_C24645016_BID_Package.pdf

STATE OF CALIFORNIA THE RESOURCES AGENCY CALIFORNIA STATE PARKS

Invitation For Bids C24645016

Septic Improvements - Comfort Station 1 McArthur Burney Falls Memorial State Park

Shasta County, CA 96013

BID PACKAGE

California Department of Parks and Recreation Northern Buttes District

400 Glen Drive Oroville, CA 95966

(530) 538-2200

C24645016 Septic Improvements -Comfort Station 1

McArthur Burney Falls MSP

Table of Contents

BID PACKAGE: Number of Pages

Public Works Bidders Checklist, Forms for Completion .……………….....……… Exhibit B, Attachment I, Public Works Bid Form ...………………………… Bidder Declarations (GSPD-05-105) ………...…...……………………………......…… Bidder’s DVBE Participation (DPR 486)* DVBE Declarations (DGS PD 843) *……………………………………………......……… Commercially Useful Function – Bidders Certification (DPR 87)* … Non-Collusion Affidavit (DPR 837) Bidder’s Bond (DPR 495) California Public Contract Code Section 10162 Questionnaire (DPR 20) Darfur Contracting Act Certification (DPR 74) ………...…………………….…......… Fair Chance Employment Act (DPR 282 PW) California Civil Rights Laws Attachment (DGS OLS 04) ……………….…......… California Contractors Certification Clauses (CCC 04/2017).………….…… Payee Data Record and Supplement (STD 204) ……………………….…….…… Payee Data Record Supplement Goods vs. Services (DPR 88) ………….……

* IF CLAIMING PREFERENCE

INVITATION FOR BID

BIDDERS CHECKLIST

For Septic Improvements -Comfort Station 1

McArthur Burney Falls MSP

C24645016

You are invited to review and respond to this invitation for bid (IFB), entitled C24645016, Septic Improvements -Comfort Station 1 at McArthur Burney Falls MSP Shasta County. Enclosed is a bid package containing information needed to provide a bid for all labor and tools and equipment necessary to complete the project. MANDATORY Job Walk- Prime Contractor must attend entire job walk in order to submit a bid for this project per instructions on Notice to Contractors.

□ Bidders Checklist, Forms for Completion

□ Exhibit B, Attachment I, Public Works Bid Form (2 pages)

□ Bidder Declarations (GSPD-05-105)

□ Bidders DVBE Participation (DPR 486) *

□ Disabled Veteran Business Enterprise Declarations (DGS PD 843) *

□ Commercially Useful Function – Bidders Certification (DPR 87) *

□ Non- Collusion Affidavit (DPR 837)

□ Bidders Bond (DPR 495)

□ California Contract Code Section 10162 Questionnaire (DPR 20)

□ Darfur Contracting Act Certification (DPR 74)

□ Fair Chance Employment Act (DPR 282 PW)

□ Unruh Civil Rights Laws Attachment (DGS OLS 04)

□ California Contractors Certification Clauses (CCC 04/2017)

□ Payee Data Record and Supplement (STD 204)

□ Payee Data Record Supplement (DPR 088)

* Fictitious Business Statement if your company is DBA under a different name

Current Department of General Services’ (DGS) SB/MB Certification+* Current DGS Disabled Veteran Business Enterprise Certification+*

+ AS SUPPLIED BY CONTRACTOR

* IF CLAIMING PREFERENCE

* The DVBE participation requirement for this solicitation has been waived- However, the DVBE participation incentive will still apply.

Nondiscrimination Compliance Statement: The prospective contractor's signature affixed hereon and dated shall constitute a certification under penalty of perjury under the laws of the State of California that the bidder has, unless exempted, complied with the nondiscrimination program requirements of Government Code Section 12990 and Title 2, California Code of Regulations, Section 8103.

Verification: By signing this Bid Form, the bidder assures the state that it has not been convicted of violating a state or federal law regarding the employment of undocumented aliens, in the preceding five years.

The prospective contractor's signature affixed hereon and dated shall constitute a certification that the representations made by the prospective contract in the bid are made under penalty of perjury under the laws of the State of California.

Important: Pursuant to Title 2, California Code of Regulations, Section 8103 and Business and Professions Code Section 7028.15, no bid will be considered unless it contains the certifications and license information requested on this form. The State reserves the right to waive any irregularity in any bid or to reject any or all bids.

LICENSE NO.

