIDDER MUST SIGN EACH ADDITIONAL SHEET TO CERTIFY ITS CONTENT AND COMPLETION OF FORM.

FEDERAL LAW REQUIRES ALL VENDORS SUBMITTING BIDS OR OFFERS PROVIDE THE INFORMATION

REQUESTED IN THIS FORM.

109304 ITB 27-15TM

45028

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

Form C-48 Rev. 10-03-25

VENDOR SURVEY

WHEN SUBMITTING A BID OR OFFER AS A PRIME CONTRACTOR, THE BIDDER MUST SUBMIT A

VENDOR SURVEY FOR THEMSELVES AND A VENDOR SURVEY FOR EACH SUBCONTRACTOR

AND SUPPLIER WHO SUBMITTED A BID OR QUOTE TO THE BIDDER.

VENDOR’S FULL LEGAL NAME: ________________________________________

VENDOR ID NO.: __________________

ADDRESS: ____________________________________

CITY: ____________________________________

STATE: _______________ ZIP CODE: _________

VENDOR’S YEARS IN BUSINESS: _____________

VENDOR’S ANNUAL GROSS RECEIPTS: ____ $ 0 - 25 million ____ $ 25 - 50 million ____ $ 50 - 75 million ____ More than $75 million

THE UNDERSIGNED, ON BEHALF OF VENDOR IDENTIFIED ABOVE, ACKNOWLEDGES AND CERTIFIES THAT THIS FORM ACCURATELY STATES THE INFORMATION CONTAINED HEREIN TO THE BEST OF VENDOR’S

KNOWLEDGE.

Printed Full Legal Name of Person Signing for Vendor

Signature: ____________________________________________

Form C-49 2-24-14

Sheet 1 of 10

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

DBE GOOD FAITH EFFORTS DOCUMENTATION

CONTRACT I.D. NUMBER ___ITB 27-15TM_________

PROJECT NUMBER ____109304__________________________

FHWA NUMBER__45028_________________________________

DISTRICT ___Hampton Roads_____________________________

DATE BID SUBMITTED___________________________________

BIDDER’S NAME________________________________________

SIGNATURE____________________________________________

TITLE _________________________________________________

VENDOR NUMBER_______________________________________

DBE GOAL FROM BID PROPOSAL____0%_______________

--DO NOT DETACH--

THIS INFORMATION MUST BE SUBMITTED

WITHIN 2 DAYS AFTER BID OPENING IF YOUR

BID DOES NOT MEET THE PROJECT DBE

REQUIREMENTS, OR

WHEN REQUESTED BY VDOT

Sheet 2 of 10

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

DBE GOOD FAITH EFFORTS DOCUMENTATION

CONTRACT I.D. NO. ITB 27-15TM DATE SUBMITTED______________

IF THE DBE GOAL ESTABLISHED FOR THIS CONTRACT HAS NOT BEEN MET OR VDOT

REQUESTS THE SUBMITTAL THEREOF, THE BIDDER IS REQUIRED TO SUBMIT GOOD

FAITH EFFORTS AS OUTLINED IN THIS DOCUMENT.

THE BIDDER ACKNOWLEDGES AND CERTIFIES THAT THIS FORM ACCURATELY

REPRESENTS THE INFORMATION CONTAINED HEREIN.

BIDDER SIGNATURE ____

TITLE

NAMES OF CERTIFIED DBEs AND THE DATES ON WHICH THEY WERE SOLICITED TO BID

ON THIS PROJECT

INCLUDE THE ITEMS OF WORK OFFERED AND THE DATES AND METHODS USED FOR

FOLLOWING UP INITIAL SOLICITATIONS TO DETERMINE WHETHER OR NOT DBEs WERE

INTERESTED.

NAMES AND VENDOR

NUMBERS OF DBEs

SOLICITED

DATE OF INITIAL

SOLICITATION

ITEM(S) OF WORK FOLLOW-UP METHODS

AND DATES

NOTE: ATTACH ADDITIONAL PAGES IF NECESSARY

ATTACH COPIES OF SOLICITATIONS, TELEPHONE RECORDS, FAX CONFIRMATIONS,

ELECTRONIC INFORMATION, ETC.

