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HomeMy WebLinkAboutOpening of Applications - 2025 Water Works Utility Service Line Program - Niezgodski PlumbingNiezgodski Plumbing, Inc. Plumbing and Heating Contractor PO Box 3096 South Bend, IN 46619 Phone: (574) 233-9774 e-mail: Niezplumkcomcast.net Indiana State License # PC88701935 Established 1922 February 26th, 2025 City Of South Bend Board of Public Works, 131h Floor County City Building, Room 1316 South Bend, Indiana. 46601 Attached please find the required documents as requested for the Water Works Utility Service Line Repair Program. Niezgodski Plumbing Inc. has been providing reliable plumbing service in South Bend for over 100 years. In addition, we have been performing water service leak repairs and stop box repairs for the City of South Bend since 1972. Our 0' Generation family owned business employs qualified and dedicated employees. From day one, instilled in all of our employees is the ethics of hard work. It is stressed that an attitude of honesty and integrity shall always be prevalent. As representatives of the City of South Bend, during the course of performing Water Works Repairs we realize that our performance serves as a front line view of how South Bend residents judge the delivery of one of the City's most essential services. Safe drinking water available to all city residents with minimal interruption is of the utmost essence for any city's administrative and departmental success. Niezgodski Plumbing Inc. will continue to deliver these services to the City of South Bend and view them as our highest priority. We are fully equipped to handle all Water Works repairs, including every manner of emergency service required. We have all the necessary tools and equipment and they are kept fully maintained. We meet all of the requirements called for in the specifications of the Board of Public Works Request for Proposals regarding the Water Works Utility Service Line Repair Program. In addition, we acknowledge that these repairs must be performed in any and all adverse weather conditions. In addition, Niezgodski Plumbing Inc. shall also be responsible for the preparing and pouring or subcontracting of all sidewalk, driveway, and street cuts, according to City specifications. Included, please find all required Commercial General Liability insurance information, Workers Compensation Insurance, required performance bond information, and a copy of our Plumbing Contractors License and Corporate Plumbing License. Also included is the signed and notarized Non -Collusion Affidavit, Non -Debarment Affidavit, Employment Eligibility Verification, and Non -Discrimination Commitment Form. We sincerely hope to have the opportunity to continue representing the needs of the South Bend City Water Works in every manner necessary for many future years to come. Please do not hesitate to contact me if there is anything further that you require. Sincerely, Grant Niezgodski President — Niezgodski Plumbing Inc. 574-233-9774 niezplumgcomcast.net 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 JV ) SS: �{ • S 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 instrutnentality 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 § 5-22-16.5-5, 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 -Debarment 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. 1, 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 (LC. 