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HomeMy WebLinkAboutContract #: 004274 - From: To: - Exception - ExceptionSchool Department Administration Building North Andover, MA FORM OF GENERAL BID To the Awarding Authority: Kang Associates, Inc. January 2, 2014 A. The undersigned proposes to fumish all labor and materials required for the School Department Administration Building, North Andover, Massachusetts, in accordance with the accompanying plans and specifications prepared by Kang Associates, Inc. for the contract price specified below, subject to additions and deductions according to the terms of the specifications. B. This bid includes addenda numbered 1; Z1 3 C. The proposed contract price is: T1,ree dollars ($ For Alternate #1: Deduct $ 41)nLs F, ve- 1 osar dollars ($ 0 Q 01.3 ) For Alternate #2: Deduct $ *e n 7 hcv 5a n dollars ($ 16,000 ). For Alternate #3: Deduct $ lxslo 16%otm— J dollars ($ For Alternate #4: Deduct $ 4r. v r E c1dollars ($ 71 ). For Alternate #5: Deduct $ Swat lean 1hoo ban 0� dollars ($ 06106 ). D. The subdivision of the proposed contract price is as follows: Item 1. The work of the general contractor, being all work other than that covered by Item 2: $ Z. Ll()_-� Qin-i Item 2. Sub -bids as follows: Bond req'd Sub -trade Name of Sub -Bidder Amount Yes/No Masonry. 04.21.0 Cast Stone Brick Masonry Masonry L-41. 1?1A50-VP-Y $ 9 q foo � Roofi07.3 1.n Shingles tomerc Membrane Roofing M Dm kvW6 $ '74 OCjp 07.53.00 Elasl 09.51.23 Acoustical Tile Ceilings Kee Acc i.,sry w Cuoym.Gj $ ,b, S 7 FORM OF GENERAL BID - 1 School Department Administration Building Kang Associates, Inc. North Andover, MA January 2, 2014 09.90.00 Painting and Coating 06 *0fta✓77ry& $ 4S-700 14.42.16 Vertical Wheelchair Lifts 61 Division 21 Fire Protection rl;Aa-i4j coo �r f Division 22 Plumbing 44AW AP044'OWC-1AZ $-5-8 ' , OV0 Division 23 HVAC ��� �• ��'�'� $ Division 26 Electrical JuPft� ���? � /fit Division 28 Fire Alarm $ .�� Total of Item 2: $ Mi E. The undersigned agrees that, if he is selected as general contractor, he will within five days, Saturdays, Sundays and legal holidays excluded, after presentation thereof by the awarding authority, execute a contract in accordance with the terms of this bid and furnish a performance bond and also a labor and materials or payment bond, each of a surety company qualified to do business under the laws of the commonwealth and satisfactory to the awarding authority and each in the sum of the contract price, the premiums for which are to be paid by the general contractor and are included in the contract price; provided, however, that if there is more than 1 surety company, the surety companies shall be jointly and severally liable. The undersigned hereby certifies that he is able to furnish labor that can work in harmony with all other elements of labor employed or to be employed on the work; that all employees to be employed at the worksite will have successfully completed a course in construction safety and health approved by the United States Occupational Safety and Health Administration that is at least 10 hours in duration at the time the employee begins work and who shall furnish documentation of successful completion of said course with the first certified payroll report for each employee; and that he will comply fully with all laws and regulations applicable to awards made subject to section 44A. The undersigned further certifies under the penalties of perjury that this bid is in all respects bona fide, fair and made without collusion or fraud with any other person. As used in this subsection the word "person" shall mean any natural person, joint venture, partnership, corporation or other business or legal entity. The undersigned further certifies under penalty of perjury that the said undersigned is not presently debarred from doing public construction work in the commonwealth under the provisions of section twenty-nine F of chapter twenty-nine, or any other applicable debarment provisions of any other chapter of the General Laws or any rule or regulation promulgated thereunder. 01-549-14- WL',;S 'Sr`�LrF.,I;t�.'✓ - Date (Name of General Bidder) By: SSrnature and T' of Perron Signing Bid Business Address 1714 City and State FORM OF GENERAL BID - 2 School Department Administration Building North Andover, MA GENERAL BIDDER'S CHECKLIST: V Addenda Recognized Bid Deposit Certificate of Corporate Bidder t� DCAM Eligibility Update Statement Certificate of Non -Collusion and Certificate of Tax Compliance V Certification of Labor Harmony and OSHA Training Requirements FORM OF GENERAL BID - 3 Kang Associates, Inc. January 2, 2014 School Department Administration Building Kang Associates, Inc. North Andover, MA January 2, 2014 CERTIFICA TE OF CORPORATE BIDDER - certify that I am the e Lcoex of the corporation named as Bidder in the Bid Form, and that KL w*U-"* J ADS who signed the Bid Form on behalf of the Bidder was then the P� of said corporation and that I know his signature; that his signature thereto is genuine and that the Bid Form was duly signed, sealed and executed for and in behalf of said corporation by authority of its governing body. Corporate Seal Secretary- lerk j'4NVj"tje 5�0. 'Zo /¢ Date CORPORATE BIDDER - 1 CERTIFICATIONS CERTIFICATE OF NON -COLLUSION The undersigned certifies under penalties of perjury that this bid or proposal has been made and submitted in good faith and without collusion or fraud with any other person. As used in this certification, the word "person" shall mean natural person, business, partnership, corporation, committee, union, club or other organization, entity, or group of individuals. Signature 71 ree"--77 J6 Print Name & Title Date a A- cvvif, xzz�*O, 64/0. Company Name CERTIFICATE OF TAX COMPLIANCE Pursuant to Chapter 62C of the Massachusetts General Laws, Section 49A (b), I tiEAIAAL?W J Vara� authorized signatory for WC -S 6Wktw Name of individual Name of contractor do hereby certify under the pains and penalties of perjury that said contractor has complied with all laws of the Commonwealth of Massachusetts, and the Town of North Andover, relating to taxes, permit or other fees, reporting of employees and contractors, and withholding and remitting child support. 