HomeMy WebLinkAboutAffirmation of Applicant - Sewer Insurance Lateral Repair - Lucas Trucking731 S. LAFAYETTE BOULEVARD
SOUTH BEND, INDiANA 46601
November 17, 2025
To BPW,
PHONE 574 / 235-9444
FAx 574 / 235-9272
CITY OF SOUTH BEND JAMES MUELLER, MAYOR
DEPARTMENT OF PUBLIC WORKS
ERIC HORVATH, DIRECTOR
I, Larry D. Parker Jr., Sewer Manager, have reviewed Lucas Trucking & Excavating
application and agree that they are in tine with the City's Sewer Insurance Program and the
2025 Sewer Insurance contractor rates. Please let me know if you have any questions.
Thanks,
Larry D. Parker, JR
N�Q
CITY OF SOUTH BEND, INDIANA
BOARD OF PUBLIC WORKS
Elizabeth A. Maradik, President
Gary A. Gilot, Member
ME i
Joseph R. Molnar, Vice President
Breanaa MMicou, Member
s^ � f #dam
Murray L. Miller, Member Attest: Hillary R. Horvath, Clerk
Date: November 25, 2025
STREETS I SEWERS I TRAFFIC SC LIGHTING
APPLICATION
PRE -QUALIFICATION FOR THE CITY OF SOUTH BEND, INDIANA SEWER
INSURANCE PROGRAM
Name of
Dll*
Pre-Qualifi cation Category
Second opinion
Attach copies of the following do
1. License NUmber
Excavatioll
[?"f
LLc.,.
Z. L'ond letter stating limits for single project and aggre gate p ro gram
3. (Corp. or LLC Only) Corporate authority and/or proof of registry with the
do business in Indiana
Principal Place of
Business:
Mailing Address:
Telephone.
2 p_ Mn
Ownership Infoi-mation
tlelenl& all owners �flhe
Nature of Company's
Business
(Brie
fly describe the tipe q1'
seili ce,vl'o if j' (' ili air i' pi- 1,,i .v)
(Provide rO�rences as needed to
re-q ua l� Pleat n)
Cell:
(6'7y) 2%gb- 0713
MtON^
Ltic cft.,s
is s �,
Fax
fie � e r4pwe ? S 0 us + G erk.
%19-a s a^ C 0 on^ J"4r
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Special
C1
Secretary of State to
I il:
00,
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IVA
S"7y- 5"/ Y.- 6'9 2 o
P
C. "a 14 +w► I GorA
equipment On Hand
use in determinallon
T, "I
Ir % v- & -* ke
41-Ny4
r 4,,t,&C )
e. %A O%e
NOD v.&- +air
Serv4c-
LVR-
$ f-Iter 5
( r t& 4 �-er +T�400
�0 t � �' i b ► �� �► �' is �t
1
By S1a111I1g and
submitting this application, 1/we agree to
follow all City of, South
Bend Prevailing
Specifications and
Special Provisions (enclosed in the Sewer
Insurmlce
Program Policy
as
Exhibit G}
By signikQ� and submitting this application for pre -qualification, Uwe understand that as a Contractor under
the City Sewer Insurance Program, I/we sham be directly and solely liable to a Homeowner for any darnage
to any Homeowner's person or properly caused by the Contractor's acts, conduct or omissions arising fi-om
or within the scope of this Program. I/we small rcicase and fully indemnify the City from any claim or caiise
of action of any kind which Horneowncr may make against the City for any act, conduct or omission by t ie
Contractor under this Prograin. indemnification includes butt is not limited to Contractor's payment of any
legal fees or legal expense incurred by the City in defending such Homeowner claim,
cry► zAee e.i
15
signaelfre
Title
D('?te
Title Title
Date
16
Date
Exhibit
TVI? the prospecti'vie Co n tractor I'S� w ta b le to ciit? to aio; `th �sIcii ienU toiv, it ha11 Me n �)lanal n to
F
this i
CONTRACTOR'S NON -COLLUSION AND NUN -DEBARMENT AFFIDAVIT, CERTIFICATION
REGARDING INVESTDZENT 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
SS:
40r° 3 � COUNTY }
The undersigned Contractor, being duly sworn upon his/her/Its oath, affirms under the realti s of perjury that
Contractor has not, nor has any other mcmber, representative, r agent of the firm, company.,
corporation or partnership represented by him. entered into any combination, collusion or aorreement with an
person relative to the price to be bid by anyone at such letting nor to prevent any Iverson from bidding nor to
induce anyone to refrain f of bidding, and that this bid is made witliout reference to any other bid and without
any agreement, understanding or combination with any other person 1n reference to such bidding. Contnictor
further says that no person or persons, firms, or corporation has, have or will receive directly or indirectly. an
rebate, fee, gift, commission or thing of value on account of such sale; and
. 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
aili ipation in this transaction by any Federal department or agency., and
. 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., .461ranl, mezins the govemment ofIran and any agency or
insti-umentality of Iran., or as other -wise defined at Ind. Cody - -�1 . - x as amended fr y tirn -
to -tide.