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 a1 tjt7 day of al-Vj , 20 r}5� Signature of ContractorV e/r or Its Agent -� Printed Name and Ti Subscribed and sworn to before me this adAID day of ?Ik^'f My Commission Expires �3 Notary Public County of Residence Non -Collusion Nan -Debarment Affidavit Non Iran Form o��RYpQ{ FELIX BUENO JR. a Commission Number NP0683443 * SEAL My Commission Expires s� a May 15, 2032 swr �'•'a.a; Indiana Professional Licensing Agency Indiana Plumbing Commission l< ; 402 W. Washington Street, W072 Indianapolis, IN 46204 Y r: PC88701935 Eric J. Holcomb Governor State of Indiana Plumber Contractor Expire Date 12/31 /2025 David L Niezgodski Lindsay M. Hyer Executive Director Indiana Professional Licensing Agency Indiana Professional Licensing Agency f 402 W. Washington Street, W072 Indianapolis, IN 46204 Plumber Contractor UCOrBe Number Expire Date PC88701935 12/31/2025 David L Niezgodski Signatum � � Western Surety Company CONTINIUATION CERTIFICATE Western Surety Company hereby continues in force Bond No. 664 briefly described as PERFORMANCE CITY- OF SOUTH BEND A for NIEZGODSKI PLUMBING, J as Principal, in the sum of $ T �-F US 00 Dollars, for the term beginning J 04 2�25 and ending 3 4 - 2026 ,subject to all the covenants and conditions of the original bond referred to above. This continuation is issued upon the express condition that the liability of Western Surety Company under said Bond and this and all continuations thereof shall not be cumulative and shall in no event exceed the total sum above written. Dated this 4th. --- day of Decemb_ er , 2024 — WESTERN SURETY COMPANY $" x By arry Kasten, Vice President THIS ,Continuation Certificate" MUST BE FILER WITH THE ABOVE BOND. Form 90-A-6-2023 A� oO CERTIFICATE 4F LIABILITY INSURANCE DATE 08/20/202418.44 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERJS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: Ifi the certificate holder Is an ADDITIONAL INSURED, the poiicy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement, A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement($). PRODUCER CONTACT NAME: Kelley. Jacob PHaNE . (574) 400-4389 FAX AIC a E AIC No - Ewalt ADDRESS: Jacab.Keuey@infarmbureau.cam 2410 Edison Rd, Suite 400 South Bend, IN 46615 INSURER(S) AFFORDING COVERAGE NAIC# INSURER A. United Farm Family MUtuat Insurance Company 15288 INSURED INSURERS: NIEZGODSKI PLUMBING, INC 232 N MAYFLOWER RD INsuRERc SOUTH BEND, IN 46619-1534 INSURER D, INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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, ILTR TYPE OF INSURANCE ADRL SUBR POLICY NUMBER Pro DO EFF MPNMiDOLIY YY I LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR I BOP8236911 108/21/2024 i 08/2112025 I EACH OCCURRENCE $1 000 000 PREMISES Ea occurrence S50,006 MED EXP (Any one Person) $ 10 000 PERSONAL& ADV INJURY $1 000 000 GEN'L AGGREGATE LIMIT APPLIES PER X POLICY ❑PRO ❑ JECT LOG OTHER: GENERAL AGGREGATE 1 $ 2,000,000 PRODUCTS - COMPIOP AGG $ 2.000 000 $ A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEpU"rD AUTOS ONLY X AUT05 HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY i CAP8524976 I 08/21 /2024 I 108/21/2025 COMBINED SINGLE LIMIT Ea a cent $ 1,00fl,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ $ A X UMBRELLALWB EXCESS LIAB OCCUR HCLAIMS-MAOEE i UMB8609087 0812112024 08/21/2025 EACH OCCURRENCE $ AGGREGATE $2.00fl,000 DED REiENTION $10.006 g A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPER ROPRf"TOR1PARTNSRIEXECUTIVE OFFICERIMEMBEREXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A WC8341646 �08/2112024 08/21/2025 X SPER TATUTE OTH $ 1 00(),000 E,E., EACH ACCIDE1�kT ' E.L. iJISEASE - EA EMPLOYEE $1.000.000 EJ_ DISEASE -POLICY LIMIT $1.000,000 DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) City of South Bend Board of Public Works 227 W. Jefferson Blvd South Bend, IN 46601 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL. BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Kelley, Jacob Q 1$a8-2015 ACOR17 CORPORATION. All rights reserved, ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD AC" p® CERTIFICATE OF LIABILITY INSURANCE 08/2212024413: 0Y' 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, EXPEND 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(les) 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 fieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE_ (574) 400-4389 FAX No Kelley, Jacob me- Jacob.KelLey@infarmbureau.corn ADDRESS: 2410 Ellison Rd, Suite 4D0 INSURERS) AFFORDING COVERAGE NAIC k South Bend, IN 46615 INSURER A: United Farm FarrlilyMutUatInsurance Company ----- _.