HomeMy WebLinkAboutOpening of Bids - 905, 907, 909 Michigan Demolition Proj No. 120-063 - Indiana Earth, Inc.CITY OF SOUTH BEND, INDIANA
CONTRACTOR'S BID FOR PUBLIC WORK
RESPONSIBLE BIDDER CHECKLIST
Project Name 905-907-909 Michigan Demolition
Project No. 120-063
For Bids Due April 13t'', 9:00a.m. (local time) via email bpwbids@southbendin.gov
Contractor Name: T
The City seeks to enhance its ability to identify responsive and responsible bidders on all City public works
projects by institution of comprehensive 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 SUBMITTED WITH YOUR BID.
INSTRUCTIONS:
If you are a pre -qualified bidder, complete Section I only.
If you are not a pre -qualified bidder, complete Section II only.
Section II acts as an application for pre -qualification. Submission of Section II will allow the bidder to be
considered for pre -qualification for bids with the City of South Bend Department of Public Works. Pre -
qualified bidders will then be exempt from a portion of the submission requirements outlined in Section 6-
63 of The Responsible Bidding Ordinance No. 10594-18 (hereinafter, "Responsible Bidding Ordinance")
for a period of twelve (12) months.
Thereafter, contractors who are pre -qualified must submit a complete application for continuation of "pre -
qualified" standing, on a form provided by the City ("Responsible Bidder Checklist (1) Pre -Qualified
Bidders") by December 315' for the upcoming calendar year, or within twelve (12) months of obtaining pre -
qualified standing. If the status of any item changes within the twelve (12) months, it is the responsibility of
the contractor to notify the City. Failure by any pre -qualified contractor to submit its complete application
for continuation of "pre -qualified" standing within the time prescribed above shall result in automatic removal
of the designation, effective January 1 of the following year, or immediately following the twelve (12) months
of pre -qualified standing.
However, the "removed" contractor or subcontractor shall still be permitted to bid on City public works
projects, though the contractor must submit all required documents under 6-63 until "pre -qualified" status
is re-established.
Please Note: The City reserves the right to request supplemental information from the bidder,
additional verification of any information provided by the bidder, and may also conduct random
inquiries of the bidder's current and previous customers regardless of pre -qualified standing.
It is the sole responsibility of the potential bidder to comply with all submission requirements applicable to
the bidder in Section 6-63 of the Responsible Bidding Ordinance no later than the date of the public bid
opening.
Version 01/13/2021 General Conditions - 6
POST BID SUBMISSIONS:
Post -bid submissions must be submitted in accordance with Section 6-64 of the Responsible Bidding
Ordinance. The post -bid submission requirements are as follows:
1. All bidders shall collect, maintain, and provide upon request, a current written list that discloses the
name, address, licensing status, and type of work for any subcontractor from whom the bidder has
accepted a bid and/or intends to hire on any part of the public work project, including individuals
performing work as independent contractors.
2. Each subcontractor, whose portion of the project is estimated to be at least one -hundred fifty
thousand dollars ($150,000.00), shall be required to adhere to the requirements of Section I of the
Responsible Bidder Ordinance as though it were bidding directly to the City, except that the
subcontractor shall submit the required information (including the name, address, and type of work)
to the successful bidder prior to the commencement of work.
3. Failure of a subcontractor to submit the required information shall not disqualify the successful
bidder from performing work on the project and shall not constitute a contractual default and/or
breach by the successful bidder. However, the City may withhold all payment otherwise due for
work performed by a subcontractor, until the subcontractor submits the required information and
the City approves such information.
4. The disclosure of a subcontractor list ("Disclosed Subcontractor(s)") to the City by a bidder shall
not create any rights in the Disclosed Subcontractor(s). Thus, a bidder may substitute another
subcontractor for a Disclosed Subcontractor by giving the City, upon request, written notice of the
name, address, licensing status, and type of work of the substitute subcontractor.
5. The successful bidder and all subcontractors on a public works project are required to submit
certified payroll utilizing the federal form known as WH-347 or a similar form on a bi-weekly basis,
submitted within 10 days after the end of each bi-weekly payroll period. Certified payrolls shall
identify the job title and craft for each employee. Certified payrolls shall be submitted
electronically.
Please Note: Submissions deemed inadequate, incomplete, or untimely by the City may result in
the automatic disqualification of the bid.
The City, after review of complete and timely submissions, shall, in its sole discretion, after taking into
account all information in the submission requirements, determine whether a bidder is responsive and
responsible, and provide a Pre -Qualification Verification Letter. The City specifically reserves the right to
utilize all information provided in the contractor's submission and any information obtained by the City
through its own independent verification of the information provided by the contractor.
Version 01/13/2021 General Conditions - 7
PRE -QUALIFIED BIDDER CHECKLIST
(a) Acknowledgements:
(i) _ By checking this box, I hereby acknowledge that I am a pre -qualified bidder with
the City of South Bend and that I have met the pre -qualification requirements within
the last twelve (12) months. A copy of my Pre -Qualification verification letter
is attached.
(ii) _ By checking this box, I hereby acknowledge that the City reserves the right to
request supplemental information, additional verification of any information
provided by me, and may also conduct random inquiries of my current and prior
customers.
(b) Attachments:
(i) _ Indiana Secretary of State's on-line records (ie. Business verification) dated within
sixty (60) days of the submission of said document showing that business is in
existence, current with the Indiana Secretary of State's Business Entity Report,
and eligible for a certificate of good standing. (Not applicable to individuals, sole
proprietors or partnerships).