Sheet 3 of 10

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

DBE GOOD FAITH EFFORTS DOCUMENTATION

CONTRACT I.D. NO. ITB 27-15TM DATE SUBMITTED______________________

IF THE DBE GOAL ESTABLISHED FOR THIS CONTRACT HAS NOT BEEN MET OR VDOT

REQUESTS THE SUBMITTAL THEREOF, THE BIDDER IS REQUIRED TO SUBMIT GOOD

FAITH EFFORTS AS OUTLINED IN THIS DOCUMENT.

THE BIDDER ACKNOWLEDGES AND CERTIFIES THAT THIS FORM ACCURATELY

REPRESENTS THE INFORMATION CONTAINED HEREIN.

BIDDER_____________________________________SIGNATURE______________________________________

TITLE

TELEPHONE LOG

DBE(s) CALLED

TELEPHONE

NUMBER

DATE

CALLED

TIME

CALLED

CONTACT PERSON OR

VOICE MAIL STATUS

NOTE: ATTACH ADDITIONAL PAGES IF NECESSARY

Sheet 4 of 10

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

DBE GOOD FAITH EFFORTS DOCUMENTATION

CONTRACT I.D. NO. ITB 27-15TM DATE SUBMITTED______________________

IF THE DBE GOAL ESTABLISHED FOR THIS CONTRACT HAS NOT BEEN MET OR VDOT

REQUESTS THE SUBMITTAL THEREOF, THE BIDDER IS REQUIRED TO SUBMIT GOOD

FAITH EFFORTS AS OUTLINED IN THIS DOCUMENT.

THE BIDDER ACKNOWLEDGES AND CERTIFIES THAT THIS FORM ACCURATELY

REPRESENTS THE INFORMATION CONTAINED HEREIN.

BIDDER SIGNATURE ____

TITLE

ITEM(S) OF WORK THAT THE BIDDER MADE AVAILABLE TO DBE FIRMS

IDENTIFY THOSE ITEM(S) OF WORK THAT THE BIDDER MADE AVAILABLE TO DBE

FIRMS OR THOSE ITEM(S) THE BIDDER IDENTIFIED AND DETERMINED TO SUBDIVIDE

INTO ECONOMICALLY FEASIBLE UNITS TO FACILITATE DBE PARTICIPATION. FOR

EACH ITEM LISTED, SHOW THE DOLLAR VALUE AND PERCENTAGE OF THE TOTAL

CONTRACT AMOUNT. IT IS THE BIDDER’S RESPONSIBILITY TO DEMONSTRATE THAT

SUFFICIENT WORK TO MEET THE GOAL WAS MADE AVAILABLE TO DBE FIRMS.

ITEM(S) OF WORK

MADE AVAILABLE

BIDDER

NORMALLY

PERFORMS ITEM(S)

(Y/N)

ITEM(S) BROKEN

DOWN TO

FACILITATE

PARTICIPATION

(Y/N)

AMOUNT IN

DOLLARS

PERCENTAGE

OF

CONTRACT

NOTE: INFORMATION REQUIRED FOR THIS SECTION CONTINUED ON SHEET 5

ATTACH ADDITIONAL PAGES IF NECESSARY

Sheet 5 of 10

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

DBE GOOD FAITH EFFORTS DOCUMENTATION

CONTRACT I.D. NO. ITB 27-15TM DATE SUBMITTED______________________

IF THE DBE GOAL ESTABLISHED FOR THIS CONTRACT HAS NOT BEEN MET OR VDOT

REQUESTS THE SUBMITTAL THEREOF, THE BIDDER IS REQUIRED TO SUBMIT GOOD

FAITH EFFORTS AS OUTLINED IN THIS DOCUMENT.

THE BIDDER ACKNOWLEDGES AND CERTIFIES THAT THIS FORM ACCURATELY

REPRESENTS THE INFORMATION CONTAINED HEREIN.

BIDDER SIGNATURE ____

TITLE

ADDITIONAL INFORMATION REGARDING ITEM(S) OF WORK THAT THE

BIDDER MADE AVAILABLE TO DBE FIRMS (Continued From Sheet 4)

ITEM(S) OF WORK MADE AVAILABLE, NAMES OF SELECTED FIRMS AND DBE STATUS,

DBEs THAT PROVIDED QUOTES, PRICE QUOTE FOR EACH FIRM, AND THE PRICE

DIFFERENCE FOR EACH DBE IF THE SELECTED FIRM IS NOT A DBE.

ITEM(S) OF WORK

MADE

AVAILABLE(CONT.)

