Loading...
HomeMy WebLinkAboutProfessional Services Agreement - RoadBotics, Inc. - 2018 Road Surface Condition Assessment Pilot Program1316 COUNTY -CH Y BuiLDINO 227'W. JEFFERSON BOULEVARL) SOUTH RFND. INDIANA 46601-1930 CITY OF Sou,rH BEND Pf--,,TE BLJTTI(3[PC,, MAYOR BBC ARD OF PUBLIC WORKS August 14, 2018 Ryan Gayman RoadBotics, Inc. 6401 Penn Avenue, 3 d Floor Pittsburgh, PA 15206 RE: Professional Services Agreement Dear Mr. Gayman: PHONE 574/235-9251 FAX 574/ 235-9171 The Board of Public Works, at its meeting held on August 14, 2018, approved the agreement regarding the 2018 Road Surface Condition Assessment Pilot Program in the amount of $33,000, Enclosed please find the original of the agreement for your signature. Please sign and return the original agreement to our office and retain a copy for your records. If you have any further questions regarding this matter, please call this office at (574) 235- 9251. Sincerely, Linda M. Martin, Clerk Enclosure G AR Y A. G i t,or SUZANNA M. FRITZBERG Ei.,iZABETI i A. MARADIK JAMEs A. Mtj[,'LLER I'll E'R FSE J. DORAU AGREEMENT FOR PROFESSIONAL SERVICES This Agreement For Professional Services (this "Agreement") is entered into on August 14, 2018 (the "Effective Date"), by and between the City of South Bend, acting by and through its Board of Public Works (the "City"), and RoadBotics, Inc., a Delaware corporation with its registered office address at 6401 Penn Avenue, 3rd Floor, Pittsburgh, Pennsylvania 15206 (the "Provider") (each a "Party" and collectively the "Parties"). For and in consideration of the mutual covenants and promises contained herein, the Parties agree as follows: I. Services. The Provider will provide to the City the professional services (the "Services") set forth in the Provider's proposal attached hereto as Exhibit A (the "Proposal"), which Proposal is incorporated herein. In the event of any conflict between the terms of this Agreement and the terms of the Proposal, the terms of this Agreement will prevail. The Provider will execute its obligations under this Agreement in accordance with the prevailing professional standard of care for projects of similar design and complexity. 2. Compensation. In exchange for the Provider's satisfactory performance of the Services, and subject to the terms and conditions of this Agreement, the City will pay the Provider the Program Fee stated in the Proposal (the "Contract Amount") in accordance with the project budget stated in the Proposal. The City will pay the Contract Amount in installments upon invoicing by the Provider as set forth in the Proposal (each a "Contract Installment"), The City will not be required to pay any Contract Installment if the City is not satisfied with the Provider's performance under this Agreement or any default or breach of this Agreement by the Provider exists, as the City may determine in its sole discretion. The sum of all Contract Installments will not exceed the Contract Amount, and the Provider will not incur or seek reimbursement for any expenses in excess of the Contract Amount. 3. Term; Termination. Unless earlier terminated in accordance with its terms, this Agreement will commence on the Effective Date and end upon the Provider's satisfaction of all its obligations hereunder and the City's final payment therefor. Notwithstanding the foregoing, effective immediately upon delivery of a written termination notice to the Provider, the City may terminate this Agreement, in whole or in part, for any reason, if the City determines that such termination is in the best interest of the City. In addition, in accordance with Ind. Code 6-1.1-18, payments are subject to appropriation by the City. If the City makes a written determination that funds are not appropriated or are otherwise unavailable to support the continuation of this Agreement, it shall be cancelled, A determination by the City that funds are not appropriated or are otherwise unavailable to support the continuation of performance shall be final and conclusive. The City will not be required to pay any Contract Installment or be otherwise liable for any cost associated with the Provider's performance of any Services after the effective date of termination. 4. Remedies for Breach of Contract. Failure to complete the Services in accordance with this Agreement will be considered a material breach. In the event of such breach, the City may suspend all payments to the Provider and may pursue any and all remedies available at law or in equity. The Provider shall repay to the City any portion of the Contract Amount expended 24203589.2 for matters not within the scope of the Services. 5. Point of Contact. The City employee identified in Section 10 below will serve as the City's principal point of contact for purposes of this Agreement. 6. Relationship. The Provider shall at all times be an independent contractor for the performance of the Services rather than an employee of the City, and no act or omission to act by the Provider shall in any way bind or obligate the City. This Agreement is strictly for the benefit of the Parties and not for any third party or person. This Agreement was negotiated by the Parties at arm's length and each of the parties hereto has reviewed the Agreement after the opportunity to consult with independent legal counsel. Neither party shall maintain that the language in the Agreement shall be construed against any signatory hereto. The City and the Provider hereby renounce the existence of any form of agency relationship, joint venture, or partnership between the Provider and the City and agree that nothing contained herein or in any document executed in connection herewith shall be construed as creating any such relationship between the City and the Provider. 