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HomeMy WebLinkAboutOpening of Qualifications - Lead Hazard Reduction Program Pre-Qualified Contractors RFQ - Environmental Assurance Co, Inc.Exhibit A: Lead Hazard Reduction Program Contractor Application City of South Bend Lead Hazard Reduction Program Contractor Application Company Name: Environmental Assurance Co.. Inc Street Address: 440 Hancock St City: Indianapolis State: Indiana Zip Code: 46222 Business Owner's Name: Jeff Hart Phone: 317-636-8500 Email: jhart@eaciusa.com / tmushen@eaciusa.com I. Is applicant a Licensed Indiana Abatement Contractor? ® Yes ❑ No If yes, provide a copy of license. 2. Will the applicant have at least one licensed Lead Project Supervisor on-site? N Yes ❑ No If yes, provide a copy of licenses of Lead Project Supervisor(s) and Lead Worker(s) for all employees or subcontractors who will be performing lead abatement work. 3. Is applicant an EPA approved Renovation, Repair and Painting certified firm? ❑ Yes j1 No If yes, provide a copy of certification. 4. Does applicant have required Commercial General Liability Insurance? ZI Yes ❑ No If yes, provide a copy of the Statement of Coverage. It must include a minimum coverage of per Person in the amount of $50,000 and per Occurrence in the amount of $1,000,000. 5. Does applicant have Worker's Compensation Insurance? IN Yes ❑ No If yes, provide a copy of the Statement of Coverage. 6. Are you or any of your employees licensed to do electrical, heating or plumbing work in the City of South Bend? ❑ Yes ]K] No (If yes, provide name and license information below): Name: License Type: License Number: 1 Exhibit A: Lead Hazard Reduction Program Contractor Application 7. Is applicant registered, or willing to register, in the System for Award Management (SAM) and the Federal Awardee Performance and Integrity Information System (FAPIIS)? IN Yes, currently registered ❑ Not currently registered, but willing to complete (the City can provide a registration guide) ❑ Not registered, and will not complete 8. Do you want to be placed on the registry for one grantor both? ❑ IHCDA Grant Only ❑ OLHCHH Grant Only ]Kl Both Grants 9. Please list any residential property owned solely or co -owned by you within the City of South Bend: I certify that the answers provided are true and accurate to the best of my knowledge: X] Yes ❑ No I understand that if placed on the Registry, I will receive notice of opportunities to bid on Lead Hazard Reduction Program work. And I understand that work will be awarded to the lowest, responsive and responsible bid: 0 Yes ❑ No I have read and agree to the minimum specifications and program conditions for participation in the Lead Hazard Reduction Program's Registry of Pre -Qualified Contractors. K] Yes ❑ No Signature Name (Printed) 3/11/2021 Date IU Exhibit C: Lead Hazard Reduction Program — COVID-19 Policy City of South Bend COVID-19 Policy The City of South Bend ("the City") requires contractors participating in the Lead Hazard Reduction Program to follow physical distancing requirements established by the CDC, as well as rules and regulations from OSHA. Contractors participating in the program are strongly encouraged to perform a self -health check prior to visiting any residences. Contractors with a temperature greater than 100.4*F or who has flu-like symptoms should not visit any City facility or any residence associated with the program. Contractors are required to wear a face mask that covers their mouths and noses at all times when at a residence enrolled in the program or at any City facility. Any contractor who believes they have COVID-19, has tested positive for COVID-19, or has been told to quarantine by a medical provider agree to the following: 1. Notify the City as soon as possible when they find out they have (or suspect they have) COVID- 19. 2. Refrain from working in any residence enrolled in the Lead Hazard Reduction Program until cleared by a medical provider. 3. Notify the City when they are cleared to return to work by a medical provider. Additionally, the City strongly encourages any contractor who has tested positive for COVID-19 or has been told to quarantine by a medical provider to participate in contact tracing thru the Indiana State Department of Health. I have read and agree to follow these requirements for a safe workplace during the COVID-19 pandemic. Signatu Date When 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 Indiana ) ) SS: Marion 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 -Collusion Non -Debarment Affidavit Non 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-Debannent Affidavit Non Iran Form 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. 5-16-8-1). 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 11 th day of March 20 21 Subscribed and sworn to before me this 11 th My Commission Expires 6ernb°/ m. County of Residence Non -Collusion Non -Debarment Affidavit Non Iran Form Environmental Assurance Co., Inc Contractor/Bidder (Firm) Sigl ont Cractor/B der or Its Agent Jeff Hart /President Printed Name and Title .day of March . 