NAME OF

SELECTED

FIRM AND

VENDOR

NUMBER

DBE OR

NON-DBE

NAME OF

REJECTED

FIRM(S)

QUOTE IN

DOLLARS

PRICE

DIFFERENCE IN

DOLLARS

NOTE: ATTACH ADDITIONAL PAGES IF NECESSARY.

IF THE FIRM SELECTED FOR THE ITEM IS NOT A DBE, PROVIDE THE REASON(S) FOR

THE SELECTION ON A SEPARATE PAGE AND ATTACH.

PROVIDE NAMES, ADDRESSES, AND TELEPHONE NUMBERS FOR THE FIRMS LISTED

ABOVE.

Sheet 6 of 10

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

DBE GOOD FAITH EFFORTS DOCUMENTATION

CONTRACT I.D. NO. ITB 27-15TM DATE SUBMITTED______________________

IF THE DBE GOAL ESTABLISHED FOR THIS CONTRACT HAS NOT BEEN MET OR VDOT

REQUESTS THE SUBMITTAL THEREOF, THE BIDDER IS REQUIRED TO SUBMIT GOOD

FAITH EFFORTS AS OUTLINED IN THIS DOCUMENT.

THE BIDDER ACKNOWLEDGES AND CERTIFIES THAT THIS FORM ACCURATELY

REPRESENTS THE INFORMATION CONTAINED HEREIN.

BIDDER SIGNATURE ____

TITLE

ADVERTISEMENTS OR PROOFS OF PUBLICATION.

NAMES AND DATES OF EACH PUBLICATION IN WHCH A REQUEST FOR DBE

PARTICIPATION FOR THE PROJECT WAS PLACED BY THE BIDDER. ATTACH COPIES OF

PUBLISHED ADVERTISEMENTS OR PROOFS OF PUBLICATION.

PUBLICATIONS DATES OF ADVERTISEMENT

NOTE: ATTACH ADDITIONAL PAGES IF NECESSARY

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

DBE GOOD FAITH EFFORTS DOCUMENTATION

CONTRACT I.D. NO. ITB 27-15TM DATE SUBMITTED______________________

IF THE DBE GOAL ESTABLISHED FOR THIS CONTRACT HAS NOT BEEN MET OR VDOT

REQUESTS THE SUBMITTAL THEREOF, THE BIDDER IS REQUIRED TO SUBMIT GOOD

FAITH EFFORTS AS OUTLINED IN THIS DOCUMENT.

THE BIDDER ACKNOWLEDGES AND CERTIFIES THAT THIS FORM ACCURATELY

REPRESENTS THE INFORMATION CONTAINED HEREIN.

BIDDER SIGNATURE ____

TITLE

NAMES OF AGENCIES CONTACTED TO PROVIDE ASSISTANCE

NAMES OF AGENCIES (SEE SPECIAL PROVISION FOR 107.15) AND THE DATES THESE

AGENCIES WERE CONTACTED TO PROVIDE ASSISTANCE IN CONTACTING,

RECRUITING, AND USING DBE FIRMS. IF THE AGENCIES WERE CONTACTED IN

WRITING, ATTACH COPIES OF SUPPORTING DOCUMENTS.

NAME OF AGENCY

METHOD AND DATE OF

CONTACT RESULTS

NOTE: ATTACH ADDITIONAL PAGES IF NECESSARY.

Sheet 8 of 10

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

DBE GOOD FAITH EFFORTS DOCUMENTATION

CONTRACT I.D. NO. ITB 27-15TM DATE SUBMITTED______________________

IF THE DBE GOAL ESTABLISHED FOR THIS CONTRACT HAS NOT BEEN MET OR VDOT

REQUESTS THE SUBMITTAL THEREOF, THE BIDDER IS REQUIRED TO SUBMIT GOOD

FAITH EFFORTS AS OUTLINED IN THIS DOCUMENT.

THE BIDDER ACKNOWLEDGES AND CERTIFIES THAT THIS FORM ACCURATELY

REPRESENTS THE INFORMATION CONTAINED HEREIN.

BIDDER SIGNATURE ____

TITLE

TECHNICAL ASSISTANCE AND INFORMATION PROVIDED TO DBEs

EFFORTS MADE TO PROVIDE INTERESTED DBEs WITH ADEQUATE INFORMATION

ABOUT THE PLANS, SPECIFICATIONS, AND REQUIREMENTS OF THE BID DOCUMENTS

TO ASSIST THE DBEs IN RESPONDING TO A SOLICITATION.