b. As provided by Ind. Code § 5-22-16.5-8, as amended from tine -to -time, a Contractor is engaged
in investment activities in Iran if either. -
Contractor, itS SLIc-cessor or its affiliate, provides goods or services of twenty million
dollars($20,000,000)or more in value its the energy sector of Iran; or
ii.Contractor� its successor` r its affiliate., i a I inaneia l ' n s tit��ti �� that extends twenty
illion dollars , 0,000 or more in credit to another person for forty-five (45)
days or more, , ifthat person will i use the credit to provides goods and services in the
N.
energy sector in Iran; and ii at the time the financial institution extends credit, is a
person identified on list published by the Indiana D partnient of Administratioll.
. Contractor_ does not knowingly eniployor contract with an tinautliorized alien, nor retain any employee
or contract with a person that the onti-act r subseqiendy learns is a ri u ti auth on zed a l i n. Contractor agrees
that h /slo it shall enroll in and verify the work eligibility status of all of ontr ct r"s newly hired ei-nployces
through the E-Verify Program as defined by I.C. - - I . - i `ontra t is documentation of enr llni nt an
participation in the E-Verify Proo-rrn 'is included and attached as part of this bid/quote,- are
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. Contractor shall require his/her/its subcontractors perfonningwork under this public contract to certify
that the subcontractors do .got knowingly mpl r contract witli an unaUtb ri e l alien., iior retain any employee
or contract with a person that the subcontractor subsequently learns is an unauthorized alien, and that th
subcontractor has enrolled in alid is participating in th E-Verify Program. The Contractor- agrees to maintain
th i s e i-tif i c a t i o n th ro u (Thout th e terns o f the c o ntrac t with- th e C ity o f S ou th B c n; a nd unde r t nd s tin at th e C i ty
may term irate 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.
. Persons, partnerships., corporations, associations,, or joint ventUrers awarded a contract by the City of
South Bend through its agencies, boards, or commissions shall not d i criminate against any eniptoyce or
applicant for emptoyment in the performance of a City contract with respect to dire, tenure,ten-iis, conditions,
r privileges of employment, or any matter; directly or indirectly r-elated to employment because of race, sex,
religion, color, national ri i n# ancestry, age, gender expression, gender identity, SC Ua.l orientation or disability
that does not affect that person's person'ability to perf r i the work.
In awarding ntr ct for the purchase of work., labor, services, supplies, equipment, m t rial , or an
combination of the foregoing in lUdin , but not limited to, ti 1ic: works contracts awarded Lmder, public bidding
laws or other contracts in which public bids are not required by law, the City, its agencies, boards, or
COM111issions 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 BUSilICSS Enterprise ("WBF)
as a factor in determining the lowest, responsible, responsive bidder.
In no evert shall persons or entities seeking the award of a Citycontract be required to award a, subcontract to
an I1 /WBE# ho i-, it May nOt Unlawfidly discriminate against said WBE/MBE. A Findin f a
discriminatmy practice by the . rt ' TRIBE /W E Utilization Board shall prohibit that person or entity from
being awarded a City contract for a period f one 1 year from the date of such determination} and such
determination may also he grounds for tei-im natin i the contact for which the discriminatorypractice or
noncompliance pertains.
7, The undersigned contractor agrees that the following non i eri min t i Oil COM i tr ent shall be made a
pall of any contract which it may henceforth enter into with the City of South Bend, Indiana ana. r airy of its
agencies, boards or commissions.
Contractor agrees not to discriminate ag in t or intimidate any employce or_ applicant for employment in th
performanceof 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 braeb of contract.
1, the undersigned bidder or agent as contractor on a p Ubl ic works pr- � eta understand my statutory ob11 fat i rrls
to the use f steel products oi- foundry products madc in the United States I . . -1 - - t - t hereby certify that
I and all subcontractors employed by nee for this }project will use steel products or foundry products on this
project if awarded. I understand that violations hereunder may result in forfeiture f contractual payments.
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I hereby a f i rin under the penalties of perjui-y that the facts and information contaffied in the foi-egoing- f+ publicwor are true and correct,
e, at, .111 ,
Contractor/Bidder (Firm)
Signatisre of Contractor/Biddei- or Its Agent
e
Pi-inted Name and Title
+1 NSubscribed and sworn to before me this � day of U M r?0
My Commission Expires 10
� '�
Nu#ary Public
County of Residence � • � ��
L-//VO
fit, JOS�,�;� �;Our�ty, State at Indiana
KI-11Y J COUR, Notary Public
-M.v commissi
���m�a��o� Number NP0729667 01) ExPirers Or-.tober 29, 2028
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