7. Indemnification of City. The Provider hereby agrees to defend, indemnify, and hold harmless the City, its officials, employees, and agents from any and all claims of any nature which arise from the performance by the Provider under this Agreement and from all costs and attorney fees in connection therewith, excepting for claims arising out of the negligence of the City, its officials, directors, employees, and agents. The obligations of the Provider under this section shall survive the termination of this Agreement. &. Work Product; Ownership', License to Data. The Provider will submit its work product (including, but not limited to, Data (as defined below)) to the City in accordance with the terms of the Proposal and this Agreement. Subject to the terms hereof and of the Proposal, Provider hereby grants to City a perpetual, non-exclusive, non-transferrable license, without the right to sublicense, to access all product image data and map files corresponding to a single complete RoadBot assessment (the "Data"). City hereby acknowledges and agrees that Provider owns all proprietary rights, including, without limitation, all patent, copyright, trade secret, database rights, trademark, know-how and other intellectual property rights in and to the Data necessary to grant the licenses and offer the services contemplated by this Agreement and the Proposal (collectively, the "Provider Intellectual Property"). Sponsor agrees that except as expressly set forth herein, Provider will retain such ownership in and to the Provider Intellectual Property, together with any related corrections, bug fixes, enhancements, updates, feedback, comments, bug reports, test results, suggestions or other modifications thereto, whether made by City, Provider, or any third party. Additionally, City hereby agrees that the license granted under this Agreement does not provide City with title to or ownership of the Data, but only a right of limited use thereof under the terms and conditions of this Agreement. Under no circumstances shall City sell, license, sublicense, publish, display, distribute, assign or otherwise transfer to any other party the Data, or any copy thereof, in whole or in part, accept as permitted in this Agreement. City agrees that Provider may develop one or more databases containing the Data and may analyze, sell, or redistribute the Data or any part thereof. 9. Assignment. The Provider shall not assign or subcontract the whole or any part of 2 24203589.2 this Agreement or its obligations hereunder without the prior written consent of the City. 10. Notices. Any notice required or permitted to be delivered hereunder shall be deemed to be delivered, whether or not actually received, when deposited in the United States Postal Service, postage prepaid, registered or certified mail, return receipt requested, addressed to the City or the Provider, as the case may be, at the address set forth below. Provider: City: RoadBotics, Inc. City of South Bend 6401 Penn Avenue, 3rd Floor 731 S Lafayette Blvd. Pittsburgh, PA 15206 South Bend, IN 46601 Attn: CEO Attn: Derick Roberts 11. Equal Opportunity; Non -Discrimination; Compliance. The Provider shall comply with all applicable laws and regulations in its hiring and employment practices and policies for any activity covered by this Agreement. The Provider shall comply with all state, federal, and municipal laws, regulations, and standards applicable to its activities pursuant to this Agreement including, but not limited to, the requirements imposed by Ind. Code 22-9-1-10 (non- discrimination), the provisions of Ind. Code 5-22-16.5 (disqualification for dealings with the government of Iran), and the provisions of Ind. Code 22-5-1.7 (requiring E-Verify for new employees and prohibiting employment of unauthorized aliens). Each of the foregoing provisions is incorporated herein as if set forth in full, and the Provider certifies that it is in compliance with each such provision and shall remain in compliance through the term of this Agreement. 12. Contractor's Affidavit. The Provider agrees, as a condition precedent to the effectiveness of this Agreement, that its authorized representative will execute and submit to the City and any other appropriate bodies an affidavit in the form attached hereto as Exhibit B. 13. Drug -Free Workplace. The Provider hereby agrees to make a good faith effort to provide and maintain a drug -free workplace. The Provider will give written notice to the City within ten (10) days after receiving actual notice that the Provider or an employee of the Provider within the State of Indiana has been convicted of a criminal drug violation occurring in the workplace. 