IDENTIFY THE DBEs ASSISTED, THE INFORMATION PROVIDED, AND THE DATE OF

CONTACT. ATTACH COPIES OF SUPPORTING DOCUMENTS.

DBEs ASSISTED INFORMATION PROVIDED DATE OF CONTACT

Sheet 9 of 10

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

DBE GOOD FAITH EFFORTS DOCUMENTATION

CONTRACT I.D. NO. ITB 27-15TM DATE SUBMITTED______________________

IF THE DBE GOAL ESTABLISHED FOR THIS CONTRACT HAS NOT BEEN MET OR VDOT

REQUESTS THE SUBMITTAL THEREOF, THE BIDDER IS REQUIRED TO SUBMIT GOOD

FAITH EFFORTS AS OUTLINED IN THIS DOCUMENT.

THE BIDDER ACKNOWLEDGES AND CERTIFIES THAT THIS FORM ACCURATELY

REPRESENTS THE INFORMATION CONTAINED HEREIN.

BIDDER SIGNATURE ____

TITLE

EFFORTS MADE TO ASSIST DBEs OBTAIN BONDING, LINES OF CREDIT, INSURANCE, ETC.

EFFORTS MADE TO PROVIDE INTERESTED DBEs IN OBTAINING BONDING, LINES OF

CREDIT, INSURANCE, NECESSARY EQUIPMENT, SUPPLIES, MATERIALS, OR RELATED

ASSISTANCE OR SERVICES, EXCLUDING SUPPLIES AND EQUIPMENT THE

SUBCONTRACTOR PURCHASES OR LEASES FROM THE PRIME CONTRACTOR OR ITS

AFFILIATES.

IDENTIFY THE DBEs ASSISTED, THE ASSISTANCE OFFERED, AND THE DATES OF

SERVICES OFFERED AND PROVIDED. ATTACH COPIES OF SUPPORTING DOCUMENTS.

DBEs ASSISTED ASSISTANCE OFFERED DATES SERVICES OFFERED

AND/OR PROVIDED

Sheet 10 of 10

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

DBE GOOD FAITH EFFORTS DOCUMENTATION

CONTRACT I.D. NO. ITB 27-15TM DATE SUBMITTED______________________

IF THE DBE GOAL ESTABLISHED FOR THIS CONTRACT HAS NOT BEEN MET OR VDOT

REQUESTS THE SUBMITTAL THEREOF, THE BIDDER IS REQUIRED TO SUBMIT GOOD

FAITH EFFORTS AS OUTLINED IN THIS DOCUMENT.

THE BIDDER ACKNOWLEDGES AND CERTIFIES THAT THIS FORM ACCURATELY

REPRESENTS THE INFORMATION CONTAINED HEREIN.

BIDDER SIGNATURE ____

TITLE

ADDITIONAL DATA TO SUPPORT DEMONSTRATION OF GOOD FAITH EFFORTS

ADDITIONAL DATA TO SUPPORT DEMONSTRATION OF GOOD FAITH EFFORTS

NOTE: ATTACH ADDITIONAL PAGES, IF NECESSARY

Form C-104 Rev. 7-13-05

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

PROJECT:

FHWA:

This form must be completed, signed and returned with bid; and failure to do so may result in the rejection of your bid. THE CONTRACTOR SHALL AFFIRM THE FOLLOWIN G STATEMENT EITHER BY SIGNING

THE AFFIDAVIT AND HA VING IT NOTARIZED OR BY SIGNING THE UNSWORN DECLARATION

UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES. A SEPARATE FORM

MUST BE SUBMITTED BY EACH PRINCIPAL OF A JOINT VENTURE BID.

STATEMENT, In preparation and submission of this bid, I, the firm, corporation or officers, agents or employees thereof did not, either directly or indirectly, enter into any combination or arrangement with any persons, firm or corporation or enter into any agreement, participate in any collusion, or otherwise take any action in the restraint of free, competitive bidding in violation of the Sherman Act (15 U.S.C. Section 1) or Article 1.1 or Chapter 12 of Title 18.2 (Virginia Governmental Frauds Act), Sections 59.1-9.1 through 59.1-

9.17 or Sections 59.1-68.6 through 59.1-68.8 of the Code of Virginia.