(ii) _ Statement on staffing capabilities, including labor sources. This statement
indicates and ensures I have sufficient employees on staff to complete the work. It
outlines how I intend to meet the staffing needs of the work.
(iii) _ List of projects of similar size and scope of work performed in all areas, including
the State of Indiana, within the last three (3) years.
(iv) _ For every project, submit evidence of participation in apprenticeship and training
programs, applicable to the work to be performed on the project, which are
approved by and registered with the United States Department of Labor's Office of
Apprenticeship, or its successor organization.
Version 01/13/2021 General Conditions - 8
II. PRE -QUALIFICATION CHECKLIST (FOR BIDDERS THAT ARE NOT PRE -QUALIFIED)
(a) Acknowledge ents:
(i) By checking this box, I hereby acknowledge that I am not a pre -qualified bidder
/ with the City of South Bend.
(ii) ✓ By checking this box, I hereby acknowledge that the City reserves the right to
request supplemental information, additional verification of any information
provided, and may also conduct random inquiries of my current and prior
customers. The City reserved the right to utilize all information provided in this
submission and all information obtained in inquiries or requests to determine if a
bidder is responsive and responsible. Additionally, I acknowledge that all
information provided to the City shall be regarded as public records.
(iii) By checking this box, I hereby acknowledge that copies of all Applicable
apprenticeship certificates or standards for training programs applicable to the
work performed on the project may be requested at any time and shall be furnished
/ upon request.
(iv) ✓ By checking this box, I hereby acknowledge and ensure that I and all sub-
contractors, from whom I have accepted a bid and/or intend to hire to perform work
on the public work project, are properly licensed. Furthermore, I acknowledge my
understanding that it is my responsibility to ensure that all sub -contractors have
the necessary licenses to undertake the work called for in this bid. If a sub-
contractor loses their license at any point, it is the responsibility of that sub-
contractor to notify the City.
(b) Attachments:
(i)
Indiana Secretary of State's on-line records (ie. Business verification) dated within
sixty (60) days of the submission of said document showing that business is in
existence, current with the Indiana Secretary of State's Business Entity Report,
and eligible for a certificate of good standing. (Not applicable to individuals, sole
proprietors or partnerships).
(ii) _Z
List identifying all former business names.
(iii)
Any determinations by a court or governmental agency any violations of federal
state, or local laws including, but not limited to, violations of contracting or antitrust
laws, tax or licensing laws, environmental laws, Occupational Safety and Health
Act (OSHA), or federal Davis -Bacon and related Acts, within the preceding five (5)
(iv) _4Z
years.
Statement about staffing capabilities, including labor sources. This statement
indicates and ensures I have sufficient employees on staff to complete the work I
/
am bidding on OR outlines how I intend to meet the staffing needs of the work.
(v) //
Statement that individuals who will perform work on the public work project on my
behalf will be properly classified as an employee or as an independent contractor
under all applicable state and federal laws and local ordinances.
(vi)
For every project, submit evidence of participation in apprenticeship and training
programs, applicable to the work to be performed on the project, which are
approved by and registered with the United States Department of Labor's Office of
Apprenticeship, or its successor organization.
(vii) ��
Copy of a written plan for employee drug testing that covers all of my employees
who will perform work on the public work project and meets or exceeds the
requirements set forth in IC 4-13-18-5 or IC 4-13-18-6.
(viii)
Evidence that I am utilizing a surety company which is on the Bureau of Fiscal
Service "Department of Treasury's Listing of Approved Sureties" as required in the
bid specifications or contract.
Version 01/13/2021 General Conditions - 9
v
(ix) _ Written statement of any federal, state or local tax liens or tax delinquencies owed
to any federal, state or local taxing body in the preceding three years.
(i) List of projects of similar size and scope of work performed in all areas, including
the State of Indiana, within three (3) years prior to the date on which the bid is due.
Date: (?-
(Sign Here) y
(Print Name Here)
IL)
(Name of Company)
(Address of Company)
0\S Ce) ly
(City)
(State)
s` 7y- 6 -7y- 6 ,
(Telephone Number)
Version 01/13/2021 General Conditions - 10
i
Building Pre -qualification checklist items:
• Indiana Earth, INC has no former business names.
• Indiana Earth, INC has had no determinations by a governmental agency of any violations.
• Indiana Earth has the crew and staff to complete this project.
• Those that work on this project will be employees of Indiana Earth or of a hired subcontractor
which are under all applicable state and federal laws and local ordinances.
• Operators and Laborers drug screening are through the BCRC Building Construction Resource
Center at BCRCNET.com.
• Teamster's drug screening are performed during pre -employment and by random through
Figment Group with quarterly random requirements.
• Indiana Earth, INC has no current tax liens.
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10343 McKinley Hwy. • Osceola, IN 46561 • (574) 674-6488 • FAX (574) 674-6480
Business Name: INDIANA EARTII, INC.
Entity Type: Domestic For -Profit Corporation
Creation Date: 03C22/1990
Principal Office Address: 10343 MCKiNLEy, H y,, OSCEOLA, IN,
46561 - 9756, USA
Jurisdiction of Formation: Indiana
-BUSINESS INFORrtiiATION
COMUE .LAWSON
INDIANA, SECUTARY OF STATE
09/20/2013 07:33 AIM
1
Business ID: 1990031137
Business Status: Active
Inactive Date:
Expiration Date: Perpetual
Business Entity Report Due
03/31/2020
Dale:
Years Due:
Title Name Address
President MARK L OSLER 10343 McKinley Hwy., Osceola61Z4, 46561, USA
Type: Individual
Name: MARL{ OSLER
Address: 10343 MCKINLEY HWY,, OSCEOLA, IN, 46561 -9756, USA
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CITY OF SOUTH BEND, INDIANA IN°
CONTRACTOR'S BID FOR PUBLIC WORK
CHECKLIST FOR BIDDERS
Project Name 905-907-909 Michigan Demolition
Project No. 120-063
For Bids Due April 13t'', 9:00a.m. (local time) via email bpwbids@southbendin.gov
From time to time the South Bend Board of Public Works finds it necessary to reject a bid because
it does not comply with statutory requirements. In preparing your bid, please use the following
checklist in order to make sure that your bid is done in the proper manner.