DPR 482B (Rev. 10/2003)(Excel 10/15/2003)

KIND OF WORK NAME AND ADDRESS

C24645016 Septic Improvements - Comfort Station 1

McArthur Burney Falls Memorial State Park

State of California - The Resources Agency

DEPARTMENT OF PARKS AND RECREATION

PUBLIC WORKS BID FORM

PROJECT LOCATION

PROJECT NAME

STATUS OF BUSINESS (Check appropriate box.)

Individual.

Corporation. State in which incorporated:

Partnership. Full names of partners:

Listed hereinafter are the names, addresses and contractor's license numbers of all subcontractors who will perform work or labor or render services in an amount in excess of one-half of one percent of the general contractor's total bid if this bid is accepted and the portion of the work that each will perform. Material vendors are not included.

FAX NO.

BY (Authorized Signature)

CITY/STATE/ZIP CODE

PRINTED NAME AND TITLE OF PERSON SIGNING

CONTRACTOR/BIDDER FIRM NAME (Printed)

ADDRESS

LICENSE CLASSIFICATION

DATE

BID DATEBID TIME

CERTIFICATION

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized to legally bind the prospective Contractor to the clause(s) listed above. This certification is made under the laws of the State of California. I understand that failure to submit the Public Works Bid Form without the appropriate bidder signature will result in rejection of the bid.

LICENSE EXPIRATION DATELICENSE NO.

Exhibit B, Attachment 1

PHONE NO.

1:00 PM PST 4/1/2025

BID FORM, McArthur Burney Falls Memorial State Park Septic Improvements - Comfort Station 1

The bidder hereby proposed to furnish all labor, materials, tools and equipment necessary to complete the work included in these plans and specifications McArthur Burney Falls Memorial State Park, Shasta County California. All work shall be in accordance with the contract documents and plans, therefore and included, for the stipulated sums, which prices include all applicable taxes and other expenses.

The bidder agrees to complete all work within the Sixty (60) calendar day performance period upon written notice to commence work, within the three hundred (300) calendar day legal contract term.

BASE BID ITEMS

Item Description Unit Qty. Unit Price Item Total Bid

1 DEMOLITION LS 1

Complete all demolition of existing facilities to prepare for new construction. This item includes, but not limited to, existing septic tanks, asphalt concrete, and existing piping to be removed/disposed or abandoned as shown on the plans and specifications.

2 CLEARING AND GRUBBING LS 1

Remove all trees, stumps and roots shown on plans for removal to prepare for new construction. $ $

3 SEWAGE TREATMENT SYSTEM LS 1

Furnish and install all components of the sewage treatment facility for a complete system per plans and specifications. This item includes, but is not limited, to all excavation, tanks, treatment modules, risers, piping, pump equipment, filters, valves, electrical service, control panels, alarms, system startup, and operator training for a complete system

5 TRENCH RESURFACING LS 1

Resurface all asphalt paved areas necessary to replace all asphalt paved areas removed or damaged from construction of new facilities as shown on the plans and specifications.

TOTAL BID $

Amount Spelled Out

Signature __________________________________ tsperling Pencil

DPR 486 (New 1/2010)(Excel 1/26/2010)

COMPANY INFORMATION

COMPANY INFORMATION: List the information (Company Name, Contact information) of subcontractor(s) and supplier(s) proposed for DVBE. If prime contractor is a DVBE, the name must be listed for participation.

COMPLETION INSTRUCTIONS

PART 1 — SUMMARY OF DISABLED VETERAN BUSINESS ENTERPRISE (DVBE) PARTICIPATION

State of California - Natural Resources Agency

DEPARTMENT OF PARKS AND RECREATION

COMPANY NAME

CONTACT

COMPANY NAME

CONTACT

I hereby certifiy that I have made a diligent effort to ascertain the facts with regard to the representations made herein. In making this certification, I am aware of Section 12650 et seq. of the Government Code providing for the imposition of treble damages for making false claims against the State and Section 10115.10 of the Public Contract Code making it a crime for intentionally making an untrue statement in this certificate.

PART 2 — BIDDER'S CERTIFICATION

BIDDING COMPANY'S NAME

SIGNATURE

DATE

TITLE (e.g. BUSINESS OWNER/CHIEF EXECUTIVE OFFICER, ETC.)

CONTRACTING WITH: Show the name of the department or company with which the company listed is contracting.