20 21 '��C2K /111/ 1� Notary Public Hendricks {�RYe% BRENDA L REED z° c Resident of Hendricks Co. SEAL * My Commission Expires 'tiolte�� December 19, 2023 October 29, 2019 Based upon the review of your license application, the Indiana Lead and Health Homes Program has determined that you have fulfilled the requirements of 410 IAC 32 and are eligible for licensing in the following lead-based discipline: Lead Contractor. Enclosed is your Lead Contractor license. This card must be available for review at all times while you are implementing a lead-based project. This license may be revoked, pursuant to 410 IAC 32-2-8, if you: (1) Violate any requirements of these rules (410 IAC 32), or any other federal, state, or local regulation pertaining to lead-based paint activities. (2) Falsify information on your application for licensing. (3) Fail to meet any qualifications specified in 410 IAC 32. (4) Conduct a lead-based paint project, or related lead-based activity, in a manner which is hazardous to the public health. Your license is valid effective 10/15/2010, and will expire on 10/15/2022, as indicated on your card. We suggest that you attend the required training and submit an application for license renewal early to insure your license does not lapse. In order to avoid re -taking the initial training course, you must attend a refresher in the discipline you are seeking a license within three (3) years from the date of issuance of your last training course certificate. Indiana State Department of Health i I CHRIS S. HART Michael R. Kirkman i The Designated Representative of: ; Environmental Assurance Company, Inc. i. i Lead Contractor License # IND000659 Effective: 10/15/2010 Expiration. 10/75/2022 Birth Date: u .;dor: Height- Eye Color: _----- fir Color. --- — SfAlEFOM1 a9iIIlx,/t6ipj i Indiana State Department of Health 100 N. Senate Avenue, N855 Indianapolis, Indiana 46204 Lead Contractor IF�D0006Sg. ---- txpiration Date 10/15/2022 CHRIS S. HART Michael R. Kirkman The Designated Representative of: Fnvirnnmantnl Accitrnnra ('_mmnnnv Inr, Kristina Box, MD, FAC OG State Health Commissioner —,_—_ Indiana State r►a„�.:.,..,,.,« ..� Wit__,.,- - Environmental Management Institute at ivy Tech Community College 9301 E 59th St. Indianapolis IN 46216 (317) 248-4848 1 Indianapolis-EMI@ivytech.edu IvyTech.edu/EMI This confirms that 2673 N Country Club Rd Martinsville, IN 46151 Completed the 8 -hour instructional refresher course Lead Albatenient SupeRwisor on July 17, 202o and successfully passed the exam on July 17, 2020 JoJn B. Ketterman, Director Certificate: L1320-107 Expires: July 17, 2023 Ah4h, 1h Approved by: Illinois Department of Public Health Indiana State Department of Health F44 44 U.S. Environmental Protection Agency !`I h cod MB &EiS Depa�tmaM ad" Head n =; ti Lead Project Supervisor. Licerise41N.D000638 Effective: 091/10/2010 Expiration: 10/19/2021 Birth Date: Qui 1711966 Gender: M f height: 5-06, Eye Color: gown Weight: 9191 fair Color: Grey 4 . _.-............. STATE FORM 497,11121 10-1 8) Scanned with CamScanner ACORO� CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDD/YYYY) `—� 03/11/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER GUNTNAME: Karen O'Connell Bonding &Insurance Specialists Agency, Inc. (A/CC, PHONN Ext), 708-598-5355 FAX No : 708-598-6686 BISA a McNeil Company, McNeil and Company, Inc. in CA E-MAIL koconnell mcneilandcom an ADDRESS: p ycom dba McNeil & Company Insurance Services Lic# OB67313 13841 Southwest Highway, Orland Park IL 60462-1354 INSURERS AFFORDING COVERAGE NAIC/t INSURERA: ARCH Specialty Insurance Company A+15 21199 INSURED INSURER B: AXIS Surplus Insurance Company (A+15) 26620 Environmental Assurance Company, Inc. INSURER C: Westchester Surplus Lines Insurance Co (A++) 10172 440 South Hancock Street INSURER D: ARCH Insurance Company A+15) 11150 INSURER E: Indianapolis IN 46222 INSURER F THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR I TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MMIDD/YYYYI POLICY EXP iMMIDDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y EACHOCCURRENCE $ 1,000,000 CLAIMS -MADE X❑ OCCUR 12 EMP 71633 12 08/18/20 08/18/21 PREMISES eHENa occurrDence $ 100,000 X `Contractors Pollution Liabilit} Ohio Stop Gap Coverage MED EXP (Any one person) $ 5,000 X Incl. Asbestos & Lead Ops PERSONAL& ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER- GENERAL AGGREGATE $ 2,000,000 POLICY ❑X PRO- El LOC JECT PRODUCTS -COMP/OP AGG $ 2,000,000 "Per Claim $ 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO Ea accident BODILY INJURY (Per person) s OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ $ A UMBRELLA LIAB X OCCUR Y Y 12EMX0531106-$5MM 08/18/20 08/18/21 EACH OCCURRENCE $ 20,000,000 B X EXCESSLIAB CLAIMS -MADE EBZ640464012020-$10MM AGGREGATE $ 20,000,000 C 671821791 001 - $5MM DED RETENTION $ 444P' Ammtm PI $ D WORKERS COMPENSATIONPl Y _ X AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE EBWCC0000412 08/18/20 08/18/21 STATUTE ER OFFICER/MEMBEREXCLUDED' ❑N N/A E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 I(Mandatory in NH) If yes, describe under E.L- DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below AONTRACTO MOLD OPS CLAIM MADE FORMRS POLLUTION LIABILITY Y Y 12 EMP 71633 12 08/18/2008/18/21 $1,000,000 - OCCU URRENCE LIMI PROFESSIONAL LIABILITY - CLAIMS MADE FORM $1,000,000 - PER CLAIM $1,000,000 - AGGREGATE DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) ALL PROJECTS DONE DURING THE CAPTIONED POLICY TERM. rrra.ri r c RUL.ucrc CANCELLATION City of South Bend SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 227 W Jefferson Blvd THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN South Bends, IN 46601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE kao —A 4Q ,-p_ CA4 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD