HomeMy WebLinkAboutOpening of Bids - Demolition of 921 Louise Street Proj No 125-043A - KLF EnterprisesCITY OF SOUTH BEND, INDIANA
CONTRACTOR'S BID FOR PUBLIC WORK
Project Name Demolition of 921 Louise Street
Project No. 125-043A
For Bids Due Tuesday, March 10, 2026 @ 9:00 A.M. (E.D.T.)
PART I
(Must be completed for all bids. Please type or print)
Date: 3 -Cf—Zh Bidder (Firm): �/�.�, ��., }c��r; A -a
Address: 2 3 ea 412 -'''` S�—
City/State/Zip: M"k)%o. 171 &Q(LZ Gj Telephone Number: ( -70 a) % —C4 10 U
Agent of Bidder (if Applicable):
Pursuant to notices given, the undersigned offers to urnish abor and/or material necessary to complete the
public works project of:
Demolition of 921 Louise Street (Qualex Building)
the City of South Bend, Indiana, in accordance with plans and specifications prepared by:
City of South Bend, Engineering Division
and dated 02/20/2026 for the sum of (enter the Total Bid as shown on the Proposal)
g 4A c- ($ 1.711ICJ )
(Enter sum of Total Base Bi lus 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 of South Bend. If the bid is to be awarded on a unit
basis, the itemization of the units shall be shown on a separate attachment.
The above bid is accepted this
Subject to the following conditions:
BOARD OF PUBLIC WORKS
Elizabeth A. Maradik, President
Abigail E. Magas, Member
Murray L. Miller, Member
By
a ure)
(Printed Name of Person Signing)
ACCEPTANCE
day of
20
Joseph R. Molnar, Vice President
Breana N. Micou, Member
Attest: Hillary Horvath, Clerk
Version 07/19/2023 Contractor's Bid for Public Works - 2
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 �^ )
SS:
Gc,awte, 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.
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.
Version 07/19/2023 Contractor's Bid for Public Works - 4
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 contract or employment, or any matter directly or indirectly related to contracting
or employment because of race, sex, religion, color, national origin, ancestry, gender expression, gender
identity, sexual orientation, or due to age 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. On goal -eligible contracts,
Contractors are required to either meet both MBE and WBE utilization goals or demonstrate that the
Contractor has made good faith efforts to obtain participation from MBE and WBE subcontractors. 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). 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. 1 understand that violations hereunder
Version 07/19/2023 Contractor's Bid for Public Works - 5
may result in forfeiture of contractual payments.
1 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 day of �wCA 20Z
k L 1'"" & I gX)
't,�s
Contractor/Bidder (Firm
on actorATMer or Its Agent
Printed Name and Title
Subscribed and sworn to before me this `7 day of t , 20a7
/ 1
My Commission Expires f �l /Z q
Notary Public
County of Residence & o
Official Seal
SUSAN MARIE HINZ
Notary Public, State of Illinois
Commission No. 100247
My Commission Expires October 16, 2029
Version 07/19/2023 Contractor's Bid for Public Works - 6
. I AIA Document A310TM - 2010
CONTRACTOR:
SURETY:
(Name, legal status and address)
(.Name, legal status and principal place
KLF Enterprises, Inc.
of business)
2300 W. 167th Street,
Hudson Insurance Company
This document has important legal
Markham, IL 60428
100 William Street, 5th Floor
consequences. Consultation with
New York, NY 10038
an attorney is encouraged with
OWNER:
respect to its completion or
(Name, legal status and address)
modification.
City of South Bend
Any singular reference to
227 W Jefferson Blvd
contractor, surety, Owner or
South Bend, IN 46601
BOND AMOUNT: Five Percent of Accompanying Bid
other party shall be considered
plural where applicable.
PROJECT:
(Name, location or address, and Project number, 'fan
)
Demolition of 921 Louise Street ('Qualex Buil ingProject No. 125-043A
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. T'he 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 conforming to such statutory or other legal requirement shall be deemed incorporated herein. When so
famished, the intent is that this Bond shall be construed as a statutory bond and not as a common law bond.
Si d sealed this 1 Oth day of March, 2026
S K En 'ses --
(W ss)
n r le), rw
A/1 '��— rants Co an
(Sure tJ (Seal)
(Wi ness) '
(Titl id A. Kotula, Attorney -In -Fact - -
CAUTION: You should sign an original AIA Comract Document, on which this text appears in RED. An oriµinalzsewa_ s-drat -
changes will not be obscured.
snit AIA Document A310^-2010.CopyrightO1963,1970and 20mbyTheAmerican Institute ofArchitect&ADrights reserved. �Vtc•.RIC:ThisMA*
Document is protected by U.S. Copyright Law and Intemational Treaties. Unauthorized reproduction or distribution of this d : Document p r .
any portion of it may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the low.
t purchasers are per nilted to reproduce ten (10) copies of this document when completed. To report copyright violations of AIA Contract Documents, email
The American Institute ofArchheas' legal counsel, mpyright@aia.org 061110
G-23208-B SS.
STATE OF IL
COUNTY OF WILL
I, Brandie Catlin, Notary Public of Will County, in the State of Illinois, do
hereby certify that David A. Kotula Attorney -in -fact, of the
Hudson Insurance Company who is personally
known to me to be the same person whose name is subscribed to the
foregoing instrument, appeared before me this day in person, and
acknowledged that he signed, sealed and delivered said instrument, for and
on behalf of the Hudson Insurance Company , for
the uses and purposes therein set forth.
Given under my hand and notarial seal at my office in the City of Lockport
in said County, this 1 Oth day of March A.D. 202&.
13R1aP DIE CAT=_i►i
NOTARY PUBLIC. s'rA.E OF !LL!cvc!S Notary Public
My Cornmissiori Expires 3/31123 Br die Catlin rY
HUDSON
TNSUIL%NC 1- GR0111''
BID BOND POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS: That HUDSON INSURANCE COMPANY, a corporation of the State of Delaware, with
offices at 100 William Street, New York, New York, 10038, has made, constituted and appointed, and by these presents, does make, constitute and
appoint
David A. Kotula, Brian DiPaola
of the State of Illinois
its true and lawful Attomey(s)-in-Fact, at New York City in the State of New York, each of them alone to have full power to act without the other or
others, to make, execute and deliver on its behalf, as Surety, bid bonds and Consents of Surety for my and all purposes.
Such bid bonds and Consents of Surety, when duly executed by said Attomey(s)-in-Fact, shall be binding upon said Company as fully and to
the same extent as if signed by the President of said Company under its corporate seal attested by its Secretary.
In Witness Whereof, HUDSON INSURANCE COMPANY has caused these presents to be of its Senior Vice President thereunto duly
mthorized,on this Ist day of November , 2025 at New York, New York.
(Corporate seal) HUDSON INSURANCE COMPANY
-P-ANYY
Attest......... �".... te By..................................................................
Karen L. Colo ana, Corpora -Secretary Andrew A. Dlckam, Senior Vim President
STATE OF NEW YORK
COUNTY OF NEW YORK SS.
On the 1st day of November 20 25 before me personally came Andrew A Dickon to me known, who being by me duly sworn did depose
and say that he is a Senior Vice President of HUDSON INSURANCE COMPANY, the Company described herein and which executed the above inshmnent,
that he knows the seal of said Company, that the seal affixed to said instrument is the corporate seal of said ComlYmy, that it was so affixed by order of the
Board of Directors of said Company, and that he sued his name thereto by like order. ,
..............;/...............................
N a Mob
pa_ ,......, ANN M.111URPHY
(Notarial Seal) ,+'NCtiq �; 5 Notary Public, State of New York
' - r No. OIMU6067553
t ie : } Qualified in Nassau County
Commission Expires December 10, 2029
4,4 FNEW
CERTIFICATION
STATE OF NEW PORK
COUNTY OF NEW YORK SS.
The undersigned Karen L. Colonna hereby certifies:
THAT the original resolution, of which the following is a true and correct copy, was duly adopted by unanimous written consent of the Board of Directors of
Hudson Insurance Company dated Ady271°. 2007, and has not since been revoked, amended or modified:
"RESOLVED, that the President, the Executive Vice Presidents, the Senior Vim Presidents and the Vice Presidents shall have the authority and
discretion, to appoint such agent or agents, or shomey or attomays-in-fact, for the purpose of carrying an this Company's surety business, and to empower
such agent or agents, or attorney or morays -in -fact, to execute and deliver, under this Company's seal or otherwise, bonds obligations, and recognizances,
whether made by this Company m surety thereon or otherwise, indemnity contracts, contracts and certificates, and my and all other contracts and
undertaking made in the course of this Company's surety business, and renewals, extensions, agreements, waivers, consents or stipulations regarding
undertakings so made; and
FURTHER RESOVVED, that the signature of my such lacer of the Company and the Company's seal may N affixed by facsimile to any power of
attorney or certification given for the execution of my bind, undertaking, recognizance, contract of indemnity or other written obligation in the nature
thereof or related thereto, such signature and seal when so used whether heretofore or hereafter, being hereby adopted by the Company as the original
signature of such officer and the original seal of the Company, to be valid and binding upon the Company with the same force and effect aS though maritally
affixed."
THAT the above and foregoing is a full, We and correct copy of Power of Attorney issued by said Company, and of the whole of the original and that the
said Power of Attorney is still in full force and effect and has not been revoked, and fudhermore that the Resolution of the Board of Directors, set forth in the said
Power of Attorney is now in force.
0 1 Witness the hand of the undersigned and the seal of said Company this 1 Oth day of March 20 26
....m✓°fBy
Karen L. Colors, Corporate Secretary
SUITE 400 - CITY HALL
215 S. DR. MARTIN LUTHER KING, JR. BLVD.
SOUTH BEND, INDIANA 46601-1830
PHONE 574/235-9251
FAx 574/ 235-9171
TDD 574/ 235-5567
CITY OF SOUTH BEND, LAMES MUELLER, MAYOR
BOARD OF PUBLIC WORKS
Date: February
24, 2026
To: All Planholders
From Hillary
Horvath, Clerk, Board of Public Works
Subject Addendum Number: 1
Project Name:
Demolition of 921 Louise Street
Project Number:
125-043A
ACKNOWLEDGEMENT OF RECEIPT OF ADDENDUM
Date Received: 2,• •3 - Z�
This addendum is being forwarded to you for the above referenced project.
Please sign below and acknowledge receipt of this Addendum
by including with your electronic bid submission.
THIS ADDENDUM MAY AFFECT YOUR BID.
Notes:
The attached documents are hereby added to the Specifications and Contract
Documents and become a part of herein.
Company:
Authorized Signature:
Date: _ ? -
Version 12/05/2025
F
I. 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.
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.
(iii) By checking this box, I hereby acknowledge that apprenticeship and training
programs that I participate in have graduated at least five (5) apprentices in each
of the past five (5) years.
(iv) By checking this box, I hereby acknowledge that all subcontractors performing
work gr ate li th�n $250,000 also meet the qualifications of the Responsible Bidder
Ordinan e. `1
(b) Attachments: ) v v -
(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).
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.
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. This includes, but may not be limited
to, letters from apprenticeship coordinators detailing the bidder's association with
the program, and the United States Department of Labor Office of Apprenticeship
Certificates of Registration of Apprenticeship Programs for each type of work to be
performed on the project.
Version 5/20/2024 General Conditions - 13
II. PRE -QUALIFICATION CHECKLIST (FOR BIDDERS THAT ARE NOT PRE -QUALIFIED)
(a) Acknowl,gements:
(i} By checking this box, I hereby acknowledge that I am not a pre -qualified bidder
with the City of South Bend.
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.
