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HomeMy WebLinkAboutContract #: 004568 - From: To: - Exception - Exception91 (fie I CC) a r School Department Administration Building Kang Associates, Inc. North Andover, MA January 2, 2014 FORM OF SUB -BID To All General Bidders Except those Excluded: A. The undersigned proposes to furnish all labor and materials required for completing, in accordance with the hereinafter described plans, specifications and addenda, all work specified in 07 31. 0� 21 f 071-3, G'dA69 ; kof the specifications and in any plans specified in such section, prepared by Kang Associates, Inc Yor the School Department Administration Building,North Andover, MA for the contract sum of: dollars ($ ). For Alternate #1: Deduct $ �2 L - dollars ($ For Alternate #2: Deduct $ (-XXL q0z::!2n0nJ dollars ($ For Alternate #3: Deduct $ dollars ($ 20 00 ). For Alternate #4: Deduct $ 42— dollars ($ For Alternate #5: Deduct $ A) dollars ($ B. This sub -bid includes addenda numbered C. This sub -bid ® may be used by any general bidder except: _iy i, I he 1-s S; Y�n1 S ❑ may only be used by the following general bidders: (To exclude general bidders, insert an "X" in one box only and fill in blank following that box. Do not answer C if no general bidders are excluded.) FORM OF SUB -BID - 1 School Department Administration Building North Andover, MA Kang Associates, Inc. January 2, 2014 D. The undersigned agrees that, if he is selected as sub -bidder, he will within five days, Saturdays, Sundays, and legal holidays excluded, after presentation of a subcontract by the general bidder selected as the general contractor, execute with such general bidder a subcontract in accordance with the terms of this sub -bid, and contingent upon the execution of the general contract, and, if requested so to do in the general bid by such general bidder, who shall pay the premiums therefor, or if pre -qualification is required pursuant to section 44D 3/4, furnish a performance and payment bond of a surety company qualified to do business under the laws of the Commonwealth and satisfactory to the awarding authority in full sum of the subcontract price. E. The names of all persons, firms and corporations furnishing to the undersigned labor or labor and materials for the class or classes or part thereof work for which the provisions of the section of the specifications for this sub -trade requires a listing in this paragraph, including the undersigned if customarily furnished by persons on his own payroll and in the absence of a contrary provisions in the specifications, the name of each such class of work or part thereto and the Bid price for such class of work or part thereof are: Name Class of Work Bid Price (Do not give bid price for any class or part thereof furnished by undersigned.) F. The undersigned agrees that the above list of bids to the undersigned represents bona fide bids based on the hereinbefore described plans, specifications and addenda and that, if the undersigned is awarded the contract, they will be used for the work indicated at the same amounts stated, if satisfactory to the awarding authority. G. The undersigned further agrees to be bound to the general contractor by the terms of the hereinbefore described plans, specifications, including all general conditions stated therein, and addenda, and to assume toward him all the obligations and responsibilities that he, by those documents, assumes toward the owner. H. The undersigned offers the following information as evidence of his qualifications to perform the work as bid upon according to all the requirements of the plans and specifications: 1. Have been in business under present business name years. � 2. Ever failed to complete any work awarded? l�I 3. List one or more recent buildings with names of the general contractor and architect on which you served as a subcontractor for work of similar character as required for the above named buildings. Building Architect . General Contractor Amount of Contract (a) ie_e t () lti� ineine LAVs asgdx,�U � / OG? FORM OF SUB -BID - 2 School Department Administration Building North Andover, MA (b) (c) t'G G11,�1 r 4. Bank reference Kang Associates, Inc. January 2, 2014 �h r�r✓ r�'�r l� ��z. _ 1a-��;�errL� �� IIS k� 6/ / y/, yL'D -_ k n� Tech b" BA10 LMT �,?