9-Z Q®-- A r� Signature Date CERTIFICATION LABOR HARMONY AND OSHA TRAINING REQUIREMENTS The undersigned certifies under penalties of perjury that he is able to furnish labor that can work in harmony with all other elements of labor employed or to be employed at the work and that all employees to be employed at the worksite and in the work will have completed an OSHA -approved construction safety and health course lasting at least ten (10) hours. Signature Date 0/1' Print Name & Title Company Name CERTIFICATE OF VOTE At a duly authorized meeting the Board of Directors of the W95 L"/yjrXvt-lnon/ 4P41'! held on RLAI Wj � /� it was T VOTED, THAT V06e - Pews /'Pary- (Name) (Officer) of W&FJ &wj,"r-t�WX4✓ 4Ze,be and hereby is authorized to execute contracts and bonds in the name and on behalf of said J#6 Go vJ1Z#u&41 6W , and affix its corporate seal hereto; and such execution of any contract or obligation in the name of Al 6,eW, on its behalf by such officer under seal of WUS ee-P41X+uW i 6W, shall be valid and binding upon 901 ( ifl y' o MIA I hereby certify that I am the clerk of the above named J&Js-S 6JYJJV,4W#✓ 6W. and that Kd-w&,-7-A- Jy e dz' is the duly elected officer as above of said WL' -'*J' ������ &jW° , and that the above vote has not been amended or rescinded and remains in full force and effect as the date of this contract. 01-60,14 (Date) Certification of the Corporate Clerk 4Z�-- c0Y: (Cl k) School Department Administration Building North Andover, MA FOREIGN CORPORATIONS CERTIFICATION AFFIDAVIT OF COMPLIANCE Form AF -4A 1/78 EXECUTIVE OFFICE FOR ADMINISTRATION AND FINANCE The Commonwealth of Massachusetts V Massachusetts Business Corporation Non-profit Corporation Foreign (non -Massachusetts) Corporation 1, X 6r11d!lZC?-A J (,�s1 Kang Associates, Inc. January 2, 2014 President Clerk of P9-:5 C- V0,M�, _W4,/ &W (Name of Corporation) whose principal office is located !/��ld��i%�'L �'��� 0z'7ep do hereby certify that the above named Corporation has filed with the State Secretary all certificates and annual reports required by Chapter 15613, Section 109 (Business Corporation), by Chapter 181, Section 4 (Foreign Corporation), or by Chapter 180, Section 26A (non-profit Corporation) of the Massachusetts General Laws. SIGNED UNDER THE PENALTIES OF PERJURY this day of J9V& , 20 . Signature of responsible Corporate Officer FOREIGN CORP - 1 DEVAL L. PATRICK GOVERNOR TIMOTHY P. MURRAY LIEUTENANT GOVERNOR My The Commonwealth of Massachusetts Executive Office for Administration and Finance Division of Capital Asset Management and Maintenance One Ashburton Place Boston, Massachusetts 02108 Tel: (617) 727-4050 Fax: (617) 727-5363 GLEN SHOR SECRETARY, ADMINISTRATION & FINANCE CAROLE CORNELISON COMMISSIONER Prime/General Certificate of Contractor Eligibility CONTRACTOR IDENTIFICATION NUMBER: 0080 This Certificate Shall Be Used for Submitting Prime/General Bids Only 1. CERTIFICATION PERIOD: This Certificate is valid from 7/10/2013 to 7/10/2014 2. CONTRACTOR'S NAME: WES Construction Corp. 3. CONTRACTOR'S ADDRESS: 650 Industrial Drive, Halifax, MA 02338 4. WORK CATEGORIES: This Contractor is certified to file bids under Massachusetts General Laws Chapter 149, . Chapter 149A and Chapter 25A in the following checked Categories of Work: ❑Alar Systems ❑ Asbestos Removal ❑ Deleading G Demolition ❑ Doors & Windows ❑ Electrical ❑Electronic Security Systems S. EVALUATIONS: 6. PROJECT LIMITS: 7. SUPP ❑ Elevators [-]Energy Management Systems ❑ Exterior Siding ❑ Fire Protection Sprinkler Systems Floor Covering jV] General Building Construction ❑Historical Building Restoration DIVERSITY OFFI ❑ Historical Masonry ❑ Historical Painting ❑ Historical Roofing ❑ HVAC ❑ Masonry ❑ Mechanical Systems ❑ Modular Construction/Prefab Number of Projects Evaluated: 7 Average Project Evaluation Rating: 91 Number of Projects Below Passing Score: 0 Single Project Limit (SPL): Aggregate Work Limit (AWL): General Building Construction Limit: FICATION: N/A Freya S. Bernstein, Deputy General Counsel, for Carole J. Cornelison, Commissioner ❑ Painting ❑ Plumbing C Pumping Stations ❑ Roofing C Sewage & Water Treatment Plants E] Telecommunication Systems ❑ Waterproofing $21,477,000.00 $48,224,000.00 $21,477,000.00 -2— 6 J) --� Approval Date NOTE TO CONTRACTORS: Complete Applications for Renewal of Contractor Eligibility are due no later than three months PRIOR to the Expiration Date of the Certification Period shown above. Failure to submit Completed Applications timely may result in a gap in Certification or a lapse in Certification altogether for your company. Reviewer's Initials __ b BID BOND Conforms with The American Institute of Architects, A.I.A. Document No. A-310 KNOW ALL BY THESE PRESENTS, That we, Wes Construction Corp. 650 Industrial Drive, Halifax, MA 02338 as Principal, hereinafter called the Principal, and the Liberty Mutual Insurance Company of 175 Berkeley Street, Boston, MA 02116 , a corporation duly organized under the laws of the State of Massachusetts as Surety, hereinafter called the Surety, are held and firmly bound unto Town of North Andover 120 Main Street, North Andover, MA 01845 as Obligee, hereinafter called the Obligee, in the sum of Five Percent of Bid Amount Dollars ($ 5% of Bid Amount ) , for the payment of which sum well and truly to be made, the said Principal and the said Surety, bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents. WHEREAS, the Principal has submitted a bid for School Department Administration Building NOW, THEREFORE, if the Obligee shall accept the bid of the Principal and the Principal shall enter into a Contract with the Obligee in accordance with the terms of such bid, and give such bond or bonds as may be specified in the bidding or Contract Documents with good and sufficient surety for the faithful performance of such Contract and for the prompt payment of labor and material furnished in the prosecution thereof, or in the event of the failure of the Principal to enter such Contract and give such bond or bonds, if the Principal shall pay to the Obligee the difference not to exceed the penalty hereof between the amount specified in said bid and such larger amount for which the Obligee 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. Signed and sealed this 30th day of January 2014 - Wes Construction Corp. (Seal) I Principal Witness ! j Title Liberty Mutual Insurance Company Witness By _ _ /imonL ons, " Attorney -in -Fact . � i VCCr ILIVV FRP THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS PRINTED ON RED BACKGROUND. 