!� Proper bid security included. The bidder has the option of providing either a Certified Check
or Bid Bond.
/ Bid prepared on the City of South Bend Contractor's Bid for Public Work Form, completely
executed.
Contractor's Non -Collusion and Non -Debarment Affidavit, Certification Regarding Investments
with Iran, Employment Eligibility Verification, Non -Discrimination Commitment, and
Certification of use of United States Steel Products or Foundry Products.
Proof of MWBE Utilization Plan [MWBE-1.0]. If minimum participation goal is not met, also
provide Evidence of Good Faith Efforts Form [MWBE-2.0] and MWBE Contacted Form
[MWBE-2.1 ].
✓ Acknowledge Receipt of Addendum(s) included with the bid.
_Z All required additional information is included with the bid.
/ Proposal statements and other affidavits all signed by the proper party with name either
✓ printed or typed underneath signature.
tZ This checklist submitted with the Bid.
This checklist is provided for bidder's use in assuring compliance with required
documentation; however, it does not include all specifications requirements and does not
relieve the bidder of the need to read and comply with the specifications.
Bidder: _T r_�v d
By Authorized Represe
Signature:
Print Name & Title:
�L• 1 1
r
Date: If—
Version 01/13/2021 Contractor's Bid for Public Works - 1
4!l
1316 COUNTY -CITY BUILDING ri'�cr. /" PHONE 574/ 235-9251
227 W. JEFFERSON BOULEVARD \ =,, i FAx 574/ 235-9171
SOUTH BEND, INDIANA 46601-1830
ISG:/ TDD 574/235-5567
CITY OF SOUTH BEND, JAMES MUELLER, MAYOR
BOARD OF PUBLIC WORKS
Date: April 9, 2021
To: All Planholders
From Anne Fuchs, Clerk, Board of Public Works
Subject Addendum Number: 1
Project Name: 905-907-909 Michigan Demolition
Project Number: 120-063
ACKNOWLEDGEMENT OF RECEIPT OF ADDENDUM
Date Received: '�— y —
This addendum is being forwarded to you for the above referenced project.
Please sign below and acknowledge receipt of this Addendum
by including in your electronic submission. A copy MUST be
included with your bid package upon submittal.
THIS ADDENDUM MAY AFFECT YOUR BID.
Notes: See attached memo/clarifications, and revised bid sheet
The attached documents are hereby added to the Specifications and Contract
Documents and become a part of herein.
Company:
Authorized Si
Date:
Version 8/11/2020
CITY OF SOUTH BEND, INDIANA
CONTRACTOR'S BID FOR PUBLIC WORK
Project Name 905-907-909 Michigan Demolition
Project No. 120-063
For Bids Due April 13th, 9:00a.m. (local time) via email bpwbids@southbendin.gov
PART I
(Must be completed for all bids. Please type or print)
Date: J-( Bidder (Firm):
Address: �O ` ' ft /�,'„ /0 /(t•-.
City/State/Zip: ��eSC.��� T.�v_iZ, Telephone umber:
Agent of Bidder (if Applicable):
Pursuant to notices given, the undersigned offers to furnish labor and/or material necessary to complete the
public works project of:
11l�G�� Sin 0z/r<<`!)s9:�
the City of South Bend, Indiana, in accordance with plans and specifications prepared by:
- ,)raJ
and dated for the sum of (enter the Total Bid as shown on the Proposal)
I 1 / / I / J w�
�W� A J,l d rc, A 1`� L'i Z-,�J :5 : X �1�/yl c� ✓r d �.C� ($
(Enter sum of Total Base Bid plus Alternates shown on Proposal) (Numerical)
The undersigned further agrees to furnish a bond or certified check with this bid for an amount specified in
the notice of the letting. If alternative bids apply, the undersigned submits a proposal for each in accordance
with the notice. Any addendums 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 contract if accepted by the City So th Bench., If�/bid is to be awarded on a unit
basis, the itemization of the units shall be shown o City
�chhe t. _
The above bid is accepted this
Subject to the following conditions:
BOARD OF PUBLIC WORKS
Elizabeth A. Maradik, President
Gary A. Gilot, Member
By V A11 r—
GAY•
I
ACCEPTANCE
day of
(Signature)
of Person Signing)
Joseph R. Molnar, Member
Jordan V. Gathers, Member
Murray Miller, Member Attest: Anne Fuchs, Clerk
20
Version 01/13/2021 Contractor's Bid for Public Works - 2
PART II
(For projects of $100,000 or more — IC 36-1-12-4)
These statements to be submitted under oath by each bidder with and as part of his/her/its bid.
Attach additional pages for each section as needed.
SECTION I EXPERIENCE QUESTIONNAIRE
1. Attach information regarding projects your organization has completed for the period of one
(1) year prior to the date of the current bid.
2. Attach a listing of public works projects currently in process of construction by your
organization.
3. Attach information regarding any failure to complete any work awarded to you and the
location thereof.
