IFB_26-005-HG_Attachment_B_-_Beecher_Street_Sidewalk_Project-City_Form_for_CDBG.pdf

City of Leesburg, Florida IFB 26-005-HG - Beecher Street Sidewalk Project (CDBG)

CITY FORMS

Page CF-1 of 8

MBE/WBE/SMALL BUSINESS ENTERPRISE PROJECT TRACKING

The undersigned bidder/offeror has satisfied the requirements of the Program specification in the following manner (please check the appropriate space):

_ _ The bidder/offeror is committed to a minimum of % business enterprise utilization on this contract.

_ _ The bidder/offeror is committed to a minimum of % business enterprise utilization on this contract and submits documentation demonstrating good faith efforts.

_ _ The bidder/offeror is committed to a minimum of % business enterprise utilization on this contract.

_ _ The bidder/offeror is committed to a minimum of % business enterprise utilization on this contract and submits documentation demonstrating good faith efforts.

Name of Offeror/bidder firm:

State Registration No.

By:

Bidder’s (Signature) (Title)

BUSINESS ENTERPRISE SUBCONTRACTS

* Subcontractors Subcontract Work Item Dollar Value Names/Addresses/ Phone Numbers

*Submit “Letter of Intent” for each Subcontractor as a condition of responsiveness.

CITY FORMS

Page CF-2 of 8

Letter of Intent

Name of Offeror/bidder firm:

Address:

City: State: Zip:

Name of firm (Subcontractor):

Address: City: State: Zip:

Telephone:

Description of work to be performed by firm (Subcontractor):

The bidder/offeror is committed to utilizing the above-named firm (Subcontractor) for the work described above. The estimated dollar value of this work is $ .

Affirmation

The above-named firm affirms that it will perform the portion of the contract for the estimated dollar value as stated above.

By:

Subcontractor Signature (Title)

If the bidder/offeror does not receive award of the prime contract, any and all representations in this Letter of Intent and Affirmation shall be null and void.

CITY FORMS

Page CF-3 of 8

Special EEO Provisions

TABLE A.

PROPOSED SUBCONTRACTS BREAKDOWN

FOR THE PERIOD COVERING 202 THROUGH 202 .

(DURATION OF THE CDBG-ASSISTED PROJECT)

COLUMN 1 COLUMN 2 COLUMN 3 COLUMN 4 COLUMN 5

TYPE OF CONTRACT TOTAL NUMBER TOTAL APPROXIMATE ESTIMATED ESTIMATED

(BUSINESS OR PRO- OF CONTRACTS DOLLAR AMOUNT NUMBER OF DOLLAR AMT

FESSIONAL) CONTRACTS PROJECT AREA

AREA

BUSINESSES*

*The Project Area is coextensive with the physical boundaries of City of Leesburg, Florida

Company

Project Name Project Number

EEO Officer (Signature) Date

CITY FORMS

Page CF-4 of 8

Special EEO Provisions

TABLE B.

ESTIMATED PROJECT WORKFORCE BREAKDOWN

Job Category Total Estimated Positions

# Positions Currently Occupied by Permanent Employees

# Positions Not Currently Occupied

# Positions to be Filled with

L.I.PA.R *

Officers Supervisors

Professionals

Technicians

Housing/Sales Rental/Mgmt

Office Clerical

Service Workers

Others

TRADES:

Journeyman

Helpers

Apprentices

Maximum # Trainees

Others

Totals

*Lower Income Project Areas Residents:

Individuals residing within the City of Leesburg whose family income does not exceed 80% of the median income in the State

CITY FORMS

Page CF-5 of 8

Federal Labor Standards Provisions

CONTRACTOR' CERTIFICATION

CONCERNING LABOR STANDARDS AND PREVAILING WAGE REQUIREMENTS

To: City of Leesburg, Florida DATE:

PROJECT NUMBER: IFB 26-005-HG

PROJECT NAME: Beecher Street Sidewalk Project (CDBG)

1. The undersigned, having executed a contract with (or the construction of the above identified project), acknowledges that

(a) The Labor Standards provisions are included in the aforesaid contract:

(b) Correction of any infractions of the aforesaid conditions, including infractions by any of his subcontractors and any lower tier subcontractors, is his responsibility:

2. He certifies that:

(a) Neither he nor any firm, partnership or association in which he has substantial interest is designated as an ineligible contractor by the Comptroller General of the United States pursuant to Section 5.6(b) of the Regulations of the Secretary of Labor, Part 5 (29 CFR, Part

5) or pursuant to Section 3(a) of the Davis-Bacon Act, as amended (40 U.S.C. 276a-2(a))

(b) No part of the aforementioned contract has been or will be subcontracted to any subcontractor if such subcontractor or any firm, corporation, partnership or association in which such subcontractor has a substantial interest is designated as an ineligible contractor pursuant to any of the aforementioned regulatory or statutory provisions.