2 t This Power of Attorney limits the acts of those named herein, and they have no authority to bind the Company except in the manner and to the extent herein stated. Certificate No. 6123913 American Fire and Casualty Company Liberty Mutual Insurance Company The Ohio Casualty Insurance Company West American Insurance Company POWER OF ATTORNEY KNOWN ALL PERSONS BY THESE PRESENTS: ThatAmerican Fire & Casualty Company and The Ohio Casualty Insurance Company are corporations duly organized under the laws of the State of New Hampshire, that Liberty Mutual Insurance Company is a corporation duly organized under the laws of the State of Massachusetts, and West American Insurance Company is a corporation duly organized under the laws of the State of Indiana (herein collectively called the "Companies"), pursuant to and by authority herein set forth, does hereby name, constitute and appoint, Claire A. Cavanaugh: Dennis W. Driscoll: George G. Powers: J. Barry Driscoll: John C.'Driscoll;'Lena Brownell: Martin L. Donovan: Timothy P. Lyons = all of the city of Norwell state of MA - each individually if there be more than one named, its true and lawful attomey-in-fact to make, execute, seal, acknowledge and deliver, for and on its behalf as surety and as its act and deed, any and all undertakings, bonds, recognizances and other surety obligations; in pursuance of these presents and shall be as binding upon the Companies as if they have been duly signed by the president and attested by the secretary of the Companies in their own proper persons. IN WITNESS WHEREOF, this Power of Attorney has been subscribed,by an authorized officer or official of the Companies and the corporate seals of the Companies have been affixed thereto this 14th day of May 2013 - ' American Fire and Casualty Company 4T 4 `` t t The Ohio Casualty Insurance Company to €11�L j P Liberty Mutual Insurance Company d WestAmerican Insurance Company SIN'' B m y:. C STATE OF WASHINGTON ss Gregory W. Davenport, Assistant Secretary r COUNTY OF KING - 4) On this 14th day of May 2013 , before me personally appeared Gregory W. Davenport, who acknowledged himself to be the Assistant Secretary of American v v y Fire and Casualty Company, Liberty Mutual Insurance Company, The Ohio Casualty Company, and West American Insurance Company, and that he, as such, being authorized so to do, N 46.2 eecute the foregoing instrument for the purposes therein contained by signing on behalf of the corporations by himself as a duly authorized officer. - = rW r > IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my notarial seal at Seattle, Washington, on the day and yearfirst above written. _ p Q , QM O i KD Riley, Not Public _ y 0'F3 t> _ IL _ R. This Power ofAttomey is made and executed pursuantto and by authority of the following By-laws and Authorizations of American fire and Casualty Company, The Ohio Casualty Insurance H C Company, Liberty Mutual Insurance Company, and West American Insurance Company which resolutions are now in full force and effect reading as follows: t e M L ARTICLE IV -OFFICERS -Section 12. Power of Attorney. Any officer or other official of the Corporation authorized for that purpose in writing by the Chairman or the President, and subject p = aD to such limitation as the Chairman or the President may prescribe, shall appoint such attomeys-in-fact, as may be necessary to act in behalf of the Corporation to make, execute, seal, > 4) O C acknowledge and deliver as surety any and all undertakings, bonds, recognizances and other surety obligations. Such attorneys -in -fact, subject to the limitations set forth in their respective .a s powers of attorney, shall have full power to bind the Corporation by their signature and execution of any such instruments and to attach thereto the seal of the Corporation. When so = y executed, such instruments shall be as binding as if signed by the President and attested to by the Secretary. Any power or authority granted to any representative or attomey-in-fact under > = the provisions of this article may be revoked at any time by the Board, the Chairman, the President or by the officer or officers granting such -power or authority. d _ ARTICLE XIII - Execution of Contracts - SECTION 5. Surety Bonds and Undertakings. Any officer of the Company authorized for that purpose in writing by the chairman or the president, oND > L and subject to such limitations as the chairman or the president may prescribe, shall appoint such attorneys -in -fact, as may be necessary to act in behalfofthe Company to make, execute, M p seal, acknowledge and deliver as surety any and all undertakings, bonds, recognizances and other surety obligations. Such attorneys -in -fact subject to the limitations set forth in their = 00 Z v respective powersof attorney, shall have full power to bind the -Company by their signature and execution of any such instruments and to attach thereto the seal of the Company. When so 00 executed such instruments shall be as binding as if signed by the president and attested by the secretary. O Certificate of Designation - The President of the Company, acting ,pursuant to the Bylaws of the Company, authorizes Gregory W. Davenport,, Assistant Secretary to appoint such r attomeys-in-fact as may be necessary to act on behalf of the -Company to make, execute, seal, acknowledge and deliver. as surety any and all undertakings, bonds, recognizances and other surety obligations. Authorization By unanimous consent of the Company's Board of Directors, the Company consents that facsimile or mechanically reproduced signature of any assistant secretary of the Company, wherever appearing upon a certified copy of any power of attorney issued by the Company in connection with surety bonds, shall be'valid and binding upon the Company with the same force and effect as though manually affixed. _ - 1, David M. Carey, the undersigned, Assistant Secretary,ofAmerican Fire and Casualty Company, The Ohio Casualty Insuranc6C6mpany`Liberty Mutual insurance Company, and West American Insurance Company do hereby certify that the original power of attorney of which the foregoing is a full, true and correct copy of the Power ofAttomey executed by said Companies, is in full force and effect and has not been revoked. _ IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seals of said Companies this lC1`day of _ 20 . ^�. 4 g lbs' �. ��.