The URL can be used to link to this page

Home My WebLink AboutOpening of Bids - Ductile Iron Pipes, Valves and Hydrant Material Specs Proj No. 120-054 - Utility Supply CompanyCI Project Name (Name ere) Project No. (Numb r her For Bids Due (Date h re) (Must Date: o Address: 63 City/State/Zip: Agent of Bidder (if Applicable): Pursuant to notices given, the u public works project of: SOUTH BEND, INDIANA R'S BID FOR PUBLIC W( Voc1 'heS ao a5g PART I pleted for all bids. Please type or print) _ Bidder (Firm): USDyit.r .215 1'e-e 1� Telephone Number: (23- ) 183- i) Ab ned offers to furnish labor and/or material necessary to complete the the City of South Bend, Indiana, if� accordance with plans and specifications prepared by: and dated (Enter sum of Total Base Bid plu Alte for the sum jof (enter the Total Bid as shown on the Proposal) f(13 tes shown on Proposal) (Numerical) The undersigned further agrees t fur ish a bond or certified check with this bid for an amount specified in the notice of the letting. If al ema ive bids apply, the undersigned submits a proposal for each in accordance with the notice. Any add ndums attached will be specifically referenced at the applicable page. If additional units of material included in the contract are needed, the cost of units must be the same as that shown in the original contrac if accepted by the City of South Bend. If the bid is to be awarded on a unit basis, the itemization of the u iits s iall be shown on a separate attachment. " ,, p� g r , ��1 f�"J�dl-L�6 Y ' (Si a (Printed Name of Person Signing) ACCEPTANCE The above bid is accepted this day of 20 Subject to the following condition BOARD OF PUBLIC WORKS Gary A. Gilot, President Elizabeth A. Maradik, Member Joseph R. Molnar, Member Jordan V. Gathers, Member Therese J. Dorau, Member Attest: Linda M. Martin, Clerk BID NAME Ductile I FOR BIDS DUE November BASE BID on P 50011tt,�, BID/PROPOSAL u C V r ITY OF SOUTH BEND IN65 pes, Valves, and Hydrants (PN 120-054) 24, 2020, 9:00 a.m., Local Time Item No. Description Quantity Unit Unit Price Total 1 4" X 18' Ductile Iron Pipe 10 EA I`1,g�,%� $ 3 L „3.� h 2 6" X 18' Ductile Iron Pipe 10 EA js(ib�� $ '� 3 8" X 18' Ductile Iron Pip 10 EA �,, 3��%� $ 3. 4 10" X 18' Ductile Iron Pie 5 EA X,3YFL $ ), 3` 8, $5 5 12" X 18' Ductile Iron Pie 5 EA 33� 63 4 $ 3. c St a 17- 6 16" X 18' Ductile Iron Pie 5 EA �`),�/�� a 6y, se $ o, 7 20" X 18' Ductile Iron Pie 5 EA 65-.I5/f� $ 5,1 "q 8 24"X 18' Ductile Iron Pie 5 EA �NfL $ 9 30"X 18' Ductile Iron Pie 5 EA (f 3,)lIrI $ 110111�.�5 10 4" Open Right, MJ vaIVE 10 EA 33Y, $ 313P,,�" 11 6" Open Right, MJ valve 50 EA $j, 12 8" 8" Open Right, MJ valve 10 EA $ 13 10" Open Right, MJ vale 5 EA j p}�,�� $ J, 304 3v 14 12" Open Right, MJ vale 5 EA ��3,�( $ 15 5.25" SB Fire Hydrant, Er FT 20 EA 1, �5 `) — $ 3(j i z u ,_ 16 5,25" SB Fire Hydrant, r,.5 F1 40 EA S9 — $ t3, 630 " 17 5.25" SB Fire Hydrant, E FT 40 EA �1r�,�"� $ 651 18 5.25" SB Fire Hydrant, E.5 F1 20 EA b _ $ 33,160 — 19 5.25" SB Fire Hydrant, 7 FT 10 EA IOU— $ „O — BASE BID TOTAL $j °I 3 "'Mechanical Joint (MJ) Bidder Name: �Pq� Bidder (Firm): Address: City/State/Zip: Telephone Number: F3 --141% S l4 L4o1' Fax Number: By (Sign jature Jl' I(Print/end me) e S (Title) QUOTATION UTILITY SUPPLY COMPANY U 52 SOUTH PARK AVENUE s PERU, IN 46970 US 765-472-4398 Bill To: SOUTH BEND WATER WORKS 915 SOUTH OLIVE STREET SOUTH BEND, IN 46619 US 574-235-5663 Attn: PEGGY HERTEL Customer ID: 101269 PO Number DUCTILE IRON, VALVE & HYDRA Order Number 1368628 Order Date E Page 11/18/2020 14:50:161 1 of 2 Quote Expires On 11/28/2020 Ship To: SOUTH BEND WATER WORKS 915 SOUTH OLIVE STREET SOUTH BEND, IN 46619 US Requested By: Mr. DARRIC COLE hip Route Taker MMUNDY Quantities Pricing LftenID Description UOM Unit Size Unit Price En:dOrdered Allocated Remaining UOM Unit Size 181.80 0.00 181.80 FT 4n TONJT FT 19.8200 3,603.28 1.0 4 C 51/350 TY N JOINT DUCTILE IRON 1.0 WATER MAIN 181.80 0.00 181.80 FT 6C 50TJ FT 15.1600 2,756.09 1.0 6" C L 50 TJ DUCTILE IRON PIPE 1.0 181.80 0.00 181.80 FT 8C 50TJ FT 20.3900 3,706.90 LO 8" C L50 TJ DUCTILE IRON PIPE 1.0 90.90 0.00 90.90 FT 10C 50 FT 26.3900 2,398.85 1.0 10" LASS 50 TYTON JT. DUCTILE 1.0 90.90 0.00 90.90 FT 12C 50 FT 33.6300 3,056.97 1.0 12" LASS 50 DUCTILE IRON PIPE 1.0 90.90 0.00 90.90 FT 16C 50 FT 49.5100 4,500.46 1.0 16" L 50 TYTON JOINT DI 1.0 90.90 0.00 90.90 FT 20C 50 FT 65.1500 5,922.14 1.0 20' LASS 50 T TON JT. 1.0 90.90 0.00 90.90 FT 24C 50 FT 82.4300 7,492.89 1.0 