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-
Vcontractor loses their license at any point, it is the responsibility of that sub-
contractor to notify the City.
(v) By checking this box, I hereby acknowledge that apprenticeship and training
L/ programs that I participate in have graduated at least five (5) apprentices in each
of the past five (5) years.
(vi) By checking this box, I hereby acknowledge that all subcontractors performing
work greater than $250,000 also meet the qualifications of the Responsible Bidder
Ordinance.
(b) Attachments:
(i) J 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) List identifying all former business names.
(iii) x7' 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)
years.
(iv) 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) Ptatement that individuals who will perform work on the public work project on my
will be properly classified as an employee or as an independent contractor
under all applicable state and federal laws and local ordinances.
(v)Ybehalf
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. This includes, but may not be limited
to, letters from apprenticeship coordinators detailing the bidder's association with
Version 5/20/2024 General Conditions -14
the program, and the United States Department of Labor Office of Apprenticeship
Certificates of Registration of Apprenticeship Programs for each type of work to be
(/ performed on the project.
(vi) 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.
(vii) 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.
(viii) Written statement of any federal, state or local tax liens or tax delinquencies owed
-C/to any federal, state or local taxing body in the preceding three years.
(ix) 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: c G Z
ign
v
(Print Name Here)
I�L r---
(Name of Company)
-Z,7, yD k,, l 6`7 &t .S)-
(Ad ress of Company)
(City)
1)1101r4q� ��
(State)
O'� ? -3 -3 Z- Q c)
(Telephone Number)
Version 5/20/2024 General Conditions - 15
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
1. 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 07/19/2023 Contractor's Bid for Public Works - 3
BID/PROPOSAL
CITY OF SOUTH BEND
Project Name: Demolition of 921 Louise Street
Project Number: 125-043A
For Bids Due: Tuesday, March 10, 2026 @ 9:00 A.M. (E.D.T.)
Contractor Name:
BASE BID
Item
No.
Description
Quantity
Unit
Unit Price
Total Amount
Lump Sum price to complete asbestos
1
abatement, building demolition, backfill,
1
LSUM
5 ell �� °
Sy �t �aa
grading and seeding as intended by
these Specifications
2
Environmental Allowance
1
LSUM
$75,000
$75,000
BASE BID TOTAL 6V-1,ye5,C)
Bidder (Firm): Y.��
Address:
City/State/Zip: M&,v a,,.., L °4ZI& Telephone Number: (70 $) �3 l if2o C.r
By
(Signature)
J �n�.�,c Orc.c.h—
(Printed Name of Person Signing)
Version 07/19/2023 Contractor's Bid for Public Works - 7
CITY OF SOUTH BEND
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN
FORM MBE-2.0
EVIDENCE OF GOOD FAITH EFFORTS
B
l •�'t
S � •n c�'Y:, 1 D i
M i
tt<t:S
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 MBE participation.
Project Number: 125-043A Date: Z
Project Name: Demolition of 921 Louise Street
Bidder: i�-L, �r�er,•S,.r
Contact Person: S !Sth Telephone: `' 6 - 33 1 -14 E o 0
Address: -2 3 0y t,.J 7
City: State: 100T L Zip: y 2 AP
Email: `0 , C.v
To determine whether a bidder has demons ra ed good faith efforts to reach the MBE 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
MBE 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: hftD://www.in.gov/idoa/.
GOOD FAITH EFFORTS TO OBTAIN MBE PARTICIPATION
The bidder shall initial each item below, as evidence of its good faith efforts to obtain MBE participation
in the awarded contract.
I affirm that I reviewed the City of South Bend's Minority and Women Business Enterprise
Inclusion Program Plan and the Indiana Department of Administration's certified list of
Indiana Minority and Women Business Enterprises, found on their website
http://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 MBE participation.
I affirm that I have made good faith efforts to solicit through all reasonable and available
means the interest of all MBEs 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
MBEs of contracting and subcontracting opportunities.
I affirm that I advertised in general circulation and/or trade association publications
concerning subcontract opportunities and allowed MBEs 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 MBEs of subcontracting opportunities and allowed
sufficient time for MBEs to participate effectively.
I affirm that I followed up on initial solicitations with interested MBEs.
I affirm that I negotiated with interested MBEs in good faith, including providing such MBEs
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 MBEs in obtaining bonding,
lines of credit, or insurance as required by the City or the bidder, where appropriate.
Version 07/19/2023 Contractor's Bid for Public Works -10
CITY OF SOUTH BEND
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN
FORM MBE-2.0
EVIDENCE OF GOOD FAITH EFFORTS
I affirm that I have made good faith efforts to assist interested MBEs in obtaining necessary
equipment, supplies, materials, or related assistances or services, where appropriate.
ft
I affirm that I did not reject any MBEs 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 MBE 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 MBE 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 07/19/2023 Contractor's Bid for Public Works - 11
CITY OF SOUTH BEND
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN
FORM WBE-2.0
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: 126-043B Date:
Project Name: Demolition of 921 Louise Street
Bidder:
Contact Person:
N
Telephone: ?n8-33 f'yLoc�
Address: Z3yo l,._. 1 L) '+VN let —
City: I ' &r State: 1- L. Zip: &6 Ll Z
Email: V>� z/U� • LG M�
To determine whether a bidder has demonstrate good faith efforts to reach the WBE 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
WBE 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: htt ://v~.in. ov/idoa/.
GOOD FAITH EFFORTS TO OBTAIN WBE PARTICIPATION
The bidder shall initial each item below, as evidence of its good faith efforts to obtain WBE participation
in the awarded contract.
I affirm that I reviewed the City of South Bend's Minority and Women Business Enterprise
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.govfidoa).
I affirm that I have made good faith efforts to select portions of the contract work to be
performed by WBEs, including, where appropriate, breaking out contract work items into
economically feasible units to facilitate WBE participation.
n
I affirm that I have made good faith efforts to solicit through all reasonable and available
means the interest of all WBEs 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
WBEs of contracting and subcontracting opportunities.
_1,6
I affirm that I advertised in general circulation and/or trade association publications
concerning subcontract opportunities and allowed WBEs 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 WBEs of subcontracting opportunities and allowed
sufficient time for WBEs to participate effectively.
I affirm that I followed up on initial solicitations with interested WBEs.
I affirm that I negotiated with interested WBEs in good faith, including providing such WBEs
with adequate information about the plans, specifications and other requirements of the
J
subcontract.
I affirm that I have made good faith efforts to assist interested WBEs in obtaining bonding,
lines of credit, or insurance as required by the City or the bidder, where appropriate.
Version 07/19/2023 Contractor's Bid for Public Works -12
CITY OF SOUTH BEND
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN
FORM WBE-2.0
EVIDENCE OF GOOD FAITH EFFORTS
I affirm that I have made good faith efforts to assist interested WBEs in obtaining
necessary equipment, supplies, materials, or related assistances or services, where
appropriate.
I affirm that I did not reject any WBEs 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 WBE 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 07/19/2023 Contractor's Bid for Public Works -13
CITY OF SOUTH BEND
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN
FORM MBE-2.1
MBE CONTACTED
•� w
w-
INS
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 -owned business meets the MBE qualifications. Attach additional pages if necessary.
PAGE OF
Project Number: 125-043A MBE Participation Goal 1.28%
Project Name: Demolition of 921 Louise Street
MBE Firm 5 r C
Owner or Contact at MBE Firm ���rh� C -Q
Telephone: 57741- 793-6.7 Fax: Email: 1s}.� S� ����Y c.52ral3 (�✓ a�nza.•1 cw-•..
TYPE OF WORK SOLICITED FOR THIS PROJECT:
RESULTS OF CONTACT WITH THE MBE FIRM:
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 07/19/2023 Contractor's Bid for Public Works - 14
CITY OF SOUTH BEND
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN
FORM MBE-2.1 ► .
WBE 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
woman -owned business meets the WBE qualifications. Attach additional pages if necessary.
PAGE OF
Project Number: 125-043A
Project Name:
Bid
By:
Demolition of 921 Louise Street
WBE Participation Goal 4.60%
WBE Firm MS C)/
Owner or Contact at WBE Firm �),
Telephone: Fax:
TYPE OF WORK SOLICITED FOR THIS PROJECT:
Email: $ C LV44 4- 4nr% S — eS . &.ea-�
�r �
Ga-.
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 07/19/2023 Contractor's Bid for Public Works - 15
CITY OF SOUTH BEND ,
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN_:► Ace �{ y
FORM WBE-1.0 1
WBE 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 woman -owned business meets the WBE qualifications.
***Goals should be calculated based on the Base Bid only.***
Project Number: 125-043A
Project Name: Demolition of 921 Louise Street
Bidder:
Base Bid Amount: yyci
_21
WBE Goal:
o
4.60 /o
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
Percentage
of Total
Component
Bid/Proposal
AMS Elite Solutions, Inc
Hauling
1862 E Belvidere Road
Julie Savitt
847/838-9501
31,000
Grayslake, IL 60030
Submitted by: Julie Savitt
Print Name
Signattte
3/9/26
Date
***Goals should be calculated based on the Base Bid only.***
Version 07/19/2023 Contractor's Bid for Public Works - 9
� o
w �
CITY OF SOUTH BEND (' 7
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSIONPROGRAM PLAN PR �.
,� �, �.:►�1.. .f
FORM MBE-1.0
MBE 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 fisted minority -owned business meets the MBE qualifications.
***Goals should be calculated based on the Base Bid only.***
Project Number: 125-043A Project Name: Demolition of 921 Louise Street
Bidder: Base Bid Amount:ad
ci MBE Goal: 1.28%
Pag .of_
Name & Address of MBE Primary Contact Person Scope of Work to be Performed Dollar Amount of MBE Percentage
(Name/Telephone) (Attach scope/schedule if you need additional space) Component of Total
p Bid/Pro osal
�i-Class Lc�is�5 1-�-(. 5�-qa3 -D���
�Iruckl�t �
CTs�".
�14
Submitted by:��/! Print Name .31 ! ,,
�htw
Signature Date
***Goals should be calculated based on the Base Bid only.***
Version 07/19/2023 Contractor's Bid for Public Works - 8
State of Indiana
Office of the Secretary of State
Certificate of Reinstatement
of
KLF DEMOLITION SERVICES, INC.
I, HOLLI SULLIVAN, Secretary of State, hereby certify that an Application for Reinstatement of the
above Foreign For -Profit Corporation has been presented to me at my office, accompanied by the fees
prescribed by law and that the documentation presented conforms to law as prescribed by the
provisions of the Indiana Code.
NOW, THEREFORE, with this document I certify that said transaction will become effective Thursday,
July 01, 2021.
In Witness Whereof, I have caused to be affixed my
signature and the seal of the State of Indiana, at the City
of Indianapolis, July 01, 2021.
HOLLI SULLIVAN
SECRETARY OF STATE
201801311237412 / 9067107
To ensure the certificate's validity, go to https://bsd.sos.in.gov/PublicBusinessSearch
Page 10 of 21 tee«,: c..,...an. 1 0c n Mn l
APPROVED AND FILED
HOLLI SULLIVAN
INDIANASECRETARY OF STATE
07/01/2021 12:49 PM
APPLICATION FOR REINSTATEMENT
i
NAME AND PRINCIPAL OFFICE ADDRESS ,r,
BUSINESS ID 2018013 H 237412
BUSINESS TYPE Foreign For -Profit Corporation
BUSINESS NAME KLF DEMOLITION SERVICES, INC.