� " rt ✓"r ; �� � C, ... � 4 �� ` � 'Y l j. •t �a � t *' t r 60v By: f c j d "n, a z r ? David M. Carey, Assistant Secretary LMS 12873 092012 180 of 300 SPECIAL NOTICE TO AWARDING AUTHORITY BIDDERS' UPDATE STATEMENTS ARE NOT PUBLIC RECORDS AND ARE NOT OPEN TO PUBLIC INSPECTION (M. G.L. C. 149, §44D) EFFECTIVE MARCH 30, 2010 Commonwealth of Massachusetts Division of Capital Asset Management PRIME/GENERAL CONTRACTOR UPDATE STATEMENT TO ALL BIDDERS AND AWARDING AUTHORITIES A COMPLETED AND SIGNED PRIME/GENERAL CONTRACTOR UPDATE STATEMENT MUST BE SUBMITTED WITH EVERY PRIME/GENERAL BID FOR A CONTRACT PURSUANT TO M.G.L. c.149, §44A AND M.G.L. c. 149A. ANY PRIME/GENERAL BID SUBMITTED WITHOUT AN APPROPRIATE UPDATE STATEMENT IS INVALID AND MUST BE REJECTED. Caution: This form is to be used for submitting Prime/General Contract bids. It is not to be used for submitting Filed Sub -Bids or Trade Sub -Bids. AWARDING AUTHORITIES If the Awarding Authority determines that the bidder does not demonstrably possess the skill, ability, and integrity necessary to perform the work on the project, it must reject the bid. BIDDER'S AFFIDAVIT I swear under the pains and penalties of perjury that I am duly authorized by the bidder named below to sign and submit this Prime/General Contractor Update Statement on behalf of the bidder named below, that I have read this Prime/General Contractor Update Statement, and that all of the information provided by the bidder in this Prime/General Contractor Update Statement is true, accurate, and complete as of the bid date. JANUARY 30, 2014 WES Construction Corp Bid Date Print Name of Prime/General Contractor School Department Administration Building 650 Industrial Drive Halifax MA 02338 Project Number (or Business Address name if no number) Town of North Andover 781-294-1080 Awarding Authority Telephone Number SIGNATURE* Bidder' uthorized Representative Kenneth J. Vogel, President INSTRUCTIONS INSTRUCTIONS TO BIDDERS • This form must be completed and submitted by all Prime/General contractors bidding on projects pursuant to M.G.L. c. 149, §44A and M.G.L. c. 149A. • You must give complete and accurate answers to all questions and provide all of the information requested. MAKING A MATERIALLY FALSE STATEMENT IN THIS UPDATE STATEMENT IS GROUNDS FOR REJECTING YOUR BID AND FOR DEBARRING YOU FROM ALL PUBLIC CONTRACTING. • This Update Statement must include all requested information that was not previously reported on the Application used for your firm's most recently issued (not extended or amended) Prime/General Contractor Certificate of Eligibility. The Update Statement must cover the entire period since the date of your Application, NOT since the date of your Certification. • You must use this official form of Update Statement. Copies of this form may be obtained from the awarding authority and from the Asset Management Web Site: www.mass..qov/dcam. • If additional space is needed, please copy the appropriate page of this Update Statement and attach it as an additional sheet. • See the section entitled "Bidding Limits" in the Instructions to Awarding Authorities for important information concerning your bidding limits. INSTRUCTIONS TO AWARDING AUTHORITIES Determination of Bidder Qualifications • It is the awarding authority's responsibility to determine who is the lowest eligible and responsible bidder. You must consider all of the information in the low bidder's Update Statement in making this determination. Remember: this information was not available to the Division of Capital Asset Management at the time of certification. • The bidder's performance on the projects listed in Parts 1 and 2 must be part of your review. Contact the project references. • AWARDING AUTHORITIES ARE STRONGLY ENCOURAGED TO REVIEW THE LOW BIDDER'S ENTIRE CERTIFICATION FILE AT THE DIVISION OF CAPITAL ASSET MANAGEMENT. Telephone (617) 727-9320 for an appointment. Bidding Limits Single Project Limit: The total amount of the bid, including all alternates, may not exceed the bidder's Single Project Limit. Aggregate Work Limit: The annual value of the work to be performed on the contract for which the bid is submitted, when added to the annual cost to complete the bidder's other currently held contracts, may not exceed the bidder's Aggregate Work Limit. Use the following procedure to determine whether the low bidder is within its Aggregate Work Limit: Step 1 Review Update Statement Question #2 to make sure that all requested information is provided and that the bidder has accurately calculated and totaled the annualized value of all incomplete work on its currently held contracts (column 9). Step 2 Determine the annual dollar value of the work to be performed on your project. This is done as follows: (i) If the project is to be completed in less than 12 months, the annual dollar value of the work is equal to the full amount of the bid. (ii) If the project will take more than 12 months to complete, calculate the number of years given to complete the project by dividing the total number of months in the project schedule by 12 (calculate to 3 decimal places), then divide the amount of the bid by the calculated number of years to find the annual dollar value of the work. Step 3 Add the annualized value of all of the bidder's incomplete contract work (the total of column 9 on page 5) to the annual dollar value of the work to be performed on your project. The total may not exceed the bidder's Aggregate Work Limit. Correction of Errors and Omissions in Update Statements Matters of Form: An awarding authority shall not reject a contractor's bid because there are mistakes or omissions of form in the Update Statement submitted with the bid, provided the contractor promptly corrects those mistakes or omissions upon request of the awarding authority. [810 CMR 8.05(1)]. Correction of Other Defects: An awarding authority may, in its discretion, give a contractor notice of defects, other than mistakes or omissions of form, in the contractor's Update Statement, and an opportunity to correct such defects, provided the correction of such defects is not prejudicial to fair competition. An awarding authority may reject a corrected Update Statement if it contains unfavorable information about the contractor that was omitted from the Update Statement filed with the contractor's bid. [810 CMR 8.05(2)]. w M r LL 0LL W� 0 QLL0 WWW F- O W� UQW ZUW J W 0 D WZ0 J W — a. 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(n W 0 W C O U >1 U) Cl. 3 m Q Ol- C cu N O Q E -= cu a) C N >O 3 >, �n o c`• � O = M .C- a) o E -C L 3 Lc�u our 3 E o cu O O'L 3 cQ c cum ocn (n a) a) c c 0 0 �'cn cn `-� S� a) Ew CL cu >- (CU U O 'O cu a) CM CO " 0 3 C N N C L U C N a- ��m ++ U O cu N L (D >+ L L 30 > (0 3 >, 0 N `O 0 0 , N Q. +C 4' PART 3 - PROJECT PERFORMANCE For Parts 3 and 4, if you answer YES to any question, please provide on a separate page a complete explanation. Information you provide herein must supplement the Application for your most recently issued (not extended or amended) DCAM Certificate of Eligibility. You must report all requested information not previously reported on that DCAM Application for Prime/General Certificate of Eligibility. Include all details [project name(s) and location(s), names of all parties involved, relevant dates, etc.]. YES NO 1. Has your firm been terminated on any contract prior to completing a project or has any officer, partner or principal of your firm been an officer, partner or principal of X another firm that was terminated or failed to complete a project? 2. Has your firm failed or refused either to perform or complete any of its work under X any contract prior to substantial completion? 3. Has your firm failed or refused to complete any punch list work under any contract? X 4. Has your firm filed for bankruptcy, or has any officer, principal or individual with a financial interest in your current firm been an officer, principal or individual with a X financial interest in another firm that filed for bankruptcy? 5. Has your surety taken over or been asked to complete any of your work under any X contract? 6. Has a payment or performance bond been invoked against your current firm, or has any officer, principal or individual with a financial interest in your current firm X been an officer, principal or individual with a financial interest in another firm that had a payment or performance bond invoked? 7. Has your surety made payment to a materials supplier or other party under your X payment bond on any contract? 8. Has any subcontractor filed a demand for direct payment with an awarding authority X fora public project on any of your contracts? 9. Have any of your subcontractors or suppliers filed litigation to enforce a mechanic's lien against property in connection with work performed or materials supplied X under any of your contracts? 10. Have there been any deaths of an employee or others occurring in connection with X any of your projects9 11. Has any employee or other person suffered an injury in connection with any of your projects resulting in their inability to return to work for a period in excess of X one year? PART 4 - Legal or Administrative Proceedings; Compliance with Laws Please answer the following questions. Information must supplement all judicial and administrative proceedings involving bidder's firm, which were instituted or concluded (adversely or otherwise) since your firm's Application for your most recently issued (not extended or amended) Certificate of Eligibility. You must report all requested information not previously reported on that DCAM Application for Prime/General Certificate of Eligibility. The term "administrative proceeding" as used in this Prime/General Contractor Update Statement includes (i) any action taken or proceeding brought by a governmental agency, department or officer to enforce any law, regulation, code, legal, or contractual requirement, except for those brought in state or federal courts, or (ii) any action taken by a governmental agency, department or officer imposing penalties, fines or other sanctions for failure to comply with any such legal or contractual requirement. The term "anyone with a financial interest in your firm" as used in this Section "I", shall mean any person and/or entity with a 5% or greater ownership interest in the applicant's firm. If you answer YES to any question, on a separate page provide a complete explanation of each proceeding or action and any judgment, decision, fine or other sanction or result. Include all details (name of court or administrative agency, title of case or proceeding, case number, date action was commenced, date judgment or decision was entered, fines or penalties imposed, etc.). YES NO 1. Have any civil, judicial or administrative proceedings involving your firm or a principal or officer or anyone with a financial interest in your firm been brought, concluded, or settled relating to the procurement or performance of any X construction contract, including but not limited to actions to obtain payment brought by subcontractors, suppliers or others? 2. Have any criminal proceedings involving your firm or a principal or officer or anyone with a financial interest in your firm been brought, concluded, or settled relating to the procurement or performance of any construction contract including, X but not limited to, any of the following offenses: fraud, graft, embezzlement, forgery, bribery, falsification or destruction of records, or receipt of stolen property? 3. Have any judicial or administrative proceedings involving your firm or a principal or officer or anyone with a financial interest in your firm been brought, concluded, X or settled relating to a violation of any state's or federal procurement laws arising out of the submission of bids or proposals? 4. Have any judicial or administrative proceedings involving your firm or a principal or officer or anyone with a financial interest in your firm been brought, concluded, X or settled relating to a violation of M.G.L. Chapter 268A, the State Ethics Law? PART 4 - Legal or Administrative Proceedings; Compliance with Laws (continued) YES NO 5. Have any judicial or administrative proceedings involving your firm or a principal or officer or anyone with a financial interest in your firm been brought, concluded, or settled relating to a violation of any state or federal law regulating hours of labor, X unemployment compensation, minimum wages, prevailing wages, overtime pay, equal pay, child labor or worker's compensation? 6. Have any judicial or administrative proceedings involving your firm or a principal or officer or anyone with a financial interest in your firm been brought, concluded, or settled relating to a violation of any state or federal law prohibiting X discrimination in employment? 7. Have any judicial or administrative proceedings involving your firm or a principal or officer or anyone with a financial interest in your firm been brought, concluded, X or settled relating to a claim of repeated or aggravated violation of any state or federal law regulating labor relations? 8. Have any proceedings by a municipal, state, or federal agency been brought, concluded, or settled relating to decertification, debarment, or suspension of your X firm or any principal or officer or anyone with a financial interest in your firm from public contracting? 9. Have any judicial or administrative proceedings involving your firm or a principal or officer or anyone with a financial interest in your firm been brought, concluded, X or settled relating to a violation of state or federal law regulating the environment? 10. Has your firm been fined by OSHA or any other state or federal agency for violations of any laws or regulations related to occupational health or safety? Note: X this information may be obtained from OSHA's Web Site at www.osha.gov 11. Has your firm been sanctioned for failure to achieve DBE/MBE/WBE goals, X workforce goals, or failure to file certified payrolls on any public projects? 12. Other than previously reported in the above paragraphs of this Section I, have any X administrative proceedings or investigations involving your firm or a principal or officer or anyone with a financial interest in your firm been brought, concluded, or settled by any local, state or federal agency relating to the procurement or performance of any construction contract? 13. Are there any other issues that you are aware which may affect your firm's X responsibility and integrity as a building contractor? Part 4 Question 1 1. D.D.S. Industries Inc. Vs. WES CONSTRUCTION CORP., and Safeco Insurance Company. This case involves a claim by a subcontractor to recover amounts the subcontractor is claiming that is due from WES CONSTRUCTION CORP. or their insurance company. Bristol Superior Court Department of the Trial Court Civil Action # BRCV2012-00861-C PENDING -Filed on August 22, 2012 Part 4 Question 10 Inspection: 797041.015 - Wes Construction Corp Inspection Information - Office: South Boston Nr: 797041.015 ReportID:0111400 Open Date: 12/13/2012 Wes Construction Corp Serious Willful Repeat Other Unclass Total 34 Main Street 3 North Easton, MA 02357 Union Status: NonUnion SIC: 3 NAICS: 236220/Commercial and Institutional Building Construction Mailing: 650 Industrial Drive, Halifax, MA 02338 Current Penalty Inspection Type: Referral 4200 Scope: Partial Advanced Notice: N Ownership: Private Safety/Health: Safety Close Conference: 12/13/2012 Close Case: Related Activity: Type ID Safety Health Referral 717232 Yes Violation Items # ID Type Standard Issuance Abate Curr$ Init$ Fta$Contest LastEvent 1.01001 Serious 19260501 B07 101/17/2013 12/13/2012 $1400 $2800 $0 I - Informal Settlement 2.01002 Serious 19260502 I03 01/17/201312/13/2012$1400$2800 $0 I - Informal Settlement 3.01003 Serious 19261053B16 01/17/201312/13/2012$1400$2800 $0 I - Informal Settlement THERE HAVE BEEN NO CIVIL, CRIMINAL, OR ADMINISTRATIVE PROCEEDINGS INVOLVING EPA OR DEP. Violation Summary Serious Willful Repeat Other Unclass Total Initial Violations 3 3 Current Violations 3 3 Initial Penalty 8400 8400 Current Penalty 4200 4200 FTA Amount Violation Items # ID Type Standard Issuance Abate Curr$ Init$ Fta$Contest LastEvent 1.01001 Serious 19260501 B07 101/17/2013 12/13/2012 $1400 $2800 $0 I - Informal Settlement 2.01002 Serious 19260502 I03 01/17/201312/13/2012$1400$2800 $0 I - Informal Settlement 3.01003 Serious 19261053B16 01/17/201312/13/2012$1400$2800 $0 I - Informal Settlement THERE HAVE BEEN NO CIVIL, CRIMINAL, OR ADMINISTRATIVE PROCEEDINGS INVOLVING EPA OR DEP. PART 5 - SUPERVISORY PERSONNEL List all supervisory personnel, such as project managers and superintendents, who will be assigned to the project if your firm is awarded the contract. Attach the resume of each person listed below. NAME TITLE OR FUNCTION Kenneth J. Vogel General Manager Joseph S. Vogel Project Manager Neil E. Schwartz Project Manager Mike Adams Project Super PART 6 - CHANGES IN BUSINESS ORGANIZATION OR FINANCIAL CONDITION Have there been any changes in your firm's business organization, financial condition or bonding capacity since the date your current Certificate of Eligibility was issued? Yes No X If YES, attach a separate page providing complete details. PART 7 — LIST OF COMPLETED CONSTRUCTION PROJECTS SUBMITTED TO THE DIVISION OF CAPITAL ASSET MANAGEMENT. Attach here a copy of the list of completed construction projects which was submitted with your firm's DCAM Application for your most recently issued (not extended or amended) DCAM Certificate of Eligibility. The Attachment must include a complete copy of the entire Section G — "Completed Projects" and the final page — "Certification" (Section J) containing the signature and date that the Completed Projects list (Section G) was submitted to the Division of Capital Asset Management. Kenneth J. Vogel, LEED AP President WORK EXPERIENCE: President/General Manager —1988 to Present WES CONSTRUCTION CORP. Qutittacas WTP; Ruane Judicial Center; The Clarendon; North Street -Salem; UMass Boston Parking Phase I;Mattapoisett WTP; Lawrence Mills Condominium Development and Park; Keith Middle School Phase I and II; Water Filtration Plant, Worcester, MA; Building 17 Demolition and Parking Lot, Boston, MA; 30" Gas Main Relocation, Boston, MA; Weston Disinfection Facility, Weston, MA; Wareham Water Pollution Facility, Wareham, MA; Weston Chlorination Facility, Weston, MA; New Bedford Pump Station, New Bedford, MA; Marlboro Sludge Composing Facility; Tufts Building Excavation; Hanscom Air Force Base Landfill Closure; Mashpee Transfer Station; Northampton Landfill Liner; Wayland Municipal Landfill Liner; Fort Devens Landfill Liner; Mansfield Sludge Composing Facility; Site Work for Medical East, Norwood, MA Project Superintendent —1986 to 1988 Maynard Sanitary Landfill Capping, Northbridge Sanitary Landfill Capping, Wayland Landfill Liner, Braintree Sanitary Landfill Capping and SEMASS Railroad Excavation Project Foreman —1984 to 1986 Concord Landfill and Genrad Corp. Excavation and Foundation Assistant Project Manager —1983 to 1984 PETER KIEWIT & SONS CO. Fort McHenry Tunnel, Baltimore, MD Quality Control Engineer —1982 to 1983 Subway Station, Baltimore, MD EDUCATION: BSCE, Northeastern University —1982 EIT Certificate OSHA Hazardous Waste Training JOSEPH VOGEL Project Manager WORK EXPERIENCE: WES CONSTRUCTION CORP. - April 2001 to Present MPA Fargo Street Chassis Service Facility - $ 2.3 Million. New Boston Prerelease Center - $11 Million. Brunswick Gardens Middle