&2 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 of subcontracts subject to section 44F. The undersigned further certifies under penalties of perjury that this sub -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. Date SUB -BIDDER'S CHECKLIST: Addenda Recognized Bid Deposit DCAM Certificate of Eligibility Sub -Bidder Update Statement Certificate of Corporate Bidder /51ek (Name of Si By: Title of Person Signing Bid Jtre-e T_ u000k�)_56-),-ka­� City and State FORM OF SUB -BID - 3 School Department Administration Building Kang Associates, Inc. North Andover, MA January 2, 2014 CERTIFICATE OF CORPORATE BIDDER' I, 1'1� i�- 1 4 � W47 Y-fY"S certify that I am the se C- 9'eT 0 �-J C ) `-yz— of the corporation named as Bidder in the Bid Form, and that L)� j A �L (0/Z- A)o k'y r who signed the Bid Form on behalf of the Bidder was then the Le C 1 cA '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 -zalte-l' & Secretary -Clerk Date CORPORATE BIDDER - 1 The Commonwealth of Massachusetts Executive Oce for Administration and Finance Division of Capital Asset Management and Maintenance One Ashburton Place Boston, Massachusetts 02108 DEVAL L. PATRICK GLEN SHOR GOVERNOR Tel: (617) 727-4050 SECRETARY, ADMINISTRATION & Fax: (617) 727-5363 FINANCE TIMOTHY P. MURRAY CAROLE CORNELISON LIEUTENANT GOVERNOR COMMISSIONER Filed Sub -Bid Certificate of Contractor Eligibility CONTRACTOR IDENTIFICATION NUMBER: 0078 This Certificate Shall Be Used for Submitting Filed Sub -Bids Only 1. CERTIFICATION PERIOD: This Certificate is valid from 1/15/2014 to 1/15/2015 2. CONTRACTOR'S NAME: Belcour Corporation 3. CONTRACTOR'S ADDRESS: 99 Front Street, Woonsocket, RI 02895 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: ❑ Acoustical Tile ❑ HVAC ❑ Miscellaneous & Ornamental Iron ❑ Terrazzo ❑ Electrical Work ❑ Lathing & Plastering ❑ Painting ❑ Tile ❑ Elevators ❑ Marble ❑ Plumbing ❑ Waterproofing, Damp ❑ Fire Protection Sprinkler Systems ❑ Masonry Work ❑ Resilient Floors proofing, and Caulking ❑ Glass and Glazing El Metal Windows d Roofing & Flashing S. EVALUATIONS: Number of Projects Evaluated: 10 Average Project Evaluation Rating: 91 Number of Projects Below Passing Score: 0 6. SUPPPMIYZRWOFFICE CERTIFICATION: N/A bl�a� gran G gsby, General Counsel, Approval Date for Car a J. Cornelison, Commissioner 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 y result in a gap in Certification or a lapse in Certification altogether for your company. Reviewer's Initials � k' DL') -,,,-AIA Document, A3101m-2010 CONTRACTOR: Name, legal status and address) BELCOUR CORP. 99 Front Street Woonsocket, RI 02895 OWNER: (Name, legal status and address) TOWN OF NORTH ANDOVER 120 MAIN STREET North Andover, MA 01845 SURETY: (Name, legal status and principal place of business) MERCHANTS BONDING COMPANY (MUTUAL) 2100 Fleur Drive Des Moines, IA 50321 BOND AMOUNT: FIVE PERCENT OF ATTACHED BID (5%) BOND NUMBER: BEL676 This document has important legal consequences. Consultation with an attorney is encouraged with respect to its completion or modification. Any singular reference to Contractor, Surety, Owner or other party shall be considered plural where applicable. PROJECT: SCHOOL DEPARTMENT ADMINISTRATION BUILDING, FILED SUB -BID SECTION 073113 & 075300 DEMO OF EXISTING POLICE STATION AND NEW CONSTRUCTION OF SCHOOL ADMINISTRATION BUILDING. (Name, location or address, and Project number, if any) The Contractor and Surety are bound to the Owner in the amount set forth above, for the payment of which the Contractor and Surety bind themselves, their heirs, executors, administrators, successors and assigns, jointly and severally, as provided herein. The conditions of this Bond are such that if the Owner accepts the bid of the Contractor within the time specified in the bid documents, or within such time period as may be agreed to by the Owner and Contractor, and the Contractor either (I) 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 a d provisions conforming to such statutory or other legal requirement shall be deemed incorporated herein. When mi hed, the intent is that this Bond shall be construed as a statutory bond and not as a common law bond. Signed and sealed this 14th day of January , 2014. 0 Mcoum (Principal) _ (Seal) (witness) (Title) Lea AMQ=C) P N M (seal) (wi�ness) (Title)Heidi odZANEY-M-FACT CAUTION: You should sign an original AIA Contract Document, on which this toRED. An original assures that changes will not be obscured AIA Document A310 TM - 2010. Copyright © 1963, 1970 and 2010 by The American Institute of Architects. All rights reserved. WARNING: This AIA® Document Init. is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AIA® Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. Purchasers are permitted to reproduce ten (10) copies of this document when completed. To report copyright violations of AIA Contract Documents, e-mail The American Institute of Architects' legal counsel, copyrightr@iaia.org. 061110 MERCHANTS BONDING COMPANY POWER OF ATTORNEY Know All Persons By These Presents, that MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC., both bbing corporations duly organized under the laws of the State of Iowa (herein collectively called the "Companies"), and that the Companies do hereby make, constitute and appoint, individually, Joline L. Binette, Melanie A. Bonnevie, Heidi Rodzen, Robert E. Shaw of Lewiston and State of Maine their true and lawful Attomey-in-Fact, with full power and authority hereby conferred in their name, place and stead, to sign, execute, acknowledge and deliver in their behalf as surety any and all bonds, undertakings, recognizances or other written obligations in the nature thereof, subject to the limitation that any such instrument shall not exceed the amount of. FIFTEEN MILLION ($15,000,000.00) DOLLARS and to bind the Companies thereby as fully and to the same extent as if such bond or undertaking was signed by the duly authorized officers of the Companies, and all the acts of said Attorney -in -Fact, pursuant to the authority herein given, are hereby ratified and confirmed. This Power-of-Attomey is made and executed pursuant to and by authority of the following By -Laws adopted by the Board of Directors of the Merchants Bonding Company (Mutual) on April 23, 2011 and adopted by the Board of Directors of Merchants National Bonding, Inc., on October 24, 2011. 'The President, Secretary, Treasurer, or any Assistant Treasurer or any Assistant Secretary or any Vice President shall have power and authority to appoint Attorneys -in -Fact, and to authorize them to execute on behalf of the Company, and attach the seal of the Company thereto, bonds and undertakings, recognizances, contracts of indemnity and other writings obligatory in the nature thereof. The signature of any authorized officer and the seal of the Company may be affixed by facsimile or electronic transmission to any Power of Attorney or Certification thereof authorizing the execution and delivery of any bond, undertaking, recognizance, or other suretyship obligations of the Company, and such signature and seal when so used shall have the same force and effect as though manually fixed." In Witness Whereof, the Companies have caused this instrument to be signed and sealed this 30th day of October 2012 STATE OF IOWA COUNTY OF POLK ss. .•��N� C0 ••• �O�pRPOA �°�" y 1933 'd • • MERCHANTS BONDING COMPANY (MUTUAL) MERCHANTS NATIONAL BONDING, INC. By /-47747//, President On this 30th day of October 1 2012 before me appeared Larry Taylor, to me personally known, who being by me duly sworn did say that he is President of the MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC.; and that the seals affixed to the foregoing instrument is the Corporate Seals of the Companies; and that the said instrument was signed and sealed in behalf of the Companies by authority of their respective Boards of Directors. In Testimony Whereof, i have hereunto set my hand and affixed my Official Seal at the City of Des Moines, Iowa, the day and year first above written. MARANDA GREENWALT Commission Number 770312 My Commission Expires October 28, 2014 Notary Public, Polk County, Iowa STATE OF IOWA COUNTY OF POLK ss. I, William Warner, Jr., Secretary of the MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC., do hereby certify that the above and foregoing is a true and correct copy of the POWER-OF-ATTORNEY executed by said Companies, which is still in full force and effect and has not been amended or revoked. In Witness Whereof I have hereunto set my hand and affixed the seal of the Companies on this 14TH day of YA&ARY , 4 . POA 0014 (11/11) 0�� Secretary IN EFFECTIVE MARCH 30, 2010 Commonwealth of Massachusetts Division of Capital Asset Management Il SUB -BIDDER UPDATE STATEMENT TO ALL SUB -BIDDERS, TRADE CONTRACTORS AND AWARDING AUTHORITIES A COMPLETED AND SIGNED SUB -BIDDER UPDATE STATEMENT MUST BE SUBMITTED WITH EVERY FILED SUB -BID PURSUANT TO M.G.L. c.149, §44F AND EVERY TRADE SUB -BID PURSUANT TO M.G.L. c. 149A. ANY FILED SUB -BID OR TRADE SUB -BID SUBMITTED WITHOUT AN APPROPRIATE SUB -BIDDER UPDATE STATEMENT IS INVALID AND MUST BE REJECTED. Caution: This form is to be used for submitting Filed Sub -Bids and Trade Sub -Bids. It is not to be used for submitting PrimelGeneral Contract bids. AWARDING AUTHORITIES If the Awarding Authority determines that the sub -bidder is not competent to perform the work as specified on the project, it should reject the bid. SUB -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 Sub -bidder Update Statement on behalf of the bidder named below, that I have read this Sub -bidder Update Statement, and that all of the information provided by the bidder in this Sub -bidder Update Statement is true, accurate, and complete as of the bid date. /_ p? 1-dolzI Belcour Corp Bid Date Print Name of Sub -bidder or Trade Contractor Project Number (or name if no number) 99 Front Street Woonsocket, RI Business Address Td(AO Dl— A)()Ittk Pr' 401-762-4685 Awarding Authority Telephone Number SIGNATURE* Representative Division of Capital Asset Management Page 1 of 10 INSTRUCTIONS INSTRUCTIONS TO SUB -BIDDERS This form must be completed and submitted by all Filed Sub -Bidders bidding on projects pursuant to M.G.L. c. 149, §44F and Trade Contractors bidding on projects pursuant to 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 SUB -BIDDER UPDATE STATEMENT IS GROUNDS FOR REJECTING YOUR BID AND FOR DEBARRING YOU FROM ALL PUBLIC CONTRACTING. This Sub -Bidder 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) Sub -Bidder Certificate of Eligibility. The Sub -Bidder Update Statement must cover the entire period since the date of that Application, NOT since the date of your Certification. You must use this official form of Sub -bidder Update Statement. Copies of this form may be obtained from the awarding authority and from the DCAM Web Site: ,gvvwxnass.aov/dca'm . If additional space is needed, please copy the appropriate page of this Sub -bidder Update Statement and attach it as an additional sheet. Division of Capital Asset Management Sub -bidder Update Statement Effective March 30, 2010 INSTRUCTIONS TO AWARDING AUTHORITIES Determination of Sub -Bidder Qualfcadons It is the awarding authority's responsibility to determine each responsible bidder. You must consider all of the information in the bidders Sub -bidder 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 sub -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 SUB -BIDDER'S ENTIRE CERTIFICATION FILE AT THE DIVISION OF CAPITAL ASSET MANAGEMENT. Telephone (617) 727-9320 for an appointment. Correction of Errors and Omissions in Sub -bidder Update Statements Matters of Form: An awarding authority shall not reject a sub -bidder's bid because there are mistakes or omissions of form in the Sub -bidder Update Statement submitted with the bid pursuant to M.G.L. c.149, §44D, provided the sub -bidder promptly corrects those mistakes or omissions upon request of the awarding authority. [810 CMR 8.13(1)]. Correction of Other Defects: An awarding authority may, in its discretion, give a sub -bidder notice of minor defects and omissions as to form in the Sub -bidder's Update Statement and provide an opportunity to correct its Sub -bidder Update Statement. However, the sub -bidder shall not be allowed to make corrections to a Sub -bidder Update Statement if material information about the sub -bidder was omitted from the Sub -bidder Update Statement filed with the sub -bidder's bid. 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Information you provide herein must supplement the Application for your most recently issued (not extended or amended) Sub -Bidder Certificate of Eligibility. You must report all requested information not previously reported on that Application. 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 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 3. any contract prior to substantial completion? Has your firm failed or refused to complete any punch list work under any contract? ❑ 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 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 6. contract? 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 been an officer, principal or individual with a financial interest in another firm that 7. hada payment or performance bond invoked? Has your surety made payment to a materials supplier or other party under your ❑ 8. payment bond on any contract? Has any subcontractor filed a demand for direct payment with an awarding authority El 9. for a public project on any of your contracts? 