PRINCIPAL OFFICE ADDRESS 2300 W 167th Street, STE 2, Markham, IL, 60428, USA
DATE WHEN THE BUSINESS WAS ADMINISTRATIVELY DISSOLVED (OR REVOKED)
DATE
YEARS FILED
YEARS
REGISTERED OFFICE AND ADDRESS
01/05/2021
2020/2021
REGISTERED AGENT TYPE
Business Commercial Registered Agent
NAME
COGENCY GLOBAL INC.
ADDRESS
9221 CRAWFORDSVILLE RD, Indianapolis, IN, 46234, USA
SERVICE OF PROCESS EMAIL
sop@cogencyglobal.com
TITLE
President
NAME
James W Bracken III
ADDRESS
9109 W 123rd Street, Palos Park, IL, 60464, USA
TITLE Secretary
NAME Kelly Bracken
ADDRESS 9109 W 123rd Street, Palos Park, IL, 60464, USA
Page I I Of21 CertificateID:18649067
- Page 1 of 4 -
APPROVED AND FILED
HOLLI SULLIVAN
INDIANA SECRETARY OF STATE
07/01/2021 12:49 PM
ASSUMED BUSINESS NAME(S) RETURNED TO ACTIVE STATUS -
No records.
ASSUMED BUSINESS NAMES) ADMINISTRATIVELY CANCELLED
The following Assumed Business Names remain administratively cancelled due to the fact that they are not distinguishable on the record. See IC
23-0.5-3-1(a).
No records.
THE SIGNATOR(S) REPRESENTS THAT THE REGISTERED AGENT NAMED IN THE APPLICATION HAS CONSENTED TO THE
APPOINTMENT OF REGISTERED AGENT.
IN WITNESS WHEREOF, THE UNDERSIGNED HEREBY VERIFIES, SUBJECT TO THE PENALTIES OF PERJURY, THAT THE
STATEMENTS CONTAINED HEREIN ARE TRUE, THIS DAY July 1, 2021
SIGNATURE Payton E Windell
TITLE Secretary
Business ID : 201801311237412
Filing No.: 9067107
Page 12 Of 21 CedlficatelD:18649067
- Page 2of4-
INDIANA DEPARTMENT OF REVENUE
DO 100 N SENATE AVE
INDIANAPOLIS IN 46204-2253
Ifs
APPROVED AND FILED
HOLLI SULLIVAN
INDIANA SECRETARY OF STATE
07/01/2021 12:49 PM
Indiana Department of Revenue
Eric J. Holcomb, Governor
Bob Grennes, Commissioner
I [lilll (IIII Ill[I 11[II 11[II IIII lllli [IIII IlIII IIlII 11111 I1111 I[11 IIII
000009 FEIN 36-4346764
K.L.F. ENTERPRISES, INC. Letter ID L0001145501
9221 CRAWFORDSVILLE RD Date Issued June 04, 2021
,X,z INDIANAPOLIS IN 46234-1521
ffff-
Certificate of Clearance for Reinstatement
To: Holli Sullivan
Secretary of State
Business Services Division
K.L.F. ENTERPRISES, INC. has filed with the Department of State Revenue an affidavit, Form AD-19,
disclosing that the corporation is applying for a Certificate of Reinstatement from the Secretary of State, and
requesting a Certificate of Clearance from this department stating all taxes and fees owed by the corporation
have been paid.
An examination of the corporation's existing accounts for listed taxes and fees required to be administered or
collected by the department has determined that all taxes, fees, interest, and penalties due have been paid or
satisfied. Execution of the document does not preclude the department from future examination and adjustment
of the corporation's Indiana tax accounts for any period.
This Certificate of Clearance shall be null and void sixty (60) days after its date of issue.
vtqt�a -
Bob Grennes, Commissioner
Indiana Department of Revenue
Laura Bates, Processing Manager
Tax Administration
By: Shivone Wilson
Instructions to the corporation:
You are to include this letter along with the other documents constituting your Application for Reinstatement
(SF4160). Do Not Mail this letter separately to the Secretary of State unless you are so directed.
PL WALevei
Page 13 Of 21 CertificateID:18649067
- Page 3 of 4 -
APPROVED AND FILED
HOLLI SULLIVAN
INDIANA SECRETARY OF STATE
07/012021 12:49 PM
File Number 6087-712-2
c
�. D
�� �.'� 1 es 1,° `Orr ��
To all to whom these Presents Shall Come, Greeting. -
I, Jesse White, Secretary of State of the State of Illinois, do hereby
certify that I am the keeper of the records of the Department of
Business Services. I certify that
K.L.F. ENTERPRISES, INC., A DOMESTIC CORPORATION, INCORPORATED UNDER THE
LAWS OF THIS STATE ON FEBRUARY 22, 2000, APPEARS TO HAVE COMPLIED WITH
ALL THE PROVISIONS OF THE BUSINESS CORPORATION ACT OF THIS STATE, AND AS
OF THIS DATE, IS IN GOOD STANDING AS A DOMESTIC CORPORATION IN THE STATE
OF ILLINOIS.
In Testimony Whereof, I hereto set
my hand and cause to be affixed the Great Seal of
the State of Illinois, this 1ST
day of JULY A.D. 2021
Authentication #: 2118202716 verifiable until 0710112022
Authenticate at: http://w .cyberdriveillinois.com
SECRETARY OF STATE
Page 14 Of 21
Certi ficateID:18649067
- Page 4of4-
APPROVED AND FILED
HOLLI SULLIVAN
INDIANA SECRETARY OF STATE
01/13/2022 12:00 PM
BUSINESS ENTITY REPORT
NAME AND PRINCIPAL OFFICE ADDRESS
BUSINESS ID
201801311237412
BUSINESS TYPE
Foreign For -Profit Corporation
BUSINESS NAME
KLF DEMOLITION SERVICES, INC.
ENTITY CREATION DATE
01/31/2018
JURISDICTION OF FORMATION
Illinois
PRINCIPAL OFFICE ADDRESS
2300 W 167th Street, STE 2, Markham, IL, 60428, USA
YEARS FILED
YEARS
EFFECTIVE DATE
EFFECTIVE DATE
EFFECTIVE TIME
REGISTERED OFFICE AND ADDRESS
2022/2023
01/13/2022
12:00 PM
REGISTERED AGENT TYPE
Business Commercial Registered Agent
NAME
COGENCY GLOBAL INC.
ADDRESS
9221 CRAWFORDSVILLE RD, Indianapolis, IN, 46234, USA
GOVERNING PERSON INFORMATION
'I II'LE
President
NAME
James Bracken JR.
ADDRESS
2044 W 163rd St., Markham, IL, 60428, USA
TITLE
Secretary
NAME
Kelly Bracken
ADDRESS
2044 W 163rd St, Markham, IL, 60428, USA
Page 15 Of 21 CertificateID:18649067
- Page 1 of 2 -
APPROVED AND FILED
HOLLI SULLIVAN
INDIANA SECRETARY OF STATE
01/13/2022 12:00 PM
SIGNATURE
IN WITNESS WHEREOF, THE UNDERSIGNED HEREBY VERIFIES, SUBJECT TO THE PENALTIES OF PERJURY, THAT THE
STATEMENTS CONTAINED HEREIN ARE TRUE, THIS DAY January 13, 2022.
THE UNDERSIGNED ACKNOWLEDGES THAT A PERSON COMMITS A CLASS A MISDEMEANOR BY SIGNING A
DOCUMENT THAT THE PERSON KNOWS IS FALSE IN A MATERIAL RESPECT WITH THE INTENT THAT THE DOCUMENT
BE DELIVERED TO THE SECRETARY OF STATE FOR FILING.
SIGNATURE Kelly Bracken
TITLE Secretary
Business ID: 201801311237412
Filing No.: 9283545
Page 16 Of 21 CertlficateID:18649067
- Page 2 of 2 -
State of Indiana
Office of the Secretary of State
Commercial Registered Agent Statement of Change
of
COGENCY GLOBAL INC.
I, DIEGO MORALES, Secretary of State, hereby certify that a Commercial Registered Agent Statement
of Change of the above Business Commercial Registered Agent has been presented to me at my
office, accompanied by the fees prescribed by law and that the documentation presented conforms to
law as prescribed by the provisions of the Indiana Code.
NOW, THEREFORE, with this document I certify that said transaction will become effective Friday,
January 19, 2024.
In Witness Whereof, I have caused to be affixed my
signature and the seal of the State of Indiana, at the City
of Indianapolis, January 19, 2024.
DIEGO MORALES
SECRETARY OF STATE
201801091232027 / 10185995
To ensure the certificate's validity, go to https://bsd.sos.in.gov/PublicBusinessSearch
Page 17 Of21 CertificateID:18649067
APPROVED AND FILED
DIEGO MORALES
INDIANA SECRETARY OF STATE
01/19/2024 01:53 PM
COMMERCIAL REGISTERED AGENT STATEMENT OF CHANGE
COMMERCIAL REGISTERED AGENT INFORMATION
NAME
COGENCY GLOBAL INC.
ID
201801091232027
ENTITY TYPE
Business Commercial Registered Agent
STATUS
Active
ASSOCIATED BUSINESS INFORMATION
BUSINESS NAME
COGENCY GLOBAL INC.
BUSINESSID
1993031327
BUSINESS ADDRESS
122 E. 42nd St, 18th FI, New York, NY, 10168, USA
ENTITY TYPE
Foreign For -Profit Corporation
EMAIL
complianceteam@cogencyglobal.com
STATUS
Active
COMMERCIAL REGISTERED AGENT ADDRESS
NEW ADDRESS 150 W. Market Street, Suite 400, Indianapolis, IN, 46204, USA
Page 18 Of21 CertificatelD:18649067
- Page I of 2 -
APPROVED AND FILED
DIEGO MORALES
INDIANA SECRETARY OF STATE
O1/19/2024 01:53 PM
THE COMMERCIAL REGISTERED AGENT UNDERSTANDS THAT IT MUST NOTIFY EACH REPRESENTED BUSINESS OF THE
CHANGE IN ITS NAME AND/OR ADDRESS MADE BY THIS STATEMENT OF CHANGE.
IN WITNESS WHEREOF, THE UNDERSIGNED HEREBY VERIFIES, SUBJECT TO THE PENALTIES OF PERJURY, THAT THE
STATEMENTS CONTAINED HEREIN ARE TRUE, THIS DAY January 19, 2024.
THE UNDERSIGNED ACKNOWLEDGES THAT A PERSON COMMITS A CLASS A MISDEMEANOR BY SIGNING A
DOCUMENT THAT THE PERSON KNOWS IS FALSE IN A MATERIAL RESPECT WITH THE INTENT THAT THE DOCUMENT
BE DELIVERED TO THE SECRETARY OF STATE FOR FILING.
SIGNATURE Krystal Beckner
TITLE Legal Representative
Commercial Registered Agent ID : 201801091232027
Filing No.: 10185995
Page 19 Of 21 CertificatcID:18649067
- Page 2of2-
APPROVED AND FILED
DIEGO MORALES
INDIANA SECRETARY OF STATE
04/24/2024 05:41 PM
BUSINESS ENTITY REPORT
NAME AND PRINCIPAL OFFICE ADDRESS
BUSINESS ID
201801311237412
BUSINESS TYPE
Foreign For -Profit Corporation
BUSINESS NAME
KLF DEMOLITION SERVICES, INC.
ENTITY CREATION DATE
01/31/2018
JURISDICTION OF FORMATION
Illinois
PRINCIPAL OFFICE ADDRESS
2300 W 167th Street, STE 2, Markham, IL, 60428, USA
'YEARS FILED
YEARS
EFFECTIVE DATE
EFFECTIVE DATE
EFFECTIVE TIME
REGISTERED OFFICE AND ADDRESS
2024/2025
04/24/2024
5:41 PM
REGISTERED AGENT TYPE Business Commercial Registered Agent
NAME COGENCY GLOBAL INC.