14. Entire Agreement; Amendment-, Applicable Law, This Agreement sets forth the entire agreement and understanding between the parties as to the subject matter hereof, and merges and supersedes all prior discussions, agreements, and understanding of any and every nature between them. This Agreement may be amended only by separate writing, signed by authorized representatives of both the Provider and the City. This Agreement will be construed and interpreted according to the laws of the State of Indiana, and any dispute arising out of this Agreement or otherwise concerning the Provider's rendering of the Services will be resolved in the courts located in St. Joseph County, Indiana, unless the Parties mutually agree to a different method of dispute resolution. 15. Seyerability. All provisions of this Agreement shall be considered as separate terns and conditions, and in the event any one shall be held illegal, invalid or unenforceable, all the other 24203599.2 provisions hereof shall remain in full force and effect as if the illegal, invalid, or unenforceable provision were not a part hereof, unless the provision held illegal, invalid or unenforceable is a material provision of this Agreement, in which case the Provider and the City agree to amend this Agreement with replacement provisions containing mutually acceptable terms and conditions. 16. Force Majeure, The Provider shall not be responsible for any failure or delay in the performance of any obligation hereunder, if such failure or delay is due to a cause beyond the Provider's reasonable control, including, but not limited to acts of God, flood, fire, volcano, war, third -party suppliers, labor disputes or governmental acts. [Signature page follows.] IN WITNESS WHEREOF, the Parties hereto have caused this Agreement For Professional Services to be effective as of the Effective Date stated above. CITY OF SOUTH BEND BOARD OF PUBLIC WORKS z� dj m� Gary Gilot, President Therese Dorau, Member Maradik, Member James Mueller, Member ATTEST: inda Martin, Cle k ROADBOTICS, INC., a Delaware corporation By: Printed: 4 24203589.2 Its: 3000.00000015490n41.001 24203589,2 EXHIBIT A Proposal [See attached.] 24203589.2 RoadBotics Proposal RoadBotics, Inc. ("RoadBotics") located at 6401 Penn Ave., V Floor, Pittsburgh, PA 15206 will provide to the City of South Bend at 227 W. Jefferson Blvd, Ste 1316, South Bend, IN 46601 access to certain services ("Services") pursuant to the provisions of this Agreement ("Agreement") as outlined below. RoadBotics and Customer agree as follows: 1. General Terms. In consideration of the payment for the assessment specified below, RoadBotics will provide Customer access to Roadway, its innovative pavement monitoring and management platform as part of its Program as further outlined in this agreement. The Services will include all components listed in Addendum A. 2. Specific Terms. Customer shall have access to the RoadWay platform along with specific Customer data collected for the period specified in Addendum A. Customer owns any RoadWay assessments specified in Addendum A. Customer hereby grants RoadBotics a perpetual, non-exclusive license to access, analyze, use internally, and publish or display on its own websites, any RoadWay assessments specified in Addendum A. Additionally, RoadBotics grants to Customer a perpetual, non- exclusive, non -transferable license to use, analyze, and publish or display on its websites, any complimentary images or visualizations provided by RoadBotics in conjunction with Customer's purchased assessments. Customer shall have access to the RoadWay platform along with access to any specific components specified in Addendum A for the period specified in Addendum A 3. Fees and Payments. 3.1 Customer shall pay to RoadBotics a Fee of $33,000.00 upon signing this agreement. All fees shall be paid within thirty (30) days of the date of invoice. 3.2 Interest shall accrue on the amount of any payment obligation not paid when due at a rate equal to the lower of (i) 1.0% per month or portion of a month; or (ii) the highest rate permitted by law. In addition, RoadBotics may suspend its performance under this Agreement if Customer fails to comply with any part of its payment obligation. 4. Warranties. RoadBotics will use reasonable commercial efforts to make the Services available during the term specified. In the event of breach of this warranty for the Services, RoadBotics's sole and exclusive obligation, and Customer's sole and exclusive remedy, shall be to refund the applicable portion of the Program Fee applicable to the Services for the period such Services were not available because of breach by RoadBotics. H RoadBotics 5. Limitation of Liability. ROADBOTICS's LIABILITY FOR DAMAGES ARISING OUT OF, RELATING TO OR IN ANY WAY CONNECTED WITH THIS AGREEMENT SHALL IN NO EVENT EXCEED THE SUBSCRIPTION FEES PAID BY CUSTOMER TO ROADBOTICS FOR THE APPLICABLE SERVICES. THE PARTIES AGREE TO THE ALLOCATION OF LIABILITY SET FORTH IN THIS SECTION. CUSTOMER ACKNOWLEDGES THAT WITHOUT ITS AGREEMENT TO THE LIMITATIONS CONTAINED HEREIN, THE FEES CHARGED FOR THE SERVICES WOULD BE HIGHER. 6. Confidentiality. "Confidential Information" means all confidential and proprietary information of a party (the "Disclosing Party") disclosed to the other party (the "Receiving Party"), whether orally or in writing, including but not limited to the terms and conditions of this Agreement business and marketing plans, technology and technical information, product designs, and business processes. Confidential Information shall not include any information that (i) is or becomes generally known to the public without breach of any obligation owed to the Disclosing Party; (ii) was known to the Receiving Party prior to its disclosure by the Disclosing Party without breach of any obligation owed to the Disclosing Party; (iii) was independently developed by the Receiving Party without breach of any obligation owed to the Disclosing Party; or (iv) is received from a third party without breach of any obligation owed to the Disclosing Party. The Receiving Party shall not disclose or use any Confidential Information of the Disclosing Party for any purpose outside the scope of this Agreement, except with the Disclosing Party's prior written permission. If the Receiving Party is compelled by law to disclose Confidential Information of the Disclosing Party, it shall provide the Disclosing Party with prior notice of such compelled disclosure (to the extent legally permitted) and reasonable assistance, at Disclosing Patty's cost, if the Disclosing Party wishes to contest the disclosure. If the Receiving Party discloses or uses (or threatens to disclose or use) any Confidential Information of the Disclosing Party in breach of confidentiality protections hereunder, the Disclosing Party shall have the right, in addition to any other remedies available to it, to seek injunctive relief to enjoin such acts, it being specifically acknowledged by the parties that any other available remedies are inadequate. 7. Miscellaneous. 7.1RoadBotics may identify Customer as a customer of RoadBotics, including a general description of the products and services provided by RoadBotics to Customer. Subject to APRA and the terms of section 6 of this Proposal, Neither party will disclose the pricing or other specific terms of this Proposal without the prior written consent of the other party except as may be required by law. 7.2 All provisions of this Agreement shall be considered as separate terms and conditions, and in the event any one shall be held illegal, invalid or unenforceable, all the other provisions hereof shall remain in full force and effect as if the illegal, invalid, or unenforceable provision were not a part hereof, unless the provision held illegal, invalid or unenforceable is a material provision of this Agreement, in which case RoadBotics and Customer agree to amend this Agreement with replacement provisions containing mutually acceptable terms and conditions. 7.3 The parties hereunder are independent contractors. Neither party shall have any right to assume, create, or incur any expense, liability, or obligation, express or implied, on behalf of the -2- RoadBotics other party. This Agreement is not intended to be nor shall it be construed as a joint venture, association, partnership or other forms of a business organization or agency relationship. 7.4 This Agreement,constitutes the entire Agreement between the Customer and RoadBotics with respect to the subject matter hereof, and no waiver, modification, alteration or amendment of any of the terms or conditions hereof shall be effective unless and until set forth in a writing duly signed by authorized representatives of RoadBotics and Customer. 7.5 RoadBotics shall not be responsible for any failure or delay in the performance of any obligation hereunder, if such failure or delay is due to a cause beyond RoadBotics's reasonable control, including, but not limited to acts of God, flood, fire, volcano, war, third -party suppliers, labor disputes or governmental acts. 7.6 All notices to either party shall be in writing and delivered by hand or by certified mail or overnight delivery service to the address set forth by Customer or RoadBotics or to such other address as either party shall give by notice to the other party. Notices shall be effective when delivered to the applicable address. 7.7 The provisions of Sections 3, 4, 5, 6, and 7 of this Agreement shall survive the expiration or termination of this Agreement for any reason Addendum A RoadBotics Current Service and Cost is Roadway Pavement Map containing images of the road every 3m. Every Assessment. Roadway point on the map can be visualized independently and Insights has a corresponding timestamp of when it was (Rw Insights) collected. Data is retained for 3-years. Each section of Iroad is scored using our advanced Al according to a 1-5 scale that runs from good condition to poor condition. Tools are provided for both planning and maintenance activities to allow users to hone in on sections of road that require attention are need to be replaced in long- term budget planning. RoadBot Full Service Co RB will arrange for our own trained service professionals to perform comprehensive data collection. Data will be collected efficiently and affordably while maintaining rigorous standards of quality to ensure the best product deliverable. -3- RoadBotics Local Data Backu Complete Local Backup! RoadBotics will provide a hard drive containing a of Product Data complete backup of all product image data and map files corresponding to a single complete RoadBot assessment. RoadBotics hereby grants an individual license to the data in such copies with the limitation that you may not resell any data without the express prior written permission of RoadBotics. $500/Hard Drive/Assessment RoadBotics Addendum A RoadBotics Pricing Proposed Roads: RoadBotics will assess 550 Centerline Miles of roads Once within the boundary of the City of South Bend, IN provided by the customer. RoadBotics Service and Cost: $33,000.00 for 550 Centerline Miles per scan. RoadWay Assessment Critical dates Contract Sign Deadline: To guarantee the pricing proposed in this offering, the contract must be signed by July 10, 2018 Anticipated Assessment Execution. Start Date: August 15, 2018** RoadBotics Assessment Delivery Deadline: September 15, 2018 * *Weather conditions might delay the assessment start date. RoadBotics will contact the customer if any such condition arises. Program Period: One year from the date of delivery of the first assessment and credentials. Contract Sign Deadline: To guarantee the pricing proposed in this offering, the contract must be signed by July 10, 2018 -5- wr RoadBotics RoadBotics Policy Regarding Ridership with Drivers RoadBotics frequently receives requests from customers to inspect the data collection process or to ride with data collection personnel while they are collecting data. Though we would like to accommodate these requests, for a variety of reasons including insurance risks and liability concerns, we are unable to accommodate such requests. RoadBotics is happy to provide you with detailed explanations of the data collection process, including sample data collection videos, or to otherwise answer questions or address concerns you may have with this process. Feel free to reach out to your dedicated account manager or contact us at info c roadbotics.com with any questions or concerns you may have. We thank you for your understanding. Sincerely, Team RoadBotics -6- EXHIBIT B Contractor's Affidavit [See attached.] 24203589.2 Wien the prospective Contractor is unable to certify to any of the statements below, it shall attach an explanation: to this Affidavit. CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, CERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY VERIFICATION, NON-DISCRIMINATION COMMITMENT AND CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR FOUNDRY PRODUCTS (Must be completed for all quotes and bids. Please type or print) STATE OF ) } SS: COUNTY ) The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury that: 1. Contractor has not, nor has any other member, representative, or agent of the firm, company, corporation or partnership represented by him, entered into any combination, collusion or agreement with any person relative to the price to be bid by anyone at such letting nor to prevent any person from bidding nor to induce anyone to refrain from bidding, and that this bid is made without reference to any other bid and without any agreement, understanding or combination with any other person in reference to such bidding. Contractor further says that no person or persons, firms, or corporation has, have or will receive directly or indirectly, any rebate, fee, gift, commission or thing of value on account of such sale; and 2. Contractor certifies by submission of this proposal that neither contractor nor any of its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency; and 3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged in investment activities in Iran. a. For purposes of this Certification, "Iran" means the government of Iran and any agency or instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as amended from time -to -time. b. As provided by Ind. Code § 5-22-16.5-8, as amended from time -to -time, a Contractor is engaged in investment activities in Iran if either: i. Contractor, its successor or its affiliate, provides goods or services of twenty million dollars ($20,000,000) or more in value in the energy sector of Iran; or ii. Contractor, its successor or its affiliate, is a financial institution that extends twenty million dollars ($20,000,000) or more in credit to another person for forty-five (45) days or more, if that person will (i) use the credit to provides goods and services in Non-Coltusion Non -Debarment Affidavit Novi Iran Form the energy sector in Iran; and (ii) at the time the financial institution extends credit, is a person identified on list published by the Indiana Department of Administration, 4. Contractor does not knowingly employ or contract with an unauthorized alien, nor retain any employee or contract with a person that the Contractor subsequently learns is an unauthorized alien. Contractor agrees that he/she/it shall enroll in and verify the work eligibility status of all of Contractor's newly hired employees through the E-Verify Program as defined by I.C. 22-5-1.7-3. Contractor's documentation of enrollment and participation in the E-Verify Program is included and attached as part of this bid/quote; and 5. Contractor shall require his/her/its subcontractors performing work under this public contract to certify that the subcontractors do not knowingly employ or contract with an unauthorized alien, nor retain any employee or contract with a person that the subcontractor subsequently learns is an unauthorized alien, and that the subcontractor has enrolled in and is participating in the E-Verify Program. The Contractor agrees to maintain this certification throughout the term of the contract with the City of South Bend, and understands that the City may terminate the contract for default if the Contractor fails to cure a breach of this provision no later than thirty (30) days after being notified by the City. 6. Persons, partnerships, corporations, associations, or joint venturers awarded a contract by the City of South Bend through its agencies, boards, or commissions shall not discriminate against any employee or applicant for employment in the performance of a City contract with respect to hire, tenure, terms, conditions, or privileges of employment, or any matter directly or indirectly related to employment because of race, sex, religion, color, national origin, ancestry, age, gender expression, gender identity, sexual orientation or disability that does not affect that person's ability to perform the work. In awarding contracts for the purchase of work, labor, services, supplies, equipment, materials, or any combination of the foregoing including, but not limited to, public works contracts awarded under public bidding laws or other contracts in which public bids are not required by law, the City, its agencies, boards, or commissions may consider the Contractor's good faith efforts to obtain participation by those Contractors certified by the State of Indiana as a Minority Business ("MBE") or as a Women's Business Enterprise ("WBE") as a factor in determining the lowest, responsible, responsive bidder. In no event shall persons or entities seeking the award of a City contract be required to award a subcontract to an MBE/WBE; however, it may not unlawfully discriminate against said WBE/MBE. A finding of a discriminatory practice by the City's MBE/WBE Utilization Board shall prohibit that person or entity from being awarded a City contract for a period of one (1) year from the date of such determination, and such determination may also be grounds for terminating the contact for which the discriminatory practice or noncompliance pertains. 7. The undersigned contractor agrees that the following nondiscrimination commitment shall be made a part of any contract which it may henceforth enter into with the City of South Bend, Indiana or any of its agencies, boards or commissions. Non -Collusion Non-Dabamient Affidavit Non Iran Foriu Contractor agrees not to discriminate against or intimidate any employee or applicant for employment in the performance of this contract with privileges of employment, or any matter directly or indirectly related to employment, because of race, religion, color, sex, gender expression, gender identity, sexual orientation, handicap, national origin or ancestry. Breach of this provision may be regarded as material breach of contract. I, the undersigned bidder or agent as contractor on a public works project, understand my statutory obligations to the use of steel products or foundry products made in the United States (I.C. 5-16-$-1). I hereby certify that I and all subcontractors employed by me for this project will use steel products or foundry products made in the United States on this project if awarded. I understand I have an affirmative duty to notify the City in my bid that my proposal does not include the use of steel products or foundry products made in the United States. I understand it is my sole obligation and responsibility to provide a justification to the City, subject to review and approval, why the cost of United States made steel or foundry products is unreasonable. Prior to award and upon submission of bid which does not use steel products or foundry products made in the United States, the City, through its director of public works, shall make a determination if the price of United States made steel or foundry is unreasonable. I understand that violations hereunder may result in forfeiture of contractual payments. I hereby affirm under the penalties of perjury that the facts and information contained in the foregoing bid for public works are true and correct. Dated this day of , 20_ Contractor/Bidder (Firm) Signature of Contractor/Bidder or Its Agent Printed Name and Title Subscribed and sworn to before me this day of , 20_ My Commission Expires Notary Public County of Residence Non -Collusion Non -Debarment Affidavit Non Iran Fowm Date Name BOARD OF PUBLIC WORKS AGENDA ITEM REVIEW REQUEST FORM 8/7/18 Derick RobertslTerri Swift Department PWIStreets BPW Date Phone Extension 7567 ® Agreement ❑ Contract U Proposal LJ Addendum ❑ Professional Services ❑ Resolution ❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet ❑ Quote Opening ❑ Quote Award ❑ Change Order No. ❑ CIO & PCA No. ❑PCA ❑ Ease/Encroach. ❑ Traffic Control ❑ Other: Required Information Company or Vendor Name RoadBotics New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing MBEIWBE Contractor ❑ MBE ❑ WBE MBEIWBE Contractor Requested ❑ No ❑ Yes Name of Company Project Name 2018 Road Surface Condition Assessment Project Number Funding Source MVH Account No. 202-0607-431.31-06 Amount 33,000.00 Terms of Contract Purpose/Description To provide additional assessment tool for road surface condition — Pilot Program ❑ Required Contractor's Certification Form Attached (Non - Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. Required ForChange Orders Only Amount of ❑ ❑ Increase $ Decrease $ Previous Amount $ Current Percent of Change: % New Amount $ Total Percent of Change: % Dispersal After Approval Copy Original ❑ ❑ Roger Nawrot ❑ ❑ Tara Wiegand ❑ ❑ Terri Swift