4. Attach references from private firms for which you have performed work.
SECTION II PLAN AND EQUIPMENT QUESTIONNAIRE
Attach an explanation of your plan or layout for performing proposed work. (Examples could
include a narrative of when you could begin work, complete the project, number of workers,
etc. and any other information which you believe would enable the City of South Bend to
consider your bid.)
2. Attach a listing of the names and addresses of all subcontractors (i.e. persons or firms outside
your own firm who have performed part of the work) that you have used on public works
projects during the past five (5) years along with a brief description of the work done by each
subcontractor.
3. If you intend to sublet any portion of the work, attach the name and address of each
subcontractor, equipment to be used by the subcontractor, and whether you will require a
bond. However, if you are unable to currently provide a listing, please understand a listing
must be provided prior to contract approval. Until the completion of the proposed project, you
are under a continuing obligation to immediately notify the City of South Bend in the event that
you subsequently determine that you will use a subcontractor on the proposed project.
4. Attach a listing of equipment you have available to use for the proposed project.
5. Have you entered into contracts or received offers for all materials which substantiate the
prices used in preparing your proposal? If not, attach an explanation for the rationale used
which would corroborate the prices listed.
SECTION III CONTRACTOR'S FINANCIAL STATEMENT
Attachment of bidder's financial statement is mandatory. Any bid submitted without said
financial statement as required by statute shall thereby be rendered invalid. The financial
statement provided hereunder to the City of South Bend awarding the contract must be specific
enough in detail so that said City of South Bend can make a proper determination of the bidder's
capability for completing the project if awarded.
Version 01/13/2021 Contractor's Bid for Public Works - 3
The above bid is accepted this
following conditions:
Contracting Authority Members:
ACCEPTANCE
day of , subject to the
PART II
(For projects of $150,000 or more — IC 36-1-12-4)
Governmental Unit: �- �y cr _��>�h �•. �w
Bidder (Firm)14 _ �n
Date (month, day, year): ez` - 14 — R
These statements to be submitted under oath by each bidder with and as a part of his bid.
Attach additional pages for each section as needed.
SECTION I EXPERIENCE QUESTIONNAIRE
What public works projects has your organization completed for the period of one (1) year prior to the
date of the current bid?
Contract Amount
Class of Work
Completion
Date
Name and Address of Owner
What public works projects are now in process of construction by your organization?
Contract Amount
Class of Work
Expected
Completion
Date
Name and Address of Owner
3. Have you ever failed to complete any work awarded to you? If so, where and why?
4. List references from private firms for
which you havee performed work.
SECTION II PLAN AND EQUIPMENT QUESTIONNAIRE
1. Explain your plan or layout for performing proposed work. (Examples could include a narrative of when
you could begin work, complete the project, number of workers, etc. and any other information which you
believe would enable the governmental unit to consider your bid.)
sc?,e � �.�4rA,..;, J
2. Please list the names and addresses of all subcontractors (i.e. persons or firms outside your own firm
who have performed part of the work) that you have used on public works projects during the past five (5)
years along with a brief description of the work done by each subcontractor.
s2- C ci �1 cz c < e-
If you intend to sublet any portion of the work, state the name and address of each subcontractor,
equipment to be used by the subcontractor, and whether you will require a bond. However, if you are
unable to currently provide a listing, please understand a listing must be provided prior to contract
approval. Until the completion of the proposed project, you are under a continuing obligation to
immediately notify the governmental unit in the event that you subsequently determine that you will use a
subcontractor on the proposed project.
4. What equipment do you have available to use for the proposed project? Any equipment to be used by
subcontractors may also be required to be listed by the governmental unit.
5. Have you entered into contracts or received offers for all materials which substantiate the prices used in
preparing your proposal? If not, please explain the rationale used which would corroborate the prices
listed.
�ic rG4
SECTION III CONTRACTOR'S FINANCIAL STATEMENT
Attachment of bidder's financial statement is mandatory. Any bid submitted without said financial
statement as required by statute shall thereby be rendered invalid. The financial statement provided hereunder to
the governing body awarding the contract must be specific enough in detail so that said governing body can make
a proper determination of the bidder's capability for completing the project if awarded.
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 .7ry )
SS:
34 Jos•, k 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 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.
Version 01/13/2021 Contractor's Bid for Public Works - 4
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, firms, 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 will consider the Contractor's good faith efforts to obtain participation by those
subcontractors 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.
Contractors seeking the award of a City contract cannot be required to award a subcontract to an-MWBE;
however, they may not unlawfully discriminate against said MBE/WBE. A finding of noncompliance or a
discriminatory practice shall prohibit that Contractor 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 to 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.
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).1 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.
Version 01/13/2021 Contractor's Bid for Public Works - 5
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 / ;; 1�\ day of z&. -d , 20a,
Contract GB' (F- j
Signature of Contractor/Bidder r Its Agent
Printed Name and Title
Subscribed and sworn to before me this 13 day of P' 1 , 20 d U
My Commission Expires a� tb o a(n ?AJk)OJ-t"
Notary Public
County of Residence el aaA
ENotofy
=County
s
of Indiana07267793/11r 028
Version 01/13/2021 Contractor's Bid for Public Works - 6
SECTION IV CONTRACTOR'S NON — COLLUSION AFFIDAVIT
The undersigned bidder or agent, being duly sworn on oath, says that he 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 include 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.
He 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.
SECTION V OATH AND AFFIRMATION
I HEREBY AFFIRM UNDER THE PENALTIES FOR PERJURY THAT THE FACTS AND INFORMATION
CONTAINED IN THE FOREGOING BID FOR PUBLIC WORKS ARE TRUE AND CORRECT.