—_— 15288 INSURED INSURERS : NIEZGODSKI PLUMBING, INC 232 N MAYFLOWER RD 114SURER C : SOUTH BEND, IN 46619-1534 INSURERD: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMRFR- REVISION NUMBER: 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 TYPE OF INSURANCE L POLiCYNUMBER PM113D/YYYC POLICY wym E%P LIMITS A COMMERClALGENERAL LWBItrrY i CLAIMS -MADE OCCUR i I BOP8236911 I 08/21/2024 �08/21/2025 ! EACH OCCURRENCE $1 OOQOOQ �X TE PREMISES Ea occurrence PRIM O AENcui $ 50 ODD MED EXP (Anyone person) $10.000 PERSONAL & ADV INJURY $ 1 000 0QO GENLAGGREGATELIMITAPPLIESPER: F_$_2.000000 x POLICY �} JEC7 LOC OTHER: GENERAL AGGREGATE 1RO- PRODUCTS-COMPIOP AGG $ 2,QQD ODD $ A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY x AUTOS }HIRED NON -OWNED X AUTOS ONLY X AUTOS ONLY i CAP8524976 10812112024 I i � I08121 /2025 I COMBINED SINGLE LIMIT Ea accident $ l .00D,000 BODILY INJURY (Per person) $ 130DILY INJURY (Per accident) I $ PROPERTYOAMAGE Per accident $ $ A ,'( UMBRELLALIAS EXCESS LIAB OCCUR CLAIMS -MADE UMB8609087 I 08/21 /2024 i08/2112025 EACH OCCURRENCE Is AGGREGATE $ 2.000,000 DED RETENTION$10,000 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY IN 4 Y ROPPR EWMGM RIPARTN ER1�CECU71VE Y❑ (Mandatory fn NH) If yes, describe under DESCRIPTION OF OPERATIONS below I (N 1 A WC 8341646 108/21/2024 OB/2112025 I i PER OTH- X 'STATUTE ER E¢. EACH ACCIDENT $ 1 000 000 EJ._DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1,000,000 I DESCRIPTIDN OF OPERATIONS f LOCATIONS [VEHICLES (ACORD 101, Additional Remarks Schedule, may Im aftaahad If more space Is required) NULLJtI{ South Bend Water Works 125 W Colfax Ave, South Bend, IN 46601 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE Keltey, Jacob (w ivtsu-LVlS Auulxu uuKr-umA I Ium AU rtgnis reservea. ACORD 26 (2016103) The ACORD name and toga are registered marks of ACORD ACC>R�� LJ CERTIFICATE 4F LIABILITY INSURANCE DATE (AiY fl8/22/2024 241313:30 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), 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 Kelley, Jacob 2410 Edison Rd, Suite 400 South Bend, IN 46615 CONTACT NAME: PHONE (574) 400-4389 FAX Ext : AfC No EA1A L ADDREss: Jacob.Keliey@infarmbureau.com INSURER S)AFFORDING COVERAGE NAIL# INSURER A: United Farm Famity Mutual Insurance Company 115288 INSURED NIEZGODSKI PLUMBING, INC INSURER B : 232 N MAYFLOWER RD INSURER C INSURERD: SOUTH BEND, IN 46619-1534 INSURER E ; INSURER F : I I COVERAGES CERTIFICATF NtIMRFR- RFVlgInI4J MIlMul=D- THIS 1S 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 I LTR TYPE OF INSURANCE ADDL INS11 SUBR wvn POLICYNUMaER POLICY EFF MM1DDNYYY) POLICY EXP JMM1DD0= LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE X OCCUR _ ! 1 I BOPS236911 08f21 /2024 ! i 08121/2025 EACH OCCURRENCE $1 000 000 G ro—Rg e PREMISES fEa occurrence $ SD.ODO MED EXP (Any one Person) f $10,000 PERSONAL & ADV INJURY $1 000 000 G£N'LAGGREGATE LIMIT APPLIES PER X POLICY PRO- �' JECT a LOC OTHER: GENERALAGGREGATE $ 2,000 000 PRODUCTS -COMPIOPADO $ 2 DDa 0()D $ q AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY X AUTOS HIRED X NON -OWNED AU745 ONLY AUTOS ONLY 1 II t CAP8524976 08121/2024 08/21/2025 ! j COMBINED SINGLE LIMrf Ea accdent $1,000,004 BODILY INJURY (Per person) $ 90t?€LYINJURY (Per aoc#dent) $ X PROPERTY DAMAGE Per accident $ A X UMBRELLALIAB EXCESS LIAB OCCUR CLAIMS -MADE I UMB8609087 108/2112024 108f2112025 1 EACH OCCURRENCE $ AGGREGATE $ 2.000.000 DED I I RETENTIONS1D.000 $ A WORKERSCOMPE14SATION AND EMPLOYERS' LIAMn Y Y 1 N ANYPROPRIETOR/PARTNER/EXECUTIVE DFFICERIMEMBEREXCLUDED? (Mandatory in NH) If D eyes SCRIPTION OF OPERATIONS balaw NIA WC 8341646 I 08/21/2024 I 1011121/2025 X ! UiE EOTRH- E.L, EACH ACCIDENT $1 000 G00 EL. DISEASE - EA EMPLOyerz $ 1,00D,00D E.L. DISEASE - POLICY LIMIT $ 1 .009.000 I DESCRIPTION OF OPERATIONS I LOCATIONS ! VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more space Is required) CERTIFICATE HOLDER CANCFLI ATInN South Bend Sewer Department 731 S. Lafayette Blvd. South Bend, IN 46601 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Kelley, Jacob ID 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD A� f �S CERTIFICATE OF LIABILITY INSURANCE 08/201202418:08 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 INSURERJS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT; If the certificate holder is an ADDITIONAL INSURED, the poiicy(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 endorsernertt(s . PRODUCER CONTACT -NAME* Kelley, Jacob F4C Na (574) 400-4389 � No 2410 Edison Rd, Suite 400 E-MAIL Jacob.Kelley@infarmbureau_com ADDRESS, South Bend, IN 46615 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: United Farm Family Mutual Insurance Company 15288 INSURED NIEZGODSKI PLUMBING, INC -INSURERS: 232 N MAYFLOWER RD INSURER C SOUTH BEND, IN 46619-1534 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 TYPE OF INSURANCE A L 5 $ 13R POLICYNUMBER POLICY EFF fmmfogynm POLICY W 11IVUDD1yyre1LIMITS A X COMMERCIAL GENI RALLIASiLITY CLAIMS -MADE OCCUR j IBOP8236911 0812112CI24 0812112025 EACHO=URRENCE1 $7.DDD 00D DAMAGE TO REM PREMISES JEao=%fenoe $50000 ME[) EXP (Anyone person) $10 000 PERSONAL &ADVINJURY $1 00()000 GENL AGGREGATE LIMIT APPLIES PER: X POLICY PRO- JECT 171 Lo c OTHER: GENERAL AGGREGATE $2,000,000 PRODUCTS - COMPIOP AGG $ 2 000 000 $ pIx AUTOMOBILE 1-Mi .ITY ANY AUTO OWNED X SCHEDULED AUTOS ONLY AUTOS HIRFD X NON -OWNED AUTOS ONLY AUTOS ONLY CAPS524976 108/21 /2024 08/2112025 COMBINED SINGLE LEMiT Ea acxident $1.000,00D BODILY INJURY (Per person) $ BODILY INJURY (Per acddenf ) $ PROPERTYDAMAGE Per acadent $ A X UMBRELLAL146 EXCESS LIAR OCCUR CLAIMS -MADE I UMBS609087 ( 0812112024 If 08121 /2025 EACH OCCURRENCE $ AGGREGATE $2,400,13D0 DED RETENTION 10.000 $ A WORKERS COMPENSATION ANDEMPLOYERSLIARILMY YfN ANYPROPRIETORIPARTNERIEXECUTNE OFHCERIMEMSEREXCLUOED? (Mandatory In NH) If yes, dawfta under DESCRIPTION OF OPERATIONS balaw NIA WC 8341646 I 111812112024 08/21/2025 PSTEA UrE I ERR- $1 .ODD ODD E-L. EACH ACCIDENT E1. DISEASE- EA EMPLOYEE $1,000,000 E.L. DISEASE -POLICY LIMIT $1 ,000.000 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If mare space Is required) Certificate holder is an Additional Insured as provided by form D3-151 when required by written contract applies to general liability which includes ongoing operations and products and completed operation and primary & non-contributory CERTIFICATE HOLDER CANCELLATION City of South Bend Bureau of Sewers SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 731 S. Lafayette Blvd ACCORDANCE WITH THE POLICY PROVISIONS. South Bend, IN 46601 AUTHORIZED REPRESENTATIVE Kelley, Jacob Q 1988 2015 ACORD CORPORATION. All rights reserved. ACORD 25 (23161103j The ACORD name and logo are registered marks of ACORD tr`orro® CERTIFICATE 4F LIABILITY INSURANCE 8Y' 08/201202418� 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(les) 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 endorsements . PRODUCER CONTACT NAME: W PHONE (574) 400-4389 FAX (AIC.No _ A!C No - Kelley. Jacob E-MAIL Jacob.Ketley@infarmbureau.eom ADDRESS: 2410 Edison Rd, Suite 400 South Bend, IN 46615 INSURER(S) AFFORDING COVERAGE NAtC# INSURER A: United Farm Family Mutual Insurance Company 15288 INSURED INSURER B NIEZGODSKI PLUMBING, INC 232 N MAYFLOWER RD INSURERC : SOUTH BEND, IN 46619-1534 INSURERD: INSURER E : INSURER F . 1 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A80VE 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. ILTR TYPE OF INSURANCE I S L S I POLICY NUMBER PMOIDDY EFF POMLICY f:7CP LIMITS A X I COMMERCIAL GENERAL LIABILITY I CLAIMS -MADE OCCUR I Ij BOP8236911 i 08/21/2024 I0812112025 EACH OCCURRENCE $ 1 000 000 PREMISE=ce $50 000 MED EAP (Any one per S 1 p pQQ PLRSONAL & ADV INJURY i $1 000 ao0 GEN'L x AGGREGATE LIMIT APPLIES PER: POLICY E PRO- JECT LOC OTHER: I GENERAL AGGREGATE $2000000 PRODUCTS - COMP/OP AGG $ 2 fl©O tIOO $ A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY X AUTOS HIRED X AUTOS AU SY ! ! CAP8524976 I I08/21/2024 i I I 108/2112025 I CUMSkNEDSINGLELIMIT Ee accident $ 1.00fl,00fl BODILY INJURY (Per person) $ X BQDILYINJURY (Per ar;ddent) $ F'erOacntlenDAMAGE S A x UMSRELLAL" EXCESsLIAH HOCCUR CLAIMS -MADE jj I UMB8609087 I i08121/2132410812112025 LEACH OCCURRENCE S AGGREGATE $2,000,00 DED RETENTION$f4000 I $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRFrTORIPARTNERIEXECUTivrz Y I N OFFiCERWEMBEREXCLUDED? (Mandatory-inNN) If yea, describe under DESCRIPTION OF OPERATIONS hekaw NIA f ! WC8341646 08/21/2024 �0812112025 , PER OTH- ` STATUTE ER I EL, EACH ACCIDENT ' S 1 001) 000 ES..DISEASE -EA EMPLOYEE $1,QOQ,000 EL DISEASE - POLICY LIMIT $ 1.000,000 I I � f DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 401, Additional Remarks Schedule, maybe attached If more space Is required) Certificate holder is an Additional Insured as provided by form 03-151 when required by written contract applies to general liability which includes ongoing operations and products and completed operation and primary R non-contributory City of South Bend 227 W. Jefferson Blvd Ste 1316 South Bend, IN 46601 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Kelley, Jacob %11988 2015 ACORD CORPORATION!. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD INDIANA FARM rat BUREAU INSURANCE@ Worker's Compensation and Employer's liability Insurance Policy Poli No. Transaction RENEWAL BUSINESS W 8341646 02 Policy Period From 0 8 / 21 / 2 0 2 4 to 0 8 / 21 / 2 0 2 5 12:01 A.M. Standard Time at the address of the Insured as stated herein Agent: Name and Phone Address JACOB KELLEY 2410 EDISON RD, SUITE 400 574-400-4389 SOUTH BEND IN 46615-3518 7601102 762 1. Named Insured and Address NIEZGODSKI PLUMBING, INC 232 N MAYFLOWER RD SOUTH BEND IN 46619-1534 Carrier# FEIN # Risk ID # Entity of insured 16454 19910SO98 CORPORATION Additional Locations: See Attached Schedule 2. The Policy Period is from 08/21/2024 to 08/21/2025 12:01 a.m. Standard Time at the Insured's mailing address. 3. A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states listed here: Indiana B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part TWO are: Bodily Injury by Accident $ 1, 000 , 000 each accident Bodily Injury by Disease $ 1, 000, 000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States insurance: Part THREE of the policy applies to the states, it any, listed here: ALL STATES EXCEPT states designated in item 3.A., North Dakota, Ohio, Washington, Wyoming D. This policy includes these endorsements and schedules: See attached schedule. 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. All information required below is subject to verification and change by audit. SEE EXTENSION OF INFORMATION PAGE Minimum Premium $ 488 Total Estimated Annual Premium $ Expense Constant $ Premium Discount $ Premium Audit Period: ® Annual; ❑ Semiannual; ❑ Ouarterly; ❑ Monthly Countersigned: DUNE 12 , 2024 Issued Date: 06/13/2024 Issuing Office: P.O. Box 1250; Indianapolis, IN 46206-1250 9,613 160 0 �J Authorized epresentative WCPCEc 04s4 INSURED 00121-00003 Paae 1 of 3 AMINDIANA FARM BUREAU INSURANCE' WORKERS COMP & EMPLOYERS LIABIUTY Policy No, WC 83416646 02 Policy Period From 0 8 / 21 / 2 0 24 to 0 8 / 21 / 2 0 2 5 at 12:01 a.m. Standard Time at the described location EXTENSION OF INFORMATION PAGE CLASSIFICATION OF OPERATIONS Premium Basis Rate Per Estimated Cade Total Est. Annual $100 of Annual No. Classification Description Remuneration Remuneration Premium Indiana Rating Period 08/21 /2024 through 08/21 /2025 Site 00001 5183 PLUMBING NOC & DRIVERS 8810 CLERICAL OFFICE EMPLOYEES - NOC 933,825 1.36000p 12,700.00 Site 00001 Total 233,160 0.100000 233.00 $ 12,933.00 Total of Sites for Rating Period $ 12, 933.00 Rating Period Total $ 12, 933.00 Rating Period 08/21 /2024 through 08/21 /2025 9812 EMPLOYER'S LIABILITY INCREASED LIMITS 9898 EXPERIENCE MODIFICATION 0.86 12,933 0.028000 362.00 9887 SCHEDULE RATING CREDIT 13,295 -0.140000 -1,861.00 0900 EXPENSE CONSTANT 11,434 -C.200000 -2,287.00 0935 STATE ASSESSMENT/SECOND INJURY FUND 9,541 