3. He agrees to obtain and forward to the aforementioned recipient within ten days after the execution of any subcontract, including those executed by his subcontractors and any lower tier subcontractors, a Subcontractor's Certification Concerning Labor Standards and Prevailing Wage Requirements executed by the subcontractors.

4. He certifies that:

(a) The legal name and the business address of the undersigned are:

(b) The undersigned is:

(1) A SINGLE PROPRIETORSHIP (2) A PARTNERSHIP

(3) A CORPORATION ORGANIZED (4) OTHER ORGANIZATION (Describe)

IN THE STATE OF

CITY FORMS

Page CF-6 of 8

(c) The name, title and address of the owner, partners or officers of the undersigned are:

NAME TITLE ADDRESS

(d) The names and address of all persons, both natural and corporate, having a substantial interest in the undersigned, and the nature of the interest are: (if name, so state)

NAME TITLE NATURE OF INTEREST

(e) The names, addresses and trade classification of all other building construction contractors in which the undersigned as a substantial interest are: (if name, so state)

NAME TITLE NATURE OF INTEREST

WARNING

(Contractor) Date

U.S. Criminal Code Section 1010, Title 18, U.S.C., provides in part: "Whoever,..makes, passes, utters or publishes any statement, knowing the same to be false...shall be fined not more than $5,000 or imprisoned not more than two years, or both".

CITY FORMS

Page CF-7 of 8

Federal Labor Standards Provisions

SUBCONTRACTOR CERTIFICATION

CONCERNING LABOR STANDARDS AND PREVAILING WAGE REQUIREMENTS

To: City of Leesburg, Florida DATE:

PROJECT NUMBER: IFB 26-005-HG

PROJECT NAME: Beecher Street Sidewalk Project (CDBG)

1. The undersigned, having executed a contract with (or the construction of the above identified project), acknowledges that

(a) The Labor Standards provisions are included in the aforesaid contract:

(b) Correction of any infractions of the aforesaid conditions, including infractions by any of his subcontractors and any lower tier subcontractors, is his responsibility:

2. He certifies that:

(a) Neither he nor any firm, partnership or association in which he has substantial interest is designated as an ineligible contractor by the Comptroller General of the United States pursuant to Section 5.6(b) of the Regulations of the Secretary of Labor, Part 5 (29 CFR, Part

5) or pursuant to Section 3(a) of the Davis-Bacon Act, as amended (40 U.S.C. 276a-2(a))

(b) No part of the aforementioned contract has been or will be subcontracted to any subcontractor if such subcontractor or any firm, corporation, partnership or association in which such subcontractor has a substantial interest is designated as an ineligible contractor pursuant to any of the aforementioned regulatory or statutory provisions.

3. He agrees to obtain and forward to the aforementioned recipient within ten days after the execution of any subcontract, including those executed by his subcontractors and any lower tier subcontractors, a Subcontractor's Certification Concerning Labor Standards and Prevailing Wage Requirements executed by the subcontractors.

4. He certifies that:

(a) The legal name and the business address of the undersigned are:

(b) The undersigned is:

(1) A SINGLE PROPRIETORSHIP (2) A PARTNERSHIP

(3) A CORPORATION ORGANIZED (4) OTHER ORGANIZATION (Describe)

IN THE STATE OF

CITY FORMS

Page CF-8 of 8

(c) The name, title and address of the owner, partners or officers of the undersigned are:

NAME TITLE ADDRESS

(d) The names and address of all persons, both natural and corporate, having a substantial interest in the undersigned, and the nature of the interest are: (if name, so state)

NAME TITLE NATURE OF INTEREST

(e) The names, addresses and trade classification of all other building construction contractors in which the undersigned as a substantial interest are: (if name, so state)

NAME TITLE NATURE OF INTEREST

WARNING

(Contractor) Date

U.S. Criminal Code Section 1010, Title 18, U.S.C., provides in part: "Whoever,..makes, passes, utters or publishes any statement, knowing the same to be false...shall be fined not more than $5,000 or imprisoned not more than two years, or both".

WARNING