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 under any of your contracts? 10. Have there been any deaths of an employee or others occurring in connection with ❑ any of your projects? 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 one year? Division of Capital Asset Management Page 7 of 10 Sub -bidder Update Statement Effective March 30, 2010 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) Sub -Bidder Certificate of Eligibility. You must report all requested information not previously reported on that DCAM Application. The term "administrative proceeding" as used in this Sub -Bidder 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 , 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 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, 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, 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, or settled relating to a violation of M.G.L. Chapter 268A, the State Ethics Law? Division of Capital Asset Management Page 8 of 10 Sub -bidder Update Statement Effective March 30, 2010 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, 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 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, 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 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, or settled relating to a violation of state or federal law regulating the environment? for ❑ 10. Has your firm been fined by OSHA or any other state or federal agency violations of any laws or regulations related to occupational health or safety? Note: 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, workforce goals, or failure to file certified payrolls on any publicprojects? I, have ❑ 12. Other than previously reported in the above paragraphs of this Section any 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? firm's El 13. Are there any other issues that you are aware which may affect your responsibility and integrity as a building contractor? Division of Capital Asset Management Page 9 of 10 Sub -bidder Update Statement Effective March 30, 2010 PART 5 - SUPERVISORY PERSONNEL List all supervisory personnel who will be assigned to the project if your firm is awarded the contract. Attach the resume of each person listed below. Donald Cournoyer NAME I TITLE OR FUNCTION President 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 If YES, attach a separate page providing complete details. PART 7 - LIST OF COMPLETED CONSTRUCTION PROJECTS SUBMITTED TO THE DIVISION OF CAPITAL ASSET MANAGEMENT ALONG WITH CERTIFICATION PAGE. Attach here a copy of the list of completed construction projects which was submitted with your firm's Application for your most recently issued (not extended or amended) Sub -Bidder Certificate of Eligibility. The Attachment must include a complete copy of the entire Section F — "Completed Projects" (Section G —"Completed Projects" for firms certified based upon their Prime/General Application), and the final page — Certification Page, (Section I in the Sub -bidder Application or Section J in Prime/General Application) containing the signature and date that the Completed Projects list (Section F or G) was submitted to the Division of Capital Asset Management. Division of Capital Asset Management Page 10 of 10 Sub -bidder Update Statement Effective March 30, 2010 J.- Certification (notarization required) The undersigned, Donald Cournoyer hereby certifies: (type name) That I am an owner or principal of Belcour Corp, (company name) and that all answers and all statements contained in the attached application (including Sections F and G) for certificate of eligibility are complete, true and correct. Providing false or misleading information or failure to provide all required information will be considered grounds for denial, decertification and/or debarment. I attest to the accuracy of all information contained in this application and verify that the information submitted is in fact complete, accurate and true, under oath. Signed and Sworn under the Pains and Penalties of Perjury. Dated at Belcour Corp This Iday of,�O 20 By (signature): Type name: Title or position: 4j Gl ; Je u, C e ss. (county) (state) Before me, & r; 5)'�a&- k4mber 1 , personally appeared and (notary public) known to me to be re c . d 0 tl .f ,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 firm. 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