0.p07500 160.04 72.00 9740 TERRORISM 9741 CATASTROPHE -OTHER THAN CERTIFIED ACTS 1,167,005 OF TERRORISM 1,167,OCS 0.010000 0.010000 117.00 Rating Period Total 117.00 $ -3,320.00 Total of all NON -SPLIT Classes Total of all SPLIT Classes $ 320 , 320.00 -3-3.00 $ , State Total $ 91613.00 Policy Total $ 9,613.00 Issued Date; 06/1-3/2024 WCPDEC 0101 INSURED 00121-00004 Page 2 of 3 INDIANA FARM Worker's Compensation and Employer's Liability BUREAU INSURANCE@ Insurance policy Policy No. WC 8341646 02 f Policy Period j From 0 8 / 21 / 2 0 2 4 to 0 8 / 21 / 2 0 2 5 at 12:01 a.m. Standard Time at the described location ENDORSEMENT SCHEDULE State Number Ed. Date Description 13 WC000000C 01/15 WORKERS COMP/EMPLOYER'S LIAB 13 TPIC000414A 01/19 NOTIFICATION OF CHG IN OWNER 13 WC000421F 01/22 CATASTROPHE (OTHER THAN CERTF) 13 WC000422C 01/21 TERRORISM RISK PROGRAM REAUTH 13 06-825 12/88 MUTUAL CONDITIONS 13 21-201WC 04/05 NOTICE TO POLICYHOLDERS Issued Date: 06/13/2024 WCPES 0494 INSURED 00121-00005 paacl, n- Applications must meet the minimum specifications as provided herein. There is no scoring matrix as all qualified vendors whose applications meet the minimum specifications and who meet and accept the following required conditions will be accepted into the program: • Plumber Contractor License in Indiana; and • Worker's Compensation Insurance; and • Performance bond in the amount of $25,000 or cash bond in the amount of $25,000; and • Proof of Commercial General Liability Insurance per Person in the amount of $50,000; and • Proof of Commercial General Liability Insurance per Occurrence in the amount of $1,000,000 • Three (3) year warranty on all work performed through this program. • Must follow City of South Bend Department of Public Works Design & Construction Standards. • Availability for on -call emergency response scheduled on a weekly rotation which includes before/after normal business hours, weekends and holidays. Emergency repairs require completion within 24 hours. Regular repairs require completion within five working days. • Ability to work in year-round adverse weather conditions. • Must follow IUPPS 811 compliance prior to and throughout all excavation work performed. • Customer contact prior to repairs with account information provided by the Water Works Utility. • Responsible for the planning, set-up and removal or subcontracting of all necessary traffic control according to INDOT requirements found in the Indiana Manual on Uniform Traffic Control Devices and the ability to work safely on heavily trafficked streets. • Ability to pinpoint water leaks and trace water service lines. • Must be fully equipped to work safely in underground excavations five feet deep or greater in compliance with OSHA trenching and excavation safety requirements. Company safety manual must be followed and a minimum requirement of two qualified persons for all excavations. • Ability to temporarily freeze water service lines to replace inoperable and/or leaking curb valves. • Must have experience working on water lines in the City of South Bend including new service line installation using open trench excavation and trenchless ground piercing methods. New service line installation will be paid per foot for one -inch service line and only Type K copper tubing pipe is allowed. The water line shall have a minimum earth cover of five feet and a maximum of six feet. • Responsible for the preparing and pouring or subcontracting of all sidewalks, driveway and street cuts, according to City specifications. Four inches of depth for sidewalks, six inches of depth for driveway and driveway approaches. Street cuts must match existing depth, but not be less than eight inches minimum. • Responsible for repairing all grass/sod property damage caused by excavation work by spreading topsoil and grass seed within two calendar weeks of leak repair. A list of all repairs completed in grass during the winter season must be kept for returning to complete the topsoil and grass seed work at the start of the spring