ADDRESS 150 W. Market Street, Suite 400, Indianapolis, IN, 46204, USA
GOVERNING PERSON INFORMATION
TITLE President
NAME James Bracken JR.
ADDRESS 2044 W 163rd St., Markham, IL, 60428, USA
TITLE
Secretary
NAME
Kelly Bracken
ADDRESS
2044 W 163rd St, Markham, IL, 60428, USA
Page 20 Of 21 CertificateID:18649067
- Page 1 of 2 -
APPROVED AND FILED
DIEGO MORALES
INDIANA SECRETARY OF STATE
04/24/2024 05:41 PM
IGNATURE
IN WITNESS WHEREOF, THE UNDERSIGNED HEREBY VERIFIES, SUBJECT TO THE PENALTIES OF PERJURY, THAT THE
STATEMENTS CONTAINED HEREIN ARE TRUE, THIS DAY April 24, 2024.
THE UNDERSIGNED ACKNOWLEDGES THAT A PERSON COMMITS A CLASS A MISDEMEANOR BY SIGNING A
DOCUMENT THAT THE PERSON KNOWS IS FALSE IN A MATERIAL RESPECT WITH THE INTENT THAT THE DOCUMENT
BE DELIVERED TO THE SECRETARY OF STATE FOR FILING.
SIGNATURE Haley Bracken
TITLE Legal Representative
Business ID: 201801311237412
Filing No.: 10309816
Page 21 Of 21 CertificateID:18649067
- Page 2of2-
FOREIGN REGISTRATION STATEMENT
. rlatOFom1 S83ty9 te-17)
/lpoMd by State @owd of Aosott % 2017
Approved and Filed
20180131123741217819685
Filing Date: 02/01/2048
Effective :011311201811:36
CONNIE LAWSON
Indiana Secretary of State
ifWdlana Code 23-OA4 3
23-0.5.2.26
23-0,6.9-29
RUNG PEE:
Fcr-Profit Entities: s17S.00 `
Fatatgn tdastacLLCai S26o.00
NOnisroltt Corporattaae: $75.00
FOREIGN REGts7RATiOH SYATElf rsh
The undafslgned, desldng to register a iateign enrdy with lhe'Secretary of State ptusuaat to the piovl ons atindlana Code 23.0S43: exavates the
fcuowlrig Foreign Regtstrailasi Statements
•
Lcpi warm oltho a (7ho esaroo must �bwEB�lr�uaa Coda 23Q5�l:) .
KIA Enterprises. Inc.
if the name does M omply W01 InEfts diode 22-0.5.3.1. Ift alternate rusrrrQ of thn aatify adopted ender i ana Code 23.0.33.e
-TICLE . I . I - ENTITY IN FORMIATION
lype (safaaf ores]
NaMmM Carpotallan ' Limlted,UabIPy Cmp�y
Cafpomflon. Induding Benefit Cafporation and P feWan CorpowlionBLJnftd
Master Lintiled Lia Cara Series UablUty P&MaMWO Umlied-PattnessMa
-
U the eawy is a no wMM to it Ilse wo leauo taeasbafa.
QYes QNa mertlbem
Inpew .parattaa lead boar tnOoepardted to tnerlCne, l vua a (6B1eci orteJc
Public Benebt Cospamilort Mutual I; 3enetit.Cofperatlon QRciigians Cot00MG06
Sho craw a United li &MI or t, wet Limited Uaway any; ttto
' yes
uawly ca be mnn byr ib rtsaaaQetr or retaescgara..
Na UThe LL O Veit! be a single•fnefs&w LLC. (opffmal)
u the entity We MastarLo Wed Uabtilty Coifrpany, the Master LLC b•authodwd transact business In tadfana in-acbardanca:wifl; Indiana Code 23-18.1
and is organtwd under a taw that alicwa.for the deslgnaticrs of one(1) or more series.
The an of famsatlan
IliiftOls
Ewe the eaatywat roenmd In Usluftclidan at tonna3lan (mount- day. year)
021?.2I2000
ARTICLE IV - s AGEW INFORMATION
9QaisZ far" ateidyM w (
XMtteQlitarCd
Comrnerdat.mgisterad agent LjNw=wnexW mglstsred"agent
or r egeeei
COGENCY GLOBAL INC.
lithe regtslbradagentf9 a nontaammardrifregfsleadag�,nf, please provide frs9 sdd�dtheregtsterod egs{sl
N sad edreet
o
ZiP coos
IN
The fogowinOFnlar #Fw is m forbolb a em memaWmgWeivd agent and a nonwwmerda) ragfslered pgoaL
rep-mm agent yet yam On ffls s arod agar -a' - M 01rseanlu et _ _. "'
r�
X By Osecking Ow IX Gm Stgnatar(s) represent(o Ihat the ReplMred Agent names oft Foreign Regtstratlon Statme has conseMd to me• �
,
appoUdIr at of Re •Agefst-
in Witness Whereof. the undemighed'didy. aWX*dZad,reprdseitteM of the ent exacules 0ftfwelgn RegWidtion Stalmeat eMd vadQes,
su*cl to penattles afpef)uy; that ale 6%tarsenta conteltned haitsin are true: this 2,�day.of January _. :20 18
siprratas'e
PdatsdUF
estserea TiEtta • •
IL e:tr4�1 �rZ-Rt.tGIG'W �G`C.{t.G"CFltd� -�_ _ Cr`'
Page 4 Of 21 CertiftcateID:18649067
Approved and Filed
20180131123741217819686
Filing Date: 02/01/2018
Effective :01/311201811:36
CONNIE LAWSON
Indiana Secretary of State
File Number 6087-712-2
v
To all to ivhorn these Presents Shall Come, Greeting.,,
I, Jesse Mite, Secretary of State of the State of Illinois, do hereby
certify that I am the keeper of the records of the Department of
Business Services. I certify that
K.L.F. ENTERPRISES, INC., A DOMESTIC CORPORATION, INCORPORATED UNDER THE
LAWS OF THIS STATE ON FEBRUARY 22, 2000, APPEARS TO HAVE COMPLIED WITH
ALL THE PROVISIONS OF THE BUSINESS CORPORATION ACT OF THIS STATE
RELATING TO THE PAYMENT OF FRANCHISE TAXES, AND AS OF THIS DATE, IS IN
GOOD STANDING AS A DOMESTIC CORPORATION IN THE STATE OF ILLINOIS.
In Testimony Whereof, r hereto Set
my hand and cause to be affixed the Great Seal of
the State of Illinois, this 29TH
day of 7ANUARY A.D. 2018
Authentication M 1802902472 verifiable until 01/29/2019
Authenticate at: http://www.cyberdriveillincis.com
SECRETARY OF STATE
Page 5 Of 21 CertificateID:18649067
4W!
Section III
2300 w 167"' ST. O MARKHAM, IL 60428
TEL, 708.331.4200 0 FAX: 708,331.4212
KLF Enterprises' financial statement is included with this submission. We respectfully request that the
financial information provided with this bid be treated as confidential and shared only with
authorized personnel within the City of South Bend, Indiana, as necessary for the evaluation of this
proposal. To the extent permitted by law, we kindly ask that KLF Enterprises' financial statements and
related financial information not be posted or distributed to the general public.
AVE 2300 w 167" ST
TEL: 708.331.4200
ENTERPRISES
PART II
SECTION I — EXPERIENCE QUESTIONNAIRE
#1 Refer to attached documentation.
#2 Refer to attached documentation.
• MARKHAM, IL 60428
• FAX: 708,331.4212
#3 KLF Enterprises has successfully completed all projects that the company has bid and been
awarded. The company has not failed to perform or complete any contract awarded to it.
#4 Please see the attached reference list.
SECTION II — PLAN AND EQUIPMENT QUESTIONNAIRE
#1 KLF Enterprises will mobilize personnel and equipment to the project site to perform an
initial site review and confirm all pre -demolition requirements have been satisfied. This includes
verification that utilities have been properly disconnected, required abatement work has been
completed ,and the structure has been secured and cleared of occupants or unauthorized
individuals. Temporary safety and site protection measures will be installed as necessary around
the project area.
Demolition activities will proceed in a controlled manner, generally working from the upper
portions of the structure downward. Materials suitable for recycling or salvage will be separated
in accordance with project specifications. Structural elements including concrete and masonry
will be demolished and removed from the site. Any below -grade removals will be properly
backfilled and compacted as required. Upon completion of demolition operations, the site will be
restored by importing topsoil, grading the area, and completing final seeding.
#2 Subcontractors
AMS Elite Solutions (Trucking / Hauling / WBE)
1862 E Belvidere, Grayslake IL 60030
l st Class Logistics (Trucking / Hauling / MBE)
2213 Saint Charles Ave
South Bend, IN 46614
0
2300 w 167"' ST. & MARKHAM, IL 60428
ENTERPRISES TEL: 708.331.4200 • FAX: 708.331.4212
Safe Environmental Co (Abatement)
1006 165" st
Hammond IN 46324
#3 A finalized list of subcontractors will be submitted prior to contract execution or upon request
by the Owner.
#4 Refer to the attached equipment list.
#5 At this time, KLF Enterprises has not entered into formal subcontract agreements related to
this project. However, pricing and rate confirmations have been obtained from vendors and
subcontractors supporting the costs included in our proposal. Formal contracts will be executed
following contract award.
7L�2300 w 16701 ST. MARKHAM, IL 60428
TEL: 708.331.4200 a FAX: 708.331.4212
ENTERPRISES
Exhibit A - Public Works Reference
1. Project: Demolition
Location: Burbank, IL
Description: Full demolition of educational facility.
Contact: Tim Geary
Phone:630-887-8640
2. Project: Demolition of 38 Residential Structures & Asbestos Coordination
Location: Chicago Heights, IL
Description: Demolition of residential structures with asbestos removal coordination.
Owner: City of Chicago Heights
Contact: TJ Somers
Phone:708-756-5315
3. Project: Demolition of Commercial Structure
Location: Hazel Crest, IL
Description: Demolition of two school buildings totaling 80,000 square feet.
Owner: Hazel Crest
Contact: Joe Sierra
Phone: 708-825-0078
4. Project: Demolition of (2) 54,000 SF structures and site restoration
Location: 1920-1930Thoreau Dr., Schaumburg, IL
0
i2 , 2300 w 167th ST
TEL: 708.331.4200
ENTERPRISES
Description: Large-scale commercial structure demolition.
Owner: Village of Schaumburg
Contact: Yasmin Rodriguez
Phone:847-923-6647
f MARKHAM. IL 60428
® FAX: 708.331.4212
2300 w 167"' ST. Y MARKHAM, IL 60428
TEL: 708.331.4200 a FAX: 708.331.4212
Private Reference
1. Project: Warehouse Demolition
Location:
Description: Full demolition of 80,000 Warehouse
2023
Owner: Nick D
Phone:708-774-4660
2. Project: Demolition 3 story Bank
Location: Schaumburg IL
Description: Demolition of 3 story Bank .
2024
Contact: Mike W
Phone:847-502-5778
3. Project: Former Church Demolition
Location: Cicero, IL
Description: Demolition of former church structure.
Contact: Robert F. Rabin
Phone:847-791-6660
2300 w 167"' ST. ® MARKHAM, IL 60428
All ENTERPRISES TEL: 708.331.4200 • FAX: 708.331.4212
Completed projects 1 year from submittal date
1. Project: Demolition
Location: Cicero, IL
Description: Full demolition of educational facility.