Dated at Vic..this l' /4, dayof /',o l , ao3r"
rY1ur'>< 0lS/� , P-esi dY'J
(Title of Person Signing)
ACKNOWLEDGEMENT
STATE OF JWAQklGL )
COUNTY OFF J(`�i�P ss
Before me, a Notary Public, personally appeared the above -named __ KUL os� and
swore that the statements contained in the foregoing document are true and correct.
Subscribed and sworn to before me this l 7f' day of ill nil
qw" �t L43
Notary Public
My Commission Expires: III I�ip �„e„E�bg
11 Notary Public Sea! State of Indiana
Count of Residence: I�—/-I{ Elkhart County
y Commission Number NP0725779
1�y Commission Expires 03/11/2028
t.
CITY OF SOUTH BEN®
PROJECT: 905-907-909 Michigan Demolition
City of South Bend
Project No.: 120-063
April 13, 2021
ITEM
NO.
DESCRIPTION
UNIT
ESTIMATED
QUANTITY
UNIT PRICE
EXTENSION
1
MOBILIZATION AND DEMOBILIZATION
L.S.
1
` -u
`f 3,0
2
MAINTENANCE OF TRAFFIC
L.S.
1
Y, -)
/y
3
EROSION CONTROL
L.S.
1
4
BELOW -GRADE DEMOLITION
L.S.
1
i y
5
DISPOSAL
L.S.
1
s-�
6
BACKFILL AND COMPACTION
L.S.
1
7
SITE RESTORATION
L.S.
1
8
ENVIRONMENTAL ALLOWANCE
DOL
25,000
$1
$25,000
9
MASONRY ALLOWANCE
DOL
25,000
$1
$25,000
la-L' 4 600
TOTAL BASE BIC
ALLOWANCE UNIT PRICES
Item No.
Description
Unit
Unit Price
1
CONTAMINATED SOIL REMOVAL AND
TON
1
&5 /7�,
DISPOSAL
ASBESTSOS CONTAINING THERMAL
2
SYSTEM PIPE INSULATION REMOVAL
LFT
�/
AND DISPOSAL
�'�)0 IL 1z,
3
MASONRY BRICK REPAIR
SFT
AjPl,4,
Contractor (Bidder):
Address: /033 il�,ti
Authorized Agent:
Title: /19 S d t-.,
Signature:
INDIANA EARTH, INC.
10343 MCKINLEY HWY
OSCEOLA, IN 46561
Section 1
Public Projects completed:
1) Excavation and Utility — Warsaw High School
$612,400 Summer 2019
2) Excavation and Utility — Laporte Intermediate School
$1,531,400 Spring 2019
3) Excavation and Utility— Howard Park
$1,923,700 Summer 2019
4) Excavation and Utility — 320 at the Cascade
$189,000 Summer 2019
5) Excavation and Utility — SR 120, Howe, IN
$300,000 Summer 2019
6) Prime Contractor — Western Ave, South Bend, IN
$2,600,000 Fall 2019
7) Excavation and Utility — Elkhart High School
$189,700 Summer 2020
8) Excavation and Utility — Lakeville, IN Fire station
$140,300 Fall 2019
9) Demo, Excavation and Utility — Concord Perf. Arts Center
$364,100 Summer 2020
10) Excavation and Utility —Goshen High School
$170,000 Summer 2020
11) Excavation and Utility — Central School
$98,000 Fall 2020
12) Excavation and Utility — Pulaski County Library
$50,000 Fall 2020
13) Demo — Portage, MI Schools
$300,000 Fall 2020
14) Excavation and Utility — Bremen School
$100,000 Summer 2021
Public Works in Process:
1) Excavation and Utility — St. Joseph County Public Library
$450,000 Fall 2021
2) Excavation and Utility — Knox Community Schools
$1,100,00 Summer 2021
3) Excavation and Utility — Eagleway Sewer
$200,000 Fall 2020
4) Demo, Excavation and Utility —Laporte County Courthouse
$700,000 Summer 2021
5) Excavation — Fulton County Jail
$100,000 Summer 2020
6) Excavation and Utility — Nappanee Water Main Replacement
$3,100,000 Fall 2021
7) Excavation and Utility— New Buffalo, MI Fire Station
$400,000 Summer 2021
8) Excavation and Utility — Penn Township Fire Station
$260,000 Summer 2021
Completed all work awarded to our firm.
References of Private Firms
1) Rieth Riley Construction 574-288-8321
2)
Gibson Lewis LLC
574-259-8581
3)
Larson Danielson
219-362-2127
4)
Holladay Group
574-234-2073
5)
Robert Henry Const.
574-232-2091
Section 2
Plan of proposed work
1) TBD
Subcontractors Utilized on Past Projects
1) Weaver Boos —South Bend, IN, Compaction Testing
2) Acorn Landscaping— IUSB West Parking Lot
3) Abonmarch —South Bend, IN, Surveying
4) Rieth Riley —Goshen, IN, Paving
5) Hawk Electric — Merrillville, IN
Subcontractors to Utilize on this Project — Possible subs listed, will determine prior to contract approval
1) Contractors to be determined
List of our Equipment Owned:
1) 29 Excavators
2) 6 Dozers
3) 7 Dump Trucks
4) 2 Semi Trucks with dump trailers
5) 6 Rollers
6) 6 Loaders
7) 6 Skidsteers
8) 2 Off Road Haul Trucks
9) 2 Man Lifts
10) 1 Vermer Vac Truck
11) Eagle Crusher
We have received pricing for services and materials by potential subcontractors.