School Site Preparation, City of Boston - $ 0.5 Million O'Connor Constructors, Inc. -1982 to March 2001 Brighton Landing 10 Story, 230,000 SF Office Building - $20 Million Brighton Landing 7 Story, 220,000 SF Office Building - $16 Million Brighton Landing 5 Level, 550,000 SF Parking Garage - $14 Million UMass Lowell, Olsen and Olney Halls Fire Protection, DCAM - $2.4 Million UMass Fire Protection, McCormack Building, Boston, MA. DCAM - $2.5 Million Logan Airport Central Cooling Renovations, Massport - $2.3 Million Building 19, Fore River Shipyard Renovation, MWRA - $2.3 Million Sludge Processing Facility Fast Track Modifications, MWRA, - $1.5 Million Boiler Plant Renovations, Phillips Academy, Andover, MA - $4.4 Million Boston Edison Engineering and Support Building, Pilgrim Nuclear Plant - $7.2 Million Orient Heights Renovation Project, BHA - $14 Million HMO Health Center, Norwood, MA Uxbridge High School Addition/Renovation - $4 million Commonwealth Electric Steam Line for Massachusetts General Hospital - $3.4 Million Boston Fish Pier Restoration, Massport - $19 million Renovations to Terminal C, Logan International Airport - $29 Million University of Massachusetts Steam Plant Renovations - $2.2 Million Marian Manor Nursing Home Design Build Auditorium, Boston, MA - $.7 Million EDUCATION: University of Massachusetts Bachelor of Science, Civil Engineering Roger Williams College Supervisor Training Programs PROFESSIONAL MEMBERSHIP: Associated General Contractors, Education Committee, Building Code Committee Massachusetts State Construction Supervisors License SE Mass. Carpenters, Apprenticeship Training Fund NEIL E. SCHWARTZ Project Manager EDUCATION Bachelors of Science, Industrial Construction Management, Colorado State University, 1982 EXPERIENCE PROJECTMANAGER WES CONSTRUCTION CORP. March 2006 to Present Halifax, Massachusetts UMass Boston Phase I Site Work 1.7M; UMass Boston Phase II Site Work 1.6M; Fargo Street Chassis Facility 2AM; Fitzgerald School Pile Driving 600K; Mattapan Library 500K; Charlestown Police Station 9.2M; Charlestown Recovery House 600K; Taunton State Hospital 79K; North Street, Salem, MA 2.1M; Building 8 West End Demo, Logan 2.7M; Morrissey Blvd. Bridge Rehab 6.2M; MCI Norfolk WWTP 8M; Salem Court House 1.5M PROJECT MANAGER /ESTIMATOR E. T. & L. CORP. January 2005 to Present Stow, Massachusetts PROJECTS MANAGED: Jackson Road Reconstruction Phase III, Devens, MA - $3.8 Million Dollars Route 125 / 193 Interchange, Wilmington, MA — $4.1 Million Dollars Reconstruction of Crosby Drive, Bedford, MA - $4.0 Million Dollars HIGHWAYAND BRIDGE WORK ESTIMATED: Types of work include bridges, modular walls, utilities, excavation, backfill, road construction and finishes. PROJECT MANAGER J. DERENZO CO. July 2003 to December 2005 Brockton, Massachusetts PROJECTS MANAGED: The Residences at Union Place, Franklin MA - $3.5 Million Dollars Shops at Long Pond, Plymouth MA — $12.6 Million Dollars Raynham Lowe's and Retail Development, Raynham MA - $5.3 Million Dollars 100 Landsdowne St. Residential Facility, Cambridge MA — $ .7 Million Dollars 23 Sidney St. Residential Facility, Cambridge MA - $ 0.5 Million Dollars July 1994 to July 2003 M. DEMATTEO CONSTRUCTION CO. Braintree, Massachusetts LEAD ENGINEER /AREA SUPERINTENDENT TYPE OF PROJECT: Elevated Walkways B and C, Massachusetts Port Authority, Logan Airport, East Boston Project worth of $80 Million Dollars. Construction of the Elevated Walkways for Terminals B and C. Four walkway truss sections. Interior and exterior finishes. Roadway construction. Installation of utilities, grading, paving, curb, sidewalks and retaining walls. Demolition of existing pedestrian walkways and terminal entrances. AREA SUPERINTENDENT AND ENGINEER TYPE OF PROJECT: Central Artery, South Boston Interchange, South Boston, MA Construction of 1500 LF of six -lane concrete cut and cover tunnels, ramps and walls. Construction of roads, bridges, ramps and utilities. Support of excavation, including sheet pile, tiebacks and slurry walls. Project worth of $180 Million Dollars HONORS AND ACTIVITIES Construction Supervisors License, Commonwealth of Massachusetts Board of Regulators Training Certificate, OSHA Course 501 -Compliance in Safety and Health Training Certificate, OSHA Confined Space Training Certificate, OSHA 10 -Hour Construction Safety and Health Standard First Aid and CPR, American Red Cross Training Certificate, MBTA ROW Safety Awareness 2003 Public Project of the Year -$50 to $100 Million, Construction Management Association of America MICHAEL E. ADAMS Project Superintendent WORK EXPERIENCE: Project Superintendent WES CONSTRUCTION CORP. - 1999 to Present Charlestown Police Station 9,265,176 Construction of a 19,250 square foot Police Station for the City of Boston. Foundation work including caissons and grade beams. Excavation and installation of site utilities and improvements. Coordinated interior finishes, security and detention systems and fuel dispensing system. MPA Building 8 Demolition and Site Restoration 2,799,556 Demolition of existing steel structure hangar. Four level cast in place concrete office building at Logan Airport. Install new metal panel wall on exterior of adjacent Delta Hangar. Excavation and installation of site utilities, perimeter security wall. Paving of parking lot. MPA Fargo Street Boston Service Facility 2,316,750 Coordinated and oversaw all earthwork and utility activities. Responsible for layout and construction. Coordinated installation of 10,000 square foot building. Keith Middle School Phase I and II 11,200,000 Coordinated and oversaw all earthwork and utility activities. Responsible for layout and construction. Coordinated installation of roads, water, pile driving and drainage. Coordinated disposal of hazardous waste material. New Boston Prerelease Center 11,000,000 Coordinated and oversaw all earthwork and utility activities. Responsible for layout and construction. Coordinated installation of roads, water, and drainage. Coordinated installation of 46,000 square foot building. MPA Conley Gate Facility 2,900,000 Coordinated and oversaw all earthwork and utility activities. Responsible for layout and construction. Coordinated installation of roads, water, and drainage. EDUCATION: NORWICH UNIVERSITY - 1983, Bachelor's Degree MILITARY SERVICE - 1980-1986, Honorably discharged Sergeant. Reserves. Certificate of completion for the IEE hazardous waste operation - 40 hour per 29 CFR 1910.120 (E) (3) i. Massachusetts Supervisor License Number CS 8051 ~ Please Enter Your Firm', lane Her Section G. Highest Value Completed Projects 8 Completed Projects / � w aao oc y s xaa ♦ � � �' :�° 1 v9° c°` Sample Project y Boston City Hall Renovation Ganaral Building Construction 31.200,000.00 Roolln0 5400,000 00 Masonry $200.000,00 $4,000.000 00 r 'Y tN5/2008 01G' 5!1512010 6 City of Boston 4 - Mr. Ci John 4or Smith CC, (617) 111-1111 5114 123 Main Street • Boston ya' MA PVo' 01234 V •- ABC Construclwn Management, Inc. 4g- Ms - 01 Jane 4�,. Jones o,. (781) 000.0000 `�.. 