Contact: Mark McKnight
Phone: 630-360-6394
2. Project: Demolition of multiple structure
Location: Blue Island, IL
Contact: Mark P
Phone:708-396-7066
3. Project: Demolition of Annex Educational facility
Location: St Charles
Contact: Amanda S
Phone:331-228-5285
SAFETY & HEALTH MANUAL
KLF ENTERPRISES 12300 West 167th Street, Markham, It. 60428
SAFETY &HEALTH MAUAL
TABLE OF CONTENTS
Section 1
Statement of Safety & Health Policy
Revision 3 December 2024
Section 2
General Safety Rules & Guidelines
Revision 3 December 2024
Section 3
Accountability & Enforcement Policy
Revision 3 December 2024
Section 4
Employee Fit for Duty Policy
Revision 3 December 2024
Section
Employee Training& Education Guidelines
Revision 3 December 2024
Section 6
Hazard Recognition Policy; Daily Brief & Job Hazard Analysis
Revision 3 December 2024
Section 7
Industrial Hygiene Program
Revision 3 December 2024
Section 8
Process Safety Management Program
Revision 3 December 2024
Section 9
OSHA Required Recordkeeping Policy
Revision 3 December 2024
Section 10
Sub -Contractor Policy
Revision 3 December 2024
Section 11
Alcohol & Drug Policy
Revision 3 December 2024
Section 12
Medical Services & First Aid Program
Revision 3 December 2024
Section 13
Hazard Communication & Globally Harmonized System Program
Revision 3 December 2024
Section 14
Spill Response Program
Revision 3 December 2624
Section 15
Emergency Action Plan
Revision 3 December 2024
Section 16
Fire Prevention & Protection Program
Revision 3 December 2024
Section 17
Accident Investigation Process
Revision 3 December 2024
Section 18
Incident & Near Miss Process
Revision 3 December 2024
Section 19
Personal Protective Equipment Policy
Revision 3 December 2024
Section 20
Occupational Noise Exposure Program
Revision 3 December 2024
Section 21
Respiratory Protection Program
Revision 3 December 2024
Section 22
Class 2 Rubber Gloves with Leather Protective Over -Gloves Policy
Revision 3 December 2024
Section 23
Asbestos Awareness Policy
Revision 3 December 2024
Section 24
Lead Awareness Program
Revision 3 December 2024
Section 25
Silica Awareness Polity
Revision 3 December 2024
Section 26
Fall Prevention & Protection Policy
Revision 3 December 2024
Section 27
Ladder Use Policy
Revision 3 December 2024
Section 28
Scaffold Polity
Revision 3 December 2024
Section 29
Aerial & Scissor Lift Policy
Revision 3 December 2024
Section 30
Excavation &Trenching Policy
Revision 3 December 2024
Section 31
Material Storage & Handling Policy
Revision 3 December 2024
Section 32
Confined Space Entry Program
Revision 3 December 2024
Section33
Hand & Power Tool Program
Revision 3 December 2024
Section 34
Electrical Safety Policy
Revision 3 December 2024
Section 35
LockOut/TagOut Policy; Control of Hazardous Energy
Revision 3 December 2024
Section 36
Spotter Use & Training Guidelines
Revision 3 December 2024
Section 37
Utility Locate Guidelines
Revision 3 December 2024
Section38
HydroVac Truck Operations Policy
Revision 3 December 2024
Section 39
Working in Energized Substations Program
Revision 3 December 2024
Section 40
Equipment Grounding in Substations Policy
Revision 3 December 2024
Section 41
Storage & Handling of Fuel on Construction Sites Policy
Revision 3 December 2024
Section 42
Anti -Drug & Alcohol Misuse Prevention Program
Revision 3 December 2024
Section 43
Working with Electro Lifting Magnets
Revision 3 December 2024
Section 44
Section 45
Section 46
Section 47
Section 48
Section 49
Section 50
SECTION: 0, Table of Contents I Page 1 of 1
SAFETY &HEALTH MANUAL
APPENDIX A-ACKNOWLEDGEMENT/RECEIPT FORM
ANTI -DRUG & ALCOHOL MISUSE PREVENTION PROGRAM
ACKNOWLEDGEMENT FORM
Acknowledgement:
I acknowledge, by signing this form, that my full compliance with the Anti -Drug and Alcohol Misuse Prevention Plan (the
"Plan") and DOT drug and alcohol regulation requirements is a condition of my initial and continued employment with the
Company.
I understand and agree that I may be discharged or otherwise disciplined for any drug and/or alcohol violation,
committed by me, as cited in the Plan and/or in the DOT drug and alcohol regulatory requirements.
I also acknowledge, by signing this form, that a copy of the Plan has been made available to me and that I have read and
understand the requirements of the Company and DOT drug and alcohol program.
I have also been provided with informational material on the dangers and problems of drug abuse and alcohol
misuse.
Print Name
Signature:
Date:
Trained by Name Trained by Signature: Date:
SECTION 42: Anti -Drug & Alcohol Misuse Prevention Plan Program I Page 38 of 49
� a SAFETY & HEALTH MAN UAL
EMERVR6 5
APPENDIX B-DESIGNATED PERSONNEL AND SERVICE AGENTS
DESIGNATED EMPLOYER REPRESENTATIVE (DER)/ALCOHOL & DRUG PROGRAM MANAGER
Name: Kelly Bracken
Address: 2300 W. 167`h Street, Markham, IL 60428
Phone Number: 708-339-4100
Name: Sue Hinz
Address: 2300 W. 167the Street, Markham, IL60428
Phone Number: 708-331-4200
MEDICAL REVIEW OFFICER (MRO)
Name: Aaron White, MD
Address: 7612 Taylor Ave. Ft. Smith, AR 72916
Phone Number: (877) 866-2161
COLLECTION SITE- DRUG AND BREATH ALCOHOL
Name: Kim's Trucker Services
Address: 7301 W. 109th PL., Worth, IL 60482
Phone Number: (708) 889-5467
CONSORTIUM/THIRD PARTY ADMINISTRATOR (C/TPA)
Name: Kim's Trucker Services
Address:7301 W. 109th PL., Worth, IL 60482
Phone Number: (708) 889-5467
SUBSTANCE ABUSE PROFESSIONAL (SAP)
James Golding, SAP (DOT)
Address: 15507 S. Cicero Ave, Oak Forest, IL 60452
Phone Number: 708-926-2789
Lori Welcher -Miles, LSW, SAP (DOT)
Address: 8214 S. Clyde Ave, Chicago, II 60617
Phone Number: 708-841-2401
Paul Fitzgerald PsyD, LEAP, MAC, SAP (DOT)
Address: 15 Spinning Wheel Road, STE 422, Hinsdale, IL 60521
Phone Number: 708-337-6936
SECTION 42: Anti -Drug & Alcohol Misuse Prevention Plan Program I Page 39 of 49
—u SAFETY & HEALTH MANUAL
E�,EaPa,E=
APPENDIX C- COVERED POSITIONS
EMPLOYEE/SUPERVISOR POSITIONS SUBJECT TO ALCOHOL & DRUG TESTING
(JOB CLASSIFICATIONS/TITLES)
SUPERVISOR POSITIONS THAT HAVE RECEIVED ALCOHOL AND DRUG TRAINING (60 MINUTES DRUG, 60 MINUTES ALCOHOL)
TITLE EMPLOYEE SUPERVISOR TITLE EMPLOYEE SUPERVISOR
Driver YES
Laborer YES
Operator YES
Supervisor YES
SECTION 42: Anti -Drug & Alcohol Misuse Prevention Plan Program I Page 40 of 49
SAFETY & HEALTH MANUAL
EMERPR6F5
APPENDIX D - COMPANY DISCIPLINARY ACTIONS AND ADDITIONAL
PROCEDURES
1. Company Discipline
Under the Anti -Druz and Alcohol Misuse Prevention Plan the Company is committed to a drug and alcohol -free
workplace. Violations to this Plan include:
a) The presence in the body, possession use distribution dispensing and/or unlawful manufacture of prohibited
drugs and the misuse of alcohol is not condoned while conducting Company business, or while in work areas or
Company vehicles on or off Company premises No employee will work under the influence of prohibited drugs
and alcohol.
b) An employee or applicant who tests positive for drugs has an alcohol concentration of 0.04 or higher, or refuses to
take any drug or alcohol test as directed by the Company.
c) The prohibited use of alcohol with a test result of 0.02 or greater, but less than 0.04.
Employees violating this Plan will be subject to disciplinary actions up to and including termination Disciplinary action
may include but is not limited to: removal from working in a covered position suspension, loss of pay. and termination
of employment.
2. Additional Company Procedures
Reservation of Rights. The Company reserves the right to interpret, modify, or revise this policy statement in whole or
in part without notice Nothing in this policy statement is to be construed as an employment contract nor does this
alter an employee's employment at -will status The employee remains free to resign his/her employment at any time
for any or no reason without notice Similarly, the Company reserves the right to terminate any employee's
employment, for any or no reason, without notice.
Compliance with All Laws. This policy statement will be amended from time to time to comply with changes in Federal
and State laws.
The Company reserves the right to revise or amend this policy with or without notice at any time.
The Company will direct an employee to take another test immediately if the test is negative -dilute and the creatinine
concentration is greater than 5 mg/dL as permitted under 49 CFR Part 40.197(2b).
SECTION 42: Anti -Drug & Alcohol Misuse Prevention Plan Program I Page 41 of 49
LV,77SAFETY & HEALTH MANUAL
APPENDIX E - PHMSA INSPECTION PLAN CROSS REFERENCE ENDNOTES
A.01.a. Verify that the operator maintains and follows a written Anti -Drug Plan that conforms to Part 199 and Part 40
and that the plan contains the following [§199.101]: 1) Methods and procedures for compliance with all the
requirements of Part 199, including the employee assistance program; 2) The name and address of each laboratory
that analyzes the specimens collected for drug testing; 3) The name and address of the operators Medical Review
Officer, and Substance Abuse Professional; and Procedures for notifying employees of the coverage and provisions of
the plan.
H.01.a. Verify that the operator maintains and follows a written Alcohol Misuse Plan that conforms to Part 199 and
Part 40 and that the plan contains methods and procedures for compliance with required testing, recordkeeping,
reporting, education and training elements [§199.202].
A.02.a. Verify that "stand -down' is prohibited before the MRO has completed the drug test verification process or that
an approved waiver is granted per the requirements of [§40.21] and 1§199.71.
H.02.e. Verify that the educational materials made available to covered employees includes detailed discussion of at
least the following (§199.239(b)]: 1)The identity of the person designated by the operator to answer covered employee
questions about the materials; 2) The categories of employees who are subject to the provisions of this subpart; 3)
Sufficient information about the covered functions performed by those employees to make clear what period of the
work day the covered employee is required to be in compliance with this subpart; 4)Specific information concerning
covered employee conduct that is prohibited by this subpart; 5) The circumstances under which a covered employee
will be tested for alcohol under this subpart; 6) The procedures that will be used to test for the presence of alcohol,
protect the covered employee and the integrity of the breath testing process, safeguard the validity of the test results,
and ensure that those results are attributed to the correct employee; 7) The requirement that a covered employee
submit to alcohol tests administered in accordance with this subpart; 8) An explanation of what constitutes a refusal to
submit to an alcohol test and the attendant consequences; 9) The consequences for covered employees found to have
violated the prohibitions under this subpart, including the requirement that the employee be removed immediately
from covered functions, and the procedures under §199.243; 10) The consequences for covered employees found to
have an alcohol concentration of 0.02 or greater but less than 0.04; and 11) Information concerning the effects of
alcohol misuse on an individual's health, work, and personal life; signs and symptoms of an alcohol problem (the
employee's or a coworker's); and including intervening evaluating and resolving problems associated with the misuse
of alcohol including intervening when an alcohol problem is suspected, confrontation, referral to any available EAP,
and/or referral to management.