CITY OF SOUTH BEND(
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN
FORM MWBE-1.0
�x
IN6 i
MWBE UTILIZATION PLAN
This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving MBE participation. It is
the bidder's sole responsibility to verify whether any listed minority or woman business meets the MBE qualifications.
Project Number:
Bidder:
120-063 Project Name: 905-907-909 Michigan Demolition
7.n, 14"aAU Tn<- Total Bid Amount: Aoc, (,-a MBE Goal: 1.4%
Page of
Name & Address of MBE
Primary Contact Person
(Name/Telephone)
Scope of Work to be Performed
(Attach scope/schedule if you need additional space)
Dollar Amount of MBE
Component
Percentage
of Total
Bid/Proposal
<a
J (W"� 1J Gzrr , c,w C
l
JcLr++.ef
57y-6LY7-,,b7y
� �
(l 43
��1,1' I L � (l
v
Submitted by: ct �� �" �% '-r�✓z ; : d5, r'�/' `t — l 3 �'�
'Print Name Si nature Date
Version 01/13/2021 Contractor's Bid for Public Works - 8
CITY OF SOUTH BEND
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN
FORM MWBE-1.0
MWBE UTILIZATION PLAN
This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving WBE participation. It is
the bidder's sole responsibility to verify whether any listed minority or woman business meets the WBE qualifications.
Project Number: 120-063 Project Name: 905-907-909 Michigan Demolition
Bidder: �,, c�'�n �ce..r �'�. /► Total Bid Amount: ac: O, 61-0 WBE Goal: 4.7%
Page of
Name & Address of WBE
Primary Contact Person
(Name/Telephone)
Scope of Work to be Performed
(Attach scope/schedule if you need additional space)
Dollar Amount of WBE
Component
Percentage
of Total
Bid/Proposal
�J CiG/ � h 1S 4wV L3� •Y /�
Submitted by: J t (ark, 0"i1'r , P . .;;
Print Name
Signature
Version 01/13/2021 Contractor's Bid for Public Works - 9
CITY OF SOUTH BEND4l J
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN I. ;i
rr.acr. �
FORM MWBE-2.0 la
EVIDENCE OF GOOD FAITH EFFORTS
This completed form should be included as part of the Bids documents related to City of South Bend Public
Works Projects requiring Good Faith Efforts to obtain MWBE participation.
Project Number: 120-063 Date:
Project Name: 905-90/7-909 Michigan Demolition
Contact Person: 7 ••�.-.�, I<cy4.C,% Telephone: �5 7)(- 4-- G `F��
Address: QZ y 3 f 4 Li, x
City: �Sc.a��q State: .T1 Zip: (o /
Email: crr r..,. �'�. �.'u ny �: ; 'i'fti `P
To determine whether a bidder has demonstrated good faith efforts to reach the MWBE utilization goals set forth in
the City of South Bend Public Works Project Specifications, the City and its agencies, boards, or commissions,
REQUIRE ALL of the following Good Faith Efforts as listed in the table below":
EVIDENCE OF GOOD FAITH EFFORTS
MWBE LIST(S): The bidder reviewed 1) the City of South Bend's Minority and Women Business
Enterprise Inclusion Program Plan; 2) the list of certified MWBEs provided by the City; and 3) the Indiana
Department of Administration list of Minority and Women Owned Businesses (both certified and non -
certified) found at: http://www.in.gov oa .
GOOD FAITH EFFORTS TO OBTAIN MWBE PARTICIPATION
The bidder shall initial each item below, as evidence of its good faith efforts to obtain MWBE
participation in the awarded contract.
I affirm that I reviewed the City of South Bend's Minority and Women Business Enterprise
k
Inclusion Program Plan and the Indiana Department of Administration's certified list of
J
Indiana Minority and Women Business Enterprises, found on their website
(hftp://www.in.gov/idoa).
I affirm that I have made good faith efforts to select portions of the contract work to be
performed by MWBEs, including, where appropriate, breaking out contract work items into
economically feasible units to facilitate MWBE participation.
I affirm that I have made good faith efforts to solicit through all reasonable and available
means the interest of all MWBEs in the scopes of work of the contract.
I affirm that I attended all pre -bid meetings scheduled by the City of South Bend to inform
r
MWBEs of contracting and subcontracting opportunities.
I affirm that I advertised in general circulation and/or trade association publications
concerning subcontract opportunities and allowed MWBEs reasonable time to respond to
such advertisements.
I affirm that I performed any and all necessary steps to provide written notices in a manner
reasonably calculated to inform MWBEs of subcontracting opportunities and allowed
sufficient time for MWBEs to participate effectively.
V 6—�
I affirm that I followed up on initial solicitations with interested MWBEs.
I affirm that I negotiated with interested MWBEs in good faith, including providing such
J
MWBEs with adequate information about the plans, specifications and other requirements
of the subcontract.
I affirm that I have made good faith efforts to assist interested MWBEs in obtaining
(J
bonding, lines of credit, or insurance as required by the City or the bidder, where
appropriate.
Version 01/13/2021 Contractor's Bid for Public Works - 10
CITY OF SOUTH BEND
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN
FORM MWBE-2.0
EVIDENCE OF GOOD FAITH EFFORTS
I affirm that I have made good faith efforts to assist interested MWBEs in obtaining
I'V—
necessary equipment, supplies, materials, or related assistances or services, where
appropriate.
_
JL
I affirm that I did not reject any MWBEs as unqualified without sound business reasons
based on a thorough investigation of their capabilities.