24" LASS 50 DUCTILE IRON PIPE 1.0 90.90 0.00 90.90 FT 30C 50 FT 113.2800 10,297.15 1.0 30 RICH CLASS 50 TYTON JOINT DUCTILE 1.0 10.00 0.00 10.00 EA 4A2 6123RN EA 338.7200 3,387.20 1.0 4" ELLER X MJ GATE VALVE OPEN 1.0 RIGHT 50.00 0.00 50.00 EA 6A236123RN EA 432.0400 21,602.00 1.0 6" MUELLER J X MJ GATE VALVE OPEN 1.0 RI T 10.00 0.00 10.00 EA 8A2 6123RN EA 688.0900 6,880.90 1.0 8" NIUELLER J X MJ GATE VALVE OPEN 1.0 RIGHT UTILITY SUPPLY COMPANY U 52 SOUTH PARK AVENUE S PERU, IN 46970 C US 765-472-4398 QUOTATION Order Number 1368628 Order Date Page 11/18/202014:50:161 2 of 2 Quote Expires On 11/28/2020 Quantities Pricing Ite Ite ID Description UOM Unit Price Extended Price Ordered Allocated Remaining UOM Unit Size Unit Size D.UU U.UU J.UU LA IUA 36123RN EA 1,072.8600 5,364.30 1.0 10" MJ R/W GATE VALVE L/ACC OPEN 1.0 5.00 0.00 5.00 EA 12A 36123RN EA 1,357.5600 6,787.80 1.0 12" ELLER X MJ GATE OPEN RIGHT 1.0 20.00 0.00 20.00 EA 423 35555 EA 1,559.0000 31,180.00 1.0 5 1/ , 3 WAY, 5 FT. BURY, OPEN RIGHT, 1.0 40.00 0.00 40.00 EA 423- 42022 EA 1,592.0000 63,680.00 1.0 5 114, 3 WAY, 51 FT. BURY, OPEN RIGHT, 1.0 40.00 0.00 40.00 EA 423- 35556 EA 1,625.0000 65,000.00 1.0 5 1/ , 6 FT. BUR , 3 WAY, OPEN RIGHT 1.0 20.00 0.00 20.00 EA 423- 42023 EA 1,658.0000 33,160.00 1.0 5 1/ , 3 WAY, 6V2 FT. BURY, OPEN RIGHT, 1.0 10.00 0.00 10.00 EA 423- 35557 IA 1,690.0000 16,900.00 1.0 51 , 7 FT. BURY, 3 WAY, OPEN RIGHT I.0 Total Lines: 19 SUB -TOTAL: 2979676.93 TAX: 0.00 AMOUNT D UE: 297,676.93 U.S. Dollars BID NAME Ductile Iron Pi es Va FOR BIDS DUE November 24, 202 , 9 Date: // - a o - acD go Address: G K0 S� H a r cW,, City/State/Zip: -`1 ��n �U ��; s y Agent of Bidder (if Applicable): When the prospective Contractor is unable CONTRACTOR'S NO -C( CERTIFICATION RE AR] ELIGIBILITY VERIFICATI CERTIFICATION OF USE OF (Must be STATE OF_ L d.- lam, A%rC,I COUNTY The undersigned Contractor, that: SS: es, and Hydrants D a.m. Lo al Time dder irm): bt f i 1, t L S" Cam, n n ;I QTelephone Number: ( 31-7 ) -7 V3 -`i G to any o the statements below, it shall attach an explanation to this Affidavit )LLUSI N AND NON -DEBARMENT AFFIDAVIT, )ING INN ESTMENT WITH IRAN, EMPLOYMENT DN, NON-DISCRIMINATION COMMITMENT AND UNITEE STATES STEEL PRODUCTS OR FOUNDRY PRODUCTS J for all quotes and bids. Please type or print) dully sworn upon his/her/its oath, affirms under the penalties of perjury 1. Contractor has iot, or has an company, corporation or p rtnershil collusion or agreemen with any per letting nor to prevent any person f bidding, and that this bid s made agreement, understanding r combi bidding. Contractor fuither says that or will receive directly or indirectly, on account of such sal ; an 2. Contractor cert of its principals are 1 ineligible, or voluntar department or agency; .y e cluded ind f other member, representative, or agent of the firm, represented by him, entered into any combination, on relative to the price to be bid by anyone at such :)m bidding nor to induce anyone to refrain from ithout reference to any other bid and without any ration with any other person in reference to such io person or persons, firms, or corporation has, have any rebate, fee, gift, commission or thing of value i of this proposal that neither contractor nor any suspended, proposed for debarment, declared participation in this transaction by any Federal 3. Contractor has �t, n�r has any successor to, nor an affiliate of, Contractor, engaged in investment activities in I an. a. For purpose of his Certification, "Iran" means the government of Iran and any agency or in entality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as amended om ime-to-time. b. As provided1by I# Code § 5-22-16.5-8, as amended from time -to -time, a Contractor is engaged i inv stment activities in Iran if either: i. Contract*, its successor or its affiliate, provides goods or services of twenty mill on d llars ($20,000,000) or more in value in the energy sector of Iran; or ii. Con xactc r, its successor or its affiliate, is a financial institution that extends twenty in Ilion dollars ($20,000,000) or more in credit to another person for fo -five (45) days or more, if that person will (i) use the credit to provides goods and services in the energy sector in Iran; and (ii) at the time the finaacial nstitution extends credit, is a person identified on list published by the 11pdia4a Department of Administration. 4. Contractor doe retain any employee c an unauthorized alien. eligibility status of a Program as defined 1: participation in the E- and 5. Contractor sh, public contract to cei with an unauthorized subcontractor subsegt enrolled in and is p maintain this certific, Bend, and understan Contractor fails to cut notified by the City. 6. Persons, partn, contract by the City of discriminate against a City contract with res] or any matter directly color, national origi orientation or disabilit In awarding con materials, or any not owingly employ or contract with an unauthorized alien, nor contract with a person that the Contractor subsequently learns is Contractor agrees that he/she/it shall enroll in and verify the work of Contractor's newly hired employees through the E-Verify I. . 22-5-1.7-3. Contractor's documentation of enrollment and Teri Program is included and attached as part of this bid/quote; uire his/her/its subcontractors performing work under this iat the subcontractors do not knowingly employ or contract nor retain any employee or contract with a person that the learns is an unauthorized alien, and that the subcontractor has eating in the E-Verify Program. The Contractor agrees to throughout the term of the contract with the City of South it the City may terminate the contract for default if the -ach of this provision no later than thirty (30) days after being corporations, associations, or joint venturers awarded a i Bend through its agencies, boards, or commissions shall not ployee or applicant for employment in the performance of a hire, tenure, terms, conditions, or privileges of employment, lirectly related to employment because of race, sex, religion, cestry, age, gender expression, gender identity, sexual does not affect that person's ability to perform the work. for he purchase of work, labor, services, supplies, equipment, nation of the foregoing including, but not limited to, public works contracts awarded under not required by law, the Contractor's good faith e the State of Indiana as Enterprise ("WBE") as bidder. Aic bidding laws or other contracts in which public bids are ity, its agencies, boards, or commissions may consider the ,rts to obtain participation by those Contractors certified by Minority Business ("MBE") or as a Women's Business factor in determining the lowest, responsible, responsive In no event shall persons 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/MB . A finding of a discriminatory practice by the City's MBE/WBE Utilization Board shal 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 r teiminating the contact for which the discriminatory practice or noncompliance pertai s. 7. The undersigned oontractor 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 Ben , Indiana or any of its agencies, boards or commissions. Contractor agrees not 1 o diE criminate against or intimidate any employee or applicant for employment in the performance of this contract with privileges of employment, or any matter directly or indi ectl related to employment, because of race, religion, color, sex, gender expression, gendet identity, sexual orientation, handicap, national origin or ancestry. Breach of th s pr vision may be regarded as material breach of contract. I, the undersigned bids statutory obligations ti States (I.C. 5-16-8-1). this project will use st project if awarded. I t that my proposal does the United States. I u justification to the Cil made steel or foundry bid which does not usi City, through its dire, United States made hereunder may result i agent as contractor on a public works project, understand my use of steel products or foundry products made in the United eby certify that I and all subcontractors employed by me for oducts or foundry products made in the United States on this stand I have an affirmative duty to notify the City in my bid nclude the use of steel products or foundry products made in Land it is my sole obligation and responsibility to provide a bject to review and approval, why the cost of United States .acts is unreasonable. Prior to award and upon submission of t products or foundry products made in the United States, the )f public works, shall make a determination if the price of or foundry is unreasonable. I understand that violations eiture of contractual payments. I hereby affirm under the per for public works are true and Dated this o�0 Subscribed and sworn to My Commission Expires -� - /0 of perjury thal the facts and information contained in the foregoing bid A. Ly f U 20 -2 0 R n LA Contractor idder irm Signature of Contractor/Bidder