PRINT OUT: In order to claim DVBE participation credit, a printout from the eProcurement system showing their supplier ID and the status of their certification must be furnished with the bidder's bid or upon the signing of contract documents. Check mark if a copy of the printout is included.

NATURE OF WORK: Identify the proposed work (or materials or equipment) to be provided.

TIER: Bidder may count toward its participation goal the dollar value of work and supplies to be obtained by its primary subcontractors and suppliers from DVBE firms as second and third level tier subcontractors/suppliers. Contracting tier should be indicated with the following designations:

DVBE company listed for participation.

0 = Prime or Joint Contractor 1 = Primary Subcontractor or Supplier 2 = Subcontractor/Supplier of Level 1 Subcontractor/Supplier 3 = Subcontractor/Supplier of Level 2 Subcontractor/Supplier

DOLLAR VALUE: The dollar amount of the bid to be performed by the listed company’s own forces.

PERCENTAGE OF BID: The percentage of the total bid amount the dollar value represents.

CONTRACTING WITH

PERCENT OF BID

PRINT-

OUT

TIER

NATURE OF WORK

CONTACT PHONE

DOLLAR VALUE

COMPANY NAME

CONTACT

CONTRACTING WITH

PERCENT OF BID

PRINT-

OUT

TIER

NATURE OF WORK

CONTACT PHONE

DOLLAR VALUE

COMPANY NAME

CONTACT

CONTRACTING WITH

PERCENT OF BID

PRINT-

TIER

NATURE OF WORK

CONTACT PHONE

DOLLAR VALUE

COMPANY NAME

CONTACT

COMPANY NAME

CONTACT

CONTRACTING WITH

PERCENT OF BID

PRINT-

TIER

NATURE OF WORK

CONTACT PHONE

DOLLAR VALUE

BIDDER'S DVBE PARTICIPATION

PRINTED NAME

OUT

OUT

SOLICITATION NUMBER

DVBE CERTIFICATION NO.

DVBE CERTIFICATION NO.

DVBE CERTIFICATION NO.

DVBE CERTIFICATION NO.

DVBE CERTIFICATION NO.: Provide the DVBE Certification Number assigned to company.

That we, , as Principal, and as Surety, are held and firmly bound unto the State of California, hereinafter called the State, in the penal sum of ten percent (10%) of the total amount of the bid of the Principal above named, submitted by said Principal to the State of California, Department of Parks and Recreation for the work described below, for the payment of which sum in lawful money of the United States, well and truly to be made, we bind ourselves, our heirs, executors, administrators and successors, jointly and severally, firmly by these presents.

WHEREAS, the Principal has submitted the above-mentioned bid to the State of California, Department of Parks and Recreation, for certain construction specifically described as follows, for which bids are to be opened at for

NOW, THEREFORE, If the aforesaid Principal is awarded the contract and, within the time and manner required under the specifications, after the prescribed forms are presented to him or her for signature, enters into a written contract, in the prescribed form, in accordance with the bid, and files the two bonds with the Department, one to guarantee faithful performance and the other to guarantee payment for labor and materials, as required by law, then this obligation shall be null and void; otherwise, it shall be and remain in full force and virtue.

In the event suit is brought upon this bond by the Obligee and judgment is recovered, the Surety shall pay all costs incurred by the Obligee in such suit, including a reasonable attorney's fee to be fixed by the court.

IN WITNESS WHEREOF, We have hereunto set our hands and seals on this day of , 20

(SEAL)

(SEAL)

(SEAL)

(SEAL)

(SEAL)

(SEAL)

NOTE: Signatures of those executing for the Surety must be properly acknowledged.

County of ss

On this day of before me, a notary public in and for the county and state aforesaid, personally appeared, known to me to be the person whose name is subscribed to the within instrument and known to me to be the attorney-in-fact of and acknowledged to me that he subscribed the name of the said company thereto as surety, and his own name as attorney-in-fact.

DPR 495 (Rev. 11/2002)(Excel 11/8/2002)

KNOW ALL PEOPLE BY THESE PRESENTS:

CERTIFICATE OF ACKNOWLEDGEMENT

BIDDER'S BOND

State of California - The Resources Agency

DEPARTMENT OF PARKS AND RECREATION

THE CONDITION of this obligation is such that:

Surety

Principal

State of California

(SEAL)

Notary Public

(Insert date of bid opening)

(Insert place where bids will be opened)

(Copy here the exact description of work, including location, as it appears on the proposal) in the year of 20 on

Bidders are cautioned that making false certification may subject the certifier to criminal prosecution.