CONTRACT RECORDS: The bidder has maintained the following records for each MWBE that has bid
on the subcontracting opportunity:
1. Name, address, and telephone number;
2. A description of information provided by the bidder or subcontractor; and
3. A statement of whether an agreement was reached, and if not, why not, including any reasons for
concluding that the MWBE was unqualified to perform the job.
*Proper demonstration of Good Faith Efforts requires your initials next to all of the above boxes. Any
omissions shall be considered grounds for rejection of the bid by the Board of Public Works. The City of
South Bend reserves the right to request additional information.
Version 01/13/2021 Contractor's Bid for Public Works - 11
CITY OF SOUTH BEND
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN
FORM MWBE-2.1
MWBE CONTACTED
This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects
requiring Good Faith Efforts to contact MBEs. It is the bidder's sole responsibility to verify whether any listed
minority or woman business meets the MBE qualifications. Attach additional pages if necessary.
PAGE OF
Project Number: 120-063 MBE Participation Goal 1.4%
Project Name: 905-907-909 Michigan Demolition
Bidder:
y• ieh
s(S(Title) (Date)
MBE Firm
Owner or Contact at MBE Firm
�Cs'rn cj
Telephone: �5 7y_ a3'7_,,, Fax: Email:
TYPE OF WORK SOLICITED FOR THIS PROJECT:
—1 + D I
I ^4 , L 1 C,
RESULTS OF CONTACT WITH THE MBE FIRM: /
Svc .S42 -a CL(.
MBE Firm
Owner or Contact at MBE Firm
Telephone: Fax: Email:
TYPE OF WORK SOLICITED FOR THIS PROJECT:
RESULTS OF CONTACT WITH THE MBE FIRM:
Version 01/13/2021 Contractor's Bid for Public Works - 12
CITY OF SOUTH BEND
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN
FORM MWBE-2.1
MWBE CONTACTED
This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects
requiring Good Faith Efforts to contact WBEs. It is the bidder's sole responsibility to verify whether any listed
minority or woman business meets the WBE qualifications. Attach additional pages if necessary.
PAGE OF
Project Number: 120-063 WBE Participation Goal 4.7%
Project Name:
Bidder: / 'c-c --a
905-907-909 Michiqan Demolition
Owner or Contact at WBE Firm J'VM
Telephone: J1%�`_,.Fax: Email:
TYPE OF WORK SOLICITED FOR THIS PROJECT:
RESULTS OF CONTACT WITH THE WBE FIRM:
WBE Firm
Owner or Contact at WBE Firm
Telephone: Fax: Email:
TYPE OF WORK SOLICITED FOR THIS PROJECT:
RESULTS OF CONTACT WITH THE WBE FIRM:
Version 01/13/2021 Contractor's Bid for Public Works - 13
,AIA Document A310T"'0-2010
CONTRACTOR:
SURETY:
(Name, legal status and address)
(Name, legal status and principal place
Indiana Earth, Inc.
of business)
10343 McKinley Highway
North American Specialty Insurance Compa
his document has important legal
Osceola, IN 46561
650 Elm Street
t
Manchester, 03101
consequences. Consultation with
OWNER:
an attorney is encouraged with
(Name, legal status and address)
respect to its completion or
City of South Bend
modification.
227 West Jefferson Boulevard
Any singular reference to
South Bend, IN 46601
Contractor, Surety, Owner or
BOND AMOUNT: ***FIVE PERCENT OF
AMOUNT BID***
other party shall be considered
plural where applicable.
PROJECT:
(Xame, location or address, and Project number, if arty)
905-907-909 Michigan Demolition
The Contractor and Surety are bound to the Owner in the amount set forth above, for the payment of which the
Contractor and Surety bind themselves, their heirs, executors, administrators, successors and assigns, jointly and
severally, as provided herein. The conditions of this Bond are such that if the Owner accepts the bid of the Contractor
within the time specified in the bid documents, or within such time period as may be agreed to by the Owner and
Contractor, and the Contractor either (1) enters into a contract with the Owner in accordance with the terms of such
bid, and gives such bond or bonds as may be specified in the bidding or Contract Documents, with a surety admitted
in the jurisdiction of the Project and otherwise acceptable to the Owner, for the faithful performance of such Contract
and for the prompt payment of labor and material furnished in the prosecution thereof; or (2) pays to the Owner the
difference, not to exceed the amount of this Bond, between the amount specified in said bid and such larger amount
for which the Owner may in good faith contract with another party to perform the work covered by said bid, then this
obligation shall be null and void, otherwise to remain in full force and effect. The Surety hereby waives any notice of
an agreement between the Owner and Contractor to extend the time in which the Owner may accept the bid. Waiver of
notice by the Surety shall not apply to any extension exceeding sixty (60) days in the aggregate beyond the time for
acceptance of bids specified in the bid documents, and the Owner and Contractor shall obtain the Surety's consent for
an extension beyond sixty (60) days.
If this Bond is issued in connection with a subcontractor's bid to a Contractor, the term Contractor in this Bond shall
be deemed to be Subcontractor and the term Owner shall be deemed to be Contractor.