B.01.b. Verify that a service agent is not used to fulfill the function of a DER (§40.15(d)].
N.01.a. Verify that an employer who is using a service agent concerning whom a PIE is issued stops using the services of
the service agent no later than 90 days after the Department has published the decision in the Federal Register or
posted it on its web site. The employer may apply to the ODAPC Director for an extension of 30 days if it is
demonstrated that a substitute service agent cannot be found within 90 days [§40.409(b)].
B.01.a. Verify that critical positions meet the applicable qualifications of Part 40 and 199; 1) Medical Review Officer
(MRO), 040.121 and §199.109(b)); 2) Substance Abuse Professionals (SAP), (§40.81) 3); 3) Urine Specimen Collectors
(§40.33).
1.01.a. Verify that Alcohol Misuse Prevention Program positions meet the applicable qualification requirements of Part
40 and Part 199 as follows: 1) Screening Test Technician (§40.213); 2) Breath Alcohol Technician (§40.213); and, 3)
Substance Abuse Professional (SAP) (§40.281).
A.01.d. Verify that DOTtests are completely separate from non-DOTtests in all respects 1§40.131.
H.01.d. Verify that the Alcohol Misuse Prevention Program ensures that the DOT tests are completely separate from
non -DOT tests in all respects [§40.13].
A.01.b. Verify that the Plan identifies covered employees (as defined in §199.3), required to be tested for drugs, are
identified [§199.1].
SECTION 42: Anti -Drug & Alcohol Misuse Prevention Plan Program I Page 42 of 49
Ems= SAFETY & HEALTH MANUAL
H.01.b. Verify that the Alcohol Misuse Prevention Program identifies the covered employees (as defined in §199.3) that
are required to be tested for the presence of alcohol [§199.1].
C.01.a. Verify drug testing information [§40.25(b)] is requested from previous DOT -regulated employers for any
employee seeking to begin covered functions for the first time (i.e., a new hire or an employee transfer) [§40.25(a)].
Covered employee must not perform their functions after 30 days from the date on which the employee first
performed safety -sensitive functions, unless a good faith effort to obtain the information has been made and
documented.
J.01.a. Verify that alcohol testing information [§40.25(b)] is requested from previous DOT -regulated employers for any
employee seeking to begin covered functions for the first time (i.e., a new hire or an employee transfer) [§40.25(a)]. In
addition, verify that a covered employee must not perform their functions after 30 days from the date on which the
employee first performed safety- sensitive functions, unless you have obtained or made and documented a good faith
effort to obtain alcohol testing information from previous DOT -regulated employers.
H.02.a. Verify that the Alcohol Misuse Plan ensures that a covered employee is not permitted to perform covered
functions if the employee has engaged in violations of §§199.215 through 199.223 (see below) or an alcohol misuse
rule of another DOTagency [§199.233]. 1) Having an alcohol concentration of 0.04 or greater [§40.23(c), §40.285 and
§199.2151; 2) Using alcohol while performing covered functions [§199.217, On -duty use]; 3) Using alcohol within 4
hours prior to performing covered functions, or, if an employee is called to duty to respond to an emergency, within
the time period after the employee has been notified to report for duty [§199.219, Pre -duty use]; 4) A covered
employee, who has actual knowledge of an accident in which his or her performance of covered functions has not been
discounted by the operator as a contributing factor to the accident, is prohibited from using alcohol for 8 hours
following the accident, unless he or she has been given a post -accident test under §199.225(a), or the operator has
determined that the employee's performance could not have contributed to the accident [§199.221, Use following an
accident]; and, 5) Upon refusal of a covered employee to submit to a post -accident alcohol test required under
§399.225(a), a reasonable suspicion alcohol test required under §199.225(b), or a follow-up alcohol test required under
§199.225(d) [§40.285 and §199.223, Refusal to submit to a required alcohol test].
H.02.c. Verify that the Alcohol Misuse Prevention Program assures that a covered employee is prohibited from
performing or continuing to perform covered functions when found to have an alcohol concentration of 0.02 or greater
but less than 0.04, until: The employee's alcohol concentration measures less than 0.02 in accordance with a test
administered under §199.225(e); or The start of the employee's next regularly scheduled duty period, but not less than
8 hours following administration of the test 1§40.23(c) and §199.237(a)].
A.02.b. Verify that a covered employee that violates DOTdrug regulations is removed from performing safety -sensitive
functions [§40.23 and §199.7]. A verified positive DOT drug test result or a refusal to test (including by adulterating or
substituting a urine specimen) constitutes a violation of DOT drug regulations [§40.285(b) and §199.103(a)]. If a
covered employee violates a DOT drug regulation, a listing of SAPS that are readily available is provided to the
employee [§40.287].
C.01.b. Verify no new personnel (new hire, contracted, or transferred employees) are used to perform covered
functions unless that person receives a negative drug test and or is covered by the Plan that conforms to Part 199
[§199.105(a)]. Procedures are in place for direct observation when required under §§40.67(a), (b) and (d).
C.02.a. Verify post -accident drug testing is performed, as soon as possible but no later than 32 hours after an accident
(§ 195.50) or incident (§ 191.3), for each employee whose performance either contributed to the accident or cannot be
completely discounted as a contributing factorto the accident [§199.105(b)]. In addition, procedures are in place for
direct observation when required under §§40.67(a), (b) and (d).
C.03.a. Verify the minimum annual percentage rate used for random drug testing of covered employees complies with
§199.105(c)(1) through (4).
C.03.b. Verify the selection of employees for random drug testing is based on a scientifically valid method, such as a
random number table or a computer -based random number generator matched with employee identification data
[199.105(c)(5)].
SECTION 42: Anti -Drug & Alcohol Misuse Prevention Plan Program I Page 43 of 49
s SAFETY & HEALTH MANUAL
C.03.c. Verify a sufficient number of covered employees will be selected for random testing during each calendar year
to equal an annual rate not less than the required minimum annual percentage rate (see Protocol C.03.a.)
[199.105(c)(6)]. The total number of covered employees eligible for random testing throughout the year will be
calculated by adding the total number of covered employees eligible for testing during each random testing period for
the year and dividing that total by the number of random testing periods [199.119(c)].
C.03.d. Verify random drug tests are unannounced and that the dates for administering the tests are spread reasonably
throughout the calendar year (199.105(c)(7)].
C.04.a. Verify decisions to test are reasonable and articulable, and based on specific contemporaneous physical,
behavioral or performance indicators of probable drug use. At least two supervisors, one of whom is trained in
detection of the symptoms of drug use, substantiate and concur in the decision to test an employee who is reasonably
suspected of drug use [§199.105(d)].
C.05.a. Verify a covered employee that violates DOT drug regulations does not return to duty for a covered function
until the employee: 1) Completes a SAP evaluation, referral, and education/treatment process [§40.285(a), §40.289(b),
and §199.105(e)]; 2) After completion of the SAP process above, successfully completes a return -to -duty drug test
(§40.305(a) and §199.105(e)]; and 3) All return -to -duty testing will be performed under direct observation [§40.67(b)].
C.06.a. Verify SAP will establish a written follow-up testing plan for a covered employee that violates DOT drug
regulations and seeks to return to the performance of a covered function [§40.307(a)). All follow-up testing will be
performed under direct observation [§40.67(b)].
C.06.b. Verify follow-up testing is performed on an unannounced basis, at a frequency established by the SAP, for a
period of not more than 60 months. At least six tests must be conducted within the first 12 months following the
covered employee's return to duty. [§40.307, §40.309, and §199.105(f)].
C.07.a. Verify procedures are in place fordirect observation when required under §§40.67(a), (b) and (d).
B.02.a. Urine Specimen Collector (§40.33) meet the applicable qualification requirements of Part 40 and Part 199.
O.01.a. Does the operator ensure that, unless no other collector is available, an immediate supervisor of an employee
does not serve as a collection site person [§40.31(c)]?
O.01.b. Do collectors meet the training requirements of §40.33 and is documentation available showing that currently
all requirements are met (§40.33(g)]?
O.01.c. Does the operator provide error correction training as required by §40.33(f) and does the training occur within
30 days of the date of notification of the error that led to the need for training?
O.02.a. Has the employer designated a collection site that meets the requirements of §40.41.
O.02.b. If the collection site uses a facility normally used for other purposes, are procedures in place to ensure before
the collection that: (1) access to collection materials and specimens is effectively restricted; and (2) the facility is
secured against access during the procedure to ensure privacy to the employee and prevent distraction of the
collector? Also, are limited -access signs posted [§40.43(c)]?
O.02.c. Are procedures in place to assure the collector maintains personal control over each specimen and CCF
throughout the collection process and to prevent unauthorized personnel from entering any part of the site in which
urine specimens are collected or stored [§40.43(d)(5) and §40.43(e)]?
O.02.d. Is the current Federal Drug Testing Custody and Control Form (CCF) or equivalent being used [§40.45]?
O.02.e. Is a collection kit used that meets the requirements of Appendix A to Part 40 [§40.49]?
O.03.a. Do collection site personnel explain the basic collection procedure to the employee, including showing the
employee the instructions on the back of the CCF [§40.61(e)]?
O.03.b. Do collection site personnel provide the donor with an individually wrapped or sealed collection container from
the collection kit materials [§40.63(c)]?
SECTION 42: Anti -Drug & Alcohol Misuse Prevention Plan Program I Page 44 of 49
c MER��E= SAFETY & HEALTH MANUAL
0.03.c. Are precautions taken to ensure that unadulterated specimens are obtained and correctly identified that meet
the following requirements: 1) Bluing agents in toilet tank and all water sources secure [§40.43(b)(1) and (2)]; 2)
Individual positively identified (photo ID, etc.) [§40.61(c)]; 3) Proper authority contacted if individual fails to arrive at
the assigned time [§40.61(a)]; 4) The donor shall remove any unnecessary outer garments. Purses or briefcases shall
remain with outer garments [§40.61(f)]; 5) Donor shall wash and dry his/her hands [§40.63(b)]; 6) To the greatest
extent possible, the collector must keep an employee's collection container within view of both himself/herself and the
employee between the time the employee has urinated and the specimen is sealed [§40.43(d)(2)]; and, 7) Any unusual
behavior noted on the CCF [§40.63(e)]
0.03.d. Are procedures being followed at the collection site after the specimen has been provided in compliance with
the requirements of §40.65
0.03.e. Have provisions been made if the donor is unable to provide at least 45 milliliters of urine [§40.65(a)]7
0.03.f. Are procedures in place for immediately collecting urine specimens under direct observation for the situations
identified in §40.67(c). As of August 31, 2009, verify that all collections for return -to -duty and follow-up testing were
performed under DER directed direct observation [§40.67(b)]
0.03.g. Are same gender collection personnel used if a collection is monitored under direct observation by non -medical
personnel [§40.69(g)]
0.03.h. Is the CCF properly executed by authorized collection site personnel upon receipt and transfer of a urine
specimen [§40.73(a)]
D.01.a. Verify drug testing laboratory used for all testing required by Part 40 and Part 199 is certified by the
Department of Health and Human Services (HHS) [§40.81(a) and §199.107(a)].
D.01.c. Verify laboratory results are reported directly, and only, to the MRO at his or her place of business. Results
must not be reported to or through the DER or a service agent (e.g., C/TPA) [§40.97(b)].