season. • A Plumber Inventory Tracking Form must be e-mailed to Water Works Utility management staff with details for each leak repair performed within one calendar week of repair date. • Invoices (two copies required) for work performed must be delivered to 915 S. Olive St. by the fifth day of the following month. All material provided by the Water Works Utility must be indicated on the invoices. City inspection and approval prior to payment being remitted within 45 days of receipt. • A Plumber Material Request Sheet must be e-mailed to Water Works Utility management staff when requesting provided parts. All material requests must be picked up at 915 S. Olive St. the following business day between the hours of 7:30am and 3:OOpm unless otherwise specified by Water Works Utility management staff. Flat Rate for Stop Box Repairs: Applicants will unearth a single excavation up to five cubic feet in grass for a flat rate of $556. For stop box repairs that require the removal of a hard surface, such as asphalt or concrete, the flat rate is increased to $667. This flat rate will include all equipment, material and labor necessary to replace the stop box and rod. This flat rate will be used for all emergency repairs made during normal business hours. A curb valve found to be inoperable and/or leaking must be replaced, and the repair is billed as a basic service leak at the rates described herein. Flat Rate for Basic Service Leak Repairs: Applicants will unearth a single excavation up to five cubic feet in grass for a flat rate of $1,724. For basic leak repairs that require the removal of a hard surface, such as asphalt or concrete, the flat rate is increased to $1,835. This flat rate will include all equipment, material and labor necessary to replace the curb valve, stop box and rod or repair a single leak on a three feet or less section of the service line. This flat rate will be used for all emergency repairs made during normal business hours. Repairs that require exceeding these specifications to complete must be reported to Water Works Utility management staff to determine if a leak repair is not considered basic repair due to special circumstances. Any special circumstance requires City approval, and the repair is billed for equipment, material and labor at the rates described herein. Special Circumstance Plumber Rates for Equipment, Material and Labor: Equipment Rates per Job: Pneumatic Ground Piercing Mole $167 Trench Shoring/Shield Box $144 Arrow Board $139 Air Compressor $123 Hammer/Rotary Drill $106 Partner Saw $100 Barricades $95 Freeze Kit $89 Plate Compactor $83 Trash Water Pump $56 Work Truck $44 Special Circumstances include, but are not limited to: Equipment Rates per Hour: Vactor $334 Backhoe $134 Dump Truck/Trailer $77 Material Rates per Job: #53 Recycled Concrete Backfill $100 Black Dirt & Seed $100 Labor Rates per Hour. Plumber $100 Laborer $77 • Any leak repair that requires subcontracting for heavy traffic control. • Any leak repair that requires more than a single excavation. • Any leak repair that requires excavating greater than a five feet square area. • Any leak repair that requires excavating greater than five feet of depth and must have trench shoring or a shield box installed for OSHA compliance. • Any leak repair that requires a portion of the street to be removed. • Any leak repair that requires extensive landscape removal. • Any leak repair involving the foundation of the structure. • Any service line repair that requires more than a single leak to be repaired. • Any leak repair that requires replacing any length of the service line greater than three feet. • Emergency leak repair designated by the Water Works Utility to be completed before/after normal business hours, weekends and holidays. The successful applicants shall comply with the City's ordinance and all other federal, state and local laws and regulations governing nondiscrimination in employment. The City reserves the right to accept, negotiate scope, or reject any or all applications.