456 Elm Street Highest Value Single Project 9 1 Second Highest Value Single Project Bosbn Water 8 Sewer Material Handlin Fee", Mattapoisetl Water Treatment Plant General Building Construction Sewage t Water Treatment Plants $7482323.00 $9.431,594.00 Modular Construction/Prefab Mechanical S stems $5,000,000.00 $2,000 000.00 Demolition Pumpin Stations $100000.00 $500,000.00 $12.582.323.00 $11,905,318.00 11/17/2007 8/14/2006 10/8/2009 8/5/2010 Boston Water 8 Sewer Commission Mallapoisen River Valley ;Vater District Commission Mr. Mr. Mark William Sheehan Nicholson 617-989-7279 508-758-4161 980 Harrison Avenue P.O. Box 1055 Boston Matta oisett MA MA 02119 02739 Camp. Dresser 8 McKee, Inc Tata 8 Howard Inc. Mr. Mr, Chris Patrick Kohler O'Neale 617-452-6821 508-946-1732 50 Hampshire Street 10 Riverside Drive 1 Charlestown Police Station General Building Construction $8,965,176.00 Mechanical $ stems $200.000.00 Sewage 8 Water Treatment Plants $100.000.00 $9,265,176.00 5/17/2007 1 12/15/2008 City of Boston Public Facilities Dept. Mr. Robert Newton 1 617-635-0546 26 Court Street, 10th Floor Boston MA 02108 HKT Architects, Inc. M, Marla Kabalin 617-776-6545 35 Medford Street 10 Post Office Square. Suite 1010 2 New Matt.Pan Branch Libra, General Building Construr-tion $11.257.274.00 Modular Construction/Prefab $25.000.00 $11,282.274.00 4/30/2007 6,15/2009 City of Boston M,. Gr Rideout 617-635-0546 26 Court Street. 1011, Floor Boston MA 02108 William Rawn Associates Mr. Rand Wilmot 617-423-3470 3 Buildine 8 Demolllon General Building Construction $1,599,556.00 Demolition $1,000,000.00 Modular Conslruction;Prefab $200,000.00 $2.799.556.00 12/1/2008 11/25/2009 Massachusetts Part Authority Mr. Ste hen Marshall 617-568-5697 One Harborside Drive, Suite 2005 East Boston MA 02128 Jacobs Edwards and Kelcey Mr. James B. Gleason 617-242-0222 343 Congress Street #2 General Building 4 New Bedford Hiph School Construction $671,953.00 Demolition $100.000.00 $774,953.00 6/17/2010 8/20/2010 City of New Bedford Mr. Larry Oliveira 508-997-4511 133 William Street New Bedford MA 02740 TRC Mr. John C. Mulhall 978-656-3575 650 Suffolk Street 5 Ouittacas Water Treatment Plant General Building Construction _.$2 947,590.00 Demolition $150,000.00 Sewage 8 Water Treatment Plants $125,000.00 $3,222,590.00 1/15/2010 1/20/2011 City of New Bedford Mr. Jim Ricci 508-979-1603 133 William Street New Bedford MA 1 02740 Camp. Dresser 8 McKee, Inc, Mr. I Lee Storrs 617-452-6000 50 Hampshire Street MCI Norfolk Waste Water Sewage 8 Water Modular 6 Treatment Plant Braintree Great Pond Water Treatment Plants $5 329,680,00 Construction!Prefab $2 000,000.00 Mechanical S stems $200,000.00 $7,529,680.00 2/8/2012 5/1/2012 DCAM Mr. Orville Henry617-727-4050 One Ashburton Place Boston MA 02108 HorsleyWhitten GroupMr. Tom Lee 508-833-6600 90 Route 6A Treatment Plant Phase It CPE Sewage $ Water Improvements Treat. ant Plant. $808,700.00 Mechanical Systems $80,000.00 Demolition $100,000.00 $709.700.00 4/15/2012 7/15/2012 Town of Braintree Mr. Robert Campbell 781494-8012 90 Pond Street Braintree MA 02184 Environmental Partners Mr. Slave Olson 617-657-0255 1900 Chown Colony Drive 8 9 10 11 12 13 14 15 16 17 1s 19 20 e Important If Applying OP for General Building Construction, list the o y9ce �9ce three largest sub -trades Oe X59 you subbed out and/or I V` GC, salt -performed and G Gam, ` 'include contract costs 114,$ for each. Sub -trade? Sub4rade 1 Contract Amount $ Sub -trade 2 Category Sub-trado 2 Contract $ Amount Sub -Trade 3 Cato o Sub -trade 3 Contract Amount Anytown MA 01567 Plumbing $400;000.00 Electrical $300,00000 MVAC $250,000.00 Cambridge MA 02139 HVAC $688,191.00 Electrical $773.870.00 Masonr $560,697.00 Lakeville MA 02347 Electrical $1,716,109.00 Masonry $716.000.00 HVAC $387,000.00 Somerville MA 02143 HVAC $678.000.00 Electrical $676,000.00 Masonry $519,227.00 Boston MA 02109 HVAC $962.005.00 Doors 8 Windows $829,784.00 Electrical $926,093.00 Boston MA 02210 Electrical $264,084.00 Structural Steel $55.000.00 - Lowell MA 01854 HVAC $147,000.00 Electrical $18,700.00 Paintin $9.200.00 Cambrid a MA 02739 Roofing $496,000.00 Doors& Windows $240.243.00 Painting $118,200.00 Sandwich MA 02563 Electrical $737,000.00 HVAC $254,000.00 Plumbin $138,680.00 Quincy MA 02169 l• J Certification (notarization required) The undersigned, William E VoQel hereby certifies: (type name) That I am an owner or principal of WES CONSTRUCTION CORP, (company name) and that all answers and all statements contained in the attached application (including Sections and G) for certificate of eligibility are complete, true and correct. Providingfalse or F information or failure to provide all required information will be considered grounds or den al, decertification and/or debarment. I attest to the accuracy of all information contained in this application and verify that the information submitted is in oath. fact complete, accurate and true, under Signed and Sworn under the Pains and Penalties of Perjury. Dated at Hal, y N1A This 101h day ofA ril, 2013. By (signature): �l Type name: William E. Vo nNl Title or position: Clerk Plymouth ss. (county) Before me, Michael E. Christian (notary public) Massachusetts (state) Personally appeared and known to me to be William E. Vogel ,based (name of officer) on satisfactory evidence which was his/her driver's license and acknowledged that he/she is authorized to execute the foregoing and that its execution is his/her free act and deed and the free act and deed of the finn. M commission expires: -11/03/-17 (notary public signature) yt I , bfic Michael E. Christian ear orU►rr 1. (print name) MYCwftssionFxprea No eTbal3, 20ii **Upon completion of this Application and the two corresponding Excel spreadsheet ` email them to Cel-tificpli ationA cation dearn(Qistate n,a save and, , t Prime/Genera! Revised March Zoil Page 16 of 16 Tmm��itor .