D.01.b. Verify drug testing laboratory only tests for the following five drugs or classes of drugs in a DOT drug test. (The
laboratories must not test "DOT specimens" for any other drugs): (a) Marijuana metabolites; (b) Cocaine metabolites;
(c) Amphetamines; (d) Opiate metabolites; and (e) Phencyclidine (PCP) [§40.3, §40.85 and §199.3].
D.01.d. Verify laboratory testing the primary specimen will retain a specimen that was reported with positive,
adulterated, substituted, or invalid results for a minimum of one year. The specimen must be kept in secure, long-term,
frozen storage in accordance with HHS requirements [§40.99 and §199.111(a)].
D.03.a. Verify laboratory retains all records pertaining to each employee urine specimen for a minimum of two years
and also keeps for two years, employer -specific data required in §40.111 [§40.109].
D.03.1a. Verify laboratory transmits an aggregate statistical summary to the Company per Part 40, Appendix B, on a
semi-annual basis.
D.02.a. If the Company or C/TPA, used by the Company, has an aggregate of 2000 or more DOT -covered employees,
blind specimens are submitted to the laboratories used. If the Company or C/TPA has an aggregate of fewer than 2000
DOT -covered employees, DOT does not require them to provide blind specimens [§40.103(a)].
E.01.a. Verify that an MRO is designated or appointed by the Anti -Drug Plan [§199.109(a)].
E.01.b. Verify that the MRO provides quality assurance reviews of the drug testing process, including ensuring the
review of the Custody and Control Form (CCF) on all specimen collections [§40.123(b)].
E.01.c. Verify that the MRO performs the review functions required by §40.127 for negative drug test results received
from a laboratory, prior to verifying the result and releasing it to the Designated Employer Representative (DER).
E.01.d. Verify that the MRO performs the review functions required by §40.129 for confirmed positive, adulterated,
substituted, or invalid drug test results received from a laboratory, prior to verifying the result and releasing it to the
SECTION 42: Anti -Drug & Alcohol Misuse Prevention Plan Program I Page 45 of 49
s r
a= SAFETY & HEALTH MANUAL
DER. In addition, the MR- must determine whether there is a legitimate medical explanation for confirmed positive,
adulterated, substituted, and invalid drug test results from the laboratory [§40.123(c)].
F.02.a. Verify that the MRO reports all drug test results to the operator [§40.163(a) and §199.109(d)] in accordance
with the requirements in §40.163, §40.165 and §40.167. These requirements include: Reporting all drug test results to
the DER, except in the circumstances provided for in §40.345, when a C/TPA may act as an intermediary [§40.165(a)];
reporting the results in a confidential manner [§40.167(a)]; and reporting the results within the required time
constraints [§40.167(b) and (c)].
E.01.e. Verify that when the MRO has verified a drug test as positive for a drug or drug metabolite, or as a refusal to
test because of adulteration or substitution, and the MRO must notify the employee of his or her right to have the split
specimen tested. The MRO must also notify the employee of the procedures for requesting a test of the split specimen,
and Inform the employee that he or she has 72 hours from the time of this notification to him or her to request a test
of the split specimen [§40.153].
E.011 If additional testing is requested by the employee, verify that the split specimen is tested. The split testing
laboratory must be certified by HHS. (Note: Correction made to inspection language.) [§199.111(b) and (c)].
J.01.16. If the operator chooses to conduct pre -employment alcohol testing, verify that the operator: 1) Conducts a pre-
employment alcohol test before the first performance of covered functions by every covered employee (whether a
new employee or someone who has transferred to a position involving the performance of covered functions)
[§399.209(b)(1)]; 2) Treats all covered employees the same for the purpose of pre -employment alcohol testing (i.e.,
you must not test some covered employees and not others) [§199.209(b)(2)];and, 3) Conducts the pre -employment
tests after making a contingent offer of employment or transfer, subject to the employee passing the pre -employment
alcohol test [§199.209(b)(3)).
J.02.a. Verify that post -accident alcohol testing is performed: 1) As soon as practicable following an accident (§195.50)
or incident (§191.3) for each surviving covered employee if that employee's performance of a covered function either
contributed to the accident or cannot be completely discounted as a contributing factor to the accident
[§199.225(a)(1)]; and, 2) Within two hours following the accident (§395.50) or incident (§191.3), otherwise, the
operator shall prepare and maintain on file a record stating the reasons the test was not promptly administered. If a
post -accident test is not administered within eight hours following the accident, the operator shall cease attempts to
administer an alcohol test and shall state in the record the reasons for not administering the test [§199.225(a)(2)].
J.03.a. Verify that decisions to test are based on specific, contemporaneous, articulable observations concerning the
appearance, behavior, speech, or body odors of the employee. The required observations shall be made by a
supervisor who is trained in detecting the symptoms of alcohol misuse (§199.225(b)(2)].
J.03.b. Verify that a covered employee is directed by the operator to undergo reasonable suspicion testing for alcohol
only while the employee is performing covered functions; just before the employee is to perform covered functions; or
just after the employee has ceased performing covered functions. [§199.225(b)(3)].
1.03.c. Verify that if a reasonable suspicion test is required and is not administered within 2 hours following the
determination under §199.225(b)(2), the operator shall prepare and maintain on file a record stating the reasons the
test was not promptly administered. If a test is not administered within 8 hours, the operator shall cease attempts to
administer an alcohol test and shall state in the record the reasons for not administering the test [§199.225(b)(4)(i)].
J.04.a. Verify that a covered employee that engages in conduct prohibited by §§199.215 through 199.223 does not
return to duty for a covered function until the employee: 1) Completes a SAP evaluation, referral, and
education/treatment process [§40.285(a), §40.289(b), §199.235, and §199.243(b)]; and, 2) After completion of the SAP
process above, undergoes a return -to -duty alcohol test with a result indicating an alcohol concentration of less than
0.02 [§40.305(a), §199.225(c), and §199.243(c)].
1.05.a. Verify that the SAP establishes a written follow-up testing plan for a covered employee that engages in conduct
prohibited by §§199.215 through 199.223 and seeks to return to the performance of a covered function [§40.307(a)].
SECTION 42: Anti -Drug & Alcohol Misuse Prevention Plan Program I Page 46 of 49
EDN.ra�, SAFETY & HEALTH MANUAL
1.05.b. Verify that follow-up testing is performed on an unannounced basis, at a frequency established by the SAP, for a
period of not more than 60 months. At least six tests must be conducted within the first 12 months following the
covered employee's return to duty [§40.307, §40.309, §199.225(d) and §199.243(c)(2)(ii)].
K.01.a. Verify that any Evidential Breath Testing Device (EBT) or Alcohol Screening Device (ASD) used for DOT required
alcohol testing is approved by the National Highway Traffic Safety Administration (NHTSA) and placed on a Conforming
Products List (CPL) [§40.229 and §40.2311
K.01.b. Verify that external calibration checks are performed at the intervals specified in the manufacturer's
instructions for any EBT used for DOT required alcohol confirmation testing 1§40.231 and §40.2331.
P.01.a. Does the operator's plan specify training for BATS and STTs that is in compliance with §40.213 and does the
documentation certify that all requirements are met [§40.213(g)]
P.01.b. Does the plan specify that a supervisor shall not serve as the BAT or STT if that supervisor makes the reasonable
cause determination [§40.211(c) and §199.225(b)(2)]
P.02.a. Does the alcohol testing site comply with the applicable physical and security requirements of §40.221 and
§40.223?
P.02.b. Does the plan specify that only EBTs and ASDs listed on the NHTSA CPL will be used for DOT alcohol testing
[§40.229]? Also, does the plan specify that an EBT must be used for conducting the confirmation tests [§40.231(a)]?
P.02.c. Does the operator follow the Quality Assurance Plan (QAP) for the EBT that is used [§40.233(c)(1)]? If this
service is contracted out does the operator, ensure that the QAP is being followed [§40.233(c)]?
P.02.d. Does the plan specify that the operator or its agents shall comply with the QAP and manufacturer's instructions
and does the operator follow the QAP for the ASD that is used [§40.235 and §40.235(c)]?
P.03.a. Does the plan prescribe that only the DOT -approved Alcohol Testing Form (ATF) shall be utilized [§40.225(a)]?
P.03.b. Does the plan specify that the employee shall provide a positive identification through use of photo ID or by
employer representative [§40.241(c)]?
P.03.c. Does the plan indicate that the BAT or STT shall explain the testing process to the employee [§40.241(e)]?
P.03.d. Does the plan contain specific instructions for conducting alcohol screening tests in compliance with §40.241
and §40.243 requirements?
P.03.e. Does the plan contain specific instructions for conducting alcohol screening tests using a saliva ASD in
compliance with §40.245 requirements?
P.03.f. Does the plan specify actions that are taken after receipt of alcohol screening test results that are in compliance
with §40.247?
P.04.a. Does the plan provide guidance for the actions a new BAT must complete to conduct a confirmation test in
compliance with §40.251(b)?
P.04.b. Does the plan specify procedures to be followed in conducting a confirmation test that are in compliance with
§40.253 and §40.255?
P.05.a. Does the plan address the situations for which the employee is considered to have refused to take an alcohol
test [§40.261(a)(1) to (7)]?
P.05.b. Does the plan specify procedures concerning an employee's inability to provide an adequate amount of saliva
for testing and instructions for requiring the employee to attempt again to provide adequate amount of saliva for
testing [§40.263]?
P.05.c. Does the plan specify procedures concerning an employee's inability to provide an adequate amount of breath
for testing in compliance with §40.265?
SECTION 42: Anti -Drug & Alcohol Misuse Prevention Plan Program I Page 47 of 49
SAFETY & HEALTH MANUAL
P.05.d. Does the plan specify under what conditions that an alcohol test shall be cancelled [§40.267 and §40.2691?
P.05.e. Does the plan specify procedures concerning the potential inability to complete an alcohol test and trying to
successfully complete the test [§40.271]?
B.01.a. Substance Abuse Professionals (SAP) meet the applicable qualification requirements of Part 40 (§40.81) and
Part 199.
H.02.b. Verify that the Alcohol Misuse Prevention Program assures that each covered employee who has engaged in
conduct prohibited by §§199.215 through 199.223 shall be advised of the resources available to the covered employee
in evaluating and resolving problems associated with the misuse of alcohol. This includes the names, addresses, and
telephone numbers of substance abuse professionals and counseling and treatment programs [§40.285(b) and
§199.243(a)]
H.02.d. Verify that the Alcohol Misuse Prevention Program assures for providing educational materials that explain
alcohol misuse requirements and the operator's policies and procedures with respect to meeting those requirements
[§199.239(a)]. The operator shall ensure that a copy of these materials is distributed to each covered employee prior to
start of alcohol testing under this subpart, and to each person subsequently hired for or transferred to a covered
position [§199.239(a)(1)]. Each operator shall provide written notice to representatives of employee organizations of
the availability of this information [§199.239(a)(2)].
I.01.b. Verify that supervisors designated to determine whether reasonable suspicion exists to require a covered
employee to undergo alcohol testing under §199.225(b) receive at least 60 minutes of training on the physical,
behavioral, speech, and performance indicators of probable alcohol misuse. [§199.241).
A.01.c. If an employer contracts drug testing, education and training [§199.115), there is a process in place and
implemented to ensure compliance with Part 199 and Part 40. The contractor must allow access to property and
records by the operator, the Administrator, and if the operator is subject to the jurisdiction of a state agency, a
representative of the state agency for the purpose of monitoring the operator's compliance [§199.115(b)].
H.01.c. If an employer contracts alcohol testing, education and training [§199.245], there is a process in place and
implemented to ensure compliance with Part 199 and Part 40. The contractor must allow access to property and
records by the operator, the Administrator, any DOT agency with regulatory authority over the operator or covered
employee, and, if the operator is subject to the jurisdiction of a state agency, a representative of the state agency for
the purposes of monitoring the operator's compliance with the requirements of Part 199 and Part 40 [§199.245(c)].