The Department of Parks and Recreation (DPR) reserves the right under California Public Contract Code Section 10162 to reject any bidder, any officer of such bidder, or any employee of such bidder who has a proprietary interest in such bidder who has been disqualified, removed or otherwise prevented from bidding on, or completing a federal, state or local govern-ment project because of a violation of law or violation of safety regulations.

Failure to return this form with the bid shall not be cause for rejection; however, bidders must furnish the completed form within the time frame prescribed by the DPR. Failure to submit this form within the time frame prescribed by the DPR may be deemed refusal of an award which shall be cause for forfeiture of bidder's security.

By my signature, I certify under penalty of perjury under the laws of the State of California that the foregoing questionnaire and statements pursuant to California Public Contract Code Section 10162 are true and correct.

DPR 20 (New 10/2003)(Excel 10/24/2008)

NOTICE TO BIDDERS

CERTIFICATION

McArthur Burney Falls MSP

State of California - The Resources Agency

DEPARTMENT OF PARKS AND RECREATION

CALIFORNIA PUBLIC CONTRACT CODE SECTION 10162

PARK UNIT NAME

In accordance with Section 10162 of the California Public Contract Code, bidders shall complete, HAVE YOU, ANY OFFICER OF YOUR BUSINESS, OR ANY EMPLOYEE OF YOUR BUSINESS WHO HAS PROPRIETARY INTEREST IN YOUR BUSINESS EVER BEEN DISQUALIFIED, REMOVED, OR OTHERWISE PREVENTED FROM BIDDING ON, OR COMPLETING A FEDERAL, STATE, OR LOCAL GOVERNMENT PROJECT BECAUSE OF A VIOLATION OF LAW OR VIOLATION OF SAFETY REGULATIONS? Yes (Explain circumstances below. Attach additional pages if needed.) No

BIDDER SIGNATURE PRINTED NAME DATE

under penalty of perjury, the question below. Please answer the following:

— Questionnaire —

PROJECT NAME

C24645016 Septic Improvements for Comfort Station 1

NAME OF BUSINESS

DPR 74 (Rev. 5/2013)(Excel 5/16/2013)

FOR DEPARTMENT USE ONLYState of California - Natural Resources Agency

DEPARTMENT OF PARKS AND RECREATION

DARFUR CONTRACTING ACT CERTIFICATION

Public Contract Code Sections 10475 -10481 applies to any company that currently or within the previous three years has had business activities or other operations outside of the United States.

For such a company to bid on or submit a proposal for a State of California contract, the company must certify that it is either a) not a scrutinized company; or b) a scrutinized company that has been granted permission by the Department of General Services to submit a proposal.

DO NOT COMPLETE OR RETURN THIS FORM IF: Within the previous three years, your company HAS NOT had any business activities or other operations outside of the United States.

AGREEMENT/PAPO NO.

OPTION #1 - CERTIFICATION

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

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

COMPANY/VENDOR NAME (Printed)

BY (Authorized Signature)

PRINTED NAME AND TITLE OF PERSON SIGNING

DATE EXECUTED EXECUTED IN THE COUNTY AND STATE OF

FEDERAL ID NUMBER

OPTION #2 - WRITTEN PERMISSION FROM DGS

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

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

COMPANY/VENDOR NAME (Printed)

INITIALS OF SUBMITTER

PRINTED NAME AND TITLE OF PERSON INITIALING

FEDERAL ID NUMBER

All other companies, complete Option #1 or Option #2 and return:

State of California - Natural Resources Agency

DEPARTMENT OF PARKS AND RECREATION

FOR DEPARTMENT USE ONLY

AGREEMENT/PAPO NO.

DPR 74 (Rev. 5/2013)(Excel 5/16/2013)

DO NOT COMPLETE THIS FORM UNLESS YOUR COMPANY MEETS THE CRITERIA OF OPTION #1 OR OPTION #2.

State of California - Natural Resources Agency

CALIFORNIA DEPARTMENT OF PARKS AND RECREATION

FAIR CHANCE EMPLOYMENT ACT

Public Contract Code 10186:

(a) This section shall be known, and may be cited, as the "Fair Chance Employment Act."