AFFIDAVIT

The undersigned is duly authorized by the bidder to make the foregoing statement to be filed with bids submitted on behalf of the bidder for contracts to be let by the Commonwealth Transportation Board.

Signed at , this day of , 20 County (City), STATE

By:

(Name of Firm) (Signature) Title (print)

STATE of COUNTY (CITY) of To-wit:

I , a Notary Public in and for the State and County(City) aforesaid, hereby certify that this day personally appeared before me and made oath that he is duly authorized to make the above statements and that such statements are true and correct.

Subscribed and sworn to before me this day of , 20

My Commission expires Notary Public

OR

UNSWORN DECLARATION

The undersigned is duly authorized by the bidder to make the foregoing statement to be filed with bids submitted on behalf of the bidder for contracts to be let by the Commonwealth Transportation Board.

Signed at , this day of , 20 County (City), STATE

By:

(Name of Firm) (Signature) Title (print)

45028

109304

ORDER NO.:

CONTRACT ID. NO.: ITB 27-15TM

CONTRACT ID. NO.:

Form C-105 Rev. 7-13-05

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

AFFIDAVIT

PROJECT:

FHWA:

This form must be completed, signed, notarized and returned with bid; and failure to do so, may result in the rejection of your bid. A separate form must be submitted by each principal of a joint venture bid.

1. I, the firm, corporation or officers, agents or employees thereof have neither directly nor indirectly entered into any combination or arrangement with any person, firm or corporation or entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of free competitive bidding in connection with such contract, the effect of which is to prevent competition or increase the cost of construction or maintenance of roads or bridges.

During the preceding twelve months, I (we) have been a member of the following Highway Contractor's Associations, as defined in Section 33.2-1106 of the Code of Virginia. (If none, so state).

NAME Location of Principal Office

2. I (we) have _____, have not _____, participated in a previous contract or subcontract subject to the equal opportunity clause, as required by Executive Orders 10925, 11114, or 11246, and that I/We have _____, have not _____, filed with the joint Reporting Committee, the Director of the Office of Federal Contract Compliance, a Federal Government contracting or administering agency, or the former President's Committee on Equal Employment Opportunity, all reports due under the applicable filing requirements.

Note: The above certification is required by the Equal Employment Opportunity Regulations of the Secretary of Labor [41 CFR 60-1.7(b)(1)], and must be submitted by bidders and proposed subcontractors only in connection with contracts and subcontracts which are subject to the equal opportunity clause. Contracts and subcontracts which are exempt from the equal opportunity clause are set forth in 41 CFR 60-1.5. (Generally only contract or subcontracts of $10,000 or under are exempt.)

Currently, Standard Form 100 (EEO-1) is the only report required by the Executive Orders or their implementing regulations.

Proposed prime contractors and subcontractors who have participated in a previous contract or subcontract subject to the Executive Orders and have not filed the required reports should note that 41 CFR 60-1.7(b) (1) prevents the award of contract and subcontract unless such contractor submits a report covering the delinquent period or such other period specified by the Federal Highway Administration or by the Director, Office of Federal Contract Compliance, U.S. Department of Labor.

(Continued)

109304

45028

Form C-105

3. The bidder certifies to the best of its knowledge and belief, that it and its principals:

(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from covered transactions by any Federal department or agency;

(b) Have not within a three year period preceding this proposal been convicted of or had a civil judgement rendered against them for commission of fraud or a criminal offence in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated above; and

(d) Where the bidders is unable to certify to any of the statements in this certification, the bidder shall show an explanation below.

Explanations will not necessarily result in denial of award, but will be considered in determining bidder responsibility. For any explanation noted, indicate below to whom it applies, initiating agency, and dates of action. Providing false information may result in federal criminal prosecution or administration sanctions. The bidder shall provide immediate written notice to the Department if at any time the bidder learns that its certification was erroneous when submitted or has become erroneous by reason of change circumstances.

The undersigned is duly authorized by the bidder to make the foregoing statements to be filed with bids submitted on behalf of the bidder for contracts to be let by the Commonwealth Transportation Board.

Signed at , this day of , 20 County (City), STATE

By:

(Name of Firm) (Signature) Title (print)

STATE of COUNTY (CITY) of To-wit:

I , a Notary Public in and for the State and County(City) aforesaid, hereby certify that this day personally appeared before me and made oath that he is duly authorized to make the above statements and that such statements are true and correct.

Subscribed and sworn to before me this day of , 20

My Commission expires Notary Public

Form C-110 Rev. 07-31-24

ORDER NO.:

CONTRACT ID. NO.:

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF TRANSPORTATION

DBE REGULAR DEALER/DISTRIBUTOR AFFIRMATION FORM

Bidder / Contractor Name:

Project No.

FHWA No.:

Contract ID:

Date Submitted:

*** INSTRUCTIONS ***

Submit this DBE Regular Dealer / Distributor Affirmation Form for each DBE listed as a regular dealer or distributor, on the Bidder’s Form C-111 within 5 days after the bid opening, along with Form C-112 - Certification of Binding Agreement. In the questions below, “you and “your” refer to the DBE.

Section 26.53(c)(1) of Title 49 Code of Federal Regulations requires the Virginia Department of Transportation to make a preliminary counting determination for each DBE listed as a regular dealer or distributor to assess its eligibility for 60 or 40 percent credit, respectively, of the cost of materials and supplies based on its demonstrated capacity and intent to perform as a regular dealer or distributor, as defined in 49 CFR § 26.55(e)(2)(iv)(A),(B),(C), and (3) under the contract at issue. The preliminary determination will be based on the DBE’s written responses to relevant questions and its affirmation that its subsequent performance of a commercially useful function will be consistent with the preliminary counting of such participation.

DBE Name:

DBE Authorized Representative:

Total Amount of DBE Subcontract / Purchase Order:

NAICS Codes Applicable to Items Sold / Leased:

1. Will all items sold or leased be provided from the on-hand inventory at your establishment?

☐ YES (If "YES," you have indicated that your performance will satisfy the regular dealer requirements and may be counted at 60%. STOP here. Read and sign the affirmation below.)

☐ NO (If "NO" Continue.)

(a) Are you selling bulk items (e.g., petroleum products, steel, concrete, concrete products, sand, gravel, asphalt, etc.) or items not typically stocked due to their unique characteristics (aka specialty items)?

☐ YES (If "YES," Go to Question 2.)

☐ NO (If "NO" Continue.)

(b) Will at least 51% of the items you are selling be provided from the inventory maintained at your establishment, and will the minor quantities of items delivered from and by other sources be of the general character as those provided from your inventory?

☐ YES (If "YES," you have indicated that your performance will satisfy the regular dealer requirements and may be counted at 60%. STOP here. Read and sign the affirmation below.

☐ NO * (*If 1,1(a), and 1(b) above are "NO," your performance on the whole will not satisfy the regular dealer requirements; therefore, only the value of items to be sold or leased from inventory can be counted at 60%. Go to Question 3, below, to determine if the items delivered from and by other sources are eligible for Distributor credit.)

109304 45028

Form C-110 Rev. 07-31-24

2. Will you deliver all bulk or specialty items using distribution equipment you own (or under a long-term lease) and operate?

☐ YES (If "YES," you have indicated that your performance will satisfy the requirements for a regular dealer of bulk items and may be counted at 60%. STOP here. Read and sign the affirmation below.)

☐ NO (If "NO," your performance will not satisfy the requirements for a regular dealer of bulk items;

the value of items to be sold or leased cannot be counted at 60%. Go to Question 3.)

3. Will the written terms of your purchase order or bill of lading from a third party transfer responsibility, including risk for loss or damage, to your company at the point of origin (e.g. a manufacture's facility)?

☐ YES ☐ NO

(a) Will you be using sources other than the manufacturer (or other seller) to deliver or arrange delivery of the items sold or leased?

☐ YES ☐NO

(If you responded "YES" to both 3 and 3(a), you have indicated that your performance will satisfy the requirements of a Distributor; therefore, the value of items sold or leased may be counted at 40%.)

(If you responded "NO" to either 3 or 3(a), your performance will not satisfy the requirements for a regular dealer and counting of your participation is limited to the reasonable cost of fees or commissions charged, including transportation charges for the delivery of materials or supplies; the cost of materials or supplies may not be counted.)

For DBE:

I affirm that the information that I provided above is true and correct and that my company's subsequent performance of a commercially useful function will be consistent with the above responses. I further affirm that my company will independently negotiate price, order specified quantities, and pay for the items listed in the Bidder's Forms C-111 and C-112.