L.01.a. Verify that the following records are retained as required by Part 40 and Part 199 and that the records are
maintained in a secure location with controlled access [§40.333(c) and §199.227(a)]. 5 years: Records of alcohol test
results indicating an alcohol concentration of 0.02 or greater 1§40.333(a)(1) and §199.227(b)(1)]; Documentation of
refusals to take required alcohol tests [§40.333(a)(1) and §199.227(b)(1)]; SAP reports [§40.333(a)(1) and
§199.227(b)(1)]; All follow-up tests and schedules for follow-up tests [§40.333(a)(1)]; MIS annual report data
[§199.227(b)(1)]; and, Calibration Documentation [§199.227(b)(1)]. 3 years: Information obtained from previous
employers under §40.25 concerning alcohol test results of employees [§40.333(a)(2)]. 2 years: Records of the
inspection, maintenance, and calibration of EBTs [§40.333(a)(3)].
M.02.a. Verify that upon written request from an employee, records of drug and alcohol use, testing results, and
rehabilitation are provided to the employee [§199.117(b) and §199.231(b)].
F.01.a. Verify that records are retained as required by Part 40 and Part 199 and that the records are maintained in a
location with controlled access [§40.333(c)]
M.01.a. Verify if this operator has more than 50 covered employees and submits an annual MIS report in accordance
with the form and instruction requirements of §40.26 and Appendix H to Part 40, not later than March 15 of each year
for the prior calendar year (January 1 through December 31) [§40.26, §399.119(a) and §199.229(a)]. Beginning with the
March 15, 2010 MIS submission date, also verify if this operator identifies all contractors who performed covered
functions, as defined under § 199.3, for this operator in a given calendar year; and, if required by either mandated
annual or PHMSA written request, is or has submitted an MIS report for each of these contractors?
SECTION 42: Anti -Drug & Alcohol Misuse Prevention Plan Program I Page 48 of49
La,D'K, SAFETY & HEALTH MANUAL
M.01.b. Verify if this operator has 50 or less covered employees and has either a compilation of data or statistical
information regarding drug and alcohol testing which, upon written request, could have been used to submit a MIS
report in accordance with the form and instruction requirements of §40.26 and Appendix H to Part 40, not later than
March 15 of each year for the prior calendar year (January 1 through December 31) [§40.26, §199.119(a) and
§199.229(a)). Beginning with the March 15, 2010 MIS submission date, verify that this operator identifies all
contractors who performed covered functions, as defined under § 199.3, for this operator and received a compilation
of data or statistical information from these contractors which, upon written request, could be used for submitting an
MIS report for each of these contractors.
M.01.c. If a service agent (e.g., Consortium/Third Party Administrator) prepares the MIS report on behalf of an
operator, verify that each report is certified by the operator's anti -drug manager/alcohol misuse prevention manager
or designated representative for accuracy and completeness [§199.119(f) and §199.229(d)).
SECTION 42: Anti -Drug & Alcohol Misuse Prevention Plan Program I Page 49 of 49
Chicagoland
ABORERS'
District Council "Draining & Apprentice Fund
Executive Director
Thomas Nordeen
Labor Trustees
James P. Connolly
Martin Dwyer
Martin Flanagan
JosephV. Healy
Charles V. LoVerde III
William Martin
Management Trustees
Seth Gudeman
Shane Higgins
Joseph Koppers
Robert G. Krug
David Lorig
Willian Vignocchi
Carol Stream Location
1200 Old Gary Avenue
Carol Stream IL 60188
(630)653-0006
Chicago Location
5700 West Homer Street
Chicago IL 60639
(773)413-3315
0
ACCREDITED'
lmftAr
31 July 20 23
KLF Enterprises
2044 W. 163rd Street
Markham, IL 60428
To Whom It Mav Concern:
caner 42-L
chicagolaborers.org
Enclosed you will please find a copy of the Department of Labor certification
that you requested recently.
You may also use this letter as verification that KLF Enterprises is indeed
signatory to the Laborers District Council and contribute to the Laborers
Training and Apprenticeship Fund.
Should you require anything further, please do not hesitate to contact me.
Yours very truly,
4�4�Z7-
Felicita Ruiz
Assistant Office Manager
UNA"'.
Feel the Power
�fiue af�1PFrn�i�eslp}T �m�nin9�'�mYla�er un,� �ia6nr�ex'nices
Purtau OfAyprMfirnift nub craitfug
so
c6d cq,Aeaom Y
q" Ae 474a4& - eandww4bot. Cw#.BaZa4e4
. t, 54.0 raM
.in ewcordance evA ISe &mic viemc lar-drs o�a�vprenfrces ip
esfa6..r,,Seor6y Z6e c5ecrefarr- of %Oa6or
DQ/eREVISED August 13, 2004
i 017QQ(001
mex,im-a/ion OG.
�►ti''' a Off` —
�O 4L7h(A
g7ES OF P ��irie»/1+ofar, �ipp�rwt�ioet�ip'J.,anias, �rP(oyera�r�F�6arcSemicee
7/31/2019 12:05 PM FROM: 708-354-0932 TO: +17083314212 * P. 5
INTEMN'ATIONATI UNION OP OPERArXI1�1' G ]DI NGINIirERS
LOCAL UNION NO. I SO, I SOB, I SOA. 1 SOC, 1 SORA, 1500, 190G, 1 SOM
AMLIATEO WITH THE A.KL.•C.LO. AND BUILDING TRADCS DCPAhTMCNT i
JAMES M. SWEENEY
PRESIDENT -BUSINESS MANAGER
KLF Enterprises Inc.
2044 W. 163n' ST. Suite # 2
Markham, IL 60428
alkA I:oes 4s2-ee00 • FAx I7081402.7186
6200 JOUST ROAD
o COUNTRYSIDE. IL 60525.3992
July 31, 2019
Re: Proof of Compliance with 30 ILCS 500/30-22(6)
Our File No. MI-00321
Dear Sir or Madam:
At the request of KLF Enterprises Inc., I am providing you with evidence of the
Company's compliance with the apprenticeship requirements in 30 JLCS 500/30-22(6) of
the Illinois Procurement Code. I am submitting this letter along with apprenticeship
certificates (Nos.IL012020003 and IL008730173).
As a signatory contractor with the International Union of Operating Engineers, Local
150, AFL-CIO, KLF Enterprises Inc., is required by Collective Bargaining Agreement to
participate in an applicable apprenticeship and training program approved by and
registered with the United States Department of Labor's Bureau of Apprenticeship and
Training. The attached certificates are evidence of compliance with the U.S. Department
of Labor's apprenticeship requirements.
Thank you for your cooperation in this matter. If you have any questions or concerns,
please do not liesitate to contact me.
Enclosures: Certificates
a<T, "36
Very truly yours,
IUOE, Local 150, AFL-CIO
District l dispatch office
C 'a"" F-10�
Caroline Frausto
CO
;D
r
s
N � � •
N
OD Of apprmfirtobr
�� �• r giar
r r
0
a t gpprtntrMOD 1p -,P ragaill
E-
4peral*19 n8iueersLocaf1S0APprentzceship Tund
rG fm ngtou, ,Irtnozs
T"or the grade --- Operating Engineer pfeavy Equipment Technician)
N
-We
yislereorasparf o�%Se 9 Caliondl 5,n,prenfices l cS s%m
M in accororance rvilSlSe �'asrc sl no,'&o�s o a ren ices z
�� p
00
es
laQ fivSeol y � f I.Se •cSecrek¢r o 2a' -or
E •
�c
w.
JW CL 5� 2002 c vwr a � Cxr
as<< wise ,dune 21, 2011
IL412420403 rEs � ortr.�w
0
'�'•t
N
r-i
M
N
CITY OF SOUTH BEND, INDIANA ` 1965 y-
CONTRACTOR'S BID FOR PUBLIC WORK
CHECKLIST FOR BIDDERS
Project Name Demolition of 921 Louise Street
Project No. 125-043A
For Bids Due Tuesday, March 10, 2026 @ 9:00 A.M. (E.D.T.)
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.
roof of M/WBE Utilization Plans [MBE-1.0 and WBE-1.0]. Also provide Evidence of Good
Faith Efforts Forms [MBE-2.0 and WBE-2.0] and M/WBE Contacted Forms [MBE-2.1 and
WBE-2.1 ].
v
Acknowledge Receipt of Addendum(s) included with the bed.
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.
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: I` Date: �l Z
I
By Authorized
Signature:
Print Name & 1
Version 07/19/2023 Contractor's Bid for Public Works -1
RAM Insurance Agency
Risk Advisors & Managers
January 28, 2025
To Whom It May Concern
RE: KLF Enterprises, Inc.
Experience Modification Rating History
Following are the current and historical Experience Modification Rating factors for KLF Enterprises,
Inc. (Risk ID 121587165)
EFFECTIVE
DATE
EMR
FACTOR
11/02/2024
0.80
11/02/2023
0.95
11/02/2022
0.91
11 /02/2021
0.94
KLF Enterprises, Inc. (KLF) shares their EMR with multiple entities. However, KLF has had no
workers compensation claims since at least 2015. The 2024 EMR for KLF would be 0.80 if calculated
alone (see attached Experience Modification calculation).
If you have any questions, please let me know.
Regards,
Z 61zy- DW04&
Douglas P. O'Neill, AIC, CIC, CRIS
Vice -President
RAM Insurance Agency
815-893-8281
doneill@raminsuranceapency.com
www.raminsuranceaeencV.corn/ 16614W. 159' Street,#303, Lockport,IL.60441/ info@raminsuranceaeencv.com
Phone: 815-893-8280
C>�
ENTERPRISES
Equipment List
Contractor: KLF Enterprises
2300 w 167"' ST
TEL, 708.331.4200
Excavation & Demolition Equipment
• 4-Link-Belt 210X2 Excavator — Track — Year 2016
• Doosan DX350 Excavator — Track — Year 2012
• Case CX210D Excavator — Track — Year 2018
• Case CX350D Excavator — Track — Year 2018
• Bobcat E60 Excavator — Track — Year 2018
• Link -Belt 490-Track-2021
• Link -belt 350-track 2022
• Kobelco 93' High Reach -2022
• Concrete Crusher
• C&D Sorter
Demolition Attachments
® MARKHAM, IL 60428
• FAX: 708.331.4212
• 3 Hydraulic Grapple Attachments —for structural demolition and debris sorting
3-Hydraulic Concrete Processor— for reinforced concrete processing
3-Hydraulic Breaker (Hammer) —for foundation and slab demolition
3 Wrecking poles
Loading & Material Handling Equipment
• Bobcat S570 Skid Steer — Track— Year 2017
• Case S V280 Skid Steer— Track— Year 2017
• 4-Bobcat T650 Skid Steer— Track— Year 2016
Trucks & Transportation
• Ford F-150 Pickup Truck —Year 2015
• Ford F-250 Pickup Truck— Year 2015
• Ford F-450 Service Truck— Year 2018
Hauling Equipment
AdI 2300 w 167"' ST. • MARKHAM, IL 60428
ENTERPRISES TEL: 708.331.4200 Y FAX: 708.331.4212
10 — 30 Cubic Yard Roll -Off Containers —debris hauling and disposal
4 — 60 Cubic Yard Wrecking Trailers —demolition debris transport
10-20- yard Semis
Support Equipment
Dust Boss Water Suppression system
Generators
Miscellaneous Hand tools, Conex boxes, saws, Etc