(b) Any person submitting a bid to the state on a contract involving onsite construction-related services shall certify that the person will not ask an applicant for onsite construction-related employment to disclose orally or in writing information concerning the conviction history of the applicant on or at the time of an initial employment application.

(c) This section shall not apply to a position for which the person or the state is otherwise required by state or federal law to conduct a conviction history background check or to any contract position with a criminal justice agency, as that term is defined in Section 13101 of the Penal Code.

(d) This section shall not apply to a person to the extent that he or she obtains workers from a hiring hall pursuant to a bona fide collective bargaining agreement.

CERTIFICATION

By my signature, I certify under penalty of perjury under the laws of the State of California that I have read, understand and will abide by California Public Contract Code Section 10186.

DPR 282PW (New 8/2016)(Word8/11/2016)

Contractor/Bidder Firm Name (Printed)

Federal ID Number

By (Authorized Bidders Signature)

Printed Name and Title of Person Signing

Date Executed

Executed in the County of

Contractor Certification Clause

CCC 04/2017

CERTIFICATION

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

Contractor/Bidder Firm Name (Printed) Federal ID Number

By (Authorized Signature)

Printed Name and Title of Person Signing

Date Executed Executed in the County of

CONTRACTOR CERTIFICATION CLAUSES

STATEMENT OF COMPLIANCE:

Contractor has, unless exempted, complied with the nondiscrimination program requirements. (GC 12990 (a-f) and CCR, Title 2, Section 8103) (Not applicable to public entities.)

DRUG-FREE WORKPLACE REQUIREMENTS:

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

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

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

1. the dangers of drug abuse in the workplace;

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

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

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

c) Provide that every employee who works on the proposed Agreement will:

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

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

Failure to comply with these requirements may result in suspension of payments under the Agreement or termination of the Agreement or both and Contractor may be ineligible for award of any future State agreements if the department determines that any of the following has occurred: (1) the Contractor has made false certification, or violated the certification by failing to carry out the requirements as noted above. (GC 8350 et seq.)

NATIONAL LABOR RELATIONS BOARD CERTIFICATION:

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

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

REQUIREMENT:

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

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

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

EXPATRIATE CORPORATIONS:

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

SWEATFREE CODE OF CONDUCT:

a. All Contractors contracting for the procurement or laundering of apparel, garments or corresponding accessories, or the procurement of equipment, materials, or supplies, other than procurement related to a public works contract, declare under penalty of perjury that no apparel, garments or corresponding accessories, equipment, materials, or supplies furnished to the state pursuant to the contract have been laundered or produced in whole or in part by sweatshop labor, forced labor, convict labor, indentured labor under penal sanction, abusive forms of child labor or exploitation of children in sweatshop labor, or with the benefit of sweatshop labor, forced labor, convict labor, indentured labor under penal sanction, abusive forms of child labor or exploitation of children in sweatshop labor. The contractor further declares under penalty of perjury that they adhere to the Sweatfree Code of Conduct as set forth on the California Department of Industrial Relations website and Public Contract Code Section 6108.

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

DOMESTIC PARTNERS:

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

GENDER IDENTITY:

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

DOING BUSINESS WITH THE STATE OF CALIFORNIA

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

CONFLICT OF INTEREST:

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

a) Current State Employees (PCC 10410):

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

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

b) Former State Employees (PCC 10411):

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

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

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

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

LABOR CODE/WORKERS' COMPENSATION:

Contractor needs to be aware of the provisions which require every employer to be insured against liability for Worker's Compensation or to undertake self-insurance in accordance with the provisions, and Contractor affirms to comply with such provisions before commencing the performance of the work of this Agreement.

(Labor Code Section 3700)

AMERICANS WITH DISABILITIES ACT:

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

12101 et seq.)

CONTRACTOR NAME CHANGE:

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

CORPORATE QUALIFICATIONS TO DO BUSINESS IN CALIFORNIA:

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

b) "Doing business" is defined in R&TC Section 23101 as actively engaging in any transaction for the purpose of financial or pecuniary gain or profit.

Although there are some statutory exceptions to taxation, rarely will a corporate contractor performing within the state not be subject to the franchise tax.

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

RESOLUTION:

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

AIR OR WATER POLLUTION VIOLATION:

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

PAYEE DATA RECORD FORM STD. 204:

This form must be completed by all contractors that are not another state agency or other government entity.