or s Agent Printed Name and Title ;fore me this �c t� day of Avem 6-e/ , 20 t Notary Public iun y of Resid nce ��uunu�rrrr oa NOTAPUBLIRY :3 SEAL ryw. O rF' i I�10; (To be completed only by Contrao INDIANA A "local Indiana business" refers to any (1) A business whose principal place of i (2) A business that pays a majority of its (3) A business that employs residents of (4) A business that makes significant cal subdivision. (5) A business that has a substantial pos the political subdivision. An "affected county" refers to St. Joseph Elkhart County, Marshall County, Starke There are the following price preferences • 5% for a purchase expected by the • 3 % for a purchase expected by the • 1 % for a purchase expected by the, Date: Pursuant to I.C. 5-22-15-20.9, preference for Project South Bend, St. Joseph County, ] the claiming to be a "locallndiana business" pursuant to I.C. 36-1-12-22) BUSINESS PREFERENCE CLAIM is located in an affected county. (in dollar volume) to residents of affected counties. counties as a majority of its employees. ,stments in the affected counties as defined in rules adopted by the political impact on the affected counties as defined by criteria in rules adopted by Indiana, or the following counties located adjacent to St. Joseph County: and LaPorte County purchased from a local Indiana business: agency to be less than $50, 000 agency to be at least $50, 000 but less than $100, 000. wencv to be at least $100, 000. claims a local Indiana business (Project # ) located within the City of ❑ The location of the principal p ace of business is (Address) ❑ St. Joseph County, Im iana ❑ The following cc unty located adjacent to St. Joseph County, Indiana: ❑ The majority of the busi ess' payroll for the 12 months prior to the date of this Bid is to residents of St. Joseph County, Indiana r the djacent county noted above. ❑ The majority of the busi es-' employees for the 12 months prior to the date of this Bid are residents of St. Joseph County, Indi a, or the adjacent county noted above. If the business is deemed to be e a arent lowest, responsible, responsive bidder, then it shall provide supporting documentation for 12 month period prior to the date of the Bid of (i) the total payroll amount paid to all employees of he b siness, and (ii) the total payroll amount paid to employees who are residents of St. Joseph County an I the adjacent county noted above. WHEN SUPPL YING SUPPIDRT�NG PAYROLL RECORDS, BIDDER SHALL REDACT ALL Dated this day of 1 1 , 20 Contractor/Bidder (Firm) Signature of Contractor/Bidder or Its Agent Printed Name and Title Project Name Project No. For Bids Due Contractor Name: M F SOUTH BEND, INDIANA PUBLIC WORK RESPONSIBLE BIDDER CHECKLIST Ductile Ilron ripes, Valves, and Hydrants Novem er 24, 2020, 9:00 a.m., Local Time The City seeks to enhance its zbility to identify responsive and responsible bidders on all City public works projects by institution of comprahensive submission requirements in compliance with State law. Quality workmanship, efficient operation, safety, and timely completion of projects requires that all bidders meet certain minimum requirements to be responsive and responsible bidders. THIS FORM MUST BE SUBMIT1 ED WITH YOUR BID. INSTRUCTIONS: If you are a pre -qualified bidde If you are not a pre -qualified bi Section II acts as an application considered for pre -qualification qualified bidders will then be exe 63 of The Responsible Bidding ( for a period of twelve (12) month Thereafter, contractors who are qualified" standing, on a form Bidders") by December 31 sc for tl qualified standing. If the status c of the contractor to notify the application for continuation of " automatic removal of the design the twelve (12) months of pre-qu However, the "removed" contra( projects, though the contractor n is re-established. Please Note: The City reserv( additional verification of any i inquiries of the bidder's currer It is the sole responsibility of the I the bidder in Section 6-63 of the opening. co plete Section I only. der, complete Section II only. Dr pre -qualification. Submission of Section II will allow the bidder to be r bids with the City of South Bend Department of Public Works. Pre- ipt from a portion of the submission requirements outlined in Section 6- -din nce No. 10594-18 (hereinafter, "Responsible Bidding Ordinance") 'e-q alified must submit a complete application for continuation of "pre- ovid d by the City ("Responsible Bidder Checklist (1) Pre -Qualified upcoming calendar year, or within twelve (12) months of obtaining pre - any item changes within the twelve (12) months, it is the responsibility ;ity. Failure by any pre -qualified contractor to submit its complete e-q alified" standing within the time prescribed above shall result in .ion, effective January 1 of the following year, or immediately following ified standing. )r or subcontractor shall still be permitted to bid on City public works st stibmit all required documents under 6-63 until "pre -qualified" status the right to request supplemental information from the bidder, Formation provided by the bidder, and may also conduct random and previous customers regardless of pre -qualified standing. ial bidder to comply with all submission requirements applicable to cnsible Bidding Ordinance no later than the date of the public bid POST BID SUBMISSIONS: Post -bid submissions must be Ordinance. The post -bid submi 1. All bidders shall collect, the name, address, licen has accepted a bid an( individuals performing w( 2. Each subcontractor, wh( thousand dollars ($150,( the Responsible Bidder 1 subcontractor shall subr work) to the successful b 3. Failure of a subcontract( bidder from performing � breach by the successfu work performed by a sut the City approves such it 4. The disclosure of a subc not create any rights in subcontractor for a Discli name, address, licensing 5. The successful bidder a certified payroll utilizing t submitted within 10 day: identify the job title an electronically. Please Note: Submissions de the automatic disqualification The City, after review of compli account all information in the s responsible, and provide a Pre utilize all information provided i through its own independent ver 00.0 )rdin der to the i in accordance with Section 6-64 of the Responsible Bidding irements are as follows: ain, and provide upon request, a current written list that discloses :atus, and type of work for any subcontractor from whom the bidder Mends to hire on any part of the public work project, including independent contractors. )rtion of the project is estimated to be at least one -hundred fifty ), shall be required to adhere to the requirements of Section I of ince as though it were bidding directly to the City, except that the required information (including the name, address, and type of )rior to the commencement of work. submit the required information shall not disqualify the successful n the project and shall not constitute a contractual default and/or �r. However, the City may withhold all payment otherwise due for actor, until the subcontractor submits the required information and :tor list ("Disclosed Subcontractor(s)") to the City by a bidder shall sclosed Subcontractor(s). Thus, a bidder may substitute another Subcontractor by giving the City, upon request, written notice of the and type of work of the substitute subcontractor. subcontractors on a public works project are required to submit eral form known as WH-347 or a similar form on a bi-weekly basis, the end of each bi-weekly payroll period. Certified payrolls shall Ft for each employee. Certified payrolls shall be submitted nadequate, incomplete, or untimely by the City may result in bid. timely submissions, shall, in its sole discretion, after taking into >n requirements, determine whether a bidder is responsive and ition Verification Letter. The City specifically reserves the right to (ntractor's submission and any information obtained by the City of the information provided by the contractor. PRE -QUALIFIED (a) Acknowledgements: (i) By checl the City within thi letter is (ii) _ By checl request provided CHECKLIST ig t is box, I hereby acknowledge that I am a pre -qualified bidder with f South Bend and that I have met the pre -qualification requirements last twelve (12) months. A copy of my Pre -Qualification verification (b) Attachments: (i) _ Indiana Sec within sixty (i is in exi ten Report, and individuals, s (ii) _ Statement c indicate an( It outline ho (iii) _ List of pr jec the StatE of I (iv) _ For evert pri programs, a approved by of Apprentice its box, I hereby acknowledge that the City reserves the right to emental information, additional verification of any information e, and may also conduct random inquiries of my current and prior tary of State's on-line records (ie. Business verification) dated 1) days of the submission of said document showing that business current with the Indiana Secretary of State's Business