When this Bond has been furnished to comply with a statutory or other legal requirement in the location of the Project,
any provision in this Bond conflicting with said statutory or legal requirement shall be deemed deleted herefrom and
provisions colaeorming to suco statutory or other legal requirement shall be deemed incorporated herein. When so
furnished,fife intent is that 19is Bond shall be construed as a statutory bond and not as a common a bond,,-�
d fthis / 13th day of April
` Ind
(Principal)
(Seal)
(Title)
%� % North merican Special nee Company _
l,t✓ l ti (Surety (Seal)
(Witne •s)
(Tille�
homasO.Chambers. ttornev-imFGCT— -�---7'--�
AIA DocumentA310- —2010. Copyright® 1963, 1970 and 2010 by The American Institute of Architects. All rights reserved. WARNING. Th.= AIAO
Init. Document Is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution ofthis AtA' Document, or
any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible underthe law.
i Purchasers are permitted to reproduce ten (10) copies of this document when completed. To report copydght violations of AIA Contract U;,(;;;me-)ts, e-mail
The American Institute of Architects' legal counsel, copydght@aia.org. 1)911lu
SWISS RE CORPORATE SOLUTIONS
NORTH AMERICAN SPECIALTY INSURANCE COMPANY
WASHINGTON INTERNATIONAL INSURANCE COMPANY
GENERAL POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, THAT North American Specialty Insurance Company, a corporation duly organized and existing under
laws of the Slate of New Hampshire, and having its principal office in the City of Overland Park, Kansas, and Washington International Insurance
Company, a corporation organized and existing under the laws of the State of New Hampshire and having its principal office in the City of Overland
Park, Kansas, each does hereby make, constitute and appoint:
THOMAS O. CHAMBERS. TODD SCHAAP
and KIMBERLY S. RASCH
JOINTLY OR SEVERALLY
Its true and lawful Attorney(s)-in-Fact, to make, execute, seal and deliver, for and on its behalf and as its act and deed, bonds or other writings
obligatory in the nature of a bond on behalf of each of said Companies, as surety, on contracts of suretyship as are or may be required or permitted by
law, regulation, contract or otherwise, provided that no bond or undertaking or contract or suretyship executed under this authority shall exceed the
amount of: FIFTY MILLION ($50,000,000.00) DOLLARS
This Power of Attorney is granted and is signed by facsimile under and by the authority of the following Resolutions adopted by the Boards of
Directors of both North American Specialty Insurance Company and Washington International Insurance Company at meetings duly called and held
on the 9 h of May, 2012:
"RESOLVED, that any two of the Presidents, any Managing Director, any Senior Vice President, any Vice President, any Assistant Vice President,
the Secretary or any Assistant Secretary be, and each or any of them hereby is authorized to execute a Power of Attorney qualifying the attorney named
in the given Power of Attorney to execute on behalf of the Company bonds, undertakings and all contracts of surety, and that each or any of them
hereby is authorized to attest to the execution of any such Power of Attorney and to attach therein the seal of the Company; and it is
FURTHER RESOLVED, that the signature of such officers and the seal of the Company may be affixed to any such Power of Attorney or to any
certificate relating thereto by facsimile, and any such Power of Attorney or certificate bearing such facsimile signatures or facsimile seal shall be
binding upon the Company when so affixed and in the future with regard to any bond, undertaking or contract of surety to which it is attached."
°�Q��c�n...... ':
1��
zto
��p!c
fir•.$
_ SEAL . n =
—a'Ty 1873
nc
Y
Sleren P. Anderson, Senior Vlce Prcldenl ofwmhloelon Iniernatlond Imurance Company•
c
SEAL �•.•k
O?
ery
&Senior Vice Presider!of Norlh American Specialty lmurance Company
imp
7/114111.111111
By
Michael A. Ito, Senior PmFrai ennii—ol %V25 melon international Jissuranc—e—Co—mpany
�a
& Senior Vice President of North American Specialty Insurance Company
IN WITNESS WHEREOF, North American Specially Insurance Company and Washington International Insurance Company have caused their
official seals to be hereunto affixed, and these presents to be signed by their authorized officers this I lth day of April 2018
North American Specialty Insurance Company
Washington International Insurance Company
State of Illinois
County of Cook ss:
On this I lth day of April 201g before me, a Notary Public personally appeared Steven P. Anderson , Senior Vice President of
Washington International Insurance Company and Senior Vice President of North American Specialty Insurance Company and Michael A. Ito
Senior Vice President of Washington International Insurance Company and Senior Vice President of North American Specialty Insurance
Company, personally known to me, who being by me duly sworn, acknowledged that they signed the above Power of Attorney as officers of and
acknowledged said instrument to be the voluntary act and deed of their respective companies.
OFFICIAL SEAL
Y.K -Sul
Notary Public -Stole DIM
hty Commission bpi— M. Kenny, Notnry Public
17104f70I1
I, Jeffrey Goldberg _the duly elected Assistant Secretary of North American Specialty Insurance Company and Washington
International Insurance Company, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney given by said North
American Specialty Insurance Company and Washington International Insurance Company, which is still in full force and effect.
IN WITNESS WHEREOF, I have set my hand and affixed the seals of the Companies this 13th day of April , 2021
'1)41111��-.-,--*a�-
Jeffrey Goldberg, Vice Pm5idenl & Assistant Sec ewy of
Washington Inlemationol Insurance Company & Noah Amerievt Specialty Insurance Company
STATE OF WISCONSIN
COUNTY OF Kenosha
ON THIS 13th day of April , 2021 ,
before me, a notary public, within and for said County and State, personally appeared
Thomas O. Chambers to me personally known, who being duly sworn,
upon oath did say that he is the Attorney -in -Fact of and for the
North American Specialty Insurance Company , a corporation
of New Hampshire , created, organized and existing under and
by virtue of the laws of the State of New Hampshire ; that the corporate seal
affixed to the foregoing within instrument is the seal of the said Company; that the seal
was affixed and the said instrument was executed by authority of its Board of Directors;
and the said Thomas O. Chambers did acknowledge that he/she
executed the said instrument as the free act and deed of said Company.
Megan Ott
Notary I,u lic,Kenosha County, Wisconsin
My Commission Expires 3/3/2024