Appendix G - SF1413-13d.pdf

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Attached to
Request for Proposals -Spedding Hall Room 10 Remodel with Addendum 2 Federal contract opportunity
Solicitation number
RFP-A23-1484
Issued by
Department of Energy Ames Laboratory

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This document is a Standard Form 1413 Statement and Acknowledgment form for a subcontract awarded by Ames Laboratory to a contractor for remodeling construction services on room 10 of Spedding Hall. The prime contract was awarded by the Department of Energy to Ames Laboratory. The subcontract number is A23-1484 for remodeling of the specified lab space including general construction work. The subcontractor acknowledged inclusion of standard clauses for compliance with labor laws and regulations. No intermediate subcontractors were listed.

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Other files attached to Request for Proposals -Spedding Hall Room 10 Remodel with Addendum 2, newest first.
File Type Posted
RFP A23-1484 Addendum 2 with attachments.pdf PDF
RFP A23-1484 Addendum 1 with attachment.pdf PDF
Appendix A - Fixed Price Construction Terms and Conditions rev. 01-2020.pdf PDF
RFP A23-1484 Sph Room 10 Remodel Project.pdf PDF
Appendix B - Contractor Requirements - May 2023 Rev.0.pdf PDF
Appendix C - WD IA20230074 Mod.6 dated 06-09-2023.pdf PDF
Appendix F - Reps and Certs Supplemental 12-8-2022.pdf PDF
Appendix A2 - Updates to Fixed Price Construction Terms and Conditions - Supplement.pdf PDF
Appendix A1 - COVID-19 Workplace Safety and Reentry Framework Rev 1.3 3-17-2022.pdf PDF
Appendix D - Contractor Safety and Quality Assurance Information Questionnaire.pdf PDF
Appendix E - Safety Requirements and Deliverables.pdf PDF
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STATEMENT AND ACKNOWLEDGMENT OMB Control Number: 9000-0014 Expiration Date: 1/31/2021

PART I - STATEMENT OF PRIME CONTRACTOR

1. PRIME CONTRACT NUMBER 2. DATE SUBCONTRACT

AWARDED

3. SUBCONTRACT NUMBER

15b. TITLE OF PERSON SIGNING

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1413 (REV. 4/2013)

Prescribed by GSA/FAR (48 CFR) 53.222(e)

4. PRIME CONTRACTOR 5. SUBCONTRACTOR

a. NAME a. NAME

b. STREET ADDRESS b. STREET ADDRESS

c. CITY d. STATE e. ZIP CODE c. CITY d. STATE e. ZIP CODE

6. The prime contract does, does not contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation."

7. The prime contractor states that under the contract shown in Item 1, a subcontract was awarded on the date shown in Item 2 to the subcontractor identified in item 5 by the following firm:

a. NAME OF AWARDING FIRM

b. DESCRIPTION OF WORK BY SUBCONTRACTOR

8. PROJECT 9. LOCATION

10a. NAME OF PERSON SIGNING 11. BY (Signature) 12. DATE SIGNED

10b. TITLE OF PERSON SIGNING

PART II - ACKNOWLEDGMENT OF SUBCONTRACTOR

13. The subcontractor acknowledges that the following clauses of the contract shown in Item 1 are included in this subcontract:

Contract Work Hours and Safety Standards Act - Overtime Compensation (If included in prime contract see Block 6) Payrolls and Basic Records Withholding of Funds Disputes Concerning Labor Standards Compliance with Construction Wage Rate Requirements and Related Regulations

Construction Wage Rate Requirements Apprentices and Trainees Compliance with Copeland Act Requirements Subcontracts (Labor Standards) Contract Termination - Debarment Certification of Eligibility

14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY

A C

B D

15a. NAME OF PERSON SIGNING 16. BY (Signature) 17. DATE SIGNED

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number.

The OMB control number for this collection is 9000-0014. We estimate that it will take .05 hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.

1.6 Presentation Agent PDFlib 3.02 (C++/Win32) D:20050617125503-04'00' D:20080212101247-05'00'

STATEMENT AND ACKNOWLEDGMENT

OMB Control Number: 9000-0014 Expiration Date: 1/31/2021

PART I - STATEMENT OF PRIME CONTRACTOR

1. PRIME CONTRACT NUMBER

2. DATE SUBCONTRACT AWARDED

3. SUBCONTRACT NUMBER

15b. TITLE OF PERSON SIGNING

AUTHORIZED FOR LOCAL REPRODUCTION PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1413 (REV. 4/2013)

Prescribed by GSA/FAR (48 CFR) 53.222(e)

4. PRIME CONTRACTOR

5. SUBCONTRACTOR

a. NAME

a. NAME

b. STREET ADDRESS

b. STREET ADDRESS

c. CITY

d. STATE

e. ZIP CODE

c. CITY

d. STATE

e. ZIP CODE

6. The prime contract does, does not contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation."

7. The prime contractor states that under the contract shown in Item 1, a subcontract was awarded on the date shown in Item 2 to the subcontractor identified in item 5 by the following firm:

a. NAME OF AWARDING FIRM

b. DESCRIPTION OF WORK BY SUBCONTRACTOR

8. PROJECT

9. LOCATION

10a. NAME OF PERSON SIGNING

11. BY (Signature)

12. DATE SIGNED

10b. TITLE OF PERSON SIGNING

PART II - ACKNOWLEDGMENT OF SUBCONTRACTOR

13. The subcontractor acknowledges that the following clauses of the contract shown in Item 1 are included in this subcontract:

Contract Work Hours and Safety Standards Act - Overtime Compensation (If included in prime contract see Block 6) Payrolls and Basic RecordsWithholding of FundsDisputes Concerning Labor StandardsCompliance with Construction Wage Rate Requirements and Related Regulations Construction Wage Rate Requirements Apprentices and Trainees Compliance with Copeland Act Requirements Subcontracts (Labor Standards) Contract Termination - Debarment Certification of Eligibility

14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY

A C B D 15a. NAME OF PERSON SIGNING

16. BY (Signature)

17. DATE SIGNED

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 9000-0014. We estimate that it will take .05 hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.

1. PRIME CONTRACT NUMBER: DE-AC02-07CH11358
4A. NAME: Ames Laboratory
4B. STREET ADDRESS: 2408 Pammel Drive, 231 TASF
4C. CITY: Ames
7A. NAME OF AWARDING FIRM: Ames Laboratory
10A. NAME OF PERSON SIGNING: Andrew Saxton
15A. NAME OF PERSON SIGNING:
15B. TITLE OF PERSON SIGNING:
10B. TITLE OF PERSON SIGNING: Contract Manager
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY. Line A.:
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY. Line D.:
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY. Line C.:
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY. Line B.:
8. PROJECT: A23-1484 Remodel of Room 10, Spedding Hall
9. LOCATION: Ames Laboratory, Ames, IA/Iowa State University
7B. DESCRIPTION OF WORK BY SUBCONTRACTOR: General remodeling construction of lab space in Spedding Hall room 10.
5C. CITY:
4E. ZIP CODE: 50011-1015
5E. ZIP CODE:
4D. STATE: IA
5D. STATE:
3. SUBCONTRACT NUMBER: A23-1484
5A. NAME:
5B. STREET ADDRESS:
2. DATE SUBCONTRACT AWARDED. Enter 2 digit month, 2 digit day and 4 digit year.:
12. DATE SIGNED. Enter 2 digit month, 2 digit day and 4 digit year.:
17. DATE SIGNED. Enter 2 digit month, 2 digit day and 4 digit year.:
6. The prime contract does contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation.": 1
6. The prime contract does not contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation.": 0
11. BY. SIGNATURE. This is a protected field.:
16. BY. SIGNATURE. This is a protected field.:

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