SF-1413 Statement and Acknowledgement of Contractor.pdf

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Attached to
Seawall Repair Leeville LA
Solicitation number
6973GH-23-Q-00133
Issued by

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This document includes a Statement and Acknowledgement form and details of a related federal contract opportunity for seawall repair services. The form is to be completed by a prime contractor and subcontractor for a construction project, acknowledging inclusion of required labor clauses.

The opportunity is a solicitation by the Federal Aviation Administration for seawall repair and associated work in Leeville, Louisiana. Interested contractors must provide all labor, materials, equipment, transportation, insurance and other requirements to perform the specified scope of work. A firm-fixed-price construction contract is anticipated to be awarded. The solicitation number is 6973GH-23-Q-00133. Questions regarding the project scope must be submitted by June 5th and proposals are due by June 16th, 2023. Contractors must be registered in SAM by the due date. The FAA will review program eligibility and may communicate with offerors. This is not a commitment and the government is not liable for any costs.

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STATEMENT AND ACKNOWLEDGMENT

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the FAR Secretariat, (VIR), Regulatory and Federal Assistance Division, GSA, Washington, DC 20405; and to the Office of Management and Budget, Paperwork Reduction Project (9000-0014), Washington, DC 20503.

PART I - STATEMENT OF PRIME CONTRACTOR

1. PRIME CONTRACT NO. 2. DATE SUBCONTRACT

AWARDED

3. SUBCONTRACT NUMBER

15b. TITLE OF PERSON SIGNING

OMB Control No. 2120-0595 (SF-1413) FAA Template No. 21 (4/11)

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 Davis-Bacon and Related Act Regulations

Davis-Bacon Act 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

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

STATEMENT AND ACKNOWLEDGMENT

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions,searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the FAR Secretariat, (VIR), Regulatory and Federal Assistance Division, GSA, Washington, DC 20405; and to the Office of Management and Budget, Paperwork Reduction Project (9000-0014), Washington, DC 20503.

PART I - STATEMENT OF PRIME CONTRACTOR

1. PRIME CONTRACT NO.

2. DATE SUBCONTRACT AWARDED

3. SUBCONTRACT NUMBER

15b. TITLE OF PERSON SIGNING OMB Control No. 2120-0595 (SF-1413) FAA Template No. 21 (4/11)

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 Davis-Bacon and Related Act Regulations Davis-Bacon Act 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

1. PRIME CONTRACT NUMBER:
4A. NAME:
4B. STREET ADDRESS:
4C. CITY:
7A. NAME OF AWARDING FIRM:
10A. NAME OF PERSON SIGNING:
15A. NAME OF PERSON SIGNING:
15B. TITLE OF PERSON SIGNING:
10B. TITLE OF PERSON SIGNING:
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:
9. LOCATION:
7B. DESCRIPTION OF WORK BY SUBCONTRACTOR:
5C. CITY:
4E. ZIP CODE:
5E. ZIP CODE:
4D. STATE:
5D. STATE:
3. SUBCONTRACT NUMBER:
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.": 0
6. The prime contract does not contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation.": 0
SignatureField1:
SignatureField2:

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