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

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

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

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

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

CITY, STATE, ZIP CODE E-MAIL ADDRESS

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

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

PARTNERSHIP

ESTATE OR TRUST

LEGAL (e.g., attorney services)

EXEMPT (e.g., nonprofit)

ALL OTHERS

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

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

For Individuals, enter SSN.

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

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

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

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

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

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

OR

Federal Employer Identification Number

(FEIN)

Section 4 – Payee Residency Status (See instructions)

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

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

No services performed in California

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

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

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

NAME OF AUTHORIZED PAYEE REPRESENTATIVE TITLE E-MAIL ADDRESS

SIGNATURE DATE TELEPHONE (include area code)

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

STATE AGENCY/DEPARTMENT OFFICE UNIT/SECTION

MAILING ADDRESS FAX TELEPHONE (include area code)

CITY STATE ZIP CODE E-MAIL ADDRESS

Department of Parks and Recreation Northern Buttes District/Northern Division

400 Glen Drive 530-538-2244 530-538-2707

Oroville CA 95966 taneya.sperling@paarks.ca.gov

Print Form Reset Form

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

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

GENERAL INSTRUCTIONS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Corporation-Medical

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

Corporation-Legal

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

Corporation-All Other

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

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

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

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

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

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

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

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

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

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

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

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

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

All suppliers doing business with the Department of Parks and Recreation must complete this form.

Upon completion, submit to the requesting department listed in box/section 6 of the attached STD. 204:

STD. 204, Payee Data Record STD. 205, Payee Data Record Supplement (If applicable) (Remit-to Address: different than Mailing, or multiple) DPR 88, Payee Data Record Supplement - Goods vs. Services

DPR 88 (Rev. 4/2021)(Excel 4/26/2021)

FOR DEPARTMENT USE ONLY

Certificate of Acceptance

Submission Checklist

Vendor Information

Authorized Representative - complete and sign (REQUIRED)

State of California - Natural Resources Agency

DEPARTMENT OF PARKS AND RECREATION

PAYEE DATA RECORD SUPPLEMENT

GOODS VS. SERVICES

PAYEE'S LEGAL BUSINESS NAME (Type or Print)

DATE

PRINTED NAME

Seller's Permit (No.

Certificate of Registration (No.

TAX ID NUMBER

When doing business with the Department of Parks and Recreation I accept and will abide by the State's IT General Provisions or General Provisions Non-IT Commodities, as applicable, located on the internet at www.pd.dgs.ca.gov/modellang/GeneralProvisions.htm.

UPLOAD TO SUPPLIER

RECORD IN FI$Cal

SUPPLIER ID. (If Known )

EXECUTED IN THE COUNTY AND STATE OF

No

NO ATTACHMENT NEEDED

- No inventory or sales staff in CA.

Will tangible goods be provided?

Attach:

Yes

No additional attachments needed.

AUTHORIZED REPRESENTATIVE'S SIGNATURE

DPR 88 (Instructions)(Rev. 4/2021)

Complete all required information and return form to the requesting department listed in Box/Section 6 of the STD.

204.

DPR 88, PAYEE DATA RECORD SUPPLEMENT (GOODS VS. SERVICES)

INSTRUCTIONS

All current and potential vendors/suppliers must have completed both the STD. 204 and DPR 88 in its entirety prior to commencing business with the Department of Parks and Recreation (DPR). STD. 205 is optional dependent upon remittance information (see form for details).

Send DPR 88, STD. 204 (with section 6 pre-filled on the STD. 204), and STD. 205 to vendor/supplier for completion.

Fill in Supplier ID if known in appropriate box in the top, right corner of the DPR 88. Once forms are returned, check for completeness. Resend to vendor/suppler if necessary until all information, signatures and attachments are included.

Once complete, upload into the FI$Cal Systems Supplier Record for FI$Cal review and approval.

Original forms must be retained in the procurement file at the District/Section level.

DPR 88 COMPLETION INSTRUCTIONS FOR VENDOR/SUPPLIER

DEPARTMENT INSTRUCTIONS

check when finished with each form

If no tangible goods provided, skip to Authorized Representative Section.If yes, complete the appropriate checkbox below

If you do NOT have inventory or sales staff in CA, check here and no additional attachments are needed.

This section must be signed with all boxes/fields completed.

If you have inventory or sales staff in CA, choose appropriate checkbox, enter permit or certificate no.

in space provided, & attach copy of permit/cert.