Entity eligible for a certificate of good standing. (Not applicable to e proprietors or partnerships). staffing capabilities, including labor sources. This statement ensures I have sufficient employees on staff to complete the work. I intend to meet the staffing needs of the work. of similar size and scope of work performed in all areas, including liana, within the last three (3) years. act, submit evidence of participation in apprenticeship and training Acable to the work to be performed on the project, which are nd registered with the United States Department of Labor's Office hip, or its successor organization. II. PRE -QUALIFICATION QHEC (a) Acknowledgements: (i) — By checking with the City — By checking request sup provided at custome s. bidder it res (iii) — By checking work pe form furnished upo (iv) — By chec ing contractors, fr work or the acknowl dge contract rs h,, bid. If a ub-c that sub ontr (b) Attachments: (i) — Indiana Secr within sixty (60) dal existence, cu and eligi le f proprietors or List iden ifyin Any detE rmir state, or loc antitrust laws Health Act preceding five Statement al indicates and am biddi g o Stateme it th; behalf w II be under all app For eve prc program;, al approved by of Appre tice Copy of a wr who will per requirements Service the bid T (FOR BIDDERS THAT ARE NOT PRE -QUALIFIED) its box, I hereby acknowledge that I am not a pre -qualified bidder f South Bend. its box, I hereby acknowledge that the City reserves the right to emental information, additional verification of any information may also conduct random inquiries of my current and prior ie City reserved the right to utilize all information provided in this d all information obtained in inquiries or requests to determine if a )onsive and responsible. Additionally, I acknowledge that all wided to the City shall be regarded as public records. this box, I hereby acknowledge that copies of all Applicable certificates or standards for training programs applicable to the sd on the project may be requested at any time and shall be r request. his box, I hereby acknowledge and ensure that I and all sub- Dm whom I have accepted a bid and/or intend to hire to perform public work project, are properly licensed. Furthermore, I ny understanding that it is my responsibility to ensure that all sub- ve the necessary licenses to undertake the work called for in this Dntractor loses their license at any point, it is the responsibility of actor to notify the City. ry of State's on-line records (ie. Business verification) dated ; of the submission of said document showing that business is in -ent with the Indiana Secretary of State's Business Entity Report, a certificate of good standing. (Not applicable to individuals, sole )artnerships). all former business names. tions by a court or governmental agency any violations of federal laws including, but not limited to, violations of contracting or tax or licensing laws, environmental laws, Occupational Safety and )SHA), or federal Davis -Bacon and related Acts, within the (5) years. )ut staffing capabilities, including labor sources. This statement Insures I have sufficient employees on staff to complete the work I OR outlines how I intend to meet the staffing needs of the work. individuals who will perform work on the public work project on my iroperly classified as an employee or as an independent contractor ;able state and federal laws and local ordinances. sct, submit evidence of participation in apprenticeship and training >licable to the work to be performed on the project, which are nd registered with the United States Department of Labor's Office hip, or its successor organization. en plan for employee drug testing that covers all of my employees rm work on the public work project and meets or exceeds the ,et forth in IC 4-13-18-5 or IC 4-13-18-6. 1 am utilizing a surety company which is on the Bureau of Fiscal rtment of Treasury's Listing of Approved Sureties" as required in rations or contract. (ix) _ Written state ent of any federal, ; owed to any federal, state or local to (i) _ List of projects of similar size and sc the StatE of Indiana, within three (� due. Date: �'? J a O (Sign Here) (Print Name Here) (Name of Company) b-310 s H " ' (Address of Company) L Y 1 Cl c\ <o (City) r"\j (State) (Telephone Number) state or local tax liens or tax delinquencies fixing body in the preceding three years. :ope of work performed in all areas, including 1) years prior to the date on which the bid is